Identifying substance misuse in primary care: TAPS Tool ...

The TAPS Tool identified adult primary care patients with high-risk ASSIST scores for all substances as well moderate-risk users of tobacco, alcohol, and marijuana, although it did not perform well in identifying patients with moderate-risk use of other drugs or non-medical use of prescription medications. The advantages of the TAPS Tool over the ASSIST are its more limited number of items and focus solely on substance use in the past 3 months.

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The interviewer and self-administered computer tablet versions of the TAPS Tool generated similar results. The interviewer-administered version (at cut-off of 2), had acceptable sensitivity and specificity for high-risk tobacco (0.90 and 0.77) and alcohol (0.87 and 0.80) use. For illicit drugs, sensitivities were '0.82 and specificities '0.92. The TAPS (at a cut-off of 1) had good sensitivity and specificity for moderate-risk tobacco use (0.83 and 0.97) and alcohol (0.83 and 0.74). Among illicit drugs, sensitivity was acceptable for moderate-risk of marijuana (0.71), while it was low for all other illicit drugs and non-medical use of prescription medications. Specificities were 0.97 or higher for all illicit drugs and prescription medications.

The National Drug Abuse Treatment Clinical Trials Network launched a multi-site trial examining the validity of a two-step screening and brief assessment for substance use termed the Tobacco, Alcohol, Prescription medication, and other Substance use (TAPS) Tool among 2,000 adults enrolled in five primary care clinics across 4 states in the Eastern US ( McNeely et al., ). The TAPS Tool is a two-step screening (TAPS-1) and brief assessment (TAPS-2) instrument. The TAPS-1 was adapted from the NIDA Quick Screen v 1.0 ( NIDA, ) and the TAPS-2 was based on the ASSIST-Lite ( Ali et al., ) and modified for the US context (as described below). The TAPS Tool in both self-administered tablet computer (iPad) and interviewer-administered versions was compared to a number of criterion measures, including the DSM-5 SUD criteria, the AUDIT-C, Fagerström Tolerance Questionnaire, and the ASSIST ( Wu et al., ). The primary analysis of the trial examined the performance of the TAPS Tool using the DSM-5 criteria as the gold standard ( McNeely et al., ). The present paper is the first report on the concurrent validity of a modified version of the ASSIST-lite (i.e., the TAPS Tool) relative to the ASSIST.

In recognition of the health problems associated with substance use and the need for an efficient approach to screen and assess substance-using individuals in primary care settings, the World Health Organization (WHO) developed the Alcohol, Smoking and Substance Involvement Screening Test ( WHO ASSIST Working Group, ). The ASSIST consists of seven questions regarding each of 10 classes of substances and a question about drug injection. Items cover lifetime use and frequency of use in the past-3 months as well as various problems associated with the use of these substances. The ASSIST was found to have good concurrent, construct, and discriminant validity among a sample of 1,047 primary care and drug treatment patients in six countries spanning five continents ( Humeniuk et al., ). Substance-specific involvement scores were developed to separate respondents into low-, moderate-, and high-risk categories for each substance. In developing the ASSIST, it was thought that the moderate-risk category, in particular, would help to identify individuals who otherwise might go undetected in health care settings ( Humeniuk et al., ), while those with high risk scores were appropriate for referral to specialist addiction treatment services. A moderate-level substance risk score on the ASSIST was subsequently used as an inclusion criterion in a multi-site study of brief intervention in primary care ( Humeniuk et al., ), that demonstrated the utility of the ASSIST in providing actionable data to triage patients to particular interventions.

