Network Water Quality at a Hospital Center in Morocco: Bacteriological Survey and Relationship with Human Health

Water is mandatory for the functioning of hospitals. Its consumption varies from one service to another, and its use can reduce the service quality on one hand and presents a major risk of nosocomial infection on the other hand. The health risks related to the use of water in hospitals are mostly microbiological, but sometimes they can be chemical. For this reason, the conducted work aimed to evaluate, for the first time, the quality and bacteriological efficiency of the network water of the provincial hospital center IBN BAJA in Taza, Northeast Morocco. During one year, 72 samples were analyzed in six surgery departments, one sample per month for each ward at a rate of six samples per month and per department. The results obtained showed that the water quality of the hospital network was in conformity with the requirements of the Moroccan standards. Nonetheless, some bacterial strains such as Aeromonas salmonicida spp salmonicida, Enterococcus spp., Pseudomonas luteola, Sphingomonas paucimobilis, Pseudomonas stutzeri, Stenotrophonomas maltophilia, Burkholderia cepacia and Micrococcus luteus, which constitute a major risk to human health, were found. Moreover, after sensitivity evaluation to the twenty-seven antibiotics, some strains have been shown to be multi-resistant, which can present a major risk of nosocomial infections in the studied hospital for human beings.


INTRODUCTION
Water plays a very important role in the functioning of health care institutions; its consumption varies between 200 to 1 200 liters per day and per bed, depending on the hospital activity [D'Alessandro et al., 2016]. The water use varies depending on different utilizations, and according to the health care units for which it is intended. The health risk of water, at the hospital level, is essentially linked to the microbiological risk due to multi-resistant bacteria; hence, hospital water must meet very precise bacteriological standards [Barbut et al., 2006].
Contaminated water leads to the transmission of waterborne diseases and hospital infections by waterborne microorganisms such as mycobacteria, Legionella, Pseudomonas..., etc causing mortality and morbidity, especially in the immuno-compromised hospitalized patients [Decker et al., 2014]. The exposure of patients to waterborne microorganisms in hospital occurs during showering, preoperative showering, skin cleansing, and water drinking. It can also occur through the contact with contaminated medical equipment such as feeding bags, medical surgical instruments, and health care equipment that have been rinsed with tap water, or by contaminated hands of health care workers, washed with tap water, which can lead to the patient exposure to pathogens [Bhattacharjee, 2015]. The presence of microorganisms isolated from different hospital water sources indicates a potential risk to human health, especially for the immunocompromised patients suffering from serious diseases [Arroyo et al., 2020].
To this end, the Center for Disease Control and Prevention (CDCP) guidelines have highlighted the practices for the control of hospital waterborne infections [Chinn et al., 2003]. Hence, hospital water microbiological monitoring and surveillance is mandatory, since it ensures its good quality and compliance with standards.
For this purpose, this study aimed to monitor and analyze the microbiological quality in the different surgical departments of the provincial hospital IBN BAJA of Taza in Morocco during one year. To the best of the authors' knowledge, no previous investigation has been conducted in the same context, in this hospital center.

MATERIALS AND METHODS
A prospective study was carried out over a period of 12 months, from October 2018 to September 2019, in a provincial hospital: Ibn Baja in Taza (Northeast Morocco) which has a capacity of 317 beds. The samples were taken from six hospital departments specialized in surgery: male surgery, women surgery, central operating room, sterilization, gynecology, and child surgery. The sampling frequency adopted during the study period (October 2018-September 2019) was one sample per month for each ward.
Sampling was carried out aseptically under hygienic conditions; hence, the water samples were collected in sterile coded 500-ml vials containing sodium thiosulfate pentahydrate (0.1 %), to allow neutralization of at least 2 mg/l and up to 5 mg/l of free chlorine, depending on the neutralization dynamics [NM ISO 19458, 2009].
The bacteriological analysis and interpretation of the sampled water was carried out in the public health laboratory at the delegation of Health Ministry of Taza Table 1. Moreover, among the exclusion criteria of this study, the toxic risk is underlined. It is certain that the water used in a health care institution is contaminated. The risks for the exposed population are of two types: the infection risk, which is the subject of this study, and the toxic risk, which is excluded from the study; because the presence of toxic substances appears more rarely in the case of dissolution of the pipe materials.
The reading and interpretation of the results were carried out following incubation. After carrying out the enumeration, the aspect and the size of the colonies found were determined; then, their purification was carried out on nutritive agar medium. The identification of the isolated germs was carried out by biochemical tests and their confirmation was performed by the API gallery. For the evaluation of the isolated germs resistance to antibiotics, these germs were tested on 27 antibi-

RESULTS AND DISCUSSION
Water can carry many germs, sometimes causing serious infections in patients and health professionals, and drinking water should normally be free of bacteria. Therefore, it is essential to be familiar with the internal distribution of water within the institution in order to limit the risk of water-related infections.

