ESKAPE Pathogens 0$/',72)0LFURELRORJLFDO&RQ˂UPDWLRQV Understanding Nosocomial Risk Factors Matrix Assisted Laser Desorption/Ionisation Time of Flight Mass The monitoring of water used in care homes and Acinetobacter baumannii $/6 (QYLURQPHQWDO DUH RQH RI WKH ˂UVW 8. ODERUDWRULHV WR YDOLGDWH DQG KDYH 7KHWHFKQLTXHLVXVHGWRDQDO\VHWKHSURWHLQɆ˂QJHUSULQWɇ healthcare facilities is covered by several pieces of Health Acinetobacter baumannii is a rapidly emerging pathogen in accredited to ISO 17025:2005 and the Drinking Water Testing Standard (DWTS), RIDPLFURRUJDQLVPSURGXFLQJDQLGHQWL˂FDWLRQXVLQJD and Safety Guidance (HSG). The majority of the guidance the health care system. A. baumannii is usually introduced DFFUHGLWWKHUDSLGLGHQWL˂FDWLRQRISRVLWLYH0LFURELRORJLFDOVDPSOHVE\0DWUL[ validated reference library. is on the monitoring of Legionella and is supported by the into a hospital by a colonised patient. Due to it’s ability to Assisted Laser Disportion and Ionistation by Time of Flight Mass Spectrometry Approved Code of Practice for Legionella (ACoPL8) and VXUYLYHRQDUWL˂FLDOVXUIDFHVDQGUHVLVWGHVLFFDWLRQLWFDQ 0$/',7R) 06  7KH JURXQG EUHDNLQJ LGHQWL˂FDWLRQ WHFKQLTXH HPSOR\HG E\ 7KHDELOLW\WRUHGXFHFRQ˂UPDWLRQWLPHVLVDVDUHVXOWRI Health Technical Memorandums (HTM); however, there are survive and potentially infect new patients for some time. It ALS Environmental, known as MALDI-ToF, allows us to remove the need for MALDI-TOF being able to be performed on colonies from a range of other risk factors that need to be considered is suspected that A. baumannii growth favours nosocomial presumptive data for bacteriological analysis, with all data reported as Colony selective agar. This removes the need for sub culturing and in nosocomial scenarios. The ESKAPE pathogens are settings due to the constant use of antibiotics by patients )RUPLQJ 8QLWV &)8  7KH LPSDFW RI 0$/',7R) FRQ˂UPDWLRQ RQ WKH (6.$3( incubation, which is the stage that incurs additional time. emerging pathogens of concern. ALS Environmental are in the hospital and causes a wide range of infection pathogens is highlighted in the table below. Depending on the organism being tested, this additional DEOH WR RIIHU UDSLG LGHQWL˂FDWLRQ RI WKHVH EDFWHULD XVLQJ including bacteremia, pneumonia, meningitis, urinary tract time can be anything from 4 hours to 5 or more days. Incubation &RQ˂UPDWLRQ &RQ˂UPDWLRQ RXU UHYROXWLRQDU\ 0$/',7R) FRQ˂UPDWLRQ WHFKQLTXH7KH infection, and wound infection. The organism’s ability to Bacteria MALDI-ToF Saving ESKAPE Pathogens are: survive under a wide range of environmental conditions, Time Traditional MALDI-ToF The method was developed in consultation with both Enterococci 2 days 1 day Minutes 1 day the United Kingdom Accreditation Service (UKAS) and Enterococcus faecium and to persist for extended periods of time on surfaces, PDNHLWDIUHTXHQWFDXVHRIRXWEUHDNVRILQIHFWLRQDQGDQ Staphylococcus aureus 2 days 1 day Minutes 1 day the Drinking Water Inspectorate (DWI). As a result, we Enterococcus faecium; formerly known as Streptococcus endemic, health care–associated pathogen. Klebsiella pneumoniae 1 day 1 day Minutes 1 day have full ISO 17025 UKAS accreditation, since December faecium until its re-categorization in 1984, is a human Acinetobacter baumannii 1 day 1 day Minutes 1 day 2013. This was extended to include Drinking Water Testing pathogen that causes nosocomial bacteremia, surgical Pseudomonas aeruginosa Pseudomonas aeruginosa 2 day 1 day Minutes 1 day 6SHFL˂FDWLRQ ':76  LQ )HEUXDU\  $OWKRXJK WKH wound infection, endocarditis, and urinary tract infections. The monitoring for Pseudomonas is covered in HTM04- technology has been used extensively in the clinical sector Enterobacteriaceae 1 day 1 day Minutes 1 day The bacteria can survive for long periods of time inside 01 Addendum. Serious infections of P. aeruginosa usually IRUDQXPEHURI\HDUV$/6LVWKH˂UVW8.