Pseudomonas in the Paediatric
Intensive care
Pamela Joannidis
Nurse Consultant - IPC
Learning Outcomes
• Pseudomonas in the healthcare setting
• An outbreak of Pseudomonas in a
paediatric intensive care setting
• Prevention and Control: Legislation and
guidance
Pseudomonas
• Gm –ve, aerobic, motile, coccobacillus
• Found in soil, water, skin flora and most
man-made environments
• Normal or hypoxic atmosphere
• Opportunistic pathogen of plants and
animals
• General inflammation and or sepsis
• Infection of lungs, kidneys or urinary
tract can be fatal
Virulence factors
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Aerobic, Facultative anaerobe
Flagellae and pili
Cell surface polysaccharides - biofilms
Toxins
Quorum sensing
Antibiotic Resistance
Biofilm
• Every non-changing non-sterile surface
• Attachment of free floating bacteria
• Growth via cell division and recruitment
Biofilms
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Self produced matrix
Extracellular DNA, polysaccharide and proteins
Form on living and non-living surfaces
Prevalent in nature, industry and healthcare
- showers, water and sewage pipes
Switch to biofilm growth mode
Marine engineering systems
Biofouling of seagoing vessels
International space station
Dental plaque
Water pipes
Human body
Outbreaks
• An Outbreak of Skin Rash Associated With A Spa
Bath In A Leisure Centre (Pseudomonas aeruginosa)
• An Outbreak of Pseudomonas aeruginosa Infection
Caused by Contaminated Mouth Swabs
• Outbreak of Pseudomonas fluorescens Bacteremia
among Oncology Patients
• An Outbreak of Pseudomonas aeruginosa Infection in
community hospitals in Japan associated with urinary
catheters
• NICU, 4 neonates, NI 2012
Risk factors for outbreak
• Environmental PA in 12 of 14 studies
• 22% infection, mort. 18.2 – 100%
• Antibiotics, no.days of antibiotics, blood
transfusion, umbilical catheters, IV fluids
• Increasing age and false nails
• Bottles water
• Special feeds preparation area
• Molecular typing
Pseudomonas aeruginosa outbreaks in the neonatal intensive care unit – a systematic review of
risk factors and environmental sources (Jeffries et al , 2012)
Northern Ireland 2012
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Only use the hand wash stations for hand washing
Do not dispose of body fluids at the hand wash station
Do not wash any patient equipment in hand wash basins
Do not use basins for storing used equipment awaiting
decontamination
Use all hand wash stations regularly Flush taps regularly, either
automatically or manually, and keep a record of when they were
flushed
Report any problems to the infection prevention and control
team
Use pre-filled single-use bottles for alcohol-based handrubs or
cleaning solutions
Ensure all staff are properly training
Setting the scene
•Original site at Garnethill
opened 1882 with 58 beds
•Royal patronage in 1889
•Designed by John James
Burnet, the latest building
opened in July 1914 paid by
charitable donations.
• Hospital currently has 266
inpatient beds, 12 day case
beds, and handles
approximately 90,000 outpatients, 15,000 in-patients
and 7,300 day cases every
year
Case study: Time line
Incident No. 1
• Late August 2007 4 patients with PA (2 in blood
cultures) All same strain
• Environmental sampling : Tap (2) +ve
• Tap(2) is at sink next to index case
• September 2007 3 new cases (1 from blood culture)
• 3 strains identified
• 5th case
Actions taken: Environmental screening
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All 6 CHWB (basin, soap nozzles, taps)
Water samples from each CHWB
Procedure trolleys
Bed space floors
IV pumps
Key boards
Ventilator control panels
Blood gas analyser
Actions taken: Environmental screening
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Microfibre mops, mop buckets
Resuscitation trolleys (inside and out)
Bottle warmers
Taps after domestic clean
Taps after estates clean
Hands before / after HH
Stethescopes
Ultrasound machine and gel
Actions taken: Audit
• Safe Patient Environment Audit
• Hand hygiene audit
• Domestic Services Review of
environmental cleaning
Actions taken: Patients
• Screening swabs on admission
• Consider isolation of patient
• Close unit to non-emergency admission
Actions taken: Communications
• OCT
• Parent fact sheets
• Staff announcements
• Media statement
Where did we find it
• Patients
• Condensate (from +ve patient)
• Tap next to +ve patient
(but not sink or water)
• Other taps, other patients
Summary of sampling
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5 patients had same by PFGE 18PA-2
2 patients had same by PFGE 18PA-4
4 patients had unique PA
1 CWHB had PFGE 18-2
4 CHWB had unique PA
Possible routes of transmission
• Condensate from the index case tested
+ve
• Staff admitted to putting this down the
CHWB
• Trough sink water splashing onto 4 and
staff uniform
• Staff touch sensor to activate tap
Actions
• Deep clean of CHWB
• Stop environmental sampling!