Distribution and enumeration of germs isolated from network water according to the Moroccan standards
In the conducted study, the 72 water samples analyzed were of good bacteriological quality. The results obtained in Table 2 showed the absence of Pseudomonas aeruginosa, spores of sulfitoreducing anaerobic microorganisms, Escherichia coli, and coliforms in all the water points of the studied services on one hand. On the other hand, intestinal enterococci were observed in the woman's surgery service and absent in the other services. Likewise, microorganisms revivable at 37 °C were present in the sterilization service water point and absent in the other services. Moreover, the presence of microorganisms revivable at 22 °C   The frequency of isolated bacterial strains varies from one health care unit to another (Table 3), due to the presence of biofilms and the adaptation of the strains to various conditions. In order to better understand the risk of these strains on humans, a bibliographical research was carried out on the different germs isolated.
Aeromonas salmonicida spp salmonicida, is a species of Gram-negative bacteria of the Aeromonadaceae family, which have the capacity to Pseudomonas luteola is a Gram-negative bacterium of the genus Pseudomonas, which has been implicated in a variety of life-threatening infections such as: endocarditis, peritonitis, meningitis, septicaemia and cerebral abscess [Gaschet et al., 2009]. Similarly, Pseudomonas stutzeri is a Gram-negative bacterium of the Pseudomomas genus, which is also mobile. This bacterium, ubiquitous in the environment, is involved in human diseases; hence, the patients infected with Pseudomonas stutzeri usually present predisposing risk factors such as immune-suppression or recent surgery [Halabi et al., 2019].
In addition, Sphingomonas paucimobilis, of the family Sphingomonadaceae, is a strict aerobic Gram-negative bacterium, not very mobile with a single polar flagellum and causes bacteraemia was noticed. Even though these values remain well below the limits of acceptability, except for intestinal enterococci which were slightly higher than the norms in the women surgery service (1UFC/100ml), this means that 98% of the water points analyzed remain within the acceptability standards according to the Moroccan Standard

Distribution of germs isolated from mains water
Concerning the biochemical identification of microorganisms isolated in the studied water points, the presence of Aeromonas salmonicida spp salmonicida, Enterococcus spp, Pseudomonas luteola, Sphingomonas paucimobilis, Pseudomonas stutzeri, and Pseudomonas luteus and Stenotrophonomas maltophilia, and Burkholdria cepacia was highlighted. Some of these bacteria are also found and isolated from the hospital environment that could be the source of serious hospital-acquired infections [Lalami et al., 2016]. and septicaemia; therefore it is responsible for nosocomial pneumonia with potential mortality [Tai Ml and al., 2014]. Stenotrophomonas maltophilia is a species of aerobic Gram-negative bacteria, belonging to the Stenotrophomonas genus, which can cause a broad spectrum of potentially fatal infections and which is found in the environment as a commensal and in hospital settings as an opportunistic pathogen in immuno-compromised patients or a true pathogen in immune-competent patients. It is consistently implicated in bacteraemia skin infections, endocarditis, acute respiratory tract infection and meningitides [Adegoke, 2017].
In turn, Burkholderia cepacia, which belongs to Gram-negative bacteria, are important opportunistic pathogens that can cause variable lung infections in the patients with cystic fibrosis, resulting in asymptomatic carriage, chronic infection or 'cepacia syndrome', which is characterized by a rapid decline in lung function that may include invasive disease [Mahenthiralingam et al., 2005], Finally, Micrococcus luteus is a Gram-positive bacterium, of the family Micrococcaceae, which is an opportunistic pathogen for nosocomial infections in immunocompromised patients [Lee et al. 2020]. This species can occur in a wide variety of infections in any area of the human body, such as bacteraemia, endocarditis, ventriculitis, peritonitis, pneumonia, endophthalmos, keratolysis and septic arthritis [Han et al., 2016].

CONCLUSIONS
This study aimed to determine the water bacteriological quality from the network of the provincial hospital of Ibn Bajja Taza (Morocco) in various surgery departments. For this purpose, 72 samples were taken according to the Moroccan standards NM 3.07.001. The samples showed compliance with regard to enterococci, intestinal coliforms, and revivable germs in addition to the absence of Escherichia coli and Pseudomonas aeruginosa. Therefore, the results of the bacteriological analysis show that this hospital's network waters are of good quality according to Moroccan standards NM 3.07.001 and those of the WHO. However, the identification of isolated germs and the evaluation of their sensitivity to antibiotics revealed that they present a major risk for hospitalized patients and healthcare professionals, given their multi-resistance to several antibiotics on the one hand, and clinically dangerous effects for humans on the other hand. Identification of the isolated germs revealed the presence of bacteria of environmental and human origins, such as Aeromonas salmonicida spp. salmonicida, Enterococcus spp., Pseudomonas luteola, Sphingomonas paucimobilis, Pseudomonas stutzeri, Pseudomonas luteus, Stenotrophonomas maltophilia, and Burkholdria cepacia, according to the different studied departments.
Therefore, it is necessary to establish a regular supervision system to control the critical water points, then to carry out periodic microbiological analyses for the identification and isolation of opportunistic bacterial strains in order to avoid exceeding an alert threshold by implementing the actions to eliminate and reduce the severity of water contamination. This will allow total or partial control of the contamination risks and dangers.