(QYLURQPHQWDO Stenotrophomonas 1 day 1 day Minutes 1 day hospitals on a variety of surfaces as well as in soil and occur in the immunocompromised. Infections of the laboratory to use and accredit this technology. sewage. Growth temperatures range from 10oC to 45oC in blood, pneumonia, and infections following surgery can basic or acidic environments, and in environments which lead to severe illness and death in these people. The Legionella 10 days 2 days Minutes 2 days $VɆWUDGLWLRQDOɇFXOWXUHEDVHGPHWKRGVDUHVWLOOXVHGIRUWKH are isotonic or hypertonic. Ent. faecium can be highly highly susceptible nosocomial patients include those on E-coli 1 day 1 day Minutes 1 day isolation, compliance with standards is maintained. We drug resistant. The spread of the disease occurs between breathing machines, premature babies and patients with Coliforms 1 day 1 day Minutes 1 day are therefore fully compliant with ACoP L8 (and HSG274), patients in hospitals due to transfer of the pathogen by wounds from surgery or from burns. Additionally, healthy Clostridium Perfringens 1 day 1 day Minutes 1 day The Water Supply (Water Quality) Regulations, The Private hands or medical instruments. Also, antibiotic use can people can also develop mild illnesses with Pseudomonas Salmonella 4 days 2 days Minutes 2 days Water Supply Regulations and HTM guidance. decrease the number of other intestinal bacteria that are aeruginosa, especially after exposure to water. Ear Listeria 4 days 2 days Minutes 2 days susceptible to the antibiotic and decrease competition for infections, especially in children, and more generalised 7KH UHGXFWLRQ LQ FRQ˂UPDWLRQ WLPHV UHPRYHV WKH ULVN the drug resistant Ent. faecium. VNLQ UDVKHV PD\ RFFXU DIWHU H[SRVXUH WR LQDGHTXDWHO\ 7KH LQVWDQW FRQ˂UPDWLRQ RI WKH (6.$3( EDFWHULD DOORZV LQIHFWLRQ FRQWURO DQG associated with acting (or not acting) on presumptive chlorinated hot tubs or swimming pools. Staphylococcus aureus water treatment to make rapid decisions on any potential remedial works that GDWDE\SURYLGLQJDQDFFUHGLWHGFRQ˂UPHGUHVXOWZLWKLQ may need to be undertaken. The MALDIToF can be used to identify any positive minutes of the presumptive result being generated. The The carriage of Staphylococcus aureus is an important Enterobacter species bacteria, including Legionella. DGGHGEHQH˂WLVWKDWLQDGGLWLRQWRDUDSLGFRQ˂UPDWLRQ VRXUFH RI QRVRFRPLDO LQIHFWLRQ DQG FRPPXQLW\DFTXLUHG The genus Enterobacter is a member of the coliform methicillin-resistant Staph. aureus (MRSA). Staph. aureus is group of bacteria. Enterobacter species, particularly E. UHVXOWLQWKHPDMRULW\RIFDVHVVSHFLHVOHYHOLGHQWL˂FDWLRQ Legionella will also be available. ALS will provide this additional common and often found in the nose or on the skin. Most cloacae and E. aerogenes, are important nosocomial 7KH 0$/',7R) FRQ˂UPDWLRQ RI /HJLRQHOOD UHPRYHV WKH SUHVXPSWLYH VWDJH information as part of the standard service. of the time these bacteria do not cause any symptoms. pathogens responsible for various infections; including PHDQLQJWKDW$/6(QYLURQPHQWDOUHSRUWSRVLWLYHFRQ˂UPHG/HJLRQHOODRQWKH The ability of the nasal passages to harbour Staph. aureus bacteremia, lower