Water-borne infections in hospitals and their prevention - no water is worse than still water
Egil Lingaas Department of Infection Prevention, Oslo University Hospital, Norway
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Legionella
54 species and 74 antigenic types Widespread in environment in low numbers Water and humid environments Compost Ca. 20 species have caused human infection Most common (> 90 %): Legionella pneumophila Legionella micdadei ca 2 % Legionella bozemanae ca 2 %
Int J Syst Evol Microbiol 2010;62:2946
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Legionella
Replicates at temperatures between 20 and 50 (45) oC
Still water increases the risk of growth
Water in buildings therefore at increased risk
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Publications on Legionella and “hospital” (medline) last 20 years
60 N = 680 50
40
30
20
Number of publications of Number 10
0
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas CID 2016:62 (1 February) • 273
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas
There are reasons to believe that Legionella is a small problem compared to other water-borne infections in hospitals
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Rutala WA: Infect Control Hosp Epidemiol 1997;1:609
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Pseudomonas Mycobacteria Legionella Enterobacter Salmonella Cryptosporidia Sphingomonas Acinetobacter Ewingella Stapylococcus Aspergillus Gram-negative bacilli Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Microorganisms associated with water- borne infections in hospitals (1)
Pseudomonas aeruginosa Stenotrophomonas maltophilia Sphingomonas paucimobilis Ralstonia pickettii Serratia marsescens
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Microorganisms associated with water- borne infections in hospitals (2)
Acinetobacer spp. Enterobacter spp. Aeromonas spp. Burkholderia spp. Halomonas Flavobacterium spp. Legionella spp.
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Microorganisms associated with water-borne infections in hospitals (3)
Mycobacterium spp.
Bacillus spp.
Aspergillus spp. Fusarium Exophalia
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Water-borne microorganisms
Opportunistic – seldomly a threat to healthy persons Often multiresistant to antibiotics Often difficult to document as source of infection
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Causal relationship
Detection of the same species in water and in clinical infection does not necessarily prove causal relationship
Genotyping is usually necessary
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Pseudomonas aeruginosa
Low nutritional demands
- Non-fermentative (O2, NO3/NO2 , Arginin) Grows at a wide temperature spectrum (4-42°C) with optimum at 37°C
Biofilm formation
Widespread in water and humid habitats
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas In 5 of 17 patients with P. aeruginosa infection, the same genotype was also detected in tap water.
Trautmann M et al. Infect Control Hosp Epidemiol 2001;22:49 Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Clin Infect Dis 2001;33:1363
Data suggest that the frequency of nosocomial outbreaks due to NTM may be increasing, and reduced hot water temperatures may be partly responsible for this phenomenon
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Clinically significant nontuberculous mycobacteria
Species Ideal Time for Frequency of temperature for growth, days nosocomial growth infections M. kansasii 37oC 10 - 20 ++ M. marinum 30oC 5 - 15 + M. szulgai 37oC 10 - 25 + M. xenopi 42oC 15 - 30 ++ M. gordonae 37oC 10 - 15 + M. avium 37oC 10 - 20 +++ M. haemophilum 30oC 15 - 20 + M. fortuitum 37oC 3 – 5 +++ M. chelonae 28oC 3 – 5 +++ M. abscessus 35oC 3 – 5 +++ Modified after Phillips MA et al. CID 2001 Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Mycobacterium mucogenicum: 4 patients Mycobacterium neoaurum: 1 patientt
Baird SF et al. J Hosp Infect 2011;79:339 Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Mycobacterium chimaera from heater-cooler unit water circuits
Clin Infect Dis 2015;61:67 Eur Heart J 2015;36:2745
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Water in hospitals
Water for consumption Decontamination Drinking water Washer-disinfectors Ice machines Endoscope washers Food preparation Dish washing Water dispensers Ultrasound baths Bottled water Bed washing machines
Personal hygiene Equipment Hand washing Dialysis machines Tooth brushing Dental units Showers/baths Nebulizers/humidifiers Whirlpool footbaths Water baths Toilet flushing
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Water in hospitals
Pools Hydrotherapy Birthing pools
Building services Cooling towers Evaporative condensors Humidifiers
Other Fountains Water features Fire systems Irrigation
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Water safety plan
A formal process to identify and manage risk
To provide a safe environments for users of the building and Provide demonstrable reassurance to: Regulators Users
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Steps in developing av water safety plan (WHO)
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Water safety plan (WHO)
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Health based targets
Need to decide on extent of concern
Targets set by: Government/Competent Authority User Vulnerability
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Example of risk categorisation
Risk Category In patients Outpatients
Very Immunocompromised Haematology Haematology high patients Transplantation Transplantation Oncology Oncology High Pasients with several Intensive care wo. Endoscopy serious disorders transplant patients Broncoscopy Operating theatres Day surgery Medium General medical and Medical wards Generelle surgical patients Surgical wards pasientarealer Low No patients Administrative Administrative functions functions
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Health based targets Need to consider the extent of the asset/facilities within the building
Drinking Water Domestic Water Hydrotherapy Pools Water Features Cooling Towers Dental Chairs Endoscope Washers Washer Disinfectors
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Health based targets
For each identified assets need to understand:
The relevant challenge organism(s)
Safe operational levels
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Water safety plan framework
Have a system in place to manage the risk Understand the risk posed your building/asset on the users Continually monitor the conditions known to influence the risk React to problems Demonstrate everything with records Show staff involved are trained Validate activity
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Management of risk
Successful implementation and operation of a Water Safety Plan requires suitable management and communication
All co-ordinated by a Water safety team
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Water safety team
Members of the team should have a thorough understanding of the systems in question: Engineers Infection Control Microbiology Clinical Specialists External Specialists
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Management of risk
It is important to identify all participants involved in the process of risk management
Generally referred to as stakeholders
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Stakeholders
