Reduction of peritoneal dialysis associated infections using a novel exit-site care practice.

INTRODUCTION: Peritoneal dialysis (PD) related infections are a significant obstacle leading to PD discontinuation. Since catheter related infections (CRI), defined as exit site infections and/or tunnel infection, can progress to peritonitis, vigorous efforts are implemented in CRI prevention. Following an increased CRI rate in our institution, partially related to environmental organisms found in water distribution systems, we hypothesized that exit site care that includes prevention of water exposure-related pathogens may reduce CRI. METHODS: In this prospective single center study, we compared a contemporary cohort consisting of PD patients who implemented the modified exit-site care protocol, mainly including water avoidance during shower with stoma bag usage and local Mupirocin ointment against a historical control group before the protocol implementation. The historical cohort was allowed water exposure and used local gentamicin ointment. The primary outcome was the development of a CRI. Secondary outcomes were PD associated peritonitis and infection related outcomes. RESULTS: There were 55 patients in contemporary cohort and 58 in historical group. The CRI rate was significantly lower in study group (0.11/episodes per patient year [EPP]) compared to control group (0.71 EPP), p < 0.001. A multivariate Cox regression analysis demonstrated a protective effect of being in the contemporary cohort compared to historical group (HR for first CRI = 12.0 95%CI: 4.0-35.7, p < 0.001). Peritonitis rate was significantly lower in contemporary cohort (0.19/EPP) compared to the historical group (0.40/EPP), p = 0.011. Transfer to hemodialysis was significantly lower in contemporary cohort than historical group (7.3% vs 31.0% in contemporary and historical group respectively, HR = 0.2, 95%CI; 0.05-0.6, p = 0.001). CONCLUSION: An exit site care protocol that includes water avoidance and local Mupirocin use reduced substantially both CRI and peritonitis rate in patients treated with PD.

Water Quality Trade-offs for Risk Management Interventions in a Green Building.

Premise plumbing water quality degradation has led to negative health impacts from pathogen outbreaks (e.g., Legionella pneumophila and non-tuberculous mycobacteria), as well as chronic effects from exposure to heavy metals or disinfection by-products (DBP). Common water quality management interventions include flushing, heat shock (thermal disinfection), supplemental disinfection (shock or super chlorination), and water heater temperature setpoint change. In this study, a Legionella pneumophila- colonized Leadership in Energy and Environmental Design (LEED) certified building was monitored to study health-relevant water quality changes before and after three controlled management interventions: (1) flushing at several points throughout the building; (2) changing the water heater set point; and (3) a combination of interventions (1) and (2) by flushing during a period of elevated water heater set point (incompletely performed due to operational issues). Microbial (culturable L. pneumophila, the L. pneumophila mip gene, and cATP) and physico-chemical (pH, temperature, conductivity, disinfectant residual, disinfection by-products (DBPs; total trihalomethanes, TTHM), and heavy metals) water quality were monitored alongside building occupancy as approximated using Wi-Fi logins. Flushing alone resulted in a significant decrease in cATP and L. pneumophila concentrations (p = 0.018 and 0.019, respectively) and a significant increase in chlorine concentrations (p = 0.002) as well as iron and DBP levels (p = 0.002). Copper concentrations increased during the water heater temperature setpoint increase alone to 140°F during December 2022 (p = 0.01). During the flushing and elevated temperature in parts of the building in February 2023, there was a significant increase in chlorine concentrations (p = 0.002) and iron (p = 0.002) but no significant decrease in L. pneumophila concentrations in the drinking water samples (p = 0.27). This study demonstrated the potential impacts of short term or incompletely implemented interventions which in this case were not sufficient to holistically improve water quality. As implementing interventions is logistically- and time-intensive, more effective and holistic approaches are needed for informing preventative and corrective actions that are beneficial for multiple water quality and sustainability goals.

High resolution data visualization and machine learning prediction of free chlorine residual in a green building water system.

