PREVENTION AND CONTROL OF HEALTHCARE-ASSOCIATED WATERBORNE INFECTIONS IN HEALTHCARE FACILITIES MICROBIAL RISK MANAGEMENT IN HOSPITAL WATER SYSTEMS

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1 PREVENTION AND CONTROL OF HEALTHCARE-ASSOCIATED WATERBORNE INFECTIONS IN HEALTHCARE FACILITIES M. EXNER 1, A. KRAMER 2, L. LAJOIE 1, J. GEBEL 1, S. ENGELHART 1, P. HARTEMANN 3 1. Institute for Hygiene and Public Health, University of Bonn,Sigmund-Freud- Str. 25 D Bonn, Germany 2. Institute for Hygiene and Environmental Medicine, University of Greifswald, Walther-Rathenau-Str. 49a, D Greifswald, Germany 3. Université de Nancy, Département Environment et Santé Publique, 9, avenue de la Forêt, F-5400 Vandœuvre Cedex ABSTRACT This is a review of the public health risks attributable to waterborne pathogens in healthcare. The consequences of healthcare-associated infections (HAIs) are discussed. Not only are Legionella spp. involved in HAIs, but also Pseudomonas aeruginosa, other Gramnegative microorganisms, fungi and amoebae-associated bacteria. This is particularly noteworthy among immunocompromised patients. New prevention strategies and control measures brought about through advanced planning, facility remodelling and reconstruction, disinfection, and filtration have resulted in a significant reduction of the incidence of waterborne HAIs. The positive consequences of a comprehensive multi-barrier approach including prevention and control programs in healthcare facilities are discussed. Environmental cultures are now integrated within the infection control program of some European countries. In high-risk areas, the application of disposable point-of-use sterile filters for faucets and shower heads appears to be the practice of choice to efficiently control waterborne pathogens and to prevent infections. Key words: waterborne pathogens - healthcare-associated infections - Legionella - Pseudomonas aeruginosa - other Gram-negative bacteria - waterborne infection - nontuberculous mycobacteria - aspergillus - amoeba-associated bacteria - amoeba-resistant microorganisms - disinfection - biofilms MICROBIAL RISK MANAGEMENT IN HOSPITAL WATER SYSTEMS BLOCK J.C., SIMON L., TRONEL H., BLECH M.F., HARTEMANN PH. Laboratoire Hygiène Hospitalière CHU Nancy Rue du Morvan Vandœuvre-les-Nancy France DI MAJO P. Services techniques Département Vigilance Santé Environnement CHU Nancy Rue du Morvan Vandœuvre-les-Nancy France Finished drinking waters frequently carry a total number of bacterial cells of about 108 cells/l with less of 0.01% of culturable heterotrophic bacteria (HPC), most of them being unidentified. Depending on the water source and its treatment, one may estimate there is at least 1% (106/L) of viable but non culturable bacteria (VNC). The bacterial biomass carried out by the finished water is multiplying into the network, resulting in higher bacterial concentrations exceeding sometimes the maximum permitted in drinking water. The proliferation of these bacteria occurs in the bulk water (from 0 to 30%) but also in the biofilms (from 70 to 100% of the bacterial production). The biofilm accumulation and activity are controlled by a large number of factors (hydraulic regime, nature or concentration of nutrients, density of bacteria and species introduced into the network, nature of the distribution materials, predators) which effects are not always predictable. There is increasingly concern about accidental intrusions of pathogens into distribution systems or deliberate pathogen contamination. Deficiencies in distribution systems (in addition to breakthrough) include cross-connection and back-siphonage, contamination while in storage, contamination during construction/repair, and broken and leaking mains. Pathogens introduced in drinking water distribution systems implant biofilm or deposits, which may then be regarded as transitory reservoirs of pathogens. Then hospital drinking water distribution systems may serve as a potential indoor reservoir of pathogens or potentially pathogenic microorganisms: Pseudomonas aeruginosa, nontuberculous Mycobacteria, molds (Fusarium, Aspergillus ), Legionella, etc. These microbiologically contaminated drinking waters have been suspected to be cause of community-acquired infection for several years, and repeatidly waterborne nosocomial infections are reported. By way of consequence, an estimated 1,400 deaths occur each year in the USA as a result of waterborne nosocomial pneumoniae caused by Pseudomonas aeruginosa alone. Despite the availability of effective control measures and guidelines, no clear single strategies exist for the prevention of these infections. Because of the seriousness of these nosocomial waterborne infections, this paper tries to analyse some of the major causes of drinking water contamination, and gives a critical review of multistep barriers used for preventing exposure of patients. 132

