Effect of heat shock on hot water plumbing microbiota and Legionella pneumophila control

Pathogenic bacteria rapidly colonize sinks of a neonatal intensive care unit: results of a prospective surveillance study

BACKGROUND

Hospital sinks are known to harbour bacteria with the potential to infect patients.

AIM

To examine bacterial growth in the sinks of a newly constructed neonatal intensive care unit (NICU) during the transition from an established NICU within the same facility.

METHODS

This was a prospective study of pathogenic bacterial growth in NICU handwashing sinks before and after the new NICU was occupied. Samples from various sink traps were cultured longitudinally, and comparison was made between the established NICU and the new NICU.

FINDINGS

Potentially pathogenic bacteria colonized sinks rapidly in the new NICU within 1 month of occupation. During the study period, between 29th June 2021 and 2nd September 2022, 62 samples were collected from 11 sinks, of which 43 (69.4%) tested positive. The mean semi-quantitative bacterial growth score was notably higher in the sink in the milk preparation room compared with the sinks in the patient care area in the new NICU (40.67 vs 1.768; P=0.025). The bacterial profiles in the sink in the new NICU milk preparation room mirrored that of the established NICU, with a predominance of Klebsiella pneumoniae and Enterobacter cloacae complex. In handwashing sinks of both the established NICU and the new NICU, the dominant colonizing pathogen was Burkholderia cepacia complex, followed by Serratia marcescens and Elizabethkingia spp. Cessation of sink use reduced the bioburden of bacteria significantly in the NICU handwashing sink drains.

CONCLUSION

Handwashing sinks were colonized rapidly with pathogenic bacteria in a newly constructed NICU. More diversified and prolific growth of pathogenic bacteria was noted in the sink in the milk preparation room.

Mechanistic modeling of Legionella in building water systems: A critical review on the essential factors

Modeling Legionella exposure from building water systems is valuable to inform water management plans, but accurate risk estimates require accounting for spatiotemporal variations in concentrations. This comprehensive literature review covers existing mathematical approaches for predicting Legionella fate and transport in building water systems and proposes a framework for advanced modeling considering all mechanisms influencing its presence in water and biofilm during different life-stages (e.g., within protozoan hosts). Current models include persistence of culturable cells in a heater, growth and decay throughout simplified hot water systems, concentrations linked to water age using fitted growth rates, and a calibrated model for a highly-monitored system. The challenges of modeling influencing factors are also discussed, including water demand, hydraulics, nutrient availability, pipe materials, temperature, and chemical disinfection. By contrasting laboratory and field observations with existing models, this review highlights knowledge gaps and data needs for integrating Legionella growth and persistence into hydraulics, water quality and, ultimately, exposure models to define minimal-risk design and operational practices.

Prevalence and distribution of Legionella in municipal drinking water supply systems in Madrid (Spain) and risk factors associated

The presence and concentration of Legionella in drinking water supply systems, in hot water (DHW) for human consumption in public buildings in Madrid with potential health risk was studied. Sampling covered a total of 1695 DHW samples and 30 cold water (DCW) as a control taken in the 21 districts of the city over a period of 14 years (2007-2020). The detection and quantification of Legionella was carried out by plate culture and quantitative qPCR. The study evaluated a series of variables including sampling year, districts, type of building, seasonality, sampling points (taps, tanks and showers), water temperature and type of disinfection used. The degree of compliance of Legionella in the water supply network of Madrid was very high (96.1 %). The degree of colonization of the positive samples ranged from 0.3 × 103 and 1.5 × 105 GU/L for a 97 % of the samples. A higher presence of this bacterium was detected in older facilities in the peripheral districts and end points able to produce aerosols such as showers. The highest number of samples with Legionella growth occurred in the 35-40 °C range. The strategies implemented have contributed to a remarkable decrease in the presence of Legionella in the last years of sampling.

Can free chlorine residuals entering building plumbing systems really be maintained to prevent microbial growth?