People spend most of their time indoors and are exposed to numerous contaminants in the built environment. Water management plans implemented in buildings are designed to manage the risks of preventable diseases caused by drinking water contaminants such as opportunistic pathogens (e.g., Legionella spp.), metals, and disinfection by-products (DBPs). However, specialized training required to implement water management plans and heterogeneity in building characteristics limit their widespread adoption. Implementation of machine learning and artificial intelligence (ML/AI) models in building water settings presents an opportunity for faster, more widespread use of data-driven water quality management approaches. We demonstrate the utility of Random Forest and Long Short-Term Memory (LSTM) ML models for predicting a key public health parameter, free chlorine residual, as a function of data collected from building water quality sensors (ORP, pH, conductivity, and temperature) as well as WiFi signals as a proxy for building occupancy and water usage in a "green" Leadership in Energy and Environmental Design (LEED) commercial and institutional building. The models successfully predicted free chlorine residual declines below 0.2 ppm, a common minimum reference level for public health protection in drinking water distribution systems. The predictions were valid up to 5 min in advance, and in some cases reasonably accurate up to 24 h in advance, presenting opportunities for proactive water quality management as part of a sense-analyze-decide framework. An online data dashboard for visualizing water quality in the building is presented, with the potential to link these approaches for real-time water quality management.

Two-year evaluation of Legionella in an aging residential building: Assessment of multiple potable water remediation approaches.

Legionella is an opportunistic waterborne pathogen that is difficult to eradicate in colonized drinking water pipes. Legionella control is further challenged by aging water infrastructure and lack of evidence-based guidance for building treatment. This study assessed multiple premise water remediation approaches designed to reduce Legionella pneumophila within a residential building located in an aging, urban drinking water system over a two-year period. Samples (n = 745) were collected from hot and cold-water lines and quantified via most probable number culture. Building-level treatment approaches included three single heat shocks, three single chemical shocks, and continuous low-level chemical disinfection in the potable water system. The building was highly colonized with L. pneumophila with 71 % L. pneumophila positivity. Single heat shocks had a statistically significant L. pneumophila reduction one day post treatment but no significant L. pneumophila reduction at one week, two weeks, and four weeks post treatment. The first two chemical shocks resulted in statistically significant L. pneumophila reduction at two days and four weeks post treatment, but there was a significant L. pneumophila increase at four weeks following the third chemical shock. Continuous low-level chemical disinfection resulted in statistically significant L. pneumophila reduction at ten weeks post treatment implementation. This demonstrates that in a building highly colonized with L. pneumophila, sustained remediation is best achieved using continuous low-level chemical treatment.

Quantitative Microbial Risk Assessment Framework Incorporating Water Ages with Legionella pneumophila Growth Rates.

Water age in drinking water systems is often used as a proxy for water quality but is rarely used as a direct input in assessing microbial risk. This study directly linked water ages in a premise plumbing system to concentrations of Legionella pneumophila via a growth model. In turn, the L. pneumophila concentrations were used for a quantitative microbial risk assessment to calculate the associated probabilities of infection (Pinf) and clinically severe illness (Pcsi) due to showering. Risk reductions achieved by purging devices, which reduce water age, were also quantified. The median annual Pinf exceeded the commonly used 1 in 10,000 (10-4) risk benchmark in all scenarios, but the median annual Pcsi was always 1-3 orders of magnitude below 10-4. The median annual Pcsi was lower in homes with two occupants (4.7 × 10-7) than with one occupant (7.5 × 10-7) due to more frequent use of water fixtures, which reduced water ages. The median annual Pcsi for homes with one occupant was reduced by 39-43% with scheduled purging 1-2 times per day. Smart purging devices, which purge only after a certain period of nonuse, maintained these lower annual Pcsi values while reducing additional water consumption by 45-62%.

Linkage of in-refrigerator water dispensing systems to elevated exposure to microbial contamination at the microbiome scale.

In-refrigerator water dispensing systems are ubiquitous in residential homes with tap water as the inflow. Passage through these systems resulted in significant microbial growth in the water, with the abundance of potential opportunistic pathogens Mycobacterium and Pseudomonas increasing by 8,053- and 221-fold, respectively. Elevated exposure to microbial contaminants linked to in-refrigerator water dispensing systems may represent a significant public health concern.

Bacterial communities of planktonic bacteria and mature biofilm in service lines and premise plumbing of a Megacity: Composition, Diversity, and influencing factors.