This study reports a preplanned secondary analysis from a multi-site study whose primary aim was to examine the TAPS Tool vs. the DSM-5 SUD criteria ( McNeely et al., ). In this secondary analysis, the TAPS Tool substance specific scores for those participants who were positive on the TAPS-1 screen, were compared to ASSIST substance specific involvement scores corresponding to moderate-risk and high-risk use, with the ASSIST serving as the reference standard measure. Because the TAPS-2, in contrast to the ASSIST-lite, separates the items for prescription stimulants and illicit stimulants (cocaine and methamphetamine) and the prescription opioids and heroin, analyses were conducted for each of the TAPS-2 items separately and then by combining illicit and prescription and illicit stimulants into a stimulant category and prescription opioids and heroin into an opioid category. Interviewer-administered and self-administered tablet computer versions of the TAPS-2 were examined. Sensitivity, specificity, and the positive and negative predictive values (PPV and NPV) were calculated. The sensitivity and the specificity represent the proportion of patients whose ASSIST severity score categories (high risk or moderate risk and above) were correctly identified by the TAPS Tool cut-points and the proportion of patients who do not have a moderate or high risk ASSIST score and who have a negative TAPS Tool score (i.e., below the cut-points) respectively. The PPV represents the proportion of patients above the cut-points on the TAPS Tool who had a high or moderate risk and above score on the ASSIST, while the NPV shows the proportion of patients who test negative on the TAPS tool who do not have a high or moderate risk or above score on the ASSIST. Receiver operator characteristic (ROC) curves were computed and the area under each curve (AUC) was examined ( Hanley & McNeil, ). The cut-point on the TAPS Tool was based on maximizing the AUC. In some cases (as shown in Table 2 and 3 ), in which the AUCs were quite similar but the marginally higher value would have resulted in a different cut-point than the other substances, the cut-point matching the other substances was chosen in order to simplify interpretation of the test by primary care providers. Excellent discrimination was considered an AUC of >.90, good discrimination was considered an AUC of > 0.8, acceptable discrimination was considered >0.7, while an AUC of < 0.7 was considered poor discrimination ( Hanley & McNeil, ). Wilson score 95% confidence intervals (CIs) were calculated for all estimates and all analyses were conducted in SAS® version 9.3.

The ASSIST 3.0 ( Humeniuk et al., ) consists of seven questions that are scored for each of 10 drug classes (tobacco, alcohol, cannabis, cocaine, amphetamine-type stimulants, inhalants, sedatives, hallucinogens, opioids, and other drugs). In addition, an eighth question (unscored) inquires about injection drug use. Only those who endorse any lifetime use in the first question for each substance category are then asked subsequent items for that substance. Questions 2 through 5 refer to the past 3-month period for each substance category and include questions on the frequency of use, cravings, problems associated with use, and failure to fulfill normal role expectations. Response categories for these items are: never, once or twice only, monthly, weekly, and daily/almost daily. Questions 6 and 7 (regarding others expressing concern over the patient's use of the substance and the patient's inability to control or stop using) are trinary items (Never; Yes, but not in the past 3 months; and Yes, in the past 3 months). The substance-specific score is obtained by adding the item scaling weights (as per the WHO scoring manual) on items 2 through 7 ( WHO, ). Substance-specific scores (except for alcohol) are divided into low (0'3), moderate (4'26), and high risk ('27). Alcohol risk categories are low (0'10), moderate (11'26), and high ('27).

Possible scores on the TAPS Tool for tobacco and each class are 0, 1, 2 or 3. For alcohol, the possible scores are 0, 1, 2, 3 or 4 (0 = no use; 1 = use but no problems; >1 = use plus one addition point for each problem per substance). Because the parent study was planned to assess the validity of the complete TAPS tool, which is the combination of TAPS-1 and TAPS-2, participants were asked to respond to all TAPS-2 questions even if their answers on the TAPS-1 indicated no use in the prior 12 months. If the participant indicated never using a substance in the past 12 months on TAPS-1, but reported use in the past 3 months on TAPS-2, the combined TAPS Tool score is 0 for the present analysis (because when the TAPS Tool will be used in clinical practice, patients denying use in the past 12 months on the TAPS-1 would not be administered the TAPS 2). Otherwise the combined TAPS Tool score is the TAPS-2 score.

