guidelines for environmental infection control in health-care facilities.doc

8/14/2019 Guidelines for Environmental Infection Control in Health-Care Facilities.doc

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Guidelines for Environmental Infection

Control in Health-Care Facilities

Recommendations of CDC and the Healthcare Infection Control

Practices Advisory Committee (HICPAC)

Prepared by

Lynne Sehulster, Ph.D.1

Raymond Y.W. Chinn, M.D.2

1Division of Healthcare Quality Promotion

National Center for Infectious Diseases2HICPAC member

Sharp Memorial Hospital

San Dieo! California

The material in this report oriinated in the !ational Center "or #n"e$tious Diseases, %ames M. &uhes,

M.D., Dire$tor' and the Di(ision o" &ealth$are )uality Promotion, Ste(en L. Solomon, M.D., *$tin

Dire$tor.

Summary

"he health#care facility environment is rarely implicate$ in $isease transmission!

e%cept amon patients &ho are immunocompromise$' Nonetheless! ina$vertent

e%posures to environmental pathoens (e''! *sperillusspp' an$ Leionellaspp') or

airborne pathoens (e''! My$oba$terium tuber$ulosisan$ varicella#*oster virus) can

result in a$verse patient outcomes an$ cause illness amon health#care &or+ers'

,nvironmental infection#control strateies an$ enineerin controls can effectively

prevent these infections' "he inci$ence of health#care##associate$ infections an$

pseu$o#outbrea+s can be minimi*e$ by 1) appropriate use of cleaners an$

$isinfectants- 2) appropriate maintenance of me$ical e.uipment (e''! automate$

en$oscope reprocessors or hy$rotherapy e.uipment)- /) a$herence to &ater#.uality

stan$ar$s for hemo$ialysis! an$ to ventilation stan$ar$s for speciali*e$ careenvironments (e''! airborne infection isolation rooms! protective environments! or

operatin rooms)- an$ 0) prompt manaement of &ater intrusion into the facility'

outine environmental samplin is not usually a$vise$! e%cept for &ater .uality

$eterminations in hemo$ialysis settins an$ other situations &here samplin is

$irecte$ by epi$emioloic principles! an$ results can be applie$ $irectly to infection#

control $ecisions'

"his report revie&s previous ui$elines an$ strateies for preventin environment#

associate$ infections in health#care facilities an$ offers recommen$ations' "hese

inclu$e 1) evi$ence#base$ recommen$ations supporte$ by stu$ies- 2) re.uirements of


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fe$eral aencies (e''! oo$ an$ Dru A$ministration! 3'S' ,nvironmental Protection

Aency! 3'S' Department of 4abor! 5ccupational Safety an$ Health A$ministration!

an$ 3'S' Department of 6ustice)- /) ui$elines an$ stan$ar$s from buil$in an$

e.uipment professional orani*ations (e''! American Institute of Architects!

Association for the A$vancement of Me$ical Instrumentation! an$ American Societyof Heatin! efrieration! an$ Air#Con$itionin ,nineers)- 0) recommen$ations

$erive$ from scientific theory or rationale- an$ 7) e%perience$ opinions base$ upon

infection#control an$ enineerin practices' "he report also suests a series of

performance measurements as a means to evaluate infection#control efforts'

Introduction

Parameters of the Reort

This report, +hi$h $ontains the $omplete list o" re$ommendations +ith pertinentre"eren$es, is Part ## o" 8ui$elines for ,nvironmental Infection Control in Health#

Care acilities' The "ull "ourpart uidelines +ill be a(ailable on CDC-s Di(ision o"

&ealth$are )uality Promotion D&)P/ +ebsite. Relati(e to pre(ious CDC uidelines,

this report

re(ises multiple se$tions e.., $leanin and disin"e$tion o" en(ironmental

sur"a$es, en(ironmental samplin, laundry and beddin, and reulated medi$al

+aste/ "rom pre(ious editions o" CDC-s 8ui$eline for Han$&ashin an$

Hospital ,nvironmental Control'

in$orporates dis$ussions o" air and +ater en(ironmental $on$erns "rom CDC-s

8ui$eline for Prevention of Nosocomial Pneumonia'

$onsolidates rele(ant en(ironmental in"e$tion$ontrol measures "rom other

CDC uidelines' and

in$ludes t+o topi$s not addressed in pre(ious CDC uidelines in"e$tion

$ontrol $on$erns related to animals in health$are "a$ilities and +ater 0uality

in hemodialysis settins.

#n the "ull uidelines, Part #, a$round #n"ormation3 4n(ironmental #n"e$tion

Control in &ealthCare 5a$ilities, pro(ides a $omprehensi(e re(ie+ o" the rele(ants$ienti"i$ literature. *ttention is i(en to enineerin and in"e$tion$ontrol $on$erns

durin $onstru$tion, demolition, reno(ation, and repair o" health$are "a$ilities. 6se o"

an in"e$tion$ontrol ris assessment is stronly supported be"ore the start o" these or

any other a$ti(ities e7pe$ted to enerate dust or +ater aerosols. *lso re(ie+ed in Part

# are in"e$tion$ontrol measures used to re$o(er "rom $atastrophi$ e(ents e..,

"loodin, se+ae spills, loss o" ele$tri$ity and (entilation, or disruption o" +ater

supply/ and the limited e""e$ts o" en(ironmental sur"a$es, laundry, plants, animals,

medi$al +astes, $loth "urnishins, and $arpetin on disease transmission in health

$are "a$ilities. Part ### and Part #8 o" the "ull uidelines pro(ide re"eren$es "or the

$omplete uideline/ and appendi$es, respe$ti(ely.