Although simulated studies have provided valuable knowledge regarding the communities of planktonic bacteria and biofilms, the lack of systematic field studies have hampered the understanding of microbiology in real-world service lines and premise plumbing. In this study, the bacterial communities of water and biofilm were explored, with a special focus on the lifetime development of biofilm communities and their key influencing factors. The 16S rRNA gene sequencing results showed that both the planktonic bacteria and biofilm were dominated by Proteobacteria. Among the 15,084 observed amplicon sequence variants (ASVs), the 33 core ASVs covered 72.8 %, while the 12 shared core ASVs accounted for 62.2 % of the total sequences. Remarkably, it was found that the species richness and diversity of biofilm communities correlated with pipe age. The relative abundance of ASV2 (f_Sphingomonadaceae) was lower for pipe ages 40-50 years (7.9 %) than for pipe ages 10-20 years (59.3 %), while the relative abundance of ASV10 (f_Hyphomonadaceae) was higher for pipe ages 40-50 years (19.5 %) than its presence at pipe ages 20-30 years (1.9 %). The community of the premise plumbing biofilm had significantly higher species richness and diversity than that of the service line, while the steel-plastics composite pipe interior lined with polyethylene (S-PE) harbored significantly more diverse biofilm than the galvanized steel pipes (S-Zn). Interestingly, S-PE was enriched with ASV27 (g_Mycobacterium), while S-Zn pipes were enriched with ASV13 (g_Pseudomonas). Moreover, the network analysis showed that five rare ASVs, not core ASVs, were keystone members in biofilm communities, indicating the importance of rare members in the function and stability of biofilm communities. This manuscript provides novel insights into real-world service lines and premise plumbing microbiology, regarding lifetime dynamics (pipe age 10-50 years), and the influences of pipe types (premise plumbing vs. service line) and pipe materials (S-Zn vs. S-PE).

Toward the autonomous flushing of building plumbing: Characterizing oxidation-reduction potential and temperature sensor dynamics.

Manual flushing of building plumbing is commonly used to address water quality issues that arise from water stagnation. Autonomous flushing informed by sensors has the potential to aid in the management of building plumbing, but a number of knowledge gaps hinder its application. This study evaluates autonomous flushing of building plumbing with online sensor and actuator nodes deployed under kitchen sinks in five residential houses. Online oxidation-reduction potential (ORP) and temperature data were collected for nine weeks during the winter and summer in houses with both free chlorine and chloramine. ORP levels in houses with free chlorine residuals decreased after overnight stagnation. The overnight decrease in ORP was not observed when tap water was automatically flushed for five minutes at 6:00 h every morning. ORP levels in houses with chloramine residuals did not decrease consistently after overnight stagnation, and daily automated flushes did not have an observable effect on the ORP signals. Additional laboratory experiments were carried out to evaluate ORP signals during chlorine decay and after incremental changes in chlorine, as would be expected in building plumbing conditions. Results from the lab and field deployments suggest on-line ORP sensors may be used to detect free chlorine decay due to stagnating water, but are not as effective in detecting chloramine decay. However, field results also suggest ORP may not respond as expected on a timely manner after free chlorine or chloramine have been restored, hindering their applicability in developing control algorithms. In this paper we tested twice-daily five-minute automatic flushing and found that it counteracts water quality degradation associated with overnight stagnation in free chlorine systems. An automatic sensor-based flushing is proposed using online temperature sensor data to determine when flushing has reached water from the main. The results suggest that flushing informed by temperature sensors can reduce the flushing time by 46 % compared to the preset five-minute static flush.

Inactivation efficacy and mechanisms of wavelength-specific UV sources for various strains of Legionella pneumophila serogroup 1.

