Guidelines for Environmental Infection Control in Health-Care Facilities

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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)
U.S. Department of Health and Human Services
Centers for Disease Control and Prevention (CDC)
Atlanta, GA 30333
2003
Suggested Citations:
Available from the CDC Internet Site:
The full-text version of the guidelines appears as a web-based document at the CDC’s Division
of Healthcare Quality Promotion’s Internet site at: www.cdc.gov/ncidod/hip/enviro/guide.htm
Part II of these guidelines appeared in the CDC’s “Morbidity and Mortality
Weekly Report:”
Centers for Disease Control and Prevention. Guidelines for environmental infection control in
health-care facilities: recommendations of CDC and the Healthcare Infection Control Practices
Advisory Committee (HICPAC). MMWR 2003; 52 (No. RR-10): 1–48.
Updates to the Part II recommendations also appeared in the MMWR in 2003 as “Errata: Vol.
52 (No. RR-10)” (MMWR Vol. 52 [42]: 1025–6) on October 24, 2003 and as a “Notice to
Readers” scheduled to appear in December 2003. The full-text version of these guidelines (this
document) incorporates these updates.
i
Centers for Disease Control and Prevention
Healthcare Infection Control Practices Advisory
Committee (HICPAC)
Guidelines for Environmental Infection Control in
Health-Care Facilities
Abstract
Background:
Although the environment serves as a reservoir for a variety of microorganisms, it is rarely implicated in
disease transmission except in the immunocompromised population. Inadvertent exposures to
environmental opportunistic pathogens (e.g., Aspergillus spp. and Legionella spp.) or airborne
pathogens (e.g., Mycobacterium tuberculosis and varicella-zoster virus) may result in infections with
significant morbidity and/or mortality. Lack of adherence to established standards and guidance (e.g.,
water quality in dialysis, proper ventilation for specialized care areas such as operating rooms, and
proper use of disinfectants) can result in adverse patient outcomes in health-care facilities.
Objective:
The objective is to develop an environmental infection-control guideline that reviews and reaffirms
strategies for the prevention of environmentally-mediated infections, particularly among health-care
workers and immunocompromised patients. The recommendations are evidence-based whenever
possible.
Search Strategies:
The contributors to this guideline reviewed predominantly English-language articles identified from
MEDLINE literature searches, bibliographies from published articles, and infection-control textbooks.
Criteria for Selecting Citations and Studies for This Review:
Articles dealing with outbreaks of infection due to environmental opportunistic microorganisms and
epidemiological- or laboratory experimental studies were reviewed. Current editions of guidelines and
standards from organizations (i.e., American Institute of Architects [AIA], Association for the
Advancement of Medical Instrumentation [AAMI], and American Society of Heating, Refrigeration,
and Air-Conditioning Engineers [ASHRAE]) were consulted. Relevant regulations from federal
agencies (i.e., U.S. Food and Drug Administration [FDA]; U.S. Department of Labor, Occupational
Safety and Health Administration [OSHA]; U.S. Environmental Protection Agency [EPA]; and U.S.
Department of Justice) were reviewed. Some topics did not have well-designed, prospective studies nor
reports of outbreak investigations. Expert opinions and experience were consulted in these instances.
Types of Studies:
Reports of outbreak investigations, epidemiological assessment of outbreak investigations with control
strategies, and in vitro environmental studies were assessed. Many of the recommendations are derived
ii
from empiric engineering concepts and reflect industry standards. A few of the infection-control
measures proposed cannot be rigorously studied for ethical or logistical reasons.
Outcome Measures:
Infections caused by the microorganisms described in this guideline are rare events, and the effect of
these recommendations on infection rates in a facility may not be readily measurable. Therefore, the
following steps to measure performance are suggested to evaluate these recommendations:
1. Document whether infection-control personnel are actively involved in all phases of a healthcare facility’s demolition, construction, and renovation. Activities should include performing a
risk assessment of the necessary types of construction barriers, and daily monitoring and
documenting of the presence of negative airflow within the construction zone or renovation
area.
2. Monitor and document daily the negative airflow in airborne infection isolation rooms (AII) and
positive airflow in protective environment rooms (PE), especially when patients are in these
rooms.
3. Perform assays at least once a month by using standard quantitative methods for endotoxin in
water used to reprocess hemodialyzers, and for heterotrophic, mesophilic bacteria in water used
to prepare dialysate and for hemodialyzer reprocessing.
4. Evaluate possible environmental sources (e.g., water, laboratory solutions, or reagents) of
specimen contamination when nontuberculous mycobacteria (NTM) of unlikely clinical
importance are isolated from clinical cultures. If environmental contamination is found,
eliminate the probable mechanisms.
5. Document policies to identify and respond to water damage. Such policies should result in
either repair and drying of wet structural materials within 72 hours, or removal of the wet
material if drying is unlikely within 72 hours.
Main Results:
Infection-control strategies and engineering controls, when consistently implemented, are effective in
preventing opportunistic, environmentally-related infections in immunocompromised populations.
Adherence to proper use of disinfectants, proper maintenance of medical equipment that uses water
(e.g., automated endoscope reprocessors and hydrotherapy equipment), water-quality standards for
hemodialysis, and proper ventilation standards for specialized care environments (i.e., airborne infection
isolation [AII], protective environment [PE], and operating rooms [ORs]), and prompt management of
water intrusion into facility structural elements will minimize health-care–associated infection risks and
reduce the frequency of pseudo-outbreaks. Routine environmental sampling is not advised except in the
few situations where sampling is directed by epidemiologic principles and results can be applied
directly to infection control decisions, and for water quality determinations in hemodialysis.
Reviewers’ Conclusions:
Continued compliance with existing environmental infection control measures will decrease the risk of
health-care–associated infections among patients, especially the immunocompromised, and health-care
workers.
iii
Centers for Disease Control and Prevention
Healthcare Infection Control Practices Advisory Committee (HICPAC)
Guidelines for Environmental Infection Control in
Health-Care Facilities
Table of Contents
Executive Summary.................................................................................................................... 1
Part I. Background Information: Environmental Infection Control in Health-Care
Facilities....................................................................................................................................... 3
A. Introduction.................................................................................................................................... 3
B. Key Terms Used in this Guideline ................................................................................................ 5
C. Air.................................................................................................................................................... 6
1. Modes of Transmission of Airborne Diseases.............................................................................. 6
2. Airborne Infectious Diseases in Health-Care Facilities................................................................ 7
3. Heating, Ventilation, and Air Conditioning Systems in Health-Care Facilities ......................... 13
4. Construction, Renovation, Remediation, Repair, and Demolition ............................................. 21
5. Environmental Infection-Control Measures for Special Health-Care Settings........................... 34
6. Other Aerosol Hazards in Health-Care Facilities ....................................................................... 40
D. Water............................................................................................................................................. 40
1. Modes of Transmission of Waterborne Diseases ....................................................................... 40
2. Waterborne Infectious Diseases in Health-Care Facilities ......................................................... 41
3. Water Systems in Health-Care Facilities .................................................................................... 46
4. Strategies for Controlling Waterborne Microbial Contamination .............................................. 53
5. Cooling Towers and Evaporative Condensers............................................................................ 57
6. Dialysis Water Quality and Dialysate......................................................................................... 59
7. Ice Machines and Ice .................................................................................................................. 65
8. Hydrotherapy Tanks and Pools................................................................................................... 67
9. Miscellaneous Medical/Dental Equipment Connected to Main Water Systems ........................ 69
E. Environmental Services ............................................................................................................... 71
1. Principles of Cleaning and Disinfecting Environmental Surfaces.............................................. 71
2. General Cleaning Strategies for Patient-Care Areas................................................................... 74
3. Cleaning Strategies for Spills of Blood and Body Substances ................................................... 77
4. Carpeting and Cloth Furnishings ................................................................................................ 78
5. Flowers and Plants in Patient-Care Areas .................................................................................. 80
6. Pest Control ................................................................................................................................ 81
7. Special Pathogen Concerns......................................................................................................... 82
F. Environmental Sampling ............................................................................................................. 88
1. General Principles: Microbiologic Sampling of the Environment ............................................. 88
2. Air Sampling............................................................................................................................... 89
3. Water Sampling .......................................................................................................................... 94
4. Environmental Surface Sampling ............................................................................................... 95
G. Laundry and Bedding.................................................................................................................. 98
1. General Information ................................................................................................................... 98
2. Epidemiology and General Aspects of Infection Control........................................................... 98
3. Collecting, Transporting, and Sorting Contaminated Textiles and Fabrics................................ 99
iv
4. Parameters of the Laundry Process .......................................................................................... 100
5. Special Laundry Situations....................................................................................................... 102
6. Surgical Gowns, Drapes, and Disposable Fabrics.................................................................... 103
7. Antimicrobial-Impregnated Articles and Consumer Items Bearing Antimicrobial Labeling .. 103
8. Standard Mattresses, Pillows, and Air-Fluidized Beds ............................................................ 104
H. Animals in Health-Care Facilities ............................................................................................ 105
1. General Information ................................................................................................................. 105
2. Animal-Assisted Activities, Animal-Assisted Therapy, and Resident Animals ...................... 106
3. Service Animals ....................................................................................................................... 108
4. Animals as Patients in Human Health-Care Facilities ............................................................. 110
5. Research Animals in Health-Care Facilities ............................................................................ 111
I. Regulated Medical Waste ........................................................................................................... 112
1. Epidemiology ........................................................................................................................... 112
2. Categories of Medical Waste ................................................................................................... 112
3. Management of Regulated Medical Waste in Health-Care Facilities ...................................... 113
4. Treatment of Regulated Medical Waste................................................................................... 113
5. Discharging Blood, Fluids to Sanitary Sewers or Septic Tanks............................................... 116
6. Medical Waste and CJD........................................................................................................... 116
Part II. Recommendations for Environmental Infection Control in Health-Care Facilities
................................................................................................................................................... 117
A. Rationale for Recommendations .............................................................................................. 117
B. Rating Categories....................................................................................................................... 117
C. Recommendations—Air ............................................................................................................ 118
D. Recommendations—Water ....................................................................................................... 125
E. Recommendations—Environmental Services ......................................................................... 133
F. Recommendations—Environmental Sampling ....................................................................... 138
G. Recommendations—Laundry and Bedding ............................................................................ 138
H. Recommendations—Animals in Health-Care Facilities......................................................... 141
I. Recommendations—Regulated Medical Waste........................................................................ 143
Part III. References................................................................................................................ 145
Part IV. Appendices............................................................................................................... 201
Appendix A. Glossary of Terms .................................................................................................... 201
Appendix B. Air .............................................................................................................................. 210
1. Airborne Contaminant Removal .............................................................................................. 210
2. Air Sampling for Aerosols Containing Legionellae................................................................. 210
3. Calculation of Air Sampling Results........................................................................................ 211
4. Ventilation Specifications for Health-Care Facilities............................................................... 212
Appendix C. Water......................................................................................................................... 220
1. Biofilms.................................................................................................................................... 220
2. Water and Dialysate Sampling Strategies in Dialysis .............................................................. 222
3. Water Sampling Strategies and Culture Techniques for Detecting Legionellae ...................... 223
4. Procedure for Cleaning Cooling Towers and Related Equipment ........................................... 225
5. Maintenance Procedures Used to Decrease Survival and Multiplications of Legionella spp. in
Potable-Water Distribution Systems ............................................................................................. 227
Appendix D. Insects and Microorganisms.................................................................................... 228
Appendix E. Information Resources............................................................................................. 229
Appendix F. Areas of Future Research ........................................................................................ 230
Index—Parts I and IV ............................................................................................................ 231
v
List of Figures, Boxes, and Tables
Figures
Figure 1. Diagram of a ventilation system .............................................................................................. 14