The TAPS-2 asks about past 3 month use of tobacco, alcohol, three classes of illicit drugs (marijuana, stimulants [cocaine, methamphetamine], and heroin), three classes of non-medical use of prescription medications (stimulants, opioids, and sedative-hypnotics), and 'other' drugs using a yes/no format. If the response is 'no,' the subsequent questions for that substance class are skipped. When the answer is 'yes' to any past 3 month use, the participant receives 2 follow-up items (3 for alcohol) specific to that substance class.

The TAP-2 (shown in Figure 2 ), in contrast to the ASSIST and in keeping with the format of the ASSIST-Lite, has three items for each substance (four for alcohol) and a binary (yes/no) rather than an ordinal response format. The TAPS-2 was modified from the ASSIST-lite by adapting the ASSIST-lite for the US context by clarifying language (e.g., replacing cannabis with marijuana), replacing the Australian guideline of more than 4 drinks for both men and women with the NIAAA-recommended gender-specific variant (5+ for men and 4+ for women), and creating separate items for prescription opioids and prescription stimulants in order to separate them from their illicit counterparts ( Wu et al., ).

As shown in Figure 1 , the TAPS-1 screen inquires about past 12-month frequency of four substance classes: tobacco, alcohol (binge drinking in excess of 5 drinks/day for men or 4 drinks/day for women); illicit drugs (including marijuana, cocaine methamphetamine, heroin); and non-medical use of prescription medications (including opioids, stimulants, and sedative-hypnotics). There are five possible response categories that range from 'never' to 'daily or almost daily.' Any response other than 'never' is considered a positive screen and leads to administration of the TAPS-2.

The order of administration of the self-administered tablet computer version or interviewer-administered TAPS Tool was determined by an electronic data capture system, which randomized participants in a counterbalanced order, such that 50% of the participants were first administered the TAPS Tool by the RA followed by self-administration of the TAPS Tool on a tablet computer (iPad). In order to accommodate low-literacy patients, the tablet included an optional computer-assisted audio self-interview that read questions and response options out loud. The other 50% of the participants were administered the TAPS Tool in the reverse order. After both formats of the TAPS Tool were completed, the RA then administered criterion measures, including the ASSIST, to each participant. The RA provided participants with $20 after completion of the measures.

The study's methods have been reported in detail elsewhere ( Wu et al., ). In brief, 2,000 adult primary care patients participated from August 'April at five primary care sites in four Eastern US states, including a Federally Qualified Health Center in Baltimore, MD, two practices in Kannapolis, NC, a public hospital clinic in New York City, and a University-based primary care clinic in Richmond, VA ( McNeely et al., ). Eligibility criteria were intentionally broad and included being a primary care patient of at least 18 years of age and being at the clinic for a medical visit on the day of recruitment. Patients who did not understand spoken English, were physically unable to use the iPad, or had already participated in the study were excluded. Willing patients meeting eligibility criteria provided verbal informed consent to Research Assistants (RAs) after reviewing an IRB-approved consent form.

The interviewer-administered TAPS Tool had good sensitivity and specificity for identification of moderate risk tobacco use (0.83 and 0.97, respectively) and good sensitivity and acceptable specificity for alcohol (0.83 and 0.74, respectively). Among illicit drugs, sensitivity was acceptable for marijuana (0.71), while for all other illicit drugs and prescription medications, it was low (ranging from 0.28 for prescription opioids to 0.47 for sedatives). In contrast, specificities were uniformly high, ranging at or exceeding 0.97 for all illicit drugs and prescription medications. PPVs for tobacco and alcohol were .96 and .34, respectively. PPVs for illicit and non-medical use of prescription drugs ranged from .42 for prescription stimulants to .93 for heroin. Finally, NPVs exceeded 0.87 for tobacco, alcohol, illicit drugs and non-medical use of prescription medications.

