by Judy A. Angelbeck, Ph.D.,
Girolamo A. Ortolano, Ph.D.,
Francis P. Canonica, Ph.D.,
and Joseph S. Cervia, M.D.
Contamination of the hospital water supply with potentially pathogenic Many waterborne microorg a n i s m s
organisms is very common. A wide range of bacteria, fungi, and protozoa
are opportunistic pathogens that
in the water supply may be pathogenic and should be cause for clinical
can increase the risk of infection in
concern. Common bacterial pathogens include Legionella spp
immunocompromised patients. Such
, and some mycobacteria. Aspergillus
is a particularly disconcerting mold
patients who come into contact with
found in hospital water. While the pathogenicity of many waterborne parasites (e.g.
contaminated tap water from point-
C ryptosporidium parv u m
) has been well documented, some protozoa such as
of-use sources such as faucets,
are not only pathogenic in their own right, but they can also protect
showers, water fountains, and ice
bacterial pathogens such as Legionella pneumophila
from destructive chemical
machines are therefore challenged with
disinfectants and environmental forces as they support bacterial growth and replication.
an increased potential for infection.
Point-of-use water filtration has not
only been shown to reduce infectiouscomplications, but it also serves as acomplementary strategy to systemicwater disinfection technologies. T h e
persistence of biofilm in healthcare
of the potential sites of
facility water delivery systems provides
further justification for implementing
sequestration within the
plumbing supply to and
within hospitals. Adapted
from Anaissie et. al.
In a recent plea for action,
Anaissie et al.1 reviewed the potentialsources of water and mechanismsthrough which water could serve as asource of infectious microorganisms(Figure 1). A recent extensive reviewof topics relevant to waterbornepathogens also outlines this risk.2
Hospital Water as a Source of
Hospitals generally draw their
water from the municipal watersupply. As a consequence of the factthat municipal water, once disinfectedat the treatment plant, travels througha system of biofilm-laden pipesbefore reaching the hospital, water-b o r n e m i c r o o rganisms have beenfound in hospital water tanks, as well
MANAGING INFECTION CONTROL
as the tap water that flows from faucets and showers. It is the
Common Waterborne Pathogens
water's contact with biofilm that is the primary cause of poor
Bacteria found in potable water include Legionella pneu -
tap water quality at the point-of-entry to the hospital. However,
mophila, Pseudomonas spp
. (particularly P s e u d o m o n a s
other factors such as distribution pipeline and storage tank age
), Stenotrophomonas maltophilia, Aeromonas spp.,
and corrosion, poor water system design, and water stagnation
Acinetobacter spp., Enterobacter spp., Flavobacterium spp.,
are also major contributors. Biofilm can become dislodged
and Serratia spp
.5 , 6 , 7 , 8 , 9 P. aeuriginosa
can persist in the
from pipe surfaces as the result of increased water demand
hospital water supply for extended periods and has been asso-
during the summer months that results in higher water flow
ciated with healthcare-associated infection (HAI) outbreaks.1,5
rates and increased shearing forces. Periods during which
The bacteria isolated and identified in association with
facility construction takes place also result in biofilm distur-
13 of 17 reported waterborne pathogen outbreaks (76%) were
bance due to direct mechanical contact with pipes, as does the
resistant to at least two classes of antibiotics (Table 1; adapted
occasional use of normally stagnant water at less frequently
from Anaissie et al.1). A number of reports show that mycobacteria
can be isolated from hospital water. These bacteria can persist in
Patient exposure to waterborne microorganisms in the
water systems over several years and have been implicated in
hospital occurs while showering, bathing, drinking water, or
ingesting ice. It can also occur through contact with contami-
spores can inhabit hospital water distribution systems. A n
nated medical equipment such as tube feed bags, flexible
a s p e rgillosis outbreak was reported in a hospital in Houston
endoscopes, and respiratory equipment that have been rinsed
leading to patient infections. There is additional evidence that
with tap water. The hands of healthcare personnel washed using
other opportunistic molds, including A s p e rgillus spp
., have been
tap water can also lead to patient exposure.1,3,4
recovered from hospital watersystems.1 7 , 1 8 , 1 9 , 2 0 Among parasites,
Healthcare-associated infections related to contaminated hospital
Molecular methods used to establish waterborne microorganisms as
water supplies (tap water and water reservoirs only) with supporting
identical to those found infection patients.
molecular relatedness data aligning the contaminating waterborne
**Resistant means resistant to two or more clases of antibiotics.
organism to the patient infection.
