Water management safety and quality is a complicated and multifaceted aspect of an Infection Prevention(IP) program. Infection preventionists are not subject matter experts when it comes to the daily workings of a facility’s plumbing and water processes. However, they are crucial in helping determine risks associated with contamination or subpar maintenance to patient outcomes and helping determine the potential source of an outbreak associated with water systems. Collaboration with facilities, environmental services, bioengineering departments, and hospital leadership is essential to a successful program.
Water is a prime environment for bacterial growth, which can contribute to the contamination of surfaces and create reservoirs for pathogens. As health care becomes more complex, water remains a key source to consider when investigating unusual clusters of health care–associated infections. In fact, sink drains should be one of“TheUsual Suspects” in any outbreak investigation.
The Usual Suspects is one of the best crime thrillers of the 1990s, and its ending has a jaw-dropping plot twist. The movie follows a group of criminals who work together on particular jobs, such as jewel heists and robberies, but their lives are put in grave danger when they’re hired by the mysterious Keyser Söze.
The job is a drugs raid on a docked ship, and Kobayashi, who is Söze’s lawyer, blackmails the suspects into working the job based on all the times they’ve stolen from Söze.
Although the movie has a concise and clear ending, The Usual Suspects‘ message is that nothing is as it seems. It’s a movie about a genius villain protagonist who hides in plain sight. It’s about the extreme lengths he will go to so that the truth about him remains as murky as possible, even to the point where the audience doesn’t have a clue.
Biofilm in sink drains and P-traps can be the “genius villain protagonist that hides in plain sight.” Now let’s develop the backstory titled, “A Case of Serial Transmission of NDM-1 Klebsiella pneumoniae Tied to a Hospital Sink Drain.”
Becky Smith, MD, medical director of infection prevention at Duke University Hospital, discusses a presentation she gave at IDWeek 2019 on a case of serial transmission of NDM-1 Klebsiella pneumoniae tied to a hospital sink drain. Here’s some key takeaways:
- “This particular research came out of finding something called NDM-1, which is 1 of the various molecular mechanisms for carbapenemase-in this case, it’s actually a metallo-beta-lactamase gene-within a germ that is considered to be a tier 2 organism per the CDC guidance. What that means is these are either multidrug-resistant pathogens with a novel resistance mechanism, or they are not yet endemic in the area. And so the state health department and CDC recommend enhanced containment efforts to really try to contain them or stop their spread because they aren’t everywhere yet, so you have an opportunity to make a difference.”
- “In 2017, we identified a patient in our hospital who had an NDM-1 Klebsiella pneumoniae…This investigation actually took place kind of in the midst of this uptick in seeing more carbapenemase-resistant organisms. We had already been in the process of trying to augment our approach to carbapenemase-producing germs in general, and what that meant at our hospital is, in addition to the normal surveillance and reaction, we wanted to be more proactive.”
- “We decided to sample the sink based on the literature that has implicated sink drains and P-traps and shower drain P-traps in being persistent point sources for carbapenemase-producing organisms. We worked very closely with Amy Mathers and the UVA lab to learn how to appropriately perform those environmental cultures and help work them up, sent off those cultures. We also actually closed the room just out of an abundance of caution, and we took out the sink because, again, based on what we had known from the literature, we were really suspicious that that was a persistent source.”
- “So, lo and behold, the sink drain culture from the biofilm was positive for the NDM-1 Klebsiella pneumoniae. The P-trap water was negative. We had already replaced the sink and opened the room and deep cleaned just like we normally would have in the past. Then we thought, “You know, this is a really compelling story we need to share because here we are trying to stay ahead of CRE and [we] hadimplemented a very robust containment bundle. And yet, we still had this event happen.”
- “We went back and got 1 other case that was from 2015, the only other case that had ever been in the hospital, and that had been a patient with a risk factor of having had a liver transplant in India. That case was 3 years prior to the most recent case. We included that in our samples, bundled it up, and sent them off for whole genome sequencing. And then found out that patient 1, the one from 2015, was unrelated to the second patient and the third patient and the sink, and the second patient, sink, and third patient were all closely related isolates. And so, this told us, ‘Wow, this was the smoking gun. Thank goodness, we removed the sink early on’.”
