Survey on legislation
regarding wet cooling systems in European countries
Ricketts
KD,
Joseph C,
Lee J,
Wewalka G;
European
Working Group for Legionella Infections
Health Protection Agency,
Centre for Infection, Respiratory Diseases Department, London, United Kingdom.
katherine.ricketts@hpa.org.uk
Euro Surveill.
2008 Sep 18;13(38). pii: 18982.
ABSTRACT:
Wet cooling
systems are often associated with large outbreaks of Legionnaires' disease.
Several European countries have legislation for registering such systems. The
authors aimed to obtain an overview of the situation in Europe. A
questionnaire survey was sent to 35 of the countries that collaborate in the
European Working Group for Legionella Infections. In two countries it was
passed to a regional level (to three regions in both Belgium and the United
Kingdom), so that 39 countries or regions were sent the survey; 37 responded.
Nine countries stated having legislation for the registration of wet cooling
systems. Separate legislation exists at a regional level for two regions in
Belgium and all three regions in the UK, giving a total of twelve
countries/regions with legislation. In nine of these countries/regions, the
legislation has been introduced since 2001. All of these countries/regions
require periodic microbiological monitoring between twice a year and weekly;
in nine, the legislation requires periodic inspection of the systems.
Regulations for the registration of wet cooling systems should be required by
public health authorities. During an outbreak of legionellosis, a register of
wet cooling systems can speed up the investigation process considerably. The
authors believe that the European Centre for Disease Prevention and Control (ECDC)
should take the initiative to propose European Community (EC) regulations for
all Member States.
Changes in prevention and
outbreak management of Legionnaires disease in the Netherlands between two
large outbreaks in 1999 and 2006
Sonder GJ,
van den
Hoek JA,
Bovée LP,
Aanhane FE,
Worp J,
Du Ry van
Beest Holle M,
van
Steenbergen JE,
den Boer
JW,
Ijzerman
EP,
Coutinho
RA.
Gemeentelijke
Gezondheidsdienst (GGD) Amsterdam (Public Health Service Amsterdam) Department
of Infectious Diseases, Amsterdam, the Netherlands.
gsonder@ggd.amsterdam.nl
Euro Surveill.
2008 Sep 18;13(38). pii: 18983.
ABSTRACT:
We describe an
outbreak of Legionnaires' disease in 2006 in Amsterdam, the Netherlands.
Comparisons with the outbreak that took place in 1999 are made to evaluate
changes in legionella prevention and outbreak management. The 2006 outbreak
was caused by a wet cooling tower. Thirty-one patients were reported. The
outbreak was detected two days after the first patient was admitted to
hospital, and the source was eliminated five days later. The 1999 outbreak was
caused by a whirlpool at a flower show, and 188 patients were reported. This
outbreak was detected 14 days after the first patient was admitted to
hospital, and two days later the source was traced. Since 1999, the awareness
of legionellosis among physicians, the availability of a urinary antigen tests
and more efficient early warning and communication systems improved the
efficiency of legionellosis outbreak management. For prevention, extensive
legislation with clear responsibilities has been put in place. For wet cooling
towers, however, legislation regarding responsibility and supervision of
maintenance needs to be improved.
Role of environmental
surveillance in determining the risk of hospital-acquired legionellosis: a
national surveillance study with clinical correlations
Stout JE, Muder RR, Mietzner
S, Wagener MM, Perri MB, DeRoos K, Goodrich D, Arnold W, Williamson T, Ruark
O, Treadway C, Eckstein EC, Marshall D, Rafferty ME, Sarro K, Page J, Jenkins
R, Oda G, Shimoda KJ, Zervos MJ, Bittner M, Camhi SL, Panwalker AP, Donskey
CJ, Nguyen MH, Holodniy M, Yu VL; Legionella Study Group.
VA Pittsburgh Healthcare
System, Pittsburgh, PA, USA. vly@pitt.edu
Infect Control Hosp Epidemiol.
2007 Jul;28(7):818-24.
ABSTRACT: OBJECTIVE:
Hospital-acquired Legionella pneumonia has a fatality rate of 28%, and the
source is the water distribution system. Two prevention strategies have been
advocated. One approach to prevention is clinical surveillance for disease
without routine environmental monitoring. Another approach recommends
environmental monitoring even in the absence of known cases of Legionella
pneumonia. We determined the Legionella colonization status of water systems
in hospitals to establish whether the results of environmental surveillance
correlated with discovery of disease. None of these hospitals had previously
experienced endemic hospital-acquired Legionella pneumonia. DESIGN: Cohort
study. SETTING: Twenty US hospitals in 13 states. INTERVENTIONS: Hospitals
performed clinical and environmental surveillance for Legionella from 2000
through 2002. All specimens were shipped to the Special Pathogens Laboratory
at the Veterans Affairs Pittsburgh Medical Center. RESULTS: Legionella
pneumophila and Legionella anisa were isolated from 14 (70%) of 20 hospital
water systems. Of 676 environmental samples, 198 (29%) were positive for
Legionella species. High-level colonization of the water system (30% or more
of the distal outlets were positive for L. pneumophila) was demonstrated for 6
(43%) of the 14 hospitals with positive findings. L. pneumophila serogroup 1
was detected in 5 of these 6 hospitals, whereas 1 hospital was colonized with
L. pneumophila serogroup 5. A total of 633 patients were evaluated for
Legionella pneumonia from 12 (60%) of the 20 hospitals: 377 by urinary antigen
testing and 577 by sputum culture. Hospital-acquired Legionella pneumonia was
identified in 4 hospitals, all of which were hospitals with L. pneumophila
serogroup 1 found in 30% or more of the distal outlets. No cases of disease
due to other serogroups or species (L. anisa) were identified. CONCLUSION:
Environmental monitoring followed by clinical surveillance was successful in
uncovering previously unrecognized cases of hospital-acquired Legionella
pneumonia.