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Part ## this report/ $ontains re$ommendations "or en(ironmental in"e$tion $ontrol in

health$are "a$ilities, des$ribin $ontrol measures "or pre(entin in"e$tions asso$iated

+ith air, +ater, or other elements o" the en(ironment. These re$ommendations

represent the (ie+s o" di""erent di(isions +ithin CDC-s !ational Center "or #n"e$tious

Diseases and the &ealth$are #n"e$tion Control Pra$ti$es *d(isory CommitteeCP*C/, a 12member roup that ad(ises CDC on $on$erns related to the

sur(eillan$e, pre(ention, and $ontrol o" health$areasso$iated in"e$tions, primarily

in 6.S. health$are "a$ilities. #n 1999, CP*C-s in"e$tion$ontrol "o$us +as

e7panded "rom a$ute$are hospitals to all (enues +here health $are is pro(ided e..,

outpatient suri$al $enters, urent $are $enters, $lini$s, outpatient dialysis $enters,

physi$ians- o""i$es, and silled nursin "a$ilities/. The topi$s addressed in this report

are appli$able to the ma:ority o" health$are "a$ilities in the 6nited States. This report

is intended "or use primarily by in"e$tion$ontrol pra$titioners, epidemioloists,

employee health and sa"ety personnel, enineers, "a$ility manaers, in"ormation

systems pro"essionals, administrators, en(ironmental ser(i$e pro"essionals, and

ar$hite$ts. ;ey re$ommendations in$lude

in"e$tion$ontrol impa$t o" (entilation system and +ater system per"orman$e'

establishment o" a multidis$iplinary team to $ondu$t in"e$tion$ontrol ris

assessment'

use o" dust$ontrol pro$edures and barriers durin $onstru$tion, repair,

reno(ation, or demolition'

en(ironmental in"e$tion$ontrol measures "or spe$ial areas +ith patients at

hih ris' use o" airborneparti$le samplin to monitor the e""e$ti(eness o" air "iltration

and dust$ontrol measures'

pro$edures to pre(ent airborne $ontamination in operatin rooms +hen

in"e$tious tuber$ulosis T/ patients re0uire surery'

uidan$e reardin appropriate indi$ations "or routine $ulturin o" +ater as

part o" a $omprehensi(e $ontrol proram "or leionellae'

uidan$e "or re$o(erin "rom +atersystem disruptions, +ater leas, and

natural disasters e.., "loodin/'

in"e$tion$ontrol $on$epts "or e0uipment usin +ater "rom main lines e..,

+ater systems "or hemodialysis, i$e ma$hines, hydrotherapy e0uipment, dental

unit +ater lines, and automated endos$ope repro$essors/'

en(ironmental sur"a$e $leanin and disin"e$tion strateies +ith respe$t to

antibioti$resistant mi$rooranisms'

in"e$tion$ontrol pro$edures "or health$are laundry'

use o" animals in health $are "or a$ti(ities and therapy'

manain the presen$e o" ser(i$e animals in health$are "a$ilities'

in"e$tion$ontrol strateies "or +hen animals re$ei(e treatment in human

health$are "a$ilities' and

a $all to reinstate the pra$ti$e o" ina$ti(atin ampli"ied $ultures and sto$s o"mi$rooranisms onsite durin medi$al +aste treatment.


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Topi$s outside the s$ope o" this report in$lude 1/ nonin"e$tious ad(erse e(ents e..,

si$ buildin syndrome/, 2/ en(ironmental $on$erns in the home, / health$areasso$iated "oodborne illness.

Where(er possible, the re$ommendations in this report are based on data "rom +elldesined s$ienti"i$ studies. &o+e(er, $ertain o" these studies +ere $ondu$ted by usin

narro+ly de"ined patient populations or spe$i"i$ health$are settins e.., hospitals

(ersus lonterm $are "a$ilities/, main enerali?ation o" "indins potentially

problemati$. Constru$tion standards "or hospitals or other health$are "a$ilities may

not apply to residential home$are units. Similarly, in"e$tion$ontrol measures

indi$ated "or immunosuppressed patient $are are usually not ne$essary in those

"a$ilities +here su$h patients are not present.

@ther re$ommendations +ere deri(ed "rom no+lede ained durin in"e$tious

disease in(estiations in health$are "a$ilities, +here su$$ess"ul termination o" the

outbrea +as o"ten the result o" multiple inter(entions, the ma:ority o" +hi$h $annot

be independently and riorously e(aluated. This is espe$ially true "or $onstru$tion

situations in(ol(in air or +ater.

@ther re$ommendations +ere deri(ed "rom empiri$ enineerin $on$epts and may

re"le$t industry standards rather than e(iden$ebased $on$lusions. Where

re$ommendations re"er to uidan$e "rom the *meri$an #nstitute o" *r$hite$ts *#*/,

the statements re"le$t standards intended "or ne+ $onstru$tion or reno(ation. 47istin

stru$tures and enineered systems are e7pe$ted to be in $ontinued $omplian$e +iththose standards in e""e$t at the time o" $onstru$tion or reno(ation.

*lso, in the absen$e o" s$ienti"i$ $on"irmation, $ertain in"e$tion$ontrol

re$ommendations that $annot be riorously e(aluated are based on stron theoreti$

rationale and suesti(e e(iden$e. 5inally, $ertain re$ommendations are deri(ed "rom

e7istin "ederal reulations.

Performance !easurements

#n"e$tions $aused by the mi$rooranisms des$ribed in this uideline are rare e(ents,and the e""e$t o" these re$ommendations on in"e$tion rates in a "a$ility may not be

readily measurable. There"ore, the "ollo+in steps to measure per"orman$e are

suested to e(aluate these re$ommendations3

1. Do$ument +hether in"e$tion$ontrol personnel are a$ti(ely in(ol(ed in all

phases o" a health$are "a$ility-s demolition, $onstru$tion, and reno(ation.

*$ti(ities should in$lude per"ormin a ris assessment o" the ne$essary types

o" $onstru$tion barriers, and daily monitorin and do$umentin o" the

presen$e o" neati(e air"lo+ +ithin the $onstru$tion ?one or reno(ation area.


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2. Monitor and do$ument daily the neati(e air"lo+ in *## rooms and positi(e

air"lo+ in P4 rooms, espe$ially +hen patients are in these rooms.

3>A2A. 6pdates and e7pands en(ironmental

in"e$tion$ontrol in"ormation "or asperillosis and Leionnaires disease' online

(ersion in$orporates *ppendi$es , C, and D addressin en(ironmental $ontrol and

dete$tion o" Leionella spp.

