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From Plumbing to Patients

Water Management Programs for Healthcare Facilities

Patient safety depends on assuring that:

  • Water entering a healthcare facility meets all applicable quality standards
  • The premise plumbing within the healthcare facility is designed and maintained in a way that minimizes growth and spread of waterborne pathogens
  • Exposure to infection risks from water is minimized


Water can harbor germs that threaten the safety of patients. Waterborne healthcare-associated infections (HAI) may occur during the many uses of potable water (i.e. water suitable for drinking) in the healthcare environment. Water management programs are an important way to help reduce the risk of transmission infection of these organisms among vulnerable patient populations, staff, and visitors.

Healthcare facilities can have large complex water systems that promote growth of pathogenic organisms if not properly maintained. For this reason, the Centers for Medicare & Medicaid Services [4 pages] (CMS) and the Centers for Disease Control and Prevention (CDC) consider it essential that hospitals and nursing homes have a water management program that is effective in limiting Legionella and other opportunistic pathogens (waterborne pathogens, for short) of premise plumbing (i.e. a building’s hot and cold water piping systems) from growing and spreading in their facility.

A healthcare water management program identifies both hazardous conditions and corrective actions that can minimize the growth and spread of waterborne pathogens.  Such programs are designed, implemented, and regularly reviewed by multidisciplinary teams that include facility managers, infection prevention professionals, clinicians, and administrators.

On the “upstream” side, system disruptions or pressure drops, loss of disinfection residual (e.g. low chlorine levels), and main breaks are all factors that can impact the quality of water within healthcare system. Thus, engagement with representatives from the local water utility is encouraged; hospitals and healthcare systems are often among a water utility’s largest customers. Water utilities represent important stakeholders in the effort to assure patient safety.

Similarly, moving “midstream” water management programs can benefit from carefully assessment of premise plumbing, including such factors as: the age of the system; the impact of overall design, plumbing modifications, and operation on water age (i.e. how long water stays in a buildings piping system); and assuring that there are no ‘dead ends’ where water can stagnate.

Finally, by focusing “downstream,” water management programs can benefit from carefully assessing the various pathways that can lead to patients becoming exposed to waterborne pathogens, in relation to ingestion, diet, hygiene, or clinical care. This is particularly important for patient populations whose host defenses might be compromised as a result of underlying condition (e.g., cancer patients, premature infants) or in relation to an invasive procedure such as surgery or the use of medical devices.

Potential outbreaks involving waterborne pathogens are one of the more common types of consultation requests that CDC/DHQP receives. The following resources provide examples of review papers, commentaries, and outbreak investigation summaries.

Waterborne Pathogens – Selected Review Papers and Commentaries

Outbreaks Involving Waterborne Pathogens – Selected Examples

Baker AW, Lewis SS, Alexander BD, Chen LF, Wallace RJ Jr, et al. Two-Phase Hospital-Associated Outbreak of Mycobacterium abscessus: Investigation and Mitigation. Clin Infect Dis. 2017; 64(7):902-911  DOI.

Brown-Elliott BA, Wallace RJ Jr, Tichindelean C, Sarria JC, McNulty S, Vasireddy R, Bridge L, Mayhall CG, Turenne C, Loeffelholz M.  Five-year outbreak of community- and hospital-acquired Mycobacterium porcinum infections related to public water supplies. J Clin Microbiol. 2011;49(12):4231-8.  DOI.

CDC.  Nosocomial Infection and Pseudoinfection from Contaminated Endoscopes and Bronchoscopes – Wisconsin and Missouri MMWR Morb Mortal Wkly Rep 1991;40(39);675-678

Conger NG, O’Connell RJ, Laurel VL, Olivier KN, Graviss EA, Williams-Bouyer N, Zhang Y, Brown-Elliott BA, Wallace RJ Jr.  Mycobacterium simae outbreak associated with a hospital water supply. Infect Control Hosp Epidemiol. 2004;25(12):1050-5.