Infections of Legionnaires' disease in the United States caused by Legionella have increased ninefold between the years 2000-2018. Legionella harbored in biofilms or inside amoeba within premise plumbing can be more resistant to disinfectants, thus causing treatment challenges. Ultraviolet-light emitting diodes (UV-LEDs) are an emerging water disinfection technology with several advantages over conventional UV lamps. In this study, we evaluated the effects of UV-LEDs (255, 265, and 285 nm), a low-pressure (LP) mercury UV lamp (254 nm), and a bandpass filtered medium-pressure (MP) mercury UV lamp (220 nm) on properties and inactivation of three strains of L. pneumophila serogroup 1. The UV-LEDs emitting at 255 and 265 nm showed greater inactivation performance against all the strains compared to the UV-LED at 285 nm and the LP UV lamp at 254 nm. Our results showed that strains of the same serogroup exhibited different UV sensitivities. Analyses of DNA and protein damage revealed that UV exposure using 254, 255, and 265 nm predominantly causes DNA damage, while protein damage is predominant at 220 nm. Both DNA and protein damage were observed at 285 nm, but the extent of DNA damage was relatively less significant compared to the other wavelengths. Electric energy consumption analysis showed that water treatment using UV-LEDs is currently unsatisfactory compared to conventional LP UV lamps due to the mediocre wall plug efficiency (WPE) of UV-LEDs. However, recent studies indicate that the WPE of UV-LEDs is continuously improving. Overall, our study highlights that UV-LEDs are a promising technology for inactivating waterborne pathogens and have the potential to replace existing UV mercury lamps for water disinfection applications.

Influence of pipe materials on in-building disinfection of P. aeruginosa and A. baumannii in simulated hot water plumbing.

A framework is needed to account for interactive effects of plumbing materials and disinfectants on opportunistic pathogens (OPs) in building water systems. Here we evaluated free chlorine, monochloramine, chlorine dioxide, and copper-silver ionization (CSI) for controlling Pseudomonas aeruginosa and Acinetobacter baumannii as two representative OPs that colonize hot water plumbing, in tests using polyvinylchloride (PVC), copper-PVC, and iron-PVC convectively-mixed pipe reactors (CMPRs). Pipe materials vulnerable to corrosion (i.e., iron and copper) altered the pH, dissolved oxygen, and disinfectant levels in a manner that influenced growth trends of the two OPs and total bacteria. P. aeruginosa grew well in PVC CMPRs, poorly in iron-PVC CMPRs, and was best controlled by CSI disinfection, whereas A. baumannii showed the opposite trend for pipe material and was better controlled by chlorine and chlorine dioxide. Various scenarios were identified in which pipe material and disinfectant can interact to either hinder or accelerate growth of OPs, illustrating the difficulties of controlling OPs in portions of plumbing systems experiencing warm, stagnant water.

Extended water stagnation in buildings during the COVID-19 pandemic increases the risks posed by opportunistic pathogens.

The regrowth and subsequent exposure of opportunistic pathogens (OPs) whilst reopening buildings that have been locked down due to the stay-at-home restrictions to limit the spread of COVID-19, is a public health concern. To better understand such microbiological risks due to lowered occupancy and water demand in buildings, first and post-flush water samples (n = 48) were sampled from 24 drinking water outlets from eight university buildings in two campuses (urban and rural), with various end-user occupancies. Both campuses were served with chlorinated water originating from a single drinking water distribution system in South-East Queensland, situated 14 km apart, where the rural campus had lower chlorine residuals. Culture-dependent and culture-independent methods (such as flow cytometry, qPCR and 16S rRNA gene amplicon sequencing) were used concurrently to comprehensively characterise the OPs of interest (Legionella spp., Pseudomonas aeruginosa, and nontuberculous mycobacteria (NTM)) and the premise plumbing microbiome. Results showed that buildings with extended levels of stagnation had higher and diverse levels of microbial growth, as observed in taxonomic structure and composition of the microbial communities. NTM were ubiquitous in all the outlets sampled, regardless of campus or end-user occupancy of the buildings. qPCR and culture demonstrated prevalent and higher concentrations of NTM in buildings (averaging 3.25 log10[estimated genomic copies/mL]) with extended stagnation in the urban campus. Furthermore, flushing the outlets for 30 minutes restored residual and total chlorine, and subsequently decreased the levels of Legionella by a reduction of 1 log. However, this approach was insufficient to restore total and residual chlorine levels for the outlets in the rural campus, where both Legionella and NTM levels detected by qPCR remained unchanged, regardless of building occupancy. Our findings highlight that regular monitoring of operational parameters such as residual chlorine levels, and the implementation of water risk management plans are important for non-healthcare public buildings, as the levels of OPs in these environments are typically not assessed.