CDC. Buidelines "or pre(entin the transmission o" mycobacterium tuberculosis in

health$are "a$ilities. MMWR 199='=


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Barner %S, &ospital #n"e$tion Control Pra$ti$es *d(isory Committee. Buideline "or

isolation pre$autions in hospitals. #n"e$t Control &osp 4pidemiol 199'1A3>


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Immunocomromised atients are those patients +hose immune me$hanisms are

de"i$ient be$ause o" immunoloi$ disorders e.., human immunode"i$ien$y (irus

J in"e$tion or $onenital immune de"i$ien$y syndrome/, $hroni$ diseases e..,

diabetes, $an$er, emphysema, or $ardia$ "ailure/, or immunosuppressi(e therapy e..,

radiation, $ytoto7i$ $hemotherapy, antire:e$tion medi$ation, or steroids/.#mmuno$ompromised patients +ho are identi"ied as hihris patients ha(e the

reatest ris o" in"e$tion $aused by airborne or +aterborne mi$rooranisms. Patients

in this subset in$lude persons +ho are se(erely neutropeni$ "or proloned periods o"

time i.e., an absolute neutrophil $ount J*!C o" G>EE $ellsFmL/, alloenei$ &SCT

patients, and those +ho ha(e re$ei(ed the most intensi(e $hemotherapy e..,

$hildhood a$ute myeloenous leuemia patients/.

A%%reviations

**M# *sso$iation "or the *d(an$ement o" Medi$al #nstrumentation

*C& air $hanes per hour

*4R automated endos$ope repro$essor

*&% authority ha(in :urisdi$tion

*#* *meri$an #nstitute o" *r$hite$ts

*## airborne in"e$tion isolation

*!S# *meri$an !ational Standards #nstitute

*S&R*4 *meri$an So$iety o" &eatin, Re"rieration, and *irConditionin

4nineers

ML iosa"ety in Mi$robioloi$al and iomedi$al Laboratories CDCF!ational

#nstitutes o" &ealth/

C5R Code o" 5ederal Reulations

C%D Creut?"eldt%aob disease

CPL $omplian$e do$ument @S&*/

D5* dire$t "luores$en$e assay

D&&S 6.S. Department o" &ealth and &uman Ser(i$es

D@T 6.S. Department o" Transportation


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4C en(ironment o" $are

4P* 6. S. 4n(ironmental Prote$tion *en$y

5D* 6.S. 5ood and Dru *dministration

&8 hepatitis (irus

&4P* hih e""i$ien$y parti$ulate air

human immunode"i$ien$y (irus

&SCT hematopoieti$ stem $ell transplant

&8*C heatin, (entilation, air $onditionin

#CR* in"e$tion$ontrol ris assessment

%C*&@ %oint Commission on *$$reditation o" &ealth$are @rani?ations

!a@& sodium hydro7ide

!TM nontuber$ulous my$oba$teria

@S&* @$$upational Sa"ety and &ealth *dministration

P4 prote$ti(e en(ironment

PP4 personal prote$ti(e e0uipment

T tuber$ulosis

6SC 6nited States Code

6SD* 6.S. Department o" *ri$ulture

68 ultra(iolet

68B# ultra(iolet ermi$idal irradiation

8&5 (iral hemorrhai$ "e(er

8R4 (an$omy$inresistant,nterococcus

8RS* (an$omy$inresistant Staphylococcus aureus


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8K8 (ari$ella ?oster (irus

Recommendations for Environmental Infection Control in Health-Care

Facilities

Rationale for Recommendations

*s in pre(ious CDC uidelines, ea$h re$ommendation is $ateori?ed on the basis o"

e7istin s$ienti"i$ data, theoreti$ rationale, appli$ability, and possible e$onomi$ e""e$t.

The re$ommendations are e(iden$ebased +here(er possible. &o+e(er, $ertain

re$ommendations are deri(ed "rom empiri$ in"e$tion$ontrol or enineerin

prin$iples, theoreti$ rationale, or "rom e7perien$e ained "rom e(ents that $annot be

readily studied e.., "loods/.

The CP*C system "or $ateori?in re$ommendations has been modi"ied to in$ludea $ateory "or enineerin standards and a$tions re0uired by state or "ederal

reulations. Buidelines and standards published by the *#*, *meri$an So$iety o"

&eatin, Re"rieration, and *irConditionin 4nineers *S&R*4/, and the

*sso$iation "or the *d(an$ement o" Medi$al #nstrumentation **M#/ "orm the basis

o" $ertain re$ommendations. These standards re"le$t a $onsensus o" e7pert opinions

and e7tensi(e $onsultation +ith aen$ies o" the 6.S. Department o" &ealth and

&uman Ser(i$es. Complian$e +ith these standards is usually (oluntary. &o+e(er,

state and "ederal o(ernments o"ten adopt these standards as reulations. 5or

e7ample, the standards "rom *#* reardin $onstru$tion and desin o" ne+ or

reno(ated health$are "a$ilities, ha(e been adopted by re"eren$e by I=E states. Certain

re$ommendations ha(e t+o $ateory ratins e.., Cateories #* and #C or Cateories

# and #C/, indi$atin the re$ommendation is e(iden$ebased as +ell as a standard or

reulation.

Ratin& Cate&ories

Re$ommendations are rated a$$ordin to the "ollo+in $ateories3

Cate&ory IA' Stronly re$ommended "or implementation and stronly supported by+elldesined e7perimental, $lini$al, or epidemioloi$ studies.

Cate&ory I' Stronly re$ommended "or implementation and supported by $ertain

e7perimental, $lini$al, or epidemioloi$ studies and a stron theoreti$ rationale.

Cate&ory IC' Re0uired by state or "ederal reulation, or representin an established

asso$iation standard. !ote3 *bbre(iations "or o(ernin aen$ies and reulatory

$itations are listed +here appropriate. Re$ommendations "rom reulations adopted at

state le(els are also noted. Re$ommendations "rom *#* uidelines $ite the appropriate

se$tions o" the standards./


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Cate&ory II' Suested "or implementation and supported by suesti(e $lini$al or

epidemioloi$ studies, or a theoreti$ rationale.

"nresolved issue'!o re$ommendation is o""ered. !o $onsensus or insu""i$ient

e(iden$e e7ists reardin e""i$a$y.

