under the microscope
under the microscope
By Priya Dhagat , MS , MLS ( ASCP ) CM , CIC
The Importance of Water Management in Infection Prevention : Is Legionella Lurking in Your Facility ?
As the summer months continue , the warmer temperatures and increased humidity are associated with increased seasonality of legionellosis — a febrile illness that can lead to severe pneumonia , also called Pontiac fever , or Legionnaires ’ disease . Legionella spp . are aerobic , Gram-negative bacilli that are common in the environment but sensitive to dry conditions and can survive in warm and humid weather thereby increasing infection and disease risk in older people and those who have certain risk factors , such as being a current or former smoker , having a chronic disease , or having a weakened immune system . Around 6,000 Legionnaires ’ disease cases are reported each year in the United States , according to the Occupational Safety and Health Administration ( OSHA ). Legionella has been detected in spas , hotels , gyms , cruise ships , apartment buildings , and healthcare facilities .
Almost any system or equipment containing non-sterile water has the potential to grow Legionella if certain factors become favorable for Legionella growth . Inadequate disinfection , fluctuations in water temperature and pH , changes in water temperature , biofilm formation , and water stagnation can all impact the water systems . Legionella can then become a health concern if detected in water systems like showerheads and sink faucets , cooling towers , hot tubs , decorative fountains , hot water tanks and heaters , and large complex water systems – such as in healthcare facilities . Infection usually occurs after inhalation of droplets that contain the bacteria .
A robust water management program in healthcare facilities includes risk assessments , surveillance and testing , and action plans , all of which are essential to limit Legionella and other opportunistic waterborne pathogens ( e . g ., Pseudomonas , Acinetobacter , Burkholderia , Stenotrophomonas , nontuberculous mycobacteria ) from growing and spreading in healthcare facilities . Inconsistencies or discrepancies in plans and actions can lead to infection , severe illness and even death , especially in immunocompromised patients . For example , in 2011 and 2012 , the VA healthcare system in Pittsburgh experienced an outbreak , which led to 22 infections and five deaths .
Microbiological cultures showed Legionella growth in various locations where environmental samples were obtained , including numerous patient rooms , potable hot water heaters , and a decorative fountain . The outbreak was ultimately linked to contamination of hospital › s potable water system during construction activities . In 2016 , a 7-month-old patient died from Legionnaire ’ s disease at UCSF Benioff Children ’ s Hospital two weeks after he had undergone a successful bone marrow transplant to cure Wiskott-Aldrich Syndrome . Testing later revealed that Legionella was present in the hospital ’ s plumbing system , including in the patients ’ room . In 2018 , University of Wisconsin Hospital reported a Legionnaire ’ s disease outbreak of 14 cases and three deaths linked to a change in its hot-water system .
As subject matter experts in prevention strategies , infection preventionists play an essential role in water-management programs by identifying devices , areas , and infrastructure that may be of
concern ( e . g ., humidifiers , ventilators , CPAP machines , hydrotherapy equipment , sinks , hot tubs , fountains , aerators , faucet flow restrictors , ice machines ). Ideally , healthcare water management teams should be multidisciplinary and include members from engineering , infection prevention , maintenance , and housekeeping who should regularly monitor water quality parameters , disinfection , temperature levels , and surveillance and sampling results in effort to continuously identify , minimize , or respond to conditions that may encourage growth of Legionella and other waterborne pathogens .
The Centers for Disease Control and Prevention ( CDC ) provides numerous resources to support healthcare facilities in developing and maintaining a framework for an effective water management program . Additionally , CMS requires healthcare facilities to develop water-management programs that are compliant with American Society of Heating , Refrigerating and Air-Conditioning Engineers ( ASHRAE ) guidelines .
As outlined by the CDC , the following steps are recommended :
1 . Establish a water-management program team 2 . Describe the building water systems 3 . Identify areas where Legionella ( or other waterborne bacteria ) could grow and spread 4 . Decide where control measures should be applied and how to monitor them
• Maintain water temperatures outside the ideal range for Legionella growth
• Prevent water stagnation
• Ensure adequate disinfection
• Maintain premise plumbing , equipment , and fixtures to prevent sediment , scale , corrosion , and biofilm 5 . Establish ways to intervene when control limits are not met 6 . Make sure the program is running as designed ( verification ) and is effective ( validation ) 7 . Document and communicate all the activities
Priya Dhagat , MS , MLS ( ASCP ) CM , CIC , is an infection preventionist and the associate director of the system-wide Special Pathogens Program within the Department of Emergency Management at New York City Health + Hospitals , overseeing special pathogen preparedness and response efforts across New York City Health + Hospitals frontline healthcare facilities . Additionally , she supports and offers subject matter expertise for infection prevention topics for the National Emerging Special Pathogens Training and Education Center ( NETEC ).
For more information , visit :
Toolkit for Controlling Legionella in Common Sources of Exposure | CDC Legionella : Healthcare Water Management Program FAQs | CDC New Standard for Water Management Program – Hospitals , Critical Access | The
Joint Commission
Decker BK , Palmore TN . Hospital water and opportunities for infection prevention . Curr Infect Dis Rep . 2014 Oct ; 16 ( 10 ): 432 . doi : 10.1007 / s11908-014-0432-y . PMID : 25217106 ; PMCID : PMC5583638 . https :// www . ncbi . nlm . nih . gov / pmc / articles / PMC5583638 /
8 july 2023 • www . healthcarehygienemagazine . com