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Tracking the Spread Routes of Opportunistic Premise Plumbing Pathogens in a Haematology Unit with Water Points-Of-Use Protected by Antimicrobial filters S

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Tracking the Spread Routes of Opportunistic Premise Plumbing Pathogens in a Haematology Unit with Water Points-Of-Use Protected by Antimicrobial filters S Journal of Hospital Infection 98 (2018) 53e59 Available online at www.sciencedirect.com Journal of Hospital Infection journal homepage: www.elsevier.com/locate/jhin Tracking the spread routes of opportunistic premise plumbing pathogens in a haematology unit with water points-of-use protected by antimicrobial filters S. Baranovsky a,b, E. Jumas-Bilak a,b, A. Lotthe´ a,b, H. Marchandin b,c, S. Parer a,b, Y. Hicheri d, S. Romano-Bertrand a,b,* a De´partement d’Hygie`ne Hospitalie`re, CHU Montpellier, Montpellier, France b UMR5569 HydroSciences Montpellier, Equipe «Pathoge`nes Hydriques Sante´ Environnements», Faculte´ de Pharmacie, Montpellier, France c Laboratoire de Bacte´riologie CHU Nıˆmes, Nıˆmes, France d De´partement d’He´matologie Clinique, CHU Montpellier, Montpellier, France ARTICLE INFO SUMMARY Article history: Background: Water networks in hospitals are frequently contaminated by opportunistic Received 18 May 2017 premise plumbing pathogens (OPPPs) leading to installation of antimicrobial filters on Accepted 24 July 2017 water points-of-use (POU) in order to limit patients’ exposure. Available online 29 July 2017 Aim: To assess the spread of OPPPs through secondary water routes (outside the plumbing system) in an adult haematology unit in which 52 out of 73 water POU were high risk for Keywords: patients and protected by antimicrobial filters. Healthcare-associated infection Methods: An observational audit identified six secondary water routes for which bacteria Haematology tracking and typing were performed in 315 surface samplings. Bacterial isolates were Pseudomonas aeruginosa identified by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry Waterborne bacteria and compared to the infra-species level by multiplex repetitive element sequence-based Hospital water use polymerase chain reaction and/or by restriction fragment length polymorphism in pulse- Antimicrobial filter field gel electrophoresis. Findings: Pseudomonas aeruginosa and Stenotrophomonas maltophilia, as well as non- pathogenic OPPP indicators, were detected in water collected upstream of antimicro- bial filters. P. aeruginosa was the sole OPPP retrieved from tested surfaces (5.1%). The same clone of P. aeruginosa spread from water source to dry surfaces in the same room and cross-contaminated two sinks in different rooms. Three clones of non-pathogenic OPPP indicators spread more widely in different rooms. Conclusion: A strategy based on filtration of most (but not all) water POU in a haematology unit could be sufficient to limit the spread of OPPPs to the environment, provided a functional mapping of ‘high-risk’ POU has been undertaken. The residual spread of OPPPs and OPPP indicators linked to non-filtered water POU argues for careful monitoring of non- filtered water use. ª 2017 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved. * Corresponding author. Address: Centre Hospitalier Re´gional Universitaire de Montpellier Infection Control, 15 Avenue du Doyen Gaston Giraud, Montpellier, 34095, France. Tel.: þ33 617206545. E-mail address: [email protected] (S. Romano-Bertrand). http://dx.doi.org/10.1016/j.jhin.2017.07.028 0195-6701/ª 2017 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved. 54 S. Baranovsky et al. / Journal of Hospital Infection 98 (2018) 53e59 Introduction twice a day. The microbiological quality of the environment (surfaces, POU, and water) is surveyed twice a year. HCWs wear In hospitals, tap water is a central resource and its micro- scrubs and shoes dedicated to the AHU. Additional safety de- biological quality is critical because of its many uses: for pa- vices such as gloves or aprons are used occasionally according tient hygiene, healthcare workers’ (HCWs) handwashing, to the infection control (IC) recommendations. Previous IC hospital hygiene, but also for drug administration and for audits showed that AHU HCWs followed the IC rules closely, drinking. Hospital water networks are generally fed by with more than 80% of compliance with standard precautions. municipal water complying with drinking quality standards, but they do contain autochthonous bacteria, described as oppor- Reconstruction of secondary water routes tunistic premise plumbing pathogens (OPPPs); these bacteria may proliferate in water networks and cause healthcare- Between January and May 2015, in order to define secondary associated infections (HCAIs) in predisposed human pop- routes of water circulation from the plumbing system, HCWs ulations [1,2]. Among OPPPs, Pseudomonas aeruginosa and were observed and questioned on their care