 |
|
The Hospital Water Supply as a Source of Nosocomial Infections
A Plea for Action
Elias J. Anaissie, MD;
Scott R. Penzak, PharmD;
M. Cecilia Dignani, MD
Arch Intern Med. 2002;162:1483-1492.
ABSTRACT
| |
Background Microbiologically contaminated drinking water is a cause of community-acquired infection, and guidelines for prevention of such infections have been established. Microbes in hospital water can also cause nosocomial infection, yet guidelines for preventing such infections do not exist. The purpose of this review is to assess the magnitude of the problem caused by waterborne nosocomial infections and to plea for immediate action for their prevention.
Methods We conducted a MEDLINE search of the literature published between January 1, 1966, and December 31, 2001.
Study Selection and Data Extraction Investigations in which microorganisms (other than Legionella species) caused waterborne nosocomial infections and public health agency recommendations for drinking water.
Results Forty-three outbreaks of waterborne nosocomial infections have been reported, and an estimated 1400 deaths occur each year in the United States as a result of waterborne nosocomial pneumonias caused by Pseudomonas aeruginosa alone. Despite the availability of effective control measures, no clear guidelines exist for the prevention of these infections. By contrast, guidelines for the prevention of community-acquired waterborne infections are now routinely used. Hospitals caring for patients at high risk for infection do not enforce the standards of water quality recommended by US and United Kingdom public health agencies for the patients' community counterparts.
Conclusion Because of the seriousness of these nosocomial waterborne infections and the availability, low cost, and proven effectiveness of sterile water, we recommend that hospitalized patients at high risk for infection avoid exposure to hospital water and use sterile water instead.
INTRODUCTION
EACH YEAR in the United States, more than 2 million nosocomial infections occur in as many as 10% of all hospitalized patients, causing significant morbidity, mortality, and financial burden.1-3 In addition, the use of antibiotics to treat these infections leads to increased resistance.4-5 These infections tend to occur more commonly in immunocompromised patients.6 Although numerous hospital sources cause nosocomial outbreaks, perhaps the most overlooked, important, and controllable source of nosocomial pathogens is hospital water.7-9
The ability of microbes to survive in hospital water tanks was described more than 30 years ago,10 and numerous studies11-52 have identified water as a source of nosocomial infection. These organisms can acquire and subsequently transfer antimicrobial resistance53 and can produce toxins, as demonstrated in a recent catastrophic outbreak secondary to contamination of hemodialysis water (110 cases and 43 deaths).54 Despite the large number of waterborne nosocomial outbreaks,11-52 no hospital guidelines exist for their prevention.
This article describes the extent of waterborne nosocomial infections and their mode of transmission and recommends guidelines for their prevention.
MATERIALS AND METHODS
Data sources included peer-reviewed publications located via a MEDLINE database search of keywords water, hospital, and infection in manuscripts published in English between January 1, 1966, and December 31, 2001. All abstracts published between January 1, 1987, and December 31, 2000, at the yearly meetings of the American Society for Microbiology, the Infectious Disease Society of America, and the Society of Healthcare Epidemiology of America were also reviewed. Studies of waterborne nosocomial infections (other than with Legionella species) were analyzed for the following: pathogens and their susceptibility patterns, source, site(s) of infection, and method(s) used to link patient and environmental isolates. Reference to legionellosis is made to highlight the similarities that exist between this infection and those caused by other waterborne pathogens. Studies describing infection as a result of colonization of the hospital water supply (as opposed to colonization of distal sites that could have come in contact with water, such as sinks and valves) were the focus of this review. Also reviewed were recommendations for the prevention of waterborne community-acquired infections and recommendations for the prevention of nosocomial pneumonia.
RESULTS
TYPES OF PATHOGENS AND INFECTIONS
Legionella pneumophila
Of all the water-related pathogens, L pneumophila is most likely to be recognized by health care workers as a cause of nosocomial infection. However, the acquisition of L pneumophila infection in the hospital setting is similar to that of other water organisms. The agents of legionellosis and those of other nosocomial waterborne infections share remarkable similarities, including (1) their presence and amplification in water reservoirs,7-8 (2) a strong association with water biofilms,55 (3) growth requirements (optimal growth at 25°C-45°C, with growth inhibition at higher and lower temperatures),56 (4) a link between infection with these agents and construction activity,6, 57 and (5) mode of transmission (aerosolization, ingestion, and contact).9, 56, 58 Similar to Legionella species, these bacteria (including Pseudomonas aeruginosa) have also been shown to exist not only in biofilms but also inside free-living amoebae.59-60 These amoebae harbor the bacteria inside their cysts, giving them a microhabitat and protecting them from disinfectants.60
Although recommendations for preventing legionellosis have become standard knowledge in medical textbooks,58, 61 nosocomial waterborne infections by other microbes have been largely ignored despite their high morbidity and mortality rates.11-52
Other Waterborne Pathogens
Bacteria.
Nosocomial infections caused by waterborne bacteria have been associated with serious morbidity and even mortality and include bacteremias, tracheobronchitis, pneumonias, sinusitis, urinary tract infections, meningitis, wound infections, peritonitis, ocular infections, and others.11-52 Specifically, P aeruginosa can persist in hospital water for extended periods20 and can cause nosocomial outbreaks,11-22 frequently with resistant organisms. Stenotrophomonas maltophilia is a multidrug-resistant organism that has been implicated in nosocomial waterborne infections.23-27 Other bacteria associated with waterborne nosocomial infections include species of Aeromonas, Acinetobacter, Burkholderia, Enterobacter, Flavobacterium, other Pseudomonas, Serratia, and others.28-41 Overall, these nosocomial waterborne infections were caused by bacteria resistant to at least 2 classes of antimicrobial agents in 13 (76%) of the 17 outbreaks for which susceptibility testing was performed (Table 1 and Table 2).
|
|
|
|
Table 1. Nosocomial Infections Related to the Hospital Water Supply (Tap Water and Water Reservoirs Only): Reports With Supporting Molecular Relatedness Studies*
|
|
|
|
|
|
|
Table 2. Nosocomial Infections Related to the Hospital Water Supply (Tap Water and Water Reservoirs Only): Reports Without Supporting Molecular Relatedness Studies
|
|
|
Mycobacteria.
Pathogenic mycobacteria have been isolated from hospital water, can persist in water systems over several years,42 and have been implicated in serious nosocomial outbreaks.42-50
Fungi.
Nosocomial aspergillosis continues to occur despite air filtration, thus suggesting that there may be other hospital sources of spores.6 Fungi can inhabit water distribution systems, including those of hospitals,63-64 and may cause nosocomial infection.51-52 The water system of one hospital in Houston, Tex, harbored Fusarium species, causing infections among its patients.51 Other opportunistic molds, including Aspergillus species, have been recovered from the same hospital and from 2 other hospital water systems in Little Rock, Ark.64 Exophiala jeanselmei was responsible for 23 life-threatening nosocomial infections.52 Additional evidence65-68 that the opportunistic molds are waterborne comes from the serious infections caused by Aspergillus species and Pseudallescheria boydii after near-drowning incidents in otherwise healthy individuals. Pneumocystis carinii DNA has been recovered from water.69 Whether P carinii exists within hospital water distribution systems needs to be determined in light of the study70 results suggesting nosocomial transmission of pneumocystosis.
Parasites.
Outbreaks of toxoplasmosis have been traced to contaminated water71; thus, Toxoplasma gondii could also potentially cause nosocomial waterborne infections.
Viruses.
Several pathogenic viruses can also be recovered from water supplies,8 although nosocomial waterborne infections with these agents have not been reported.
