1. P. aeruginosa in augmented care- Should we worry
P. aeruginosa in augmented care- Should we worry? or Quid, me anxius sum

2. When did pseudomonas become important?
Compared microbial causes of death between with
E. coli deaths “superseded by an unusual pathogen, Pseudomonas aeruginosa”
% of infections causing death arose in the community
% hospital acquired
Rogers, D. E. (1959). "The changing pattern of life-threatening microbial disease." N Engl J Med 261:

3. Is there a problem with P. aeruginosa?

4. Looked at another way Quarter P. aeruginosa All bacteraemia
2006-1
615
28,781
2.1%
2006-2
632
29,430
2006-3
840
30,552
2.7%
2006-4
732
28,816
2.5%
2007-1
694
31,440
2.2%
2007-2
677
31,302
2007-3
825
34,984
2.4%
2007-4
838
35,192
2008-1
729
33,129
2008-2
738
32,941
2008-3
849
32,656
2.6%
2008-4
750
32,888
2.3%
2009-1
680
33,303
2.0%
2009-2
702
32,385
2009-3
892
31,728
2.8%
2009-4
907
31,512
2.9%
2010-1
656
31,327
2010-2
713
30,178
2010-3
895
30,383
2010-4
867
32,472
Grand Total
15,231
635,399

5. And looked at a 3rd way
Between 2004 & 2008 the number of Pseudomonal bacteraemias increased by 24%

9. A new source of P. aeruginosa
Wilson, M. G., R. C. Nelson, et al. (1961). "New source of Pseudomonas aeruginosa in a nursery." JAMA 175:

10. Welsh estates alert the home countries
6 August 2010
From the Chief Medical Officer
Welsh Assembly Llywodraeth Cynulliad
Government Cymru
Cathays Park Parc Cathays
Cardiff Caerdydd
CF10 3NQ CF10 3NQ
CMO(2010)13
WATER SOURCES AND POTENTIAL FOR CROSS INFECTION FROM TAPS AND SINKS
O.C. Durojaiye, N. Carbarns, S. Murray, S. Majumdar. Journal of Hospital Infection 78 (2011) 152–159.
Outbreak of multidrug-resistant Pseudomonas aeruginosa in an intensive care unit.

11. Water quality at the point of entry into NHS premises
“drinking water must be wholesome at the time of supply”

12. The legislation
Water Supply (Water Quality) Regulations 2000 (as amended in 2001, and 2010) , which implemented the European Council Drinking Water Directive 98/83/EC 1998.
Compliance with the quality standards is overseen by the Drinking Water Inspectorate
Microbiological standards or “Prescribed Concentrations or Values” (PCV)
Escherichia coli and Enterococci
The standard is 0 per 100ml.
Clostridium perfringens
Coliform bacteria
Colony Counts
The standard is ‘no abnormal change’# -”taste and odor problems”
#"no significant variation and no abnormal change is when all the results obtained in the two years (or in the results of the last 12 samples where less than this number has been taken in two years) are within plus or minus one order of magnitude of the mean for that zone“
Anon The bacteriological examination of water supplies, HMSO, London “Report 71”

13. Guidance on pseudomonads
Drinking Water Safety-Guidance to health and water professionals, 2009 (
HTM 04-01, 2006
Provided water is supplied from the public mains and its quality is preserved by correct design, installation and maintenance, it can be regarded as microbiologically acceptable for use. Minimum hot water temp 55°C at furthest point, delivered at 41°C twice weekly flushing
WHO – Water Safety in Buildings, 2011
Hospitals need-water safety plans; higher quality than drinking water; water treatment at the point of entry; pasteurisation of hot water systems >70°C
Other countries
France
“Incidences of high numbers of the organism in packaged waters has been associated with complaints of taste and odour, and this has resulted in a monitoring standard of per 250ml being set for bottled waters. Bottled water regulations can be found at There is no equivalent standard for public water supplies due to the fact they are not normally in packaged form.”