Figure 2. Example of positive-pressure room control for protection from airborne environmental
microbes (PE) .................................................................................................................................. 35
Figure 3. Example of negative-pressure room control for airborne infection isolation (AII) ................. 36
Figure 4. Example of airborne infection isolation (AII) room with anteroom and neutral anteroom ..... 37
Figure 5. Diagram of a typical air conditioning (induced draft) cooling tower ...................................... 58
Figure 6. Dialysis water treatment system .............................................................................................. 60
Boxes
Box 1. Environmental infection control: performance measures .............................................................. 2
Box 2. Eight criteria for evaluating the strength of evidence for environmental sources of infection...... 4
Box 3. Chain of infection components ...................................................................................................... 4
Box 4. Suggested members and functions of a multi-disciplinary coordination team for construction,
renovation, repair, and demolition projects ..................................................................................... 24
Box 5. Construction design and function considerations for environmental infection control ............... 25
Box 6. Unresolved issues associated with microbiologic air sampling................................................... 28
Box 7. Construction/repair projects that require barrier structures ......................................................... 32
Box 8. Strategy for managing TB patients and preventing airborne transmission in operating rooms... 39
Box 9. Recovery and remediation measures for water-related emergencies........................................... 52
Box 10. Contingency planning for flooding............................................................................................ 53
Box 11. Steps in an epidemiologic investigation for legionellosis.......................................................... 56
Box 12. General steps for cleaning and maintaining ice machines, dispensers, and storage chests ....... 66
Box 13. Preliminary concerns for conducting air sampling .................................................................... 90
Box 14. Selecting an air sampling device ............................................................................................... 93
Box 15. Undertaking environmental-surface sampling........................................................................... 95
Box C.1. Potential sampling sites for Legionella spp. in health-care facilities ..................................... 224
Box C.2. Procedures for collecting and processing environmental specimens for Legionella spp....... 225
Tables
Table 1. Clinical and epidemiologic characteristics of aspergillosis......................................................... 7
Table 2. Environmental fungal pathogens: entry into and contamination of the health-care facility........ 8
Table 3. Clinical and epidemiologic characteristics of tuberculosis (TB)............................................... 10
Table 4. Microorganisms associated with airborne transmission............................................................ 13
Table 5. Filtration methods ..................................................................................................................... 15
Table 6. Engineered specifications for positive- and negative pressure rooms....................................... 19
Table 7. Ventilation hazards in health-care facilities that may be associated with increased potential of
airborne disease transmission .......................................................................................................... 22
Table 8. Strategies to reduce dust and moisture intrusion during external demolition and construction 30
vi
Table 9. Infection-control measures for internal construction and repair projects ................................. 32
Table 10. Summary of ventilation specifications in selected areas of health-care facilities................... 39
Table 11. Clinical and epidemiologic characteristics of legionellosis/Legionnaires disease.................. 41
Table 12. Pseudomonas aeruginosa infections in health-care facilities ................................................. 42
Table 13. Other gram-negative bacteria associated with water and moist environments ....................... 43
Table 14. Nontuberculous mycobacteria—environmental vehicles ....................................................... 45
Table 15. Water and point-of-use fixtures as sources and reservoirs of waterborne pathogens ............. 47
Table 16. Water demand in health-care facilities during water disruption emergencies ........................ 50
Table 17. Additional infection-control measures to prevent exposure of high-risk patients to waterborne
pathogens......................................................................................................................................... 57
Table 18. Microbiologic limits for hemodialysis fluids.......................................................................... 62
Table 19. Factors influencing microbial contamination in hemodialysis systems.................................. 63
Table 20. Microorganisms and their sources in ice and ice machines .................................................... 65
Table 21. Infections associated with use of hydrotherapy equipment .................................................... 67
Table 22. Levels of disinfection by type of microorganism ................................................................... 72
Table 23. Air sampling methods and examples of equipment ................................................................ 91
Table 24. Examples of eluents and diluents for environmental-surface sampling.................................. 96
Table 25. Methods of environmental-surface sampling.......................................................................... 97
Table 26. Examples of diseases associated with zoonotic transmission ............................................... 105
Table 27. Microorganisms and biologicals identified as select agents ................................................. 115
Table B.1. Air changes/hour (ACH) and time required for airborne-contaminant removal efficiencies of
99% and 99.9% ............................................................................................................................. 210
Table B.2. Ventilation requirements for areas affecting patient care in hospitals and outpatient facilities
....................................................................................................................................................... 212
Table B.3. Pressure relationships and ventilation of certain areas of nursing facilities........................ 217
Table B.4. Filter efficiencies for central ventilation and air conditioning systems in general hospitals
....................................................................................................................................................... 219
Table B.5. Filter efficiencies for central ventilation and air conditioning systems in outpatient facilities
....................................................................................................................................................... 219
Table B.6. Filter efficiencies for central ventilation and air conditioning systems in nursing facilities
....................................................................................................................................................... 220
Table B.7. Filter efficiencies for central ventilation and air conditioning systems in psychiatric hospitals
....................................................................................................................................................... 220
Table D.1. Microorganisms isolated from arthropods in health-care settings ...................................... 228
vii
List of Abbreviations Used in This Publication
AAA
AAMI
AAT
ACGIH
ACH
ADA
AER
AFB
AHA
AHJ
AIA
AII
AmB
ANC
ANSI
AORN
ASHE
ASHRAE
BCG
BCYE
BHI
BMBL
BOD
BSE
BSL
C
CAPD
CCPD
CMAD
CDC
CFR
CFU
CJD
cm
CMS
CPL
CT/EC
DFA
DHHS
DHBV
DNA
DOP
DOT
EC
ELISA
EPA
ESRD
animal-assisted activity
Association for the Advancement of Medical Instrumentation
animal-assisted therapy
American Council of Governmental Industrial Hygienists
air changes per hour
Americans with Disabilities Act
automated endoscope reprocessor
acid-fast bacilli
American Hospital Association
authorities having jurisdiction
American Institute of Architects
airborne infection isolation
amphotericin B
absolute neutrophil count
American National Standards Institute
Association of periOperative Registered Nurses
American Society for Healthcare Engineering
American Society of Heating, Refirgeration, and Air-Conditioning Engineers
Bacille Calmette-Guérin
buffered charcoal yeast extract medium
brain-heart infusion
CDC/NIH publication “Biosafety in Microbiological and Biomedical Laboratories”
biological oxygen demand
bovine spongiform encephalopathy
biosafety level
Centigrade
continuous ambulatory peritoneal dialysis
continual cycling peritoneal dialysis
count median aerodynamic diameter
U.S. Centers for Disease Control and Prevention
Code of Federal Regulations
colony-forming unit
Creutzfeldt-Jakob disease
centimeter
U.S. Centers for Medicare and Medicaid Services
compliance document (OSHA)
cooling tower/evaporative condenser
direct fluorescence assay; direct fluorescent antibody
U.S. Department of Health and Human Services
duck hepatitis B virus
deoxyribonucleic acid
dioctylphthalate
U.S. Department of Transportation
environment of care (JCAHO)
enzyme-linked immunosorbent assay
U.S. Environmental Protection Agency
end-stage renal disease
viii
EU
F
FDA
FIFRA
FRC
ft
FTC
GISA
HBV
HCV
HEPA
HICPAC
HIV
HPV
HSCT
HVAC
ICRA
ICU
ID50
IPD
JCAHO
kg
L
MAC
MDRO
MIC
µm
mL
min
mg
MMAD
MMWR
MRSA
MSDS
N
NaCl
NaOH
NCID
NCCDPHP
NCCLS
ng
NICU
NIH
NIOSH
nm
NNIS
NTM
OPL
OSHA
Pa
PCP
endotoxin unit
Fahrenheit
U.S. Food and Drug Administration
Federal Insecticide, Fungicide, and Rodenticide Act
free residual chlorine
foot (feet)
U.S. Federal Trade Commission
glycopeptide intermediate resistant Staphylococcus aureus
hepatitis B virus
hepatitis C virus
high efficiency particulate air
Healthcare Infection Control Practices Advisory Committee
human immunodeficiency virus
human papilloma virus
hematopoietic stem cell transplant
heating, ventilation, air conditioning
infection control risk assessment
intensive care unit
50% median infectious dose
intermittent peritoneal dialysis
Joint Commission on Accreditation of Healthcare Organizations
kilogram
liter
Mycobacterium avium complex; also used to denote MacConkey agar
multiple-drug resistant organism
minimum inhibitory concentration
micrometer; micron
milliliter
minute
milligram
mass median aerodynamic diameter
“Morbidity and Mortality Weekly Report”
methicillin-resistant Staphylococcus aureus
material safety data sheet
Normal
sodium chloride
sodium hydroxide
National Center for Infectious Diseases
National Center for Chronic Disease Prevention and Health Promotion
National Committee for Clinical Laboratory Standards
nanogram
neonatal intensive care unit
U.S. National Institutes of Health
National Institute for Occupational Safety and Health
nanometer
National Nosocomial Infection Surveillance
nontuberculous mycobacteria
on-premises laundry
U.S. Occupational Safety and Health Administration
Pascal
Pneumocystis carinii pneumonia
ix
PCR
PD
PE
PEL
PPE
ppm
PVC
RAPD
RODAC
RSV
RO
SARS
SARS-CoV
sec
spp
SSI
TB
TLV®-TWA
TSA
TSB
TSE
U.S.
USC
USDA
USPS
UV
UVGI
VAV
vCJD
VISA
VRE
VRSA
v/v
VZV
polymerase chain reaction
peritoneal dialysis
protective environment
permissible exposure limit
personal protective equipment
parts per million
polyvinylchloride
randomly amplified polymorphic DNA
replicate organism direct agar contact
respiratory syncytial virus
reverse osmosis
severe acute respiratory syndrome
SARS coronavirus
second
species
surgical site infection
tuberculosis
threshold limit value-time weighted average
tryptic soy agar
tryptic soy broth
transmissible spongiform encephalopathy
United States
United States Code
U.S. Department of Agriculture
U.S. Postal Service
ultraviolet
ultraviolet germicidal irradiation
variable air ventilation
variant Creutzfeldt-Jakob disease
vancomycin intermediate resistant Staphylococcus aureus
vancomycin-resistant Enterococcus
vancomycin-resistant Staphylococcus aureus
volume/volume
varicella-zoster virus
Note: Use of trade names and commercial sources is for identification only and does not imply
endorsement by the U.S. Department of Health and Human Services. References to non-CDC
sites on the Internet are provided as a service to the reader and does not constitute or imply
endorsement of these organization s or their programs by CDC or the U.S. Department of Health
and Human Services. CDC is not responsible for the content of pages found at these sites.
x
The following CDC staff member and HICPAC member prepared this report:
Lynne Sehulster, PhD
Division of Healthcare Quality Promotion
National Center for Infectious Diseases
Raymond Y.W. Chinn, MD
HICPAC Advisor
Sharp Memorial Hospital
San Diego, California
Disclosure of Relationship: Raymond Y.W. Chinn is a private-practice physician and salaried
employee of Sharp Memorial Hospital in San Diego, California. Dr. Chinn received no research funds
from commercial sources either directly, or indirectly through awards made to the hospital, before or
during the development of these guidelines.
Contributions were made by the following CDC staff members:
Matthew Arduino, DrPH
Joe Carpenter, PE
Rodney Donlan, PhD
Lynne Sehulster, PhD
Division of Healthcare Quality Promotion
National Center for Infectious Diseases
David Ashford, DVM, Dsc, MPH
Richard Besser, MD
Barry Fields, PhD
Michael M. McNeil, MBBS, MPH
Cynthia Whitney, MD, MPH
Stephanie Wong, DMV, MPH
Division of Bacterial and Mycotic Diseases
National Center for Infectious Diseases
Dennis Juranek, DVM, MSC
Division of Parasitic Diseases
National Center for Infectious Diseases
Jennifer Cleveland, DDS, MPH
Division of Oral Health
National Center for Chronic Disease Prevention and Health Promotion
In collaboration with the Healthcare Infection Control Practices Advisory Committee
(HICPAC)
xi
HICPAC Members, February 2002
Robert A. Weinstein, MD
Chair
Cook County Hospital
Chicago, IL
Jane D. Siegel, MD
Co-Chair
University of Texas Southwestern Medical Center
Dallas, TX
Michele L. Pearson, MD
Executive Secretary
Centers for Disease Control and Prevention
Atlanta, GA
Raymond Y.W. Chinn, MD
Sharp Memorial Hospital
San Diego, CA
Alfred DeMaria, Jr., MD
Massachusetts Department of Public Health
Jamaica Plain, MA
Elaine L. Larson, RN, PhD
Columbia University School of Nursing
New York, NY
James T. Lee, MD, PhD
University of Minnesota
VA Medical Center
St. Paul, MN
Ramon E. Moncada, MD
Coronado Physician’s Medical Center
Coronado, CA
William A. Rutala, PhD, MPH, CIC
University of North Carolina School of
Medicine
Chapel Hill, NC
William E. Scheckler, MD
University of Wisconsin Medical School
Madison, WI
Beth H. Stover, RN, CIC
Kosair Children’s Hospital
Louisville, KY
Marjorie A. Underwood, RN, BSN, CIC
Mt. Diablo Medical Center
Concord, CA
Liaison Members
Loretta L. Fauerbach, MS, CIC
Association for Professionals in Infection
Control and Epidemiology (APIC)
Washington, DC
Sandra L. Fitzler, RN
American Health Care Association
Washington, DC
Dorothy M. Fogg, RN, BSN, MA
Association of periOperative Registered
Nurses (AORN)
Denver, CO
Stephen F. Jencks, MD, MPH
U.S. Centers for Medicare and Medicaid
Services
Baltimore, MD
Chiu S. Lin, PhD
U.S. Food and Drug Administration
Rockville, MD
James P. Steinberg, MD
Society for Healthcare Epidemiology of America,
Inc. (SHEA)
Atlanta, GA
xii
Liaison Members (continued)
Michael L. Tapper, MD
Advisory Committee for the Elimination of
Tuberculosis (ACET)
New York, NY
Expert Reviewers
Trisha Barrett, RN, MBA, CIC
Alta Bates Medical Center
Berkeley, CA
Judene Bartley, MS, MPH, CIC
Epidemiology Consulting Services, Inc.
Beverly Hills, MI
Michael Berry
University of North Carolina
Chapel Hill, NC
Col. Nancy Bjerke, BSN, MA, MEd, MPH, CIC
(USAF, Retired)
Infection Control Associates (ICA)
San Antonio, TX
Walter W. Bond, MS
RCSA, Inc.
Lawrenceville, GA
Cheryl Carter, RN
University of Iowa Health Center
Iowa City, IA
Douglas Erickson, FASHE
American Society for Healthcare
Engineering (ASHE)
Park Ridge, IL
Martin S. Favero, PhD
Advanced Sterilization Products, Johnson and
Johnson
Irvine, CA
Richard Miller, MD
University of Louisville School of Medicine
Louisville, KY
Col. Shannon E. Mills, DDS
HQ USAF / Surgeon General Detail
Bolin AFB, DC
Gina Pugliese, RN, MS
Premier Safety Institute
Oak Brook, IL
Craig E. Rubens, MD, PhD
Children’s Hospital and Medical Center
Seattle, WA
James D. Scott, PE
Michigan Department of Consumer and
Industry Services
Lansing, MI
Andrew J. Streifel, MPH, REHS
University of Minnesota
Minneapolis, MN
Dale Woodin
American Society for Healthcare Engineering
(ASHE)
Chicago, IL
1
Executive Summary
The Guidelines for Environmental Infection Control in Health-Care Facilities is a compilation of
recommendations for the prevention and control of infectious diseases that are associated with healthcare environments. This document a) revises multiple sections from previous editions of the Centers for
Disease Control and Prevention [CDC] document titled Guideline for Handwashing and Hospital
Environmental Control;1, 2 b) incorporates discussions of air and water environmental concerns from
CDC’s Guideline for the Prevention of Nosocomial Pneumonia;3 c) consolidates relevant environmental
infection-control measures from other CDC guidelines;4–9 and d) includes two topics not addressed in
previous CDC guidelines — infection-control concerns related to animals in health-care facilities and
water quality in hemodialysis settings.