OUTBREAKS SUPPORTED BY QUALITY EVIDENCE, INCLUDING MOLECULAR RELATEDNESS STUDIES
Some of the older studies16, 22, 27, 29-31,33-36,38-40,43 included in our review did not use the appropriate epidemiologic methods or the modern molecular relatedness tools and relied on weakly discriminatory methods for strain typing, such as serotyping and antibiotic susceptibility patterns (Table 2). However, 29 recent studies11-15,17-21,23-26,28, 32, 37, 41-42,44-52 present solid evidence, both epidemiologic and molecular, incriminating the hospital water system as the source of serious waterborne nosocomial infections (Table 1).
The outbreaks mentioned herein probably represent only a subset of the total number of waterborne nosocomial infections because these outbreaks are limited to reports in which the pathogen involved was recovered from the water supply. However, the water supply could also have been the reservoir for pathogens in other outbreaks in which cultures of the water supply were not obtained or did not yield the pathogen because of inadequate sampling or variations of the pathogen's load in the water system (related to external factors such as status of the plumbing system and recent obstruction of flow). In such settings, hospital water may have contaminated environmental surfaces (eg, sinks, drains, and whirlpool baths), medical equipment (eg, by rinsing tube feed bags, endoscopes, respiratory equipment, etc, with tap water), or health care providers, leading ultimately to patient exposure7, 72-119 (Figure 1). Thus, the environmental surfaces, medical equipment, or health care workers may seem to be the pathogen's source; however, hospital water was the primary reservoir but was not tested or the organism was not recovered because of the variables mentioned previously. Forty-nine reported outbreaks7, 72-119 in which such a scenario could have occurred include infections with the following pathogens: Acinetobacter baumannii, Acinetobacter calcoaceticus, Alcaligenes faecalis, Alcaligenes xylosoxidans, Burkholderia cepacia, Enterobacter cloacae, Ewingella americana, Flavobacterium species, group A streptococci, P aeruginosa, Serratia marcescens, S maltophilia, Pseudomonas thomassii, Pseudomonas species, Rahnella aquatilis, Salmonella urbana, vancomycin-resistant enterococci, Mycobacterium chelonae, Candida tropicalis, Aspergillus niger, Acremonium kiliense, and Cryptosporidium species. However, because of the difficulty in identifying the original source of the infection in such reports, we elected to exclude these outbreaks and to limit our review to instances in which the hospital water was clearly documented to be the pathogen's reservoir.
|
|
|
|
Transmission of waterborne pathogens in the hospital setting. Thick arrows indicate routes of transmission that are the subject of this review; thin arrows, other possible routes of transmission that are not included in this review.
|
|
|
MAGNITUDE OF THE PROBLEM
Although it may be difficult to accurately measure the magnitude of the problem of nosocomial waterborne infections, an estimation of the minimal incidence of these infections and their attributable consequences is possible by focusing on pneumonia with P aeruginosa only.
Nosocomial pneumonias account for 20% to 45% of all nosocomial infections120-121 and for 23 000 deaths per year in the United States alone (1993 data), and 20% of these pneumonias are caused by P aeruginosa.121 Water was confirmed as the source of 10 P aeruginosa nosocomial outbreaks in the studies that included molecular relatedness (Table 1), suggesting that outbreaks of nosocomial P aeruginosa infections are frequently related to water sources. Indeed, Trautmann et al11 found in a 7-month prospective study at a surgical intensive care ward that 5 (29%) of 17 patients were infected with P aeruginosa genotypes detectable in tap water. Despite an extensive literature search, we did not find studies (that included molecular relatedness studies) that linked nosocomial P aeruginosa infections with other accepted hospital sources for P aeruginosa, such as fruits, vegetables, and plants.
Because 20% of nosocomial pneumonias are caused by P aeruginosa,121 for an estimated 4600 deaths per year, and because 30% of these infections are waterborne,11 the annual mortality from waterborne P aeruginosa nosocomial pneumonia in the United States is approximately 1400. This estimate is conservative considering that several other waterborne pathogens can also be responsible for nosocomial pneumonia (Table 1 and Table 2), that these pathogens may cause a variety of other infections (Table 1 and Table 2), and that such waterborne infections are frequently underdiagnosed122 or missed for several years.123-125 Thus, the effect of waterborne pathogens in the hospital setting may be enormous.
MODE OF TRANSMISSION TO PATIENTS
The primary cause of diminished water quality is the buildup of biofilm and the corrosion of distribution lines and tank surfaces resulting from poor design or aging of distribution systems and water stagnation.55, 126 Increased water demand during summer or when construction activity increases flow through stagnant pipelines, dislodging organisms from biofilms and releasing them into the water supply.55, 57
Patient exposure to waterborne microorganisms in the hospital occurs while showering, bathing, and drinking (water or ice)127-129 and through contact with contaminated medical equipment (eg, tube feed bags, endoscopes, and respiratory equipment) rinsed with tap water.7, 12 The sources of organisms include hospital water tanks, faucet tap water, and showers. Even small quantities of organisms in water can cause infection66-68,126-130; 1 oocyst of Cryptosporidium parvum per 1000 L of drinking water could result in 6000 infections per year in a city the size of New York,131 and a single exposure to 200 mL of water may result in serious mold infections.66-69,130
Only one20 of the studies evaluated the hospital water supply for the presence of this pathogen and did not find it. The absence of this organism in the water supply does not by itself rule out the fact that the system was contaminated. Potential explanations include the limited number of samples obtained in the study and the contamination of a segment of the system only. It is possible, however, that contamination of the faucets by patients may have occurred.
CURRENT PREVENTIVE GUIDELINES
Community Guidelines for the Prevention of Waterborne Infections
After the 1993 outbreak of cryptosporidiosis in Milwaukee, Wis (403 000 infections, 4400 hospitalizations, and 104 deaths),132 several public health agencies issued recommendations that targeted immunodepressed patients.133-134 These recommendations stated that such patients "should be provided information about measures to ensure their drinking water is safe" and should "only drink water that is bottled sterile, submicron filtered or boiled, in outbreak settings."134 After the outbreaks of cryptosporidiosis, the Departments of the Environment and Health133 of the United Kingdom issued even stricter recommendations that "people with impaired immunity should not drink unboiled water." Additional US government–mandated water purity standards for the prevention of community-acquired infections were recently announced under amendments to the Safe Drinking Water Act.135
Hospital Guidelines for the Prevention of Legionellosis and Aspergillosis
The Centers for Disease Control and Prevention (CDC), Atlanta, Ga, developed recommendations for the prevention of nosocomial pneumonia and legionellosis that include routine maintenance of the hospital water supply system and consideration for the use of sterile water in immunodepressed patients.136 For the prevention of hospital-acquired aspergillosis,136 the CDC "strongly recommends" the following: (1) minimizing exposure of high-risk patients to potential sources of Aspergillus species and to activities that may aerosolize Aspergillus and other fungi and (2) eliminating the source of aspergilli. Because opportunistic molds can inhabit hospital water systems and aerosolize after water activities,63-64 these CDC recommendations imply that water precautions need to be introduced in hospitals caring for patients at risk for opportunistic mycoses. Because the data on the potential waterborne nature of nosocomial aspergillosis were not available at the time of these recommendations, specific recommendations to avoid water exposure to prevent aspergillosis were not offered.136
Finally, when the hospital water of institutions caring for stem cell transplant recipients is colonized with Legionella species, the CDC recommends the use of sterile water for drinking, brushing teeth, flushing nasogastric tubes, and rinsing nebulization devices and other semicritical respiratory care equipment. The CDC also recommends avoiding showering (using sponge baths instead) and exposure to faucet water and prompt cleaning and repair of water leaks to prevent mold proliferation in patient care areas (Table 3).137
|
|
|
|
Table 3. Public Health Agency Guidelines Regarding Community and Hospital Water Precautions
|
|
|
RECOMMENDATIONS FOR PREVENTING NOSOCOMIAL WATERBORNE INFECTIONS
Government agencies have established guidelines for water safety in the community, particularly for immunocompromised persons.133-134 Given the greater vulnerability of these patients to infection when hospitalized (usually at the peak of their immunosuppression), hospitals caring for such patients should provide higher standards of drinking water quality than the community and should take immediate measures to prevent waterborne infections. These measures are likely to be successful, as demonstrated by the significant reduction in waterborne infections (such as legionellosis and cryptosporidiosis) when guidelines are applied.129, 138
To this end, we offer the single new recommendation of minimizing patient exposure to tap water for all hospitalized immunocompromised patients and reinforce previously published recommendations, ie, to educate staff and patients, implement existing infection control measures, and perform targeted surveillance.