Site(s) of infection
Method(s) Used to Link
Trautmann et al. 20015
Blood, lungs, peritoneum,
Bert et al. 19987
Lung, sinuses, urine
DNA macroestriction analysis
Ferroni et al. 19986
Ezpeleta et al. 199832
Richard et al. 199433
Blood, ling, wound
DNA typing, serotyping
Worlitzsch et al. 198934
Weber et al. 199935
Talon et al. 199436
Blood, stools, throat, urine
Carlyn et al. 199837
Pina et al. 199838
Picard and Goullet 198739
Electrophoretic esterase typing
De Schuijmer et al.199840
MANAGING INFECTION CONTROL
outbreaks of toxoplasmosis have been reported in municipal
deaths per year occur in U.S. hospitals due to waterborne
water supplies and could therefore also potentially reside in
healthcare-associated pneumonias caused by P s e u d o m o n a s
a hospital water system.2 1 F i n a l l y, while pathogenic viruses
can be recovered from water supplies, no HAIs associated withwaterborne viruses have been reported to date.2 2
DEFINITION FOR METHOD ABBREVIATIONS USED IN
What is the evidence that healthcare-associated infections
TABLE 1 PARTS A, B. AND C.
have been traced to water supplies and/or point-of-use
Arbitrarily Primed Polymerase Chain Reaction
water in the hospital?
Anaissie et al.1 conducted a Medline search and identified
Pulse-field Gel Electropheresis
43 outbreaks of waterborne healthcare-associated infections
Enterbacterial Repetitive Intergenic Consensus
for the period 1966-2001. In 29 of the more recent studies
Random Amplified Polymorphic DNA
where discriminatory methods of strain typing and antibioticsusceptibility testing were performed, they presented solid
evidence that linked the hospital water system to waterborne
Restriction Fragment Length Polymorphism
HAIs in patients (Table 1A, B and C tabulating evidence
Amplified Fragment Length Polymorphism
for water as a source of bacteria, mycobacteria, and fungi that caused infections). Anaissie et al.1 estimated that 1,400
Inter-repeat Polymerase Chain Reaction
Sequence Specific DNA Primer Analysis
Site(s) of infection
Method(s) Used to Link
Von Reyn et al. 199410
Kauppinen et al. 199912
Burns et al. 199113
plasmid profiles, PFGE
Desplaces et al. 199514
Picardeau et al. 199715
Abscess, blood, bone,
RFLP, PFGE, AFLP, PCR
sputum, stomach, urine
Sternal wound infection,
Electrophoresis of enzymes,
Wallace et al. 198916
Sternal wound infection
Method(s) Used to Link
Site(s) of infection
RFLP, RAPD, IR-PCR
Nucci et al. 199842
Anaissie et al. 200220
MANAGING INFECTION CONTROL
Healthcare-associated pneumonias account for
Paterson et al.24 tested hot and cold point-of-use water supplies in
20 to 45% of all HAIs and 23,000 deaths per year in
81 transplant units in the UK. As depicted in Figure 2, almost half
the U.S., with 20% of these pneumonias associated
(39/81) of the water outlets in these transplant units were found to be
with P. aeruginosa
. This suggests that waterborne P.
contaminated with Legionella
a e ru g i n o s a
may be a significant contributor to
In a recent editorial, Stout et al. identified hospital acquired
healthcare-associated pneumonia in U.S. hospitals.1
Legionnaires' disease as a global public health issue.25
During a seven-month period, Trautmann et al.5
Key factors influencing the risk of transmission of L e g i o n e l l a
i n c l u d e :
observed that 29% (5/17) of patients in a surgical
Host susceptibility (immunosuppressed patients such as organ
intensive care unit were infected with P. aeruginosa
transplant patients and elderly patients with chronic lung disease).
genotypes that were the same as those detected in the
Degree of Legionella
colonization within the water supply.
unit's tap water.
Jarvis et al.2 3 reported that healthcare-associ-
is a common inhabitant in water distribution systems.
ated bloodstream infections have been traced to
In many hospitals, Legionnaires' disease may go undiagnosed and
water in the operating room environment, with water
unrecognized as a cause of patient morbidity and mortality.25 Sabria et
or healthcare workers' hands playing a critical role in
a l .2 6 conducted an environmental surveillance of 20 hospitals in
the contaminating event.