respiratory tract infections, skin RULJLQDOUHDGGD\V FXUUHQWO\GD\VDQG 7KLVLVTXLFNHUWKDQWKH results from a combination of a compromised host immune and softtissue infections. Risk factors for nosocomial ,I\RXZRXOGOLNHPRUHLQIRUPDWLRQRQVSHFL˂FRUJDQLVPV traditional approach and is fully ISO 17025:2005 accredited. ALS Environmental that we are able to identify, please contact our customer system combined with the bacteria’s ability to evade a Enterobacter infections include hospitalisation of greater have one of the world’s largest Legionella species libraries held within our MALDI- services department. host’s innate immunity. The spectrum of Staphylococcus than 2 weeks, invasive procedures in the past 72 hours, 7R):LWKRQO\NQRZQVSHFLHVXQLGHQWL˂DEOHWZRRIWKHVHDUH9LDEOH%XW1RW infections can range from skin abscess to life-threatening treatment with antibiotics in the past 30 days, and the &XOWXUDEOH 9%1& DQGWKH˂QDOVSHFLHVLVEHLQJVRXUFHGE\RXUODERUDWRU\ infections such as septicaemia or endocarditis. SUHVHQFHRIDFHQWUDOYHQRXVFDWKHWHU6SHFL˂FULVNIDFWRUV for infection with nosocomial multidrug-resistant strains Klebsiella pneumoniae of Enterobacter species include the recent use of broad- In nosocomial settings, Klebsiella bacteria can be spread spectrum cephalosporins or aminoglycosides and ICU care. LEGIONELLA SPECIES TABLE through person-to-person contact or by contamination of the environment; it is important to note that the bacteria Stenotrophomonas Maltophilia Name of species Number of serotypes Linked to humaninfection Geographic origin Common Matrix Type are not spread through the air. Patients in healthcare Stenotrophomonas maltophilia is an organism of low Legionella anisa YES USA Process, Drinking, Surface and Recreational settings may be exposed to Klebsiella when they are YLUXOHQFHZKLFKFDQIUHTXHQWO\FRORQLVH˃XLGVXVHGLQWKH Legionella adelaidensis Unknown Adelaide in South Australia Process Water on ventilators, or have intravenous catheters or wounds. KRVSLWDOVHWWLQJ HJLUULJDWLRQVROXWLRQVLQWUDYHQRXV˃XLGV  Unfortunately, these medical tools and conditions may and patient secretions (eg, respiratory secretions, urine, Legionella beliardensis Unknown Montbeliard in France Process Water allow Klebsiella to enter the body and cause infection; wound exudates). S. maltophilia usually bypasses normal Legionella birminghamensis YES %LUPLQJKDP$ODEDPD86$ Process Water which can be fatal in the immuno-compromised. host’s defenses to cause human infection. The growth of Legionella bozemanii (bozemanae) 2 YES 1DPHGDIWHU)0DULO\Q%R]HPDQ Clinical Isolation S. maltophilia from sites which would normally be sterile Legionella brunensis Unknown %UQR&]HFK5HSXEOLF Process Water (e.g., blood) usually represents true infection; growth of S. maltophilia in microbiological cultures of respiratory Legionella busanensis Unknown %XVDQLQ.RUHD Process Water RU XULQDU\ VSHFLPHQV LV WKHUHIRUH VRPHWLPHV GLI˂FXOW WR Legionella cardiaca YES 1RUWKZHVWHUQ8QLYHUVLW\&KLFDJR86$ Clinical Isolation interpret and not always a proof of infection. Legionella cherrii Unknown Minnesota, USA Process Water Legionella cincinnatiensis YES Cincinnati, Ohio, USA Clinical Isolation Legionella donaldsonii Unknown Process, Drinking, Surface and Recreational STENOTROPHOMONAS Legionella drancourtii Unknown Amoebae ALS Environmental are proud to be one of the few Legionella dresdenensis Unknown Dresden, Germany Recreational and Surface Water laboratories in the UK and Ireland to offer an analytical speciation service