I. Minimize Patient Exposure to Tap Water: Inexpensive Yet Potentially Effective
This measure is the easiest and least expensive to implement. Its effectiveness has been demonstrated by studies in which provision of sterile water or avoidance of tap water markedly reduced the incidence of legionellosis129 and cryptosporidiosis138 and terminated several other outbreaks of nosocomial waterborne infections (Table 4).
|
|
|
|
Table 4. Effective Measures Used to Terminate Outbreaks of Nosocomial Waterborne Infections
|
|
|
We recommend implementation of the CDC guidelines136-137 regardless of the colonization of hospital water systems by Legionella species. We further recommend expanding these CDC guidelines to all immunocompromised patients. Our recommendations are based on the following: (1) culturing of hospital water for Legionella species is not routinely performed at most transplantation centers, as evidenced by the outbreaks of legionellosis on such units, which may go unrecognized for up to 10 years123-125; (2) opportunistic molds can inhabit hospital water systems and aerosolize after water activities, leading to patient exposure63-64; and (3) other hospitalized immunocompromised patient populations (cancer patients, solid organ transplant recipients, etc) are also at risk for legionellosis58 and other nosocomial waterborne infections.11-52 These patient populations should, thus, be offered the same level of protection given to recipients of hematopoietic stem cell transplants.
Sterile water can be produced by vigorous boiling for 3 minutes or can be purchased at a minimal cost ($0.49/gal average price). Of note, bottled water is not necessarily sterile unless so labeled. Other water disinfection technologies are available, but distillation seems to be the most appropriate approach to producing sterile water in small quantities (Table 5). However, extraordinary effort would be required to establish and maintain distillation systems sufficient to provide sterile drinking water to all hospitalized patients. Because of its low cost and worldwide availability, sterile drinking water (obtained by vigorous boiling or purchased as bottled water) should be provided to immunocompromised patients. Because showering is associated with nosocomial waterborne infections127 and results in aerosolization of pathogens,63-64 it would seem prudent to avoid showering and to rely instead on disposable sterile sponges for bathing. These sponges are inexpensive (<$1.50 per patient per day), require less nursing time in the bathing of patients compared with showering these patients or providing them with the usual self-prepared bed baths, and are well accepted by caregivers.139 Alternatively, patients may prepare their own sterile sponge bath with towels that have been steamed or microwaved and water that has been boiled. Special care must be taken to avoid serious burns in this setting. Appropriate disinfection of hospital equipment and avoidance of contact of such equipment with tap water is also recommended.140
|
|
|
|
Table 5. Efficacy of Water Disinfection Methods Against Various Pathogens*
|
|
|
It could be argued that it was failure in infection control practices (such as failure to wash hands) that contributed to some of these waterborne outbreaks and that implementation of effective practices will suffice to prevent these infections. However, a significant rate of nosocomial infections (10%) persisted even after a significant improvement in compliance with hand hygiene (from 48% to 66%).141 In addition, and despite extensive education about the importance of infection control measures, adherence among health care workers remains low.141 Thus, a more redundant system needs to be put in place that relies on more than one method to prevent these infections. Provision of sterile water is an inexpensive measure that could provide such redundancy.
It could also be argued that institutions caring for high-risk patients have already undertaken such precautions. Such is not the case, however, as evidenced by the recent reports of outbreaks of legionellosis in transplantation units that went undetected for up to 10 years.123-125
II. Educate Staff and Patients and Implement Existing Infection Control Measures
Hospital staff members and patients should receive education about the procedures that prevent infection from waterborne pathogens in hospital and outpatient settings (per US and United Kingdom public health agencies).133-134 Reinforcement of infection control measures that have ended outbreaks in the past is also needed. These measures include hand disinfection, use of other aseptic techniques, discontinuation of the use of contaminated equipment, restriction of equipment connection to water sources until immediately before use, effective instrument sterilization, and meticulous disinfection of the ward environment (Table 4).
III. Perform Targeted Surveillance
Two approaches for the control of nosocomial legionellosis have been recommended: (1) intensive surveillance for infections and monitoring of water systems when infections occur142 and (2) routine surveillance cultures of water distribution systems in hospitals caring for high-risk patients.143
Although we favor the latter approach in the case of legionellosis, we believe that intensive surveillance for infections other than by Legionella species is more appropriate until the extent of the relationship between infection and water colonization by these pathogens has been established. Such surveillance, however, should be intensive, comprehensive of all hospital wards, and prolonged and should rely on appropriate tools to diagnose these infections and their relation to the water source.
IV. Other Measures
One potentially effective approach is to maintain hot water at 60°C or higher140 in an attempt to decrease the concentration of organisms in hospital water systems. However, we do not view this approach as particularly appealing because of the considerable costs, the short-term effectiveness of this measure, and the risk of accidental scalding injury of patients and staff.
New hospitals should construct water distribution systems that meet the American Institute of Architects specifications,140 and, per CDC and Association for Professionals in Infection Control and Epidemiology recommendations, all hospitals should conduct routine preventive maintenance of their water distribution system. Unlike residential water tanks, which are based on flow-through systems, large buildings such as hospitals are required to have recirculating hot water systems, which are associated with a significant increase in risk of colonization by and amplification of these pathogens.8 Water filtration systems are not consistently effective, are expensive, and are difficult to maintain.144 Thus, physical barriers (avoidance of exposure) remain the best forms of protection. This conclusion is supported by the lower cost, ease of implementation, and effectiveness of such measures compared with the high cost, complexity, and limited success of disinfection methods (waterborne organisms rapidly recolonize water structures).145 Important measures to decrease the concentration of organisms present in hospital water systems consist of repairing and disinfecting damaged and contaminated water systems (including tanks) and establishing a regular maintenance program (Table 4).
CONCLUSIONS
The literature demonstrates a strong association between waterborne pathogens and nosocomial infections other than legionellosis. This association is not well appreciated and is still not fully understood. The most rigorous approach to better understanding the magnitude of the problem is the conduct of carefully planned prospective studies. These studies should prospectively assess the magnitude of the problem of nosocomial waterborne infections and the percentage of hospitals that have microbial contamination of their water supply. These studies should also attempt to correlate rates of nosocomial pneumonia with counts of waterborne gram-negative organisms such as P aeruginosa and with certain hospital practices such as superheating and flushing or other control methods for waterborne legionellosis.
This review does not demonstrate that instituting our new recommendation of avoiding patient exposure to tap water would result in a decreased incidence of all waterborne nosocomial infections. However, the effectiveness of this easy, inexpensive, and readily and widely available approach has been demonstrated by studies in which provision of sterile water or avoidance of tap water markedly reduced the incidence of waterborne infections, including legionellosis129 and cryptosporidiosis,138 and terminated several other outbreaks of nosocomial waterborne infections (Table 4).12, 14, 16, 19, 24-25,31-32,34, 36-37,39, 43, 48
AUTHOR INFORMATION
Accepted for publication November 15, 2001.
This study was presented in part at the 38th Interscience Conference for Antimicrobial Agents and Chemotherapy, San Diego, Calif, September 27, 1998.
