Pseudomonas aeruginosaPseudomonas aeruginosa and hospital water and hospital water systemssystems
Dr Chinari P K SubudhiConsultant Microbiologist & Clinical LeadSalford Royal Hospital
Outbreaks of Outbreaks of P. P. aeruginosaaeruginosaIntensive care units
Neonatal intensive care units
Burns units
Haematology units
Premature babies in NICUPremature babies in NICUVery susceptible to infection with P.aeruginosa
Immature immune system
Immature and delicate skin – can be damaged and infected easily
Presence of devices i.e ventilation, catheters, etc increase the risk of colonisation and infection
Incubator – humid environment – favourable for P. aeruginosa to thrive
Water - reservoir or Water - reservoir or vehiclevehicleMoist environment and aqueous
solutions in health care settings have potential to serve as reservoirs for water borne organisms
Favourable circumstances eg., temperature, presence of source of nutrition, etc – can facilitate active growth of organisms or they remain for long periods in highly stable and resistant forms
Water – point source Water – point source outbreaksoutbreaksContaminated water baths
Humidifying equipment for ventilators
Taps and sink drains
Feeding bottles
Mineral water bottle
Water borne infections – Modes of Water borne infections – Modes of transmissiontransmissionDirect contact (eg. hydrotherapy pool)
Ingestion of water (eg. consuming contaminated ice)
Indirect contact transmission (eg. contaminated hands, devices, equipment, surfaces etc)
Inhalation of aerosols dispersed from water sources i.e. from fountains, showers, cooling towers, air-conditioning units
Aspiration of contaminated water
Water borne bacterial agents causing Water borne bacterial agents causing infections or outbreaks in health care infections or outbreaks in health care facilitiesfacilities
Legionella sp.
Pseudomonas aeruginosa
Other Gram negative bacteria – Pseudomonas sp, Burkholderia cepacia, Ralstonia picketii, Stenotrophomonas maltophila, Sphingomonas sp, Acinetobacter sp, Enterobacter sp, Serratia sp.
Nontuberculous mycobacteria
Pseudomonas aeruginosaPseudomonas aeruginosa
Commonly found in soil, water and plants
Can colonise healthy humans and animals
Tolerant to temperature as high as 45°C to 50°C
Can produce a biofilm which creates a protective layer when it grows in the water system
Opportunistic pathogen – more likely to infect those who are already very sick or vulnerable
Relatively resistant to many antibiotics
Pseudomonas aeruginosaPseudomonas aeruginosa (culture)(culture)
Habitat of Habitat of P.aeruginosaP.aeruginosa in in hospitalshospitalsCan colonise moist surfaces of patients
on axilla, ear, perineum, wounds, etc
Can be isolated from other moist, inanimate environments including water in sinks and drains, toilets and showers
Hospital equipment that comes in contact with water such as mops, respiratory ventilators, cleaning solutions and food and food processing machines, can be source
PseudomonasPseudomonas and water and water systemssystems
Water systems frequently colonised with Pseudomonas with biofilms developing in pipework, taps and U bends when there is a source of carbon for growth
Insufficient temperature favours growth – below 55°C in hot water pipes and above 20°C in cold water pipes
Stagnant water in system if taps are not used or flushed regularly
Secondary contamination of taps and sinks because of inappropriate infection control practices
Human carriage of Human carriage of P. P. aeruginosaaeruginosaUp to 7% of healthy humans carry in
throat, nasal mucosa or on the skin
Faecal carriage rates – 15% to 25% reported, higher in vegetarians
Dies rapidly on dry human skin
Survives well in moist or superhydrated skin
Examples of community Examples of community acquired infections due to acquired infections due to P. P. aeruginosaaeruginosa
Skin infections – Folliculitis - related to use of hot tubs, whirlpools, swimming pools, other baths; Toe web rot in soldiers – interdigital space between the toes
Eye infection in contact lens wearers (extended wear variety) – Ulcerative keratitis – because of contamination of the contact lens solutions
Ear infections – Otitis externa (Swimmer’s ear)
Respiratory tract infections – Cystic fibrosis, Bronchiectasis
Hot tub folliculitisHot tub folliculitis
Health care associated infections (HCAI) – Health care associated infections (HCAI) – P. aeruginosaP. aeruginosa
Ventilator associated pneumonia
Hospital acquired pneumonia
Urinary tract infections – catheter associated
Wound infections – eg. burns, ulcers, exit sites
Bacteremia
Patient on mechanical Patient on mechanical ventilationventilation
Department of Health, March Department of Health, March 20122012 Water sources and potential Pseudomonas
aeruginosa contamination of taps and water systems Advice for augmented care units
Previous guidance issued by CMO in August 2010 & February 2012 as “Dear Colleague” letters
Best practice technical guidance to reduce risk to patients and recommendations to establish systems to monitor, prevent and control infections
Intended for professionals engaged in infection prevention and control, estates and facilities and the Responsible person (Water)
Advice to health care Advice to health care providersproviders
Assessing risk to patients if water systems become contaminated with P.aeruginosa or other pathogens
What actions to take if water systems become contaminated with P.aeruginosa
Protocol for sampling, testing and monitoring water for P.aeruginosa
Developing local water safety plans
Risk assessment Risk assessment
Should be undertaken to identify actions to mitigate risks by June 2012
To ensure appropriate sampling, monitoring and clinical surveillance arrangements are being implemented and adhered to
To undertake appropriate water sampling by end of 2012 where required
