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Prevention PortWaterborne Disease Management in Healthcare Settings
Healthcare-associated Infections and Emerging Infectious Diseases Workshops
January 28, 2020: Metairie
February 4, 2020: Bossier City
February 5, 2020: Lafayette
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The speaker does not have a financial or non-financial relationship with a commercial interest that would create a conflict of interest with this presentation.
Disclosure Statement
Objectives
By the end of this presentation, attendees will be able to:Describe transmission, burden, and prevention measuresLegionella pneumophila and Pseudomonas aeruginosa
Describe a Water Management Plan
Legionella pneumophila
Gram-negative rod-shaped bacteriafound naturally in the environment worldwide, usually
in aquatic environmentsat least 60 different species, ~20 implicated in human
disease
Natural Habitat
Occurs worldwidePrefers WARM WATERS with scale, sediment, metallic ions,
and commensal flora
Max multiplication from 25ºC to 45ºC (77-113F)
Reduction at >50ºC (122F)
No growth above 58.8ºC (138F)
Found in 1-30% of home hot water systems
Transmission
Generally is not present in sufficient numbers in environment to cause disease
Inhalation of water contaminated with Legionella
aerosols generated by cooling towers, showers, faucets, spas, respiratory therapy equipment, and fountains
Aspiration of contaminated potable water also proposed
NO Person-to-person transmission
Burden of Disease
CDC estimates:
8,000 –18,000 cases in the U.S. annually
130-300 in LA
Many infections not diagnosed or reported
~50 cases/year reported in Louisiana
Class B reportable; 1 Business Day
Reported Legionella Cases Louisiana, 1990-2017
Reported Legionella Cases and Incidence Rates per 100,000 Population Louisiana, 1990-2016
Burden of Disease80% of reported cases are SPORADIC
Outbreaks in hospitals, cruise ships, hotels, and other large buildings complex water systems
LegionellosisDisease occurs in 3 forms: Legionnaires’ Disease (LD)
Incubation 2-10 days Pneumonia illness accompanied by fever, cough, chills, myalgia, or
respiratory failure 10% of people who get sick with Legionnaires’ disease die; 25% of
healthcare associated cases
Pontiac Fever (PF) Incubation 1-2 days; lasts 2-5 days Flu-like illness (fever, chills, malaise) without pneumonia Self-limiting, does not benefit from abx
Extrapulmonary legionellosis (XPL) Disease outside the lungs (for example, associated with endocarditis,
wound infection, joint infection)
Risk FactorsRecent travel with an overnight stay outside of the home, including stay in a
healthcare facility
Exposure to hot tubs
Recent repairs or maintenance work on domestic plumbing
Renal or hepatic failure
Diabetes
Chronic lung disease
Systemic malignancy
Smoking (current or historical)
Immune system disorders
Age ≥50 years
Diagnosis Culture: Isolation of Legionella from respiratory secretions,
lung tissue, pleural fluid, or a normally sterile site
+Detects all species and serogroups+Clinical & environmental samples can be molecularly compared-Technically difficult & slow-May be affected by abx
Urinary Antigen: Detection L. pneumophila serogroup 1 antigens in the urine
+Rapid-Can only identify Lp1-Cannot molecularly compare to environmental samples
Diagnosis
Nucleic Assay: detection of Legionella species by PCR
Seroconversion: Four-fold rise in ab titer to Legionella by indirect immunoflourescent antibody assay (IFA)
+Less affected by abx-1 elevated ab titer does NOT confirm case of recent Legionellosis: 5-10% of population have single acute titers ≥1:256
Healthcare Associated Cases
Presumptive: Patient had 10 or more days of continuous stay at a healthcare facility during the 14 days before onset of symptoms.
Possible: Patient had exposure to a healthcare facility for a portion of the 14 days prior to onset.
Outbreak Definitions
Dependent on the circumstances behind the cases exposure Travel-associated: CDC defines travel-associated outbreaks as two or more
Legionnaires’ disease cases associated with the same travel accommodation in a 12-month period.