Experimental based
experiences with the introduction of a water safety plan for a multi-located
university clinic and its efficacy according to WHO recommendations
Dyck A, Exner M, Kramer
A.
Institute for Hygiene and
Environmental Medicine of the Ernst-Moritz-Arndt-University, Greifswald,
Germany. alexander.dyck@web.de
BMC Public Health. 2007 Mar
13;7:34.
BACKGROUND: Due to the high
number of immunosuppressed and other predisposed patients hospitals have to
control and ensure the microbiological water quality. The origin for the
occurrence of pathogenic microorganisms in water pipes is the formation of
biofilm. METHODS: For the permanent control of water safety a water safety
plan (WSP) was realized as recommended by the WHO following the principle
"search and destroy". The WSP is based on an established HACCP concept due to
the special focus. The most important measures include the concept for sample
taking depending on patient risk. 3 different categories) are distinguished:
risk area1 (high infection risk), risk 2 (moderate infection risk), and risk
area 3 (not increased infection risk). Additionally to the threshold value of
the German law for the quality of drinking water (TrinkwV) three more limiting
values were defined (warning, alert, and worst case) for immediate risk
adapted reaction. Additional attention has to be focussed on lavatory sinks,
which are an open bacterial reservoir. Therefore continuous disinfecting
siphons were installed as part of the WSP in high risk areas.If extended
technical equipment is not available, especially for immunocompromised
patients the following measures are easy to realize: boiled (or sun exposed)
water for nursing procedures as well alimentary use, no showering. RESULTS:
Comparing data over 3 years the microbial water quality was significantly
improved resulting in no new case of nosocomial Legionella pneumoniae and
decrease in neonatal sepsis. CONCLUSION: According to average situations with
highly contaminated water system the management must be defined with
implementation of water task force, immediate providing of special equipment,
information of patients and staff and control of the water quality, an example
for successful decontamination of the hospital within 24 hours is given.
Outbreak detection and
secondary prevention of Legionnaires' disease: a national approach
Den Boer JW, Verhoef
L, Bencini MA, Bruin JP, Jansen R, Yzerman EP.
Municipal Health Service
Kennemerland, P.O. Box 5514, 2000 GM Haarlem, The Netherlands.
jwdenboer@hdk.nl
Int J Hyg Environ Health.
2007 Jan;210(1):1-7.
BACKGROUND: To stop a
possible outbreak of Legionnaires' disease (LD) at an early stage an outbreak
detection programme was installed in The Netherlands. METHODS: The programme
consisted of sampling and controlling of potential sources to which LD
patients had been exposed during their incubation period. Potential sources
were considered to be true sources of infection if two or more LD patients
(cluster) had visited them, or if available patients' isolates and
environmental Legionella spp. were indistinguishable by amplified fragment
length polymorphism genotyping. RESULTS: Rapid sampling and genotyping as well
as cluster recognition helped to target control measures. Despite these
measures, two small outbreaks were only stopped after renewal of the water
system. The combination of genotyping and cluster recognition lead to 29 of
190 (15%) patient-source associations. CONCLUSION: Systematic sampling and
cluster recognition can contribute to outbreak detection and lead to
cost-effective secondary prevention of Legionnaires' disease.
The impact of new
guidelines in Europe for the control and prevention of travel-associated
Legionnaires' disease
Ricketts KD, Joseph
CA; European Working Group for Legionella Infections.
Respiratory Department,
Health Protection Agency Centre for Infections, 61 Colindale Avenue, London,
UK. katherine.ricketts@HPA.org.uk
Int J Hyg Environ Health.
2006 Nov;209(6):547-52.
ABSTRACT: On 1 July 2002,
EWGLINET introduced European guidelines for the control and prevention of
travel-associated legionnaires' disease. This paper presents the results
gathered by the surveillance scheme during the first two and a half years of
the operation of the guidelines (to the end of 2004). Two hundred and
thirty-seven new clusters and 70 cluster updates were identified.
Investigations at 146 sites returned positive samples for legionella, and the
proportion of positive sites reached over 60% in 2004. Thirty-four cluster
sites were reported to have been investigated satisfactorily, but have gone on
to be associated with subsequent cases ('repeater sites'). Fifty-one sites
were published on the European Working Group for Legionella Infections (EWGLI)
website; the publication states that EWGLINET cannot be confident that the
sites have adequate control measures in place. The operation of the guidelines
is discussed, and the situation in Turkey highlighted as a particular success.
Evaluation of standardized
scored inspections for Legionnaires' disease prevention, during the Athens
2004 Olympics
Hadjichristodoulou Ch,
Goutziana G, Mouchtouri V, Kapoula Ch, Konstantinidis A, Velonakis E,
Vatopoulos A, Kremastinou J.