for Stenotrophomonas species, which Legionella drozanskii Unknown Leeds, England, UK Process and Drinking Water are of particular concern to healthcare facilities as they are a /HJLRQHOODGXPRI˂L YES Clinical Isolation common water-borne organism. Although infection by this Legionella erythra 2 YES Seattle, WA,USA Process Water opportunistic bacteria is rare, cases of Stenotrophomonas /HJLRQHOODIDLU˂HOGHQVLV YES )DL˂HOG9LFWRULD$XVWUDOLD Process Water maltophila (S. maltophila) are potentially lethal. Following Legionella fallonii Unknown Cruise ship in international waters Process Water D UHTXHVW IURP RQH RI RXU HVWDEOLVKHG FOLHQWV ZH KDYH GHYHORSHGDUDSLGWHFKQLTXHWRFRQ˂UPDQGLGHQWLI\WKH Legionella feeleii YES Process Water and Clinical Isolation colonies of Stenotrophomonas. Legionella geestiana Unknown *HHVWRI˂FHEXLOGLQJ/RQGRQ(QJODQG Drinking and Process Water Legionella genomspecies 1 Unknown Unknown $QDTXDWLFXELTXLWRXVRSSRUWXQLVWLFRUJDQLVP6PDOWRSKLOD Legionella gormanii YES Atlanta, USA Soil may be a particular burden to healthcare facilities due Legionella gratiana Unknown Savoy region in France Recreational and Process Water to the susceptibility of immuno-compromised patients. ALS Environmental are employing our latest technology Although it has no natural infection route to humans S. LQ RUGHU WR SURGXFH UDSLG VSHFLHV OHYHO LGHQWL˂FDWLRQV Legionella gresilensis Unknown ,Q)UDQFHIURPWKHFLW\*U«RX[OHV%DLQV Recreational, Drinking and Process Water maltophila infection can be facilitated by contaminated this means that we do not report presumptive results, Legionella hackeliae YES USA, Pennsylvania Clinical Isolation prosthetics such as catheters and intravenous lines. S. but instead provide a full list of the Stenotrophomonas Legionella impletisoli Unknown Japan 6RLOVQHDU7UDGH(I˃XHQW:DWHUV maltophila’s resitance to most antibiotics has proved fatal species present in the sample. The full species breakdown Legionella israelensis YES In Gaash in Israel Surface Water and Recreational Water to severely immunocompromised hosts. for Stenotrophomonas is important as not all species are pathogenic to humans. Legionella jamestowniensis Unknown -DPHVWRZQ1HZLegionella longbeachae 2 YES /RQJ%HDFK&DOLIRUQLD86$ Soil and Compost GHYHORSPHQWLQWRYDOLGDWLQJDQHZPHWKRGIRUWKLVJHQXV Legionella lytica YES Poland Soil and Amoebae JURXS%\XWLOLVLQJWKHODWHVWWHFKQRORJ\ZHZHUHDEOHWR Legionella maceachernii YES Drinking Water SURYLGHDIXOOVSHFLDWLRQRI6WHQRWURSKRPRQDVLQXQGHUD Legionella massiliensis Unknown Marseille, France, Process Water PRQWKɊ Legionella micdadei -L. pittsburghensis YES USA Clinical Isolation and Drinking Water Species of the Stenotrophomonas genus are common in Legionella monrovica YES USA Unknown the environment and human infection is rare. However, Legionella moravica Unknown Moravia, Czech Republic Process Water Traditional testing for Stenotrophomonas involves a infection risk of opportunistic pathogens such as the general screen that produces presumptive results for Legionella nagasakiensis YES Aomori, Japan Clinical Isolation, Recreational and Drinking Water maltophila species of Stenotrophomonas can be elevated the prescence of members of the genus. This is usually Legionella nautarum Unknown London , UK Drinking and Process Water in healthcare settings and other environments where followed by biochemical tests which indicate whether S. Legionella oakridgensis YES Oak Ridge, Tennessee , USA Clinical Isolation and Process Water immuno-compromised patients, such as