2 XVI e Congrès national de la SFHH - Reims - 2 et 3 juin 2005 Symposium Eau et Hôpital - 4 juin 2005/Water and Hospital Symposium - June, 4th 2005 ECOLOGY OF PSEUDOMONAS AERUGINOSA IN THE INTENSIVE CARE UNIT AND THE EVOLVING ROLE OF WATER OUTLETS AS A RESERVOIR OF THE ORGANISM MATTHIAS TRAUTMANN, MD, A. PHILIPP M. LEPPER, MD, B AND MATHIAS HALLER, MDC STUTTGART, ULM, AND KEMPTEN, GERMANY In spite of the significant changes in the spectrum of organisms causing intensive care unit (ICU)-associated infections, Pseudomonas aeruginosa has held a nearly unchanged position in the rank order of pathogens causing ICU-related infections during the last 4 decades. Horizontal transmissions between patients have long been considered the most frequent source of P aeruginosa colonizations/infections. The application of molecular typing methods made it possible, during the last ; 7 years, to identify ICU tap water as a significant source of exogenous P aeruginosa isolates. A review of prospective studies published between 1998 and 2005 showed that between 9.7% and 68.1% of randomly taken tap water samples on different types of ICUs were positive for P aeruginosa, and between 14.2% and 50% of infection/colonization episodes in patients were due to genotypes found in ICU water. Faucets are easily accessable for preventive measures, and the installation of single-use filters on ICU water outlets appears to be an effective concept to reduce water-to-patient transmissions of this important nosocomial pathogen. (Am J Infect Control 2005;33:nnn-nnn.) 133

3 1 FEVER EPISODE DURING A DIALYSIS SESSION : PROTOCOL OF MANAGEMENT AND MICROBIOLOGICAL INVESTIGATION DUBOUIX A., DUPRÉ-GOUDABLE C., LACROIX P., MARTY N. B. CHU Rangueil-Larrey, Toulouse, France During the last week of July 2004, four patients hospitalised in our institution for an ambulatory haemodialysis session suffered severe fever. While, after the event, no infectious origin could be found out for 3 of them, a Pseudomonas aeruginosa bacteraemia was rapidly diagnosed for one of these patients. Because of the hydric feature of such an opportunistic pathogen, a contamination of the local network was suspected. Furthermore, during the week before the event, one of the handwash point had been evicted because of the presence of the same rod. Several samples were thus carried out among the patients present in the ward as well as in the environment. However, none was able to put in evidence any Pseudomonas. Furthermore, the genomic analysis of the clinical and environmental (handwash point) demonstrated that there was no link between these two events. A posteriori, it was so decided that a management and an alarm protocols should be systematically performed in front of patients displaying fever during a dialysis session. Indeed, microbiological and endotoxin analyses of the osmotic water and the diluted infusion are thus actually carried out while blood culture is performed on the catheter and on another peripheric blood vessel. Furthermore, when positive samples are isolated from patients or/and environment, strains are immediately compared thanks to several methods (antibiotyping, serotyping, genomic analysis by RAPD and PFGE). Though, this approach helped us in keeping the ward opened while a Pseudomonas aeruginosa epidemic was suspected and could be rejected thanks to rapid comparison of the strains. This protocol setting up led us to better manage the infectious risk and to provide the physicians a quicker answer in front of a fever episode. 2 EXPERIENCE OF CONTROL OF LEGIONELLA IN WATER NETWORKS OF A M 2 BUILDING KRAEWINKELS L., HOUZEL Q-O. European Parliament, Luxembourg Background It is always difficult to master the Legionella risk in a big building with multiple water networks and numerous supply points. The objective of this communication is to present the development of the results recorded in a situation of this type subsequent to the discovery - widely reported in the media - of a contamination in Material and method The building taken as an example is a construction of 220,000 m 2, built on 20 levels, comprising 1,150 offices (of which 670 are equipped with sanitation cabins - i.e., a unit comprising shower, toilet and wash-basin), 40 meeting-rooms including one debatingchamber ( hemicycle ) with 732 seats, 2 restaurants, 4 bars and a car-park with 1,200 places. The building comprises 9 water-supply networks, of which 4 are hot water for sanitary purposes, 4 are cold water for sanitary purposes and 1 is a botanical watering network. This summary does not include the technical networks. Subsequent to the Legionalla crisis, all the hot water sanitary networks were emptied, and only those serving the sanitation cabins were restored to function, albeit subject to a monitoring operation and an on-going risk analysis. Following this professional assessment, an extensive programme of work was carried out on the hot water and cold water networks over three years and more, mainly comprising these measures: - The networks (hot water and cold water) were made into looped circuits; - Installation of automatic discharge systems in the showers; - Modification of water-distribution in the sanitary systems (shower, toilet, wash-basin) to bring them