Assessing residential activity in a home plumbing system simulator: monitoring the occurrence and relationship of major opportunistic pathogens and phagocytic amoebas.

Opportunistic premise plumbing pathogens (OPPPs) have been detected in buildings' plumbing systems causing waterborne disease outbreaks in the United States. In this study, we monitored the occurrence of OPPPs along with free-living amoeba (FLA) and investigated the effects of residential activities in a simulated home plumbing system (HPS). Water samples were collected from various locations in the HPS and analyzed for three major OPPPs: Legionella pneumophila, nontuberculous mycobacterial species (e.g., Mycobacterium avium, M. intracellulare, and M. abscessus), and Pseudomonas aeruginosa along with two groups of amoebas (Acanthamoeba and Vermamoeba vermiformis). A metagenomic approach was also used to further characterize the microbial communities. Results show that the microbial community is highly diverse with evidence of spatial and temporal structuring influenced by environmental conditions. L. pneumophila was the most prevalent pathogen (86% of samples), followed by M. intracellulare (66%) and P. aeruginosa (21%). Interestingly, M. avium and M. abscessus were not detected in any samples. The data revealed a relatively low prevalence of Acanthamoeba spp. (4%), while V. vermiformis was widely detected (81%) across all the sampling locations within the HPS. Locations with a high concentration of L. pneumophila and M. intracellulare coincided with the highest detection of V. vermiformis, suggesting the potential growth of both populations within FLA and additional protection in drinking water. After a period of stagnation lasting at least 2-weeks, the concentrations of OPPPs and amoeba immediately increased and then decreased gradually back to the baseline. Furthermore, monitoring the microbial population after drainage of the hot water tank and partial drainage of the entire HPS demonstrated no significant mitigation of the selected OPPPs. This study demonstrates that these organisms can adjust to their environment during such events and may survive in biofilms and/or grow within FLA, protecting them from stressors in the supplied water.

Benzene Diffusion and Partitioning in Contaminated Drinking Water Pipes under Stagnant Conditions.

Benzene contamination in drinking water systems affected by wildfires is a problem of emerging concern. Polyethylene pipes used in service lines and premise plumbing are vulnerable to permeation by benzene and can potentially cause challenges in sampling and remediation of contaminated systems. However, the kinetics and equilibria of the uptake of benzene by and release of benzene from pipes of differing polyethylene types and manufacturers are not well studied, leading to additional uncertainty when interpreting sampling data and selecting remediation options. This work addresses this data gap by providing diffusion and partitioning data for benzene and several varieties of polyethylene pipes, including field samples from water distribution systems. All polyethylene pipes that were studied exhibited similar partitioning behavior during benzene uptake and release, but some differences in kinetics were observed among pipes. However, these differences were of minor practical importance in the pipe contamination scenario examined in this work. The results of this study can be used in conjunction with diffusion modeling to inform remediation decisions for benzene-contaminated, polyethylene service lines, and premise plumbing.

Impact of fixture purging on water age and excess water usage, considering stochastic water demands.

Higher water ages are linked with water quality decline as chlorine dissipates, temperatures become more favorable for microbial growth, and metals and organic matter leach from the pipes. Water fixtures with automated purging devices can limit water age in premise plumbing systems, but also increase water use. To develop purging strategies that lower age while also minimizing water use, the stochastic nature of water demands must be considered. In this research, a hydraulic plumbing network model, with stochastic demands at fixtures, was used to compare water age and water use for five purging conditions: purging at regular intervals, "smart" purging (considering the time of last use), purging with different volumes of water, purging at different fixtures, and the purging with different levels of home occupancy. Higher purging frequency and volume resulted in lower water ages, but higher water use. Purging greatly reduced the variability in water ages, avoiding extreme ages entirely. Water age was minimized by scheduling the purging around occupancy behavior, such as before the occupants wake up or return from work. Scheduled purging used more water than smart purging. Purging after 12 h of nonuse used only 55% of the additional water required for purging every 12 h. Purging after 24 h of nonuse at the kitchen tap and shower used only 38% of the additional water required for purging every 24 h, while maintaining lower water ages and removing the variability in water ages. While larger purging volumes had a greater impact on water age, there were diminishing returns. Purging has a larger impact on low-occupancy homes because fixtures have less frequent use. Overall, this research provides a methodology to compare purging strategies that minimize both water age and water use. While the numerical results presented here are only valid for the specific layout and usage habits, they provide insights and trends applicable to other cases.

