INFECTION PREVENTION AND CONTROL


following some outbreaks, which prompted the purchase of a UV machine. Since the introduction, levels have plummeted. Dr. Garvey went on to highlight a paper which looked at Pseudomonas aeruginosa infection in augmented care areas in four large UK hospitals (Halstead et al, 2021).8 Over a 16-week period, all water outlets in the augmented care units of four hospitals were sampled for Pseudomonas aeruginosa (P. aeruginosa), and clinical isolates were collected. The outlet and clinical isolates underwent whole-genome sequencing (WGS).


Persistently positive outlets Outlets were positive in each hospital, and there were 51 persistently positive outlets in total. WGS identified likely transmission from outlets to patients in three hospitals for P. aeruginosa positive patients. Approximately 5% of patients in the study ‘definitely’ acquired their P. aeruginosa from their water outlets in the intensive care unit. Extensive evidence of transmission was found from the outlet to the patients – particularly in the newest hospital, which had the highest rate of positive outlets. The overall findings suggest that


water outlets are the most likely source of P. aeruginosa nosocomial infections in some settings, and that widespread introduction of control measures would have a substantial impact on infections. Dr. Garvey showed a photo of a sink with


paper towels on the floor, surrounding the area, to demonstrate just how far water is dispersed in the room, as well as an image of a water droplet on impact – highlighting the potential spread and trajectory of waterborne pathogens in aerosols. He went on to explain how can we tackle the


risk of Pseudomonas aeruginosa from an engineering perspective, highlighting a paper co-authored with Christina Bradley, among others, which looked at possible interventions on a critical care unit. Water sampling undertaken on the ICU indicated that 30% of the outlets were positive for P. aeruginosa at any one time. Molecular typing of patient and water isolates via Pulsed Field Gel Electrophoresis suggested there was a 30% transmission rate of P. aeruginosa from the water to patients on the ICU. From February 2014, QEHB implemented engineering interventions, consisting of new tap outlets and Pall point-of-use filters, as well as holistic measures, from February 2016, including a revised tap cleaning method, and appropriate disposal of patient wastewater. Breakpoint models indicated that the engineering and holistic interventions resulted in a significant (p<0.001) 50% reduction in the number of P. aeruginosa clinical patient isolates over a year.9


Dr. Garvey pointed out


that appropriate management of water, including both holistic and engineering interventions, is needed to stop transmission of P. aeruginosa from water to patients. The disposal of patient wastewater, cleaning of tap outlets, and cleaning of medical equipment, all need to be considered, along with engineering solutions. “We had three patients who had central


line infections involving P. aeruginosa. When we looked at this, they all had the same type. The tap in the IV prep room did not have a Pall filter, and the infusion therapy procedure trays were being washed in the water. This shows the importance of teaching staff about cleaning,” Dr. Garvey explained.10 The speaker further highlighted


new guidelines on automated room decontamination published by a Healthcare Infection Society Working Party.11


The document states that ‘good


practice’ includes: n Manual cleaning should be completed to the same high standard regardless of the subsequent use of automated cleaning devices.


n On first use of a fumigant or ultraviolet light in a specific room design, efficacy of sealing should be monitored to ensure safety.


n Prioritise different cleaning systems to the type of infection of the most recent room occupant by use of a red/amber/ green rating based on local nosocomial infection rates.


n Remove foam materials from the room if fumigant is used, unless sealed under an impervious cover.


n Before purchasing or renting a system, run a mock decontamination cycle in a hospital room to determine turnaround times.


n After purchasing an ultraviolet-light decontamination system, consider the impact on surface finishes such as whitened polyvinyl chloride (PVC) before purchasing other equipment, and ask the equipment supplier to confirm compatibility.


n Monitor levels of fumigant or ultraviolet light at regular intervals during the contract to ensure efficacy.


n When adopting a new automated system or disinfecting a new room design, conduct microbiological culture tests (if permitted in the hospital), or take in-use environmental swab tests before and after disinfection to confirm efficacy.


Ultimately, Dr. Garvey argued that


August 2022 Health Estate Journal 53


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