Department of Hygiene and
Epidemiology, Faculty of Medicine, University of Thessalia, Larisa, Greece.
xhatzi@med.uth.gr
Epidemiol Infect. 2006
Oct;134(5):1074-81.
ABSTRACT: The study was
designed to determine the contribution of standardized scored inspections
implemented during the Athens 2004 Pre-Olympic and Olympic period, in
assessing the presence of Legionella spp. in water sites. Inspection grading
scores of 477 water supply systems, 127 cooling towers and 134 decorative
fountains were associated with the corresponding microbiological test results
of 2514 samples for Legionella spp. Nine violations of water supply systems
and nine of cooling towers significantly associated with positive
microbiological test results, and four violations of water supply systems and
one of cooling towers were among those designated as 'critical' water safety
hazards in the inspection reports. The study documents a strong correlation
[water supply systems (RR 1.92), cooling towers (RR 1.94)] between
unsatisfactory inspection scoring results and Legionella-positive
microbiological test results (in excess of 10,000 c.f.u./l) and suggests the
utility of inspection scoring systems in predicting Legionella proliferation
of water systems and in preventing Legionnaires' disease.
A
proactive approach to prevention of health care-acquired Legionnaires'
disease: the Allegheny County (Pittsburgh)
experience
Squier
CL, Stout JE, Krsytofiak S, McMahon J, Wagener MM, Dixon B,
Yu VL.
Association for Professionals in Infection Control and Epidemiology, Three
Rivers Chapter, and Veterans Administration Pittsburgh
Healthcare System, Pennsylvania, USA.
Am
J Infect Control. 2005 Aug;33(6):360-7.
BACKGROUND: The Allegheny County Health Department (ACHD) in Pennsylvania
distributed the first guidelines for prevention and control of health
care-acquired Legionnaires' disease (LD) by 1995. The proactive approach
advocated in the guidelines differed notably from that of the Centers for
Disease Control and Prevention (CDC) by recommending routine environmental
testing of the hospital water distribution system even when cases of health
care-acquired Legionnaires' disease had never been identified. OBJECTIVES:
Our purpose was to (1) evaluate the impact of the ACHD guidelines on the
Legionella diagnostic and preventive practices of health care facilities in
Allegheny and surrounding counties and (2) compare the incidence of health
care-acquired LD before and after issuance of the ACHD guidelines. METHODS:
CDC case reports of LD from 1991 to 2001 were tabulated and compiled by the
ACHD Infectious Disease Unit and the Association for Professionals in
Infection Control and Epidemiology, Inc, Three Rivers Chapter. A survey was
distributed to 110 hospitals and long-term care facilities in the region.
The results were analyzed as occurring either in the preguideline period
(1991-1994) or postguideline period (1995-2001). RESULTS: A significant
decrease in the number of health care-acquired cases was demonstrated
between the preguideline (33%) and postguideline (9%) periods (P=.0001). In
contrast, community-acquired cases increased from 67% pre guideline to 91%
post guideline. A total of 71% of the facilities were colonized with
Legionella. Disinfection of the water distribution system was initiated by
44% of facilities. Use of urinary antigen testing significantly increased
from 40% pre guideline to 79% post guideline (P=.0001). CONCLUSIONS: Health
care-acquired LD declined significantly after the issuance of guidelines for
prevention and control of health care-acquired LD. The decline was
associated with health care facilities performing routine environmental
monitoring of their water distribution systems followed by the initiation of
disinfection methods if indicated. Two unanticipated benefits were (1) cases
of LD in the community and long-term care facilities were uncovered as a
result of increased availability of Legionella tests and (2) litigation and
unfavorable publicity involving ACHD hospitals ceased.
Surveillance, prevention, and control of legionellosis in a tropical
city-state
Goh KT,
Ng DL, Yap J, Ma S, Ooi EE.
Am J
Infect Control. 2005 Jun;33(5):286-91.
ABSTRACT:
Legionellosis is endemic in Singapore, with sporadic cases reported
throughout the year. The absence of outbreak could be due to the low
prevalence of the highly pathogenic Pontiac subtype of Legionella
pneumophila in the urban environment. Mandatory maintenance of cooling
towers and water fountains has been put in place, and the effectiveness of
legislation in minimizing the occurrence and risk of outbreak of
legionellosis is being evaluated.
Prevention and control of health care-associated waterborne infections in
health care facilities
Exner M,
Kramer A, Lajoie L, Gebel J, Engelhart S, Hartemann P.
Am J
Infect Control. 2005 Jun;33(5 Pt 2):S26-40.
ABSTRACT:
The current article is a review of the public health risks attributable to
waterborne pathogens in health care. The consequences of health
care-associated infections (HAIs) are discussed. Not only are Legionella spp
involved in HAIs, but also Pseudomonas aeruginosa, other gram-negative
microorganisms, fungi, and amoeba-associated bacteria. This is particularly
noteworthy among immunocompromised patients. New prevention strategies and
control measures brought about through advanced planning, facility
remodelling and reconstruction, disinfection, and filtration have resulted
in a significant reduction of the incidence of waterborne HAIs. The positive
consequences of a comprehensive multibarrier approach including prevention
and control programs in health care facilities are discussed. Environmental
cultures are now integrated within the infection control program of some
European countries. In high-risk areas, the application of disposable
sterile point-of-use filters for faucets and shower heads appears to be the
practice of choice to efficiently control waterborne pathogens and to
prevent infections.