Edens C, Liebich L, Halpin AL, Moulton-Meissner H, Eitniear S, Zgodzinski E, Vasko L, Grossman D, Perz JF, Mohr MC. Mycobacterium chelonae Eye Infections Associated with Humidifier Use in an Outpatient LASIK Clinic–Ohio, 2015. MMWR Morb Mortal Wkly Rep. 2015 Oct 23;64(41):1177

Kinsey CB, Koirala S, Solomon B, Rosenberg J, Robinson BF, Neri A, Halpin AL, Arduino MJ, Moulton-Meissner H, Noble-Wang J, Chea N. Pseudomonas aeruginosa Outbreak in a Neonatal Intensive Care Unit Attributed to Hospital Tap Water. Infect Control Hospital Epidemiol 2017; 38(7):801-808.  DOI.

Loveday HP, Wilson JA, Kerr K, Pitchers R, Walker JT, Browne J.  Association between healthcare water systems and Pseudomonas aeruginosa infections: a rapid systematic review.  J Hosp Infect. 2014;86(1):7-15  DOI.

Moore LS, Owens DS, Jepson A, Turton JF, Ashworth S, Donaldson H, Holmes AH.  Waterborne Elizabethkingia meningoseptica in Adult Critical Care. Emerg Infect Dis. 2016;22(1):9-17.  DOI.

Peralta G, Tobin-D’Angelo M, Parham A, et al. Notes from the Field. Mycobacterium abscessus Infections Among Patients of a Pediatric Dentistry Practice — Georgia, 2015. MMWR Morb Mortal Wkly Rep 2016;65:355–356. DOI.

Opportunistic Pathogens of Premise Plumbing – Selected Examples

Opportunistic Pathogens of Premise Plumbing

Clusters of infections due to these organisms should alert one to suspect water as a potential source.  Selected Examples:

Gram negative bacteria

  • Pseudomonas aeruginosa
  • Pseudomonas putida-P. fluorescens
  • Burkholderia cepcia complex (B. cepacia, B. cenocepacia, at least 8 other genomospecies)
  • Cupriviadus (Ralstonia) pauculus
  • Herbaspirillium
  • Methylobacterium spp.
  • Ralstonia pickettii, Ralstonia mannitolilytica
  • Sphingomonas paucimobilis, Sphingomonas mucosissima, other Sphingomonas spp
  • Stenotrophomonas maltophilia
  • Acinetobacter baumannii, A. calcoaceticus
  • Alcaligenes xylosoxidans, A. faecalis,
  • Aeromonas hydrophila, Aeromonas spp
  • Elizabethkingia anaophelis, E. meningosepticum
  • Legionella pneumophia

 Non-fecal coliforms

  • Enterobacter cloacae
  • Klebseilla spp
  • Pantoae aggloerans
  • Rahnella aquatilis
  • Serratia liquifaciens, Serratia marcescens

Nontuberculous mycobacteria (NTM or Environmental Mycobacteria)

  • M. abscessus clade (M. abscessus, M. bolettii, M. massiliense)
  • M. chelonae
  • M. mucogenicum clade (M. mucogenicum, M. phociacum)
  • M. fortuitum clade (M. fortuitum, M. cosmeticum, mageritiense, M. porcinum, M. septicum)
  • M. immunogenum
  • M. smegmatis clade (M. goodii, M. wolinskyi)
  • M. aurum
  • M. simiae
  • M. avium complex (M. avium, M. intracellulare, M. chimaera, M avium ss hominissuis, M. columbiense)
  • M. scrofulaecuem
  • M parascrofulaceum
  • M. xenopi
  • M. arupense
  • M. kansasii
  • M. haemophilum
  • M. nonchromogenicum clade (M. nonchromogenicum, M. triviale, M. terrae)
  • M. gordonae (only among patients with severe immune deficiency)

Other bacteria/actinomyces

  • Microbacterium spp
  • Tsukamurella spp
  • Rhodococcus equi, Rhodococcus spp
  • Gordonae spp


  • Yeasts (eg. Candida parapsilosis, C. tropicalis)
  • Aspergillus fumigatus, A. niger
  • Fusarium spp
  • Exophiala spp.

Protozoa:  Acanthameba spp, Vermamoeba vermiformis, Naegleria spp