Dissemination of antibiotic resistance and other healthcare waterborne pathogens. The price of poor design, construction, usage and maintenance of modern water/sanitation services.

Classical waterborne pathogens (cholera/typhoid) drove the development of safe water and sanitation during the industrial revolution. Whilst effective against these organisms, other bacteria exploited the potential to form biofilm in the narrow pipes of buildings. 1976 saw the discovery of legionella. Despite evidence dating back to 1967 (including paediatric deaths in Manchester in 1995 from splashes from a sink contaminating parenteral nutrition) it required the deaths of four neonates and the might of the Press in 2011 for the UK medical services to accept waterborne transmission of other Opportunistic Plumbing Premise Pathogens (OPPP). Human nature, a healthcare construction industry largely devoid of interest in water safety, and failures in recognising transmission are major forces hindering progress in preventing infection/deaths from waterborne infections. The advent of highly resistant Gram-negative bacteria is highlighting further deficiencies in modern drainage systems. These bacteria are not thought to have special adaptations promoting their dispersal but purely attract our attention to the well-trodden routes used by sensitive organisms, which go undetected. The O'Neill report warns of the bleak future without effective antibiotics. This paper examines the evidence as to why modern water services/sanitation continue to present a risk to patient safety (and the general public) and also suggests their designs may be flawed if they are to stem the modern equivalent of cholera, the dissemination of antibiotic resistance.

Observation study of water outlet design from a cross-infection/user perspective: time for a radical re-think?

BACKGROUND: Handwashing is a key barrier to cross-infection performed at a handwash station (HWS). Elbow-operated outlets, if used incorrectly (with hands), become highly touched objects, potentially providing a route for cross-infection. AIM: To study how elbow-operated outlets were used by staff in this hospital, whether the correct type of HWS had been installed in the various ward areas according to the Health Building Note (HBN) 00-10 Part C: Sanitary Assemblies (hands-free outlets in clinical, food preparation and laboratory areas), and factors impinging on design/setup which may affect compliance with correct use. METHODS: Observation of outlet use was performed by mounting a video camera above four HWSs. Review of suitability of outlet was conducted by two of the authors by visiting ward areas and assessing compliance against HBN recommendations. Angle of elbow-operated lever setup was measured using a protractor and water temperature in relation to angle of movement of elbow lever was measured using a calibrated thermocouple. FINDINGS: Ninety-two percent of staff used hands to turn on the outlet and 68% used hands to turn the outlet off, potentially re-contaminating their hands. More than 70% of users moved the lever ≤45°. Almost half of elbow levers were set up incorrectly, being flush or within 3.5 cm of the rear panel, making elbow operation extremely difficult. Selection of outlet type according to HBN was most incorrect in the intensive treatment unit but also occurred in the newly built parts of the hospital. CONCLUSIONS: Although handwashing is a key barrier to cross-infection, poor selection and incorrect use of outlet undermines its effectiveness. Design and incorrect instalment further compromise the intended means of operation of elbow levers. Of equal concern is that this risk mostly goes unrecognized. There is an opportunity to improve handwashing safety, but it requires engagement across a broad stratum from Government Departments of Health and manufacturers down to the user.

The handwash station: friend or fiend?

Handwashing is a key barrier to cross-infection performed at a handwash station (HWS, an interface between water and drainage systems). Widespread and often uncritical placement/design and use of HWSs is not without attendant risks. Recognition of the associated hazards went unheeded for over 45 years despite warnings in the literature, until the neonatal outbreak of pseudomonas in Belfast in 2012 forced change. Minimizing risk requires a holistic approach beyond the mere testing of water from the outlet of a HWS for the presence of Pseudomonas aeruginosa or other pathogens. Literature reports of outbreaks linked to HWSs outside of neonatal units are over-represented by multi-resistant organisms, and increasingly by carbapenemase-producing organisms. Evidence suggests that a large proportion of waterborne transmissions go undetected. Much could be done to improve current design, use and placement of HWSs, and this is assessed critically in this article.

Optimization of the blood culture pathway: a template for improved sepsis management and diagnostic antimicrobial stewardship.

Laboratory processing of blood cultures has remained static over the past 30 years, despite increasing antibiotic resistance and advances in analyser design. At the study hospital, siting the blood culture analyser in the blood sciences laboratory and optimizing the pre-analytical and analytic phases of blood culture management resulted in a reduction in the time taken to detect most blood culture isolates to <12h. Fifty percent of positive blood cultures containing Escherichia coli were definitively reported with antibiotic susceptibilities in <24h. More than 85% of blood cultures positive for E. coli had antibiotic susceptibilities reported within 36h of collection, compared with 66h at a comparator hospital.

Pharmacokinetics of antibiotics in burn patients.

Drug pharmacokinetics are significantly altered in the burned patient but the interplay of a large number of variables is involved in deciding how an individual will deal with a drug. Consequently the burn patient population shows significant inter- and intrapatient variation. In 1976 altered aminoglycoside pharmacokinetics and the need for increased dosage in burn patients was reported but, despite this early study, a review of the currently available literature shows that for many drugs there is a paucity of information to support current dosage recommendations. In addition, many reports are based upon small numbers of patients, and even in larger studies there is no standardization of the study population with regard to the important variables known to affect drug handling. For the sub-population of burn patients who eliminate drugs extremely rapidly, a concern exists over the adequacy of antibiotic dosing. It is suggested that antibiotic serum concentrations be measured for all drugs in every patient to ascertain whether there is a significant problem with dosing. Additionally, future pharmacokinetic studies need to be standardized in burn patients.

Streptococcal mural endocarditis and myocardial abscess occurring in a left ventricular aneurysm--case report and review.

Infection of the mural endocardium within a left ventricular aneurysm without valvular involvement is exceedingly rare. The presenting clinical features can be non-specific, and a high index of suspicion is required for its diagnosis. Delay in diagnosis invariably leads to a fatal outcome. Although no controlled studies are available to guide therapy and management of these patients, appropriate antibiotic therapy and early surgical resection of the infected ventricular aneurysm remain the cornerstone of therapy.

Haemophilus aphrophilus discitis and vertebral osteomyelitis.

An unusual case of discitis and vertebral osteomyelitis due to Haemophilus aphrophilus is described. Infections due to this organism have usually responded to treatment with beta-lactam antibiotics. However, our isolate was resistant to third-generation cephalosporins which has not been reported previously in the world literature. The patient made a good clinical response to ciprofloxacin treatment.

Mycoplasma hominis sternal wound infection and bacteraemia.

Mycoplasma hominis is a rare cause of bacteraemia in adult males. We believe this report to be the first of Mycoplasma hominis bacteraemia and wound infection complicating cardiac surgery. Because of difficulties in isolating the organism, cases may be missed. Review of the literature on M. hominis bacteraemia in adult males reveals that infection is often mild and most often associated with urethral catheterisation. M. hominis is resistant to many antibiotics including erythromycin. If treatment is indicated, tetracycline or clindamycin is the drug of choice.

Streptococcal necrotising fasciitis.

Three cases of streptococcal necrotising fasciitis are described. Its relative rarity and the lack of superficial inflammation leading to diagnostic difficulty is emphasised. The diagnosis is readily confirmed microbiologically but the clinician should bear in mind that antibiotics may not be curative and that surgery is often required.