Secondary disinfection aims to prevent microbial regrowth during distribution by maintaining disinfectant residuals in water systems. However, multi-factorial interactions contribute to free chlorine decay in distribution systems, and even more so in building plumbing. Assembling 1737 samples from nine large institutional buildings, a meta-analysis was conducted to determine whether building managers can actively rely on incoming free chlorine residuals to prevent in-building microbial amplification. Findings showed that free chlorine concentrations in first draws met the 0.2 mg/L common guide level in respectively 26 %, 6 % and 2 % of cold, tepid and hot water samples, whereas flushing for 2-60 min only significantly increased this ratio in cold water (83 %), without reaching background levels found in service lines. Free chlorine was significantly but weakly (R≤ 0.2) correlated to adenosine triphosphate, heterotrophic plate count and total and intact cell counts, thus evidencing that residuals contributed to decreased culturable and viable biomass. Detection of culturable Legionella pneumophila spanning over a 4-log distribution solely occurred when free chlorine levels were below 0.2 mg/L, but no such trend could be distinguished clearly for culturable Pseudomonas aeruginosa. Water temperatures below 20 °C and >60 °C also completely prevented L. pneumophila detection. Overall, the majority of elevated microbial counts were measured in distal sites and in tepid and hot water, where free chlorine is less likely to be present due to stagnation and increased temperature. Therefore, building managers cannot solely rely on this chemical barrier to mitigate bacterial growth in bulk water.

Interactions between chaperone and energy storage networks during the evolution of Legionella pneumophila under heat shock

Waterborne transmission of the bacterium Legionella pneumophila has emerged as a major cause of severe nosocomial infections of major public health impact. The major route of transmission involves the uptake of aerosolized bacteria, often from the contaminated hot water systems of large buildings. Public health regulations aimed at controlling the mesophilic pathogen are generally concerned with acute pasteurization and maintaining high temperatures at the heating systems and throughout the plumbing of hot water systems, but L. pneumophila is often able to survive these treatments due to both bacterium-intrinsic and environmental factors. Previous work has established an experimental evolution system to model the observations of increased heat resistance in repeatedly but unsuccessfully pasteurized L. pneumophila populations. Here, we show rapid fixation of novel alleles in lineages selected for resistance to heat shock and shifts in mutational profile related to increases in the temperature of selection. Gene-level and nucleotide-level parallelisms between independently-evolving lineages show the centrality of the DnaJ/DnaK chaperone system in the heat resistance of L. pneumophila. Inference of epistatic interactions through reverse genetics shows an unexpected interaction between DnaJ/DnaK and the polyhydroxybutyrate-accumulation energy storage mechanism used by the species to survive long-term starvation in low-nutrient environments.

Domestic hot-water boilers harbour active thermophilic bacterial communities distinctly different from those in the cold-water supply

Running cold and hot water in buildings is a widely established commodity. However, interests regarding hygiene and microbiological aspects had so far been focussed on cold water. Little attention has been given to the microbiology of domestic hot-water installations (DHWIs), except for aspects of pathogenic Legionella. World-wide, regulations consider hot (or warm) water as 'heated drinking water' that must comply (cold) drinking water (DW) standards. However, the few reports that exist indicate presence and growth of microbial flora in DHWIs, even when supplied with water with disinfectant residual. Using flow cytometric (FCM) total cell counting (TCC), FCM-fingerprinting, and 16S rRNA-gene-based metagenomic analysis, the characteristics and composition of bacterial communities in cold drinking water (DW) and hot water from associated boilers (operating at 50 - 60 °C) was studied in 14 selected inhouse DW installations located in Switzerland and Austria. A sampling strategy was applied that ensured access to the bulk water phase of both, supplied cold DW and produced hot boiler water. Generally, 1.3- to 8-fold enhanced TCCs were recorded in hot water compared to those in the supplied cold DW. FCM-fingerprints of cold and corresponding hot water from individual buildings indicated different composition of cold- and hot-water microbial floras. Also, hot waters from each of the boilers sampled had its own individual FCM-fingerprint. 16S rRNA-gene-based metagenomic analysis confirmed the marked differences in composition of microbiomes. E.g., in three neighbouring houses supplied from the same public network pipe each hot-water boiler contained its own thermophilic bacterial flora. Generally, bacterial diversity in cold DW was broad, that in hot water was restricted, with mostly thermophilic strains from the families Hydrogenophilaceae, Nitrosomonadaceae and Thermaceae dominating. Batch growth assays, consisting of cold DW heated up to 50 - 60 °C and inoculated with hot water, resulted in immediate cell growth with doubling times between 5 and 10 h. When cold DW was used as an inoculum no significant growth was observed. Even boilers supplied with UVC-treated cold DW contained an actively growing microbial flora, suggesting such hot-water systems as autonomously operating, thermophilic bioreactors. The generation of assimilable organic carbon from dissolved organic carbon due to heating appears to be the driver for growth of thermophilic microbial communities. Our report suggests that a man-made microbial ecosystem, very close to us all and of potential hygienic importance, may have been overlooked so far. Despite consumers having been exposed to microbial hot-water flora for a long time, with no major pathogens so far been associated specifically with hot-water usage (except for Legionella), the role of harmless thermophiles and their interaction with potential human pathogens able to grow at elevated temperatures in DHWIs remains to be investigated.