We thank Robert Bradsher, MD, J. Peter Donnelly, PhD, Thomas Marrie, MD, Janet Stout, PhD, and Robert Rubin, MD, for their insight and critical review of the manuscript.
Corresponding author: Elias J. Anaissie, MD, Myeloma and Transplantation Research Center, University of Arkansas for Medical Sciences, 4301 W Markham, Mail Slot 776, Little Rock, AR 72205 (e-mail: anaissieeliasj{at}uams.edu or elias114{at}aol.com).
From the Myeloma and Transplantation Research Center, University of Arkansas for Medical Sciences, Little Rock.
REFERENCES
| |
1. Pittet D. Nosocomial bloodstream infections. In: Wenzel RP, ed. Prevention and Control of Nosocomial Infections. Baltimore, Md: Williams & Wilkins; 1997:711-769.
2. Rex JH, Sobel JD. Preventing intra-abdominal infections in surgical patients. Crit Care Med. 1999;27:1033-1034.
FULL TEXT
|
ISI
| PUBMED
3. Emori TG, Gaynes RP. An overview of nosocomial infections, including the role of the microbiology laboratory. Clin Microbiol Rev. 1993;6:428-442.
FREE FULL TEXT
4. Weber DJ, Raasch R, Rutala WA. Nosocomial infections in the ICU: the growing importance of antibiotic-resistant pathogens. Chest. 1999;115(suppl):34S-41S.
5. Pfaller MA, Herwaldt LA. The clinical microbiology laboratory and infection control: emerging pathogens, antimicrobial resistance, and new technology. Clin Infect Dis. 1997;25:858-870.
ISI
| PUBMED
6. Rex JH, Walsh TJ, Anaissie EJ. Fungal infections in iatrogenically compromised hosts. Adv Intern Med. 1998;43:321-371.
PUBMED
7. Rutala W, Weber D. Water as a reservoir of nosocomial pathogens. Infect Control Hosp Epidemiol. 1997;18:609-616.
ISI
| PUBMED
8. Geldreich EE. Creating microbial quality in drinking water. In: Geldreich EE, ed. Microbial Qualities of Water Supply in Distribution Systems. Boca Raton, Fla: CRC Press Inc; 1996:39-102.
9. Yu V, Liu Z, Stout JE, Goetz A. Leginonella disinfection of water distribution systems: principles, problems, and practice. Infect Control Hosp Epidemiol. 1993;14:571-575.
ISI
| PUBMED
10. Moffet HL, Williams T. Bacteria recovered from distilled water and inhalation therapy equipment. AJDC. 1967;114:7-12.
11. Trautmann M, Michalsky T, Heidemarie W, Radosavljevic V, Ruhnke M. Tap water colonization with Pseudomonas aeruginosa in a surgical intensive care unit (ICU) and relation to Pseudomonas infections of ICU patients. Infect Control Hosp Epidemiol. 2001;22:49-52.
FULL TEXT
|
ISI
| PUBMED
12. Bert F, Maubec E, Bruneau B, Berry P, Lambert-Zechovsky N. Multi-resistant Pseudomonas aeruginosa outbreak associated with contaminated tap water in a neurosurgery intensive care unit. J Hosp Infect. 1998;39:53-62.
FULL TEXT
|
ISI
| PUBMED
13. Buttery JP, Alabaster SJ, Heine RG, Scott SM, Crutchfield RA, Garland SM. Multiresistant Pseudomonas aeruginosa outbreak in a pediatric oncology ward related to bath toys. Pediatr Infect Dis J. 1998;17:509-513.
FULL TEXT
|
ISI
| PUBMED
14. Ferroni A, Nguyen B, Pron B, Quesne G, Brusset MC, Berche P. Outbreak of nosocomial urinary tract infections due to Pseudomonas aeruginosa in a pediatric surgical unit associated with tap-water contamination. J Hosp Infect. 1998;39:301-307.
FULL TEXT
|
ISI
| PUBMED
15. Ezpeleta C, Larrea I, Martinez J, Arrese E, Cisterna R. Pseudomonas aeruginosa bacteremia following ERCP: an investigation of sources by molecular typing methods. In: Program and abstracts of the 38th Interscience Conference on Antimicrobial Agents and Chemotherapy; September 24-27, 1998; San Diego, Calif. Abstract K-73.
16. Rudnick J, Beck-Sague CM, Anderson RL, Schable B, Miller JM, Jarvis WR. Gram-negative bacteremia in open-heart surgery patients traced to potable tap-water contamination of pressure-monitoring equipment. Infect Control Hosp Epidemiol. 1996;17:281-285.
ISI
| PUBMED
17. Burucoa C, Lhomme V, Gorin V, et al. Water-borne hospital outbreak due to Pseudomonas aeruginosa. In: Program and abstracts of the 35th Interscience Conference on Antimicrobial Agents and Chemotherapy; September 17-20, 1995; San Francisco, Calif. Abstract J-126.
18. Richard P, Le Floch R, Chamoux C, Pannier M, Espaze E, Richet H. Pseudomonas aeruginosa outbreak in a burn unit: role of antimicrobials in the emergence of multiply resistant strains. J Infect Dis. 1994;170:377-383.
ISI
| PUBMED
19. Kolmos HJ, Thuesen B, Nielsen SV, Lohmann M, Kristoffersen K, Rosdahl VT. Outbreak of infection in a burn unit due to Pseudomonas aeruginosa originating from contaminated tubing used for irrigation of patients. J Hosp Infect. 1993;24:11-21.
FULL TEXT
|
ISI
| PUBMED
20. Grundmann H, Kropec A, Hartung D, Berner R, Daschner F. Pseudomonas aeruginosa in a neonatal intensive care unit: reservoirs and ecology of the nosocomial pathogen. J Infect Dis. 1993;168:943-947.
ISI
| PUBMED
21. Worlitzsch D, Wolz C, Botzenhart K, et al. Molecular epidemiology of Pseudomonas aeruginosa: urinary tract infections in paraplegic patients. Zentralbl Hyg Umweltmed. 1989;189:175-184.
ISI
| PUBMED
22. Martino P, Venditti M, Papa G, Orefici G, Serra P. Water supply as a source of Pseudomonas aeruginosa in a hospital for hematological malignancies. Boll Ist Sieroter Milan. 1985;64:109-114.
ISI
| PUBMED
23. Weber DJ, Rutala WA, Blanchet CN, Jordan M, Gergen MF. Faucet aerators: a source of patient colonization with Stenotrophomonas maltophilia. Am J Infect Control. 1999;27:59-63.
FULL TEXT
|
ISI
| PUBMED
24. Verweij PE, Meis JF, Christmann V, et al. Nosocomial outbreak of colonization and infection with Stenotrophomonas maltophilia in preterm infants associated with contaminated tap water. Epidemiol Infect. 1998;120:251-256.
FULL TEXT
| PUBMED
25. Chachaty E, Castagna L, Massei B, et al. Outbreak of Stenotrophomonas maltophilia infections in neutropenic patients: role of water distribution in hospital. In: Program and abstracts of the 38th Interscience Conference on Antimicrobial Agents and Chemotherapy; September 24-27, 1998; San Diego, Calif. Abstract K-74.
26. Talon D, Bailly P, Leprat R, et al. Typing of hospital strains of Xanthomonas maltophilia by pulsed-field gel electrophoresis. J Hosp Infect. 1994;27:209-217.
FULL TEXT
|
ISI
| PUBMED
27. Khardori N, Elting L, Wong E, Schable B, Bodey GP. Nosocomial infections due to Xanthomonas maltophilia (Pseudomonas maltophilia) in patients with cancer. Rev Infect Dis. 1990;12:997-1003.
ISI
| PUBMED
28. Carlyn C, Simmonds J, Kondracki S, et al. An outbreak of Serratia marcescens conjunctivitis in a neonatal care unit: genotypic link to an environmental source. In: Program and abstracts of the 8th Annual Meeting of the Society for Healthcare Epidemiology of America; April 5-7, 1998; Orlando, Fla. Abstract 1998: Oral 116.