Efficacy of new point-of-use water filter for preventing exposure to
Legionella and waterborne bacteria
Sheffer PJ,
Stout JE, Wagener MM, Muder RR.
Am J
Infect Control. 2005 Jun;33(5 Pt 2):S20-5.
ABSTRACT:
Background Legionella species cause health care-acquired infections in
which immunocompromised patients are disproportionately affected.
Epidemiologic studies have demonstrated that point-of-use water fixtures are
the reservoirs for these infections. The current approach to prevention is
system-wide chemical disinfection of the hospital water system. These
methods affect both low-risk and high-risk areas. A more effective approach
to prevention may be a targeted approach aimed at protecting high-risk
patients. One option is the application of a physical barrier (filter) at
the point-of-use water fixture. Objectives To evaluate the ability of
point-of-use filters to eliminate Legionella and other pathogens from water.
Methods One hundred twenty-milliliter hot water samples were collected from
7 faucets (4 with filters and 3 without) immediately and after a 1-minute
flush. Samples were collected every 2 or 3 days for 1 week. This cycle was
repeated for 12 weeks. Samples were cultured for Legionella , total
heterotrophic plate count (HPC) bacteria, and Mycobacterium species. Results
Five hundred ninety-four samples were collected over 12 cycles. No
Legionella or Mycobacterium were isolated from the faucets with filters
between T = 0 and T = 8 days. The mean concentration of L pneumophila and
Mycobacterium from the control faucets was 104.5 CFU/mL and 0.44 CFU/mL,
respectively. The filters achieved a greater than 99% reduction in HPC
bacteria in the immediate and postflush samples. Conclusions Point-of-use
filters completely eliminated L pneumophila and Mycobacterium from hot water
samples. These filter units could prevent exposure of high-risk patients to
waterborne pathogens.
The
role of the intensive care unit environment in the pathogenesis and
prevention of ventilator-associated pneumonia
Crnich
CJ, Safdar N,
Maki DG.
Dennis G
Maki MD, University of Wisconsin Hospital and Clinics, 600 Highland Avenue,
Madison WI 53792.
Respir
Care. 2005 Jun;50(6):813-38.
ABSTRACT:
Ventilator-associated pneumonia is preceded by lower-respiratory-tract
colonization by pathogenic microorganisms that derive from endogenous or
exogenous sources. Most ventilator-associated pneumonias are the result of
exogenous nosocomial colonization, especially, pneumonias caused by
resistant bacteria, such as methicillin-resistant Staphylococcus aureus and
multi-resistant Acinetobacter baumannii and Pseudomonas aeruginosa, or by
Legionella species or filamentous fungi, such as Aspergillus. Exogenous
colonization originates from a very wide variety of animate and inanimate
sources in the intensive care unit environment. As a result, a strategic
approach that combines measures to prevent cross-colonization with those
that focus on oral hygiene and prevention of microaspiration of colonized
oropharyngeal secretions should bring the greatest reduction in the risk of
ventilator-associated pneumonia. This review examines strategies to prevent
transmission of environmental pathogens to the vulnerable
mechanically-ventilated patient.
The
pathogenesis of ventilator-associated pneumonia: its relevance to developing
effective strategies for prevention
Safdar N,
Crnich CJ,
Maki DG.
Dennis G
Maki, University of Wisconsin Hospital and Clinics, 600 Highland Avenue,
Madison WI 53792.
Respir
Care. 2005 Jun;50(6):725-41.
ABSTRACT:
Ventilator-associated pneumonia (VAP) is the most common nosocomial
infection in the intensive care unit and is associated with major morbidity
and attributable mortality. Strategies to prevent VAP are likely to be
successful only if based upon a sound understanding of pathogenesis and
epidemiology. The major route for acquiring endemic VAP is oropharyngeal
colonization by the endogenous flora or by pathogens acquired exogenously
from the intensive care unit environment, especially the hands or apparel of
health-care workers, contaminated respiratory equipment, hospital water, or
air. The stomach represents a potential site of secondary colonization and
reservoir of nosocomial Gram-negative bacilli. Endotracheal-tube biofilm
formation may play a contributory role in sustaining tracheal colonization
and also have an important role in late-onset VAP caused by resistant
organisms. Aspiration of microbe-laden oropharyngeal, gastric, or tracheal
secretions around the cuffed endotracheal tube into the normally sterile
lower respiratory tract results in most cases of endemic VAP. In contrast,
epidemic VAP is most often caused by contamination of respiratory therapy
equipment, bronchoscopes, medical aerosols, water (eg, Legionella) or air (eg,
Aspergillus or the severe acute respiratory syndrome virus). Strategies to
eradicate oropharyngeal and/or intestinal microbial colonization, such as
with chlorhexidine oral care, prophylactic aerosolization of antimicrobials,
selective aerodigestive mucosal antimicrobial decontamination, or the use of
sucralfate rather than H(2) antagonists for stress ulcer prophylaxis, and
measures to prevent aspiration, such as semirecumbent positioning or
continuous subglottic suctioning, have all been shown to reduce the risk of
VAP. Measures to prevent epidemic VAP include rigorous disinfection of
respiratory equipment and bronchoscopes, and infection-control measures to
prevent contamination of medical aerosols. Hospital water should be
Legionella-free, and high-risk patients, especially those with prolonged
granulocytopenia or organ transplants, should be cared for in hospital units
with high-efficiency-particulate-arrestor (HEPA) filtered air. Routine
surveillance of VAP, to track endemic VAPs and facilitate early detection of
outbreaks, is mandatory.
