Water

A Source of
HOSPITAL Concern for
Infections
by Judy A. Angelbeck, Ph.D.,
Girolamo A. Ortolano, Ph.D.,
Francis P. Canonica, Ph.D.,
and Joseph S. Cervia, M.D.

C
ontamination of the hospital water supply with potentially pathogenic Many waterborne microorganisms
organisms is very common. A wide range of bacteria, fungi, and protozoa are opportunistic pathogens that
in the water supply may be pathogenic and should be cause for clinical can increase the risk of infection in
concern. Common bacterial pathogens include Legionella spp., Pseudomonas immunocompromised patients. Such
aeruginosa, and some mycobacteria. Aspergillus is a particularly disconcerting mold patients who come into contact with
found in hospital water. While the pathogenicity of many waterborne parasites (e.g. contaminated tap water from point-
C ryptosporidium parv u m) has been well documented, some protozoa such as of-use sources such as faucets,
Acanthamoeba are not only pathogenic in their own right, but they can also protect showers, water fountains, and ice
bacterial pathogens such as Legionella pneumophila from destructive chemical machines are therefore challenged with
disinfectants and environmental forces as they support bacterial growth and replication. an increased potential for infection.
Point-of-use water filtration has not
Figure 1 only been shown to reduce infectious
complications, but it also serves as a
complementary strategy to systemic
water disinfection technologies. The
Schematic representation persistence of biofilm in healthcare
of the potential sites of facility water delivery systems provides
waterborne organism further justification for implementing
sequestration within the
point-of-use filtration.
plumbing supply to and
within hospitals. Adapted Overview
from Anaissie et. al.1
In a recent plea for action,
Anaissie et al.1 reviewed the potential
sources of water and mechanisms
through which water could serve as a
source of infectious microorganisms
(Figure 1). A recent extensive review
of topics relevant to waterborne
pathogens also outlines this risk.2

Hospital Water as a Source of

Infectious Microorganisms
Hospitals generally draw their
water from the municipal water
supply. As a consequence of the fact
that municipal water, once disinfected
at the treatment plant, travels through
a system of biofilm-laden pipes
before reaching the hospital, water-
borne microorganisms have been
found in hospital water tanks, as well

44 MANAGING INFECTION CONTROL JANUARY 2006

 as the tap water that flows from faucets and showers. It is the
water’s contact with biofilm that is the primary cause of poor
tap water quality at the point-of-entry to the hospital. However,
other factors such as distribution pipeline and storage tank age
and corrosion, poor water system design, and water stagnation
are also major contributors. Biofilm can become dislodged
from pipe surfaces as the result of increased water demand
during the summer months that results in higher water flow
rates and increased shearing forces. Periods during which
facility construction takes place also result in biofilm distur-
bance due to direct mechanical contact with pipes, as does the
occasional use of normally stagnant water at less frequently
accessed points-of-use.
Patient exposure to waterborne microorganisms in the
hospital occurs while showering, bathing, drinking water, or
ingesting ice. It can also occur through contact with contami-
nated medical equipment such as tube feed bags, flexible
endoscopes, and respiratory equipment that have been rinsed
with tap water. The hands of healthcare personnel washed using
tap water can also lead to patient exposure.1,3,4
Common Waterborne Pathogens
Bacteria found in potable water include Legionella pneu -
mophila, Pseudomonas spp. (particularly Pseudomonas
aeruginosa), Stenotrophomonas maltophilia, Aeromonas spp.,
Acinetobacter spp., Enterobacter spp., Flavobacterium spp.,
and Serratia spp. 5,6,7,8,9 P. aeuriginosa can persist in the
hospital water supply for extended periods and has been asso-
ciated with healthcare-associated infection (HAI) outbreaks.1,5
The bacteria isolated and identified in association with
13 of 17 reported waterborne pathogen outbreaks (76%) were
resistant to at least two classes of antibiotics (Table 1; adapted
from Anaissie et al.1). A number of reports show that mycobacteria
can be isolated from hospital water. These bacteria can persist in
water systems over several years and have been implicated in
HAI outbreaks.10,11,12,13,14,15,16 Among the fungi, Aspergillus
spores can inhabit hospital water distribution systems. An
a s p e rgillosis outbreak was reported in a hospital in Houston
leading to patient infections. There is additional evidence that
other opportunistic molds, including Aspergillus spp., have been
recovered from hospital watersystems.17,18,19,20 Among parasites,

Healthcare-associated infections related to contaminated hospital Molecular methods used to establish waterborne microorganisms as
water supplies (tap water and water reservoirs only) with supporting identical to those found infection patients.
molecular relatedness data aligning the contaminating waterborne **Resistant means resistant to two or more clases of antibiotics.
organism to the patient infection.