Part I of this report, Background Information: Environmental Infection Control in Health-Care
Facilities, provides a comprehensive review of the scientific literature. Attention is given to
engineering and infection-control concerns during construction, demolition, renovation, and repairs of
health-care facilities. Use of an infection-control risk assessment is strongly supported before the start of
these or any other activities expected to generate dust or water aerosols. Also reviewed in Part I are
infection-control measures used to recover from catastrophic events (e.g., flooding, sewage spills, loss
of electricity and ventilation, and disruption of the water supply) and the limited effects of
environmental surfaces, laundry, plants, animals, medical wastes, cloth furnishings, and carpeting on
disease transmission in healthcare facilities.
Part II of this guideline, Recommendations for Environmental Infection Control in Health-Care
Facilities, outlines environmental infection control in health-care facilities, describing measures for
preventing infections associated with air, water, and other elements of the environment. These
recommendations represent the views of different divisions within CDC’s National Center for Infectious
Diseases (NCID) (e.g., the Division of Healthcare Quality Promotion [DHQP] and the Division of
Bacterial and Mycotic Diseases [DBMD]) and the consensus of the Healthcare Infection Control
Practices Advisory Committee (HICPAC), a 12-member group that advises CDC on concerns related to
the surveillance, prevention, and control of health-care–associated infections, primarily in U.S. healthcare facilities.10 In 1999, HICPAC’s infection-control focus was expanded from acute-care hospitals to
all venues where health care is provided (e.g., outpatient surgical centers, urgent care centers, clinics,
outpatient dialysis centers, physicians’ offices, and skilled nursing facilities). The topics addressed in
this guideline are applicable to the majority of health-care venues in the United States. This document
is intended for use primarily by infection-control professionals (ICPs), epidemiologists, employee health
and safety personnel, information system specialists, administrators, engineers, facility managers,
environmental service professionals, and architects for health-care facilities.
Key recommendations include a) infection-control impact of ventilation system and water system
performance; b) establishment of a multidisciplinary team to conduct infection-control risk assessment;
c) use of dust-control procedures and barriers during construction, repair, renovation, or demolition; d)
environmental infection-control measures for special care areas with patients at high risk; e) use of
airborne particle sampling to monitor the effectiveness of air filtration and dust-control measures; f)
procedures to prevent airborne contamination in operating rooms when infectious tuberculosis [TB]
patients require surgery; g) guidance regarding appropriate indications for routine culturing of water as
part of a comprehensive control program for legionellae; h) guidance for recovering from water system
disruptions, water leaks, and natural disasters [e.g., flooding]; i) infection-control concepts for
equipment that uses water from main lines [e.g., water systems for hemodialysis, ice machines,
hydrotherapy equipment, dental unit water lines, and automated endoscope reprocessors]); j)
environmental surface cleaning and disinfection strategies with respect to antibiotic-resistant
2
microorganisms; k) infection-control procedures for health-care laundry; l) use of animals in health care
for activities and therapy; m) managing the presence of service animals in health-care facilities; n)
infection-control strategies for when animals receive treatment in human health-care facilities; and o) a
call to reinstate the practice of inactivating amplified cultures and stocks of microorganisms on-site
during medical waste treatment.
Whenever possible, the recommendations in Part II are based on data from well-designed scientific
studies. However, certain of these studies were conducted by using narrowly defined patient
populations or for specific health-care settings (e.g., hospitals versus long-term care facilities), making
generalization of findings potentially problematic. Construction standards for hospitals or other healthcare facilities may not apply to residential home-care units. Similarly, infection-control measures
indicated for immunosuppressed patient care are usually not necessary in those facilities where such
patients are not present. Other recommendations were derived from knowledge gained during infectious
disease investigations in health-care facilities, where successful termination of the outbreak was often
the result of multiple interventions, the majority of which cannot be independently and rigorously
evaluated. This is especially true for construction situations involving air or water.
Other recommendations are derived from empiric engineering concepts and may reflect an industry
standard rather than an evidence-based conclusion. Where recommendations refer to guidance from the
American Institute of Architects (AIA), the statements reflect standards intended for new construction
or renovation. Existing structures and engineered systems are expected to be in continued compliance
with the standards in effect at the time of construction or renovation. Also, in the absence of scientific
confirmation, certain infection-control recommendations that cannot be rigorously evaluated are based
on a strong theoretical rationale and suggestive evidence. Finally, certain recommendations are derived
from existing federal regulations. The references and the appendices comprise Parts III and IV of this
document, respectively.
Infections caused by the microorganisms described in these guidelines are rare events, and the effect of
these recommendations on infection rates in a facility may not be readily measurable. Therefore, the
following steps to measure performance are suggested to evaluate these recommendations (Box 1):
Box 1. Environmental infection control: performance measures
1.
Document whether infection-control personnel are actively involved in all phases of a health-care
facility’s demolition, construction, and renovation. Activities should include performing a risk
assessment of the necessary types of construction barriers, and daily monitoring and documenting
of the presence of negative airflow within the construction zone or renovation area.
2. Monitor and document daily the negative airflow in airborne infection isolation (AII) rooms and
positive airflow in protective environment (PE) rooms, especially when patients are in these rooms.
3. Perform assays at least once a month by using standard quantitative methods for endotoxin in
water used to reprocess hemodialyzers, and for heterotrophic and mesophilic bacteria in water
used to prepare dialysate and for hemodialyzer reprocessing.
4. Evaluate possible environmental sources (e.g., water, laboratory solutions, or reagents) of specimen
contamination when nontuberculous mycobacteria (NTM) of unlikely clinical importance are
isolated from clinical cultures. If environmental contamination is found, eliminate the probable
mechanisms.
5. Document policies to identify and respond to water damage. Such policies should result in either
repair and drying of wet structural or porous materials within 72 hours, or removal of the wet
material if drying is unlikely with 72 hours.
3
Topics outside the scope of this document include a) noninfectious adverse events (e.g., sick building
syndrome); b) environmental concerns in the home; c) home health care; d) bioterrorism; and e) healthcare–associated foodborne illness. This document includes only limited discussion of a)
handwashing/hand hygiene; b) standard precautions; and c) infection-control measures used to prevent
instrument or equipment contamination during patient care (e.g., preventing waterborne contamination
of nebulizers or ventilator humidifiers). These topics are mentioned only if they are important in
minimizing the transfer of pathogens to and from persons or equipment and the environment. Although
the document discusses principles of cleaning and disinfection as they are applied to maintenance of
environmental surfaces, the full discussion of sterilization and disinfection of medical instruments and
direct patient-care devices is deferred for inclusion in the Guideline for Disinfection and Sterilization in
Health-Care Facilities, a document currently under development. Similarly, the full discussion of hand
hygiene is available as the Guideline for Hand Hygiene in Health-Care Settings: Recommendations of
the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA
Hand Hygiene Task Force. Where applicable, the Guidelines for Environmental Infection Control in
Health-Care Facilities are consistent in content to the drafts available as of October 2002 of both the
revised Guideline for Prevention of Health-Care–Associated Pneumonia and Guidelines for Preventing
the Transmission of Mycobacterium tuberculosis in Health-Care Facilities.
This guideline was prepared by CDC staff members from NCID and the National Center for Chronic
Disease Prevention and Health Promotion (NCCDPHP) and the designated HICPAC advisor.
Contributors to this document reviewed predominantly English-language manuscripts identified from
reference searches using the National Library of Medicine’s MEDLINE, bibliographies of published
articles, and infection-control textbooks. Working drafts of the guideline were reviewed by CDC
scientists, HICPAC committee members, and experts in infection control, engineering, internal
medicine, infectious diseases, epidemiology, and microbiology. All recommendations in this guideline
may not reflect the opinions of all reviewers.
Part I. Background Information: Environmental
Infection Control in Health-Care Facilities
A. Introduction
The health-care environment contains a diverse population of microorganisms, but only a few are
significant pathogens for susceptible humans. Microorganisms are present in great numbers in moist,
organic environments, but some also can persist under dry conditions. Although pathogenic
microorganisms can be detected in air and water and on fomites, assessing their role in causing infection
and disease is difficult.11 Only a few reports clearly delineate a “cause and effect” with respect to the
environment and in particular, housekeeping surfaces.
Eight criteria are used to evaluate the strength of evidence for an environmental source or means of
transmission of infectious agents (Box 2).11, 12 Applying these criteria to disease investigations allows
scientists to assess the contribution of the environment to disease transmission. An example of this
application is the identification of a pathogen (e.g., vancomycin-resistant enterococci [VRE]) on an
environmental surface during an outbreak. The presence of the pathogen does not establish its causal
role; its transmission from source to host could be through indirect means (e.g., via hand transferral).11
The surface, therefore, would be considered one of a number of potential reservoirs for the pathogen,
but not the “de facto” source of exposure. An understanding of how infection occurs after exposure,
4
based on the principles of the “chain of infection,” is also important in evaluating the contribution of the
environment to health-care–associated disease.13 All of the components of the “chain” must be
operational for infection to occur (Box 3).
Box 2. Eight criteria for evaluating the strength of evidence for environmental sources of
infection* +
1.
2.
3.
4.
5.
6.
7.
8.
The organism can survive after inoculation onto the fomite.
The organism can be cultured from in-use fomites.
The organism can proliferate in or on the fomite.
Some measure of acquisition of infection cannot be explained by other recognized modes of
transmission.
Retrospective case-control studies show an association between exposure to the fomite and
infection.
Prospective case-control studies may be possible when more than one similar type of fomite is in
use.
Prospective studies allocating exposure to the fomite to a subset of patients show an assication
between exposure and infection.
Decontamination of the fomite results in the elimination of infection transmission.
* These criteria are listed in order of strength of evidence.
+ Adapted from references 11 and 12.
Box 3. Chain of infection components*
1.
2.
3.
4.
5.
Adequate number of pathogenic organisms (dose)
Pathogenic organisms of sufficient virulence
A susceptible host
An appropriate mode of transmission or transferal of the organism in sufficient number from
source to host
The correct portal of entry into the host
* Adapted from reference 13.
The presence of the susceptible host is one of these components that underscores the importance of the
health-care environment and opportunistic pathogens on fomites and in air and water. As a result of
advances in medical technology and therapies (e.g., cytotoxic chemotherapy and transplantation
medicine), more patients are becoming immunocompromised in the course of treatment and are
therefore at increased risk for acquiring health-care–associated opportunistic infections. Trends in
health-care delivery (e.g., early discharge of patients from acute care facilities) also are changing the
distribution of patient populations and increasing the number of immunocompromised persons in nonacute-care hospitals. According to the American Hospital Association (AHA), in 1998, the number of
hospitals in the United States totaled 6,021; these hospitals had a total of 1,013,000 beds,14 representing
a 5.5% decrease in the number of acute-care facilities and a 10.2% decrease in the number of beds over
the 5-year period 1994–1998.14 In addition, the total average daily number of patients receiving care in
U.S. acute-care hospitals in 1998 was 662,000 (65.4%) – 36.5% less than the 1978 average of
1,042,000.14 As the number of acute-care hospitals declines, the length of stay in these facilities is
concurrently decreasing, particularly for immunocompetent patients. Those patients remaining in acutecare facilities are likely to be those requiring extensive medical interventions who therefore at high risk
for opportunistic infection.
5
The growing population of severely immunocompromised patients is at odds with demands on the
health-care industry to remain viable in the marketplace; to incorporate modern equipment, new
diagnostic procedures, and new treatments; and to construct new facilities. Increasing numbers of
health-care facilities are likely to be faced with construction in the near future as hospitals consolidate to
reduce costs, defer care to ambulatory centers and satellite clinics, and try to create more “home-like”
acute-care settings. In 1998, approximately 75% of health-care–associated construction projects
focused on renovation of existing outpatient facilities or the building of such facilities;15 the number of
projects associated with outpatient health care rose by 17% from 1998 through 1999.16 An aging
population is also creating increasing demand for assisted-living facilities and skilled nursing centers.
Construction of assisted-living facilities in 1998 increased 49% from the previous year, with 138
projects completed at a cost of $703 million.16 Overall, from 1998 to 1999, health-care–associated
construction costs increased by 28.5%, from $11.56 billion to $14.86 billion.16
Environmental disturbances associated with construction activities near health-care facilities pose
airborne and waterborne disease threats risks for the substantial number of patients who are at risk for
health-care–associated opportunistic infections. The increasing age of hospitals and other health-care
facilities is also generating ongoing need for repair and remediation work (e.g., installing wiring for new
information systems, removing old sinks, and repairing elevator shafts) that can introduce or increase
contamination of the air and water in patient-care environments. Aging equipment, deferred
maintenance, and natural disasters provide additional mechanisms for the entry of environmental
pathogens into high-risk patient-care areas.
Architects, engineers, construction contractors, environmental health scientists, and industrial hygienists
historically have directed the design and function of hospitals’ physical plants. Increasingly, however,
because of the growth in the number of susceptible patients and the increase in construction projects, the
involvement of hospital epidemiologists and infection-control professionals is required. These experts
help make plans for building, maintaining, and renovating health-care facilities to ensure that the
adverse impact of the environment on the incidence of health-care–associated infections is minimal.
The following are examples of adverse outcomes that could have been prevented had such experts been
involved in the planning process: a) transmission of infections caused by Mycobacterium tuberculosis,
varicella-zoster virus (VZV), and measles (i.e., rubeola) facilitated by inappropriate air-handling
systems in health-care facilities;6 b) disease outbreaks caused by Aspergillus spp.,17–19 Mucoraceae,20
and Penicillium spp. associated with the absence of environmental controls during periods of health-care
facility-associated construction;21 c) infections and/or colonizations of patients and staff with
vancomycin-resistant Enterococcus faecium [VRE] and Clostridium difficile acquired indirectly from
contact with organisms present on environmental surfaces in health-care facilities;22–25 and d) outbreaks
and pseudoepidemics of legionellae,26, 27 Pseudomonas aeruginosa,28–30 and the nontuberculous
mycobacteria (NTM)31, 32 linked to water and aqueous solutions used in health-care facilities. The
purpose of this guideline is to provide useful information for both health-care professionals and
engineers in efforts to provide a safe environment in which quality health care may be provided to
patients. The recommendations herein provide guidance to minimize the risk for and prevent
transmission of pathogens in the indoor environment.