into series; - Replacement of the pressure regulators and installation of oneway valves; - Replacement of steel pressure boosters and pipes with stainless steel; - Replacement of all the water distribution networks and valves in the basement; - Regulation of the hydraulic equilibrium of the networks every 6 months. In order to avoid stagnation of water in the dead branches of the sanitation cabins water is drawn off manually on a weekly basis with measurement of the temperature in every rising column. Results The initial contamination of the hot water supplies was of the order of 450,000 UFC/l of Legionella sp in the hot water and 85,000 UFC/l of Legionella sp in the cold water, among which 4 groups of different pulsotypes were identified, demonstrating the co-existence of several strains of Legionella with a majority of Lp 1, as well as Lp 12, Lp 7 and L. anisa. Increasing the temperature of the networks, a sustained effort to search-out and eliminate dead branches and contaminated zones, followed by intensive technical interventions, made it possible to effect a drastic reduction whereby, in 3 years, 100% of results were brought below a target-limit of 250 UFC/l on samples taken after 2 minutes of flow. 2002: 44% of the results < 50 UFC/l (From 125 samples taken, 74 > 50 UFC/l) 2003: 96% of the results < 1000 UCL/l (From 221 samples taken, 8 > 1000 UFC/l) 2004: 100% of the results < 250 UFC/l (From 220 samples taken, 0 > 250 UFC/l) However, in the new situation - in general more than satisfactory from the regulatory point of view - a biofilm analysis showed the presence of Legionella in the circulating hot water loop at 61 C, with, on the other hand, an absence of Legionella in small-diameter pipes for the distribution to the shower-cabins. Legionella analyses on samples taken from the initial water-jet from these pipes fairly regularly yield positive values with concentrations of the order of 700 to 55,000 UFC/l. Conclusion The health risk for the user is almost zero taking into account this low level of concentration for a volume of about one litre and the very good analytical results recorded after two minutes of flow, representing the water actually used for a shower. However, we must continue our efforts at improvement towards negative firstjet results. The biofilm exists mainly in circulating sections, probably showing that by taking refuge there the Legionella organisms are able to adapt to the high temperature and poor conditions of survival. 136

4 XVI e Congrès national de la SFHH - Reims - 2 et 3 juin 2005 Symposium Eau et Hôpital - 4 juin 2005/Water and Hospital Symposium - June, 4th A NEW MODEL TO TEST EFFICIENCY OF CHLORINE DIOXIDE AND UV-C IRRADIATION ON BIOFILM REMOVAL AND PREVENTION OTTE A., EXNER M., GEBEL J. Institute of Hygiene and Public Health, WHO collaborating Centre, University of Bonn, Sigmund-Freud-Str. 25, D Bonn, Germany ( Abstract: Biofilms as a source of pathogens may also pose a health risk via hospital water distribution systems. Bacteria released from biofilms can cause infections, particulary in elderly people, children and immunosuppressed patients. Because biofilms are difficult to eliminate, (i) it is crucial to prevent their formation by suppressing the level of planctonic bacteria in the water supply system, (ii) and a reliable and continuing disinfection of the water supply must be guaranteed. The purpose of this study was to show the differences in efficiency of chlorine dioxide and UV-C irradiation with regard to their capacity of removing existing biofilms and inhibiting the formation of new biofilms using a silicone tube model with running tap water from the hospital water distribution system. A permanent exposure to chlorine dioxide prevents formation of a new biofilm and does eliminate bacteria embedded in an existing two years-old biofilm within 70 days. UV irradiation is capable of preventing formation of new biofilms. It will not significantly change the level of viable bacteria in the biofilm. The research shows that the silicone tube model is a useful tool to demonstrate the effect of different water treatments on biofilms under simulated worst case conditions. Keywords Biofilm, chlorine dioxide, UV-C irradiation, water distribution system, silicone tube model 4 DETECTION AND QUANTIFICATION OF LEGIONELLAE IN HOSPITAL WATER SAMPLES BY QUANTITATIVE REAL-TIME PCR TRONEL H., SIMON L., HARTEMANN PH. Laboratoire Hygiène Hospitalière CHU Nancy rue du Morvan Vandœuvre-les-Nancy France Background: Legionella pneumophila (LP) infection is normally acquired by inhalation or aspiration of contaminated water. Water systems of large buildings, such as hospitals, are often contaminated with legionellae and therefore represent a potential hazard to patients. For risk assessment of nosocomial Legionella infection, surveillance and rapid monitoring of suspected hospital water supplies is essential. As identification of LP takes three to ten days by conventional culture, several assays based on the polymerase chain reaction (PCR) have been evaluated. The advent of real