Recommendations --- Air

I' Air-Handlin& ystems in Health-Care Facilities

*. 6se *#* uidelines as minimum standards +here state or lo$al reulations are

not in pla$e "or desin and $onstru$tion o" (entilation systems in ne+ or

reno(ated health$are "a$ilities. 4nsure that e7istin stru$tures $ontinue to

meet the spe$i"i$ations in e""e$t at the time o" $onstru$tion 1/. Cateory #C

*#*3 1.1.*, >.=/. Monitor (entilation systems in a$$ordan$e +ith enineers- and manu"a$turers-

re$ommendations to ensure pre(enti(e enineerin, optimal per"orman$e "or

remo(al o" parti$ulates, and elimination o" e7$ess moisture 1##9/. Cateory

#, #C *#*3 A.2, A.

di""erentials, and "iltration e""i$ien$ies by usin "a$ilityspe$i"i$ data as part o"

the multidis$iplinary ris

assessment. Tae into a$$ount the ae and reliability o" the system.

b. Do$ument these parameters, espe$ially the pressure di""erentials.


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Cateory ##

>. 4nsure that air intaes and e7haust outlets are lo$ated properly in

$onstru$tion o" ne+ "a$ilities and reno(ation o" e7istin "a$ilities 1!2


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=. 4nsure that "reshair re0uirements "or the area are met //!/7/. Cateory ##

D. 5ollo+ appropriate pro$edures "or use o" areas +ith throuhthe+all

(entilation units 1/. Cateory #C *#*3 .enineerin $ontrol, install "i7tures 1/ on the +all near the $eilin or

suspended "rom the $eilin as an upper air unit' 2/ in the airreturn du$t o" an

*## area' or .1, >.2' %C*&@3

4C 1.=/

%. Do not shut do+n &8*C systems in patient$are areas e7ept "or maintenan$e,

repair, testin o" emeren$y ba$up $apa$ity, or ne+ $onstru$tion 1!0:/.

Cateory #, #C *#*3 >.1, >.2., C/

1. Coordinate &8*C system maintenan$e +ith in"e$tion$ontrol sta"" and

relo$ate immuno$ompromised patients i" ne$essary 1/. Cateory #C *#*3>.1, >.2/
http://www.cdc.gov/mmwr/preview/mmwrhtml/00035909.htmhttp://www.cdc.gov/mmwr/preview/mmwrhtml/00035909.htmhttp://www.cdc.gov/mmwr/preview/mmwrhtml/00020788.htmhttp://www.cdc.gov/mmwr/preview/mmwrhtml/00035909.htmhttp://www.cdc.gov/mmwr/preview/mmwrhtml/00035909.htmhttp://www.cdc.gov/mmwr/preview/mmwrhtml/00035909.htmhttp://www.cdc.gov/mmwr/preview/mmwrhtml/00020788.htmhttp://www.cdc.gov/mmwr/preview/mmwrhtml/00035909.htm


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2. Pro(ide ba$up emeren$y po+er and airhandlin and pressuri?ation

systems to maintain "iltration, $onstant *C&, and pressure di""erentials in P4

rooms, *## rooms, operatin

rooms, and other $riti$al$are areas 1!/.2/

. *llo+ su""i$ient time "or *C& to $lean the air on$e the system is

operational Table 1/ 1!///. Cateory #C *#*3 >.1, >.2/

;. &8*C systems ser(in o""i$es and administrati(e areas may be shut do+n "or

enery $onser(ation purposes, but the shutdo+n must not alter or ad(ersely

a""e$t pressure di""erentials maintained in laboratories or $riti$al$are areas

+ith spe$i"i$ (entilation re0uirements i.e., P4 rooms, *## rooms, operatin

rooms/. Cateory ##

L. Whene(er possible, a(oid ina$ti(atin or shuttin do+n the entire &8*C

system, espe$ially in a$ute$are "a$ilities. Cateory ##

M. Whene(er "easible, desin and install "i7ed ba$up (entilation systems "or

ne+ or reno(ated $onstru$tion o" P4 rooms, *## rooms, operatin rooms, and

other $riti$al$are areas identi"ied by #CR* 1/. Cateory #C *#*3 1.>.*1/

II' Construction* Renovation* Remediation* Reair* and Demolition

*. 4stablish a multidis$iplinary team that in$ludes in"e$tion$ontrol sta"" to

$oordinate demolition, $onstru$tion, and reno(ation pro:e$ts and $onsider

proa$ti(e pre(enti(e measures at the in$eption' produ$e and maintain

summary statements o" the team-s a$ti(ities 1!;!11##1:!/9!09##71/. Cateory

#, #C *#*3 >.1/

. 4du$ate both the $onstru$tion team and health$are sta"" in

immuno$ompromised patient$are areas reardin the airborne in"e$tion riss

asso$iated +ith $onstru$tion pro:e$ts, dispersal o" "unal spores durin su$h

a$ti(ities, and methods to $ontrol the dissemination o" "unal spores 11##

1:!2


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1. 6sin a$ti(e sur(eillan$e, monitor "or airborne in"e$tions in

immuno$ompromised patients 2

$ultures as "easible 11!1/##

1:!2.1/

a. Determine i" immuno$ompromised patients may be at ris "or e7posure to

"unal spores "rom dust enerated durin the pro:e$t 1/##1:!09!71/.

b. De(elop a $ontinen$y plan to pre(ent su$h e7posures 1/##1:!09!71/.

2. #mplement in"e$tion$ontrol measures "or e7ternal demolition and

$onstru$tion a$ti(ities 11!1/##1:!7=!:1!:2/. Cateory #

a. Determine i" the "a$ility $an operate temporarily on re$ir$ulated air' i"

"easible, seal o"" ad:a$ent air intaes.

b. #" this is not possible or pra$ti$al, $he$ the lo+e""i$ien$y rouhin/

"ilter bans "re0uently and repla$e as needed to a(oid buildup o" parti$ulates.

$. Seal +indo+s and redu$e +here(er possible other sour$es o" outside air

intrusion e.., open doors in stair+ells and $orridors/, espe$ially in P4 areas.


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$. #mplement dust$ontrol measures on sur"a$es and di(ert pedestrian tra""i$

a+ay "rom +or ?ones 1!09!0;!:0/.

d. Relo$ate patients +hose rooms are ad:a$ent to +or ?ones, dependin on

their immune status, the s$ope o" the pro:e$t, the potential "or eneration o"

dust or +ater aerosols, andthe methods used to $ontrol these aerosols 1!:0!:7/.