Barcelona, Spain. Some of the key findings were:
There are 29 recent studies (Table 1) containing
was isolated from 85% (17/20) of the
both epidemiological and molecular relatedness data
hospital portable hot water systems.
that incriminate hospital point-of-use tap water and
Each hospital had its own unique DNA subtypes of L. pneumophila
water reservoirs as sources of HAIs in patients. A r e a sof the hospital with patient infection outbreaks include:
Patients at high risk of infection due to waterborne microorganisms
Surgical Intensive Care Unit
include those who are immunocompromised as a consequence of
Neurosurgery Intensive Care Unit
their diseases and/or the treatment regimens for their diseases. These include:
Pediatric Oncology Ward
Pediatric Surgical Unit
Organ transplant recipients
Cardiovascular Surgery Unit
Neonatal Intensive Care Unit
Critically ill patients
Contamination of water supply
outlets in transplant units.
Adapted from Patterson et al.
MANAGING INFECTION CONTROL
Contaminated water can lead to infection via inhalation of water droplets,
Solutions to the Problem of
ingestion of water, immersion in water, or contact with equipment, environ-
mental surfaces or hands that have been in contact with water.1,25,27,43 Table 2
Can an entire water delivery system be
summarizes several studies which describe the parameters of hospital disease
effectively treated to prevent or eradicate
outbreaks traced to water.
Providing safe water for hospital use
provides the obvious benefit of minimizingat-risk patient exposure to microbial
pathogens. However, in order to determine
whether or not total and complete microbialeradication from a hospital water supply is
feasible, it is necessary to understand thechallenges that must be overcome in the
attempt to attain that goal.
Factors that contribute to the microbial
contamination of water include:
The temperature of water at various
points in the water distribution system.
The development and persistence of
biofilm in the water delivery system,particularly in areas of the water distribu-tion system where water tends to stagnate.
The contamination of medical instruments with waterborne microbes is one
The inability of systemic disinfection
potential route of infection that has been extensively discussed. The scientific liter-
technologies (e.g. chlorine dioxide, hyper-
ature contains references to patient exposure to waterborne microorganisms through
chlorination, copper-silver ionization, hot
contact with contaminated medical equipment (e.g. flexible endoscopes, respiratory
water flushing) to reach all locations
equipment, tube feed bags, etc.) that had been rinsed with tap water.1 , 2 8 , 2 9
within the water delivery system.
The magnitude of the problem caused by waterborne HAIs is largely unrecog-
The accumulation of scale in a water
nized. Anaissie et al.1 estimated that healthcare-associated P. aeru g i n o s a
delivery system and the role it plays
infections alone are responsible for 1,400 deaths annually in the U.S. While
in enhancing the conditions for micro-
is the best recognized of all waterborne pathogens, and that recogni-
tion has led to recommendations for preventing patient exposure that areL e g i o n e l l a
-specific in nature, healthcare-associated waterborne infections by
Systemic water disinfection technologies
other microbes such as P. aeruginosa
have been largely ignored.1
vary in efficacy and cost.2 Superheated water
Facts to consider include the following:
can be used to flush the water delivery system,
P s e u d o m o n a s
can exist not only in biofilms, but also inside free-living
but this method is expensive (e.g. labor to
amoebae. The amoebae that harbor pseudomonads provide a microhabitat
perform the operation), potentially dangerous
that protects them from disinfectants.1
(e.g. risk of scalding), and can damage water
Small quantities of bacteria can cause infections.1,19
systems that may not be designed for repeated
Waterborne bacteria may be antibiotic resistant, further complicating treat-
high temperature operations.
ment of the HAIs that they cause.1,7,33,35,36,41
Periodic chemical disinfection with
There is a risk of false diagnosis from samples collected by instruments
agents such as chlorine, chlorine dioxide
contaminated with waterborne microbes.