in care homes maltophila is present. may be exposed. Despite the low infection rate, nomo- Legionella parisiensis YES Paris, France Clinical Isolation, Process and Surface Water social outbreaks of S. maltophila are of increasing concern Legionella pittsburghensis Unknown USA Clinical Isolation LQPRGHUQLQIHFWLRQFRQWUROEHFDXVHLWFDQEHGLI˂FXOWWR Legionella pneumophila 15 YES USA Clinical Isolation, Surface and Recreational Water treat effectively as it is resistant to most broad-spectrum Legionella pneumophila ssp fraseri YES Los Angeles, USA Clinical Isolation antibiotics. Legionella pneumophila ssp pascullei YES Clinical Isolation Legionella pneumophila ssp pneumophila YES Philadelphia , USA Clinical Isolation ALS SERVICE OVERVIEW /HJLRQHOODTXDWHLUHQVLV Unknown Quarteira, Portugal Process and Drinking Water UK and Ireland Locations /HJLRQHOODTXLQOLYDQLL 2 Unknown Australia Process Water Legionella rowbothamii Unknown Process Water and Sludge Quality Legionella rubrilucens YES Los Angeles,California, USA Drinking and Recreational Water Providing customers with UKAS ISO 17025:2005, MCERTS Legionella sainthelensi 2 YES Mount St. Helens, Washington, USA Clinical Isolation, Surface, Recreational and Ground Water and DWTS accredited data from our laboratories across the Legionella santicrucis Unknown 6W&URL[9LUJLQ,VODQGV Drinking and Process Water 8.:HSDUWLFLSDWHLQDEURDGUDQJHRI3UR˂FLHQF\7HVWLQJ Legionella shakespearei Unknown Stratford-upon-Avon , England, UK Process Water schemes and hold a DEFRA import licence for soils. Legionella spiritensis 2 Unknown St. Helens, Oregon, USA Recreational and Surface Water Did you know that? Legionella steelei YES California, USA and South Australia Clinical Isolation We are able to provide a broad range of additional services Legionella steigerwaltii Unknown 6W&URL[9LUJLQ,VODQGV Drinking and Process Water to help with your sampling including: Legionella taurinensis Unknown Turin, Italy Process Water Ɏ Internal refrigerated and tracked courier network Legionella tucsonensis YES Tucson, Arizona , USA Clinical Isolation Ɏ 1DWLRQDOSRUWIROLRRIGURSRIIORFDWLRQV Ɏ Pre-Registration of samples via our “Pre-Reg” system Legionella tunisiensis Unknown Lake Sabkha ,Tunisia Recreational and Surface Water Ɏ Dedicated customer service advisor Legionella wadsworthii YES Los Angeles, California, USA Clinical Isolation Ɏ Online reporting via our WebTrieve system Legionella waltersii 2 Unknown Adelaide , Australia Drinking and Process Water Legionella worsleiensis Unknown Worsley, England, UK Process Water Legionella yabuuchiae Unknown Japan Soils

Contaminated Land Legionella and Microbiology Waste Management Drinking Water ,I\RXKDYHDQ\TXHVWLRQVRQRXUVHUYLFHVRUZRXOGOLNHPRUHLQIRUPDWLRQRQ We understand the time pressures of large scale %HLQJPHPEHUVRIWKH/HJLRQHOOD&RQWURO$VVRFLDWLRQ /&$  %\ ZRUNLQJ FORVHO\ ZLWK VRPH RI WKH ODUJHVW FRPSDQLHV We are one of only a handful of commercial laboratories ALS Environmental please call the Coventry laboratory on 02476 42 12 13 or 5HPHGLDWLRQDQG%URZQ˂HOGSURMHFWVDQGDUHDPHPEHU we understand the emphasis placed on laboratory analysis in this sector we are able to offer unrivalled analytical WRKDYHDGHGLFDWHG'ULQNLQJ:DWHU7HVWLQJ6SHFL˂FDWLRQ visit our website. of the AGS. Our Coventry laboratory utilises state of the for the Control of Legionella. With 3 methods for testing and administration services to ensure that your samples ':76 DFFUHGLWHGODERUDWRU\EDVHGLQ:DNH˂HOG

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