Legionella pneumophila Cas2 Promotes the Expression of Small Heat Shock Protein C2 That Is Required for Thermal Tolerance and Optimal Intracellular Infection

Previously, we demonstrated that Cas2 encoded within the CRISPR-Cas locus of Legionella pneumophila strain 130b promotes the ability of the Legionella pathogen to infect amoebal hosts. Given that L. pneumophila Cas2 has RNase activity, we posited that the cytoplasmic protein is regulating the expression of another Legionella gene(s) that fosters intracellular infection. Proteomics revealed 10 proteins at diminished levels in the cas2 mutant, and reverse transcription-quantitative (qRT-PCR) confirmed the reduced expression of a gene encoding putative small heat shock protein C2 (HspC2), among several others. As predicted, the gene was expressed more highly at 37°C to 50°C than that at 30°C, and an hspC2 mutant, but not its complemented derivative, displayed ~100-fold reduced CFU following heat shock at 55°C. Compatible with the effect of Cas2 on hspC2 expression, strains lacking Cas2 also had impaired thermal tolerance. The hspC2 mutant, like the cas2 mutant before it, was greatly impaired for infection of Acanthamoeba castellanii, a frequent host for legionellae in waters. HspC2 and Cas2 were not required for entry into these host cells but promoted the replicative phase of intracellular infection. Finally, the hspC2 mutant exhibited an additional defect during the infection of macrophages, which are the primary host for legionellae during lung infection. In summary, hspC2 is upregulated by the presence of Cas2, and HspC2 uniquely promotes both L. pneumophila extracellular survival at high temperatures and infection of amoebal and human host cells. To our knowledge, these findings also represent the first genetic proof linking Cas2 to thermotolerance, expanding the repertoire of noncanonical functions associated with CRISPR-Cas proteins.

Variable Legionella Response to Building Occupancy Patterns and Precautionary Flushing

When stay-at-home orders were issued to slow the spread of COVID-19, building occupancy (and water demand) was drastically decreased in many buildings. There was concern that widespread low water demand may cause unprecedented Legionella occurrence and Legionnaires’ disease incidence. In lieu of evidenced-based guidance, many people flushed their water systems as a preventative measure, using highly variable practices. Here, we present field-scale research from a building before, during, and after periods of low occupancy, and controlled stagnation experiments. We document no change, a > 4-log increase, and a > 1.5-log decrease of L. pneumophila during 3- to 7-week periods of low water demand. L. pneumophila increased by > 1-log after precautionary flushing prior to reoccupancy, which was repeated in controlled boiler flushing experiments. These results demonstrate that the impact of low water demand (colloquially called stagnation) is not as straight forward as is generally assumed, and that some flushing practices have potential unintended consequences. In particular, stagnation must be considered in context with other Legionella growth factors like temperature and flow profiles. Boiler flushing practices that dramatically increase the flow rate and rapidly deplete boiler temperature may mobilize Legionella present in biofilms and sediment.