Water Safety Group Water Safety Group A multi-disciplinary group to undertake risk assessment and
management of water safety issues
Identification of microbiological hazards, assessing risks, identifies and monitors control measures and develop incident protocols
Can be a sub-group of the hospital’s Infection control committee
Accountable to DIPC
Comprising:◦ Infection prevention and control team◦ Consultant Medical Microbiologist◦ Estates and Facilities◦ Senior nurses from relevant augmented care units◦ Hotel / cleaning services◦ Director of infection prevention and control (DIPC)
Risk assessment in Risk assessment in hospitalshospitalsLocal risk assessment required for
identification of vulnerable patient groups
Case mix and patient susceptibility varies between units
Risk assessment of environment and practices
For incorporating appropriate preventative measures and monitoring arrangements
Augmented care unitsAugmented care unitsCritical Care areas – Adult ICU,
Pediatric ICU, Neonatal ICUHigh Dependency unitsBurns unitsTransplant UnitsHaematology – Oncology wardsRenal units / wards
Hospital water systems and patient Hospital water systems and patient safetysafety
Correct maintenance of hot and cold water supply systems
Continuous delivery of microbiologically safe water
Effective management and operation throughout the water supply and distribution system
Role of Infection prevention and Role of Infection prevention and control teamscontrol teams
Ensure application of and compliance with appropriate guidelines to prevent HCAI
Ensure best practice advice relating to hand wash stations is followed to minimise risk of P.aeruginosa contamination
Continue to monitor clinical isolates of P.aeruginosa as an alert organism
To be aware of possible outbreaks of infection with P.aeruginosa
Hand wash stations – Best Hand wash stations – Best practicepracticeONLY FOR HANDWASHING
No disposal of body fluidsNo disposal of used environmental cleaning
fluidsNo washing of patient equipmentNo storing of used equipment awaiting
decontaminationTaps should be cleaned before the rest of
the handbasin (NHS Cleaning manual)Washing patients with water from outlets
demonstrated to be safe
Flushing tapsFlushing tapsHTM 04-01 Part B, Chapter 5
All taps that are infrequently used – to be flushed regularly manually – at least daily in the morning for 1 minute
Some taps can be programmed to flush automatically, such flushing could be recorded on the building management system
Keep a record of when the taps were flushed
Wash hand stations – problems / Wash hand stations – problems / concernsconcernsIdentify any problems or concern
relating to safety, maintenance and cleaning of wash hand stations to
◦Infection Prevention & Control Team◦Estates◦Facilities Department◦Infection control committee – if there
are unresolved issues
Risk assessment - factors to Risk assessment - factors to considerconsiderSusceptibility of patient groups
Clinical practice and ongoing care of invasive devices
Cleaning of patient equipment
Engineering assessment of water systems – installation, commissioning and maintenance
Sampling and monitoring programme
Water safety plan (WSP) – Water safety plan (WSP) – LegionellaLegionella and and P.aeruginosaP.aeruginosaTo assist with understanding and
mitigating risks associated with bacterial contamination of water distribution and supply system
To provide a risk-management approach to the microbiological safety of water
To establish good practices in local water distribution and supply
WSPsWSPsWorking documents should be kept up to date
and to be reviewed annually
Responsible person (Water) should lead the development of WSP and will be responsible for it’s implementation
Complement the existing Operational management requirements of HTM 04-0
Complement the work that has to be undertaken to fulfill the statutory requirement for a Legionella risk assessment and written scheme for the control and management of Legionella
Protecting the patients when water Protecting the patients when water contamination problem is suspected / contamination problem is suspected / confirmedconfirmedUse water of a known satisfactory quality for
direct contact with patients – sterile, filtered or a contamination free source
Review water outlets / showers where there may be patient contact (direct / indirect)
Single use wipesSupplement hand washing with use of alcohol
hand rubRigorous adherence to infection control
practicesReview cleaning, storage and usage of patient
contact equipment
Remediation of water quality Remediation of water quality deliverydelivery
Check for underused outlets Assess water distribution system for non-metallic
materials eg. Flexible hose Assess water system for blind ends and dead legs Point of use filters, where they can be fitted –
regarded as a temporary measure Consider disinfection of hot and cold water
distribution system that supply the unit to treat the contaminated outlets
Ensure TMV providing the safe hot water is located as close to the tap / shower outlet as possible
Consider replacing contaminated taps with new taps – lack of evidence
Microbiological Microbiological investigationsinvestigations
Water sampling and testing protocol for P.aeruginosa
Pre-flush and post flush water samplesSwabbing – use sterile swab to take a sample of
the tap’s aerator / flow –straightener and spout’s metal collar
Microbiological typing – environmental and water samples to be sent to HPA LHCAI for molecular analysis of P. aeruginosa – ONLY if isolates have been confirmed as P. aeruginosa and possible epidemiological link to the outbreak strain under investigation
Comparison of typing results between clinical isolates and isolates from microbiological sampling of environment / water
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