Due to their complex design and often considerable size, hospital water systems can harbor a multitude of pathogens and microorganisms. Amongst the most commonly found in healthcare water systems are gram-negative bacteria such as legionella, with other lesser known organisms such as mycobacteria, fungi and mould also present, if less abundant.
Water Safety Groups [WSG] need to be aware of the multiple water hygiene threats that could potentially colonise their water systems and result in dangerous bacterial outbreaks amongst vulnerable populations. Where there is a foreseeable risk from any one of a multitude of waterborne pathogens, then a suitable action plan including appropriate control measures must be put into place via the WSG. HTM04-01 provides a limited overview of possible potential waterborne pathogens, though whether this is adequate could be debated as the focus remains primarily on Legionella and P.aeruginosa.
Pathogens found within hospital water systems are highlighted as follows.
Legionella remains the most well-known bacteria present in healthcare water systems due to media attention and on-going management practices over many years. Significant Legionella contamination of a water system can result in people contracting Legionnaires’ disease [LD] - a form of atypical acute pneumonia. LD results in fever, muscle pain, nausea and can cause death if left untreated in the worst cases. Risks are dependent upon a combination factors including the bacteria being present in sufficient numbers, suitable conditions ie temps between 20°C and 45°C, a source of nutrients ie scale, corrosion etc., a means of disseminating aerosols and significantly in healthcare sites, the presence of people who have compromised immune or respiratory systems or other factors ie smoking, that increase their susceptibility to Legionella infection. Comprehensive guidance is present in the form of L8 and the associated HSG274 publications and particularly HTM04-01, updated during 2016.
In the UK the role of water in the transmission of Pseudomonas aeruginosa has come under particular scrutiny following the death of three infants in a Belfast hospital in 2012. It is has the potential to cause severe infections, especially in patients compromised by underlying disease, age or immune deficiency.ie the augmented care demographic found within many healthcare sites. P. aeruginosa has also shown resistance to antibiotics, and has a virulence which means it can thrive in varying environments and with varying levels of nutrients. Unlike Legionella, where the source of the bacteria ie the incoming water supply is clear, the origin of P.aeruginosa may be via the water system, and particularly within the last two metres before the point of discharge or via surface-to-surface contact, following washing hands in contaminated water, from surfaces contaminated with water or from contaminated equipment. Given this variety, the challenge for the WSG is to risk-assess operational practices in an attempt to minimise contamination from any of these sources.
HTM04-01 Parts B & C published in 2016, address P.aeruginosa in augmented care settings and stress the importance of the WSG and WSP in the routine management of this pathogen.
Stenotrophomonas infections have been associated with disease and mortality in severely immunocompromised and debilitated individuals. Whilst S. maltophilia is not a virulent organism, it is naturally resistant to many broad-spectrum antibiotics Risk factors associated with S.maltophilia infection include HIV infection, malignancy, cystic fibrosis, neutropenia, mechanical ventilation, central venous catheters, recent surgery, trauma, prolonged hospitalization and broad-spectrum antibiotic use. Robust infection control procedures will ensure spreading of the pathogen can be controlled.
Infection with Mycobacteria is very rare but can be fatal and these outbreaks usually involve sternal wound infections, plastic-surgery wound infections or post-injection abscesses but also in patients undergoing dialysis treatment. There are also significant concerns relating to contaminated heater cooler units [HCU] used in theatre during cardiothoracic surgery. The HCU function is to regulate the temperature of the blood perfusing the patient using water in the HCU tanks to indirectly raise or lower the patient’s body temperature. Whilst there have been no reported NHS cases since 2015, HCUs must be operated and decontaminated according to the manufacturer’s instructions, and conjunction with a risk assessment approved by the WSG.
Fusarium infection can affect both immunocompromised and healthy individuals, with the former being most at risk for complications and prolonged illness. That said, only a few of the many species are known to cause infection in humans.
Fusarium is present in water biofilms that can occur in healthcare settings and especially in large areas of little used pipework and large water storage vessels.
Aspergillosis infection is a rare but potentially harmful infection caused by the aspergillosis fungi. The infection is typically prevalent in the respiratory tract (meaning inhalation of the pathogen via aerosol can cause infection.) Again immunocompromised people are at high risk from prolonged illness and complications if infected.
Other pathogens of concern in hospital water systems
Waterborne outbreaks or clusters have also been seen in recent years throughout Europe for a multitude of pathogens, including Rotavirus, Cryptosporidium, Norovirus, Campylobacter, Giardia and others. Guidance within the UK may be limited to infection control practices and lesser known bacteria are not typically discussed within Water Hygiene forums.
WSG’s have many factors to consider when addressing water hygiene in their buildings, and issues and responsibilities relating to less well known waterborne pathogens are perhaps not yet fully evident. However, we should be optimistic in dealing with the myriad of other bacteria which inhabit our water systems. Great strides continue to be made in the management of Legionella and P.aeruginosa and our findings should be used to aid the development of robust methods and useable guidance in the risk minimisation of ‘other bacteria’ within our water systems.
Editors Note: The information provided in this blog is correct at date of original publication - August 2017.
© Water Hygiene Centre 2019