Tenets of a holistic approach to drinking water-associated pathogen research, management, and communication

In recent years, drinking water-associated pathogens that can cause infections in immunocompromised or otherwise susceptible individuals (henceforth referred to as DWPI), sometimes referred to as opportunistic pathogens or opportunistic premise plumbing pathogens, have received considerable attention. DWPI research has largely been conducted by experts focusing on specific microorganisms or within silos of expertise. The resulting mitigation approaches optimized for a single microorganism may have unintended consequences and trade-offs for other DWPI or other interests (e.g., energy costs and conservation). For example, the ecological and epidemiological issues characteristic of Legionella pneumophila diverge from those relevant for Mycobacterium avium and other nontuberculous mycobacteria. Recent advances in understanding DWPI as part of a complex microbial ecosystem inhabiting drinking water systems continues to reveal additional challenges: namely, how can all microorganisms of concern be managed simultaneously? In order to protect public health, we must take a more holistic approach in all aspects of the field, including basic research, monitoring methods, risk-based mitigation techniques, and policy. A holistic approach will (i) target multiple microorganisms simultaneously, (ii) involve experts across several disciplines, and (iii) communicate results across disciplines and more broadly, proactively addressing source water-to-customer system management.

Compromised Effectiveness of Thermal Inactivation of Legionella pneumophila in Water Heater Sediments and Water, and Influence of the Presence of Vermamoeba vermiformis

Intermittent reduction of temperature set-points and periodic shutdowns of water heaters have been proposed to reduce energy consumption in buildings. However, the consequences of such measures on the occurrence and proliferation of Legionella pneumophila (Lp) in hot water systems have not been documented. The impact of single and repeated heat shocks was investigated using an environmental strain of L. pneumophila and a reference strain of V. vermiformis. Heat shocks at temperatures ranging from 50 °C to 70 °C were applied for 1 h and 4 h in water and water heaters loose deposits (sludge). The regrowth potential of heat-treated culturable L. pneumophila in presence of V. vermiformis in water heaters sludges was evaluated. A 2.5-log loss of culturability of L. pneumophila was observed in simulated drinking water at 60 °C while a 4-log reduction was reached in water heaters loose deposits. Persistence of Lp after 4 h at 55 °C was shown and the presence of V. vermiformis in water heater’s loose deposits resulted in a drastic amplification (5-log). Results show that thermal inactivation by heat shock is only efficient at elevated temperatures (50 °C) in both water and loose deposits. The few remaining organisms can rapidly proliferate during storage at lower temperature in the presence of hosts.

Low Efficacy of Periodical Thermal Shock for Long-Term Control of Legionella spp. in Hot Water System of Hotels

Different guidelines and regulations for the prevention of legionellosis in public facilities include the recommendation of a periodical thermal shock in the hot water system. The purpose of this study was to assess the efficacy of periodical thermal shocks along a 1-year period on the presence of Legionella spp. in the domestic hot water system of hotels. The Legionella testing results from the period January–December 2019 coming from a group of 77 hotel facilities in the Balearic Islands (Spain) conducting periodical thermal shocks were analyzed. A second group of 44 hotels operating without periodical thermal shocks was used for a comparative analysis. In the facilities where the periodical thermal shock was performed, 16.0% of the results (429 hot water samples collected) were positive for Legionella spp., compared to 21.1% (298 samples), where periodical thermal shock was not performed. Overall, in the thermal shock group, 32.5% of the sites presented at least 1 positive sample along the period of study versus 45.5% in the control group. None of these differences was statistically significant (p-value > 0.05). These findings suggest that the efficacy of regular thermal shock for long-term control of Legionella spp. in domestic hot water systems of hotels is low.

Bacteriophage treatment before chemical disinfection can enhance removal of plastic surface-associated Pseudomonas aeruginosa