Healthcare-associated: ≥1 case of presumptive healthcare-associated Legionnaires’ disease at any time or ≥2 cases of possible healthcare-associated Legionnaires’ disease within 12 months of each other
Community-associated: You have identified one or more cases of Legionnaires’ disease at a correctional facility or other facility where people cannot leave the premises or you have analyzed available data and found an increase in Legionnaires’ disease in a certain geographic area
Prevention Measures Grows poorly at < 20°C (68°F) and > 50°C (122°F) Killed at temperatures > 58.8°C (138°F) Susceptible to chlorine and bromine disinfectants, ozone,
heavy metal ions, and UV lightNebulizer, respiratory therapy equipment: Use sterile
water, do not let water stand, clean regularly
Prevention Measures
Hot water systems:flushing for >5min at temp > 65°C
hyperchlorination but causes corrosion
May grow back unless hot water maintained at ≥ 50°C but risk of scalding users
cold water at ≤ 20°C
residual chlorine at ≥ 1-2 mg/L of free chlorine
remove scale and sediments
Mentimeter Question #1What is the threshold of healthcare acquired Legionellosis cases to be considered an outbreak?
a) 1 presumptive healthcare acquired case
b) 2 presumptive healthcare acquired cases
c) 2 possible healthcare acquired cases in 12 months
d) 4 possible healthcare acquired cases in 12 months
e) a&c
f) b&d
1. Go to www.menti.com on either your mobile device or computer’s web browser.
2. Use the code shown on the screen to participate in live polling for this activity.
3. See results.
www.menti.com
Enter Code
Pseudomonas
Bacteria commonly found in soil and waterMost common causing infection Pseudomonas aeruginosaCauses infections in the blood, lungs (pneumonia), or other parts of
the body after surgery
Transmission
Live in the environment and can be spread to people in healthcare settings when they are exposed to water or soil that is contaminated with these germs.
Person to person through: contaminated hands
Equipment
Surfaces
Burden of Disease
In 2017, multidrug-resistant Pseudomonas aeruginosa caused an estimated 32,600 infections among hospitalized patients and 2,700 estimated deaths in the United States
Cases Over Time
Who is at risk?
Those most at risk include patients in hospitals, especially those:on breathing machines (ventilators)
with devices such as catheters
with wounds from surgery or burns
Prevention Measures
Patients and caregivers should:Keep their hands clean to avoid getting sick and spreading germs
that can cause infectionsWash their hands with soap and water or use alcohol-based hand sanitizer,
particularly before and after caring for wounds or touching a medical device
Remind healthcare providers and caregivers to clean their hands before touching the patient or handling medical devices
Allow healthcare staff to clean their room daily when in a healthcare setting
Water Management Plan
Limits germ growth by:Keeping hot water temperatures high enough
Making sure disinfectant amounts are right
Keeping water flowing (preventing stagnation)
Operating and maintaining equipment to prevent slime (biofilm), organic debris, and corrosion
Monitoring factors external to buildings, such as construction, water main breaks, and changes in municipal water quality
Water Management Plan - Components
1. Establish a water management program team
Water Management Plan - Components
2. Describe the building water systems using flow diagrams and a written description
Include details like where the building connects to the municipal water supply, how water is distributed, and where hot tubs, water heaters or boilers, and cooling towers are located.
Water Management Plan - Components
3. Identify areas where Legionella could grow and spread
Identify where potentially hazardous conditions could occur in your building water systems, such as areas where water temperature could promote Legionella growth or where water flow might be low.
Healthcare facilities think about:Areas where medical procedures may expose patients to water
droplets, such as hydrotherapy
Areas where patients are more vulnerable to infection, such as bone marrow transplant units, oncology floors, or intensive care units
Water Management Plan - Components
4. Decide where you need to apply control measures and how to monitor them.
Establish control measures and limits for each hazardous condition, as well as plans for where and how to monitor them.Control measures are actions you take in your building water
systems to limit growth and spread of Legionella, such as heating, adding disinfectant, or cleaning.
Control limits are the maximum value, minimum value, or range of values that are acceptable for the control measures that you are monitoring to reduce the risk for Legionella growth and spread.
Water Management Plan - Components
5. Establish ways to intervene when control limits are not met.
Determine what corrective actions or contingency responses to take when control measures are outside of the control limits you established.
Construction on a floor
Documents all activities
Daily flushing of both hot/cold water
Increase frequency of temperature and chlorine monitoring
Water Management Plan - Components
6. Make sure the program is running as designed and is effective.
Verification: Are we doing what we said we would do?
Validation: Is our program actually working?
Update the program when necessary.
Water Management Plan - Components
7. Document and communicate all activities.
Document all the activities and communicate with building occupants, employees, and colleagues on a continual basis. If an event triggers you to review or update your water management program, remember toUpdate the flow diagrams, associated control points, control limits, and
corrective actions
Update the written description of your building water systems
Train those responsible for implementing and monitoring the updated program
Water Management Plan - Toolkit
https://www.cdc.gov/legionella/downloads/toolkit.pdf