>. Per"orm those enineerin and +orsite related in"e$tion$ontrol measures

as needed "or internal $onstru$tion, repairs, and reno(ations

1!09!0;!71!:0!::/. Cateory #, #C *#*3

>.1, >.2/

a. 4nsure proper operation o" the airhandlin system in the a""e$ted area

a"ter ere$tion o" barriers and be"ore the room or area is set to neati(e pressure

/;!0

#

b. Create and maintain neati(e air pressure in +or ?ones ad:a$ent to

patient$are areas and ensure that re0uired enineerin $ontrols are maintained

1!09!0;!71!:0!::/.

$. Monitor neati(e air"lo+ inside riid barriers 1!:


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remo(e dust' and either pass air throuh an industrialrade, portable &4P*

"ilter $apable o" "iltration rates o"

#1:!09##7=/.

. 5lush the +ater system to $lear sediment "rom pipes to minimi?e

+aterborne mi$rooranism proli"eration 1!://.

l. Restore appropriate *C&, humidity, and pressure di""erential' $lean or

repla$e air "ilters' dispose o" spent "ilters /!0!29!0


17/50

1. Colle$t en(ironmental samples "rom potential sour$es o" airborne "unal

spores, pre"erably by usin a hih(olume air sampler rather than settle plates

2!0!11!1/##

1:!2. #" possible, per"orm mole$ular subtypin o"Asperillusspp. isolated "rom

patients and the en(ironment to $ompare their strain identities ;=##;0/.

Cateory ##

;. #" airsupply systems to hihris areas e.., P4 rooms/ are not optimal, use

portable, industrialrade &4P* "ilters on a temporary basis until rooms +ith

optimal airhandlin systems be$ome a(ailable 1!1/##1:!2


18/50

doors, and intae and e7haust ports' 2/ maintainin $eilins that are smooth

and "ree o" "issures, open :oints,

and $re(i$es'


19/50

*. #n$orporate $ertain spe$i"i$ations into the plannin and $onstru$tion or

reno(ation o" *## units 1!/0!1==!1=1!1=0/ 5iure Pa JE.E1 in$h +ater aue/

in relation to the air pressure in the $orridor' monitor air pressure periodi$ally,pre"erably daily, +ith

audible manometers or smoe tubes at the door "or e7istin *## rooms/, or

+ith a permanently installed (isual monitorin me$hanism. Do$ument the

results o" monitorin

1!1==!1=1/. Cateory #C *#*3 A.2.CA, Table A.2/

2. 4nsure that rooms are +ellsealed by properly $onstru$tin +indo+s, doors,

and airintae and e7haust ports' +hen monitorin indi$ates air leaae, lo$ate

the lea and mae

ne$essary repairs 1!;;!1==/. Cateory #, #C *#*3 A.2.C


20/50

+ith an anteroom, to redu$e the ris o" o$$upational e7posure to aerosoli?ed

in"e$tious material in blood, (omitus, li0uid stool, and respiratory se$retions

present in lare amounts

durin the end stae o" a patient-s illness 1=9##11=/. Cateory ##

a. #" an anteroom is not a(ailable, use portable, industrialrade &4P*

"ilters in the patient-s room to pro(ide additional *C& e0ui(alents "or

remo(in airborne parti$ulates.

b. 4nsure that health$are +orers +ear "a$e shields or oles +ith

appropriate respirators +hen enterin the rooms o" 8&5 patients +ith

prominent $ouh, (omitin, diarrhea, or

hemorrhae 1=;/.


21/50

. 5ollo+ pre$autionary pro$edures "or in"e$tious T patients +ho also re0uire

emeren$y surery /0!12;!1/=/. Cateory #, #C

1. 6se an !9> respirator appro(ed by the !ational #nstitute "or @$$upational

Sa"ety and &ealth +ithout e7halation (al(es in the operatin room 12;!1/1/.Cateory #C @$$upational

Sa"ety and &ealth *dministration J@S&*' 29 Code o" 5ederal Reulations

JC5R 191E.1


22/50

+I' ther Potential Infectious Aerosol Ha.ards in Health-Care Facilities

*. #n settins +here suri$al lasers are used, +ear appropriate personal prote$ti(e

e0uipment PP4/, in$ludin !9> or !1EE respirators, to minimi?e e7posure to

laser plumes 12;!1/7!1/:/. Cateory #C @S&*' 29 C5R 191E.1Recommendations --- /ater

I' Controllin& the read of /ater%orne !icroor&anisms

*. Pra$ti$e hand hyiene to pre(ent the hand trans"er o" +aterborne pathoens,

and use barrier pre$autions e.., lo(es/ as de"ined by other uidelines

/:!102##10:/. Cateory #*

. 4liminate $ontaminated +ater or "luid en(ironmental reser(oirs e.., in

e0uipment or solutions/ +here(er possible 102!101NC/, e7plore

enineerin options e.., installin preset thermostati$ (al(es in pointo"use

"i7tures/ to help minimi?e the ris o" s$aldin 17/). Cateory ##

C. When state reulations or $odes do not allo+ hot +ater temperatures abo(e the

rane o" 1E>N512EN5 =E.NC=9NC/ "or hospitals or 9>N511EN5 NC
http://www.cdc.gov/mmwr/preview/mmwrhtml/00035909.htmhttp://www.cdc.gov/mmwr/preview/mmwrhtml/00045365.htmhttp://www.cdc.gov/mmwr/preview/mmwrhtml/00035909.htmhttp://www.cdc.gov/mmwr/preview/mmwrhtml/00045365.htm


23/50

=minutes, or use hihtemperature +ater "lushin or $hlorination

17/!17


24/50

to 1EN51AEN5 A1NCAANC/ and maintain that le(el +hile proressi(ely

"lushin ea$h outlet around the

system "or I> minutes 2


25/50

Investi&ation for Controllin& /ater%orne* Health-Care--Associated 0e&ionnaires

Disease

*. When usin a pulse or onetime de$ontamination method, superheat the +ater

by "lushin ea$h outlet "or I> minutes +ith +ater at 1EN51AEN5 A1NCAANC/

or hyper$hlorinate the system by "lushin all outlets "or I> minutes +ith +ater

$ontainin I2 mFL I2 ppm/ "ree residual $hlorine usin a $hlorinebased

produ$t reistered by the 4P* "or +ater treatment e.., sodium hypo$hlorite

J$hlorine blea$h/ 17/!177!1:1##1:0/. Cateory #


26/50

. *"ter a pulse treatment, maintain both the heated +ater temperature at the

return and the $old +ater temperature per the re$ommendation Water3 ## */

+here(er pra$ti$al and permitted by state $odes, or $hlorinate heated +ater to

a$hie(e 12 mFL 12 ppm/ "ree residual $hlorine at the tap by usin a

$hlorinebased produ$t reistered by the 4P* "or +ater treatment e.., sodiumhypo$hlorite Jblea$h/ 17/!1:7##1:;/. Cateory #C States' *S&R*43