29. Bassett D, Stokes KJ, Thomas WRG. Wound infections with Pseudomonas multivorans: waterborne contaminant of disinfectant solutions. Lancet. 1970;1:1188-1191.
ISI
| PUBMED
30. Gilchrist MJ, Kraft JA, Hammond JG, Connelly BL, Myers MG. Detection of Pseudomonas mesophilica as a source of nosocomial infections in a bone marrow transplant unit. J Clin Microbiol. 1986;23:1052-1055.
FREE FULL TEXT
31. Crane LR, Tagle LC, Palutke WA. Outbreak of Pseudomonas paucimobilis in an intensive care nursery. JAMA. 1981;246:985-987.
FREE FULL TEXT
32. Pina P, Guezenec P, Grosbuis S, Guyot L, Ghnassia JC, Allouch PY. An Acinetobacter baumannii outbreak at the Versailles Hospital Center. Pathol Biol (Paris). 1998;46:385-394.
PUBMED
33. Ritter E, Thurm V, Becker-Boost E, Thomas P, Finger H, Wirsing von Konig CH. Epidemic occurrences of multiresistant Acinetobacter baumannii strains in a neonatal intensive care unit. Zentralbl Hyg Umweltmed. 1993;193:461-470.
ISI
| PUBMED
34. Banjeree G, Ayyagari A, Prasad KN, Dhole TN, Singh SK. Nosocomial infection due to Enterobacter cloacae in a tertiary care hospital in Northern India. Indian J Med Res. 1996;103:58-61.
ISI
| PUBMED
35. Pokrywka M, Viazanko K, Medvick J, et al. A Flavobacterium meningosepticum outbreak among intensive care patients. Am J Infect Control. 1993;21:139-145.
FULL TEXT
|
ISI
| PUBMED
36. Abrahamsen TG, Finne PH, Lingaas E. Flavobacterium meningosepticum infections in a neonatal intensive care unit. Acta Paediatr Scand. 1989;78:51-55.
ISI
| PUBMED
37. Picard B, Goullet P. Epidemiological complexity of hospital Aeromonas infections revealed by electrophoretic typing of esterases. Epidemiol Infect. 1987;98:5-14.
PUBMED
38. Rautelin H, Koota K, von Essen R, Jahkola M, Siitonen A, Kosunen TU. Waterborne Campylobacter jejuni epidemic in a Finnish hospital for rheumatic diseases. Scand J Infect Dis. 1990;22:321-326.
ISI
| PUBMED
39. Vanholder R, Vanhaecke E, Ringoir S. Waterborne Pseudomonas septicemia. ASAIO Trans. 1990;36:M215-M216.
40. Pegues DA, Arathoon EG, Samayoa B, et al. Epidemic gram-negative bacteremia in a neonatal intensive care unit in Guatemala. Am J Infect Control. 1994;22:163-171.
FULL TEXT
|
ISI
| PUBMED
41. De Schuijmer J, Vammeste M, Vannecchoutte M, Verschraegen G. Chryseobacterium in a burn unit. In: Program and abstracts of the 4th International Conference of the Hospital Infection Society; September 13-17, 1998; Edinburgh, Scotland.
42. Von Reyn C, Maslow JN, Barber TW, Falkinham III JO, Arbeit RD. Persistant colonisation of potable water as a source of Mycobacterium avium infection in AIDS. Lancet. 1994;343:1137-1141.
FULL TEXT
|
ISI
| PUBMED
43. Soto LE, Bobadilla M, Villalobos Y, et al. Post-surgical nasal cellulitis outbreak due to Mycobacterium chelonae. J Hosp Infect. 1991;19:99-106.
FULL TEXT
|
ISI
| PUBMED
44. Kauppinen J, Nousiainen T, Jantunen E, Mattila R, Katila ML. Hospital water supply as a source of disseminated Mycobacterium fortuitum infection in a leukemia patient. Infect Control Hosp Epidemiol. 1999;20:343-345.
FULL TEXT
|
ISI
| PUBMED
45. Hector JS, Pang Y, Mazurek GH, Zhang Y, Brown BA, Wallace RJ Jr. Large restriction fragment patterns of genomic Mycobacterium fortuitum DNA as strain-specific markers and their use in epidemiologic investigation of four nosocomial outbreaks. J Clin Microbiol. 1992;30:1250-1255.
FREE FULL TEXT
46. Burns DN, Wallace RJ, Schultz ME, et al. Nosocomial outbreak of respiratory tract colonization with Mycobacterium fortuitum: demonstration of the usefulness of pulsed-field gel electrophoresis in an epidemiologic investigation. Am Rev Respir Dis. 1991;144:1153-1159.
ISI
| PUBMED
47. Benitez MA, Alcaide F, Rufi G, Sanuy B, Gudiol F, Martin R. Investigation of a nosocomial outbreak of Mycobacterium xenopi associated with a hospital water supply. In: Program and abstracts of the 39th Interscience Conference on Antimicrobial Agents and Chemotherapy; September 26-29, 1999; San Diego, Calif. Abstract 753.
48. Desplaces N, Picardeau M, Dinh V, et al. Spinal infections due to Mycobacterium xenopi after discectomies. In: Program and abstracts of the 35th Interscience Conference on Antimicrobial Agents and Chemotherapy; September 17-20, 1995; San Francisco, Calif. Abstract J-145.
49. Picardeau M, Prod'Hom G, Raskine L, Le Pennec MP, Vincent V. Genotypic characterization of five subspecies of Mycobacterium kansasii. J Clin Microbiol. 1997;35:25-32.
ABSTRACT
50. Wallace RJ, Musser JM, Hull SI, et al. Diversity and sources of rapidly growing mycobacteria associated with infections following cardiac surgery. J Infect Dis. 1989;159:708-716.
ISI
| PUBMED
51. Anaissie E. Emerging fungal infections: don't drink the water. In: Program and abstracts of the 38th Interscience Conference on Antimicrobial Agents and Chemotherapy; September 24-27, 1998; San Diego, Calif. Abstract S-147.
52. Nucci M, Akiti T, Silveira F, et al. Fungemia due to Exophiala jeanselmei: report of 23 cases. In: Program and abstracts of the 38th Interscience Conference of Antimicrobial Agents and Chemotherapy; September 24-27, 1998; San Diego, Calif. Abstract J-141.
53. Armstrong JL, Calomiris JJ, Seidler RJ. Selection of antibiotic-resistant standard plate count bacteria during water treatment. Appl Environ Microbiol. 1982;44:308-16.
FREE FULL TEXT
54. Jochimesen EM, Carmichael WW, An JS, et al. Liver failure and death after exposure to microcystins at a hemodialysis center in Brazil. N Engl J Med. 1998;338:873-878.
FREE FULL TEXT
55. Geldreich EE. Biofilms in water distribution system. In: CRC Press Inc, ed. Microbial Qualities of Water Supply in Distribution Systems. Boca Raton, Fla: Lewis Publisher; 1996:159-214.
56. Geldreich EE. Biological profiles in drinking water. In: Geldreich EE, ed. Microbial Qualities of Water Supply in Distribution Systems. Boca Raton, Fla: CRC Press Inc; 1996:104-144.
57. Mermel L, Josephson SL, Giorgio CH, Dempsey J, Parenteau S. Association of Legionnaire's disease with construction: contamination of potable water? Infect Control Hosp Epidemiol. 1995;16:76-81.
ISI
| PUBMED
58. Yu VL. Legionella pneumophila (Legionnaires' disease). In: Mandell DAD, ed. Principles and Practice of Infectious Diseases. Vol 2. 5th ed. Philadelphia, Pa: Churchill Livingstone Inc; 2000:2424-2435.