The interviewer-administered TAPS Tool had good sensitivity and specificity for high risk use of tobacco (0.90 and 0.77, respectively) and alcohol (0.87 and 0.80, respectively). For illicit drugs, sensitivity ranged from a low of 0.82 for heroin to a high of 0.96 for marijuana. For non-medical use of prescription drugs, sensitivities were lower. For prescription opioids, sensitivity was 0.41. As described above, the ASSIST has a single item that combines heroin and prescription opioid use. Therefore, the single ASSIST opioid item was compared to the combined heroin and prescription opioid items on the TAPS Tool which yielded a sensitivity of 0.92. The prescription stimulant and sedative items had very low sample size with high risk scores on the ASSIST for non-medical use of these medications (ns=4 and 8, respectively). Specificities exceeded .91 for all illicit substances. PPVs for tobacco and alcohol were 0.20 and 0.13, respectively. PPVs for illicit substances ranged from 0.70 for heroin to 0.14 for marijuana. Finally, NPVs exceeded 0.99 for alcohol, tobacco, illicit substances and use of non-prescription medications.

The optimal cut-points on the TAPS Tool for detecting 'high risk' and 'moderate risk or higher' on the ASSIST were 2 and 1, respectively. Table 3 shows the sensitivity, specificity, PPV, NPV, and AUC for the interviewer-administered TAPS Tool, while Table 4 presents results for the self-administered tablet computer TAPS-2. These two formats for TAPS Tool administration had small differences in sensitivity, specificity, PPV, NPV, and AUC. Sensitivity exceeded 0.77 for all substance classes for detecting high risk ASSIST thresholds, except for prescription stimulants, prescription opioids, and prescription sedatives (because, as indicated in the methods section above, in contrast to the TAPS-2, the ASSIST combines prescription stimulants and illicit stimulants into a single item and heroin and prescription opioids into a single item). Specificities also exceeded 0.75 for all substances for detecting high risk with the exception of prescription stimulants. Given the similarities in their properties, for simplicity below we present in detail the properties of the interviewer-administered TAPS Tool.

The demographic characteristics of the 2,000 participants are shown in Table 1 . Their mean (SD) age was 46.0 (14.7) and 56.2% of the sample were women. Slightly more than half were African American (55.6%), a third were White (33.4%) and 11.7% were Hispanic. The lifetime and past three month frequencies of substance use and the ASSIST risk categories (low, medium, high) by substance are shown in Table 2 .

4. Discussion

The present study examined the concurrent validity of the TAPS Tool (a modified version of the ASSIST-Lite) in comparison to the full WHO ASSIST as part of a large, multi-site study in Eastern US primary care patients. The TAPS Tool was found to have favorable sensitivity and specificity at a cutpoint of 2 to detect high risk use of tobacco, alcohol, marijuana, stimulants (prescription and cocaine/methamphetamine combined) and opioids (prescription opioids and heroin combined).

The TAPS Tool at a cutpoint of 1 also had favorable sensitivity and specificity for detecting moderate risk use of alcohol, tobacco, and marijuana. In contrast, its sensitivity was unacceptably low in detecting moderate risk use of stimulants (cocaine, prescription stimulants) opioids (heroin, prescription opioids), and sedatives. One likely reason for this finding is that participants who report current abstinence but have experienced certain problems in the past (concern expressed by friends or relatives, and failed attempts to control, cut down, or stop using) can still score in the moderate risk range on the ASSIST. In contrast, participants who did not use the substance in the past 3 months would have a zero score on the TAPS Tool. A moderate risk score on the ASSIST in the face of no recent drug use might prove confusing to primary care providers because it includes people who may be at risk for using as well as those who are using and have some use-related problems. Thus, a potential benefit of the ASSIST-Lite and the TAPS Tool is that only recent (past 3 month) use garners any score. Notwithstanding its low sensitivity for detecting moderate risk of certain drugs, a score of 1 should prompt providers to conduct further assessment of their patient's use of these substances