Table 1A

Organism Source Site(s) of infection Method(s) Used to Link Antibiotic

Patient and Susceptibly
Environmental Strain* of Organism**

BACTERIA

Trautmann et al. 20015 Blood, lungs, peritoneum, AP-PCR Not reported

trachea, urine

Bert et al. 19987 Lung, sinuses, urine DNA macroestriction analysis Resistant
Pseudomonas
Ferroni et al. 19986 Urine PFGE Not reported
aeruginosa
Ezpeleta et al. 199832 Blood ERIC-PCR,RAPD Not reported

Richard et al. 199433 Blood, ling, wound DNA typing, serotyping Resistant

Worlitzsch et al. 198934 Urine ExpoA DNA probe Not reported

Weber et al. 199935 Peritoneum,skin, PFGE Resistant

Stenotrophomonas
respiratory tract,
maltophilia
Talon et al. 199436 Blood, stools, throat, urine PFGE Resistant

Serratia marcescens Carlyn et al. 199837 Eye, stools PFGE Not reported

Acinetobacter Pina et al. 199838 Skin, wound PFGE, biotyping Not reported
baumannii

Aeromonas Picard and Goullet 198739 Blood Electrophoretic esterase typing Not reported
hydrophilia

Chryseobacterium De Schuijmer et al.199840 Blood AP-PCR Not reported

species

46 MANAGING INFECTION CONTROL JANUARY 2006

outbreaks of toxoplasmosis have been reported in municipal deaths per year occur in U.S. hospitals due to waterborne
water supplies and could therefore also potentially reside in healthcare-associated pneumonias caused by Pseudomonas
a hospital water system.21 Finally, while pathogenic viruses aeruginosa alone.
can be recovered from water supplies, no HAIs associated with
waterborne viruses have been reported to date.22
DEFINITION FOR METHOD ABBREVIATIONS USED IN
What is the evidence that healthcare-associated infections TABLE 1 PARTS A, B. AND C.
have been traced to water supplies and/or point-of-use
AP-PCR Arbitrarily Primed Polymerase Chain Reaction
water in the hospital?
Anaissie et al.1 conducted a Medline© search and identified PFGE Pulse-field Gel Electropheresis
43 outbreaks of waterborne healthcare-associated infections ERIC-PCR Enterbacterial Repetitive Intergenic Consensus
for the period 1966-2001. In 29 of the more recent studies
RAPD Random Amplified Polymorphic DNA
where discriminatory methods of strain typing and antibiotic
susceptibility testing were performed, they presented solid ExoA Exotoxin A
evidence that linked the hospital water system to waterborne RFLP Restriction Fragment Length Polymorphism
HAIs in patients (Table 1A, B and C tabulating evidence AFLP Amplified Fragment Length Polymorphism
for water as a source of bacteria, mycobacteria, and fungi
IR-PCR Inter-repeat Polymerase Chain Reaction
that caused infections). Anaissie et al.1 estimated that 1,400
SSDP Sequence Specific DNA Primer Analysis

Table 1B
Organism Source Site(s) of infection Method(s) Used to Link Antibiotic
Patient and Susceptibly of
Environmental Strains Organism**

MYCOBACTERIA

Mycobacterium Von Reyn et al. 199410 Disseminated PFGE Not reported

avium

Kauppinen et al. 199912 Disseminated AP-PCR Susceptible

Mycobacterium
fortuitum Burns et al. 199113 Sputum Phenotype analysis, Partially
plasmid profiles, PFGE reported

Mycobacterium Desplaces et al. 199514 Spine Chromosomal restriction Resistant

xenopi fragment patterns

Mycobacterium Picardeau et al. 199715 Abscess, blood, bone, RFLP, PFGE, AFLP, PCR Not reported
kansasii sputum, stomach, urine

Mycobacterium Sternal wound infection, Resistant to

chelonae prosthetic valve Electrophoresis of enzymes, doxycycline
Wallace et al. 198916 plasmid profiling
Mycobacterium Sternal wound infection Susceptible to
fortuitum doxycycline

Table 1C

Method(s) Used to Link Antibiotic

Organism Source Site(s) of infection Patient and Susceptibly of
Environmental Strains Organism