time PCR technology has made possible reductions in analysis time. Method: This study relates the use of tests designed for the icycler iq thermal cycler (Bio-Rad) for real-time PCR detection and quantification of LP (iq-check Quanti Legionella pneumophila) and Legionella spp. (iq-check Quanti Legionella spp.) in water samples after filtration. One hundred environmental water samples from various sites of the CHU Nancy were investigated by LP realtime PCR assay, of which 80 were also tested by Legionella spp. real-time PCR assay. In parallel conventional culture method was used. Results: twenty water samples were found to be positive for LP by culture (nine were positive for LP serogroup 1, eleven for LP serogroup 2-14). All twenty LP culture-positive samples were positive in the real time PCR assay for LP (detection limit (Ld) : 133 genomic units/l (GU/L)), of which 19 displayed results superior to the quantification limit (Lq) (Lq : 373 GU/L) : median PCR results (4200 GU/L [mean 4400 GU/L ; range 500 to GU/L]). Among these 20 LP culture-positive samples, data for Legionella spp. real time PCR assay were available for 15 water samples : median PCR results (15000 GU/L [mean GU/L ; range 900 to GU/L]). Eighty water samples contained fewer viable LP cells than the detection limit (250 CFU/L) of the culture method, of which 20 were negative for LP real time PCR assay (with no inhibition of amplification), 19 were under the Ld, 9 between the Ld and Lq, and 32 displayed results superior to the Lq : median PCR results (2200 GU/L [mean 3100 GU/L ; range 500 to GU/L]). Among these 80 LP culture-negative samples, data for Legionella spp. real time PCR assay were available for 66 samples : two water samples had results superior to the upper quantification limit (UQL: GU/L) and required adapted dilution of DNA samples for precise quantification ; for the remaining 64 samples, 6 were negative (with no inhibition of amplification), 17 were under the Ld, 3 between the Ld and the Lq, and 38 displayed results superior to the Lq: median PCR results (4300 GU/L [mean GU/L; range 400 to GU/L]). For 20 water samples, results for both LP and Legionella spp. real time PCR assays were between the Lq and UQL: LP PCR assay: median PCR results (1900 GU/L [mean 2700 GU/L; range 500 to GU/L] ; Legionella spp. PCR assay: median PCR results (9000 GU/L [mean GU/L; range 900 to GU/L]. Although there was no correlation between these results, the association of both tests (iq-check Quanti Legionella pneumophila and iq-check Quanti Legionella spp.) leads to a better knowledge of hazards related to Legionella contamination in hospital water supplies. Conclusion: These data support previous findings indicating that culture frequently underestimates the presence of LP in water samples. Thus, real time PCR assays may therefore be useful both for routine monitoring for Legionella contamination, and for rapid screening of large numbers of water samples during outbreak investigations, while the results of culture are still awaited. 5 Non communiqué/not transmitted 6 WATER MICROFILTRATION : A PROCEDURE TO PREVENT PSEUDOMONAS AERUGINOSA INFECTION VAN DER MEE-MARQUET N. 1,2, BLOC D. 2, BRULARD V. 2, BESNIER J.-M. 3, QUENTIN R. 1,2 Département de Microbiologie Médicale et Moléculaire, Unité de Bactériologie, EA Service de Bactériologie et Hygiène2, Hôpital Trousseau, Tours, France Service de Maladies Infectieuses3, Hôpital Bretonneau, Tours, France Pseudomonas aeruginosa is a major cause of pulmonary, urinary, wound and bloodstream nosocomial infections, especially in intensive care units (ICU). Taps and the moist environment surrounding them are easily contaminated and have been reported to be a source of nosocomial infections. The purpose of our study was to assess the impact of a systematic installation of water microfiltration on the incidence of P. aeruginosa infections in the ICU of a 600-bed surgery teaching hospital. 137

5 Over a five-year period, comprising patient-days and started by a 30-month no-filtration period, we numbered bloodstream, urinary- and pulmonary- P. aeruginosa infections which occurred in the ICU : 104 and 46 P. aeruginosa infections were found respectively during the no-filtration and the post-filtration periods, showing a significant decrease of the incidence of P. aeruginosa infections (8.7/1000 patient-days without filtration, 3.92 with filtration). Considering the only infections characterised with multisensible P. aeruginosa isolates [more likely originating from water source of contamination rather than multiresistant isolates], the incidence decrease was again more marked (2.7/1000 patient-days without filtration, 0.5 with filtration). Our study demonstrated the significant positive impact of the water filtration in our ICU, and a noticeable effect over nosocomial infection prevention. 