59. Michel R, Burghardt H, Bergmann H. Acanthamoeba, naturally intracellularly infected with Pseudomonas aeruginosa, after their isolation from a microbiologically contaminated drinking water system in a hospital. Zentralbl Hyg Umweltmed. 1995;196:532-544.
ISI
| PUBMED
60. Walochnik J, Picher O, Aspock C, Ullman M, Sommer R, Aspock H. Interactions of "Limax amoebae" and gram-negative bacteria: experimental studies and review of current problems. Tokai J Exp Clin Med. 1998;23:273-278.
PUBMED
61. Pannuti CS. Hospital environment for high risk patients. In: Wenzel RP, ed. Prevention and Control of Nosocomial Infections. 3rd ed. Baltimore, Md: Williams & Wilkins; 1997:463-489.
62. Anaissie EG, Stratton SL, Dignani MC, et al. Pathogenic Aspergillus species recovered from a hospital water system: a 3-year prospective study. Clin Infect Dis. 2002;34:780-789.
FULL TEXT
|
ISI
| PUBMED
63. Anaissie E, Kuchar R, Rex J, Summerbell R, Walsh T. The hospital water system as a reservoir of Fusarium. In: Program and abstracts of the 37th Interscience Conference on Antimicrobial Agents and Chemotherapy; September 28–October 1, 1997; Toronto, Ontario. Abstract J-94.
64. Anaissie EJ, Monson TP, Penzak SR, Stratton SL. Opportunistic fungi recovered from hospital water systems. In: Program and abstracts of the 37th Interscience Conference on Antimicrobial Agents and Chemotherapy; September 28–October 1, 1997; Toronto, Ontario. Abstract J-93.
65. Anonymous. Air is apparent, but water can also be a source. In: Evans G, ed. Infection Control Sourcebook. Atlanta, Ga: American Health Consultants; 1997:E32-E33.
66. Mizukane R, Sawatari K, Araki J, et al. Invasive pulmonary aspergillosis caused by aspiration of polluted water after nearly drowning [in Japanese]. Kansenshogaku Zasshi. 1996;70:1181-1185.
PUBMED
67. ter Maaten JC, Golding RP, Strack van Schijndel RJ, Thijs LG. Disseminated aspergillosis after near drowning. Neth J Med. 1995;47:21-24.
FULL TEXT
|
ISI
| PUBMED
68. Wilichowski E, Christen HJ, Schiffmann H, Schulz-Schaeffer W, Behrens-Baumann W. Fatal Pseudallescheria boydii panencephalitis in a child after nearly drowning. Pediatr Infect Dis J. 1996;15:365-370.
FULL TEXT
|
ISI
| PUBMED
69. Casanova L, Leibowitz M. Detection of DNA from Pneumocystis carinii in water. In: Program and abstracts of the 37th Interscience Conference of Antimicrobial Agents and Chemotherapy; September 28–October 1, 1997; Toronto, Ontario. Abstract K-116.
70. Gerberding JL. Nosocomial transmission of opportunistic infections. Infect Control Hosp Epidemiol. 1998;19:574-577.
ISI
| PUBMED
71. Bowie WR, King AS, Werker DH, et al for the BC Toxoplasma Investigation Team. Outbreak of toxoplasmosis associated with municipal drinking water. Lancet. 1997;350:173-177.
FULL TEXT
|
ISI
| PUBMED
72. Muyldermans G, de Smet F, Pierard D, et al. Neonatal infections with Pseudomonas aeruginosa associated with a water-bath used to thaw fresh frozen plasma. J Hosp Infect. 1998;39:309-314.
FULL TEXT
|
ISI
| PUBMED
73. Piper J, Tuttle D, McGrail L, Steele-Moore L, Bollinger E, Berg D. Pseudomonas aeruginosa outbreak in a neonatal ICU due to construction related water line alterations. In: Program and abstracts of the 37th Interscience Conference of Antimicrobial Agents and Chemotherapy; September 28–October 1, 1997; Toronto, Ontario. Abstract J-21.
74. De Vos D, Lim A Jr, Pirnay JP, et al. Analysis of epidemic Pseudomonas aeruginosa isolates by isoelectric focusing of pyoverdine and RAPD-PCR: modern tools for an integrated anti-nosocomial infection strategy in burn wound centres. Burns. 1997;23:379-386.
FULL TEXT
|
ISI
| PUBMED
75. Doring G, Jansen S, Noll H, et al. Distribution and transmission of Pseudomonas aeruginosa and Burkholderia cepacia in a hospital ward. Pediatr Pulmonol. 1996;21:90-100.
FULL TEXT
|
ISI
| PUBMED
76. Kerr JR, Moore JE, Curran MD, et al. Investigation of a nosocomial outbreak of Pseudomonas aeruginosa pneumonia in an intensive care unit by random amplification of polymorphic DNA assay. J Hosp Infect. 1995;30:125-131.
FULL TEXT
|
ISI
| PUBMED
77. Doring G, Horz M, Ortelt J, Grupp H, Wolz C. Molecular epidemiology of Pseudomonas aeruginosa in an intensive care unit. Epidemiol Infect. 1993;110:427-436.
PUBMED
78. Tredget EE, Shankowsky HA, Joffe AM, et al. Epidemiology of infections with Pseudomonas aeruginosa in burn patients: the role of hydrotherapy. Clin Infect Dis. 1992;15:941-949.
ISI
| PUBMED
79. Casewell MW, Slater NG, Cooper JE. Operating theatre water-baths as a cause of pseudomonas septicemia. J Hosp Infect. 1981;2:237-247.
FULL TEXT
| PUBMED
80. Griffith SJ, Nathan C, Selander RK, et al. The epidemiology of Pseudomonas aeruginosa in oncology patients in a general hospital. J Infect Dis. 1989;160:1030-1036.
ISI
| PUBMED
81. Schlech WF, Simonsen N, Sumarah R, Martin RS. Nosocomial outbreak of Pseudomonas aeruginosa folliculitis associated with a physiotherapy pool. CMAJ. 1986;134:909-913.
ABSTRACT
82. Levin MH, Olson B, Nathan C, Kabins SA, Weinstein RA. Pseudomonas in the sinks in an intensive care unit: relation to patients. J Clin Pathol. 1984;37:424-427.
FREE FULL TEXT
83. McGuckin MB, Thorpe RJ, Abrutyn E. Hydrotherapy: an outbreak of Pseudomonas aeruginosa wound infections related to Hubbard tank treatments. Arch Phys Med Rehabil. 1981;62:283-285.
ISI
| PUBMED
84. Burdon DW, Whitby JL. Contamination of hospital disinfectants with Pseudomonas species. BMJ. 1967;2:153-155.
85. Cross DF, Benchimol A, Dimond EG. The faucet aerator: a source of pseudomonas infection. N Engl J Med. 1966;274:1430-1431.
86. Kresky B. Control of gram-negative bacilli in a hospital nursery. AJDC. 1964;107:363-369.
87. Wilson MG, Nelson RC, Phillips LH, Boak RA. New source of Pseudomonas aeruginosa in a nursery. JAMA. 1961;175:1146-1148.
88. Villarino ME, Stevens LE, Schable B, et al. Risk factors for epidemic Xanthomonas maltophilia infection/colonization in intensive care unit patients. Infect Control Hosp Epidemiol. 1992;13:201-206.
ISI
| PUBMED
89. Wishart MM, Riley TV. Infection with Pseudomonas maltophilia hospital outbreak due to contaminated disinfectant. Med J Aust. 1976;2:710-712.
ISI
| PUBMED
90. Simor AE, Ramage L, Wilcox L, Bull SB, Bialkowska-Hobrzanska H. Molecular and epidemiologic study of multiresistant Serratia marcescens infections in a spinal cord injury rehabilitation unit. Infect Control. 1988;9:20-27.