( C l O2), ozone, and hydrogen peroxide can
Extensive contamination of clinical samples with waterborne microorgan-
also be used to reduce the level of microbial
isms can lead to false diagnosis of infection.
contamination. However, if used regularly
Fourteen patients were wrongly diagnosed with tuberculosis after contami-
at the concentrations recommended, these
nation of bronchoscopes with nontuberculous mycobacteria.30,31
compounds can be corrosive to piping
Several different patients who were initially diagnosed with L e g i o n e l l a
f a i l e d
materials. Although chlorine is routinely
to develop symptoms. Further investigation identified L e g i o n e l l a
in the water
added to drinking water, many org a n i s m s
s u p p l y. Bronchoscopes that had been used in the initial diagnoses were likely
are resistant (e.g. C ryptosporidium sp
. ) .
contaminated during the final rinse step of the reprocessing protocol.4 2
Also, since organic material absorbs
MANAGING INFECTION CONTROL
chlorine, biocidal activity will be negatively impacted as
presence of organic material, high microbial bioburden, and
o rganic material concentrations increase. Finally, when
high turbidity. The effectiveness of UV-generating lamps is
amoeba-resistant bacteria take up residence inside an amoeba
also reduced over time by the accumulation of scale, requiring
host that is in turn resistant to a particular chemical disinfectant,
maintenance and/or replacement.
they can escape destruction by that disinfectant.
Monochloramine (NH2Cl) has been used in certain U.S.
Copper-silver ionization has also been used successfully municipalities to effectively reduce Legionella
in many healthcare facilities. This technology employs an
exists, however, regarding its toxic disinfection products.
ionization chamber containing electrodes composed of both
Furthermore, there are presently no point-of-entry systems
copper and silver. Electrical current is applied to the electrodes
available to deliver monochloramine to individual buildings.
as water passes through the chamber, and copper and silver
Systemic water disinfection technologies, although
ions, which have biocidal properties, are released into the water
certainly a step in the right direction as relates to the control of
stream. This technology is usually applied only to the hot water
waterborne pathogens, vary in their respective abilities to
line and is primarily directed to the control of Legionella sp
effectively respond to changes in water quality that result from
H o w e v e r, failure to address the cold water line leads to seasonal variation, abrupt changes in municipal water systemoversight of the many waterborne organisms that reside in cold
pressure, and construction activities within or outside the
water, form biofilm in cold water pipes, and reach the at-risk
healthcare facility. In addition, all are incapable of completely
patient in the healthcare setting.
and permanently eradicating biofilm that continually exists and
Ultraviolet (UV) radiation is also used systemically, reestablishes itself at downstream locations in the water
but the equipment required is often expensive. Furthermore,
delivery system. Finally, they are not maintenance-free and
UV effectiveness is reduced by high water flow, as well as the
require periodic attention to maintain peak operating efficiency.
Atlantic AirAD 1/2 HPage 51RS:
MANAGING INFECTION CONTROL
Point-of-use filtration complements systemic water
by these technologies is not attainable due to the continual
establishment of biofilm communities downstream of the
Point-of-use 0.2 micron filters on faucets, showers, water
point-of-disinfection. Point-of-use 0.2µm filters present
fountains, and ice machines can reduce the risk of patient and
a viable option to provide water for hospital use that
healthcare staff exposure to waterborne pathogens. They can also
minimizes patient exposure to waterborne pathogens and
provide a cost effective alternative to the use of bottled water or
the risk of waterborne HAIs. While hospital-wide use is
sterile water for drinking by at-risk patients. In hospital units
often not required, their application to areas housing
where patient showering and bathing has been restricted for fear
patients at highest risk is prudent. Furthermore, in
of waterborne pathogen transmission, point-of-use filters can
outbreak situations, the effect of point-of-use filters is
improve patient comfort and quality of life.
immediate, and their implementation can mitigate risk
Point-of-use filters complement systemic water disinfection
while providing hospital personnel with the appropriate
technologies by trapping free-floating organisms that have survived
time to implement a corrective action plan. Finally, with
exposure to disinfectants, broken away from existing biofilm
point-of-use filters in place, hospital administration can
colonies located downstream from the point of disinfection, or
calmly assess the features and benefits of the various
traveled to the point-of-use from stagnant locations in the water
systemic disinfection technology options. ✛
distribution system. Unlike some systemic disinfection technologiespreviously described, they also act on both hot and cold water.
Point-of-use water filters have been a staple for reducing the
Anaissie EJ, Penzak SR, Dignani C. The hospital water supply or asource of nosocomial infection; a plea for action. Arch Intern Med
risk of exposure to waterborne pathogens in healthcare facilities
outside the U.S. for the last 10 years, particularly in Europe.
Ortolano GA, McAlister MB, Angelbeck JA, Schaffer J, Russell RL,
However, awareness of their potential benefits is still growing in
Maynard E, Wenz B. Hospital Water Point-of-Use Filtration: AComplementary Strategy to Reduce the Risk of Nosocomial Infection.
the U.S. In light of the broad base of scientific literature that has
American Journal of Infection Control 2005; 33(5, Supple 1):S1-S19.