FUNGI

Fusarium solani Anaissie, 199841 Disseminated RFLP, RAPD, IR-PCR Resistant

Exophiala Nucci et al. 199842 Disseminated RAPD Not reported

jeanselmei

Aspergillus Anaissie et al. 200220 Lungs PCR, SSDP Not reported

fumigatus

JANUARY 2006 MANAGING INFECTION CONTROL 47

 Healthcare-associated pneumonias account for
20 to 45% of all HAIs and 23,000 deaths per year in
the U.S., with 20% of these pneumonias associated
with P. aeruginosa. This suggests that waterborne P.
aeruginosa may be a significant contributor to
healthcare-associated pneumonia in U.S. hospitals.1
During a seven-month period, Trautmann et al.5
observed that 29% (5/17) of patients in a surgical
intensive care unit were infected with P. aeruginosa
genotypes that were the same as those detected in the
unit’s tap water.
Jarvis et al.23 reported that healthcare-associ-
ated bloodstream infections have been traced to
water in the operating room environment, with water
or healthcare workers’ hands playing a critical role in
the contaminating event.
There are 29 recent studies (Table 1) containing
both epidemiological and molecular relatedness data
that incriminate hospital point-of-use tap water and
water reservoirs as sources of HAIs in patients. Areas
of the hospital with patient infection outbreaks include:
 Surgical Intensive Care Unit
 Neurosurgery Intensive Care Unit
 Pediatric Oncology Ward
 Pediatric Surgical Unit
 Cardiovascular Surgery Unit
 Burn Unit
 Neonatal Intensive Care Unit
Figure 2
Contamination of water supply
outlets in transplant units.
Adapted from Patterson et al.24
48 MANAGING INFECTION CONTROL
Paterson et al.24 tested hot and cold point-of-use water supplies in
81 transplant units in the UK. As depicted in Figure 2, almost half
(39/81) of the water outlets in these transplant units were found to be
contaminated with Legionella species.
In a recent editorial, Stout et al. identified hospital acquired
Legionnaires’ disease as a global public health issue.25
Key factors influencing the risk of transmission of Legionella include:
 Host susceptibility (immunosuppressed patients such as organ
transplant patients and elderly patients with chronic lung disease).
 Degree of Legionella colonization within the water supply.
Legionella is a common inhabitant in water distribution systems.
In many hospitals, Legionnaires’ disease may go undiagnosed and
unrecognized as a cause of patient morbidity and mortality.25 Sabria et
al.26 conducted an environmental surveillance of 20 hospitals in
Barcelona, Spain. Some of the key findings were:
 Legionella pneumophial was isolated from 85% (17/20) of the
hospital portable hot water systems.
 Each hospital had its own unique DNA subtypes of L. pneumophila.
Patients at high risk of infection due to waterborne microorganisms
include those who are immunocompromised as a consequence of
their diseases and/or the treatment regimens for their diseases. These include:
 AIDS patients
 Organ transplant recipients
 Oncology patients
 Neonates
 Critically ill patients
JANUARY 2006
 Contaminated water can lead to infection via inhalation of water droplets, Solutions to the Problem of
ingestion of water, immersion in water, or contact with equipment, environ- Contaminated Water
mental surfaces or hands that have been in contact with water.1,25,27,43 Table 2 Can an entire water delivery system be
summarizes several studies which describe the parameters of hospital disease effectively treated to prevent or eradicate
outbreaks traced to water. microbial contamination?
Providing safe water for hospital use
Table 2
provides the obvious benefit of minimizing
Likely
at-risk patient exposure to microbial
Site of pathogens. However, in order to determine
Number of Hospital Site Organism Contaminated
Infection
Patients Water Source whether or not total and complete microbial