B. Key Terms Used in this Guideline
Although Appendix A provides definitions for terms discussed in Part I, several terms that pertain to
specific patient-care areas and patients who are at risk for health-care–associated opportunistic
infections are presented here. Specific engineering parameters for these care areas are discussed more
6
fully in the text. Airborne Infection Isolation (AII) refers to the isolation of patients infected with
organisms spread via airborne droplet nuclei <5 µm in diameter. This isolation area receives numerous
air changes per hour (ACH) (>12 ACH for new construction as of 2001; >6 ACH for construction
before 2001), and is under negative pressure, such that the direction of the airflow is from the outside
adjacent space (e.g., corridor) into the room. The air in an AII room is preferably exhausted to the
outside, but may be recirculated provided that the return air is filtered through a high efficiency
particulate air (HEPA) filter. The use of personal respiratory protection is also indicated for persons
entering these rooms.
Protective Environment (PE) is a specialized patient-care area, usually in a hospital, with a positive
airflow relative to the corridor (i.e., air flows from the room to the outside adjacent space). The
combination of HEPA filtration, high numbers of air changes per hour (>12 ACH), and minimal leakage
of air into the room creates an environment that can safely accommodate patients who have undergone
allogeneic hematopoietic stem cell transplant (HSCT).
Immunocompromised patients are those patients whose immune mechanisms are deficient because of
immunologic disorders (e.g., human immunodeficiency virus [HIV] infection, congenital immune
deficiency syndrome, chronic diseases [such as diabetes, cancer, emphysema, and cardiac failure]) or
immunosuppressive therapy (e.g., radiation, cytotoxic chemotherapy, anti-rejection medication, and
steroids). Immunocompromised patients who are identified as high-risk patients have the greatest risk
of infection caused by airborne or waterborne microorganisms. Patients in this subset include those who
are severely neutropenic for prolonged periods of time (i.e., an absolute neutrophil count [ANC] of <500
cells/mL), allogeneic HSCT patients, and those who have received intensive chemotherapy (e.g.,
childhood acute myelogenous leukemia patients).
C. Air
1. Modes of Transmission of Airborne Diseases
A variety of airborne infections in susceptible hosts can result from exposures to clinically significant
microorganisms released into the air when environmental reservoirs (i.e., soil, water, dust, and decaying
organic matter) are disturbed. Once these materials are brought indoors into a health-care facility by
any of a number of vehicles (e.g., people, air currents, water, construction materials, and equipment),
the attendant microorganisms can proliferate in various indoor ecological niches and, if subsequently
disbursed into the air, serve as a source for airborne health-care–associated infections.
Respiratory infections can be acquired from exposure to pathogens contained either in droplets or
droplet nuclei. Exposure to microorganisms in droplets (e.g., through aerosolized oral and nasal
secretions from infected patients33) constitutes a form of direct contact transmission. When droplets are
produced during a sneeze or cough, a cloud of infectious particles >5 µm in size is expelled, resulting in
the potential exposure of susceptible persons within 3 feet of the source person.6 Examples of
pathogens spread in this manner are influenza virus, rhinoviruses, adenoviruses, and respiratory
syncytial virus (RSV). Because these agents primarily are transmitted directly and because the droplets
tend to fall out of the air quickly, measures to control air flow in a health-care facility (e.g., use of
negative pressure rooms) generally are not indicated for preventing the spread of diseases caused by
these agents. Strategies to control the spread of these diseases are outlined in another guideline.3
The spread of airborne infectious diseases via droplet nuclei is a form of indirect transmission.34
Droplet nuclei are the residuals of droplets that, when suspended in air, subsequently dry and produce
7
particles ranging in size from 1–5 µm. These particles can a) contain potentially viable microorganisms,
b) be protected by a coat of dry secretions, c) remain suspended indefinitely in air, and d) be transported
over long distances. The microorganisms in droplet nuclei persist in favorable conditions (e.g., a dry,
cool atmosphere with little or no direct exposure to sunlight or other sources of radiation). Pathogenic
microorganisms that can be spread via droplet nuclei include Mycobacterium tuberculosis, VZV,
measles virus (i.e., rubeola), and smallpox virus (i.e., variola major).6 Several environmental pathogens
have life-cycle forms that are similar in size to droplet nuclei and may exhibit similar behavior in the
air. The spores of Aspergillus fumigatus have a diameter of 2–3.5 µm, with a settling velocity estimated
at 0.03 cm/second (or about 1 meter/hour) in still air. With this enhanced buoyancy, the spores, which
resist desiccation, can remain airborne indefinitely in air currents and travel far from their source.35
2. Airborne Infectious Diseases in Health-Care Facilities
a. Aspergillosis and Other Fungal Diseases
Aspergillosis is caused by molds belonging to the genus Aspergillus. Aspergillus spp. are prototype
health-care–acquired pathogens associated with dusty or moist environmental conditions. Clinical and
epidemiologic aspects of aspergillosis (Table 1) are discussed extensively in another guideline.3
Table 1. Clinical and epidemiologic characteristics of aspergillosis
References
Causative agents
Modes of transmission
Activities associated with
infection
Clinical syndromes and
diseases
Patient populations at
greatest risk
Factors affecting severity
and outcomes
Occurrence
Mortality rate
Aspergillus fumigatus (90%–95% of Aspergillus infections among
hematopoietic stem cell transplant (HSCT) patients; A. flavus, A. niger, A.
terreus, A. nidulans
Airborne transmission of fungal spores; direct inhalation; direct inoculation
from environmental sources (rare)
Construction, renovation, remodeling, repairs, building demolition; rare
episodes associated with fomites
Acute invasive: pneumonia; ulcerative tracheobronchitis; osteomyelitis;
abscesses (aspergillomas) of the lungs, brain, liver, spleen, and kidneys;
thrombosis of deep blood vessels; necrotizing skin ulcers; endophthalmitis;
and sinusitis
Chronic invasive: chronic pneumonitis
Hypersensity: allergic bronchopulmonary aspergillosis
Cutaneous: primary skin and burn-wound infections
Hematopoietic stem cell transplant patients (HSCT):
immunocompromised patients (i.e., those with underlying disease), patients
undergoing chemotherapy, organ transplant recipients, preterm neonates,
hemodialysis patients, patients with identifiable immune system deficiencies
who receive care in general intensive care units (ICUs), and cystic fibrosis
patients (may be colonized, occasionally become infected)
The immune status of the patient and the duration of severe neutropenia
Rare and sporadic, but increasing as proportion of immunocompromised
patients increases; 5% of HSCT patients infected, <5% of solid organ
transplant recipients infected
Rate can be as high as 100% if severe neutropenia persists; 13%–80%
mortality among leukemia patients
36–43
37
44–51
44, 45, 52–58
36, 59–78
79, 80
36, 37, 81–88
58, 83, 89, 90
Aspergillus spp. are ubiquitous, aerobic fungi that occur in soil, water, and decaying vegetation; the
organism also survives well in air, dust, and moisture present in health-care facilities.91–93 The presence
of aspergilli in the health-care facility environment is a substantial extrinsic risk factor for opportunistic
invasive aspergillosis (invasive aspergillosis being the most serious form of the disease).69, 94 Site
renovation and construction can disturb Aspergillus-contaminated dust and produce bursts of airborne
8
fungal spores. Increased levels of atmospheric dust and fungal spores have been associated with
clusters of health-care–acquired infections in immunocompromised patients.17, 20, 44, 47, 49, 50, 95–98
Absorbent building materials (e.g., wallboard) serve as an ideal substrate for the proliferation of this
organism if they become and remain wet, thereby increasing the numbers of fungal spores in the area.
Patient-care items, devices, and equipment can become contaminated with Aspergillus spp. spores and
serve as sources of infection if stored in such areas.57
Most cases of aspergillosis are caused by Aspergillus fumigatus, a thermotolerant/thermophilic fungus
capable of growing over a temperature range from 53.6°F–127.4°F (12°C–53°C); optimal growth occurs
at approximately 104°F (40°C), a temperature inhibitory to most other saprophytic fungi.99 It can use
cellulose or sugars as carbon sources; because its respiratory process requires an ample supply of
carbon, decomposing organic matter is an ideal substrate.
Other opportunistic fungi that have been occasionally linked with health-care–associated infections are
members of the order Mucorales (e.g., Rhizopus spp.) and miscellaneous moniliaceous molds (e.g.,
Fusarium spp. and Penicillium spp.) (Table 2). Many of these fungi can proliferate in moist
environments (e.g., water-damaged wood and building materials). Some fungi (e.g., Fusarium spp. and
Pseudoallescheria spp.) also can be airborne pathogens.100 As with aspergillosis, a major risk factor for
disease caused by any of these pathogens is the host’s severe immunosuppression from either
underlying disease or immunosuppressive therapy.101, 102
Table 2. Environmental fungal pathogens: entry into and contamination of the healthcare facility
Implicated environmental vehicle
References
Aspergillus spp.
Improperly functioning ventilation systems
Air filters*,+
Air filter frames
Window air conditioners
Backflow of contaminated air
Air exhaust contamination+
False ceilings
Fibrous insulation and perforated metal ceilings
Acoustic ceiling tiles, plasterboard
Fireproofing material
Damp wood building materials
Opening doors to construction site
Construction
Open windows
Disposal conduit door
Hospital vacuum cleaner
Elevator
Arm boards
Walls
Unit kitchen
Food
Ornamental plants
20, 46, 47, 97, 98, 103, 104
17, 18, 105–107
17, 18
96
107
104
48, 57, 97, 108
66
18, 109
48, 49
49
110
69
20, 108, 111
68
68
112
57
113
114
21
21
Mucorales / Rhizopus spp.
Air filter
False ceilings
Heliport
20, 115
97
115
Scedosporium spp.
Construction
116
9
(Table 2. continued)
Implicated environmental vehicles
References
Penicillium spp.
Rotting cabinet wood, pipe leak
Ventilation duct fiberglass insulation
Air filters
Topical anesthetic
21
112
105
117
Acremonium spp.
Air filters
105
Cladosporium spp.
Air filters
105
Sporothrix
Construction (pseudoepidemic)
118
*. Pigeons, their droppings and roosts are associated with spread of Aspergillus, Cryptococcus, and Histoplasma spp. There have been at
least three outbreaks linked to contamination of the filtering systems from bird droppings98, 103, 104 Pigeon mites may gain access into a
health-care facility through the ventilation system.119
+. The American Institute of Architects (AIA) standards stipulate that for new or renovated construction a) exhaust outlets are to be placed
>25 feet from air intake systems, b) the bottom of outdoor air intakes for HVAC systems should be 6 feet above ground or 3 feet above
roof level, and c) exhaust outlets from contaminated areas are situated above the roof level and arranged to minimize the recirculation of
exhausted air back into the building.120
Infections due Cryptococcus neoformans, Histoplasma capsulatum, or Coccidioides immitis can occur
in health-care settings if nearby ground is disturbed and a malfunction of the facility’s air-intake
components allows these pathogens to enter the ventilation system. C. neoformans is a yeast usually 4–
8 µm in size. However, viable particles of <2 µm diameter (and thus permissive to alveolar deposition)
have been found in soil contaminated with bird droppings, particularly from pigeons.98, 103, 104, 121 H.
capsulatum, with the infectious microconidia ranging in size from 2–5 µm, is endemic in the soil of the
central river valleys of the United States. Substantial numbers of these infectious particles have been
associated with chicken coops and the roosts of blackbirds.98, 103, 104, 122 Several outbreaks of
histoplasmosis have been associated with disruption of the environment; construction activities in an
endemic area may be a potential risk factor for health-care–acquired airborne infection.123, 124 C.
immitis, with arthrospores of 3–5 µm diameter, has similar potential, especially in the endemic
southwestern United States and during seasons of drought followed by heavy rainfall. After the 1994
earthquake centered near Northridge, California, the incidence of coccidioidomycosis in the surrounding
area exceeded the historical norm.125
Emerging evidence suggests that Pneumocystis carinii, now classified as a fungus, may be spread via
airborne, person-to-person transmission.126 Controlled studies in animals first demonstrated that P.
carinii could be spread through the air.127 More recent studies in health-care settings have detected
nucleic acids of P. carinii in air samples from areas frequented or occupied by P. carinii-infected
patients but not in control areas that are not occupied by these patients.128, 129 Clusters of cases have
been identified among immunocompromised patients who had contact with a source patient and with
each other. Recent studies have examined the presence of P. carinii DNA in oropharyngeal washings
and the nares of infected patients, their direct contacts, and persons with no direct contact.130, 131
Molecular analysis of the DNA by polymerase chain reaction (PCR) provides evidence for airborne
transmission of P. carinii from infected patients to direct contacts, but immunocompetent contacts tend
to become transiently colonized rather than infected.131 The role of colonized persons in the spread of
P. carinii pneumonia (PCP) remains to be determined. At present, specific modifications to ventilation
systems to control spread of PCP in a health-care facility are not indicated. Current recommendations
10
outline isolation procedures to minimize or eliminate contact of immunocompromised patients not on
PCP prophylaxis with PCP-infected patients.6, 132
b. Tuberculosis and Other Bacterial Diseases
The bacterium most commonly associated with airborne transmission is Mycobacterium tuberculosis. A
comprehensive review of the microbiology and epidemiology of M. tuberculosis and guidelines for
tuberculosis (TB) infection control have been published.4, 133, 134 A summary of the clinical and
epidemiologic information from these materials is provided in this guideline (Table 3).