1232EEE/

C. 47plore enineerin or edu$ational options e.., install preset thermostati$

mi7in (al(es in pointo"use "i7tures or post +arnin sins at ea$h outlet/ to

minimi?e the ris o" s$aldin "or patients, (isitors, and sta"". Cateory ##

D. !o re$ommendation is o""ered "or treatin +ater in the "a$ility-s distribution

system +ith $hlorine dio7ide, hea(ymetal ions e.., $opper or sil(er/,

mono$hloramines, o?one, or 68 liht 1 years' or patients +ith

$hroni$ underlyin disease e.., diabetes mellitus, $onesti(e heart "ailure, or

$hroni$ obstru$ti(e lun disease/ 2


27/50

measures e.., an edu$ational $ampain/ to enhan$e $lini$ians- use o" the

tests/ 1;//. Cateory #

4. #" one $ase o" laboratory$on"irmed, health$areasso$iated Leionnaires

disease is identi"ied, or i" t+o or more $ases o" laboratorysuspe$ted, health

$areasso$iated Leionnaires disease o$$ur durin a month period, $ertaina$ti(ities should be initiated 191!19;!1;1!1;/!1;;!2==/. Cateory #

1. Report the $ases to state and lo$al health departments +here re0uired.

Cateory #C States/

2. #" the "a$ility does not treat se(erely immuno$ompromised patients, $ondu$t

an epidemioloi$ in(estiation, in$ludin retrospe$ti(e re(ie+ o"

mi$robioloi$, seroloi$, and postmortem

data to loo "or pre(iously unidenti"ied $ases o" health$areasso$iated

Leionnaires disease, and bein intensi(e prospe$ti(e sur(eillan$e "or

additional $ases

2

inter(als durin < months/, reassess the $ontrol measures, modi"y them

a$$ordinly, and repeat the

de$ontamination pro$edures' $onsider intensi(e use o" te$hni0ues used in

the initial de$ontamination, or a $ombination o" superheatin and

hyper$hlorination 2


28/50

&. !o re$ommendation is o""ered reardin routine $ulturin o" +ater systems in

health$are "a$ilities that do not ha(e patient$are areas i.e., P4 or transplant

units/ "or persons at hih ris "or4eionellaspp. in"e$tion see *ppendi7/

1:1!1:7!1:

#. !o re$ommendation is o""ered reardin the remo(al o" "au$et aerators inareas "or immuno$ompetent patients. 6nresol(ed issue

%. ;eep ade0uate re$ords o" all in"e$tion$ontrol measures and en(ironmental

test results "or potable +ater systems. Cateory ##

+I' Preventin& 0e&ionnaires Disease in Protective Environments and $ranslant

"nits

*. When implementin strateies "or pre(entin Leionnaires disease amon

se(erely immuno$ompromised patients housed in "a$ilities +ith &SCT or

solidoran transplant prorams, in$orporate these spe$i"i$ sur(eillan$e and

epidemioloi$ measures in addition to the steps outlined pre(iously see

*ppendi7/.

1. Maintain a hih inde7 o" suspi$ion "or leionellosis in transplant patients

e(en +hen en(ironmental sur(eillan$e $ultures do not yield leionellae

19;!217/. Cateory #

2. #" a $ase o$$urs in a se(erely immuno$ompromised patient, or i" se(erely

immuno$ompromised patients are present in hihris areas o" the hospital

e.., P4 or transplant units/ and$ases are identi"ied else+here in the "a$ility, $ondu$t a $ombined

epidemioloi$ and en(ironmental in(estiation to determine the sour$e o"

4eionellaspp. 19;!21=/. Cateory #

. #mplement $ulture strateies and potable +ater and "i7ture treatment measures

in addition to those pre(ious outlined Water3 8/. Cateory ##

1. Dependin on state reulations on potable +ater temperature in publi$

buildins 21:/, hospitals housin patients at hih ris "or health$are

asso$iated leionellosis should either

maintain heated +ater +ith a minimum return temperature o" I12=N5

I>1NC/ and $old +ater at GN5 G2ENC/, or $hlorinate heated +ater to a$hie(e

12 mFL 12 ppm/ o" "ree

residual $hlorine at the tap 17/##177!1:7!1:


29/50

or solidoran transplant units.

6nresol(ed issue

=. #n areas +ith patients at ris, +hen4eionellaspp. are not dete$table in unit

+ater, remo(e, $lean, and disin"e$t sho+er heads and tap aerators monthly by

usin a $hlorinebased,4P*reistered produ$t. #" an 4P*reistered $hlorine disin"e$tant is not

a(ailable, use a $hlorine blea$h solution >EE1> ppm J131EE (F( dilution/

17/!19


30/50

test results "rom leionellosis

outbrea in(estiations 17//. Cateory #C *S&R*4 122EEE/

C. #" $oolin to+ers or e(aporati(e $ondensers are impli$ated in health$are

asso$iated leionellosis, de$ontaminate the $oolinto+er system1;;!2=/!221!22//. Cateory #

+III' Dialysis /ater 2uality and Dialysate

*. *dhere to $urrent **M# standards "or 0ualityassuran$e per"orman$e o"

de(i$es and e0uipment used to treat, store, and distribute +ater in

hemodialysis $enters both a$ute and maintenan$e J$hroni$ settins/ and "or

the preparation o" $on$entrates and dialysate 220##2/7/. Cateory #*, #C

**M#3 *meri$an !ational Standards #nstitute J*!S#F**M# RD>31992,

*!S#F**M# RD=A319931992,

*!S#F**M# RD=A319931992, *!S#F**M# RD=A3199


31/50

$an harbor ba$teria 22:## 229!2/1!2/:/. Cateory #*, #C **M#3

*!S#F**M# RD232EE1/

5. When storae tans are used in dialysis systems, they should be routinely

drained, disin"e$ted +ith an 4P*reistered produ$t, and "itted +ith an

ultra"ilter or pyroeni$ "ilter membrane "ilter +ith a pore si?e su""i$ient toremo(e parti$les and mole$ules I1 ilodalton/ installed in the +ater line distal

to the storae tan 2/:/. Cateory #C **M#3 *!S#F**M# RD232EE1/

I3' Ice !achines and Ice

*. Do not handle i$e dire$tly by hand, and +ash hands be"ore obtainin i$e.

