We won't argue with Johns Hopkins researchers when they say they found more Legionella bacteria in electronic hands-free faucets in their hospital than they did in the innards of manual faucets. Whether that means anything, however, remains to be seen.
On p. 1 of this issue, we cover the hospital’s announcement of its research results and the plumbing industry's reaction to it. We can think of many questions: where were the faucets located, was the same amount of Legionella found in each one, were the manual faucets in locations similar or identical to the hands-free faucets, how high were the concentrations of Legionella, was the bacteria being aerosolized, and if they did it all over again today, would the study get the same result?
Jeremy Cressman, vice president and general manager of American Standard's Commercial Business Unit, noted that there are factors, such as internal rubber components, that can provide a hospitable environment for bacteria inside a faucet. Cressman also pointed out, however, that the faucet is just one component in a plumbing system that is already germy. Legionella is everywhere. The real danger comes from spraying it out of showerheads in patient rooms. Cressman also mentioned that changing over to single-patient rooms cuts the chances of spreading hospital acquired infections in half.
And it's not just the plumbing industry that's scratching its collective head. The healthcare pros are too.
In a joint statement, American Society for Healthcare Engineering and the Association for Professionals in Infection Control & Epidemiology noted that electronic faucets are allowed in their joint Guidelines for Design and Construction of Health Care Facilities.
In the statement, loaded with footnotes and citations, ASHE and APIC said other studies have found the exact opposite.
"Several studies have found that manual, handle-operated faucets were the source of bacterial infections in patients, including Legionella," the associations said. "This demonstrates there is no single design feature that can mitigate all risk of cross transmission. In fact, the findings from one of these studies were incorporated into the 2010 Guidelines …
"Another study of electronic faucets did not find these fixtures to be a source of bacteria. In fact, a sample from a manual, handle-operated faucet was the only one that detected bacteria. Electronic faucets do help with water conservation, which is important, as hospitals are an industry noted for high use of water. The hands-free feature of electronic faucets also lessens risk of recontamination of hands after washing as there is no need to manually turn off the water supply after use."
One potential cause of the problem may be low-flow from the faucets, which is good for water conservation but prevents thorough flushing of the faucet and connected plumbing. The groups pointed out that any faucet that is not in continuous use may hold stagnant water that could allow bacteria to proliferate.
The healthcare engineers and infection control specialists also have questions about the specifics of the Johns Hopkins study.
"This study was presented in an oral session at a scientific meeting," the associations said. "It has not been published in a peer-reviewed, scientific journal. As such it is an interesting study, but any major changes in policy or actions by others should await publication."
There is no direct connection between the faucets, bacterial growth and patient illness.
"This was an in vitro investigation, in which cultures of water were obtained and studied," ASHE and APIC stated. "There were no infections seen in patients with the same bacteria, including Legionella identified at the institution where this study took place. Tap water is not sterile and in most facilities contains low levels of bacteria; these bacteria are a possible source of infection to patients, but actual infections from this source are relatively infrequent in most facilities. Findings similar to those of this study are present in the literature; however, many of these are in vitro investigations that were not associated with infections in patients."
In June, the American Society of Plumbing Engineers will gather all of the relevant plumbing industry stakeholders — manufacturers, engineers, contractors, standards developers, health professionals and code officials — at its suburban Chicago headquarters to see how the industry can respond to this study. We wish them luck and we’ll be following their work closely.