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American Journal of Critical Care. 2009;18: 31-40 doi:10.4037/ajcc2009968
Copyright © 2009 by the American Association of Critical-Care Nurses.
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Patients’ Bath Basins as Potential Sources of Infection: A Multicenter Sampling Study

By Debra Johnson, RN, BSN, OCN, CIC, Lauri Lineweaver, RN, BSN, CCRN and Lenora M. Maze, RN, MSN, CNRN. Debra Johnson is the infection control coordinator at Westerly Hospital, Westerly, Rhode Island, Lauri Lineweaver is an education resource nurse in cardiac critical care at Presbyterian Hospital, Albuquerque, New Mexico. Lenora M. Maze is a clinical nurse specialist in critical care and neuroscience at Wishard Health Services, Indianapolis, Indiana.

Corresponding author: Debra Johnson, RN, OCN, IC Solutions Consulting, 9 Fawn Circle, Charlestown, RI 02813 (e-mail: Debrn78{at}msn.com).


   Abstract
Top
 Abstract
Methods
 Results
 Discussion and Recommendations
 Conclusion
 References
 
Background Nosocomial infections are a marked burden on the US health care system and are linked to a high number of patient deaths.

Objective To identify and quantify bacteria in patients’ bath basins and evaluate the basins as a possible reservoir for bacterial colonization and a risk factor for subsequent hospital-acquired infection.

Methods In a prospective study at 3 acute care hospitals, 92 bath basins, including basins from 3 intensive care units, were evaluated. Sterile culture sponges were used to obtain samples from the basins. The culture sponges were sent to an outside laboratory, and qualitative and quantitative microbial tests were conducted and the results reported.

Results Some form of bacteria grew in 98% of the samples (90 sponges), either by plating or on enrichment (95% confidence interval, 92%–99.7%). The organisms with the highest positive rates of growth on enrichment were enterococci (54%), gram-negative organisms (32%), Staphylococcus aureus (23%), vancomycin-resistant enterococci (13%), methicillin-resistant S aureus (8%), Pseudomonas aeruginosa (5%), Candida albicans (3%), and Escherichia coli (2%). Mean plate counts, in colony-forming units, were 10 187 for gram-negative organisms, 99 for E coli, 30 for P aeruginosa, 86 for S aureus, 207 for enterococci, and 31 for vancomycin-resistant enterococci.

Conclusions Bath basins are a reservoir for bacteria and may be a source of transmission of hospital-acquired infections. Increased awareness of bath basins as a possible source of transmission of hospital-acquired infections is needed, particularly for high-risk patients.

Each year, an estimated 1.75 to 3.5 million patients in the United States, 5% to 10% of all patients admitted to US hospitals annually, contract nosocomial infections.1 Health care–associated infection (HAI) is linked to nearly 90 000 deaths annually,2 is ranked as the fifth leading cause of death in acute care hospitals, and results in an annual financial burden thought to exceed $6.5 billion.2 Multiple studies3–6 have shown that the cost of care is even higher in hospitalized patients in whom methicillin-resistant Staphylococcus aureus (MRSA) infections develop.

Nobel laureate Robert Koch first correlated high heterotrophic counts of bacteria with tap water hygiene in 1883 in Berlin.1 Since then, researchers around the globe have substantiated his findings and have, more recently, discovered that in health care facilities such as hospitals, hospices, and residential care centers, contaminated water supplies can spread infection among patients whose health is already compromised.1,7,8 Infection control measures such as water chlorination, filtration, thermal disinfection, and UV irradiation can decrease microbial counts in hospital water.1,9–12

However, water often is merely a conduit. Pathogens, such as Enterobacter cloacae, can create highly potent biofilms that lodge in hospital pipes, hot water tanks, air conditioning cooling towers, sinks, and even touchless faucets and then contaminate the water upon contact.1,13,14 Without proper education and hygienic practice, hospital staff can transmit pathogens both into and via water that has become contaminated after contacting a contaminated surface.15,16

A review of the evidence suggests a link between waterborne pathogens in the health care setting and the development of biofilm (multiple colonies of microorganisms attached to a surface). The ability of organisms to form a biofilm, combined with transmission of organisms through contact with contaminated items or unwashed hands, can create a reservoir of bacteria that can be transferred to and maintained in a patient’s bath basin (defined as a container in which water is placed for use in bathing a patient).

On the basis of ample, documented evidence for microbial colonization of patients’ skin, health care facility water supplies, and environmental surfaces such as dry disposable bath basins, we asked the following question: Can patients’ bath basins harbor microorganisms that are potential sources of HAI, even after the removal of the possibly contaminated water? A prospective, multicenter study was done to identify and quantify bacteria in patients’ bath basins to evaluate bath basins as a possible reservoir for bacterial colonization and as a risk factor for subsequent HAI.