Mycobacterial contamination in tap and shower waters in Thailand.

Waterborne disease is increasingly becoming associated with opportunistic premise plumbing pathogens (OPPPs), which can resist residual chlorination, regrow throughout drinking water distribution systems, and colonize premise plumbing. Nontuberculous mycobacteria (NTM) include clinically important species and exert a high burden on healthcare systems. We briefly report a qPCR-based survey of Mycobacterium spp. numbers in tap, POU-treated, and shower waters from Bangkok, Thailand. Non-stagnant tap waters and non-stagnant shower waters had mean numbers of 1.3 × 103 and 2.4 × 103 copies/mL, respectively. Water stagnation resulted in mean numbers higher by up to 1.0 log. The lowest number, 25 copies/mL, was obtained from a POU-treated sample, while the highest number, 2.0 × 104 copies/mL, came from a stagnant tap. Comparing with international data, mean numbers in this study were greater than those in nine out of 11 (82%) comparable studies, and the maximum numbers in this study were also high. Our samples of Bangkok waters exhibited relatively high Mycobacterium spp. numbers, suggesting the need for appropriate POU treatment systems where NTM infection is a health concern. This survey data can be used to set inactivation performance targets in POU water disinfection system design and may also lead to quantitative microbial risk assessment (QMRA) studies.

Two-Year Evaluation of Legionella in an Aging Residential Building: Assessment of Multiple Potable Water Remediation Approaches.

Legionella is an opportunistic waterborne pathogen that is difficult to eradicate in colonized drinking water pipes. Legionella control is further challenged by aging water infrastructure and lack of evidence-based guidance for building treatment. This study assessed multiple premise water remediation approaches designed to reduce Legionella pneumophila (Lp) within a residential building located in an aging, urban drinking water system over a two-year period. Samples (n=745) were collected from hot and cold-water lines and quantified via most probable number culture. Building-level treatment approaches included three single heat shocks (HS), three single chemical shocks (CS), and continuous low-level chemical disinfection (CCD) in the potable water system. The building was highly colonized with Lp with 71% Lp positivity. Single HS had a statistically significant Lp reduction one day post treatment but no significant Lp reduction one, two, and four weeks post treatment. The first two CS resulted in statistically significant Lp reduction at two days and four weeks post treatment, but there was a significant Lp increase at four weeks following the third CS. CCD resulted in statistically significant Lp reduction ten weeks post treatment implementation. This demonstrates that in a building highly colonized with Lp, sustained remediation is best achieved using CCD.

Building water quality deterioration during water supply restoration after interruption: Influences of premise plumbing configuration.

Premise plumbing plays an essential role in determining the final quality of drinking water consumed by customers. However, little is known about the influences of plumbing configuration on water quality changes. This study selected parallel premise plumbing in the same building with different configurations, i.e., laboratory and toilet plumbing. Water quality deteriorations induced by premise plumbing under regular and interrupted water supply were investigated. The results showed that most of the water quality parameters did not vary under regular supply, except Zn, which was significantly increased by laboratory plumbing (78.2 to 260.7 µg/l). For the bacterial community, the Chao1 index was significantly increased by both plumbing types to a similar level (52 to 104). Laboratory plumbing significantly changed the bacterial community, but toilet plumbing did not. Remarkably, water supply interruption/restoration led to serious water quality deterioration in both plumbing types but resulted in different changes. Physiochemically, discoloration was observed only in laboratory plumbing, along with sharp increases in Mn and Zn. Microbiologically, the increase in ATP was sharper in toilet plumbing than in laboratory plumbing. Some opportunistic pathogen-containing genera, e.g., Legionella spp. and Pseudomonas spp., were present in both plumbing types but only in disturbed samples. This study highlighted the esthetic, chemical, and microbiological risks associated with premise plumbing, for which system configuration plays an important role. Attention should be given to optimizing premise plumbing design for managing building water quality.

