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 Safe Water for Patient Care
  Safe Water for Patient Care

Clinical Problem
Contamination of the water supply with potentially pathogenic organisms is very common.

Bacteria, fungi and protozoa in the water supply can be pathogenic. Common bacterial pathogens include Legionella species, Pseudomonas aeruginosa and some mycobacteria. Some water-borne protozoa such as the spore-forming Cryptosporidium are also pathogenic1 and some non-pathogenic protozoa support the growth of bacterial pathogens such as Legionella species.

Many water-borne microorganisms are "opportunistic pathogens" that would not cause serious disease in healthy individuals, but can establish infections in susceptible people.

Hospital water supplies are also frequently contaminated with pathogens. In one study2, almost half of the water outlets in transplant units were found to be contaminated with Legionella species. Hot and cold water supplies were tested in sixty-nine of the eighty-one transplant units in the UK:

Figure 1. Contamination of water supply outlets in transplant units

The presence of Legionella pneumophila in shower fixtures across the United States has been documented.27 In three hospitals studied, isolates of the bacteria from shower heads were found to be from the same serogroups as those causing nosocomial Legionnaires’ disease in susceptible patients. The hospitals’ potable water systems were suspected to be the source of L. pneumophila contamination.

A recent survey in the US found five out of six hospitals in one area had Legionella species in the water supply.5 Twelve of the previously unidentified cases of nosocomial legionnaires’ disease were found to have occurred in three of the hospitals where contamination was identified. The CDC noted 23% of all Legionnaires’ disease reported in the US during the 1980’s were hospital-acquired and that the 40% mortality rate was twice as high as that for community-acquired cases.6

Under certain conditions, microorganisms can grow in water supply systems. Water temperatures at 30 - 40 °C in dead end pipe segments provide optimal growth conditions for some species of waterborne pathogens. Under these circumstances high concentrations of microorganisms such as Legionella spp. and Pseudomonas spp. may be found in tap water. Some of these organisms may pose a threat to even healthy individuals.2-4

For severely ill or immunocompromised patients even low concentrations of opportunistic or pathogenic bacteria in tap water may result in life threatening infections. Highest hygienic standards must also be applied to water used in the rinsing of medical instruments (i.e., endoscopes) which are used internally.13,18


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Patient Protection
There is a higher risk of infection due to waterborne organisms for certain patient groups.

Transplant recipients, critically ill patients, neonates, and individuals with aquired immunodeficiency syndrome (AIDS) are most at risk of infection from environmental sources of microbial contamination. In a Chicago hospital, Pseudomonas aeruginosa was found to be a significant pathogen only for patients with compromised immune systems such as oncology patients.28 This study also confirmed that while 10% of the patients admitted to the unit were colonized on admission, 10% acquired P. aeruginosa during their hospital stay.

Table 1. Nosocomial Pseudomonas aeruginosa
infections traced to contaminated water7-10

Patients
involved		 Site of
infection		 Source
suggested		 Reference
27, neurosurgery Various Water supply 7
9, burns Septicaemia, burns Irrigation water used in ER 8
3, burns Septicaemia, burns Water used in hydrotherapy 9
3, neonates Various Taps and sinks 10

Legionella pneumophila is a well-known waterborne pathogen and there are numerous reports of outbreaks in hospitals.3-5,11-27 Inhalation of contaminated aerosols from air conditioning units and showers is not the only route of transmission; thirteen cases of Legionnaires’ disease were traced to contaminated water used to wash nebulisers13 and one case in an intensive care unit was traced to a contaminated ice machine.14

Another outbreak involved thirteen patients in a renal transplant unit where there were no air conditioning units or showers; the microbe was believed to bedispersed by aerosols from ordinary taps.15 Fatal respiratory distress developed following Legionella pneumonia in a premature infant, where the water in the neonatal unit was found to be contaminated with the same strain of the organism.16

Table 2. Nosocomial Legionella infections
traced to contaminated water13-17

Patients
involved		 Site of
infection		 Source
suggested		 Reference
13, respiratory care Lung Water used to wash nebulisers 13
1, intensive care Lung Ice machine 14
13, renal transplant Lung Aerosol from taps 15
1, neonate Lung Water supply 16
4, cardiac surgery Sternal wound Water used to bathe wound 17


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Filtration Solution

Point of use protection is critical.

The Pall-Aquasafe™ Water Filter can be attached to water taps and shower heads to remove inadvertent microbial contamination from water.

Containing 0.2 µm Posidyne® membrane, the Pall-Aquasafe Water Filter can prevent the passage of bacteria and is effective in preventing bacterial breakthrough and reducing endotoxin levels. This membrane is incorporated in other filters from Pall Corporation for use in the pharmaceutical industry, where it has met the standards for sterilizing filtration of parenteral solutions.29,30,31


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Summary
Clinical Problem:
  • Contamination of the water supply with potentially pathogenic organisms is common.
  • Hospital water supplies are also frequently contaminated with pathogens.
Patient Protection Issues:
  • There is a higher risk of infection due to waterborne organisms for certain patient groups.
  • Contamination of medical instruments with waterborne microbes is a potential route of infection.
  • There is a risk of false diagnosis from samples collected by medical instruments contaminated with waterborne organisms.
  • Normal methods of water treatment may not effectively remove pathogens from the water supply.
Filtration Solution:
  • Point-of-use filtration can provide microbiologically clean water for topical applications, instrument rinsing, and patient consumption, conveniently and economically.

