Infection Control Today

MAR 2019

ICT delivers to infection preventionists & their colleagues in the operating room, sterile processing/central sterile, environmental services & materials management, timely & relevant news, trends & information impacting the profession & the industry

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17 March 2019 ICT Sinks: Some studies demonstrate a transmission link between a colonized sink and infected patients. Gram-negative bacilli can survive wet environments, including sinks, for as long as 250 days. Transmission can be caused by splashing of water droplet from contaminated sinks to hands of healthcare personnel, followed by transient colonization of hands. • Use separate sinks for handwashing and disposal of contaminated fuids • Decontaminate or eliminate sinks as a reservoir if epidemic spread of gram-negative bacteria via sinks is suspected Faucet aerators may serve as a platform for accumulation of waterborne pathogens • Routine screening and disinfection or permanent removal of all aerators are not warranted at present • For Legionella outbreak s, clean and disinfec t faucet aerator s in high-risk patient areas periodically or consider removing them in the case of additional infections Showers: Some outbreaks are linked to contaminated shower heads or inhalation of aerosols • Prohibit use of showers in neutropenic patients • Control Legionella colonization of potable water Ice and ice machines: Patients can acquire pathogens by sucking on ice, ingesting iced drinks, or use of contaminated ices for cooling medical procedure and patients' skin • Do not handle ice by hand • Do not store pharmaceuticals or medical solutions on ice for consumption • Use automatic dispenser rather than open chest storage compartments in patient areas • Clean and disinfect ice-storage chests regularly • Meaningful microbial standards for ice and ice machines do not exist • Routine culturing of ice machines are not recommended • A regular disinfection program for ice machines is recommended • Eyewash stations: Stationary and portable eyewash stations may not be used for months or years, and the water source may stand in the incoming pipes at room temperature for a long period • Use sterile water for eye flush or regularly (such as monthly) flush eyewash stations Bathing, tub immersion, and hydro- therapy can cause cross-transmission, transmission from environmental reservoirs, or auto-transmission • Consider routine cleaning, disinfection, and changing of water in water baths • Add germicide to water bath or use plastic overwrap of blood products and keep the surfaces dry Electronic faucets are likely to be contaminated by several waterborne pathogens than handle-operated faucets • Electronic faucets need to be designed so that they do not promote the growth of microorganisms • No guideline (but some authors have recommended) to remove electronic faucets from high-risk patient-care areas • Some studies have recommended periodic monitoring of water samples for growth of Legionella. Decorative water wall fountains have been associated with some Legionella pneumonia cases • Avoid ins t allation, esp e cially in healthcare facilities serving immuno- compromised patients or in areas caring for high-risk patients • P e r fo r m mainte nan ce re gular l y and monitor water safety strictly unless removed Risk Assessment and Management Regarding the key elements of a risk identifcation and reduction strategy based on current guidelines and recommendations, Keane emphasizes that the healthcare institution's engineering department must take ownership of building water systems. "If infection preventionists (IPs) try to take ownership of the engineering aspects, the results may be very high costs and low risk reduction," he says. "IPs just don't have the knowledge base to address issues related to building water systems. Instead, they should review plans and provide oversight to the overall plan, make sure engineering complies with the CDC Toolkit, ASHRAE 188 and ASHRAE Guideline 12, making sure that engineering takes the lead on plan development for the hospital water systems." Keane continues, "If the facility wants to hire a consultant to assist in plan development, I strongly recommend hiring an engineer that is a building water system expert who specializes in risk management for building water systems. There are lots of salesman out there selling services for legionella risk management, so the best thing to do is to hire someone who can provide a good engineering audit of your systems, identify root cause problems if any exist, implement most cost-effective solutions and then — and only then — fnalize any type of risk management plan, including treatment, testing, monitoring, etc. If you hire a water treatment company to do your plan, likely the result will be to buy their chemicals and if you hire someone that provides testing services then you are likely to be paying for a lot of testing. I disagree with CDC on some of their positions on this issue but one document they produced that offers good direction is titled Considerations When Working with Legionella Consultants." In that document, the CDC makes the following recommendations regarding factors to discuss with consultants: • Level of experience: For example, what kind of Legionella-specifc experience do the employees of this company have? Do the employees have appro- priate training in critical felds (e.g., engineering, environmental health or industrial hygiene, water treatment, plumbing, microbiology)? Does the company have Legionella-specific experience with a facility of your size/type? Do they have experience with water system remediation, implementation of water management programs to prevent Legionnaires' disease, or both? • Laboratory expertise: For example, is the laboratory they use accredited for environmental testing? Does it participate in a proficiency testing program for Legionella? Does their laboratory perform culture for Legionella (which is particularly important following remediation to ensure adequacy of the remediation process)? What level of identifcation (species/serogroup) can their laboratory perform? Is their laboratory willing to save samples and isolates and share them with public health laboratories if requested during an outbreak investigation? • Environmental assessment expertise: For example, how much experience does the company have with environmental assessments and /or sampling for Legionella? Can they describe situations where they performed an environmental assessment and/or Legionella sampling in a facility of your size/type?

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