Cateory ##

. 6se a smoothsur"a$e i$e s$oop to dispense i$e 20/!200/. Cateory ##

1. ;eep the i$e s$oop on a $hain short enouh that the s$oop $annot tou$h the

"loor or eep the s$oop on a $lean, hard sur"a$e +hen not in use 20/!200/.

Cateory ##

2. Do not store the i$e s$oop in the i$e bin. Cateory ##

C. Do not store pharma$euti$als or medi$al solutions on i$e intended "or

$onsumption' use sterile i$e to eep medi$al solutions $old, or use e0uipment

spe$i"i$ally manu"a$tured "or this purpose 200!207/. Cateory #

D. Ma$hines that dispense i$e are pre"erred to those that re0uire i$e to be

remo(ed "rom bins or $hests +ith a s$oop 20:!20


32/50

3' Hydrotheray $an4s and Pools

*. Drain and $lean hydrotherapy e0uipment e.., &ubbard tans, tubs,

+hirlpools, +hirlpool spas, or birthin tans/ a"ter ea$h patient-s use, and

disin"e$t e0uipment sur"a$es and $omponents by usin an 4P*reisteredprodu$t in a$$ordan$e +ith the manu"a$turer-s instru$tions. Cateory ##

. #n the absen$e o" an 4P*reistered produ$t "or +ater treatment, add sodium

hypo$hlorite to the +ater3

1. Maintain a 1>ppm $hlorine residual in the +ater o" small hydrotherapy

tans, &ubbard tans, and tubs 27=/. Cateory ##

2. Maintain a 2>ppm $hlorine residual in the +ater o" +hirlpools and

+hirlpool spas 271/. Cateory ##


33/50

+ater J+ater "iltered throuh E.1E.2Hm "ilters/ 270!27:##279/. Cateory

#

2. Dry the internal $hannels o" the repro$essed endos$ope or bron$hos$ope by

usin a pro(en method e.., AE al$ohol "ollo+ed by "or$edair treatment/ to

lessen the potential "orproli"eration o" +aterborne mi$rooranisms and to help pre(ent bio"ilm

"ormation 27;##2://. Cateory #

. 6se +ater that meets nationally re$oni?ed standards set by the 4P* "or

drinin +ater G>EE C56FmL "or heterotrophi$ plate $ount/ "or routine dental

treatment output +ater 2:0##2:


34/50

This may be "ollo+ed by an appli$ation o" an 4P*reistered hospital

disin"e$tant +ith or +ithout a

tuber$ulo$idal $laim dependin on the nature o" the sur"a$e and the deree

o" $ontamination/, in a$$ordan$e +ith ermi$ide label instru$tions 2


35/50

substan$es. Cateory ##


36/50

. 5ollo+ proper pro$edures "or site de$ontamination o" spills o" blood or blood

$ontainin body "luids 2;/##/==/. Cateory #C @S&*3 29 C5R 191E.1E


37/50

C. *(oid use o" $arpetin in hihtra""i$ ?ones in patient$are areas or +here

spills are liely e.., burn therapy units, operatin rooms, laboratories, or

intensi(e $are units/ 00!/=7!/=:/. Cateory #

D. 5ollo+ appropriate pro$edures "or manain spills on $arpetin.

1. Spot$lean blood or body substan$e spills promptly 2;/!/=1!/=0!/=


38/50

+' Pest Control

*. De(elop pest$ontrol strateies, +ith emphasis on it$hens, $a"eterias,

laundries, $entral sterile supply areas, operatin rooms, loadin do$s,

$onstru$tion a$ti(ities, and other areas prone to in"estations /1/##/17/.Cateory ##

. #nstall s$reens on all +indo+s that open to the outside' eep s$reens in ood

repair /10/. Cateory #

C. Contra$t "or routine pest $ontrol ser(i$e by a $redentialed pest$ontrol

spe$ialist +ho +ill tailor the appli$ation to the needs o" a health$are "a$ility

/17/. Cateory ##

D. Pla$e laboratory spe$imens e.., "i7ed sputum smears/ in $o(ered $ontainers

"or o(erniht storae /1:!/1


39/50

1. @btain prior appro(al "rom in"e$tion$ontrol sta"" and the $lini$al laboratory

be"ore per"ormin en(ironmentalsur"a$e $ulturin. Cateory ##

2. #n"e$tion$ontrol sta"", +ith $lini$al laboratory sta"" $onsultation, must

super(ise all en(ironmental $ulturin. Cateory ##

D. Thorouhly $lean and disin"e$t en(ironmental and medi$al e0uipment sur"a$es

on a reular basis by usin 4P*reistered disin"e$tants in a$$ordan$e +ith

manu"a$turers- instru$tions 2


40/50

housin a $on"irmed or suspe$ted C%D patient 2 to 13< (F(, respe$ti(ely, o" 6.S. household $hlorine blea$h' $onta$t themanu"a$turers o" $ommer$ially a(ailable sodium hypo$hlorite produ$ts "or

ad(i$e/ to de$ontaminate

operatin room or autopsy sur"a$es +ith $entral ner(ous system or $erebral

spinal "luid $ontamination "rom a dianosed or suspe$ted C%D patient

2


41/50

II' Air* /ater* and Environmental urface amlin&

*. When $ondu$tin any "orm o" en(ironmental samplin, identi"y e7istin

$omparati(e standards and "ully do$ument departures "rom standard methods

/0/##/0


42/50

III' Routine Handlin& of Contaminated 0aundry

*. &andle $ontaminated te7tiles and "abri$s +ith minimum aitation to a(oid

$ontamination o" air, sur"a$es, and persons /:!2;/!/77!/7:/. Cateory #C

@S&*3 29 C5R 191E.1E


43/50

4. Pa$ae, transport, and store $lean te7tiles and "abri$s by methods that +ill

ensure their $leanliness and prote$t them "rom dust and soil durin inter"a$ility

loadin, transport, and unloadin 2


44/50

4. #" usin a mattress $o(er $ompletely made o" "abri$, $hane these $o(ers and

launder bet+een patient use /


45/50

4. Tae prompt a$tion +hen an in$ident o" bitin or s$rat$hin by an animal

o$$urs durin an animalassisted a$ti(ity or therapy.