Health care–associated infections are the 5th leading cause of death in acute care hospitals.

 


   Methods
Top
 Abstract
 Methods
Results
 Discussion and Recommendations
 Conclusion
 References
 
Setting and Sample
A total of 92 bath basins in 3 acute care hospitals were evaluated; these included basins from 3 intensive care units (cardiac care, surgical intensive care, and medical intensive care) and a rehabilitation unit. The hospitals were Presbyterian Hospital, Albuquerque, New Mexico, a large acute care hospital and state tertiary medical center (453 licensed beds); Wishard Health Services, Indianapolis, Indiana, a teaching hospital and level I trauma center (319 licensed beds); and Westerly Hospital, Westerly, Rhode Island, a smaller acute care community hospital (125 licensed beds). Sampling was limited to basins used at least twice for whole-body bathing of patients hospitalized for 48 hours or longer. Bath basins were not cleaned with any substance after patients were bathed. The study had no inclusion or exclusion criteria for patients because the focus of the research was the bath basin. One registered nurse from each hospital was assigned to carry out all study activities and to record data, including collecting data on patients’ demographics, length of stay, and bathing regimen. The method used for bathing was not observed or reported. In general, nonlicensed and licensed staff of all facilities bathed patients or assisted the patients in bathing and followed universal precautions and accepted bathing practices. These practices included taping a bag or some type of protector around a wound before the bath to avoid contamination. No antiseptic soaps were used during the bathing process. Patients’ caregivers were not told of the study to ensure that the caregivers continued with usual practices. All nurses who conducted basin sampling were trained to maintain consistency in the sampling technique. One liaison trained by the outside testing laboratory ensured that data collectors used standardized and appropriate data collection techniques.


Biofilm-forming pathogens create potent biofilms that lodge on hospital equipment and structures.

 

Sampling Procedures
The designated nurse from each hospital sampled the bath basins during the course of a single day. For each basin sampled, 1 culture sponge, which was prewetted with 10 mL of neutralizer, was used to swab the entire interior of the basin, including the walls and base. The neutralizer provided the moisture necessary to remove potential organisms from the basin surface; the neutralizer is not a nutrient and should not encourage growth of organisms. Culturing of the samples included an enrichment step to increase the numbers of organisms to allow qualitative detection of bacterial growth. Testing was based on the qualitative, rather than quantitative, presence of bacteria, and so the results would not be affected if any growth occurred during transport.

Swabbing of basins was performed at least 2 hours after patient bathing, after the bath water had been emptied and the basins were allowed to air dry. All basins were disposable and were used for only 1 patient admission. After swabbing the basin, using aseptic technique, the nurse who obtained the sample placed each sponge into a separate sterile bag and sealed the bag with a Whirl-Pak–style tie (Nasco, Fort Atkinson, Wisconsin). The bags were then packaged and mailed in bulk by express mail on the same day the samples were gathered to a predetermined off-site microbiological testing laboratory.


Ninety-eight percent of all cultures grew some form of bacteria after either plating or enrichment.

 

Culture Procedures
Once the samples were received in the laboratory, 20 mL of trypticase soy broth was introduced into each bag for a 1:30 dilution, and each sponge was thoroughly manipulated for 1 minute to release organisms. This step was to allow enough bacterial growth to allow detection of the different species present on the sponge. Direct plating was used for an aerobic plate count; yeast and mold count; and counts of gram-negative organisms, Escherichia coli, S aureus, Pseudomonas aeruginosa, and enterococci. Immediately after plating, the remainder of the sponge and diluent were incubated for 48 hours (±4 hours) at 35°C (±2°C) for enrichment. After incubation, samples were streaked onto selective or differential agars for the isolation of gram-negative organisms, E coli, S aureus, P aeruginosa, enterococci, MRSA, and Candida albicans.

If plates that were streaked with enrichment samples had growth of enterococci, samples from the enterococcal colonies were streaked onto brain-heart infusion agar with 6 µg/mL vancomycin to evaluate vancomycin resistance.

Organism Identification and Confirmation
Identifications of organisms were confirmed by using various techniques, including but not limited to latex test and coagulase test. Methicillin resistance of coagulase-positive, gram-positive cocci was determined by streaking samples onto oxacillin-resistance screening agar. No quantitative measures were conducted. No genotypic identification was done, and all results were based on the growth or reactions of organisms on selective plates.