ISI
| PUBMED
91. Conly JM, Klass L, Larson L, Kennedy J, Low DE, Harding GK. Pseudomonas cepacia colonization and infection in intensive care units. CMAJ. 1986;134:363-366.
ABSTRACT
92. Rapkin RH. Pseudomonas cepacia in an intensive care nursery. Pediatrics. 1976;57:239-243.
FREE FULL TEXT
93. Phillips I, Eykyn S, Laker M. Outbreak of hospital infection caused by contaminated autoclaved fluids. Lancet. 1972;1:1258-1260.
ISI
| PUBMED
94. Faoagali JL, Johnson RA, Smith L. Infection in a neonatal unit [letter]. N Z Med J. 1977;86:495.
95. Mitchell RG, Hayward AC. Postoperative urinary-tract infections caused by contaminated irrigating fluid. Lancet. 1966;1:793-795.
ISI
| PUBMED
96. Tankovic J, Legrand P, De Gatines G, Chemineau V, Brun-Buisson C, Duval J. Characterization of a hospital outbreak of imipenem-resistant Acinetobacter baumannii by phenotypic and genotypic typing methods. J Clin Microbiol. 1994;32:2677-2681.
FREE FULL TEXT
97. Beck-Sague CM, Jarvis WR, Brook JH, et al. Epidemic bacteremia due to Acinetobacter baumannii in five intensive care units. Am J Epidemiol. 1990;132:723-733.
FREE FULL TEXT
98. Abrutyn E, Goodhart GL, Roos K, Anderson R, Buxton A. Acinetobacter calcoaceticus outbreak associated with peritoneal dialysis. Am J Epidemiol. 1978;107:328-335.
FREE FULL TEXT
99. Wang SA, Levine RB, Carson LA, et al. Gram-negative bacteremia in a hemodialysis unit traced to portable drain port contamination. In: Program and abstracts of the 37th Interscience Conference on Antimicrobial Agents and Chemotherapy; September 28–October 1, 1997; Toronto, Ontario. Abstract J-27.
100. Jackson BM, Beck-Sague CM, Bland LA, Arduino MJ, Meyer L, Jarvis WR. Outbreak of pyrogenic reactions and gram-negative bacteremia in a hemodialysis center. Am J Nephrol. 1994;14:85-89.
ISI
| PUBMED
101. Wang CC, Chu ML, Ho LJ, Hwang RC. Analysis of plasmid pattern in pediatric intensive care unit outbreaks of nosocomial infection due to Enterobacter cloacae. J Hosp Infect. 1991;19:33-40.
FULL TEXT
|
ISI
| PUBMED
102. Stamm WE, Colella JJ, Anderson RL, Dixon RE. Indwelling arterial catheters as a source of nosocomial bacteremia: an outbreak caused by Flavobacterium species. N Engl J Med. 1975;292:1099-1102.
ABSTRACT
103. Boukadida J, Monastiri K, Snoussi N, Jeddi M, Berche P. Nosocomial neonatal meningitis by Alcaligenes xylosoxidans transmitted by aqueous eosin. Pediatr Infect Dis J. 1993;12:696-697.
FULL TEXT
|
ISI
| PUBMED
104. Last PM, Harbison PA, Marsh JA. Bacteraemia after urological instrumentation. Lancet. 1966;1:74-76.
FULL TEXT
|
ISI
| PUBMED
105. Maraki S, Samonis G, Marnelakis E, Tselentis Y. Surgical wound infection caused by Rahnella aquatilis. J Clin Microbiol. 1994;32:2706-2708.
FREE FULL TEXT
106. Hoppe JE, Herter M, Aleksic S, Klingebeil T, Niethhammer D. Catheter-related Rahnella aquatilis bacteremia in a pediatric bone marrow transplant recipient. J Clin Microbiol. 1993;31:1911-1912.
FREE FULL TEXT
107. Alballaa SR, Qadri SM, al-Furayh O, al-Qatary K. Urinary tract infection due to Rahnella aquatilis in a renal transplant patient. J Clin Microbiol. 1992;30:2948-2950.
FREE FULL TEXT
108. Pien FD, Bruce AE. Nosocomial Ewingella americana bacteremia in an intensive care unit. Arch Intern Med. 1986;146:111-112.
FREE FULL TEXT
109. Sirinavin S, Hotrakitya S, Suprasongsin C, Wannaying B, Pakeecheep S, Vorachit M. An outbreak of Salmonella urbana infection in neonatal nurseries. J Hosp Infect. 1991;18:231-238.
FULL TEXT
|
ISI
| PUBMED
110. Claesson BE, Claesson UL. An outbreak of endometritis in a maternity ward caused by spread of group A streptococci from a showerhead. J Hosp Infect. 1985;6:304-311.
ISI
| PUBMED
111. Noble MA, Isaac-Renton JL, Bryce EA, et al. The toilet as a transmission vector of vancomycin-resistant enterococci. J Hosp Infect. 1998;40:237-241.
FULL TEXT
|
ISI
| PUBMED
112. Dandalides PC, Rutala WA, Sarubbi FA Jr. Postoperative infections following cardiac surgery: association with an environmental reservoir in cardiothoracic intensive care unit. Infect Control. 1984;5:378-384.
ISI
| PUBMED
113. Vlodavets VV, Belokrysenko SS. The epidemiology of interhospital outbreaks of nosocomial infections. Zh Mikrobiol Epidemiol Immunobiol. 1984;7:75-77.
114. Newsom SWB. Hospital infection from contaminated ice. Lancet. 1968;2:620-623.
ISI
| PUBMED
115. Bolan G, Reingold AL, Carson LA, et al. Infections with Mycobacterium chelonei in patients receiving dialysis and using processed hemodialyzers. J Infect Dis. 1985;152:1013-1019.
ISI
| PUBMED
116. Loudon KW, Coke AP, Burnie JP, Shaw AJ, Oppenheim BA, Morris CQ. Kitchens as a source of Aspergillus niger infection. J Hosp Infect. 1996;32:191-198.
FULL TEXT
|
ISI
| PUBMED
117. Yuen KY, Seto WH, Ching TY, Cheung WC, Kwok Y, Chu YB. An outbreak of Candida tropicalis in patients on intermittent peritoneal dialysis. J Hosp Infect. 1992;22:65-72.
FULL TEXT
|
ISI
| PUBMED
118. Fridkin SK, Kremer FB, Bland FA, Padhye A, McNeil MM, Jarvis WR. Acremonium kiliense endophthalmitis that occurred after cataract extraction in an ambulatory surgical center and was traced to an environmental reservoir. Clin Infect Dis. 1996;22:222-227.
ISI
| PUBMED
119. Ravn P, Lundgren JD, Kjaeldgaard P, et al. Nosocomial outbreak of cryptosporidiosis in AIDS patients. BMJ. 1991;302:277-280.
120. Vincent J, Bihari DJ, Suter PM, et al. The prevalence of nosocomial infection in intensive care units in Europe: results of the European Prevalence of Infection in Intensive Care (EPIC) study. JAMA. 1995;274:639-644.
FREE FULL TEXT
121. Richards MJ, Edwards JR, Culver DH, Gaynes RP. Nosocomial infections in medical intensive care units in the United States. Crit Care Med. 1999;27:887-892.
FULL TEXT
|
ISI
| PUBMED
122. Petignat C, Blanc DS, Francoli P. Occult nosocomial infections. Infect Control Hosp Epidemiol. 1998;19:593-596.
ISI
| PUBMED
123. Kool JL, Fiore AE, Kioski CM, et al. More than 10 years of unrecognized nosocomial transmission of legionnaires' disease among transplant patients. Infect Control Hosp Epidemiol. 1998;19:898-904.