7 EXPERIENCES WITH WATER SAFETY PLAN IN AN UNIVERSITY HOSPITAL OVER ONE YEAR INCLUDING PREVENTION OF BACTERIAL EMISSION FROM SINK DRAINS KRAMER A. 1, DYCK A. 1, DAESCHLEIN G. 1, EXNER M. 2, WEBER U Institute of Hygiene and Environmental Medicine, University Hospital Greifswald 2. Institute for Hygiene and Public Health, University Hospital Bonn Due to the high number of immunosuppressed and other predisposed patients hospitals have to control the microbiological water quality. Water born nosocomial infections caused e.g. by Legionella pneumophila or Pseudomonas aeruginosa still are a common problem. Anaissie et al. recently estimated the number of fatal waterborne pneumonias acquired in U.S. hospitals caused by Pseudomonas aeruginosa at about 1400 cases per year. Each year severe Legionella outbreaks in health care facilities are reported worldwide, e.g. in summer 2003 in Frankfurt/Oder in Germany. The routes of infection could be identified by molecular subtyping methods and water taps became obvious as important source of nosocomial infections. The underlying cause for the occurrence of pathogenic microorganisms in water pipes in buildings is the formation of biofilm. Biofilm can even be found not only in older but also in newly opened hospitals because the water stagnates for weeks or even months till the official opening. At first we will report the strategy and management of such situation with a highly contaminated cold water system (i.e. P. stutzeri cfu/100ml) after opening a new part of our hospital during normal clinical curse of operation. First we had to choose a hopeful decontamination technique. In case of Legionella contamination of the hospital water system several systemic measures are recommended. Most frequently thermic shock (flushing water >70 C through all pipes over 3 min) is used for hot water systems. It has a rapid killing effect on planctonic bacteria but it is unable not destroy biofilms. UV radiation has only effects on planctonic bacteria passing the UV lamps but cannot reach the already established biofilm areas and needs special technique. Chlorine in concentrations according to European standards (German standard is 0.3%, in exceptional cases up to 0.6%) has sufficient effects on planctonic bacteria, but is also not suited to remove biofilm. Electrolytic disinfection concepts such as anodic oxidation are also based on the disinfecting effect of free chlorine. The effect on biofilm is controversially discussed. Therefore we selected the chlorine dioxide decontamination with a reaction time of 1 h of 20 ppm. This procedure decontaminated the water supply system completely inclusively tanks, washer disinfectors and other water bypasses. The key for the result was the following: Creation of general logistic with implementation of water task force (nurses, technical support, clinical management, external technical provider) guided by the head of hygiene institute immediate providing of special equipment (dosage pump, chemicals and devices) background information of water distribution in the building, to realize the follow up of opening, and consecutive closing (for reaction time) and re-opening (to clear water from chlorine dioxide and by-products) of all water taps (n=2237), toilets, washer disinfectors and other bypasses parallel information of all patients and staff about the sanitation and the necessity to avoid the use of the contaminated water for ingestion, hand washing and nursery after decontamination day to day control of the water quality following national standards with external control. After the successfull decontamination we have installed a water safety plan following the principle search and destroy based on an established and adapted HACCP concept. The most important measures are: concept for sample taking immediate response to any significant test result to fix the extend of measures depending on the degree of contamination and risk assessment with the following steps: 1. cfu > 100 cfu/1 ml, but no pathogens: Cleaning of perlators, flooding of water system, control, if still positive, ClO2 decontamination 2. Pseudomonas spp. in 100 ml: in risk areas POI filters and the same measures as above, in other wards only use of hot instead of cold water for nursering 3. Legionella spp. in 100 ml: in risk areas POI filters and the same measures as above, shower excluded from use permanent heating level of 55 C, additionally monthly thermo disinfection of hot water system identyfing and eliminating resp. continuous use of non used end points of tap water installation of point of use (POU) filters in risk wards with immunodeficient patients, e.g. haematological-oncological units, transplant units, burned patient units, intensive care units as well as for the last washing cycle for endoscopic instruments. Since implementation of the full concept we were able to avoid systemic contamination by chemical ways. Further attention has to be focussed on lavatory sinks. They contain 105 to 1010 cfu/ml of bacteria, thereof about 103 to 106 cfu/ml proved to be gramnegative rods. In internal, surgical and neonatal intensive care, general and visceral surgery, oncology, and transplantation unit we measured the bacterial aerosol (n=257) 10 cm above the sinks during tap water running into the sink drain over 1 min. During the tap water running aerosols containing bacteria from the sink fluid were emitted into the surrounding area. Accordingly sink drains function as open bacterial reservoir. The higher was the microbial burden of the siphon fluid, the more bacteria were emitted into the air. Bacteria colonizing oncologic patients were found in the sinks and in aerosols around the basin of the patient room. Continuous thermo-disinfection in combination with low frequency vibration of the siphon prevented biofilm formation and eliminated siphons as bacterial reservoir. 138

