Could Pseudomonas baby deaths have been avoided?

Industry experts question whether hospitals are doing enough to protect patients

Three babies have died from the Pseudomonas outbreak at the Royal Jubilee Maternity Hospital in Northern Ireland. Other infants are now being screened

Experts have told Building Better Healthcare that the outbreak of a deadly bug that killed three babies in a neonatal unit in Northern Ireland could have been prevented.

After the country’s health minister, Edwin Poots, confirmed this week that the infants who died at the Royal Jubilee Maternity Hospital (RJMH) had tested positive for the Pseudomonas bacteria, industry leaders suggested more could, and should, have been done to monitor water systems and pipework, a known breeding ground for the bug.

Their comments come just hours after Poots confirmed that Pseudomonas had been found in a number of taps in the intensive care area of the hospital. In addition to the deaths, four other infants at the RJMH have tested positive for the bacteria, together with four babies from wards at Altnagelvin Hospital and Craigavon Hospital, although they are not showing signs of active infection.

In a statement, Poots said: “Pseudomonas is present in many natural environments, including soil and water. It can be found in sinks, taps and water systems and can be difficult to eradicate.

“I can report that investigations so far have shown the Pseudomonas bacteria have been found in a number of taps in the intensive care area of the neonatal unit at the RJMH. The trust health estates team are in the process of removing and replacing all taps and related pipework in the affected area.”

He added that no evidence had been found to suggest the bacteria was present in the water system itself.

I can report that investigations so far have shown the Pseudomonas bacteria have been found in a number of taps in the intensive care area of the neonatal unit at the RJMH. The trust health estates team are in the process of removing and replacing all taps and related pipework in the affected area

The statement continues: “Specialist advice has been received from experts in England and action is based on current best available evidence. This work should be completed within the next couple of weeks. The unit will only be opened once all remedial work is completed and tests show that it is safe to nurse babies in this environment.”

As a result of the deaths, other babies in neonatal units at other hospitals were tested, and two additional colonisations were recorded at both Altnagelvin and Craigavon.

This discovery has led to claims from water treatment experts that the situation could have been prevented.

A UK water treatment specialist, who asked not to be named, told BBH : “In theory this should never have happened.

Pseudomonas is perfectly preventable and most hospitals have a very strict regime of chlorination and disinfecting. Either this was not adequate in this case, or the regime was not being followed properly.”

Hospitals pose a particular problem as many buildings are old and the pipework is complex, with multiple deadlegs where water can stagnate.

The specialist said: “It is very difficult to keep the pipework in good condition. It’s a question of doing a proper risk assessment of the entire water system regularly. It could be a problem with the temperature of the water not being high enough, not enough chlorination, inadequate flushing, or a combination of all three.”

Bhartu Patel of Stansted Laboratories added that hospitals needed to ensure they continuously monitor the supply and are vigilant about the decontamination and replacement of plastic devices such as catheters and tubing.

He said: “Hospital estates are very complex and water supplies are often redirected, leaving deadlegs in the system that provide an ideal breeding ground for bacteria. Pseudomonas produces a slime that anchors the cells to the environment, making it particularly difficult to kill. Disinfectant of the pipework alone is not enough. You need to have a continuous dosing system.

“My advice to hospitals in the wake of this incident is to ensure constant testing and monitoring of pipework and fixtures and to be vigilant about the contamination of plastic tubing, which is the ideal environment for the bacteria to take hold and transfer to patients.”

In theory this should never have happened.Pseudomonas is perfectly preventable and most hospitals have a very strict regime of chlorination and disinfecting. Either this was not adequate in this case, or the regime was not being followed properly

Pseudomonas is perfectly preventable and most hospitals have a very strict regime of chlorination and disinfecting. Either this was not adequate in this case, or the regime was not being followed properly

As well as complex hospital estates providing an ideal breeding ground for the bacteria, they also pose the biggest risk as Pseudomonas particularly affects those with supressed immunity or the very sick.

Poots said: “Outbreaks have occurred in intensive care facilities around the world as patients in these facilities are frequently immunocompromised. Unfortunately babies in neonatal units are already vulnerable due to clinical conditions and varying degrees of prematurity. Their immune systems are not fully developed, and this makes them less able to withstand infections including those that would not cause problems in healthy babies. It is important to keep these facts in mind as we seek to understand how this outbreak could have happened and what we need to do in response.”

As well as testing other babies across the region for infection, a thorough deep clean has been carried out at the RJMH and the affected taps and pipework are being replaced with ultraviolet technology. Expectant mums are being diverted to other facilities while the unit remains closed.

This is not the first time concerns have been raised over the presence of Pseudomonas in UK hospitals. An outbreak at Guy’s Hospital in London in 2005 infected 19 patients in the urological surgery department, resulting in one death. And the paediatric intensive care unit at Glasgow’s Royal Hospital for Sick Children was closed for 48 hours in 2007 after Pseudomonas was confirmed in five children.

In 2010, the Department of Health issued an alert to NHS trusts across England and Wales following outbreaks stemming from handwash basins at Morriston Hospital in Swansea. In the document, the then Director of Public Health, Clara Swinson, said: “It is important for all NHS trusts and their infection control teams to assess the risk to their patients and where appropriate establish if the water used in hand washing has an unacceptable bacterial count.”

The document also suggested the sink taps could have been colonised after the basins were used for purposes other than hand washing, such as disposing of bodily fluids, and ruled that sinks should be cleaned in a manner that ‘minimises the contamination of the faucet from organisms in the sink trap (via plug hole or overflow)’. It also called for improved hand hygiene and the installation of point-of-use filters.

“It is important that estates and facilities managers review current site engineering and cleaning protocols and establish that they are in accordance with current guidance and that manufacturers’ instructions with regard to installation and maintenance have been followed,” the alert added.

My advice to hospitals in the wake of this incident is to ensure constant testing and monitoring of pipework and fixtures and to be vigilant about the contamination of plastic tubing, which is the ideal environment for the bacteria to take hold and transfer to patients

Unlike MRSA and C.difficile infections, surveillance of Pseudomonas is not mandatory. However, statistics from the Health Protection Agency’s voluntary reporting scheme show instances of the bacteria are dropping slightly across England, Wales and Northern Ireland. It reports a prevalence of 6.7 cases per 100,000 people.

What do you think needs to be done? Are hospitals taking the necessary measures to protect patients? Send your comments to jom@hpcimedia.com

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