1. Remo(e the animal permanently "rom these prorams /;1/. Cateory ##

2. Report the in$ident promptly to appropriate authorities e.., in"e$tion$ontrol sta"", animal proram $oordinator, or lo$al animal $ontrol personnel/

/;1/. Cateory ##


46/50

4. !o re$ommendation is o""ered reardin permittin pet (isits to terminally ill

immuno$ompromised patients outside their P4 units. 6nresol(ed issue.

I+' ervice Animals

*. *(oid pro(idin "a$ility a$$ess to nonhuman primates and reptiles as ser(i$e

animals /;/!/;


47/50

4. Clean and disin"e$t en(ironmental sur"a$es thorouhly by usin an 4P*

reistered produ$t in the room a"ter the animal has been remo(ed. Cateory ##

5. *llo+ su""i$ient *C& to $lean the air and help remo(e airborne dander,

mi$rooranisms, and allerens Table 1/. Cateory ##

B. Clean and disin"e$t usin 4P*reistered produ$ts or sterili?e e0uipment thathas been in $onta$t +ith the animal' or use disposable e0uipment. Cateory ##

&. #" reusable medi$al or suri$al instruments are used in an animal pro$edure,

restri$t "uture use o" these instruments to animals only. Cateory ##

+I' Research Animals in Health-Care Facilities

*. 6se animals obtained "rom 0uality sto$, or 0uarantine in$omin animals to

dete$t ?oonoti$ diseases. Cateory ##

. Treat si$ animals or remo(e them "rom the "a$ility. Cateory ##

C. Pro(ide prophyla$ti$ (a$$inations, as a(ailable, to animal handlers and

$onta$ts at hih ris. Cateory ##

D. 4nsure proper (entilation throuh appropriate "a$ility desin and lo$ation

/;;/. Cateory #C 6.S. Department o" *ri$ulture J6SD*3 A 6SC 21


48/50

*. Desinate the "ollo+in as ma:or $ateories o" medi$al +aste that re0uire

spe$ial handlin and disposal pre$autions3 1/ mi$robioloy laboratory +astes

Je.., $ultures and sto$s o" mi$rooranisms' 2/ bul blood, blood produ$ts,

blood, and bloody body "luid spe$imens'


49/50

D. Store reulated medi$al +astes a+aitin treatment in a properly (entilated area

ina$$essible to (ertebrate pests' use +aste $ontainers that pre(ent de(elopment

o" no7ious odors. Cateory #C States/

4. #" treatment options are not a(ailable at the site +here the medi$al +aste is

enerated, transport reulated medi$al +astes in $losed, imper(ious $ontainersto the onsite treatment lo$ation or to another "a$ility "or treatment as

appropriate. Cateory #C States/

I+' $reatment and Disosal of Re&ulated !edical /astes

*. Treat reulated medi$al +astes by usin a method e.., steam sterili?ation,

in$ineration, interment, or an alternati(e treatment te$hnoloy/ appro(ed by

the appropriate authority ha(in :urisdi$tion *&%/ e.., state, #ndian &ealth

Ser(i$e, or 8eterans *dministration/ be"ore disposal in a sanitary land"ill.

Cateory #C States, *&%/

. 5ollo+ pre$autions "or treatin mi$robioloi$ +astes e.., ampli"ied $ultures

and sto$s o" mi$rooranisms/ 0==/. Cateory #C D&&S3 ML/

1. iosa"ety le(el = laboratories must ina$ti(ate mi$robioloi$ +astes in the

laboratory by usin an appro(ed ina$ti(ation method e.., auto$la(in/ be"ore

transport to and disposal in a

sanitary land"ill 0==/. Cateory #C D&&S3 ML/

2. iosa"ety le(el < laboratories must ina$ti(ate mi$robioloi$ +astes in the

laboratory by usin an appro(ed ina$ti(ation method e.., auto$la(in/ orin$inerate them at the "a$ility

be"ore transport to and disposal in a sanitary land"ill 0==/. Cateory #C

D&&S3 ML/

C. iosa"ety le(els 1 and 2 laboratories should de(elop strateies to ina$ti(ate

ampli"ied mi$robial $ultures and sto$s onsite by usin an appro(ed

ina$ti(ation method e.., auto$la(in/ instead o" pa$ain and shippin

untreated +astes to an o""site "a$ility "or treatment and disposal 0==!0=:##

0=9/. Cateory ##

D. Laboratories that isolate sele$t aents "rom $lini$al spe$imens must $omply

+ith "ederal reulations "or re$eipt, trans"er, manaement, and appropriate

disposal o" these aents 0=;/. Cateory #C D&&S3 =2 C5R A2 O A2..i.1.iii/

4. Sanitary se+ers may be used "or sa"e disposal o" blood, su$tioned "luids,

round tissues, e7$retions, and se$retions, pro(ided that lo$al se+ae

dis$hare re0uirements are met and that the state has de$lared this to be an

a$$eptable method o" disposal 01=/. Cateory ##

+' ecial Precautions for /astes Generated Durin& Care of Patients 1ith Rare

Diseases


50/50

*. When dis$ardin items $ontaminated +ith blood and body "luids "rom 8&5

patients, $ontain these reulated medi$al +astes +ith minimal aitation durin

handlin /:!1=;/. Cateory ##

. Manae properly $ontained +astes "rom areas pro(idin $are to 8&5 patients

in a$$ordan$e +ith re$ommendations "or other isolation areas ReulatedMedi$al Waste3 ### / /:!1=;!2

guidelines for environmental infection control in health-care facilities.doc

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