6 1 NON-TOUCH FITTINGS IN HOSPITALS: A PROCEDURE TO ERADICATE PSEUDOMONAS AERUGINOSA CONTAMINATION VAN DER MEE-MARQUET N. 1,2, BLOC D. 2, BRIAND L. 3, AURY J.-L. 3, BESNIER J.-M. 4, QUENTIN R. 1,2 1. Département de Microbiologie Médicale et Moléculaire, Unité de Bactériologie, EA Service de Bactériologie et Hygiène, Hôpital Trousseau, Tours, France 3. Direction Services Techniques, Hôpital Trousseau, Tours, France 4. Service de Maladies Infectieuses, Hôpital Bretonneau, Tours, France Non-touch taps, which are now common in hospitals, can easily be contaminated with Pseudomonas aeruginosa. We report our experience with 87 non-touch taps in a newly built wing of our teaching hospital contaminated with P. aeruginosa due to the central pipe water system. Serotyping and genotyping of strains revealed genetic diversity of implicated isolates but also showed that major clones are able to persist a long time in non-touch taps despite chlorination. It is notoriously difficult to decontaminate such taps with biocides and disinfectants. We describe an easy and economical procedure for the eradication of P. aeruginosa contamination from non-touch taps. This procedure does not require the removal of contaminated taps. 2 STERILISABLE WATER FILTERS: COST OF OBTAINING A WATER OF MICROBIOLOGICAL QUALITY MAGDELAINE A., LABRY M.F., MARTIN L., ARA S., DURNET-ARCHERAY M.J. Service Pharmacie - Stérilisation centrale, CHU Dijon, 3, rue du Faubourg-Raines, DIJON. INTRODUCTION Obtaining water of bacteriological quality is essential in the fight against nosocomial infections. Micro filtration, by installation of final filters on the water points, makes it possible to control the quality of water to the operating theatre. ln the CHU of Dijon, water sterilisable filters are currently used. A study was then undertaken to evaluate the cost of annual operation of the points of water supply. ln parallel, the results of the bacteriological analyses carried out on the filters were analysed over the year MATERIEL AND METHODS The cost of operation of the points of water supply with filters corresponds to the sum of the purchase price, the incineration cost, the 45 sterilizations and 3 bacteriological analysis cost. The unit cost of the sterilization of a filter was estimated by distinguishing various expenditures: personnel, consumable and small material, equipment and operating costs. The costs were calculated by Excel on the basis of price and hourly wages in The results of the bacteriological analyses carried out on the filters were provided by the service of bacteriology and treated by Excel. RESULTS 55 points of water supply were equipped in 2004 with water filters: 50 stations of hand washing (30 on the site of «Hopital du Bocage» (HB) and 20 on the site of «Hopital général» (HG)) and 5 showers (HB). The cost of sterilization of this filter was estimated at 2.74 in HG and 2.08 in HB. 63 and 50% of these costs are represented by the personnel. The cost of consumable represents the 2nd expenditure. Annual operation with reusable water filters then has a cost of approximately of The bacteriological analyses carried out on the sterilisable filters show a rate of non-conformity considered to be satisfactory (15%) and increasing regularly with the number of sterilizations. DISCUSSION-CONCLUSION The annual cost of operation of the points of water supply with reusable filters is high. It is higher than single use filters (about ), which would carry out an annual saving of 5000, without no major difference in quality. These results led the Committee of fight against nosocomial infections to recommend the use of single use filters, while waiting the systematic use of the alcohol-based hand rub. 3 PREVENTION DU RISQUE INFECTIEUX LORS DU TRANSFERT D UN SERVICE D HEMODIALYSE DUBOUIX A., LACROIX P., BORIES P., SEIGNEURIC M., MALAVAUD S., MARTY N. CHU Rangueil-Larrey, Toulouse Six mois avant le transfert d un service d hémodialyse ambulatoire sur un site partiellement occupé jusqu alors, une cellule de réflexion multi-disciplinaire s est constituée. Celle-ci comprenait le pharmacien en charge de l hémodialyse, un microbiologiste hygiéniste, un néphrologue référent, un représentant administratif, l industriel concevant le réseau, un membre des services techniques ainsi que le technicien d hémodialyse présent sur le site. En outre, un nouveau système de désinfection de la boucle (désinfection thermique) était envisagé. Une réflexion s est ainsi engagée non seulement en terme de maîtrise