• Strip all CHWB and deep clean with chlorine
• Stop using CHWB for condensate disposal
• Review of ventilator circuit with manufacturer
• Hand hygiene techniques (sensor)
• Adjust strength of water flow
Incident Summary
• Index case +ve 30.07.07 (NPA/ETA)
• Condensate from 1 index case only
• 5 patients
• 1 CWHB tap
Guidance in Scotland
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The control of Legionella bacteria in water systems.
Approved Code of Practice and Guidance (L8)
• Water safety for healthcare premises Part A: Design,
installation and testing. SHTM 04-01
• Water sources and potential infection risks to patients
in high risk units – revised guidance. CEL 08(2013)
• Guidance for neonatal units (NNUs) (levels 1, 2 & 3),
adult and paediatric intensive care units (ICUs) in
Scotland to minimise the risk of Pseudomonas
aeruginosa infection from water ( HPS, 2014)
Control of Pseudomonas
The Six Critical Control Points
• The hospital water delivery system
• Flushing taps to reduce the risk of pipework system
contamination
• Preventing direct water usage colonising/ infecting
vulnerable patients
• Preventing indirect water usage from
colonising/infecting patients
• Preparedness for clinical incidents and earliest
possible detection of any clinical incidents
• Prompt investigation and control measure application
for any clinical incidents IPCTs
Guidance
• Set up a water safety group to develop an action plan
for each board
• Develop separate risk assessments for Legionnaires
and Pseudomonas
• Ensure correct clean and dirty separation is
maintained
• Ensure taps and thermostatic mixing valves have
been commissioned and routinely validated
according to the manufacturer’s instructions
Local actions
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Engineering controls
All CHWB appropriate
CHWB cleaned daily, not ‘little used’
No water baths, defrosting milk
Sterile water where possible
Patient equipment cleaning
Hand hygiene and aseptic practices
Chief Executive’s Responsibilities
As detailed in SHTM 04-01 and CEL 08 (2013) 1;30 the CEO is ultimately
responsible for ensuring:
• Clinical areas where patients at the highest risk of P. aeruginosa or
similar infection have been identified.
• Clinical Directors and Senior Charge Nurses of these clinical areas
have been informed of the risks and the actions in this guidance
needed to prevent P. aeruginosa.
• Best practice relating to the use of hand washing facilities is
consistently and fully applied.
• There is a nominated Responsible Person (Water) for their NHS board.
• There are robust systems and documentary evidence of safe water
management systems which includes having a Water Safety Group
(WSG) a Water Safety Plan (WSP), inclusive of risk assessments and
actions to mitigate risks.
• A report is provided to the board, at least annually providing assurance
Checklist
Risk Assessment and identification of actions that are
required to reduce or negate P. aeruginosa risks:
• An assessment in these clinical areas of the
suitability of the water distribution system including
design, maintenance and configuration of pipework,
provision, location and design of thermostatic control
devices, design and layout of hand wash stations i.e.
position of sensor, soap, gel and angle of lever on
operated tap, identifying unused and under-used
outlets and hand wash stations and the unnecessary
use of flexible hoses and any containing
inappropriate lining materials.
Checklist
• Confirmation that there are sufficient easily accessible hand
wash stations that are all being used or flushed at least daily in
all NNUs and ICUs and other recognised clinical units.
• An assessment of the clinical practice and ongoing care of
invasive devices, cleaning of patient equipment and usage of
hand wash stations that could compromise patients.
• The sampling and monitoring that needs to be put in place in the
event of an outbreak or incident.
• Those NHS boards with existing robust water management
policies for Legionella will already have in place much of the
integral requirements for developing a WSP.
Thank you