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Anaissie and colleagues¹ need to be congratulated on an impressive review of reported outbreaks of nosocomial illness linked to hospital water supplies. However, their conclusions about the burden of nosocomial disease due to water supplies are severely flawed. The authors' review exhibits several sources of bias that together would lead to substantial overestimation of disease burden.

The first source of bias derives from their search strategy that would detect articles that have found an association with water in preference to ones that have not. For example, they do not cite articles that are highly relevant to this debate but which do not support their preferred conclusion.^2-3

The second source of bias comes from relying on a single published study to estimate the disease burden due to waterborne Pseudomonas nosocomial infections in the United States. This study by Trautmann and colleagues⁴ was conducted in a single intensive care unit in Germany . . . [Full Text of this Article]

Paul R. Hunter, MD
Norwich, England

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