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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., Pseudomonas immunocompromised patients. Such aeruginosa, 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, Acanthamoeba 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.1
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
Infectious Microorganisms

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
JANUARY 2006
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 aeruginosa), 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
Patient and
Trautmann et al. 20015 Blood, lungs, peritoneum, Bert et al. 19987 Lung, sinuses, urine DNA macroestriction analysis Pseudomonas 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 Peritoneum,skin, respiratory tract, 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
JANUARY 2006
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
Patient and
Von Reyn et al. 199410 Kauppinen et al. 199912 Burns et al. 199113 Phenotype analysis, plasmid profiles, PFGE Desplaces et al. 199514 Chromosomal restriction fragment patterns Picardeau et al. 199715 Abscess, blood, bone, RFLP, PFGE, AFLP, PCR sputum, stomach, urine Sternal wound infection, Electrophoresis of enzymes, Wallace et al. 198916 plasmid profiling Sternal wound infection Method(s) Used to Link
Site(s) of infection
Patient and
Fusarium solani RFLP, RAPD, IR-PCR Nucci et al. 199842 Aspergillus Anaissie et al. 200220 JANUARY 2006
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 species. 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- Legionella 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  Legionella pneumophial 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  AIDS patients  Pediatric Surgical Unit  Organ transplant recipients  Cardiovascular Surgery Unit  Oncology patients  Neonatal Intensive Care Unit  Critically ill patients Contamination of water supply
outlets in transplant units.
Adapted from Patterson et al.
24
MANAGING INFECTION CONTROL
JANUARY 2006
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 Number of
pathogens. However, in order to determine Water Source
whether or not total and complete microbialeradication from a hospital water supply is P. aeruginosa feasible, it is necessary to understand thechallenges that must be overcome in the attempt to attain that goal.
Factors that contribute to the microbial P. aeruginosa 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- Legionella is the best recognized of all waterborne pathogens, and that recogni- bial growth.
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
JANUARY 2006
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 levels. Concern 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: JANUARY 2006
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.
been generated regarding the potential for waterborne pathogens 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 hospital. Scandinavian J Infectious Disease 1994;26:417-425.
Marrie TJ et al. Each water outlet is a unique ecological niche for disease outbreaks traced to waterborne pathogens that are Legoinella pneumophila. 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 would certainly benefit patients and the healthcare community.
M. Tap water colonization with Pseudomonas aeruginosa in a surgicalintensive care unit (ICU) and relation to Pseudomonas infections ofICU patients. Infect Control Hosp Epidemiol 2001;22:49-52. 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 ain a pediatric surgical unit associated with tap-watercontamination. J Hosp Infec. 1998;39:301-307.
problem is largely unrecognized, and there are no specific guide- Bert F, Maubec E, Bruneau B, Berry P, Lambert-Zechovsky N. Multi- lines for protecting patients from exposure. Point-of-use water resistant Pseudomonas aeru g i n o s a outbreak associated with (faucets and showers, water fountains, ice machines) may be the contaminated tap water in a neurosurgery intensive care unit. J HospInfect. 1998;39:53-62. source of the transmission of waterborne microorganisms. Patient Weber DJ, Rutala WA, Blanchet CN, Jordan M, Gergen MF. Faucet exposure to waterborne pathogens is derived from a number of aerators: a source of patient colonization with S t e n o t ro p h o m o n a s sources that include showering, bathing, drinking water, ingestion m a l t o p h i l i a. Am J Infect Control. 1999;27:59-63.
Carlyn C, Simmonds J, Kondracki S, et al. An outbreak of Serratia of ice, exposure to contaminated medical equipment that has been marcescens conjunctivitis in a neonatal care unit: genotypic link to an rinsed with tap water, or the hands of medical personnel washed environmental source. In Program and abstracts of the 8th Annual and rinsed in tap water.
Meeting of the Society for Healthcare Epidemiology of A m e r i c a ;April 5-7, 1998: Orlando, Fla. Abstract 1998: Oral 116.
Ample evidence has now been accumulated to support the Von Reyn C, Maslow JN, Barber T W, Falkinham JO III, Arbeit RD.
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 w a t e r. Molecular relatedness studies have also shown that these a v i u m infection in AIDS. Lancet 1994;343:11 3 7 - 11 4 1 .