Reporting
At the end of the study for each location, the laboratory provided a summary report of the microorganisms identified that included a comparison of microorganism recovery from the different centers.

Data Analysis
Standard biostatistical quantification methods were used. Semiquantitative data on plate counts were summarized with means, standard deviations, medians, and ranges after truncating text such as "est," "<," and ">." Qualitative data on enrichment results were summarized with counts, percentages, and exact 95% confidence intervals. All percentages have been rounded to whole numbers. Enrichment results were assessed by using an exact binomial test with the null hypothesis of a 5% positive rate.

Multivariable logistic regression modeling techniques were used to explore the difference between medical and surgical units with respect to 2 separate end points: enrichment MRSA and vancomycin-resistant enterococci (VRE) results. The following potential covariates were explored in the model: age, sex, and length of stay. Significance was set at P = .05.


   Results
Top
 Abstract
 Methods
 Results
Discussion and Recommendations
 Conclusion
 References
 
Results Compiled From All Centers
A total of 92 basins were sampled. Samples were collected from basins of 49 men and 43 women 19 to 101 years old (mean, 64). Mean length of stay was 8.1 days; however, 1 outlier (a patient who stayed 122 days) skewed this mean. When data on the outlier was removed, the mean length of stay was 6.9 days. Some form of bacteria grew in 98% of the samples (90 sponges), either by plating or on enrichment (95% confidence interval, 92%–99.7%). Median plate counts were 30 for all but the aerobic plate counts, which had a median of 1150 (Table 1Go).


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  		Table 1 Plate count results for 92 samples

 
After the enrichment step, the highest positive growth rates, in order, were 54% for enterococci, 32% for gram-negative organisms, 23% for S aureus, and 13% for VRE (Table 2Go). Positive growth rates were less than 10% for all other enrichment cultures: MRSA, 8%; P aeruginosa, 5%; C albicans, 3%; and E coli, 2%. The positive growth rates were statistically significantly different from 5% for enterococci, gram-negative organisms, S aureus, and VRE.


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  		Table 2 Enrichment results

 
Multivariable logistic regression modeling techniques clearly indicated that age, sex, and length of stay did not affect the findings (Table 3Go). In addition, no differences were found between the units for either MRSA (P = .65; Table 4Go) or VRE (P = .25; Table 5Go).


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  		Table 3 Multivariable logistic regression

 

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  		Table 4 Enrichment methicillin-resistant Staphylococcus aureus end point

 

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  		Table 5 Enrichment vancomycin-resistant enterococci end point

 
Of note, medical conditions of all patients were recorded; however, the diagnoses were numerous and varied, so it was not possible to report meaningful data. For instance, basin samples from patients with known critical illnesses had no bacterial growth, whereas samples from patients with less acute conditions had more bacterial growth. Analysis of data indicated no pattern or predictability.


   Discussion and Recommendations
Top
 Abstract
 Methods
 Results
 Discussion and Recommendations
Conclusion
 References
 
Clark and John13 reviewed the literature on tap water contamination in health care facilities and suggested the need to keep contaminated water away from patients who are immunosuppressed, have fresh surgical wounds, or are at high risk for infection. Shannon et al17 found that bath water specimens collected after a routine patient’s bath contained bacterial counts of more than 105 colony-forming units/mL, a colony count similar to the number of bacteria found in urine samples from patients with urinary tract infections. In addition, they noted that most nurses disposed of used bath water in hand washing sinks, a practice that could contaminate the sink and surrounding areas.17

Biofilm Formation
In recently published correspondence, Cervia et al18 noted the concurrent reemergence of gram-negative HAI and recent reports of gram-negative bacteria, including Pseudomonas and Enterobacter organisms, in hospital water supplies. Cervia et al also mentioned the problem of the formation of biofilms, which may occur despite efforts to prevent contamination of water supplies. In addition, they sampled the water of 9 metropolitan area hospitals and found as many as 14 bacterial species in samples from a single source. Disturbingly, about one-third of the bacterial species found were known to be responsible for HAIs. The authors18 concluded that further investigation was warranted to determine whether or not water should be considered a potential source of HAI.


VRE and MRSA were cultured from bath basins of patients who were not carriers.

 

Cross-Contamination
It is a universally accepted practice for caregivers to wash their hands to reduce bacterial transmission between patients and themselves and objects in the environment. Cross-contamination can occur when a caregiver touches a patient who is colonized with a bacterial species and then touches an object in the environment. If MRSA or VRE resides on an object in the environment and the caregiver touches that object, he or she can transmit the organisms to the next object or person he or she touches. Additionally, bath basins are often left out in the patient’s room and are often used as storage basins. Basins are often used to hold personal items and may be used to hold soiled cloths from incontinence cleanups or may even be used as emesis basins.19

Disinfection and Sterilization
A rational approach to disinfection and sterilization of objects in the patient environment to reduce bacterial spread was developed by Spaulding,20 who divided the objects into 3 categories: critical items, semicritical items, and noncritical items. Critical items are those that enter sterile tissue or the vascular system and that can thus introduce infection; these items should be sterilized before use. Examples include surgical instruments and catheters.