and cleaning Stenotrophomonas maltophilia are (frequently multidrug- practices regarding when, where, and for what they used wa- resistant) agents of HCAI and hospital outbreaks [3,4]. ter. A secondary water route was defined as beginning by an Disposable antimicrobial filters can be fixed on taps or action performed on a POU and ending in a patient’s bedroom. showers to protect patients from OPPP exposure. The effi- The different routes between beginning and end points were ciency of point-of-use (POU) filters to lower P. aeruginosa HCAI traced over a one-month period of observations. All surfaces in risk has been demonstrated [5,6]. However, leaks around fil- contact with water by wet hands or by splash (intermediary ters, filtering membrane saturation, and contamination of the points) were included as potentially contaminated by OPPPs filter surface are frequently observed [7]. In addition, for and hydric bacteria, and water routes were then mapped by budgetary reasons, only the ‘high-risk’ POU directly exposing retracing the circulation between each surface in contact with patients to OPPPs are generally equipped, i.e. tap and shower water (data not shown). in patients’ room, washbasin for particular care activities, or for HCW handwashing. In a hospital ward, secondary routes of Sampling, culture, and bacterial species identification water and OPPPs could originate from non-filtered water POU. In the haematology unit of the University Hospital of Mont- Dry and wet surfaces were sampled with sterile cotton pellier (France), tap water is chronically contaminated by swabs (Copan Diagnostics Inc., Murrieta, CA, USA). Swabs were P. aeruginosa. As immunocompromised patients are at high risk pre-incubated for 12 h at 37C in a soybean typticase broth for OPPP infections, water POU used for patient care is filtered (Difco, Bordeaux, France) before streaking on to MacConkey on this ward, but a few POU remain non-filtered. The objective and cetrimide agar media (Difco, Bordeaux, France), then of the study was to assess the effectiveness of water filtration incubated for 72 h at 37C in aerobic conditions. Volumes of in daily practice and to track secondary non-filtered water 250 mL water were collected in bottles containing sodium routes in the ward leading to the potential circulation of and thiosulfate (final concentration of 20 mg/L), filtered on to exposure to OPPPs. cellulose nitrate membrane of 0.45 mm porosity (Sartorius Stedim Biotech, Dourdan, France). The membranes were Methods incubated on cetrimide agar plates for 72 h at 30 C. Each growing colony was identified by matrix-assisted laser desorp- Settings tion/ionization time-of-flight mass spectrometry (MALDI-TOF MS) (Brucker, Champs sur Marne, France). The Adult Haematology Unit (AHU) of the University Hospital of Montpellier treats patients with acute haematological ma- Epidemiological survey of P. aeruginosa and lignancies, including before and after allogenic or autogenic S. maltophilia bacteraemia haematological stem cell transplant (HSCT). The 19 single bedrooms include a bathroom of 2.5 m2 with shower, wash- From January 2011 to May 2015, a period including the basin, and toilet. The whole unit has 73 water POU, including environmental study period, clinical isolates of P. aeruginosa 52 ‘high-risk POU’ defined by the infection control team and S. maltophilia from blood cultures in patients hospitalized (Figure 1) that are equipped with antimicrobial filters. Filters in AHU were prospectively collected. are made from polyethersulfone membrane with asymmetric pore structure (diameters from 0.001 to 20 mm) (Filtranios Infra-specific molecular typing 31DA, Anios, LilleeHellemmes, France). These 52 POU are taps and showers in patients’ rooms, washbasins used for healthcare Clinical or environmental isolates within same bacterial or for HCW handwashing. In housekeeping rooms, the patient species were genotyped by multiplex multiplex repetitive satellite kitchen, and in nurse tearoom, one tap in each room is element sequence-based polymerase chain reaction (rep-PCR) filtered and dedicated to high-risk practices. All filters are and pulsed-field gel electrophoresis (PFGE) after SpeI macro- changed monthly. restriction, in order to compare isolates and assess their Patient rooms are cleaned once a day: rooms occupied by a clonality [8,9]. P. aeruginosa strains isolated from bacteraemia patient are cleaned in the morning (using housekeeping room 1) were also characterized by multi-locus sequence typing to and unoccupied rooms are cleaned in the afternoon (using identify potential sequence type (ST) corresponding to high- housekeeping room 2). The nurse tearoom, patient satellite epidemic risk clones after comparison to pudMLST database kitchen, and the room for preparing chemotherapy are cleaned and published data [10]. S. Baranovsky et al. / Journal of Hospital Infection 98 (2018) 53e59 55 4 >10 >104 3 >104 >104
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