Table 3. Clinical and epidemiologic characteristics of tuberculosis (TB)*
Causative agents
Mode of transmission
Patient factors associated with
infectivity and transmission
Activities associated with
infections
Clinical syndromes and disease
Populations at greatest risk
Factors affecting severity and
outcomes
Occurrence
Mortality
Chemoprophylaxis / treatment
Mycobacterium tuberculosis, M. bovis, M. africanum
Airborne transmission via droplet nuclei 1–5 µm in diameter
▪ Disease of the lungs, airways, or larynx; presence of cough or other forceful
expiratory measures
▪ Presence of acid-fast bacilli (AFB) in the sputum
▪ Failure of the patient to cover the mouth and nose when coughing or sneezing
▪ Presence of cavitation on chest radiograph
▪ Inappropriate or shortened duration of chemotherapy
▪ Exposures in relatively small, enclosed spaces
▪ Inadequate ventilation resulting in insufficient removal of droplet nuclei
▪ Cough-producing procedures done in areas without proper environmental controls
▪ Recirculation of air containing infectious droplet nuclei
▪ Failure to use respiratory protection when managing open lesions for patients with
suspected extrapulmonary TB135
Pulmonary TB; extrapulmonary TB can affect any organ system or tissue; laryngeal
TB is highly contagious
▪ Immunocompromised persons (e.g., HIV-infected persons)
▪ Medically underserved persons, urban poor, homeless persons, elderly persons,
migrant farm workers, close contacts of known patients
▪ Substance abusers, present and former prison inmates
▪ Foreign-born persons from areas with high prevalence of TB
▪ Health-care workers
▪ Concentration of droplet nuclei in air, duration of exposure
▪ Age at infection
▪ Immunosuppression due to therapy or disease, underlying chronic medical
conditions, history of malignancies or lesions or the lungs
Worldwide; incidence in the United States is 5.6 cases/100,000 population (2001)136
930 deaths in the United States (1999)136
Treatment of latent infection includes isoniazid (INH) or rifampin (RIF).4, 134, 137–139
Directly observed therapy (DOT) for active cases as indicated: INH, RIF,
pyrazinamide (PZA), ethambutol (EMB), streptomycin (SM) in various combinations
determined by prevalent levels of specific resistance.4, 134, 137–139 Consult therapy
guidelines for specific treatment indications.139
* Material in this table is compiled from references 4, 133–141.
M. tuberculosis is carried by droplet nuclei generated when persons (primarily adults and adolescents)
who have pulmonary or laryngeal TB sneeze, cough, speak, or sing;139 normal air currents can keep
these particles airborne for prolonged periods and spread them throughout a room or building.142
However, transmission of TB has occurred from mycobacteria aerosolized during provision of care
(e.g., wound/lesion care or during handling of infectious peritoneal dialysis fluid) for extrapulmonary
TB patients.135, 140
Gram-positive cocci (i.e., Staphylococcus aureus, group A beta-hemolytic streptococci), also important
health-care–associated pathogens, are resistant to inactivation by drying and can persist in the
11
environment and on environmental surfaces for extended periods. These organisms can be shed from
heavily colonized persons and discharged into the air. Airborne dispersal of S. aureus is directly
associated with the concentration of the bacterium in the anterior nares.143 Approximately 10% of
healthy carriers will disseminate S. aureus into the air, and some persons become more effective
disseminators of S. aureus than others.144–148 The dispersal of S. aureus into air can be exacerbated by
concurrent viral upper respiratory infection, thereby turning a carrier into a “cloud shedder.”149
Outbreaks of surgical site infections (SSIs) caused by group A beta-hemolytic streptococci have been
traced to airborne transmission from colonized operating-room personnel to patients.150–153 In these
situations, the strain causing the outbreak was recovered from the air in the operating room150, 151, 154 or
on settle plates in a room in which the carrier exercised.151–153 S. aureus and group A streptococci have
not been linked to airborne transmission outside of operating rooms, burn units, and neonatal
nurseries.155, 156 Transmission of these agents occurs primarily via contact and droplets.
Other gram-positive bacteria linked to airborne transmission include Bacillus spp. which are capable of
sporulation as environmental conditions become less favorable to support their growth. Outbreaks and
pseudo-outbreaks have been attributed to Bacillus cereus in maternity, pediatric, intensive care, and
bronchoscopy units; many of these episodes were secondary to environmental contamination.157–160
Gram-negative bacteria rarely are associated with episodes of airborne transmission because they
generally require moist environments for persistence and growth. The main exception is Acinetobacter
spp., which can withstand the inactivating effects of drying. In one epidemiologic investigation of
bloodstream infections among pediatric patients, identical Acinetobacter spp. were cultured from the
patients, air, and room air conditioners in a nursery.161
Aerosols generated from showers and faucets may potentially contain legionellae and other gramnegative waterborne bacteria (e.g., Pseudomonas aeruginosa). Exposure to these organisms is through
direct inhalation. However, because water is the source of the organisms and exposure occurs in the
vicinity of the aerosol, the discussion of the diseases associated with such aerosols and the prevention
measures used to curtail their spread is discussed in another section of the Guideline (see Part I: Water).
c. Airborne Viral Diseases
Some human viruses are transmitted from person to person via droplet aerosols, but very few viruses are
consistently airborne in transmission (i.e., are routinely suspended in an infective state in air and capable
of spreading great distances), and health-care–associated outbreaks of airborne viral disease are limited
to a few agents. Consequently, infection-control measures used to prevent spread of these viral diseases
in health-care facilities primarily involve patient isolation, vaccination of susceptible persons, and
antiviral therapy as appropriate rather than measures to control air flow or quality.6 Infections caused
by VZV frequently are described in health-care facilities. Health-care–associated airborne outbreaks of
VZV infections from patients with primary infection and disseminated zoster have been documented;
patients with localized zoster have, on rare occasions, also served as source patients for outbreaks in
health-care facilities.162–166 VZV infection can be prevented by vaccination, although patients who
develop a rash within 6 weeks of receiving varicella vaccine or who develop breakthrough varicella
following exposure should be considered contagious.167
Viruses whose major mode of transmission is via droplet contact rarely have caused clusters of
infections in group settings through airborne routes. The factors facilitating airborne distribution of
these viruses in an infective state are unknown, but a presumed requirement is a source patient in the
early stage of infection who is shedding large numbers of viral particles into the air. Airborne
transmission of measles has been documented in health-care facilities.168–171 In addition, institutional
outbreaks of influenza virus infections have occurred predominantly in nursing homes,172–176 and less
frequently in medical and neonatal intensive care units, chronic-care areas, HSCT units, and pediatric
12
wards.177–180 Some evidence supports airborne transmission of influenza viruses by droplet nuclei,181, 182
and case clusters in pediatric wards suggest that droplet nuclei may play a role in transmitting certain
respiratory pathogens (e.g., adenoviruses and respiratory syncytial virus [RSV]).177, 183, 184 Some
evidence also supports airborne transmission of enteric viruses. An outbreak of a Norwalk-like virus
infection involving more than 600 staff personnel over a 3-week period was investigated in a Toronto,
Ontario hospital in 1985; common sources (e.g., food and water) were ruled out during the
investigation, leaving airborne spread as the most likely mode of transmission.185
Smallpox virus, a potential agent of bioterrorism, is spread predominantly via direct contact with
infectious droplets, but it also can be associated with airborne transmission.186, 187 A German hospital
study from 1970 documented the ability of this virus to spread over considerable distances and cause
infection at low doses in a well-vaccinated population; factors potentially facilitating transmission in
this situation included a patient with cough and an extensive rash, indoor air with low relative humidity,
and faulty ventilation patterns resulting from hospital design (e.g., open windows).188 Smallpox
patients with extensive rash are more likely to have lesions present on mucous membranes and therefore
have greater potential to disseminate virus into the air.188 In addition to the smallpox transmission in
Germany, two cases of laboratory-acquired smallpox virus infection in the United Kingdom in 1978
also were thought to be caused by airborne transmission.189
Airborne transmission may play a role in the natural spread of hantaviruses and certain hemorrhagic
fever viruses (e.g., Ebola, Marburg, and Lassa), but evidence for airborne spread of these agents in
health-care facilities is inconclusive.190 Although hantaviruses can be transmitted when aerosolized
from rodent excreta,191, 192 person-to-person spread of hantavirus infection from source patients has not
occurred in health-care facilities.193–195 Nevertheless, health-care workers are advised to contain
potentially infectious aerosols and wear National Institute of Occupational Safety and Health (NIOSH)
approved respiratory protection when working with this agent in laboratories or autopsy suites.196
Lassa virus transmission via aerosols has been demonstrated in the laboratory and incriminated in
health-care–associated infections in Africa,197–199 but airborne spread of this agent in hospitals in
developed nations likely is inefficient.200, 201 Yellow fever is considered to be a viral hemorrhagic fever
agent with high aerosol infectivity potential, but health-care–associated transmission of this virus has
not been described.202 Viral hemorrhagic fever diseases primarily occur after direct exposure to
infected blood and body fluids, and the use of standard and droplet precautions prevents transmission
early in the course of these illnesses.203, 204 However, whether these viruses can persist in droplet nuclei
that might remain after droplet production from coughs or vomiting in the latter stages of illness is
unknown.205 Although the use of a negative-pressure room is not required during the early stages of
illness, its use might be prudent at the time of hospitalization to avoid the need for subsequent patient
transfer. Current CDC guidelines recommend negative-pressure rooms with anterooms for patients with
hemorrhagic fever and use of HEPA respirators by persons entering these rooms when the patient has
prominent cough, vomiting, diarrhea, or hemorrhage.6, 203 Face shields or goggles will help to prevent
mucous-membrane exposure to potentially-aerosolized infectious material in these situations. If an
anteroom is not available, portable, industrial-grade high efficiency particulate air (HEPA) filter units
can be used to provide the equivalent of additional air changes per hour (ACH).
13
Table 4. Microorganisms associated with airborne transmission*
Fungi
Numerous reports
in health-care
facilities
Atypical,
occasional reports
Airborne in nature;
airborne
transmission in
health care settings
not described
Under investigation
Bacteria
Viruses
Aspergillus spp.+
Mucorales (Rhizopus spp.)97, 115
Mycobacterium
tuberculosis+
Measles (rubeola) virus168-170
Varicella-zoster virus162-166
Acremonium spp.105, 206
Fusarium spp.102
Pseudoallescheria boydii100
Scedosporium spp.116
Sporothrix cyanescens¶118
Coccidioides immitis125
Cryptococcus spp.121
Histoplasma capsulatum124
Acinetobacter spp.161
Bacillus spp.¶160, 207
Brucella spp.**208-211
Staphylococcus aureus148, 156
Group A Streptococcus151
Coxiella burnetii (Q fever)212
Smallpox virus (variola)§188, 189
Influenza viruses181, 182
Respiratory syncytial virus183
Adenoviruses184
Norwalk-like virus185
Hantaviruses193, 195
Lassa virus205
Marburg virus205
Ebola virus205
Crimean-Congo virus205
Pneumocystis carinii131
—
—
* This list excludes microorganisms transmitted from aerosols derived from water.
+ Refer to the text for references for these disease agents.
§ Airborne transmission of smallpox is infrequent. Potential for airborne transmission increases with patients who are effective disseminators
present in facilities with low relative humidity in the air and faulty ventilation.
¶ Documentation of pseudoepidemic during construction.
** Airborne transmission documented in the laboratory but not in patient-care areas
3. Heating, Ventilation, and Air Conditioning Systems in Health-Care
Facilities
a. Basic Components and Operations
Heating, ventilation, and air conditioning (HVAC) systems in health-care facilities are designed to a)
maintain the indoor air temperature and humidity at comfortable levels for staff, patients, and visitors;
b) control odors; c) remove contaminated air; d) facilitate air-handling requirements to protect
susceptible staff and patients from airborne health-care–associated pathogens; and e) minimize the risk
for transmission of airborne pathogens from infected patients.35, 120 An HVAC system includes an
outside air inlet or intake; filters; humidity modification mechanisms (i.e., humidity control in summer,
humidification in winter); heating and cooling equipment; fans; ductwork; air exhaust or out-takes; and
registers, diffusers, or grilles for proper distribution of the air (Figure 1).213, 214 Decreased performance
of healthcare facility HVAC systems, filter inefficiencies, improper installation, and poor maintenance
can contribute to the spread of health-care–associated airborne infections.
The American Institute of Architects (AIA) has published guidelines for the design and construction of
new health-care facilities and for renovation of existing facilities. These AIA guidelines address indoor
air-quality standards (e.g., ventilation rates, temperature levels, humidity levels, pressure relationships,
and minimum air changes per hour [ACH]) specific to each zone or area in health-care facilities (e.g.,
operating rooms, laboratories, diagnostic areas, patient-care areas, and support departments).120 These
guidelines represent a consensus document among authorities having jurisdiction (AHJ), governmental
regulatory agencies (i.e., Department of Health and Human Services [DHHS]; Department of Labor,
Occupational Safety and Health Administration [OSHA]), health-care professionals, professional
organizations (e.g., American Society of Heating, Refrigeration, and Air-Conditioning Engineers
[ASHRAE], American Society for Healthcare Engineering [ASHE]), and accrediting organizations (i.e.,
Joint Commission on Accreditation of Healthcare Organizations [JCAHO]). More than 40 state
agencies that license health-care facilities have either incorporated or adopted by reference these
14
guidelines into their state standards. JCAHO, through its surveys, ensures that facilities are in
compliance with the ventilation guidelines of this standard for new construction and renovation.
Figure 1. Diagram of a ventilation system*
Outdoor air and recirculated air pass through air cleaners (e.g., filter banks) designed to reduce the concentration of airborne
contaminants. Air is conditioned for temperature and humidity before it enters the occupied space as supply air. Infiltration is
air leakage inward through cracks and interstitial spaces of walls, floors, and ceilings. Exfiltration is air leakage outward
through these same cracks and spaces. Return air is largely exhausted from the system, but a portion is recirculated with fresh,
incoming air.
* Used with permission of the publisher of reference 214 (ASHRAE)
Engineering controls to contain or prevent the spread of airborne contaminants center on a) local
exhaust ventilation [i.e., source control], b) general ventilation, and c) air cleaning.4 General ventilation
encompasses a) dilution and removal of contaminants via well-mixed air distribution of filtered air, b)
directing contaminants toward exhaust registers and grilles via uniform, non-mixed airflow patterns, c)
pressurization of individual spaces relative to all other spaces, and d) pressurization of buildings relative
to the outdoors and other attached buildings.