eradication from a hospital water supply is
27 Neurosurgery Various P. aeruginosa Water supply7 feasible, it is necessary to understand the
challenges that must be overcome in the
4 Cardiac Sternal Legionella Water used to
Surgery Wound bathe wound43 attempt to attain that goal.
Factors that contribute to the microbial
17 Surgical ICU Blood, lungs, P. aeruginosa Tap water5 contamination of water include:
peritoneum
trachea, urine
 The temperature of water at various
points in the water distribution system.
13 Renal Lung Legionella Aerosol  The development and persistence of
Transplant from tap44 biofilm in the water delivery system,
particularly in areas of the water distribu-
tion system where water tends to stagnate.
The contamination of medical instruments with waterborne microbes is one  The inability of systemic disinfection
potential route of infection that has been extensively discussed. The scientific liter- technologies (e.g. chlorine dioxide, hyper-
ature contains references to patient exposure to waterborne microorganisms through chlorination, copper-silver ionization, hot
contact with contaminated medical equipment (e.g. flexible endoscopes, respiratory water flushing) to reach all locations
equipment, tube feed bags, etc.) that had been rinsed with tap water.1,28,29 within the water delivery system.
The magnitude of the problem caused by waterborne HAIs is largely unrecog-  The accumulation of scale in a water
nized. Anaissie et al.1 estimated that healthcare-associated P. aeruginosa delivery system and the role it plays
infections alone are responsible for 1,400 deaths annually in the U.S. While in enhancing the conditions for micro-
Legionella is the best recognized of all waterborne pathogens, and that recogni- bial growth.
tion has led to recommendations for preventing patient exposure that are
L e g i o n e l l a-specific in nature, healthcare-associated waterborne infections by Systemic water disinfection technologies
other microbes such as P. aeruginosa have been largely ignored.1 vary in efficacy and cost.2 Superheated water
Facts to consider include the following: can be used to flush the water delivery system,
 Pseudomonas can exist not only in biofilms, but also inside free-living but this method is expensive (e.g. labor to
amoebae. The amoebae that harbor pseudomonads provide a microhabitat perform the operation), potentially dangerous
that protects them from disinfectants.1 (e.g. risk of scalding), and can damage water
 Small quantities of bacteria can cause infections.1,19 systems that may not be designed for repeated
 Waterborne bacteria may be antibiotic resistant, further complicating treat- high temperature operations.
ment of the HAIs that they cause.1,7,33,35,36,41 Periodic chemical disinfection with
 There is a risk of false diagnosis from samples collected by instruments agents such as chlorine, chlorine dioxide
contaminated with waterborne microbes. (ClO2), ozone, and hydrogen peroxide can
 Extensive contamination of clinical samples with waterborne microorgan- also be used to reduce the level of microbial
isms can lead to false diagnosis of infection. contamination. However, if used regularly
 Fourteen patients were wrongly diagnosed with tuberculosis after contami- at the concentrations recommended, these
nation of bronchoscopes with nontuberculous mycobacteria.30,31 compounds can be corrosive to piping
 Several different patients who were initially diagnosed with Legionella failed materials. Although chlorine is routinely
to develop symptoms. Further investigation identified Legionella in the water added to drinking water, many org a n i s m s
supply. Bronchoscopes that had been used in the initial diagnoses were likely are resistant (e.g. Cryptosporidium sp.).
contaminated during the final rinse step of the reprocessing protocol.42 Also, since organic material absorbs

