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 60 50 40 Publications on Legionella and “hospital” (medline) last 20 years 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 N = 680 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