In preparation for today’s Journal Club in partnership with the Healthcare Infection Society around water hygiene (details and registration here), I’ve reviewed this article in the Journal of Hospital Infection.

Why I choose this article?

Waterborne healthcare associated infections (and the prevention of), have always been an area of interest for me. Papers and evidence identifying the significance of the risk (particularly in the intensive care setting), and the challenges posed by outlets other than sinks and showers, such as toilets (read related blog here) have increased significantly.

This has resulted in novel ways of reducing the risks posed by waterborne infections being explored, including the concept of water-free or water light patient care. With that in mind I was really interested to read this article by Teresa Inkster  and colleagues. What better way than a narrative review from some of the world’s leading authorities on water, to examine if there really is a benefit to implementing water-free care?

Using a defined search criterion, the narrative review identified seven papers, the majority of which focused on implementing water-free care in the intensive care unit (ICU) setting. 

Key findings

• Water-free care was largely instigated in response to outbreaks by Gram-negative bacteria (GNB)
• 2 of the papers reported outbreaks of multidrug resistant Pseudomonas aeruginosa. In both papers removal or limiting use of sinks and implementing water-free alternatives resulted in the termination of outbreaks.
• 2 papers reported outbreaks in neonatal intensive care. One the studies conducted in Australia, showed that complete removal of sinks (apart for one sink for hand washing at entry and exit points) result in decreased colonisation of neonates with GNB and the unit reporting no outbreaks (traceable to water systems) for over 10 years!
• 2 quasi experimental studies both conducted in ICU settings reported benefits when implementing water-free care. One of the studies showed an overall decrease in GNB colonisation rates. The other study showed a reduction in the incidence of MDR GNB infection, with the greatest impact observed on reducing new cases of Klebsiella pneumoniae.

Limitations of the study

The studies identified in the narrative review are weakly powered. Further research should focus on higher powered studies which focus on water-free care as the sole intervention. We can also aspire to a randomised controlled trial to hopefully provide unequivocal evidence. There are also questions to be answered on the methodology we use to sample a sink (something Jon Otter and I wrote about recently). Where and how do we sample? Can we employ whole genome sequencing more effectively?

What strategies should be adopted by healthcare providers?

Terminating outbreaks and reducing colonisation of GNB are clear benefits when implementing water-free care. The authors helpfully set out challenges which need to be addressed before healthcare providers can consider the implementation of water-free strategies. These challenges include:

• ‘Water-free’ being a confusing term which can be a barrier in itself
• Risk from water and wastewater systems are not appropriately risk assessed in terms of risk to vulnerable patients
• Surveillance methods often lack sensitivity
• Standard IPC precautions are designed to be ‘catch all’ so lack effectiveness in preventing water and wastewater transmission events

Requirement for change

The article highlights the looming global antimicrobial resistance (AMR) crisis and considers the current strategy of infection control, antimicrobial stewardship and development of new antibiotics, being largely ‘oblivious’ to the built environment. The authors make an excellent point that through improved design, installation and commission/maintenance the built environment provides an excellent opportunity to tackle the AMR crisis head on. The authors go on to emphasise how the UK New Hospital Programme  (NHP) provides an opportunity to develop solutions to implement optimal water-free care. I couldn’t agree more!

As part of the requirement for change the authors also highlight why the move to water-free care has been relatively slow. These factors include lack of awareness and recognition of risks, low sensitivity of surveillance, concerns of risk to patient safety when removing clinical hand wash basins and an increase in skin related conditions (associated with increased alcohol-based sanitisers). 

What this means for IPC?

Clearly the evidence surrounding the reduction in risk and transmission of healthcare associated infections when adopting water-free care is gathering traction. There is work to do to overcome the challenges, but also opportunities via the NHP. The authors call for empowerment of clinical staff, followed by ownership to support the successful implementation of water-free care. However, this requires support and guidance from organisations such as the Department of Health (in England).

Collaboration between IPC and estates and facilities staff, as well as executive buy in and engagement with front line staff is required to reduce the risks associated with water and wastewater. Overcoming barriers to implement water-free care will rely on a change in culture and financial investment to support its successful adoption and for the benefits to be realised. Finally with the looming AMR crisis, prevention is always better than cure, especially as we are running out of options for the cure (antibiotics)!