Reusable
terminal tap water filters for nosocomial legionellosis prevention
Vonberg
RP, Rotermund-Rauchenberger D, Gastmeier P.
Institut
fur Medizinische Mikrobiologie und Krankenhaushygiene, Medizinische
Hochschule Hannover, Carl-Neuberg-Str. 1,
30625, Hannover, Germany.
Ann Hematol. 2005
Jun;84(6):403-5.
ABSTRACT:
Hospital water supplies often contain Legionella spp. and therefore
represent a source of nosocomial infection especially for immunocompromised
patients in intensive care or organ transplant units. Therefore,
pathogen-free water should be provided for the care of these patients.
Approaches of long-term Legionella spp. eradication from the plumbing system
are rarely successful. Exposition prophylaxis might be another reasonable
approach in high-risk patient care. To investigate the ability to provide
water free of Legionella spp. with reusable water filters, a surveillance of
splash water samples was performed. After determining the burden of
Legionella spp. in the plumbing system of a paediatric oncological ward by
ten unfiltered splash water samples, ten designated water taps were provided
with terminal tap water filters that could be reprocessed by thermal
disinfection. A further 129 samples were taken after a usage interval of 7
days and 10 more samples after a usage interval of 21 days before
reprocessing the filters. All samples were checked for growth of Legionella
spp. as well as other pathogenic bacteria. A total germ count of all samples
was also performed. Half of the unfiltered splash water samples revealed
growth of Legionella spp. All filtered water samples remained free of
Legionella. Total germ count did not increase before a usage interval of 7
days. We believe the water filters tested are suitable for prevention of
nosocomial legionellosis when reprocessed after 7 days as recommended by the
manufacturer. To avoid retrograde contamination of filters, education of
staff and patients in handling these devices is mandatory.
Use of terminal tap water filter systems
for prevention of nosocomial legionellosis
Vonberg RP, Eckmanns T, Bruderek J, Ruden H, Gastmeier P.
Division of Hospital Epidemiology and Infection Control, Institute for
Medical Microbiology and Hospital Epidemiology, Medical School Hannover,
Carl-Neuberg-Str. 1, D-30625 Hannover, Germany.
J Hosp Infect. 2005
Jun;60(2):159-62.
ABSTRACT: Hospital water supplies often contain Legionella spp. and
represent a potential source of nosocomial infection, especially for
immunocompromised patients or those in intensive care units. Therefore,
pathogen-free water should be provided for such high-risk patients.
Surveillance of splash water was performed in high-risk patient care areas
at Berlin Charite-University Medicine (506 samples) and Medical School
Hannover (767 samples) to investigate the ability to provide water that was
free from Legionella spp. by the use of disposable, terminal tap water
filter systems with non-impregnated, as well as impregnated, filters with
prolonged usage intervals. Twenty (Berlin) and 32 (Hannover) water outlets
were provided with disposable filters with a pore size of 0.2 microm.
Testing of unfiltered tap water revealed growth of Legionella spp. in 53 of
210 (Berlin) and 30 of 32 (Hannover) samples. Non-impregnated, terminal,
disposable water filters at taps used for high-risk patient care led to
water free from Legionella spp. in 154 of 155 (99.4%) samples after three to
four days and in 137 of 141 (97.2%) samples after six to seven days. When
testing a new impregnated filter, 255 of 256 (99.6%) samples remained free
from Legionella spp. after continuous use for seven days, as recommended by
the manufacturers, and also after 10 days. Samples that were positive for
Legionella spp. contained 1-4 cfu/mL. We believe that an impregnated filter
system is suitable for the prevention of nosocomial Legionellosis in
high-risk patient care areas.
Surveillance of hospital water and primary prevention of nosocomial
legionellosis: what is the evidence?
O'Neill
E, Humphreys H.
Department of Clinical Microbiology, Royal College of Surgeons in Ireland,
Dublin, Ireland.
J Hosp
Infect. 2005 Apr;59(4):273-9.
ABSTRACT:
Hospital-acquired Legionnaires' disease may be sporadic or may occur as part
of an outbreak. As Legionella spp. are ubiquitous in many water systems, it
is not surprising that hospital water may be colonized with Legionella
pneumophila and other species. However, there is some controversy about the
relationship between the presence of legionella in hospital water systems
and nosocomial legionellosis. Primary prevention, i.e. measures to prevent
legionella in a hospital or healthcare facility with no previous documented
cases of nosocomial legionellosis, includes heightened awareness of
hospital-acquired Legionnaires' disease with appropriate laboratory
diagnostic facilities, and ensuring that the water system is well designed
and maintained in accordance with national standards, e.g. the circulating
hot water is maintained above 55 degrees C. Secondary prevention, i.e.
preventing further cases occurring when a case has been confirmed, should
include an investigation to exclude the hospital water system as a source.
