Infection Control & Hospital Epidemiology


utility to minimize transmission of pathogens from wastewater drains. As part of a multifaceted response to ongoing transmis- sion of Klebsiella pneumoniae carbapenemase-producing organ- isms (KPRO) among ICU patients, Mathers et al17 installed covers on hoppers in ICU rooms and noted a subsequent decrease in acquisition of KPROs following the intervention (odds ratio [OR], 0.51; 95% confidence interval [CI], 0.31–0.81; P=.003). Similarly, Livingston et al18 demonstrated the potential efficacy and feasibility of using a novel drain cover that allows passage of water from sink bowl to drain but prevents dispersion of patho- gens from a contaminated sink drain to surrounding surfaces. Compared to no intervention, the drain cover prevented con- tamination of the sink interior (0 vs 18%) and surrounding sur- faces (0 vs 11%) in experiments when water was run for 30 seconds to simulate hand washing.18 Questions regarding the long-term feasibility of use, cleaning,


and maintenance schedules will need to be answered before drain cover types of interventions are adopted widely for use in hospital patient rooms. Livingston et al9 used the drain covers in ICU sinks for a 14-day trial period, changing the covers after 7 days of use. When used in this way, the outer surface became colonized with gram-negative bacteria in only 1 of 20 sinks, and there was still no detectable transmission of bacteria from the sink drain or cover when the cover had been in place for 7 days.18 Still, a 7-day replacement schedule might present challenges for real-world implementation of such a device, particularly when ICU patient lengths of stay are highly variable, making it infeasible to rely on a standardized point in time (eg, terminal clean following patient discharge) for replacement.


Engineering modifications to reduce biofilm formation


As previously discussed, attempts to disinfect sinks drains once biofilms become colonized with multidrug-resistant organisms have typically failed.3 Novel disinfectant strategies that can suc- cessfully penetrate or mechanically disrupt biofilms may be more effective than typical chemical disinfectants. Additionally, tech- nologies that do not require manual application but instead provide continuous disinfection are appealing. Mathers et al17 reported a decrease in KPRO acquisition following the installation of devices that heat and vibrate on the exterior of P traps. However, because this intervention coincided with the installation of hopper covers in the same ICU rooms, the impact of the vibrator and heater units could not be determined.17 In this issue, Livingston et al9 demonstrate potential efficacy of ozone to dis- infect contaminated sink drains in an experimental setting. We anticipate that many similar technologies will enter the market- place; however, additional study is needed to demonstrate their efficacy and cost-effectiveness. In summary, recent studies provide mounting evidence that


in-room sink drains are an important and underrecognized reservoir for pathogens in the chain of hospital-acquired infec- tion. While published epidemiologic investigations have linked sink drains to transmission of multidrug-resistant organisms, we suspect that multidrug-resistant pathogens only represent the “tip of the iceberg” and that sink drains are also a source of trans- mission of susceptible gram-negative pathogens that has not yet been quantified. Multifaceted prevention and mitigation strategies are needed to minimize the risk of pathogen transmission from contaminated sinks. At a minimum, we need to return to the basics of infection prevention with clear separation of clean and dirty tasks. As such, sinks used for clean tasks such as hand


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washing should not be used for disposal of body fluids. The most promising adjunctive solutions include (1) design modifications of sinks and hospital rooms that minimize dispersion of pathogens from the drain and contamination of surrounding surfaces and (2) technologies that provide continuous disinfection of sink drains.


Acknowledgments. Financial support. No financial support was provided relevant to this article.


Conflicts of interest. All authors report no conflicts of interest relevant to this article.


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