Semicritical items are those that come into contact with mucous membranes or nonintact skin. The mucous membranes and nonintact skin are not sterile tissue but are susceptible to the introduction of certain pathogens. Respiratory therapy equipment and laryngoscopes are examples of these types of items. Bathing with contaminated supplies can potentially expose a patient’s mucous membranes or nonintact skin to bacteria. Thus, it is reasonable to consider that although a bath basin is classified as a noncritical item, at times it is a semicritical item. The Spaulding classification suggests that these semi-critical items should be free of all microorganisms.

At-Risk Patients
Exner et al1 noted that control of waterborne pathogens must include reducing the number of harmful microbes and specifically protecting patients at high risk for infection. Attentiveness to identifying which patients are at high risk is a prerequisite for protecting them from potential pathogens. Patients at high risk are numerous and include both children and adults who are immunocompromised, have indwelling catheters or drains, undergo invasive procedures such as surgery, or have wounds or underlying disease. In addition, the elderly are at increased risk.21–24 Environmental factors such as widespread microbial antibiotic resistance and a lack of infection control measures and environmental hygiene also play a role in determining risk for hospitalized patients.21,24

Hospitalized patients themselves can harbor potentially dangerous microorganisms. Increasing rates of colonization by antibiotic-resistant organisms, such as MRSA, VRE, and Acinetobacter organisms, may present significant problems in patients who have indwelling catheters or in those who are immuno-compromised.17,25,26 Methicillin-resistant Staphylococcus epidermidis has also received attention recently for its role in purulent infection in soft tissues and skin.27

During bathing, mechanical friction releases skin flora into bath water.28 Via inhalation, ingestion, or direct contact with excoriated skin, contaminated water in bath basins can become a source of cross-contamination of organisms from one body system to another and can be potential reservoirs for the transmission of HAI.12,16 The bath basin itself often becomes contaminated with gram-negative bacteria from the environment and can be a source of bacterial exposure during future baths.29,30

Our results confirm that potentially harmful microorganisms are present in bath basins even after the bath water is removed; 98% of all cultures grew some form of bacteria, either on plating or after enrichment. All at-risk patients admitted to intensive care units and surgical and medical care units in 1 of the 3 hospitals in the study were screened for MRSA (nares) on admission and VRE, and all the patients so tested during the course of the study were negative for MRSA. Therefore, VRE and MRSA were present in the hospital environment and were cultured from patients who had not been previously identified as carriers of VRE or MRSA.

In 1 patient whose basin sample was positive for MRSA, a sternal wound infection developed from which MRSA was cultured. The patient did not have colonization with MRSA at the time of admission, but did have MRSA in the nares at the time of discharge (on day 7 of admission). In another patient, a VRE infection developed after VRE was detected in the patient’s wash basin. This patient initially had negative cultures for VRE/MRSA, but samples obtained when he was readmitted from a nursing home 10 days later were positive. In this patient, the first cultures possibly were false-negatives (ie, the patient was colonized during his stay in the nursing home) or the VRE exposure in the hospital led to the wound infection and to the colonization that was noted upon readmission. These temporal associations are not sufficient to establish a cause-and-effect relationship, but they raise the question of whether the infections were due to exposure to the contaminated wash basin. It is not surprising that bacteria were cultured from samples from patients’ bath basins, because previously documented evidence has indicated that water in health care settings may harbor microorganisms. Our results suggest that the bath basins themselves may be an additional way that harmful bacteria are spread.


Most nurses disposed of used bath water in hand-washing sinks, which could then contaminate the sink and surrounding areas.

 

Of note, 100% of the basins sampled were positioned upright instead of upside down. Storing basins upright allows any remaining droplets of water to pool at the bottom, and the pooling allows biofilms to form. Additionally, multiple basins were stacked on top of each other, and items used for incontinence cleanup were stored inside (see FigureGo), a situation that creates another opportunity for contamination.


Figure 1
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  		Figure Typical storage of bath basin. Note upright storage, sink, and used incontinence tubes.