However, the necessity to sample hospital water routinely to detect
legionella outside of outbreaks, i.e. as a component of primary prevention,
is unclear. Some studies demonstrate a clear link but others do not.
Differences between the patient populations studied, the methods of
laboratory diagnosis of clinical cases, the analysis of hospital water and
differences in the design of hospital water systems may partly explain this.
Whilst further research, probably in the form of multi-centred prospective
trials, is needed to confirm the relationship between environmental
legionella and hospital-acquired legionellosis, including establishing the
relative importance of L. pneumophila group 1 vs. non-group 1 and other
Legionella spp., each hospital should consider the spectrum of patients at
particular risk locally. Centres with transplant units or other patients
with significant immunosuppression should, in the interim, consider routine
sampling for legionella in hospital water in addition to other control
measures. Therefore, infection control teams must work closely with hospital
engineering and technical services departments and hospital management, as
well as ensuring that physicians and others have a heightened awareness of
hospital-acquired legionellosis.
Risk
and management in hospital water systems for Legionella pneumophila: a case
study in Rio de Janeiro-Brazil
Ferreira
AP.
Oswaldo
Cruz Foundation. Sergio Arouca National School of Public Health,
Rio
de Janeiro
,
Brazil
.
aldoferreira@fiocruz.br
Int
J Environ Health Res. 2004 Dec;14(6):453-9.
ABSTRACT:
This article analyses the water used at hospitals in
Rio
de Janeiro
,
Brazil
.
The research, based on microbiological and physical-chemical aspects,
suggests subsidies for normalization of hospital potable water systems and
makes recommendations for standardization of operational procedures for
inspection for Legionella pneumophila. A total of 16 hospitals were
inspected and positive results for the presence of L. pneumophila were found
at five hospitals. These hospitals were integrated in a research project
aiming at the detection and quantification of this pathogen. During 10
consecutive weeks, four collections representing a total of 200 analyses
were done at the five researched hospitals. In this way seven
physical-chemical parameters and three microbiological parameters were
observed to evaluate the quality of water in each hospital. The results
showed that routine surveillance for a hospital water distribution system is
fundamental for public health and must include, as a priority, monitoring of
L. pneumophila. The water quality varies in accordance with the hospital
water system involved. It is important and necessary to implement
environmental culturing in order to minimize hospital infection, in
particular, pneumonia data and also to provide the basis for disinfection of
the water system.
Guidelines
for community-acquired pneumonia: are they reflected in practice?
Flanders
SA, Halm EA.
Department
of Medicine, University of California, San Francisco, California, USA. flandrz@itsa.ucsf.edu
Treat
Respir Med. 2004;3(2):67-77.
ABSTRACT:
Community-acquired pneumonia (CAP) is common, costly, and clinically serious.
Several national and international practice guidelines have been developed
to promote more appropriate, cost-effective care for patients with CAP. This
article compares and contrasts eight international practice guidelines for
the management of CAP, describes the extent to which recommendations are
reflected in practice, and proposes explanations for non-adherence to
guidelines. We found consistency in recommendations across all the
guidelines for the management of patients with CAP requiring intensive care.
In this setting, all guidelines recommend chest radiography, sputum Gram
stain and culture, blood cultures, testing for Legionella pneumophila, and
timely administration of antibiotics active against both typical (i.e.
Streptococcus pneumoniae, Hemophilus influenzae) and atypical organisms
(i.e. Legionella spp., Mycoplasma pneumoniae, and Chlamydia pneumoniae).
Recommendations for the management of the average inpatient with pneumonia
were more variable, with the greatest differences between the North American
and European guidelines. The North American guidelines (in contrast to
European ones), recommended empiric treatment of typical and atypical
organisms in all inpatients. There were also differences in policies
regarding the necessity of chest radiography, sputum studies, and serologic
testing. Some guidelines explicitly embrace the use of prediction rules to
inform the decision to hospitalize, while others do not. Some of these
admission decision algorithms focus on identifying low risk patients, while
others are most concerned with high risk patients. There was also
considerable variation in the specificity and operationalization of clinical
criteria for switching from parenteral to oral antibiotics or judging
appropriateness for discharge. Many recommendations for key management
decisions tended to lack explicit, objective, and actionable criteria that
could be easily implemented in real world practice. Review of the pneumonia
literature revealed that physician performance of guideline-recommended best
practices is often suboptimal. Administration of timely antibiotics (< or
=8 hours of presentation) and use of first-line antibiotics occurred in
75-85% and 18-79% of cases, respectively. Collection of blood cultures
within 24 hours of presentation and prior to administration of antibiotics
was achieved in 69-83% and 63-82% of cases, respectively. Screening the
eligibility of CAP patients for hospital-based pneumococcal and influenza
vaccination occurred on average in 11 and 14% of hospitalizations,
respectively, in the US. Lack of awareness of guidelines, conflicting advice
among them, and lack of specific, objective, actionable recommendations most
likely contribute to nonadherence to CAP guidelines. Increased attention to
these factors will be needed if professional society practice guidelines are
to fulfill their promise as tools for improving the quality and outcomes of
care for patients with pneumonia.
Surveillance
data from public spa inspections--United States, May-September 2002
Centers
for Disease Control and Prevention (CDC).
www.cdc.gov/mmwr/preview/mmwrhtml/mm5325a2.htm
MMWR
Morb Mortal Wkly Rep. 2004 Jul 2;53(25):553-5.