du risque infectieux pour le patient, mais aussi en terme de gestion des coûts pour la structure. L eau circulant dans la boucle plusieurs mois avant l ouverture, un série de points stratégiques à contrôler permettant de refléter la qualité microbiologique de l eau au sein de la boucle a donc été définie ainsi que la fréquence des prélèvements à effectuer. En outre, un cahier des charges ainsi qu une procédure d alerte dégradée en cas de non conformité ont été mis en place. Quelques jours avant le transfert, des contrôles microbiologiques de l air et des surfaces ont été pratiqués en coordination avec le service clinique conformément aux recommandations DGS/DHOS CTIN Face à la présence massive d Aspergillus dans tout le service, l alerte immédiate donnée par le laboratoire au cadre a permis la mise en oeuvre d une désinfection efficace des locaux et la disparition du pathogène sans différer la date prévue d arrivée des premiers patients. La mise en place de cette cellule plusieurs mois avant le transfert du service nous a ainsi permis de planifier efficacement les différents contrôles au fur et à mesure de l avancée des travaux, de réduire le surcoût lié aux non conformités ainsi qu au retard éventuel du transfert du service, de permettre une continuité des soins pour les patients concernés ainsi que de valider la méthode de désinfection thermique. 4 MISE EN PLACE D UNE STRATEGIE D AQUAVIGILANCE EN SECTEUR DE DIALYSE AU CHU DE TOULOUSE DUBOUIX A., LACROIX P., BORIES P., SEIGNEURIC M., ROSSIGNOL S., DUPRÉ-GOUDABLE C., BOUISSOU P., THIVEAUD D., MALAVAUD S., MARTY N. CHU Rangueil-Larrey, Toulouse La circulaire DGS/DH/AFSSAPS n du 20 Juin 2000 relative à la diffusion d un guide sur la production de l eau pour 142

7 XVI e Congrès national de la SFHH - Reims - 2 et 3 juin 2005 Symposium Eau et Hôpital - 4 juin 2005/Water and Hospital Symposium - June, 4th 2005 l hémodialyse fixe un nombre minimal annuel de contrôles des installations de traitement de l eau en fonction du nombre de scéances pratiquées par an dans l établissement. Etant donné la politique de prévention du risque infectieux lié à l eau de dialyse dans notre établissement, nous avons souhaité mettre en place une stratégie d aquavigilance en vue d une amélioration de la qualité des soins. Une cellule a donc été constituée, impliquant : le pharmacien responsable de la qualité en dialyse, un microbiologiste hygiéniste, un biochimiste, un néphrologue référent, un responsable administratif, un membre des services techniques ainsi qu un technicien d hémodialyse. Le but de cette cellule d aquavigilance a été d établir en partenariat : un planning des contrôles microbiologiques et biochimiques à effectuer ainsi qu une procédure d alerte dégradée de façon à signaler les non conformités, les actions correctives ainsi que les nouveaux contrôles; le tout dans une logique de rapidité et de traçabilité. A ce jour, la mise en place de cette stratégie nous a essentiellement permis de réduire régulièrement les non conformités, en particulier concernant la qualité microbiologique de l eau et la présence d endotoxines en quantité supérieure à la norme (évènements indésirables : 2004 : 6 ; 2003 : 10 ; 2002 : 11 ; le nombre de contrôles étant resté identique). En outre, la réflexion concertée entre les différents acteurs impliqués nous a permis de préparer la mise en place de la technique d hémodiafiltration en ligne aux plans logistique et technique, mais également financier, grâce à une évaluation du coût minimal engendré pour le pôle de néphrologie. 5 SOFTWARE: RES EAU FONTAINE H., consulting ingeneer for water and public health FOUQUEY J-P., pharmacist hygienist - Company ICS EAU Management software about medical risks in reference with water in hospital environment and especially prevention of Legionnaires disease risk. This software allows to replace the paper version of the health book which was needed for the follow-up and maintenance of the equipments in relation with the water networks (ou water system). It allows: - the identification of your installations, of your equipments, of the responsibility concerning the management of the water inside the health center ; - planification and follow-up of maintenance ; - management of water analysis ; - definition and follow-up of the investigations, which are to be set up in case of detecting Legionnaire s disease or high levels of this bacterium in the water networks (ou water system). This allows the health center: - to play for time (ou to win time); - to avoid any loss of information ; - to permit a better relation between the different parties (technical services / healt service / laboratory / person responsible for quality / CLIN / Management). The aim of this software, which is a quality tool to help decision, is to be able to trace any operations realised on the water network, be it maintenance or control and to improve reactivity in case of drifting. 