14. Colony counts and “nuisance” organisms
total viable counts (TVC)
aerobic colony counts (ACC) and
heterotrophic plate counts (HPC)
A heterotroph is an organism that cannot fix carbon and uses organic carbon for growth.

15. Sources of utilisable carbon in a hospital water distribution system
Provider
surface
bore hole
Added in distribution
materials from construction
Water Regulation Advisory Schemes ( Water Supply (Water Fitings) Regs 1999
the unintended
Carbon content will vary in place and time

16. And then there is the plumbing

17. The natural history of pseudomonas and faucets 1
Water contains sufficient organic utilisable carbon for heterotrophic growth.
P. aeruginosa is present in the provider supply, or
poor separation of clean & dirty contaminates the faucet, or
P. aeruginosa is introduced at installation/commissioning.
Biofilm is formed and persists and gives rise to:
planktonic &
sessile populations

18. Factors contributing to contamination 1
Concern for hand hygiene increased the number of outlets and:
reduces flushing
increases relative dead legs
Delays between installation-commissioning-use
Circulation of hot water is between 60°C & 50°C
Aerators and coarse filters increase surface area

19. Why does the Flying Fickle Finger of Fait also point at Thermostatic Mixing Valves(TMVs)?
Dan Rowan and Dick Martin

20. Factors contributing to contamination- are TMVs and infrared taps an issue?
Contamination occurs within the last 2 metres of the distribution system
TMVs contain larger surface areas of polymers which will support growth through liberation of utilisable carbon
Mixed water exiting a TMV is not hot enough to pasteurise
Flows are reduced and less turbulence to scour biofilm
P. aeruginosa comes pre-installed
Installation may be incorrect
Infra red switching taps contain polymer diaphragms adding to the utilisable carbon load

21. What has been done about the problem?
Produced interim guidance to assist in the prevention of the problem
Organisation-water safety plan
Risk assessment
Water testing
Produce an appendix to HTM 04-01: The control of Legionella, hygiene, “safe” hot water, cold water and drinking water systems

22. What needs still to be done
revise HSE L8 document to take into account water quality and opportunistic infection other than Legionella.
Establish a standard for water AT THE POINT OF USE in healthcare premises.
Hygiene
Washer disinfectors
Pharmacies

24. And that’s all I have time for folks

25. Still to be achieved in water safety
Encourage the industry to seek engineering solutions to the problem of tap & TMV design
Commission research
Materials
Growth
Biofilm

26. Utilisable carbon sources added from materials in buildings
Water Regulation Advisory Schemes ( Water Supply (Water Fitings) Regs 1999
fitting approval
showers
thermostatic mixer valves
(Buildcert, MES D08)
material approval BS

27. England's DH responds

30. 600C
<200C
410C
Diagram illustrating the components of a thermostatic mixing valve (TMV) & faucet
Hot water circulates continuously with a minimum temperature at the most distant part of 55°C. On return to the heat exchanger or calorifier the temperature must not be below 50°C.
Cold water distribution temperature must not exceed 20°C as this is the temperature above which Legionella will proliferate.
An adjustable thermostatic regulator that will blend incoming hot and cold water supplies to achieve an output at the faucet of between 41 and 43°C. The designs will require water to be provided above a certain pressureto function correctly.
The tap controls the flow at the faucet. Where these are operated by infrared sensors and an electronic solenoid, additional polymer surfaces are introduced together with a residual volume at a temperature that will encourage growth. {
The distance between the TMV and the tap or faucet can be critical. Water leaving the TMV is at most 43°C which is not sufficient to pasteurise. It will rapidly fall to ambient temperature and if contaminated will allow the proliferation of biofilm. Some devices incorporate the TMV within the tap design to minimise this distance.
The “flow straightener”, inserted at the tip of the faucet to reduce splashing. Often complex designs and are where scale and biofilm accumulate. They are always the leading “suspect” where there is a problem with P. aeruginosa. They are removable and manufacturers are producing designs of spout without them. The combination of water, air and utilisable carbon make them irisistable to P. aeruginosa.

31. John Wayne and Tiny Tim