Hospital Director Estates Director Infection Control Estates Staff Clinical Staff External Contractors
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Management and communication
Management Tree Include all stakeholders
Roles and Responsibility For each stakeholder
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Management and communication
The Water Safety Plan should include written details of:
All processes to be used Consistency Transparency Escalation procedures Procedures for communicating with other parties
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Assessment of risk
For each system/identified asset
1) Assess the system Describe it Create a drawing of it
2) Carry out an analysis of risk
3) Consider steps required to reduce the risk
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Assessment of risk
The outcome of the assessment should:
Be used to create an action plan to address any issue identified by the assessment
The foundation for the implementation of a monitoring/control programme
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Asessment of risk
Identify Control Measures Identify the means by which risks may be controlled
Monitor Control Measures Define the limits of acceptable performance and how these are monitored
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Monitoring
Control measures must support:
Health based targets
Identified elements within the risk assessment
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Monitoring
The processes employed should be validated
Observation/Inspections
Measurement of critical parameters Temperature Disinfectant levels
Microbiological testing
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Monitoring
Ensure staff/external contractors are capable of carrying out the identified tasks
Maintain a record
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Surveillance
The Water Safety Plan should have a system whereby its effectiveness is measured:
Internal Audit
External Audit
Independent review of the system(s) assessment
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Steps to success
Create a Water Safety Team
Identify all asset where water is present
Apply health based targets
Assess risk
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Steps to success
Create a Water Safety Plan Identify management process Assign Roles and Responsibilities Catalogue monitoring processes Create escalation procedures
Employ audit process to validate
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Temperature
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Temperature control
Minimum 60 o C in water outgoing from calorifier
Minimum 50 o C within one minute flushing of outlets in the periphery
Cold water below 20 o C
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas D-value for Legionella Thermostatic mixing valves
Inhibits flushing with hot water (to avoid scalding)
Promotes growt of Legionella
Should only be used in connection with whole body immersion (showers and bath tubs)
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Water usage
- no water is worse than still water !
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Flush all low use outlets at least twice weekly
in augmented units fliush daily
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Best practice relating to handwash stations
Do not dispose of body fluids at the wash- hand basin – use the dirty utility area Do not wash any patient equipment in wash-hand basins Do not use wash-hand basins for storing used equipment awaiting decontamination
Source: NHS, UK Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Best practice relating to handwash stations contd.
Taps should be cleaned before the rest of the handbasin Wash patients, including neonates, on augmented care units with water from outlets demonstrated by risk assessment and if necessary by water samling as safe Do not dispose of used environmental cleaning fluids at wash-hand basins
Source: NHS, UK Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Alcoholic hand disinfection has some potential drawbacks
Can significantly reduce water usage, thereby increasing the risk of stagnant water and the risk of waterborne infections
Can alcohol vapour provide nutritients (carbon) for P. aeruginosa to grow in adjacent taps?
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Avoid deadlegs
– they are deadly
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Systematic risk assessment - dead legs
Sinks removed
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Risk assessment
Low use outlets
Eye washer
Emegency shower
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Water from dispenser
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Electronic faucets/non-touch fittings
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas 5 patients with bacteremia during 6 months An electronic faucet was the source
Livni G et al. J Hosp Infect 2008;70:253 Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Electronic faucets were more frequently contaminated with Legionella species and other bacteria and were less likely to be disinfected after chlorine dioxide remediation Point of use filters
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Unfiltered water samples grew P. aeruginosa (2/4) and S. maltophilia (1/4). No growth in filtered water samples. Infections per 100 patient days
Filtrering Total Gram neg. bacilli No 1,4 0,4 Yes 0,18 0,09
Oslo University Hospital Transpl Infect DiseaseDepartment 2010;12:238 of Infection Prevention 03/2016 Egil Lingaas Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas … but point of use filteres reduces water flow and can contribute to build-up og biofilm and Legionella behind the filter
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Hemodialysis
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Dialysis machine
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Water for hemodialysys
Produced on site Mixed with dialysis concentrate Chemical and microbiological specifications Regulated by European pharmacopeia Defined as a medical device or drug depending on country
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Exposure to water during hemodialysis
A hemodialysys patient is exposed to 25 times more water in each treatment than an average person drinks per day.
In contrast to the mucous membranes of the gut, a dialysis membrane only partly protects against influx of chemical and microbiological contaminants in drinking water.
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas ”The device from hell”
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Final rinse water (1) EN ISO 15883-2/6.3 og 6.12.4 EN ISO 15883-1/6.4.2.4
At least 2 x 100 ml
Recommended as part of type testing and operational qualification, and at least yearly (weekly in the beginning)
Total viable count (TVC) per 100 ml
Absence of P. aeruginosa, legionellae and mycobacteria. Microbiological testing of final rinse water
NS EN ISO 15883-4
< 10cfu / 100ml acceptable
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas Final rinse water (UK)
Final rinse water for invasive endoscopes should be ”free from bacteria”
Weekly test of 2 x 100 ml rinse water: no microorganisms
Yearly test for mycobacteria Weekly testing of final rinse water
TVC, cfu/100ml Judgement <1 Satisfactory
1 -9 Acceptable
10 -100 Unsatisfactory
>100 Not acceptable
When TVC > 10/100ml: dominating colonies should be identified Thank you for listening
Oslo University Hospital Department of Infection Prevention 03/2016 Egil Lingaas