Opportunistic pathogens can linger on surfaces in hospital and building plumbing environments, leading to infections in at-risk populations. Further, biofilm-associated bacteria are protected from removal and inactivation protocols, such as disinfection. Bacteriophages show promise as tools to treat antibiotic resistant infections. As such, phages may also be useful in environmental applications to prevent newly acquired infections. In the current study, the potential of synergies between bacteriophage and chemical disinfection of the opportunistic pathogen Pseudomonas aeruginosa was assessed under various conditions. Specifically, surface-associated P. aeruginosa was treated with various concentrations of phages (P1 or JG004), chemical disinfectant (sodium hypochlorite or benzalkonium chloride), or combined sequential treatments under three distinct attachment models (spot inoculations, dry biofilms, and wet biofilms). Phages were very effective at removing bacteria in spot inoculation (>3.2 log₁₀ removal) and wet biofilms (up to 2.6 log₁₀ removal), while phages prevented regrowth of dry biofilms in the application time. In addition, phage treatment followed by chemical disinfection inactivated more P. aeruginosa under wet biofilm conditions better than either treatment alone. This effect was hindered when chemical disinfection was applied first, followed by phage treatment, suggesting additive benefits of combination treatments are lost when phage is applied last. Further, we confirm prior evidence of greater phage tolerance to benzalkonium chloride relative to sodium hypochlorite, informing choices for combination phage-disinfectant approaches. Overall, this paper further supports the potential of using combination phage and chemical disinfectant treatments to improve inactivation of surface-associated P. aeruginosa. Importance Phages are already utilized in the healthcare industry to treat antibiotic resistant infections, such as on implant-associated biofilms and in compassionate care cases. Phage treatment could also be a promising new tool to control pathogens in the built environment, preventing infections from occurring. This study shows that phage can be combined effectively with chemical disinfectants to improve removal of wet biofilms and bacteria spotted onto surfaces while preventing regrowth in dry biofilms. This has the potential to improve pathogen containment within the built environment and drinking water infrastructure to prevent infections of opportunistic pathogens.

Environmental Management of Legionella in Domestic Water Systems: Consolidated and Innovative Approaches for Disinfection Methods and Risk Assessment

Legionella is able to remain in water as free-living planktonic bacteria or to grow within biofilms that adhere to the pipes. It is also able to enter amoebas or to switch into a viable but not culturable (VBNC) state, which contributes to its resistance to harsh conditions and hinders its detection in water. Factors regulating Legionella growth, such as environmental conditions, type and concentration of available organic and inorganic nutrients, presence of protozoa, spatial location of microorganisms, metal plumbing components, and associated corrosion products are important for Legionella survival and growth. Finally, water treatment and distribution conditions may affect each of these factors. A deeper comprehension of Legionella interactions in water distribution systems with the environmental conditions is needed for better control of the colonization. To this purpose, the implementation of water management plans is the main prevention measure against Legionella. A water management program requires coordination among building managers, health care providers, and Public Health professionals. The review reports a comprehensive view of the state of the art and the promising perspectives of both monitoring and disinfection methods against Legionella in water, focusing on the main current challenges concerning the Public Health sector.

Response of high-, mid- and low-abundant taxa and potential pathogens to eight disinfection methods and their interactions in domestic hot water system

Eight disinfection methods were applied to control biofilm contamination in domestic hot water system. The inactivation efficiency, responses of high- (≥1%), mid- (0.1% ~ 1%) and low-abundant taxa (≤0.1%) to disinfection, and interactions within and across three sub-communities were investigated. Ultraviolet was the most effective disinfection method for total bacteria and Escherichia coli, and chlorine dioxide had the highest inactivation efficiency on heterotrophic bacteria, while silver ions exhibited poor performance on all of them. At the phylum level, the responses of microorganisms to eight disinfection methods were different, but Proteobacteria and Firmicutes dominated in most samples. Eight disinfection methods had a greater impact on the proportion of high- and mid-abundant taxa than that of low-abundant taxa, and led to dissimilar transformations of genera among high-, mid- and low-abundant taxa in each sample. High-, mid- and low-abundant taxa of different samples showed similar structures and were roughly clustered into three Groups. Moreover, high-abundant taxa had more complex internal interactions than mid- and low-abundant taxa, and mainly presented co-occurrence patterns. The associations between high- and low-abundant taxa were close, and some low-abundant genera were identified as hub bacteria, such as Paracoccus, Thioalkalispira and Flavitalea. Furthermore, a total of 23 potential pathogens were detected in this study, and they mainly showed positive interactions, with Mycobacteria and Streptococcus as keystone genera. These results highlight the dissimilar responses of high-, mid- and low-abundant taxa to disinfection, and the critical role of some low-abundant genera in the microbial network, as well as the co-occurrence patterns among potential pathogens.