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Darelid J, et al. An outbreak of Legionnaires' Disease in a Swedish
to complicate matters in the care of at-risk patients, as well as the
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Marrie TJ et al. Each water outlet is a unique ecological niche for
disease outbreaks traced to waterborne pathogens that are
. Epidemiology Infection 1992;108:261-270.
frequently reported, broad adoption of this technology in the U.S.
Trautmann M, Michalsky T, Heidemaire W. Radosavljevic V, Ruhnke
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Ferroni A, Nguyen B, Pron B, Quesne G, Brusset MC, Berche P.
Contamination of the hospital water supply with potentially
Outbreak of nosocomial urinary tract infections due to Pseudomonas
pathogenic organisms is very common, but the magnitude of the
a e ru g i n o s a
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Bert F, Maubec E, Bruneau B, Berry P, Lambert-Zechovsky N. Multi-
lines for protecting patients from exposure. Point-of-use water
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outbreak associated with
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contaminated tap water in a neurosurgery intensive care unit. J HospInfect. 1998;39:53-62.
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Weber DJ, Rutala WA, Blanchet CN, Jordan M, Gergen MF. Faucet
exposure to waterborne pathogens is derived from a number of
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sources that include showering, bathing, drinking water, ingestion
m a l t o p h i l i a
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Carlyn C, Simmonds J, Kondracki S, et al. An outbreak of Serratia
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presence of waterborne bacteria, fungi, and protozoa in hospital
Persistent colonization of potable water as a source of M y c o b a c t e r i u m
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populations are at greater risk for infection by waterborne
Kauppinen J, Nousiainen T, Jantunen E, Mattila R, Katila ML.
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infection in a leukemia patient. Infect Control Hosp
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Systemic water disinfection technologies are not completely
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Desplaces N, Picardeau M, Dinh V, et al. Spinal infections due to
Carlyn C, Simmonds J, Kondracki S, et al. An outbreak of S e rr a t i a
after discectomies. In: Program and abstracts of the
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35th Interscience Conference on Antimicrobial Agents and Chemotherapy:
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September 17-20, 1995; San Francisco, Calif. Abstract J-145.
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Genotypic characterization of five subspecies of Mycobacterium kansasii.
Pina P, Guezenec P, Grosbuis S, Guyot L, Ghnassia JC, Allouch PY. An
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outbreak at the Versailies Hospital Center.
Wallace RJ, Musser JM, Hull SI, et al. Diversity and sources of rapidly
Pathol Biol (Paris), 1998;46:385-394.
growing mycobacteria associated with infections following cardiac
Picard B, Goullet P. Epidemiological complexity of hospital Aeromonas
surgery. J Infect Dis. 1989;159:708-716.
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Rex JH, Walsh TJ, Anaissie EJ. Fungal infections in iatrogenically
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De Schuijmer J, Vammeste M, Vennecchoutte M, Verschraegen G.
Anaissie E, Kuchar R, Rex J, Summerbell R, Walsh T. The hospital water
Chryseso bacterium in a burn unit. In: Program and abstracts of the 4th
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Bowie WR, King AS, Werker DH, et al, for the BC To x o p l a s m a
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Judy A. Angelbeck, Ph.D., is Senior Vice President of Pall
legonellosis. J Hospital Infect. 1997;37:7-17 and 259-260.
Stout JE, Yu VL. Legionella in the Hospital water supply: a plea for
Life Sciences. She has both North American and global medical
decision making based on evidence-based medicine. Infection Control and
p roduct experience from more than 22 years in marketing,
Hospital Epidemiology 2001;22:670-672.
regulatory and general management. Dr. Angelbeck is currently
Sabria M, Garcia-Nunez M, Pedro-Bouel ML, Sopena N, Gimeno JM,
working on development of new products for the somatic cell
Reynaga E, et al. Presence and chromosomal subtyping in potable watersystems in 20 hospitals of Catalonia, Spain. Infect. Control Hosp.
Girolamo A. Ortolano, Ph.D., is Vice President for Scientific
Emmerson AM. Emerging Waterborne Infections in Health-Care Settings.
Affairs at Pall Corporation. Dr. Ortolano graduated fro m
Emerging Infectious Disease. 2001;7:272-276.
