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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19 March 2019 ICT The World Health Organization (WHO)'s Water Safety Plan contained in its Guidelines for Drinking Water Qualit y calls for a systematic risk assessment to be conducted, with special emphasis on the identifcation of relevant pathogens, knowledge of their infecting pathways (from source to patient), and their public health consequences. The following steps must be included: 1. Hazard identifcation 2. Exposure assessment 3. Dose-response assessment 4. Risk characterization combined with knowledge of ecologic criteria (identi- fcation of the source and reservoirs of waterborne pathogens in the distribution system) The development of a control strategy of waterborne pathogens must be based on two aspects: the reduction of the number of microbes that can harm the patient and the specifc protection of patients at high risk for infection. Spagnolo, et al. (2016) emphasize, "Only WSPs based on locally adapted interventions and continuous surveillance can effectively prevent such nosocomial infections as legionellosis. By providing safe water, proper implementation of the WSP ensures patient safety and reduces costs, in that waterborne infections increase morbidity, mortality, treatment costs and compensation claims, and prolong hospitalization. Exner, et al. (2005) say that prevention and control strategies to address waterborne pathogens in healthcare institutions should take into consideration the following points: • Because the association between waterborne pathogens and HAIs has not been well known until now, a strong education strategy will be essential to communicate new information to all people involved in water utilities, building architecture, hospitals, etc. • Clinicians, infection preventionists, risk managers, facilities engineers, and other professionals involved in healthcare must be aware of the fact that plumbing systems and water outlets are now regarded as important reservoirs of infection. • Complete prevention of the penetration of waterborne pathogens into the hospital water supply may be regarded as unattainable. However, the risk can be minimized by fltration and disinfection processes. • T h e ins t allat i o n of disinfe c t i o n s y s t e m s s u c h a s c o p p e r / s i l v e r ionization, chlorine dioxide, chlorine, and ultraviolet light irradiation may prevent the formation of bioflms but preventing bioflm formation is only attainable if these disinfection systems are placed into operation from the frst moment of water fow into the plumbing system. • If bioflms have developed in a hospital plumbing system, it appears to be very diffcult to subsequently bring their formation completely under control. • Strategies to prevent bioflm formation must be stringent. • An important strategic step in the control of waterborne pathogens is control of systemic contamination of the plumbing system. If systemic contamination by Legionella and other waterborne pathogens exists, it will not be possible to fush them from water outlets. • Much greater attention must be paid to the possible contamination of water outlets. Non-touch fttings in hospitals have been identified as possible sources of P aeruginosa and Legionella spp. This alarming situation must be controlled through the development of technical procedures to reduce and/or eliminate contamination of non-touch fttings. • The application of sterile point-of-use flters on faucets and shower heads has become a part of the infection control program not only for the prevention of Legionella but also of P. aeruginosa infections. • The discussion concerning whether to perform environmental cultures should be brought to conclusion in the near future. The purposes of environmental cultures are as follows: (1) to provide information about the status of the contamination of a plumbing system with different waterborne pathogens and (2) to permit verification and validation of the quality of the control measures applied. • In the case of systemic contamination from Legionella or P. aeruginosa, clinicians should be promptly informed that there is an infection risk which should be recognized. • Sur veillance for infec tions from Legionella, P. aeruginosa, and other waterborne pathogens is important. If there is a high incidence or an increase in infections attributable to these microorganisms, the water system must be considered as an infection reservoir, and control measures must be introduced. Knowing that waterborne infections are a viable threat, should hospitals go on the offense, or play defense when it comes to risk reduction. As Freije (2005) acknowledges, "The question is whether to take a proactive approach that aims to minimize pathogens in water systems or a reac tive approach that considers environmental measures only after disease is identifed. This issue must be considered for a given pathogen on the basis of severity of associated illness, sources of contamination, data on preventive measures, available detection and remedial technology, and legal issues. Hospitals should have a waterborne pathogens team that includes members from facilities management, infection control, risk management, administration, and the medical staff. The team should write a management plan that paints a clear picture of the overall risk reduction strategy and outlines detailed preventive measures for potable water systems and cooling towers, and then meet periodically to ensure that the plan is being implemented, to review results, and to consider revisions." References: Anaissie E, Penzak S and Dignani C. The hospital water supply as a source of nosocomial infections. Arch Intern Med, 162 (2002), pp. 1483-1492. ASHRAE Standard 188-2015: Legionellosis: Risk Management for Building Water Systems. June 26, 2015 Bartram J., Chartier Y., Lee J.V., Pond K., Surman-Lee S. Legionella and the Prevention of Legionellosis. World Health Organization; Geneva, Switzerland: 2007. Bentham R and Whiley H. Quantitative Microbial Risk Assessment and Opportunist Waterborne Infections: Are There Too Many Gaps to Fill? Int J Environ Res Public Health. 2018 Jun; 15(6):1150. Centers for Medicare and Medicaid Services (CMS). Center for Clinical Standards and Quality/Quality, Safety and Oversight Group Ref: QSO-17-30- Hospitals/CAHs/NHs. July 6, 2018. Exner M, Kramer A, Lajoie L, Gebel J, Engelhart S and Hartemann P. Prevention and control of healthcare-associated waterborne infections in healthcare facilities. Am J Infect Control. Vol. 33, No. 5. Supplement pages S26-S40. June 2005. Freije MR. Formulating a risk reduction strategy for waterborne pathogens in hospital water systems. Am J Infect Control. Vol. 33, No. 5. Supplement pages S26-S40. June 2005. Kanamori H, Weber DJ and Rutala WA. Healthcare Outbreaks Associated With a Water Reservoir and Infection Prevention Strategies. Clin Infect Dis. Vol. 62, No. 11. Pp. 1423-1435. June 2016. Spagnolo AM, Orlando P, Perdelli F and Cristina ML. Hospital water and prevention of waterborne infections. Reviews in Medical Microbiology: Vol. 27, No. 1. PP 25-32. January 2016

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