A centralized HVAC system operates as follows. Outdoor air enters the system, where low-efficiency
or “roughing” filters remove large particulate matter and many microorganisms. The air enters the
distribution system for conditioning to appropriate temperature and humidity levels, passes through an
additional bank of filters for further cleaning, and is delivered to each zone of the building. After the
conditioned air is distributed to the designated space, it is withdrawn through a return duct system and
delivered back to the HVAC unit. A portion of this “return air” is exhausted to the outside while the
remainder is mixed with outdoor air for dilution and filtered for removal of contaminants.215 Air from
toilet rooms or other soiled areas is usually exhausted directly to the atmosphere through a separate duct
exhaust system. Air from rooms housing tuberculosis patients is exhausted to the outside if possible, or
passed through a HEPA filter before recirculation. Ultraviolet germicidal irradiation (UVGI) can be
used as an adjunct air-cleaning measure, but it cannot replace HEPA filtration.
15
b. Filtration
i. Filter Types and Methods of Filtration
Filtration, the physical removal of particulates from air, is the first step in achieving acceptable indoor
air quality. Filtration is the primary means of cleaning the air. Five methods of filtration can be used
(Table 5). During filtration, outdoor air passes through two filter beds or banks (with efficiencies of
20%–40% and >90%, respectively) for effective removal of particles 1–5 µm in diameter.35, 120 The
low-to-medium efficiency filters in the first bank have low resistance to airflow, but this feature allows
some small particulates to pass onto heating and air conditioning coils and into the indoor
environment.35 Incoming air is mixed with recirculated air and reconditioned for temperature and
humidity before being filtered by the second bank of filters. The performance of filters with <90%
efficiency is measured using either the dust-spot test or the weight-arrestance test.35, 216
Table 5. Filtration methods*
Basic method
Straining
Impingement
Interception
Diffusion
Electrostatic
Principle of performance
Particles in the air are larger than the openings between the
filter fibers, resulting in gross removal of large particles.
Particles collide with filter fibers and remain attached to the
filter. Fibers may be coated with adhesive.
Particles enter into the filter and become entrapped and
attached to the filter fibers.
Small particles, moving in erratic motion, collide with filter
fibers and remain attached.
Particles bearing negative electrostatic charge are attracted to
the filter with positively charged fibers.
Filtering efficiency
Low
Low
Medium
High
High
* Material in this table was compiled from information in reference 217.
The second filter bank usually consists of high-efficiency filters. This filtration system is adequate for
most patient-care areas in ambulatory-care facilities and hospitals, including the operating room
environment and areas providing central services.120 Nursing facilities use 90% dust-spot efficient
filters as the second bank of filters,120 whereas a HEPA filter bank may be indicated for special-care
areas of hospitals. HEPA filters are at least 99.97% efficient for removing particles >0.3 µm in
diameter. (As a reference, Aspergillus spores are 2.5–3.0 µm in diameter.) Examples of care areas
where HEPA filters are used include PE rooms and those operating rooms designated for orthopedic
implant procedures.35
Maintenance costs associated with HEPA filters are high compared with other types of filters, but use of
in-line disposable prefilters can increase the life of a HEPA filter by approximately 25%. Alternatively,
if a disposable prefilter is followed by a filter that is 90% efficient, the life of the HEPA filter can be
extended ninefold. This concept, called progressive filtration, allows HEPA filters in special care areas
to be used for 10 years.213 Although progressive filtering will extend the mechanical ability of the
HEPA filter, these filters may absorb chemicals in the environment and later desorb those chemicals,
thereby necessitating a more frequent replacement program. HEPA filter efficiency is monitored with
the dioctylphthalate (DOP) particle test using particles that are 0.3 µm in diameter.218
HEPA filters are usually framed with metal, although some older versions have wood frames. A metal
frame has no advantage over a properly fitted wood frame with respect to performance, but wood can
compromise the air quality if it becomes and remains wet, allowing the growth of fungi and bacteria.
Hospitals are therefore advised to phase out water-damaged or spent wood-framed filter units and
replace them with metal-framed HEPA filters.
16
HEPA filters are usually fixed into the HVAC system; however, portable, industrial grade HEPA units
are available that can filter air at the rate of 300–800 ft3/min. Portable HEPA filters are used to a)
temporarily recirculate air in rooms with no general ventilation, b) augment systems that cannot provide
adequate airflow, and c) provide increased effectiveness in airflow.4 Portable HEPA units are useful
engineering controls that help clean the air when the central HVAC system is undergoing repairs,219 but
these units do not satisfy fresh-air requirements.214 The effectiveness of the portable unit for particle
removal is dependent on a) the configuration of the room, b) the furniture and persons in the room, c)
the placement of the units relative to the contents and layout of the room, and d) the location of the
supply and exhaust registers or grilles. If portable, industrial-grade units are used, they should be
capable of recirculating all or nearly all of the room air through the HEPA filter, and the unit should be
designed to achieve the equivalent of >12 ACH.4 (An average room has approximately 1,600 ft3 of
airspace.) The hospital engineering department should be contacted to provide ACH information in the
event that a portable HEPA filter unit is necessary to augment the existing fixed HVAC system for air
cleaning.
ii. Filter Maintenance
Efficiency of the filtration system is dependent on the density of the filters, which can create a drop in
pressure unless compensated by stronger and more efficient fans, thus maintaining air flow. For optimal
performance, filters require monitoring and replacement in accordance with the manufacturer’s
recommendations and standard preventive maintenance practices.220 Upon removal, spent filters can be
bagged and discarded with the routine solid waste, regardless of their patient-care area location.221
Excess accumulation of dust and particulates increases filter efficiency, requiring more pressure to push
the air through. The pressure differential across filters is measured by use of manometers or other
gauges. A pressure reading that exceeds specifications indicates the need to change the filter. Filters
also require regular inspection for other potential causes of decreased performance. Gaps in and around
filter banks and heavy soil and debris upstream of poorly maintained filters have been implicated in
health-care–associated outbreaks of aspergillosis, especially when accompanied by construction
activities at the facility.17, 18, 106, 222
c. Ultraviolet Germicidal Irradiation (UVGI)
As a supplemental air-cleaning measure, UVGI is effective in reducing the transmission of airborne
bacterial and viral infections in hospitals, military housing, and classrooms, but it has only a minimal
inactivating effect on fungal spores.223–228 UVGI is also used in air handling units to prevent or limit
the growth of vegetative bacteria and fungi. Most commercially available UV lamps used for
germicidal purposes are low-pressure mercury vapor lamps that emit radiant energy predominantly at a
wave-length of 253.7 nm.229, 230 Two systems of UVGI have been used in health-care settings – duct
irradiation and upper-room air irradiation. In duct irradiation systems, UV lamps are placed inside ducts
that remove air from rooms to disinfect the air before it is recirculated. When properly designed,
installed, and maintained, high levels of UVGI can be attained in the ducts with little or no exposure of
persons in the rooms.231, 232 In upper-room air irradiation, UV lamps are either suspended from the
ceiling or mounted on the wall.4 Upper air UVGI units have two basic designs: a) a “pan” fixture with
UVGI unshielded above the unit to direct the irradiation upward and b) a fixture with a series of parallel
plates to columnize the irradiation outward while preventing the light from getting to the eyes of the
room’s occupants. The germicidal effect is dependent on air mixing via convection between the room’s
irradiated upper zone and the lower patient-care zones.233, 234
Bacterial inactivation studies using BCG mycobacteria and Serratia marcescens have estimated the
effect of UVGI as equivalent to 10 ACH–39 ACH.235, 236 Another study, however, suggests that UVGI
may result in fewer equivalent ACH in the patient-care zone, especially if the mixing of air between
zones is insufficient.234 The use of fans or HVAC systems to generate air movement may increase the
effectiveness of UVGI if airborne microorganisms are exposed to the light energy for a sufficient length
17
of time.233, 235, 237–239 The optimal relationship between ventilation and UVGI is not known.
Because the clinical effectiveness of UV systems may vary, UVGI is not recommended for air
management prior to air recirculation from airborne isolation rooms. It is also not recommended as a
substitute for HEPA filtration, local exhaust of air to the outside, or negative pressure.4 The use of UV
lamps and HEPA filtration in a single unit offers only minimal infection-control benefits over those
provided by the use of a HEPA filter alone.240 Duct systems with UVGI are not recommended as a
substitute for HEPA filters if the air from isolation rooms must be recirculated to other areas of the
facility.4 Regular maintenance of UVGI systems is crucial and usually consists of keeping the bulbs
free of dust and replacing old bulbs as necessary. Safety issues associated with the use of UVGI
systems are described in other guidelines.4
d. Conditioned Air in Occupied Spaces
Temperature and humidity are two essential components of conditioned air. After outside air passes
through a low- or medium-efficiency filter, the air undergoes conditioning for temperature and humidity
control before it passes through high-efficiency or HEPA filtration.
i. Temperature
HVAC systems in health-care facilities are often single-duct or dual-duct systems.35, 241 A single-duct
system distributes cooled air (55°F [12.8°C]) throughout the building and uses thermostatically
controlled reheat boxes located in the terminal ductwork to warm the air for individual or multiple
rooms. The dual-duct system consists of parallel ducts, one with a cold air stream and the other with a
hot air stream. A mixing box in each room or group of rooms mixes the two air streams to achieve the
desired temperature. Temperature standards are given as either a single temperature or a range,
depending on the specific health-care zone. Cool temperature standards (68°F–73°F [20°C–23°C])
usually are associated with operating rooms, clean workrooms, and endoscopy suites.120 A warmer
temperature (75°F [24°C]) is needed in areas requiring greater degrees of patient comfort. Most other
zones use a temperature range of 70°F–75°F (21°C–24°C).120 Temperatures outside of these ranges
may be needed occasionally in limited areas depending on individual circumstances during patient care
(e.g., cooler temperatures in operating rooms during specialized operations).
ii. Humidity
Four measures of humidity are used to quantify different physical properties of the mixture of water
vapor and air. The most common of these is relative humidity, which is the ratio of the amount of water
vapor in the air to the amount of water vapor air can hold at that temperature.242 The other measures of
humidity are specific humidity, dew point, and vapor pressure.242
Relative humidity measures the percentage of saturation. At 100% relative humidity, the air is
saturated. For most areas within health-care facilities, the designated comfort range is 30%–60%
relative humidity.120, 214 Relative humidity levels >60%, in addition to being perceived as
uncomfortable, promote fungal growth.243 Humidity levels can be manipulated by either of two
mechanisms.244 In a water-wash unit, water is sprayed and drops are taken up by the filtered air;
additional heating or cooling of this air sets the humidity levels. The second mechanism is by means of
water vapor created from steam and added to filtered air in humidifying boxes. Reservoir-type
humidifiers are not allowed in health-care facilities as per AIA guidelines and many state codes.120
Cool-mist humidifiers should be avoided, because they can disseminate aerosols containing allergens
and microorganisms.245 Additionally, the small, personal-use versions of this equipment can be
difficult to clean.
18
iii. Ventilation
The control of air pollutants (e.g., microorganisms, dust, chemicals, and smoke) at the source is the most
effective way to maintain clean air. The second most effective means of controlling indoor air pollution
is through ventilation. Ventilation rates are voluntary unless a state or local government specifies a
standard in health-care licensing or health department requirements. These standards typically apply to
only the design of a facility, rather than its operation.220, 246 Health-care facilities without specific
ventilation standards should follow the AIA guideline specific to the year in which the building was
built or the ANSI/ASHRAE Standard 62, Ventilation for Acceptable Indoor Air Quality.120, 214, 241
Ventilation guidelines are defined in terms of air volume per minute per occupant and are based on the
assumption that occupants and their activities are responsible for most of the contaminants in the
conditioned space.215 Most ventilation rates for health-care facilities are expressed as room ACH. Peak
efficiency for particle removal in the air space occurs between 12 ACH–15 ACH.35, 247, 248 Ventilation
rates vary among the different patient-care areas of a health-care facility (Appendix B).120
Health-care facilities generally use recirculated air.35, 120, 241, 249, 250 Fans create sufficient positive
pressure to force air through the building duct work and adequate negative pressure to evacuate air from
the conditioned space into the return duct work and/or exhaust, thereby completing the circuit in a
sealed system (Figure 1). However, because gaseous contaminants tend to accumulate as the air
recirculates, a percentage of the recirculated air is exhausted to the outside and replaced by fresh
outdoor air. In hospitals, the delivery of filtered air to an occupied space is an engineered system design
issue, the full discussion of which is beyond the scope of this document.
Hospitals with areas not served by central HVAC systems often use through-the-wall or fan coil air
conditioning units as the sole source of room ventilation. AIA guidelines for newly installed systems
stipulate that through-the-wall fan-coil units be equipped with permanent (i.e., cleanable) or replaceable
filters with a minimum efficiency of 68% weight arrestance.120 These units may be used only as
recirculating units; all outdoor air requirements must be met by a separate central air handling system
with proper filtration, with a minimum of two outside air changes in general patient rooms (D. Erickson,
ASHE, 2000).120 If a patient room is equipped with an individual through-the-wall fan coil unit, the
room should not be used as either AII or as PE.120 These requirements, although directed to new
HVAC installations also are appropriate for existing settings. Non-central air-handling systems are
prone to problems associated with excess condensation accumulating in drip pans and improper filter
maintenance; health-care facilities should clean or replace the filters in these units on a regular basis
while the patient is out of the room.
