As the Centers for Disease Control and Prevention (CDC) expands its focus on waterborne pathogens, infection preventionists are viewed as having a critical role in their facilities’ water management plans.

“We envision these water management programs to be very multidisciplinary — they require expertise from different areas of the hospital,” says Kiran M. Perkins, MD, MPH, a team lead for outbreak and response at the CDC. “IPs are an obvious part of that program. They play a critical role in this area. They need to really think through all the areas of the hospital where patients could be exposed to water and increased risk of infections.”

Perkins and colleagues “reviewed internal CDC records from Jan. 1, 2014, through Dec. 31, 2017 … to identify consultations that involved potential or confirmed transmission of water-related organisms in healthcare.” The study¹ excluded Legionella, which is under the purview of another branch at the CDC.

“Of 620 consultations during the study period, we identified 134 consultations (21.6%), with 1,380 patients, [that were related to water in a healthcare facility]," Perkins and colleagues wrote.

“We identified a variety of plausible water-exposure pathways, including medication preparation near water splash zones and water contamination at the manufacturing sites of medications and medical devices,” they reported. (See the related story in this issue for more information.)

Although water-related investigations comprise almost one-fourth of the CDC consultations reviewed, they probably only represent a fraction of these outbreaks nationally.

Waterborne infections really came to the fore in 2017, when the Centers for Medicare & Medicaid Services (CMS) mandated water management programs after a series of Legionella outbreaks. While the primary focus of the CMS memo has been Legionella, the agency document also calls for water management programs to control “other opportunistic pathogens in water.”²

“The way the CMS memo is worded, we are hopeful that employers understand it is not just specific to Legionella,” Perkins said.

Other waterborne pathogens of concern include nontuberculous mycobacteria (NTM), Pseudomonas species, and a host of other bugs.

“These organisms can be transmitted to patients, directly or indirectly, through typical water uses involving showers, sinks, and toilets,” the CDC investigators report.

As a resource for investigating water-related outbreaks, Perkins recommends guidelines³ on the CDC’s new “From Plumbing to Patients” website, available at: https://bit.ly/2MG64iI.

The guidelines include checklists and key issues to consider when investigating an outbreak that may be related to water.

“That is targeted at what a facility might be encountering — maybe an outbreak or spike of cases of water-related infections,” Perkins says.

“They can see if there is something that could be remediated. That checklist asks about the pH of the water, the hot and cold temperatures — things of that nature. It helps guide facilities to look at certain areas of water quality.”

Unlike Legionella investigations, which can be triggered by a single case, investigating other waterborne pathogens requires a little more detective work.

“With the other water-related organisms, we don’t have as much, at this point, of a systematic approach,” Perkins says. “We are learning more as we go. I think what triggers an investigation is really dependent on the organism, the setting, and the patient population.”

The critical concept in a water management program is to be proactive, not waiting for infections to appear before you begin looking at factors that could degrade water quality.

“Make sure you are doing everything you can at the facility level to [ensure] that these organisms are not being perpetuated throughout the water system or causing biofilm formation,” she says.

Water Hazards

One of the recurrent causes of waterborne outbreaks in healthcare is storing patient care items or preparing medication near sinks, toilets, or other water sources.

“We hear about that all the time,” Perkins says. “Providers, nursing staff, medical techs — all of the people that are entering the patient area — need to understand that basic concept: Keep medication and patient care items away from water sources.”

Some of this can be mitigated by design — for example, by using stand-alone sinks that do not have attached countertops.

“Another engineering issue with sinks is when the faucet is right over the drain,” she says.

“There is a risk of a direct splash up from the drain. There could be multidrug-resistant organisms [MDROs] in the drain, and those can splash up and colonize the faucet.”

If that occurs, the faucet may become contaminated with colonies of bacteria, in some cases contaminating the water as it flows through, she notes.

To avoid this recurrent cause of water-related outbreaks, some healthcare facilities are offsetting faucets so they are not placed directly over the drain.

With Legionella excluded in this study, the CDC found that NTM was the most common cause of water-related healthcare outbreaks, often in connection with surgery or contaminated medical devices.

“This is where we really have to pay attention to the continuum of clinical care — all areas where water can be introduced,” she says.

“For example, should this be a sterile water source instead of just tap water?”

Of course, tap water is safe for public consumption, but it poses a threat to patients if it enters the body during medical procedures.

“We have consulted on outbreaks of NTM in outpatient settings, where they are doing things like cosmetic or liposuction procedures,” Perkins says. “They are doing somewhat invasive procedures but not using sterile water. This is an extreme example, but rinsing a wound with tap water is obviously a set up for an NTM or other water-related organisms.”

NTM outbreaks also are being identified in clinics that perform injections, such as those for joint pain.

“Those are common procedures where there could be the introduction of water,” she says. “Practitioners need to really pay close attention to that.”

More than one-third of the CDC water-related consultations involved pathogens that were resistant to multiple antibiotics.

“These MDROs are definitely in the environment of patient care settings,” Perkins says.

“Often, these organisms are living in sink drains, toilets, on bed rails and things of that nature. If they are not paying close attention to infection control practices, healthcare workers could potentially transmit these MDROs to patients.”

As more invasive procedures move beyond the hospital, there is the expectation that more water-related infections will occur in ambulatory care.

“Unfortunately, we don’t have a national surveillance system for all water-related organisms to know if they are increasing nationwide or in ambulatory care settings,” Perkins says. “I think, anecdotally, there are reasons that they could be. Outpatient settings often do not have the regulatory oversight and IP capacity that acute care settings have.”

REFERENCES

1. Perkins KM, Reddy SC, Fagan R, et al. Investigation of healthcare infection risks from water-related organisms: Summary of CDC consultations, 2014-2017. Infect Control Hosp Epidemiol 2019;40(6):621-626.
2. CMS. Center for Clinical Standards and Quality/Survey & Certification Group. Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires’ Disease (LD). Ref: S&C 17-30-ALL. June 02, 2017: http://go.cms.gov/2r3ue6B.
3. CDC. Tap Water Quality and Infrastructure Discussion Guide for Investigation of Potential Water-Associated Infections in Healthcare Facilities. Updated Dec. 11, 2018. Available at: https://bit.ly/31Efjn5.