ABSTRACT:
Approximately 5 million public and private hot tubs, whirlpools, and spas
are used in the United States. Extensive spa use combined with inadequate
maintenance contribute to recreational water illnesses (RWIs) caused by
pathogens such as Pseudomonas spp., Legionella spp., and Mycobacterium spp.
In the United States, local environmental health inspectors periodically
inspect public spas to determine their compliance with local or state health
regulations. During inspections for regulatory compliance, data pertaining
to spa water chemistry, filtration and recirculation, and management and
operations are collected. This report summarizes spa inspection data from
six sites in the United States during May 1-September 1, 2002. The findings
underscore the utility of these data for public health decision-making and
the need for increased training and vigilance by operators to ensure
high-quality spa water for use by the public.
Guidelines
for preventing health-care-associated pneumonia, 2003: recommendations of
CDC and the Healthcare Infection Control Practices Advisory Committee
Tablan
OC,
Anderson
LJ, Besser R, Bridges
C, Hajjeh R; CDC and the Healthcare Infection Control Practices Advisory
Committee.
Division
of Healthcare Quality Promotion,
National
Center
for Infectious Diseases,
USA
.
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm
MMWR
Recomm Rep. 2004 Mar 26;53(RR-3):1-36.
ABSTRACT:
This report updates, expands, and replaces the previously published CDC
"Guideline for Prevention of Nosocomial Pneumonia". The new
guidelines are designed to reduce the incidence of pneumonia and other
severe, acute lower respiratory tract infections in acute-care hospitals and
in other health-care settings (e.g., ambulatory and long-term care
institutions) and other facilities where health care is provided. Among the
changes in the recommendations to prevent bacterial pneumonia, especially
ventilator-associated pneumonia, are the preferential use of oro-tracheal
rather than naso-tracheal tubes in patients who receive mechanically
assisted ventilation, the use of noninvasive ventilation to reduce the need
for and duration of endotracheal intubation, changing the breathing circuits
of ventilators when they malfunction or are visibly contaminated, and (when
feasible) the use of an endotracheal tube with a dorsal lumen to allow
drainage of respiratory secretions; no recommendations were made about the
use of sucralfate, histamine-2 receptor antagonists, or antacids for
stress-bleeding prophylaxis. For prevention of health-care--associated
Legionnaires disease, the changes include maintaining potable hot water at
temperatures not suitable for amplification of Legionella spp., considering
routine culturing of water samples from the potable water system of a
facility's organ-transplant unit when it is done as part of the facility's
comprehensive program to prevent and control health-care--associated
Legionnaires disease, and initiating an investigation for the source of
Legionella spp. when one definite or one possible case of
laboratory-confirmed health-care--associated Legionnaires disease is
identified in an inpatient hemopoietic stem-cell transplant (HSCT) recipient
or in two or more HSCT recipients who had visited an outpatient HSCT unit
during all or part of the 2-10 day period before illness onset. In the
section on aspergillosis, the revised recommendations include the use of a
room with high-efficiency particulate air filters rather than laminar
airflow as the protective environment for allogeneic HSCT recipients and the
use of high-efficiency respiratory-protection devices (e.g., N95 respirators)
by severely immunocompromised patients when they leave their rooms when
dust-generating activities are ongoing in the facility. In the respiratory
syncytial virus (RSV) section, the new recommendation is to determine, on a
case-by-case basis, whether to administer monoclonal antibody (palivizumab)
to certain infants and children aged <24 months who were born prematurely
and are at high risk for RSV infection. In the section on influenza, the new
recommendations include the addition of oseltamivir (to amantadine and
rimantadine) for prophylaxis of all patients without influenza illness and
oseltamivir and zanamivir (to amantadine and rimantadine) as treatment for
patients who are acutely ill with influenza in a unit where an influenza
outbreak is recognized. In addition to the revised recommendations, the
guideline contains new sections on pertussis and lower respiratory tract
infections caused by adenovirus and human parainfluenza viruses and refers
readers to the source of updated information about prevention and control of
severe acute respiratory syndrome.
Guidelines
for community-acquired pneumonia in the ICU
Wilkinson
M, Woodhead MA.
Manchester
Royal Infirmary, Manchester, UK.
Mark.Woodhead@CMMC.nhs.uk
Curr
Opin Crit Care. 2004 Feb;10(1):59-64.
ABSTRACT:
Community-acquired pneumonia remains a common and serious condition
worldwide. Severe community-acquired pneumonia requiring ICU admission is a
distinct entity with different pathogens, outcomes, and management. The
mortality rate in severe community-acquired pneumonia can be more than 50%.
Over the past decade, some international guidelines for the management of
community-acquired pneumonia have been developed in an attempt to optimize
patient care. These guidelines have developed prediction tools to direct
clinicians in the management of community-acquired pneumonia, including when
to admit a patient to the ICU and selecting appropriate investigations and
antimicrobial therapy. The individual recommendations of these guidelines
and the guidelines as a whole require further studies.
European
Guidelines for Control and Prevention of Travel Associated Legionnaires'
Disease: the Italian experience
Rota
MC, Caporali MG, Massari M.
Laboratorio
di Epidemiologia e Biostatistica, Istituto Superiore di Sanita, Rome, Italy.