Laminar airflow ventilation systems are designed to move air in a single pass, usually through a bank of
HEPA filters either along a wall or in the ceiling, in a one-way direction through a clean zone with
parallel streamlines. Laminar airflow can be directed vertically or horizontally; the unidirectional
system optimizes airflow and minimizes air turbulence.63, 241 Delivery of air at a rate of 0.5 meters per
second (90 + 20 ft/min) helps to minimize opportunities for microorganism proliferation.63, 251, 252
Laminar airflow systems have been used in PE to help reduce the risk for health-care–associated
airborne infections (e.g., aspergillosis) in high-risk patients.63, 93, 253, 254 However, data that demonstrate
a survival benefit for patients in PE with laminar airflow are lacking. Given the high cost of installation
and apparent lack of benefit, the value of laminar airflow in this setting is questionable.9, 37 Few data
support the use of laminar airflow systems elsewhere in a hospital.255
iv. Pressurization
Positive and negative pressures refer to a pressure differential between two adjacent air spaces (e.g.,
rooms and hallways). Air flows away from areas or rooms with positive pressure (pressurized), while
19
air flows into areas with negative pressure (depressurized). AII rooms are set at negative pressure to
prevent airborne microorganisms in the room from entering hallways and corridors. PE rooms housing
severely neutropenic patients are set at positive pressure to keep airborne pathogens in adjacent spaces
or corridors from coming into and contaminating the airspace occupied by such high-risk patients. Selfclosing doors are mandatory for both of these areas to help maintain the correct pressure differential.4, 6,
120
Older health-care facilities may have variable pressure rooms (i.e., rooms in which the ventilation
can be manually switched between positive and negative pressure). These rooms are no longer
permitted in the construction of new facilities or in renovated areas of the facility,120 and their use in
existing facilities has been discouraged because of difficulties in assuring the proper pressure
differential, especially for the negative pressure setting, and because of the potential for error associated
with switching the pressure differentials for the room. Continued use of existing variable pressure
rooms depends on a partnership between engineering and infection control. Both positive- and
negative-pressure rooms should be maintained according to specific engineering specifications (Table
6).
Table 6. Engineered specifications for positive- and negative pressure rooms*
Pressure differentials
Air changes per hour (ACH)
Filtration efficiency
Room airflow direction
Clean-to-dirty airflow in
room
Ideal pressure differential
Positive pressure areas (e.g.,
protective environments [PE])
Negative pressure areas (e.g.,
airborne infection isolation [AII])
> +2.5 Pa§ (0.1″ water gauge)
>12
Supply: 99.97% @ 0.3 µm DOP¶
Return: none required**
Out to the adjacent area
Away from the patient (high-risk patient,
immunosuppressed patient)
> + 8 Pa
> -2.5 Pa (0.1″ water gauge)
>12 (for renovation or new construction)
Supply: 90% (dust spot test)
Return: 99.97% @ 0.3 µm DOP¶ ^
In to the room
Towards the patient (airborne disease
patient)
> - 2.5 Pa
* Material in this table was compiled from references 35 and 120. Table adapted from and used with permission of the publisher of reference
35 (Lippincott Williams and Wilkins).
§ Pa is the abbreviation for Pascal, a metric unit of measurement for pressure based on air velocity; 250 Pa equals 1.0 inch water gauge.
¶ DOP is the abbreviation for dioctylphthalate particles of 0.3 µm diameter.
** If the patient requires both PE and AII, return air should be HEPA-filtered or otherwise exhausted to the outside.
^ HEPA filtration of exhaust air from AII rooms should not be required, providing that the exhaust is properly located to prevent re-entry into
the building.
Health-care professionals (e.g., infection control, hospital epidemiologists) must perform a risk
assessment to determine the appropriate number of AII rooms (negative pressure) and/or PE rooms
(positive pressure) to serve the patient population. The AIA guidelines require a certain number of AII
rooms as a minimum, and it is important to refer to the edition under which the building was built for
appropriate guidance.120
In large health-care facilities with central HVAC systems, sealed windows help to ensure the efficient
operation of the system, especially with respect to creating and maintaining pressure differentials.
Sealing the windows in PE areas helps minimize the risk of airborne contamination from the outside.
One outbreak of aspergillosis among immunosuppressed patients in a hospital was attributed in part to
an open window in the unit during a time when both construction and a fire happened nearby; sealing
the window prevented further entry of fungal spores into the unit from the outside air.111 Additionally,
all emergency exits (e.g., fire escapes and emergency doors) in PE wards should be kept closed (except
during emergencies) and equipped with alarms.
e. Infection Control Impact of HVAC System Maintenance and Repair
A failure or malfunction of any component of the HVAC system may subject patients and staff to
discomfort and exposure to airborne contaminants. Only limited information is available from formal
20
studies on the infection-control implications of a complete air-handling system failure or shutdown for
maintenance. Most experience has been derived from infectious disease outbreaks and adverse
outcomes among high-risk patients when HVAC systems are poorly maintained. (See Table 7 for
potential ventilation hazards, consequences, and correction measures.)
AIA guidelines prohibit U.S. hospitals and surgical centers from shutting down their HVAC systems for
purposes other than required maintenance, filter changes, and construction.120 Airflow can be reduced;
however, sufficient supply, return, and exhaust must be provided to maintain required pressure
relationships when the space is not occupied. Maintaining these relationships can be accomplished with
special drives on the air-handling units (i.e., a variable air ventilation [VAV] system).
Microorganisms proliferate in environments wherever air, dust, and water are present, and air-handling
systems can be ideal environments for microbial growth.35 Properly engineered HVAC systems require
routine maintenance and monitoring to provide acceptable indoor air quality efficiently and to minimize
conditions that favor the proliferation of health-care–associated pathogens.35, 249 Performance
monitoring of the system includes determining pressure differentials across filters, regular inspection of
system filters, DOP testing of HEPA filters, testing of low- or medium efficiency filters, and manometer
tests for positive- and negative-pressure areas in accordance with nationally recognized standards,
guidelines, and manufacturers’ recommendations. The use of hand-held, calibrated equipment that can
provide a numerical reading on a daily basis is preferred for engineering purposes (A.Streifel,
University of Minnesota, 2000).256 Several methods that provide a visual, qualitative measure of
pressure differentials (i.e., airflow direction) include smoke-tube tests or placing flutter strips, ping-pong
balls, or tissue in the air stream.
Preventive filter and duct maintenance (e.g., cleaning ductwork vents, replacing filters as needed, and
properly disposing spent filters into plastic bags immediately upon removal) is important to prevent
potential exposures of patients and staff during HVAC system shut-down. The frequency of filter
inspection and the parameters of this inspection are established by each facility to meet their unique
needs. Ductwork in older health-care facilities may have insulation on the interior surfaces that can trap
contaminants. This insulation material tends to break down over time to be discharged from the HVAC
system. Additionally, a malfunction of the air-intake system can overburden the filtering system and
permit aerosolization of fungal pathogens. Keeping the intakes free from bird droppings, especially
those from pigeons, helps to minimize the concentration of fungal spores entering from the outside.98
Accumulation of dust and moisture within HVAC systems increases the risk for spread of health-care–
associated environmental fungi and bacteria. Clusters of infections caused by Aspergillus spp., P.
aeruginosa, S. aureus, and Acinetobacter spp. have been linked to poorly maintained and/or
malfunctioning air conditioning systems.68, 161, 257, 258 Efforts to limit excess humidity and moisture in
the infrastructure and on air-stream surfaces in the HVAC system can minimize the proliferation and
dispersion of fungal spores and waterborne bacteria throughout indoor air.259–262 Within the HVAC
system, water is present in water-wash units, humidifying boxes, or cooling units. The dual-duct system
may also create conditions of high humidity and excess moisture that favor fungal growth in drain pans
as well as in fibrous insulation material that becomes damp as a result of the humid air passing over the
hot stream and condensing.
If moisture is present in the HVAC system, periods of stagnation should be avoided. Bursts of
organisms can be released upon system start-up, increasing the risk of airborne infection.206 Proper
engineering of the HVAC system is critical to preventing dispersal of airborne organisms. In one
hospital, endophthalmitis caused by Acremonium kiliense infection following cataract extraction in an
ambulatory surgical center was traced to aerosols derived from the humidifier water in the ventilation
system.206 The organism proliferated because the ventilation system was turned off routinely when the
21
center was not in operation; the air was filtered before humidification, but not afterwards.
Most health-care facilities have contingency plans in case of disruption of HVAC services. These plans
include back-up power generators that maintain the ventilation system in high-risk areas (e.g., operating
rooms, intensive-care units, negative- and positive-pressure rooms, transplantation units, and oncology
units). Alternative generators are required to engage within 10 seconds of a loss of main power. If the
ventilation system is out of service, rendering indoor air stagnant, sufficient time must be allowed to
clean the air and re-establish the appropriate number of ACH once the HVAC system begins to function
again. Air filters may also need to be changed, because reactivation of the system can dislodge
substantial amounts of dust and create a transient burst of fungal spores.
Duct cleaning in health-care facilities has benefits in terms of system performance, but its usefulness for
infection control has not been conclusively determined. Duct cleaning typically involves using
specialized tools to dislodge dirt and a high-powered vacuum cleaner to clean out debris.263 Some ductcleaning services also apply chemical biocides or sealants to the inside surfaces of ducts to minimize
fungal growth and prevent the release of particulate matter. The U.S. Environmental Protection Agency
(EPA), however, has concerns with the use of sanitizers and/or disinfectants to treat the surfaces of
ductwork, because the label indications for most of these products may not specifically include the use
of the product in HVAC systems.264 Further, EPA has not evaluated the potency of disinfectants in
such applications, nor has the agency examined the potential attendant health and safety risks. The EPA
recommends that companies use only those chemical biocides that are registered for use in HVAC
systems.264 Although infrequent cleaning of the exhaust ducts in AII areas has been documented as a
cause of diminishing negative pressure and a decrease in the air exchange rates,214 no data indicate that
duct cleaning, beyond what is recommended for optimal performance, improves indoor air quality or
reduces the risk of infection. Exhaust return systems should be cleaned as part of routine system
maintenance. Duct cleaning has not been shown to prevent any health problems,265 and EPA studies
indicate that airborne particulate levels do not increase as a result of dirty air ducts, nor do they diminish
after cleaning, presumably because much of the dirt inside air ducts adheres to duct surfaces and does
not enter the conditioned space.265 Additional research is needed to determine if air-duct contamination
can significantly increase the airborne infection risk in general areas of health-care facilities.
4. Construction, Renovation, Remediation, Repair, and Demolition
a. General Information
Environmental disturbances caused by construction and/or renovation and repair activities (e.g.,
disruption of the above-ceiling area, running cables through the ceiling, and structural repairs) in and
near health-care facilities markedly increase the airborne Aspergillus spp. spore counts in the indoor air
of such facilities, thereby increasing the risk for health-care–associated aspergillosis among high-risk
patients. Although one case of health-care–associated aspergillosis is often difficult to link to a specific
environmental exposure, the occurrence of temporarily clustered cases increase the likelihood that an
environmental source within the facility may be identified and corrected.
22
Table 7. Ventilation hazards in health-care facilities that may be associated with
increased potential of airborne disease transmission*
Problem§
Consequences
Possible solutions
Water-damaged building materials (18,
266)
Water leaks can soak wood, wall board,
insulation, wall coverings, ceiling tiles,
and carpeting. All of these materials
can provide microbial habitat when wet.
This is especially true for fungi growing
on gypsum board.
Filter bypasses (17)
Rigorous air filtration requires air flow
resistance. Air stream will elude
filtration if openings are present because
of filter damage or poor fit.
1. Replace water-damaged materials.
2. Incorporate fungistatic compounds
into building materials in areas at
risk for moisture problems.
3. Test for all moisture and dry in less
than 72 hours. Replace if the
material cannot dry within 72
hours.
1. Use pressure gauges to ensure that
filters are performing at proper
static pressure.
2. Make ease of installation and
maintenance criteria for filter
selection.
3. Properly train maintenance personnel
in HVAC concerns.
4. Design system with filters downstream from fans.
5. Avoid water on filters or insulation.
Improper fan setting (267)
Air must be delivered at design voume
to maintain pressure balances. Air flow
in special vent rooms reverses.
Ductwork disconnections (268)
Dislodged or leaky supply duct runs can
spill into and leaky returns may draw
from hidden areas. Pressure balance
will be interrupted, and infectious
material may be disturbed and entrained
into hospital air supply.
Air flow impedance (213)
Debris, structural failure, or improperly
adjusted dampers can block duct work
and prevent designed air flow.
Open windows (96, 247)
Open windows can alter fan-induced
pressure balance and allow dirty-toclean air flow.
Dirty window air conditioners (96, 269)
Dirt, moisture, and bird droppings can
contaminate window air conditioners,
which can then introduce infectious
material into hospital rooms.
1. Routinely monitor air flow and
pressure balances throughout
critical parts of HVAC system.
2. Minimize or avoid using rooms that
switch between positive and
negative pressure.
1. Design a ductwork system that is
easy to access, maintain, and repair.
2. Train maintenance personnel to
regularly monitor air flow volumes
and pressure balances throughout
the system.
3. Test critical areas for appropriate
air flow
1. Design and budget for a duct system
that is easy to inspect, maintain, and
repair.
2. Alert contractors to use caution when
working around HVAC systems
during the construction phase.
3. Regularly clean exhaust grilles.
4. Provide monitoring for special
ventilation areas.
1. Use sealed windows.
2. Design HVAC systems to deliver
sufficient outdoor dilution
ventilation.
3. Ensure that OSHA indoor air quality
standards are met.
1. Eliminate such devices in plans for
new construction.
2. Where they must be used, make sure
that they are routinely cleaned and
inspected.
23
Problem§
Consequences
Inadequate filtration (270)
Infectious particles may pass through
filters into vulnerable patient areas.
Maintenance disruptions (271)
Fan shut-offs, dislodged filter cake
material contaminates downstream air
supply and drain pans. This may
compromise air flow in special
ventilation areas.
Excessive moisture in the HVAC
system (120)
Chronically damp internal lining of the
HVAC system, excessive condensate,
and drip pans with stagnant water may
result from this problem.
Duct contamination (18, 272)
Debris is released during maintenance
or cleaning.
Possible solutions
1. Specify appropriate filters during
new construction design phase.
2. Make sure that HVAC fans are sized
to overcome pressure demands of
filter system.
3. Inspect and test filters for proper
installation.
1. Budget for a rigorous maintenance
schedule when designing a facility.