Legionnaires' Disease Mortality in Guinea Pigs Involves the p45 Mobile Genomic Element

Background

Legionella can cause Legionnaires’ disease, a potentially fatal form of pneumonia that occurs as sporadic epidemics. Not all strains display the same propensity to cause disease in humans. Because Legionella pneumophila serogroup 1 is responsible for >85% of infections, the majority of studies have examined this serogroup, but there are 3 commonly used laboratory strains: L pneumophila serogroup 1 Philadelphia (Phil-1)-derived strains JR32 and Lp01 and 130b-derived strain AA100.

Methods

We evaluated the ability of Phil-1, JR32, Lp01, and AA100 to cause disease in guinea pigs.

Results

We found that, although Phil-1, JR32, and AA100 cause an acute pneumonia and death by 4 days postinfection (100%), strain Lp01 does not cause mortality (0%). We also noted that Lp01 lacks a mobile element, designated p45, whose presence correlates with virulence. Transfer of p45 into Lp01 results in recovery of the ability of this strain to cause mortality, leads to more pronounced disease, and correlates with increased interferon-γ levels in the lungs and spleens before death.

Conclusions

These observations suggest a mechanism of Legionnaires’ disease pathogenesis due to the presence of type IVA secretion systems that cause higher mortality due to overinduction of a proinflammatory response in the host.

Viability and infectivity of viable but nonculturable Legionella pneumophila strains induced at high temperatures

Thermal disinfection is commonly used to prevent the proliferation of culturable Legionella in engineered water systems (EWS). In response to such stress, culturable Legionella populations can switch into a viable but nonculturable (VBNC) state. The importance of such VBNC Legionella cells is currently hotly debated. Here, we investigated the stress response patterns and transitions of the bacteria to the VBNC state at 55 °C, 60 °C and 70 °C on two L. pneumophila strains for >80 days using a combination of cell-based viability indicators. Complete loss of culturability at 55 °C, 60 °C and 70 °C occurred after 3-8 h, 60 min and <2 min, respectively. In contrast, L. pneumophila strains required 9 days at 55 °C, 8 h at 60 °C and 20 min at 70 °C to achieve a 2 log reduction in cells with intact membranes and high esterase activity; a 4 log reduction was achieved only after 150, 8-15 and 1-4 days, respectively. In parallel, the presence of diagnostic outer-membrane epitopes (OMEs) and changes in the infectivity patterns of the two strains towards amoebae and THP-1 cells were assessed. OMEs were more persistent than viability indicators, showing their potential as targets for VBNC Legionella detection. L. pneumophila strains infected amoebae and THP-1 cells for at least 85 days at 55 °C and 60 °C and for up to 8 days at 70 °C. However, they did so with reduced efficiency, requiring prolonged co-incubation times with the hosts and higher Legionella cell numbers in comparison to culturable cells. Consequently, infection of amoebae by thermally induced VBNC L. pneumophila with lowered virulence can be expected in EWS. Although the gold standard method cannot detect VBNC Legionella, it provides important information about the most virulent bacterial subpopulations. Our results indicate that a prolonged thermal regime ≥60 °C at the central parts of warm water systems is not only effective against culturable L. pneumophila but in the long run even against VBNC cells.

Legionella pneumophila p45 element influences host cell entry and sensitivity to sodium

Legionella pneumophila are environmental bacteria found ubiquitously in both natural and man-made water reservoirs, sometimes as constituents of biofilm communities, but mostly intracellularly within protozoal hosts. In the event that Legionella become aerosolized in water droplets and inhaled by humans, they can cause a potentially fatal form of pneumonia called Legionnaires' disease. Strains of L. pneumophila have highly plastic genomes that harbor numerous inter- and intra-genomic elements, enhancing their ability to live under diverse environmental conditions. One such mobile genomic element, p45 carries ~45 kbp of genes, including the Lvh (Legionella Vir homolog) type IVa secretion system. This element was evaluated for its contribution to L. pneumophila environmental resilience and virulence-related characteristics by comparing clinically isolated strain Philadelphia-1 that carries p45, Lp01 that lacks p45, and Lp01 with p45 reintroduced, Lp01+p45. We found that the p45 element impacts host cell entry and resistance to sodium, both virulence-related characteristics in Legionella species.