50 MANAGING INFECTION CONTROL JANUARY 2006

chlorine, biocidal activity will be negatively impacted as
organic material concentrations increase. Finally, when
amoeba-resistant bacteria take up residence inside an amoeba
host that is in turn resistant to a particular chemical disinfectant,
they can escape destruction by that disinfectant.
Copper-silver ionization has also been used successfully
in many healthcare facilities. This technology employs an
ionization chamber containing electrodes composed of both
copper and silver. Electrical current is applied to the electrodes
as water passes through the chamber, and copper and silver
ions, which have biocidal properties, are released into the water
stream. This technology is usually applied only to the hot water
line and is primarily directed to the control of Legionella sp.
However, failure to address the cold water line leads to
oversight of the many waterborne organisms that reside in cold
water, form biofilm in cold water pipes, and reach the at-risk
patient in the healthcare setting.
Ultraviolet (UV) radiation is also used systemically,
but the equipment required is often expensive. Furthermore,
UV effectiveness is reduced by high water flow, as well as the
Atlantic Air
AD 1/2 H
Page 51
RS:
JANUARY 2006
presence of organic material, high microbial bioburden, and
high turbidity. The effectiveness of UV-generating lamps is
also reduced over time by the accumulation of scale, requiring
maintenance and/or replacement.
Monochloramine (NH2Cl) has been used in certain U.S.
municipalities to effectively reduce Legionella levels. Concern
exists, however, regarding its toxic disinfection products.
Furthermore, there are presently no point-of-entry systems
available to deliver monochloramine to individual buildings.
Systemic water disinfection technologies, although
certainly a step in the right direction as relates to the control of
waterborne pathogens, vary in their respective abilities to
effectively respond to changes in water quality that result from
seasonal variation, abrupt changes in municipal water system
pressure, and construction activities within or outside the
healthcare facility. In addition, all are incapable of completely
and permanently eradicating biofilm that continually exists and
reestablishes itself at downstream locations in the water
delivery system. Finally, they are not maintenance-free and
require periodic attention to maintain peak operating efficiency.
MANAGING INFECTION CONTROL 51
 Point-of-use filtration complements systemic water
disinfection technologies.
Point-of-use 0.2 micron filters on faucets, showers, water
fountains, and ice machines can reduce the risk of patient and
healthcare staff exposure to waterborne pathogens. They can also
provide a cost effective alternative to the use of bottled water or
sterile water for drinking by at-risk patients. In hospital units
where patient showering and bathing has been restricted for fear
of waterborne pathogen transmission, point-of-use filters can
improve patient comfort and quality of life.
Point-of-use filters complement systemic water disinfection
technologies by trapping free-floating organisms that have survived
exposure to disinfectants, broken away from existing biofilm
colonies located downstream from the point of disinfection, or
traveled to the point-of-use from stagnant locations in the water
distribution system. Unlike some systemic disinfection technologies
previously described, they also act on both hot and cold water.
Point-of-use water filters have been a staple for reducing the
risk of exposure to waterborne pathogens in healthcare facilities
outside the U.S. for the last 10 years, particularly in Europe.
However, awareness of their potential benefits is still growing in
the U.S. In light of the broad base of scientific literature that has
been generated regarding the potential for waterborne pathogens
to complicate matters in the care of at-risk patients, as well as the
disease outbreaks traced to waterborne pathogens that are
frequently reported, broad adoption of this technology in the U.S.
would certainly benefit patients and the healthcare community.
Summary
Contamination of the hospital water supply with potentially
pathogenic organisms is very common, but the magnitude of the
problem is largely unrecognized, and there are no specific guide-
lines for protecting patients from exposure. Point-of-use water
(faucets and showers, water fountains, ice machines) may be the
source of the transmission of waterborne microorganisms. Patient
exposure to waterborne pathogens is derived from a number of
sources that include showering, bathing, drinking water, ingestion
of ice, exposure to contaminated medical equipment that has been
rinsed with tap water, or the hands of medical personnel washed
and rinsed in tap water.
Ample evidence has now been accumulated to support the
presence of waterborne bacteria, fungi, and protozoa in hospital
water. Molecular relatedness studies have also shown that these
waterborne organisms are responsible for infections. Certain patient
populations are at greater risk for infection by waterborne
pathogens, namely those who are rendered immunocompromised
either by their disease or by the treatment for their disease (e.g.
chemotherapy patients).
Systemic water disinfection technologies are not completely
and sustainably effective in reducing the bioburden of pathogens in
hospitals water. Complete eradication of waterborne microorganisms
52 MANAGING INFECTION CONTROL
by these technologies is not attainable due to the continual
establishment of biofilm communities downstream of the
point-of-disinfection. Point-of-use 0.2µm filters present
a viable option to provide water for hospital use that
minimizes patient exposure to waterborne pathogens and
the risk of waterborne HAIs. While hospital-wide use is
often not required, their application to areas housing
patients at highest risk is prudent. Furthermore, in
outbreak situations, the effect of point-of-use filters is
immediate, and their implementation can mitigate risk
while providing hospital personnel with the appropriate
time to implement a corrective action plan. Finally, with
point-of-use filters in place, hospital administration can
calmly assess the features and benefits of the various
systemic disinfection technology options. ✛
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54 MANAGING INFECTION CONTROL
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Judy A. Angelbeck, Ph.D., is Senior Vice President of Pall
Life Sciences. She has both North American and global medical
p roduct experience from more than 22 years in marketing,
regulatory and general management. Dr. Angelbeck is currently
working on development of new products for the somatic cell
therapy market.
Girolamo A. Ortolano, Ph.D., is Vice President for Scientific
Affairs at Pall Corporation. Dr. Ortolano graduated from
Columbia University (BS) and the University of Rhode Island
(MS, PhD in Pharmacology), completed a post-doctoral fellow -
ship at the University of Michigan Hospital, and continued
research there before joining Pall Corporation. He has authored
over 90 scientific articles and abstracts including co-authoring
book chapters.
Francis P. Canonica, Ph.D., is the Vice President, U.S.
Healthcare Water Filtration Marketing, at Pall Medical. He has
more than 25 years of experience in research, product development
and marketing of medical devices and clinical diagnostics.
Joseph S. Cervia, M.D., is Professor of Clinical Medicine
and Pediatrics at the Albert Einstein College of Medicine in New
York and Medical Director and Senior Vice President for Pall
Corporation. A board-certified internist, pediatrician, adult and
pediatric infectious diseases specialist, Dr. Cervia has dedicated
much of his career to the care of individuals and families battling
HIV and other infectious diseases, and to clinical re s e a rc h
related to therapeutics, complicating illnesses, and quality of
life issues. He has authored more than 100 articles, chapters
and abstracts, lectured widely, and serves as a consultant
to numerous local and national organizations on HIV and
infectious disease-related issues.
JANUARY 2006