Soto LE, Bobadilla M, Villalobos Y, et al. Post-surgical nasal cellulites waterborne organisms are responsible for infections. Certain patient outbreak due to Mycobacterium chelonae. J Hosp Infect. 1991;19:99-106.
populations are at greater risk for infection by waterborne Kauppinen J, Nousiainen T, Jantunen E, Mattila R, Katila ML.
pathogens, namely those who are rendered immunocompromised Hospital water supply as a source of disseminated Mycobacteriumf o rt u i t u m infection in a leukemia patient. Infect Control Hosp either by their disease or by the treatment for their disease (e.g.
Burns DN, Wallace RJ, Schultz ME, et al. Nosocomial outbreak Systemic water disinfection technologies are not completely of respiratory tract colonization with Mycobacterium fort u i t u m:demonstration of the usefulness of pulsed-field gel electrophoresis in and sustainably effective in reducing the bioburden of pathogens in an epidemiologic al investigation. Am Rev Respir Dis. 1991;144: hospitals water. Complete eradication of waterborne microorg a n i s m s MANAGING INFECTION CONTROL
JANUARY 2006
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 Mycobacterium xenopi after discectomies. In: Program and abstracts of the marcescens conjunctivitis in a neonatal care unit: genotypic link to an 35th Interscience Conference on Antimicrobial Agents and Chemotherapy: environmental source. In: Program and abstracts of the 8th A n n u a l September 17-20, 1995; San Francisco, Calif. Abstract J-145.
Meeting of the Society for Healthcare Epidemiology of America; April 5- Picardeau M, Prod'Hom G, Raskine L, Le Pennec MP, Vincent V.
7, 1998: Orlando, Fla. Abstract 1998: Oral 116.
Genotypic characterization of five subspecies of Mycobacterium kansasii.
Pina P, Guezenec P, Grosbuis S, Guyot L, Ghnassia JC, Allouch PY. An J Clin Microbiol. 1997;35:25-32.
Acinetobacter baumannii 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.
infections revealed by electrophoretic typing of esterases. Epidemiol Rex JH, Walsh TJ, Anaissie EJ. Fungal infections in iatrogenically compromised hosts. Adv Intern Med. 1998;43:321-371.
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 system as a reservoir of Fusarium. In: Program and abstracts of the 37th International Conference of the Hospitals Infection Society; September Interscience Conference on Antimicrobial Agents and Chemotherapy; 13-17, 1998; Edinburgh, Scotland.
September 28-October 1, 1997: Toronto, Ontario. Abstract J-94.
Anaissie E. Emerging fungi infections: don't drink the water. In: Program and ter Maaten JC, Golding RP, Strack van Schijndel RJ, Thijs LG. Disseminated abstracts of the 38th Interscience Conference on Antimicrobial Agents and a s p e rgillosis after near drowning. Neth J Med. 1995;47:21-24.
Chemotherapy; September 24-27, 1998; San Diego, Calif. Abstract J-147.
Anaissie EJ, Stratton SL, M, Dignani MC, Summerbell RC, Rex JH, Nucci M, Akiti T, Silveira F, et al. Fungemia due to Exophiala jeanselmei: Monson TP, Spencer T, Kasai M, Francesconi A, Walsh TJ. Pathogenic report of 23 cases. In: Program and Abstracts of the 38th Interscience A s p e rg i l l u s species recovered from a hospital water system: A 3 - y e a r Conference of Antimicrobial Agents and Chemotherapy; September Prospective Study. CID 2002;34:780-789.
24-27, 1998; San Diego, Calif. Abstract J-141.
Bowie WR, King AS, Werker DH, et al, for the BC To x o p l a s m a Lowry PW et al. A cluster of Legionella sternal-wound infections due to Investigation Team. Outbreak of toxoplasmosis associated with municipal postoperative topical exposure to contaminated tap water. New England J drinking water. Lancet 1997;350:173-177.
Geldreich EE. Creating microbial quality in drinking water. In: Geldreich A l l e r b e rger F, et al. Nosokomiale Legionellen pneumonia bei EE. Microbial Qualities of Water Supply in Distribution Systems. Boca Nierentranplantieren in Insbruck. Krankenhaus -Hygiene+I nfekt. Ve r h .
Raton, Fla: CRC Press Inc 1996;39-102.
Jarvis WR, Temprado Cookson S, Robles B. Prevention of NosocomialBlood Stream Infections: A National and International Priority. InfectionControl and Hospital Epidemiology 1996;17:272-274.
Patterson WJ, et al. Colonization of transplant unit water supplies with Legionella and protozoa: precautions required to educe the risk of 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.
therapy market. 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; book chapters. 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 aeruginosa 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 Pseudomonas aeruginosa 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
JANUARY 2006

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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.)