infection control and hospital epidemiology

march 2006, vol. 27, no. 3

concise communication

Bacteriological Monitoring of Water Reservoirs in Oxygen Humidifiers: Safety of Prolonged and Multipatient Use of Prefilled Disposable Oxygen Humidifier Bottles
Nobuharu Kobayashi, PhD; Tsutomu Yamazaki, MD, PhD; Shigefumi Maesaki, MD, PhD
Bacterial colony counts in water specimens from oxygen humidifiers that used reusable water reservoirs were compared with counts in water specimens from humidifiers that used prefilled disposable reservoir bottles to evaluate the effects of prolonged and multipatient use of humidifiers. Bacteria were detected after 1 week of operation in water specimens collected from many humidifiers with reusable reservoirs, but no bacteria were detected in water specimens from disposable bottles for up to 12 weeks during use of the humidifier by multiple patients. Infect Control Hosp Epidemiol 2006; 27:320-322

Patients receiving mechanical ventilation were excluded in this study. Water samples (volume, 15 mL) were obtained from the water reservoir of each oxygen humidifier by means of a sterile syringe and needle before (at day 0) and after operation of the humidifier began. Within a few hours after sampling, 1 mL of the water sample was diffused through a 0.22-mm membrane filter with a diameter of 25 mm (Millipore). The membrane filter was removed from the filter holder and placed on a Muller-Hinton agar plate for incubation at 35ЊC for 3-5 days, at which time the number of bacterial colonies was determined. Table 1 shows bacterial colony counts in the water reservoirs maintained by the recommended procedure. The number of colonies detected on day 0 in all water specimens except that from reservoir 4 from ward F was negligible and, except for samples from reservoir 3 from ward F, did not increase significantly during operation of the oxygen humidifiers. The bacterial colony count in reservoir 3 from ward F was aptable 1. Bacterial Colony Counts in Reusable Water Reservoirs Maintained in Accordance With Recommended Procedure Humidifier Location, Reservoir No. Ward 1 2 3 Ward 1 2 Ward 1 2 Ward 1 2 Ward 1 2 3 4 Ward 1 2 3 4 5 A 0 0 0 B 0 0 C 0 0 D 0 0 E 1 0 0 0 F 0 0 0 1.0 # 102 a 0 0 0 2.1 # 102 1.0 # 103 a 0 0 0 3.1 # 104 2.7 # 104 0 29 1 7.2 # 104 9.5 # 103 0 5 0 0 0 2 0 0 0 4 0 0 0 0 33 4 X 0 X 0 1 X X X X 0 0 42 2 5 0 0 0 0 0 0 0 1 0 X Bacteria Colony Count in colonies/mL, by Time of Sampling Day 0 Day 1 Day 3 Day 7

Nosocomial pneumonia is the major cause of death among hospital-acquired infectious diseases.1 It is common to use mechanical ventilation and administer oxygen in modern medical practice, and the presence of bacteria in a mechanical ventilator is one of the major risk factors for pneumonia.2 There is no certain evidence that pneumonia can be caused by exposure to a humidified oxygen supply, but the Centers for Disease Control and Prevention (CDC) guideline for prevention of nosocomial pneumonia strongly recommends following manufacturers’ instructions for use and maintenance of reusable wall-mounted oxygen humidifiers.3,4 The recommended procedure is laborious and is therefore difficult to perform in clinical settings with limited manpower. The safe use of prefilled disposable oxygen humidifiers for periods of up to 30 days has been reported.5 We evaluated the safety of prolonged and multipatient use of a closed humidifying system by comparing results of quantitative and sequential aerobic bacterial cultures of water samples obtained from the humidifiers with those for water samples obtained from reusable humidifiers.

methods
Reusable water reservoirs of oxygen humidifiers were maintained by the procedure recommended by CDC guidelines: when the water volume decreased, the water reservoir was exchanged with a freshly washed and dried reservoir filled with sterilized water.3 A commercial closed system with 1,500mL disposable water reservoirs (Respi Flo; Tyco Healthcare) was also used by successive patients for a duration of 12 weeks each, with mouthpieces and lines changed between patients.

note. Day 0 was the day humidifier use was started. X p water sample was completely exhausted. a Reexamination of the stocked samples at 4ЊC for 3 days did not show any bacterial growth.