 
The finding of MRSA and VRE in the basins is not surprising, given the difficulty in eradicating microorganisms from the hospital environment, yet this finding underscores the need to identify and eliminate reservoirs where possible. Doing so is particularly important for bath basins because of the direct exposure to the bacteria that can occur if a contaminated basin is used for bathing. It is reasonable to anticipate that patients who are immunocompromised or who have open wounds would be at risk for infection after direct exposure to contaminated bathing materials. Any activity that potentially spreads antibiotic-resistant bacteria from a contaminated surface to the skin works directly against efforts to eradicate such bacteria from the hospital or health care environment.

We recommend interventions or protocols that address bath basins as a potential source of bacterial exposure for patients. Sterilizing bath basins is not common practice and may not be cost-effective or provide the most efficient use of time for staff members. Alternative methods of bathing that are effective and cost-and time-efficient have been reviewed in the literature and deserve further evaluation and consideration.29–31


Storing basins upright allows for any remaining droplets of water to pool at the bottom, which allows biofilms to form.

 

Alternative Bathing Methods and Research
Larson29 and Vernon et al31 found that microbial counts on patients’ skin were lower after a prepackaged bath than after a bath given with a patient bath basin, although these differences were not significant. Larson concluded that the disposable bath is a desirable form of bathing, and possibly preferable to traditional basin baths, for patients in both critical care and long-term care settings who cannot bathe themselves.

Furthermore, McGuckin et al32 investigated the rate of urinary tract infections after a hospital eliminated a prepackaged bath product and replaced it with standard basins, tap water, and paper towels. The study findings showed a significant increase in the rate of urinary tract infections after the elimination of the prepackaged bath product and an increase in cost of $107 741, which represented an increase in cost in a 14-bed intensive care unit during a 9-month period.

Although contaminated water within the health care environment and the development of biofilms on bath basins are important concerns, Lazzari et al33 point out that HAIs are preventable. Multiple opportunities for intervention exist in the health care setting, many of which are related to the removal of potential etiologic factors.

Use of cleansing cloths can reduce microbial counts and avoids exposing patients to potentially contaminated bath basins29,30 and potentially contaminated tap water and water conduits.1 The use of a prepackaged bath product has other benefits as well. With a properly used bath pack, the same washcloth is not used to bathe the entire body, thus possibly reducing the potential for spread of bacteria from one area of the body to another.29,30 The use of bath packs would also allow bathing methods to be standardized, thus reducing variability in technique between nurses. Such baths require less time to administer than do bed baths and appear to avoid the skin-drying effects associated with the use of soap, water, and towel drying.29,30 More important, use of a product that contains a skin conditioner apparently is less damaging to the skin than are plain soap and water and towel drying.29,30

Of note, our study had a few weaknesses. Clean bath basins were not cultured because of cost restraints; however, a null hypothesis of 5% was used throughout data analysis to account for presumed contamination. Incontinence materials were found within basins, and these materials were not tested inside or outside of the basin. Basins were not sampled on the same day of use, and some may have been used more than others were. The presence of urinary catheters, drains, and/or wounds was not accounted for. A close examination of these variables in future studies may elicit additional valuable data.


   Conclusion
Top
 Abstract
 Methods
 Results
 Discussion and Recommendations
 Conclusion
References
 
We conclude that bath basins are a reservoir for bacteria and that further investigations into bath basins as a potential source of transmission of HAI are warranted. Increased awareness of bath basins as a possible source of bacterial cross-contamination is necessary, particularly in high-risk patients. In addition, alternative bathing methods should be investigated. Our findings are a call to action to health care providers to develop and implement protocols for patients’ bathing that address the potential for patients’ exposure to pathogens. A system that uses prepackaged bathing supplies could be a useful adjunct to such a protocol.


   ACKNOWLEDGMENTS
 
We thank Michelle Secic, MS, for her expertise in biostatistical analysis of the results reported in this study, and Dr Rhonda Porterfield and Kersten Hammond for their expertise and assistance in the development of the manuscript.

This article is followed by an AJCC Patient Care Page on page 41.

FINANCIAL DISCLOSURES
Part of this study was supported by an unrestricted grant from Sage Products, Inc, Cary, Illinois.

eLetters
Now that you’ve read the article, create or contribute to an online discussion on this topic. Visit www.ajcconline.org and click "Respond to This Article" in either the full-text or PDF view of the article.

SEE ALSO
For more about health care–associated infections, visit www.ccnonline.org, and read the article by Montefour et al, "Acinetobacter baumannii: An Emerging Multidrug-Resistant Pathogen in Critical Care" (Critical Care Nurse, February 2008).

To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints{at}aacn.org.


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Top
 Abstract
 Methods
 Results
 Discussion and Recommendations
 Conclusion
 References
 

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