Rota@iss.it
Euro Surveill. 2004 Feb;9(2):10-1.
ABSTRACT:
In Italy, 35 clusters of travel associated Legionnaires' disease were
identified from July 2002, when the European Guidelines for Control and
Prevention of Travel Associated Legionnaires' Disease have been adopted by
the EWGLINET network, to October 2003. Eight per cent (28.6%) would not have
been identified without the network. The clusters detected were small,
ranging from 2 cases to a maximum of 6. All clusters involved 5 camping
sites and 30 hotels/residences, and an overall of 87 patients. The diagnosis
was confirmed in 92.0% of the cases and mainly performed by urinary antigen
detection (84.7%). A clinical isolate was available only in one case.
Following environmental investigations, samples were collected for all the
35 clusters from the water system, and Legionella pneumophila was found in
23 occasions (65.7%). In 15 resorts out of 35, investigations were already
in progress at the time of EWGLI cluster notification, since in Italy full
environmental investigation is performed even after notification of a single
case. Control measures were implemented in all accommodation sites at risk
and one hotel only was closed. In all the 35 clusters, reports were
completed and sent on time, highlighting that it is possible to comply with
the procedures requested by the European Guidelines.
Update
of practice guidelines for the management of community-acquired pneumonia in
immunocompetent adults
Mandell LA, Bartlett JG, Dowell SF, File TM Jr, Musher DM, Whitney C;
Infectious Diseases Society of America.
McMaster University, Hamilton, Ontario, Canada. lmandell@mcmaster.ca
Clin
Infect Dis. 2003 Dec 1;37(11):1405-33.
NO ABSTRACT
Guidelines
for environmental infection control in health-care facilities.
Recommendations of CDC and the Healthcare Infection Control Practices
Advisory Committee (HICPAC)
Sehulster
L, Chinn RY; CDC; HICPAC.
Division
of Healthcare Quality Promotion, National Center for Infectious Diseases.
www.cdc.gov/mmwr/preview/mmwrhtml/rr5210a1.htm
MMWR
Recomm Rep. 2003 Jun 6;52(RR-10):1-42.
ABSTRACT:
The health-care facility environment is rarely implicated in disease
transmission, except among patients who are immunocompromised. Nonetheless,
inadvertent exposures to environmental pathogens (e.g., Aspergillus spp. and
Legionella spp.) or airborne pathogens (e.g., Mycobacterium tuberculosis and
varicella-zoster virus) can result in adverse patient outcomes and cause
illness among health-care workers. Environmental infection-control
strategies and engineering controls can effectively prevent these infections.
The incidence of health-care--associated infections and pseudo-outbreaks can
be minimized by 1) appropriate use of cleaners and disinfectants; 2)
appropriate maintenance of medical equipment (e.g., automated endoscope
reprocessors or hydrotherapy equipment); 3) adherence to water-quality
standards for hemodialysis, and to ventilation standards for specialized
care environments (e.g., airborne infection isolation rooms, protective
environments, or operating rooms); and 4) prompt management of water
intrusion into the facility. Routine environmental sampling is not usually
advised, except for water quality determinations in hemodialysis settings
and other situations where sampling is directed by epidemiologic principles,
and results can be applied directly to infection-control decisions. This
report reviews previous guidelines and strategies for preventing
environment-associated infections in health-care facilities and offers
recommendations. These include 1) evidence-based recommendations supported
by studies; 2) requirements of federal agencies (e.g., Food and Drug
Administration, U.S. Environmental Protection Agency, U.S. Department of
Labor, Occupational Safety and Health Administration, and U.S. Department of
Justice); 3) guidelines and standards from building and equipment
professional organizations (e.g., American Institute of Architects,
Association for the Advancement of Medical Instrumentation, and American
Society of Heating, Refrigeration, and Air-Conditioning Engineers); 4)
recommendations derived from scientific theory or rationale; and 5)
experienced opinions based upon infection-control and engineering practices.
The report also suggests a series of performance measurements as a means to
evaluate infection-control efforts.
Prevenzione
della legionellosi: confronto tra linee guida europee ed extraeuropee
Ditommaso S, Biasin C, Giacomuzzi M, Zotti CM, Ruggenini A, Moiraghi A
Dip.
Sanità Pubblica e Microbiologia, Università degli Studi di Torino, Torino.
savina.ditommaso@unito.it
Giornale
Italiano delle Infezioni Ospedaliere
vol.10, n.1, Gennaio-Marzo 2003, pag 7-24.
RIASSUNTO:
Negli ultimi anni, a seguito del verificarsi di numerosi casi di
legionellosi, molti paesi hanno emanato raccomandazioni e linee guida in
relazione al problema. Obiettivo di questo lavoro è stato quello di mettere
in evidenza concordanze e divergenze su temi fondamentali quali: rischio di
contrarre l’infezione, opportunità di controlli ambientali e di
bonifiche, rischio professionale. Le divergenze riscontrate sono numerose,
tuttavia l’argomento è in continua evoluzione.
Soltanto la sperimentazione sul campo della sorveglianza
e del controllo potrà consentire di acquisire comportamenti validati,
e di adottare misure di intervento efficaci e fattibili, superando la
disomogeneità delle indicazioni presenti nelle documentazioni esistenti.