. although it was possible that bacteria from the patients could have contaminated the water reservoirs. Ward A 4 5 6 7 Ward E 5 6 7 8 Ward F 6 7 8 9 note. The results suggest that the prolonged use of a humidifier containing prefilled disposable water reservoir bottles by successive patients could be a more economic alternative than use of humidifiers with reusable reservoirs. which is not well understood. The bacterial colony counts in samples from the reusable water reservoirs that were maintained in accordance with CDC recommendations were fairly low. Reservoir No. No bacteria were detected in 4 reservoirs (reservoir 4 from ward A. Recently. The detected bacteria were not pseudomonads or staphylococci because they did not grow on nalidixic acid–cetrimide agar plates or mannitol salt agar plates (data not shown). The water in reservoir 4 from ward F was already contaminated on day 0. and 9 from ward F).6 discussion No bacteria were detected in the disposable water reservoirs from the commercial closed systems even after operation for 84 days (Table 2). such as Pseudomonas aeruginosa and some other gram-negative bacteria. can grow even in distilled water. ND p not done. probably because fluids from the patient using this humidifier entered the reservoir. One remaining concern is the use of the closed humidifier system for patients with legionellosis or tuberculosis. and reservoir 7 from ward F) during the 12-week study period and in the other 8 reservoirs during weeks 4-10. The use of disposable reservoirs in a closed system may provide the best protection for the patients. particularly if the water in the reservoir cannot be consumed completely. but this procedure is expensive. but it is also complex and time-consuming.8 Maintenance of oxygen humidifiers according to the recommended procedure seems to be safe and inexpensive. of colonies/mL. Table 2 shows the bacterial colony counts in 12 disposable water reservoirs from 3 wards over an 84-day period. The colony counts for reservoirs 3 and 4 from ward F increased during the operation of the oxygen humidifier (Table 1). reservoirs 7 and 8 from ward E. because the pathogens causing these diseases cannot Bacterial Colony Counts on Muller-Hinton Agar for Water Samples From Prefilled Disposable Reservoirs Bacteria Colony Count in colonies/mL. We also examined a commercial closed humidifying system that uses disposable reservoir bottles prefilled with water. D0 was the day humidifier use was started. 8. Data are no.bacteriological monitoring in water reservoirs 321 proximately 102 colonies/mL on day 1.7. Data in parentheses are counts measured after the reservoir was withdrawn from patient use because of low water levels. Use of the latter 5 reservoirs was discontinued because of too little water. These studies were stopped early because of complete exhaustion of water levels (in reservoirs 5 and 7 from ward A and reservoir 5 from ward E) or almost complete exhaustion of water (in reservoir 6 from ward A. The contaminating bacteria grew in the water reservoirs during operation of the oxygen humidifiers because some bacterial species. but sampling for measurement of the bacterial colony count was continued through the end of the 12week period. which must have been caused by incomplete washing and drying of the reservoir.5. the usefulness of prefilled disposable humidifiers has been reported. could have come from the oral cavity or the distal airway of the patient currently using the reservoir. but bacteria sometimes grew in the water reservoirs (Table 1). by Time of Sampling After Initiation of Humidifier Operation D0 0 0 0 0 0 0 0 0 0 0 0 0 D1 0 0 0 0 0 0 0 0 0 0 0 0 D3 0 0 0 0 0 0 0 0 0 0 0 0 W1 0 0 0 0 0 0 0 0 0 0 0 0 W2 0 0 0 0 0 0 0 0 0 0 0 0 W3 0 0 0 0 0 0 0 0 0 0 0 0 W4 0 0 0 0 X (0) 0 0 0 0 0 0 W5 0 0 0 0 X (0) 0 0 0 0 0 0 W6 0 0 0 0 X (0) 0 0 0 0 0 0 W7 0 X 0 0 X (0) 0 0 ND 0 0 0 W8 0 X 0 0 X (0) 0 0 0 0 0 0 W9 0 X 0 X X (0) 0 0 (0) 0 (0) (0) W10 0 X (0) X X (0) 0 0 (0) 0 (0) (0) W11 0 X (0) X X (0) 0 0 (0) 0 (0) (0) W12 0 X (0) X X (0) 0 0 (0) 0 (0) (0) Humidifier Location. The characteristics of the water in the closed system may have caused the bacteria to enter into a viable but nonculturable state. reservoir 6 from ward E. and reservoirs 6. The bacteria table 2. X p water sample was completely exhausted. The exact colony counts on days 0 and 1 for reservoir 4 from ward F were not determined because reexamination of the stocked samples at 4ЊC for 3 days did not show any bacterial growth.9-12 We have demonstrated that humidifiers containing prefilled disposable reservoirs can be safely used for up to 84 days.

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