- “The takeaway for everyone is that 1) as we already know, bacteria are always 1 step ahead, or probably 20 steps ahead, from us. And that, despite really aggressive prevention efforts, we found that the sink had become contaminated.”
In a second example of biofilm in sink drains causing the death of several patients, there’s this…Pseudomonas aeruginosa has been increasingly recognized for its ability to cause significant hospital-associated outbreaks, particularly since the emergence of multidrug-resistant strains. Biofilm formation allows the pathogen to persist in environmental reservoirs. Thus, multiple hospital room design elements, including sink placement and design, can impact nosocomial transmission of P. aeruginosa and other pathogens.
Methods: From December 2004 through March 2006, 36 patients exposed to the intensive care unit or transplant units of a tertiary care hospital were infected with a multidrug-resistant strain of P. aeruginosa. All phenotypically similar isolates were examined for genetic relatedness by means of pulsed-field gel electrophoresis. Clinical characteristics of the affected patients were collected, and a detailed epidemiological and environmental investigation of potential sources was carried out.
Results: Seventeen of the infected patients died within 3 months; for 12 (71%) of these patients, infection with the outbreak organism contributed to or directly caused death. The source of the outbreak was traced to hand hygiene sink drains, where biofilms containing viable organisms were found. Testing by use of a commercial fluorescent marker demonstrated that when the sink was used for handwashing, drain contents splashed at least 1 meter from the sink. Various attempts were made to disinfect the drains, but it was only when the sinks were renovated to prevent splashing onto surrounding areas that the outbreak was terminated.
Conclusion: This report highlights the importance of biofilms and of sink and patient room design in the propagation of an outbreak and suggests some strategies to reduce the risks associated with hospital sinks.
Outbreaks of hospital sink-related infections involve a diverse spectrum of microorganisms (e.g., gram negative pathogens). They can be attributed to defects in sink design and hospital wastewater systems that promote the formation and dispersion of biofilm.
Emphasis should be placed on optimizing best practices in sink design and placement to prevent infections. Hospitals should consider developing a rational surveillance and prevention strategy based on the current design and state of their sinks.
As more and more hospitals become aware of the potential for bacteria and “super bug” contamination from their plumbing systems, the industry is responding by developing new fixtures and systems that reduce or eliminate the potential of infection. These include implementing UV lights, low-splash sinks, and exhaust in fixtures, as well as automatic injection of sanitizing agents.
Of course, these more sophisticated fixtures’ planning, design and installation require infrastructure to support their associated strategies. Electrical and exhaust connections, along with new piping systems and other central systems, bolster the different strategies that are designed to reduce infection in the care environment. Reimagining an entire system from the ground up can drive up construction costs, but in the end reduce the overall costs of healthcare.
Existing drain disinfection chemistries and technologies are not effective at killing bacteria in drains and they depend on employees who actually perform the service. Efforts to disinfect drains have included complete replacement of the sink or its components, installing self-cleaning traps, disinfection with processed steam, enhanced manual cleaning, descaling of pipes, and disinfection with chlorine-based solutions or other liquid disinfectants. It’s important to note that liquid disinfectants do not come in contact with the surface of the drain long enough to meet the contact time needed to kill the bacteria.
CALL TO ACTION
Now that you have a grasp of the issues surrounding sinks in hospitals, you need to take the next step to discover the only patented complete solution that addresses the splash zone and biofilm. The ReSet265 sink is ADA compliant and combines multiple layers of smart technologies working in unison to separate the sewer from the care environment.
Let me challenge you to:
1. Do your own Infection Prevention Risk Assessment
2. Complete the CONTACT FORM for more information
3. Buy a sink, install it
4. Follow the SHS roadmap for your own 4-week study
If your in-house convinces the facility stakeholders that the ReSet265 sink will prevent sinks from being the source of HAIs in your hospital, Tom Hicks will help you with a 2-3 year replacement program as you install ReSet265 sinks in your critical care units and where your most vulnerable patients receive care (eg. Emergency Department, Oncology Unit, Transplant Unit, Burn Unit, Scrub sinks in the OR, etc.).