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Opioid misuse is a growing problem in the US (Compton et al., ) and elsewhere (Degenhardt et al., ). Patients who misuse prescription opioids may switch to heroin because of its lower price (Mars et al., ). Primary care practices provide a potentially rich venue in which to identify patients misusing opioids. In the present study, 181 (9%) of participants were identified with moderate or higher opioid risk scores on the ASSIST and 39 (2%) had a high-risk opioid score. At a cutpoint of 2 (i.e., identifying participants with high risk opioid use scores), the TAPS Tool had a sensitivity of 0.92, specificity of 0.99, PPV of 0.59, NPV of 1.0, and AUC of 0.95. Although these results should be interpreted with some caution because of the relatively small sample size, it would be prudent to carefully assess patients with a TAPS Tool score of 2 for the need for opioid treatment.

In the present study, the mean time required to complete the TAPS Tool was 4.47 for the computer self-administered version, and 2.39 minutes for the interviewer-administered version. This compares favorably to the length of time required for the interviewer-administered ASSIST, which has been reported to require between 5 and 15 minutes (Ali et al. ). It should be noted that the time required to administer the TAPS Tool via tablet computer in the present study may overestimate the time required in clinical practice, since all participants completed the TAPS-2 regardless of their responses on TAPS-1. In practice, a patient who reported no illicit drug use on the TAPS-1, for example, would not be administered the TAPS-2 items for marijuana, cocaine, or heroin. The time required to complete the self-administered TAPS Tool also compared favorably to the computer self-administered versions of the ASSIST reported in the literature. In the ACASI ASSIST validation study in adult primary care patients, the mean time was 4 minutes, (McNeely et al., ). Another study of a computer self-administered ASSIST with incarcerated men reported that the ACASI ASSIST was completed in 5'10 minutes (Wolff et al., ).

The study has a number of strengths, including a large sample size, a diverse population recruited from multiple primary care settings across several Eastern US states, and comparison to a criterion measure (the ASSIST) that underwent rigorous psychometric testing (Humeniuk et al., ; Newcombe et al., ). However, there are also a number of limitations to be considered, including sampling only from the Eastern US states, and having only an English language version. Hence, findings may not generalize to other parts of the US or to other countries. In addition, data were collected under research conditions, and results were not given to medical providers. The extent to which the instrument would perform equally well when delivered by primary care staff and entered into the patient's medical record is not known. Although research assistants used a systematic strategy for approaching patients in the clinics' waiting rooms to minimize bias in recruitment, we do not know the extent to which study participants were representative of the clinic patient populations.

The TAPS Tool has a number of potential advantages compared to other screeners. In contrast to single item screens, it inquires about specific substances and goes beyond simple endorsement of use by obtaining data on problematic use. It screens for all classes of substances, in contrast to single substance screeners such as the AUDIT for alcohol (Bradley et al., ) or the Fagerstrom for tobacco (Tate & Schmitz, ). It is much briefer and easier to score than the full ASSIST and can lead to actionable results based on the scores, such that individuals who score zero need only receive praise and encouragement and those who score 2 or above need an assessment for treatment. The individuals who score 1 would also benefit from further assessment, and may be appropriate for brief intervention with prevention messaging and follow-up. Because the self-administered tablet computer instrument performed as well as the interviewer-administered instrument, either approach could be used in primary care practices, permitting flexibility and affording the possibility of direct entry into the patient's medical record or self-completion while waiting for the scheduled appointment.

Biofilms and scales that adhere to taps are difficult to clean because they harbor numerous bacteria [ 8 9 ], and some biofilms and scales contain CRE. Methods for cleaning taps effectively and efficiently remain unclear. This study aimed to investigate effective methods for cleaning and disinfecting taps using commonly used detergents and disinfectants by conducting a bacteriological survey for areas around washbasins, including taps.

