In 2012 a UK NICU experienced an outbreak of Ps aeruginosa. 4 months earlier the unit installed sensor taps containing a complex flow straightener with an infra-red sensor on the end of the tap. The same strain of Ps. aeruginosa was found in the flow straightener of 5 sensor taps and clinical samples.1 Sensor taps were subsequently installed without flow straighteners.Methods
Weekly sampling of tap water was commenced. If a water sample was positive for Ps aeruginosa, the tap and sink were de-commissioned and the tap removed and analysed. Inpatients were screened with weekly skin swabs for Pseudomonas.Results
Over 20 months 4040 samples of tap water were analysed, 2 were positive for Ps aeruginosa. The first episode involved formation of biofilm in threads of a screw on collar at the tap outlet. The second was associated with a visible calcified deposit adjacent to the outlet.Results
During this period 3 infants were colonised with unique strains of Ps aeruginosa.Discussion
Beginning with the outbreak the tap design was modified after each episode of contamination. The current design has:Discussion
An environmental source was not identified for any of the colonised infants.