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References
  1. UK Public Health Laboratory Service data
  2. WJ Patterson et al. Colonization of transplant unit water supplies with Legionella and protozoa: precautions required to reduce the risk of legionellosis. J Hospital Infection 1997;37:7-17 and 259-260.
  3. J Darelid et al. An outbreak of Legionnaires’ Disease in a Swedish hospital. Scandinavian J Infectious Disease 1994;26:417-425.
  4. TJ Marrie et al. Each water outlet is a unique ecological niche for Legionella pneumophila. Epidemiology Infection 1992;108:261-270.
  5. AM Goetz et al. Nosocomial Legionnaires’ Disease discovered in community hospitals following cultures of the water system: seek and ye shall find. American J Infection Control 1998;26:8-11.
  6. CDC Editorial note on Transmission of nosocomial Legionnaires’ Disease.J American Medical Assoc 1997;277:1927-8
  7. F Bert et al. Multi-resistant Pseudomonas aeruginosa outbreak associated with contaminated tap water in a neurosurgery intensive care unit.J Hospital Infection 1998;39:53-62.
  8. HJ Kolmos et al. Outbreak of infection in a burns unit due to Pseudomonas aeruginosa originating from contaminated tubing used for irrigation of patients. J Hospital Infection 1993;24:11-21.
  9. EE Tredget et al. Epidemiology of infections with Pseudomonas aeruginosa in burns patients: the role of hydrotherapy. Clinical Infectious Diseases 1992;15:941-949.
  10. H Grundman et al. Pseudomonas aeruginosa in a neonatal intensive care unit: reservoirs and ecology of the nosocomial pathogen. J Infectious Diseases 1993;168:943-947
  11. PC Luck et al. Nosocomial pneumonia caused by three genetically different strains of Legionella pneumophila and detection of these strains in the hospital water supply. J Clinical Microbiology 1998;36:1160-1163.
  12. C Kiosh et al. Transmission of nosocomial Legionnaires’ Disease. J American Medical Assoc 1997;277:1927-8
  13. TD Mastro et al. Nosocomial Legionnaires’ Disease and the use of medication nebulizers. J Infectious Diseases 1991;163:667-671.
  14. PS Graman et al. Nosocomial legionellosis traced to a contaminated ice machine. Infection Control & Hospital Epidemiology 1997: 18:637-640.
  15. F Allerberger et al. Nosokomiale Legionellenpneumonia bei Nierentranplantieren in Innsbruck. Krankenhaus-Hygeine + Infection 1993;15:43-47.
  16. PC Luck et al. Analysis of Legionella pneumophila strains associated with nosocomial pneumonia in a neonatal intensive care unit. Eur J Clinical Microbiology Infectious Disease 1994;13:565-571.
  17. PW Lowry et al. A cluster of Legionella sternal-wound infections due to postoperative topical exposure to contaminated tap water. New England J Medicine 1991;324:109-113.
  18. A Dorozynski. Poor sterilisation of instruments leads to infection outbreak in Paris. British Medical Journal 1997;315:699.
  19. DH Mitchell et al. Pseudoepidemic of Legionella pneumophila serogroup 6 associated with contaminated bronchoscopes. J Hospital Infection 1997;37:19-23.
  20. JGH Gubler et al. Pseudoepidemic of non-tuberculous mycobacteria due to a contaminated bronchoscope cleaning machine. Chest 1992;101:1245-1249.
  21. K Nye et al. Mycobacterium chelonae isolation from broncho-alveolar lavage fluids and its implications. J Hospital Infection 1990;16:257-261.
  22. TM Stine et al. A pseudoepidemic due to atypical mycobacteria in a hospital water supply. J American Medical Association 1987;258:809-811.
  23. ST Goldstein et al. Cryptosporidiosis: an outbreak associated with drinking water despite state-of-the-art water treatment. Annals Internal Medicine 1996;124:459-468.
  24. G Phillips et al. Experience with a chlorine dioxide dosing system for Legionella control. J Hospital Infection 1998;40 (Supp A):P9.5.6.
  25. MC Vos et al. Eradicating Legionella from hospital water distribution systems: experience with a search and destroy strategy. J Hospital Infection 1998;40(SuppA):P9.5.9.
  26. WU Farber et al. Untersuchungen von Sterilfiltrationssystemen bezuglich Abscheideleistung und Verlauf der retrograden Kontamination bei unterscheidlichen Sterilisationszyklen unter Belastung mit Legionella pneumophila. Krankenhaus-Hygeine + Infect. verh. 1995;17:174-179.
  27. Cordes et al. Isolation of Legionella pneumophila from Hospital Shower Heads. Annals of Internal Medicine 1981;94: 195-197
  28. Griffith et al, The Epidemiology of Pseudomonas aeruginosa in Oncology Patients in a General Hospital. The Journal of Infectious Diseases Vol. 160, No. 6, December 1989
  29. Food and Drug Administration, “Guideline on sterile drug products produced by aseptic processing”, Center for Drugs and Biologics, Division of Manufacturing and Product Quality ( HFN-320 ), Office of Compliance, FDA, Rockville, MD, (1987)
  30. American Society for Testing and Materials (ASTM), “Standard test method for determining bacterial retention of membrane filters used for liquid filtration,” ASTM Standard F838-83 ( Re-approved 1993 ), ASTM, Philadelphia, PA, (1983)
  31. Health Industry Manufacturers Association, “Microbiological evaluation of filters for sterilizing liquids”, HIMA Document 3, Volume 4, Washington, DC (1982)

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