We conducted an environmental survey of washbasin units, including the taps, in the high-care unit (HCU, 36 beds) of the Advanced Emergency and Critical Care Center of Tokai University Hospital in . We detected the presence of, a carbapenem-resistant Enterobacterales (CRE), in a tap. CRE is highly drug resistant, and CRE infections lead to longer hospital stays and higher medical costs than non-CRE infections [ 5 ]. The treatment and cure of pneumonia as well as bloodstream infections caused by CRE can be difficult owing to the limited availability of effective antibiotics, and the reported mortality is high [ 6 ]. Furthermore, CRE has the propensity to spread via plasmids, thus posing the risk of causing nosocomial outbreaks [ 7 ]. Therefore, the prevention of horizontal transmission of CRE is crucial for infection control.

The areas around washbasins in hospital wards used by staff and patients are contaminated by pathogenic bacteria [ 1 2 ]. An outbreak of drug-resistantoccurred in the intensive care unit of our Advanced Emergency and Critical Care Center of Tokai University Hospital due to a biofilm of drug-resistantwhich adhered to the inside of a washbasin tap and contaminated the water supply pipe for a prolonged period [ 3 ]. Immunosuppressed patients are prone to develop opportunistic infections caused by environmental bacteria [ 4 ]; therefore, it is important to keep washbasins, including taps, clean in hospital wards.

Based on the results of the bacteriological survey, we focused on evaluating different methods for cleaning taps using various cleaning agents, including an environmentally neutral detergent (Mypet, Kao Corporation, Tokyo, Japan), citric acid, baking soda, a cleanser (Kaneyo Soap Co., Ltd., Fukui, Japan), 80% ethanol, 0.1% sodium hypochlorite, and an environmental detergent (Space Shot rust remover/toilet cleaner, Orb Tech Co., Ltd., Tokyo, Japan), hereinafter referred to as Space Shot. Space Shot, a strongly acidic phosphoric acid-based environmental cleaning agent, is composed of phosphoric acid, ethanol, hydrochloric acid, zinc, dye, and water. Space Shot has a pH of approximately 1.6, which is lower than that of citric acid. The cleaning effect was evaluated based mainly on its effect on removing hard scale from taps.

We conducted a bacteriological survey around four washbasins in the HCU shared by patients for brushing their teeth and gargling ( Figure 1 ). Swab samples were collected from drains, sink sides, and taps, including the inside surface of the tap and foam caps, using one sterilised cotton Nissui swab (Nissui Pharmaceutical Co., Ltd., Tokyo, Japan) per environmental surface. After sample collection, the swabs were immediately applied to blood agar, cultured in an incubator at 37 °C for 24 h, and then allowed to stand at room temperature for 24 h. The bacterial count was measured according to a semi-quantitative culture method [ 10 11 ], and the number of bacteria on culture was quantified according to theguidelines as follows: colony growth on less than 1/3 of the medium = 1+; 1/3 to less than 2/3 = 2+; 2/3 or more = 3+; and the entire medium = 4+ [ 12 ]. Bacterial identification and susceptibility testing of the isolates were performed to obtain minimum inhibitory concentration (MIC) values using a microdilution method (CLSI, ) and a DxM Microscan WalkAway (Beckman Coulter Inc., Brea, CA, USA) microorganism identification susceptibility analyser. Genotyping was conducted to identify drug-resistant bacteria, as described previously [ 13 ].

The hard scale on the taps could not be removed by physically scraping it off with a clip or screwdriver nor by soaking tissue paper with a chemical solution, applying it to the scale, and leaving it for over 30 min. Cleaning the taps with an environmentally neutral detergent, citric acid, baking soda, a cleanser, 80% ethanol, or 0.1% sodium hypochlorite also had little impact on the scale on both the inner surface of the tap and the foam cap ( Table 2 ). Application of tissue paper soaked with Space Shot for 30 min resulted in a softening of the hard scale and allowed easy removal of the scale without using physical force. We visually confirmed that the tap was clean ( Figure 3 ), and a bacteriological survey cultured a few bacteria ( Table 3 ). No CRE or other pathogens were detected. Space Shot was the only cleaning agent that was effective in removing hard scale. Despite its strong detergent effect, Space Shot did not result in corrosion or discoloration of the taps.