ISI
| PUBMED
124. Lepine AL, Jernigan DB, Butler JC, et al. A recurrent outbreak of nosocomial legionnaires' disease detected by urinary antigen testing: evidence for long-term colonization of a hospital plumbing system. Infect Control Hosp Epidemiol. 1998;19:905-910.
ISI
| PUBMED
125. Prodinger WM, Bonatti H, Allerberger F, et al. Legionella pneumonia in transplant recipients: a cluster of cases of eight years' duration. J Hosp Infect. 1994;26:191-202.
FULL TEXT
|
ISI
| PUBMED
126. Ciesielski C, Blaser M, Wang W. Role of stagnation and obstruction of water flow in isolation of Legionella pneumophila from hospital plumbing. Appl Environ Microbiol. 1984;48:984-987.
FREE FULL TEXT
127. Breiman RF, Fields BS, Sanden GN, Volmer L, Meier A, Spika JS. Association of shower use with Legionnaire's disease: possible role of amoebae. JAMA. 1990;263:2924-2926.
FREE FULL TEXT
128. Yu VL. Could aspiration be the major mode of transmission for Legionella? Am J Med. 1993;95:13-15.
FULL TEXT
|
ISI
| PUBMED
129. Marrie T, Haldane D, MacDonald S. Control of endemic nosocomial Legionnaire's disease by using sterile potable water for high risk patients. Epidemiol Infect. 1991;107:591-605.
PUBMED
130. Ruchel R, Wilichowski E. Cerebral Pseudallescheria mycosis after near drowning. Mycoses. 1995;38:473-475.
ISI
| PUBMED
131. Perz JF, Ennever FK, Le Blancq SM. Cryptosporidium in tap water: comparison of predicted risks with observed levels of disease. Am J Epidemiol. 1998;147:289-301.
FREE FULL TEXT
132. Hoxie NJ, Davis JP, Vergeront JM, Nashold RD, Blair KA. Cryptosporidiosis-associated mortality following a massive waterborne outbreak in Milwaukee, Wisconsin. Am J Public Health. 1997;87:2032-2035.
FREE FULL TEXT
133. Department of the Environment and Department of Health. Cryptosporidium in Water Supplies: Second Report of the Group of Experts (Badenoch Report). London, England: HMSO; 1995.
134. US Environmental Protection Agency and Centers for Disease Control and Prevention. Guidance for People With Severely Weakened Immune Systems. 1999. Document No. EPA 816-F-99-005. Available at: http://www.epa.gov/safewater/crypto.html. Accessed September 2001.
135. US Environmental Protection Agency. Water on Tap: A Consumer's Guide to the Nation's Drinking Water. 1997. Document No. EPA 815-K-97-002. Available at: http://www.epa.gov/OGWDW/wot/ontap.html. Accessed September 2001.
136. Tablan O. Nosocomial pneumonia. In: Olmsted RN, ed. APIC Infection Control and Applied Epidemiology: Principles and Practice. St Louis, Mo: Mosby–Year Book Inc; 1996:10.1-10.14.
137. CDC, Infectious Disease Society of America, and American Society of Blood and Marrow Transplantation. Guidelines for preventing opportunistic infections among hematopoietic stem cell transplant recipients. MMWR Morb Mortal Wkly Rep. 2000;49:1-128.
PUBMED
138. Addiss D, Pond RS, Remshak M, Juranek DD, Stokes S, Davis JP. Reduction of risk of watery diarrhea with point-of-use water filters during a massive outbreak of waterborne Cryptosporidium infection in Milwaukee, Wisconsin, 1993. Am J Trop Med Hyg. 1996;54:549-553.
139. Skewes SM. No more bed baths. RN. 1994;57:34-35.
140. Bartley J. Water. In: Olmsted RN, ed. APIC Infection Control and Applied Epidemiology: Principles and Practice. St Louis, Mo: Mosby–Year Book Inc; 1996:118.1-118.4.
141. Jenner EA, Mackintosh C, Scott GM. Infection control: evidence into practice. J Hosp Infect. 1999;42:91-104.
FULL TEXT
|
ISI
| PUBMED
142. Goetz AYV. Legionella species. In: Olmsted RN, ed. APIC Infection Control and Applied Epidemiology: Principles and Practice. St Louis, Mo: Mosby–Year Book Inc; 1996:64.1-64.4.
143. Yu VL. Resolving the controversy on environmental cultures for Legionella: a modest proposal. Infect Control Hosp Epidemiol. 1998;19:893-897.
ISI
| PUBMED
144. Cooke RPD, Whymant-Morris A, Umasankar RS, Goddard SV. Bacteria-free water for automatic washer-disinfectors: an impossible dream? J Hosp Infect. 1998;39:63-65.
FULL TEXT
|
ISI
| PUBMED
145. Geldreich EE. Characterizing the distribution system: microbial issues. In: Geldreich EE, ed. Microbial Qualities of Water Supply in Distribution Systems. Boca Raton, Fla: CRC Press Inc; 1996:1-37.
 CiteULike  Connotea  Del.icio.us  Digg  Reddit  Technorati  Twitter
What's this?
RELATED LETTERS
National Disease Burden Due to Waterborne Transmission of Nosocomial Pathogens Is Substantially Overestimated
Paul R. Hunter
Arch Intern Med. 2003;163(16):1974.
EXTRACT
| FULL TEXT
National Disease Burden Due to Waterborne Transmission of Nosocomial Pathogens Is Substantially Overestimated—Reply
Elias J. Anaissie
Arch Intern Med. 2003;163(16):1974-1975.
EXTRACT
| FULL TEXT
Water as a Source of Health Care–Associated Infections
Joseph Steven Cervia, Frank Canonica, and Girolomo Ortolano
Arch Intern Med. 2007;167(1):92.
EXTRACT
| FULL TEXT
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
|
Association between Contaminated Faucets and Colonization or Infection by Nonfermenting Gram-Negative Bacteria in Intensive Care Units in Taiwan
Wang et al.
J. Clin. Microbiol. 2009;47:3226-3230.
ABSTRACT
| FULL TEXT
Potentially Pathogenic Bacteria in Shower Water and Air of a Stem Cell Transplant Unit
Perkins et al.
Appl. Environ. Microbiol. 2009;75:5363-5372.
ABSTRACT
| FULL TEXT
Patients' Bath Basins as Potential Sources of Infection: A Multicenter Sampling Study
Johnson et al.
Am J Crit Care 2009;18:31-40.
ABSTRACT
| FULL TEXT
Systematic Literature Review of Oral Hygiene Practices for Intensive Care Patients Receiving Mechanical Ventilation
Berry et al.
Am J Crit Care 2007;16:552-562.
ABSTRACT
| FULL TEXT
Water as a Source of Health Care-Associated Infections
Cervia et al.
Arch Intern Med 2007;167:92-92.
FULL TEXT
rpoB gene sequence-based characterization of emerging non-tuberculous mycobacteria with descriptions of Mycobacterium bolletii sp. nov., Mycobacterium phocaicum sp. nov. and Mycobacterium aubagnense sp. nov.
Adekambi et al.
Int. J. Syst. Evol. Microbiol. 2006;56:133-143.
ABSTRACT
| FULL TEXT
rpoB-Based Identification of Nonpigmented and Late-Pigmenting Rapidly Growing Mycobacteria
Adekambi et al.
J. Clin. Microbiol. 2003;41:5699-5708.
ABSTRACT
| FULL TEXT
National Disease Burden Due to Waterborne Transmission of Nosocomial Pathogens Is Substantially Overestimated
Hunter
Arch Intern Med 2003;163:1974-1974.
FULL TEXT
National Disease Burden Due to Waterborne Transmission of Nosocomial Pathogens Is Substantially Overestimated--Reply
Anaissie
Arch Intern Med 2003;163:1974-1975.
FULL TEXT
|