6 QUANTIFICATION OF LEGIONELLA PNEUMOPHILA BY REAL- TIME PCR ASSAY HALLIER-SOULIER S. 1, MÉNARD-SZCZEBARA F. 2, DELABRE K. 2, FESTOC G GeneSystems, 1 rue du Courtil, Centre d Affaires CICEA, Bâtiment 1, 35170, Bruz, France. Phone: , fax: , 2. Centre d Analyses Environnementales (CAE), Veolia Environnement, 1 Place de Turenne, Saint-Maurice, France. Phone : , fax: Background: A real-time PCR assay for the quantification of Legionella pneumophila in environmental water samples was developped using two platforms: GeneExtract for DNA preparation and GeneDisc Cycler for real-time PCR operations run with GeneDiscs, a ready to use PCR product. Materials and methods: Specificity of the detection was evaluated on a panel of 104 bacterial strains including environmental Legionella strains and other bacterial strains likely to be recovered in environmental water samples. Detection and quantification limits of the real-time PCR assay were measured with seriai dilutions of L. pneumophila SI DNA under repeatability conditions. The optimal yield of the method was evaluated in water samples seeded artificially with seriai dilutions of cultured L. pneumophila SI. Four water types were tested: potable water, warm water, river water and cooling tower water. Results: The designed set of primers/probe was specific for our extended list of bacterial species: positive PCR results were obtained with ail L. pneumophila strains tested and no cross-amplification was found in any species of Legionella spp. and other bacteria. The detection limit of the PCR assay was of 5 genomic units per reaction PCR which corresponded to 167 genomic units per Liter of water sample. The quantification threshold was of 20 genomic units per PCR reaction i.e. 666 genomic units per Liter of water sample. This molecular method was able to detect L. pneumophila in the approximate seeded log concentrations whatever the water type. Standard curves were obtained by plotting the cycle threshold (Ct) obtained by real-time PCR versus the logarithm of the number of seeded L. pneumophila. The obtained linear regressions demonstrated that molecular method was efficient and reproducible. Conclusion: The technology developed by GeneSystems proved to be valuable tools for investigation of Legionella pneumophila contaminations in water systems. 7 EVALUTATION OF THE EFFICACY OF DISPOSABLE SHOWER HEAD FILTER FOR PROTECTION AGAINST LEGIONELLA SALVATORELLI G. 1, MEDICI S. 2, FINZI G. 2, DE LORENZI S Dept. of Biology, University of Ferrara-Italy 2. Hospital Management, Policlinico S.Orsola Malpigli,Bologna-Italy Legionella pneumophila is frequently found in hospital hot water mains. To prevent Legionella infection, numerous methods have been applied to eradicate Legionella pneumophila from the hospital water circuit, hyperchlorinization through the use of sodium hypochlorite, calcium hypochlorite and chlorine dioxide, overheating and flushing, copper and silver ionization, UV radiation and ozonization. Nevertheless, the above methods are not always effective, at times achieving only temporarily solving the problem. 143

8 Installation of anti-bacterial filters at the points where water is used (taps and shower heads) offers some indisputable advantages: installation can be limited to the high risk areas; installation and maintenance are simple and inexpensive. Nevertheless, it is worth noting that most filters last a maximum of 15 days and this constitutes a significant drawback to their use. Recently, however, a filter to protect showerheads from passage of Legionella has been created with a porosity of 0.2 mm (Pall Aquasafe Shower Head Filter, AQL3). The filter membrane resists a maximum recommended water temperature of 60 C and has an operating lifespan of one month. The purpose of the present research was to evaluate whether installation of this filter in 8 showers found in different departments located in different areas of the S. Orsola Malpighi Hospital in Bologna, Italy could prevent the presence of this microorganism in the water over the period of one month. At the time of installation all showers showed the presence of Legionella contamination ( cfu/l). Moreover, it is worth noting that, for the entire test period, no other water sanitation system was used. The samples were taken before installation of the filter and once a week thereafter for 4 weeks. After a month the filters were changed and additional samples were taken after 15 and 30 days. All colonies fell under serum group 3. After installation of the filter, no Legionella colonies were found in the water downstream of the filter nor was it possible to detect Legionella 15 and 30 days after the filters were replaced. For the quantities sampled and the dilutions used, the lower limit for Legionella detection was 50 cfu/l. The results lead one to conclude that, prior to installation of the filter, the number of Legionella bacteria present in the hot water mains was at limit levels. As in most countries, Italian Guidelines permit possible water contamination containing between cfu/l of Legionella. Therefore it is clear that use of the filters made it possible to eliminate the potential risk of infection. 144

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