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FACILITIES MANAGEMENT


with elevated filter outlet that increase the activity space are therefore a helpful barrier measure against water outlet- directed RC. In addition to water orientation, the


intensity of the water stream plays a role. Aggressive water stream naturally enhances back-splashing and thereby water outlet-directed RC. When wound rinsing, extra care should be taken not to use an aggressive water stream, leading to back-splashing organic matter and bacteria from the wound to the shower surface. A water flow regulator, enabling a steady water stream independent of water pressure and tap handle opening intensity, is a helpful barrier measure but also a potential biofilm trap. There are POU filters available with integrated water flow regulators.


Tap and sink design Sinks should be large enough to contain most splashes and wall-mounted to facilitate cleaning. Swan-neck tap outlets should be avoided since they do not empty after use.10 Integral back outlets are preferable since they enhance the activity space and facilitate sink cleaning.11 Unfortunately, there seem to be no


gold standard against contamination of the tap control. Elbow-operated lever tap handles are still touched with hands by most of its users. Sensor taps, helping for infection prevention by the no-touch feature, contain a solenoid valve, which could serve as bacteria trap.12 Most hospital sinks in the UK, for


example, have the drain hole at the rear of the sink, which also serves as a barrier measure for water outlet-directed RC, since back-splashing is minimised. Unfortunately, this feature is seldom integrated in other parts of Europe. Fast drainage can additionally serve as biofilm-preventing measure. Getting rid of biofilm-enhancing equipment is a good preventative measure in particular for water supply- directed RC. Aerators, often made of plastic material, have ideal conditions for the growth of aerobic bacteria by mixing air and water producing aerosols. The WHO recommends not to use aerators and diffusers in taps, especially in high- risk areas.4 As an ultimate barrier measure to avoid drain-directed RC and water outlet-directed RC, the sink should not be located in the patient room.13


Siphon and sewage system aerosols Aerosols from the drain have higher concentrations of bacteria compared to those from the sink wall, whose smooth surface in contrast to drain and siphon can also be regularly cleaned from nutrients for biofilm growth or even coated with bacteriostatic additives. Even worse, studies have shown that bacteria can grow upwards the siphon


88


100.0 75.0


Ag+ Bacteria


>4.2 log reduction >99.9% reduction


50.0


25.0


Permanent protection


0.1 0 1 2 12 Time (hours)


Efficacy of bacteriostatic additives, antimicrobial silver in reducing surface bacteria growth.


through biofilm production at a speed of up to 2.5cm per day. There is equipment available for siphon thermal disinfection as well as anti-backsplash drain hole inlets to reduce colonization respectively spreading from the drain. Drain-directed RC-related outbreaks has been documented in two studies.11,14 In the first study, an outbreak of multidrug-resistant P. aeruginosa, involving 85 patients, as well as a smaller outbreak in a unit of another hospital involving four cases could be linked to strains in the sewage system.11


In the other


report, one patient was infected and several showers, taps and an air sample were colonised with carbapenemase- producing P. aeruginosa, most probably through airborne transmission from a shower drain of a collection sewage point connected to all mentioned outlets.14 When constructing new hospitals, showers with separated sewage systems are preferable to minimise outbreaks related to drain-directed RC.


Check valves against water supply-directed RC Dental practices are at enhanced risk of water supply-directed RC since they usually experience a frequent exchange of patients treated with instruments in direct oral contact and connected to the water supply. In dental facilities, streptococci were identified in the water supply, which are known to be from oral origin.2 The gold standard barrier measure to


prevent water supply-directed RC is a check valve (different from a simple non-return valve) setting a literal barrier between bacteria and the water distribution system. Check valves need


to be approved according to national legislation (UK: BS EN 13959; Germany: DIN 1717, DIN 1988-100; most European countries: EN 1717). There are POU filters available with integrated check valves.


Bacteriostatic additives To reduce biofilm growth on its surface, water outlet equipment can be equipped with bacteriostatic additives as a key preventive measure to reduce water outlet-directed RC, in form of coating or integrated in the material. Since coating always bears the risk of being worn out, material integration is preferable. The most used bacteriostatic additives in water outlet equipment are based on silver or copper. The main construction material should


be approved to national drinking water certifications (UK: WRAS/BS6920, Germany: KTW and DVGW W270; France: ACS; USA: NSF 61) and not leach out material supporting biological growth. There is an enhanced risk of water


supply-directed RC through biofilm in shower hoses, exposed to mixed water, long stagnation intervals, and mainly made of flexible polymeric materials, which have a significantly higher leaching of biofilm-enhancing organic carbon than piping material. A lack of disinfectant, the use of new showers, bad material quality and irregular use all contribute to an increased biofilm formation.15 Bacteriostatic additives can help


reducing biofilm. In an article in Health Estate Journal from July 2020, Johs. Tandrup proved in a lab trial that shower hoses with bacteriostatic additives can significantly reduce CFU-numbers and P aeruginosa for up to 12 weeks.16


IFHE DIGEST 2021 24


Bacteria (%)


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