The taps of the washbasins in hospital rooms were extremely contaminated ( Figure 2 ). In the bacteriological survey of the environment, many bacteria were cultured from washbasin drains. The bacterial count was high on the sides of sinks and taps (including the inside surface of the tap and the outside surface of the foam cup). The following pathogenic bacteria were identified:sp.,sp., coagulase-negative, gram-positive rods,sp., glucose non-fermentative gram-negative bacilli,sp.,sp.,sp.,, alpha-hemolyticsp.,sp.,group, andsp. Bacteria detected on taps included pathogenicand Table 1 ). These were detected in the drain, on the sides of the basin, and on the tap. Theisolate harboredandresistance genes.

4. Discussion

The hard scale adhering to taps consists mainly of alkaline deposits such as calcium carbonate. According to our findings, Space Shot was the only agent tested that could effectively remove hard scale. This is probably because the low pH of this product acts on alkaline deposits.

P. aeruginosa

P. aeruginosa

According to a survey by the Ministry of Land, Infrastructure, Transport and Tourism in Japan, there are only nine countries where tap water is drinkable [ 14 ]. In Japan, tap water is hygienic and is considered potable [ 15 ]. Hospitalised, ambulatory patients wash their hands, brush their teeth, and gargle at the washbasins. Therefore, the detection of even a small number of pathogenic microorganisms in tap water used by patients, such as in high-care units where immunocompromised patients are hospitalised, poses an infection risk. Outbreaks have been reported due to the contamination of tap and drinking water with various microorganisms [ 3 21 ]. Notably, a previous report suggests that more than half of the bacteria detected in tap water showed antimicrobial resistance [ 22 ], as did our findings. Hand and equipment contamination from the taps and surrounding sink surfaces can promote transmission of antimicrobial-resistant pathogenic bacteria, which may result in hospital-associated infections. In a study investigating the genotype ofcontaminating the tap of a surgical intensive care ward, 5 of 17 cases (29%) had the same genotype asdetected in the tap over a 7-month period [ 21 ]. This suggests that the tap serves as an environmental reservoir of pathogenic microorganisms. It is clear that it is important to remove bacteria adhering to taps to prevent infections caused by pathogens in the environment. In this study, we immediately implemented cleaning after CRE was detected in the environmental survey. The Advanced Emergency and Critical Care Center actively conducts bacteriological tests on patients on hospital admission and discharge; however, to date, no CRE has been detected on discharge in patients who used the taps in the centre. CRE may have adhered to taps due to splash-back from the washbasin during hand washing and gargling by patients with CRE colonisation. When drug-resistant bacteria, such as CRE, adhere to a tap, it is possible that patients who use water from the tap contract CRE infection. No pathogenic bacteria, including CRE, were detected in patients who used the washbasins after effective cleaning of the taps, suggesting that effective cleaning can prevent horizontal infection from the environment.

In an outbreak of CRE detected in the water supply of an intensive care unit (ICU), it was reported that even deep cleansing with sodium hypochlorite and pressurised steam decontamination at 170 °C could not remove CRE [ 23 ]. A strength of our study is that we found an effective and efficient cleaning method for removing CRE. Introducing this method may be useful in other medical facilities with CRE in the water supply.

Our study has some limitations. First, the bacterial count values were not determined and a quantitative comparison was not possible. Second, the investigation of various detergents did not include a bacteriological investigation and the cleaning effect was judged only with the naked eye. Third, we did not determine the optimal interval at which Space Shot should be used for disinfection. Further research is required to address these questions.

To maintain hygiene, sinks should be cleaned daily, and taps should be cleaned regularly. The appropriate interval for cleaning taps is currently unclear. At our facility, due to human resource and cost issues, taps are cleaned once every 6 months using Space Shot. During the past 4 years since the implementation of this cleaning method, we have not detected new hard scale build-up or associated pathogenic bacteria on taps and have not detected any hospital-associated infections attributable to tap water contamination. Establishing an effective method of cleaning taps as part of hygiene management is important for hospital infection control.

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