Pseudomonas aeruginosa and hospital water systems

1. Pseudomonas aeruginosa and hospital water systems Dr Chinari P K Subudhi Consultant Microbiologist & Clinical Lead Salford Royal Hospital

3. Outbreaks of P. aeruginosa • Intensive care units • Neonatal intensive care units • Burns units • Haematology units

4. Premature babies in NICU • Very 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

6. Water - reservoir or vehicle • Moist 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

7. Water – point source outbreaks • Contaminated water baths • Humidifying equipment for ventilators • Taps and sink drains • Feeding bottles • Mineral water bottle

8. Water borne infections – Modes of transmission • Direct 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

9. Water borne bacterial agents causing infections or outbreaks in health care facilities • 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

10. Pseudomonas 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

11. Pseudomonas aeruginosa (culture)

12. Habitat of P.aeruginosa in hospitals • Can 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

13. Pseudomonas and water systems 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

14. Human carriage of P. aeruginosa • Up 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

15. Examples of community acquired infections due to P. aeruginosa • 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

16. Hot tub folliculitis

17. Health care associated infections (HCAI) – P. aeruginosa • Ventilator associated pneumonia • Hospital acquired pneumonia • Urinary tract infections – catheter associated • Wound infections – eg. burns, ulcers, exit sites • Bacteremia

19. Patient on mechanical ventilation

21. Department of Health, March 2012 • 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)

22. Advice to health care providers • 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

23. 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

24. 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)

25. Risk assessment in hospitals • Local 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

26. Augmented care units • Critical Care areas – Adult ICU, Pediatric ICU, Neonatal ICU • High Dependency units • Burns units • Transplant Units • Haematology – Oncology wards • Renal units / wards

27. Hospital water systems and patient safety • 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

28. Role of Infection prevention and control 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

29. Hand wash stations – Best practice • ONLY FOR HANDWASHING • No disposal of body fluids • No disposal of used environmental cleaning fluids • No washing of patient equipment • No storing of used equipment awaiting decontamination • Taps should be cleaned before the rest of the handbasin (NHS Cleaning manual) • Washing patients with water from outlets demonstrated to be safe

30. Flushing taps • HTM 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

31. Wash hand stations – problems / concerns • Identify 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

32. Risk assessment - factors to consider • Susceptibility 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

33. Water safety plan (WSP) – Legionella and P.aeruginosa • To 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

34. WSPs • Working 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

35. Protecting the patients when water contamination problem is suspected / confirmed • Use 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 wipes • Supplement hand washing with use of alcohol hand rub • Rigorous adherence to infection control practices • Review cleaning, storage and usage of patient contact equipment

36. Remediation of water quality delivery • 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

37. Microbiological investigations • Water sampling and testing protocol for P.aeruginosa • Pre-flush and post flush water samples • Swabbing – 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