Estimating Waterborne Infectious Disease Burden by Exposure Route, United States, 2014.

More than 7.15 million cases of domestically acquired infectious waterborne illnesses occurred in the United States in 2014, causing 120,000 hospitalizations and 6,600 deaths. We estimated disease incidence for 17 pathogens according to recreational, drinking, and nonrecreational nondrinking (NRND) water exposure routes by using previously published estimates. In 2014, a total of 5.61 million (95% credible interval [CrI] 2.97-9.00 million) illnesses were linked to recreational water, 1.13 million (95% CrI 255,000-3.54 million) to drinking water, and 407,000 (95% CrI 72,800-1.29 million) to NRND water. Recreational water exposure was responsible for 36%, drinking water for 40%, and NRND water for 24% of hospitalizations from waterborne illnesses. Most direct costs were associated with pathogens found in biofilms. Estimating disease burden by water exposure route helps direct prevention activities. For each exposure route, water management programs are needed to control biofilm-associated pathogen growth; public health programs are needed to prevent biofilm-associated diseases.

Containment of a Verona Integron-Encoded Metallo-Beta-Lactamase-Producing Pseudomonas aeruginosa Outbreak Associated With an Acute Care Hospital Sink-Tennessee, 2018-2020.

Background: Contaminated healthcare facility wastewater plumbing is recognized as a source of carbapenemase-producing organism transmission. In August 2019, the Tennessee Department of Health (TDH) identified a patient colonized with Verona integron-encoded metallo-beta-lactamase-producing carbapenem-resistant Pseudomonas aeruginosa (VIM-CRPA). A record review revealed that 33% (4 of 12) of all reported patients in Tennessee with VIM had history of prior admission to acute care hospital (ACH) A intensive care unit (ICU) Room X, prompting further investigation. Methods: A case was defined as polymerase chain reaction detection of blaVIM in a patient with prior admission to ACH A from November 2017 to November 2020. The TDH performed point prevalence surveys, discharge screening, onsite observations, and environmental testing at ACH A. The VIM-CRPA isolates underwent whole-genome sequencing (WGS). Results: In a screening of 44% (n = 11) of 25 patients admitted to Room X between January and June 2020, we identified 36% (n = 4) colonized with VIM-CRPA, resulting in 8 cases associated with Room X from March 2018 to June 2020. No additional cases were identified in 2 point-prevalence surveys of the ACH A ICU. Samples from the bathroom and handwashing sink drains in Room X grew VIM-CRPA; all available case and environmental isolates were found to be ST253 harboring blaVIM-1 and to be closely related by WGS. Transmission ended after implementation of intensive water management and infection control interventions. Conclusions: A single ICU room's contaminated drains were associated with 8 VIM-CRPA cases over a 2-year period. This outbreak highlights the need to include wastewater plumbing in hospital water management plans to mitigate the risk of transmission of antibiotic-resistant organisms to patients.

A Critical Review on the Factors that Influence Opportunistic Premise Plumbing Pathogens: From Building Entry to Fixtures in Residences.

Residential buildings provide unique conditions for opportunistic premise plumbing pathogen (OPPP) exposure via aerosolized water droplets produced by showerheads, faucets, and tubs. The objective of this review was to critically evaluate the existing literature that assessed the impact of potentially enhancing conditions to OPPP occurrence associated with residential plumbing and to point out knowledge gaps. Comprehensive studies on the topic were found to be lacking. Major knowledge gaps identified include the assessment of OPPP growth in the residential plumbing, from building entry to fixtures, and evaluation of the extent of the impact of typical residential plumbing design (e.g., trunk and branch and manifold), components (e.g., valves and fixtures), water heater types and temperature setting of operation, and common pipe materials (copper, PEX, and PVC/CPVC). In addition, impacts of the current plumbing code requirements on OPPP responses have not been assessed by any study and a lack of guidelines for OPPP risk management in residences was identified. Finally, the research required to expand knowledge on OPPP amplification in residences was discussed.