Columbia University (BS) and the University of Rhode Island
Dorozynski A. Poor sterilization of instruments leads to infection outbreak
(MS, PhD in Pharmacology), completed a post-doctoral fellow -
in Paris. British Medical Journal 1997;325-699.
Mastro TD et al. Nosocomial Legionnaires' Disease at the use of medication
ship at the University of Michigan Hospital, and continued
nebulizers. J Infectious Diseases 1991;163:667-671.
research there before joining Pall Corporation. He has authored
Gubler JGH, et al. Pseudoepidemic of non-tuberculosus mycobacteria
over 90 scientific articles and abstracts including co-authoring
due to a contaminated bronchoscope cleaning machine. Chest 1992;
Bennett SN, Peterson DE, Johnson DR, Hall WN, Robinson-Dunn B,
Francis P. Canonica, Ph.D., is the Vice President, U.S.
Dietrich S. Am J Respir Crit Care Med. 1994;150:245-250.
H e a l t h c a re Water Filtration Marketing, at Pall Medical. He has
Ezpeleta C, Larrea I, Martinez J, Arrese E, Cisterna R, P s e u d o m o n a s
m o re than 25 years of experience in re s e a rch, product development
bacteremia following ERCP: an investigation of sources by
and marketing of medical devices and clinical diagnostics.
molecular typing methods. In: Program and abstracts of the 38th
Joseph S. Cervia, M.D., is Professor of Clinical Medicine
Interscience Conference on Antimicrobial Agents and Chemotherapy;September 24-27, 1998: San Diego,Calif. Abstract K-73.
and Pediatrics at the Albert Einstein College of Medicine in New
Richard P, LeFloch R, Chamoux C, Pannier M. Espanze E, Richet H.
York and Medical Director and Senior Vice President for Pall
outbreak in a burn unit: role of antimicrobials in the
Corporation. A board-certified internist, pediatrician, adult and
e m e rgences of multiple resistant strains. J Infect Dis. 1994;170:377-383.
pediatric infectious diseases specialist, Dr. Cervia has dedicated
Worlitzsch D, Wolz C, Botzenhart K, et al. Molecular epidemiology ofPseudomonas aeruginosa
urinary tract infections in paraplegic patients.
much of his career to the care of individuals and families battling
Zentralbl Hyg Umweltmed. 1989;189:175-184.
H I V and other infectious diseases, and to clinical re s e a rc h
Weber DJ, Rutala WA, Blanchet CN, Jordan M, Gergen MF. Faucet aerators;
related to therapeutics, complicating illnesses, and quality of
a source of patient colonization with Stenotrophomonas maltophilia
. Am J
life issues. He has authored more than 100 articles, chapters
Infec Control 1999;27:59-63.
and abstracts, lectured widely, and serves as a consultant
Talon D, Bailly P, Leprat R, et al. Typing of hospital strains ofXanthomonas maltophilia
by pulsed-field gel electrophoresis. J Hosp
to numerous local and national organizations on HIV and
infectious disease-related issues.
MANAGING INFECTION CONTROL
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Strength of Recommendation Taxonomy (SORT):A Patient-Centered Approach to Grading Evidencein the Medical Literature Mark H. Ebell, MD, MS, Jay Siwek, MD, Barry D. Weiss, MD,Steven H. Woolf, MD, MPH, Jeffrey Susman, MD, Bernard Ewigman, MD, MPH, andMarjorie Bowman, MD, MPA A large number of taxonomies are used to rate the quality of an individual study and the strength of arecommendation based on a body of evidence. We have developed a new grading scale that will be usedby several family medicine and primary care journals (required or optional), with the goal of allowingreaders to learn one taxonomy that will apply to many sources of evidence. Our scale is called theStrength of Recommendation Taxonomy. It addresses the quality, quantity, and consistency of evidenceand allows authors to rate individual studies or bodies of evidence. The taxonomy is built around theinformation mastery framework, which emphasizes the use of patient-oriented outcomes that measurechanges in morbidity or mortality. An A-level recommendation is based on consistent and good qualitypatient-oriented evidence; a B-level recommendation is based on inconsistent or limited quality patient-oriented evidence; and a C-level recommendation is based on consensus, usual practice, opinion,disease-oriented evidence, or case series for studies of diagnosis, treatment, prevention, or screening.Levels of evidence from 1 to 3 for individual studies also are defined. We hope that consistent use ofthis taxonomy will improve the ability of authors and readers to communicate about the translation ofresearch into practice. (J Am Board Fam Pract 2004;17:59 – 67.)