2. Design system for easy maintenance.
3. Ensure communication between
engineering and maintenance
personnel.
4. Institute an ongoing training program
for all involved staff members.
1. Locate duct humidifiers upstream of
the final filters.
2. Identify a means to remove water
from the system.
3. Monitor humidity; all duct take-offs
should be downstream of the
humidifiers so that moisture is
absorbed completely.
4. Use steam humidifiers in the HVAC
system.
1. Provide point-of-use filtration in the
critical areas.
2. Design air-handling systems with
insulation of the exterior of the
ducts.
3. Do not use fibrous sound attenuators.
4. Decontaminate or encapsulate
contamination.
* Reprinted with permission of the publisher of reference 35 (Lippincott Williams and Wilkins).
§ Numbers in parentheses are reference citations.
Construction, renovation, repair, and demolition activities in health-care facilities require substantial
planning and coordination to minimize the risk for airborne infection both during projects and after their
completion. Several organizations and experts have endorsed a multi-disciplinary team approach (Box
4) to coordinate the various stages of construction activities (e.g., project inception, project
implementation, final walk-through, and completion).120, 249, 250, 273–276 Environmental services,
employee health, engineering, and infection control must be represented in construction planning and
design meetings should be convened with architects and design engineers. The number of members and
disciplines represented is a function of the complexity of a project. Smaller, less complex projects and
maintenance may require a minimal number of members beyond the core representation from
engineering, infection control, environmental services, and the directors of the specialized departments.
24
Box 4. Suggested members and functions of a multi-disciplinary coordination team for
construction, renovation, repair, and demolition projects
Members
Infection-control personnel, including hospital epidemiologists
Laboratory personnel
Facility administrators or their designated representatives, facility managers
Director of engineering
Risk-management personnel
Directors of specialized programs (e.g., transplantation, oncology and ICU* programs)
Employee safety personnel, industrial hygienists, and regulatory affairs personnel
Environmental services personnel
Information systems personnel
Construction administrators or their designated representatives
Architects, design engineers, project managers, and contractors
Functions and responsibilities
Coordinate members’ input in developing a comprehensive project management plan.
Conduct a risk assessment of the project to determine potential hazards to susceptible patients.
Prevent unnecessary exposures of patients, visitors, and staff to infectious agents.
Oversee all infection-control aspects of construction activities.
Establish site-specific infection-control protocols for specialized areas.
Provide education about the infection-control impact of construction to staff and construction
workers.
Ensure compliance with technical standards, contract provisions, and regulations.
Establish a mechanism to address and correct problems quickly.
Develop contingency plans for emergency response to power failures, water supply disruptions,
and fires.
Provide a water-damage management plan (including drying protocols) for handling water
intrusion from floods, leaks, and condensation.
Develop a plan for structural maintenance.
* ICU is intensive care unit.
Education of maintenance and construction workers, health-care staff caring for high-risk patients, and
persons responsible for controlling indoor air quality heightens awareness that minimizing dust and
moisture intrusion from construction sites into high-risk patient-care areas helps to maintain a safe
environment.120, 250, 271, 275–278 Visual and printed educational materials should be provided in the
language spoken by the workers. Staff and construction workers also need to be aware of the potentially
catastrophic consequences of dust and moisture intrusion when an HVAC system or water system fails
during construction or repair; action plans to deal quickly with these emergencies should be developed
in advance and kept on file. Incorporation of specific standards into construction contracts may help to
prevent departures from recommended practices as projects progress. Establishing specific lines of
communication is important to address problems (e.g., dust control, indoor air quality, noise levels, and
vibrations), resolve complaints, and keep projects moving toward completion. Health-care facility staff
should develop a mechanism to monitor worker adherence to infection-control guidelines on a daily
basis in and around the construction site for the duration of the project.
25
b. Preliminary Considerations
The three major topics to consider before initiating any construction or repair activity are as follows: a)
design and function of the new structure or area, b) assessment of environmental risks for airborne
disease and opportunities for prevention, and c) measures to contain dust and moisture during
construction or repairs. A checklist of design and function considerations can help to ensure that a
planned structure or area can be easily serviced and maintained for environmental infection control (Box
5) .17, 250, 273, 275–277 Specifications for the construction, renovation, remodeling, and maintenance of
health-care facilities are outlined in the AIA document, Guidelines for Design and Construction of
Hospitals and Health Care Facilities.120, 275
Box 5. Construction design and function considerations for environmental infection
control
Location of sinks and dispensers for handwashing products and hand hygiene products
Types of faucets (e.g., aerated vs. non-aerated)
Air-handling systems engineered for optimal performance, easy maintenance, and repair
ACH and pressure differentials to accommodate special patient-care areas
Location of fixed sharps containers
Types of surface finishes (e.g., porous vs. non-porous)
Well-caulked walls with minimal seams
Location of adequate storage and supply areas
Appropriate location of medicine preparations areas (e.g., >3 ft. from a sink)
Appropriate location and type of ice machines (e.g., preferably ice dispensers rather than ice bins)
Appropriate materials for sinks and wall coverings
Appropriate traffic flow (e.g., no “dirty” movement through “clean” areas)
Isolation rooms with anterooms as appropriate
Appropriate flooring (e.g., seamless floors in dialysis units)
Sensible use carpeting (e.g., avoiding use of carpeting in special care areas or areas likely to become
wet)*
Convenient location of soiled utility areas
Properly engineered areas for linen services and solid waste management
Location of main generator to minimize the risk of system failure from flooding or other emergency
Installation guidelines for sheetrock
* Use of carpet cleaning methods (e.g., “bonneting”) that disperse microorganisms into the air may increase the risk of airborne infection
among at-risk patients, especially if they are in the vicinity of the cleaning activity.111
Proactive strategies can help prevent environmentally mediated airborne infections in health-care
facilities during demolition, construction, and renovation. The potential presence of dust and moisture
and their contribution to health-care–associated infections must be critically evaluated early in the
planning of any demolition, construction, renovation, and repairs.120, 250, 251, 273, 274, 276–279 Consideration
must extend beyond dust generated by major projects to include dust that can become airborne if
disturbed during routine maintenance and minor renovation activities (e.g., exposure of ceiling spaces
for inspection; installation of conduits, cable, or sprinkler systems; rewiring; and structural repairs or
replacement).273, 276, 277 Other projects that can compromise indoor air quality include construction and
repair jobs that inadvertently allow substantial amounts of raw, unfiltered outdoor air to enter the facility
(e.g., repair of elevators and elevator shafts) and activities that dampen any structure, area, or item made
of porous materials or characterized by cracks and crevices (e.g., sink cabinets in need of repair, carpets,
ceilings, floors, walls, vinyl wall coverings, upholstery, drapes, and countertops).18, 273, 277 Molds grow
and proliferate on these surfaces when they become and remain wet.21, 120, 250, 266, 270, 272, 280 Scrubbable
26
materials are preferred for use in patient-care areas.
Containment measures for dust and/or moisture control are dictated by the location of the construction
site. Outdoor demolition and construction require actions to keep dust and moisture out of the facility
(e.g., sealing windows and vents and keeping doors closed or sealed). Containment of dust and
moisture generated from construction inside a facility requires barrier structures (either pre-fabricated or
constructed of more durable materials as needed) and engineering controls to clean the air in and around
the construction or repair site.
c. Infection-Control Risk Assessment
An infection-control risk assessment (ICRA) conducted before initiating repairs, demolition,
construction, or renovation activities can identify potential exposures of susceptible patients to dust and
moisture and determine the need for dust and moisture containment measures. This assessment centers
on the type and extent of the construction or repairs in the work area but may also need to include
adjacent patient-care areas, supply storage, and areas on levels above and below the proposed project.
An example of designing an ICRA as a matrix, the policy for performing an ICRA and implementing its
results, and a sample permit form that streamlines the communication process are available.281
Knowledge of the air flow patterns and pressure differentials helps minimize or eliminate the
inadvertent dispersion of dust that could contaminate air space, patient-care items, and surfaces.57, 282, 283
A recent aspergillosis outbreak among oncology patients was attributed to depressurization of the
building housing the HSCT unit while construction was underway in an adjacent building. Pressure
readings in the affected building (including 12 of 25 HSCT-patient rooms) ranged from 0.1 Pa–5.8 Pa.
Unfiltered outdoor air flowed into the building through doors and windows, exposing patients in the
HSCT unit to fungal spores.283 During long-term projects, providing temporary essential services (e.g.,
toilet facilities) and conveniences (e.g., vending machines) to construction workers within the site will
help to minimize traffic in and out of the area. The type of barrier systems necessary for the scope of
the project must be defined.12, 120, 250, 279, 284
Depending on the location and extent of the construction, patients may need to be relocated to other
areas in the facility not affected by construction dust.51, 285 Such relocation might be especially prudent
when construction takes place within units housing immunocompromised patients (e.g., severely
neutropenic patients and patients on corticosteroid therapy). Advance assessment of high-risk locations
and planning for the possible transport of patients to other departments can minimize delays and waiting
time in hallways.51 Although hospitals have provided immunocompromised patients with some form of
respiratory protection for use outside their rooms, the issue is complex and remains unresolved until
more research can be done. Previous guidance on this issue has been inconsistent.9 Protective
respirators (i.e., N95) were well tolerated by patients when used to prevent further cases of constructionrelated aspergillosis in a recent outbreak.283 The routine use of the N95 respirator by patients, however,
has not been evaluated for preventing exposure to fungal spores during periods of non-construction.
Although health-care workers who would be using the N95 respirator for personal respiratory protect
must be fit-tested, there is no indication that either patients or visitors should undergo fit-testing.
Surveillance activities should augment preventive strategies during construction projects.3, 4, 20, 110, 286, 287
By determining baseline levels of health-care–acquired airborne and waterborne infections, infectioncontrol staff can monitor changes in infection rates and patterns during and immediately after
construction, renovations, or repairs.3
d. Air Sampling
Air sampling in health-care facilities may be conducted both during periods of construction and on a
periodic basis to determine indoor air quality, efficacy of dust-control measures, or air-handling system
performance via parametric monitoring. Parametric monitoring consists of measuring the physical
27
performance of the HVAC system in accordance with the system manufacturer’s specifications. A
periodic assessment of the system (e.g., air flow direction and pressure, ACH, and filter efficiency) can
give assurance of proper ventilation, especially for special care areas and operating rooms.288
Air sampling is used to detect aerosols (i.e., particles or microorganisms). Particulate sampling (i.e.,
total numbers and size range of particulates) is a practical method for evaluating the infection-control
performance of the HVAC system, with an emphasis on filter efficiency in removing respirable particles
(<5 µm in diameter) or larger particles from the air. Particle size is reported in terms of the mass
median aerodynamic diameter (MMAD), whereas count median aerodynamic diameter (CMAD) is
useful with respect to particle concentrations.
Particle counts in a given air space within the health-care facility should be evaluated against counts
obtained in a comparison area. Particle counts indoors are commonly compared with the particulate
levels of the outdoor air. This approach determines the “rank order” air quality from “dirty” (i.e., the
outdoor air) to “clean” (i.e., air filtered through high-efficiency filters [90%–95% filtration]) to
“cleanest” (i.e., HEPA-filtered air).288 Comparisons from one indoor area to another may also provide
useful information about the magnitude of an indoor air-quality problem. Making rank-order
comparisons between clean, highly-filtered areas and dirty areas and/or outdoors is one way to interpret
sampling results in the absence of air quality and action level standards.35, 289
In addition to verifying filter performance, particle counts can help determine if barriers and efforts to
control dust dispersion from construction are effective. This type of monitoring is helpful when
performed at various times and barrier perimeter locations during the project. Gaps or breaks in the
barriers’ joints or seals can then be identified and repaired. The American Conference of Governmental
Industrial Hygienists (ACGIH) has set a threshold limit value-time weighted average (TLV®-TWA) of
10 mg/m3 for nuisance dust that contains no asbestos and <1% crystalline silica.290 Alternatively,
OSHA has set permissible exposure limits (PELs) for inert or nuisance dust as follows: respirable
fraction at 5 mg/m3 and total dust at 15 mg/m3.291 Although these standards are not measures of a
bioaerosol, they are used for indoor air quality assessment in occupational settings and may be useful
criteria in construction areas. Application of ACGIH guidance to health-care settings has not been
standardized, but particulate counts in health-care facilities are likely to be well below this threshold
value and approaching clean-room standards in certain care areas (e.g., operating rooms).100
Particle counters and anemometers are used in particulate evaluation. The anemometer measures air
flow velocity, which can be used to determine sample volumes. Particulate sampling usually does not
require microbiology laboratory services for the reporting of results.
Microbiologic sampling of air in health-care facilities remains controversial because of currently
unresolved technical limitations and the need for substantial laboratory support (Box 6). Infectioncontrol professionals, laboratorians, and engineers should determine if microbiologic and/or particle
sampling is warranted and assess proposed methods for sampling. The most significant technical
limitation of air sampling for airborne fungal agents is the lack of standards linking fungal spore levels
with infection rates. Despite this limitation, several health-care institutions have opted to use
microbiologic sampling when construction projects are anticipated and/or underway in efforts to assess
the safety of the environment for immunocompromised patients.35, 289 Microbiologic air sampling
should be limited to assays for airborne fungi; of those, the thermotolerant fungi (i.e., those capable of
growing at 95°F–98.6°F [35°C–37°C]) are of particular concern because of their pathogenicity in
immunocompromised hosts.35 Use of selective media (e.g., Sabouraud dextrose agar and inhibitory
mold agar) helps with the initial identification of recovered organisms.
Microbiologic sampling for fungal spores performed as part of various airborne disease outbreak
28
investigations has also been problematic.18, 49, 106, 111, 112, 289 The precise source of a fungus is often
difficult to trace with certainty, and sampling conducted after exposure may neither reflect the
circumstances that were linked to infection nor distinguish between health-care–acquired and
community-acquired infections. Because fungal strains may fluctuate rapidly in the environment,
health-care–acquired Aspergillus spp. infection cannot be confirmed or excluded if the infecting strain is
not found in the health-care setting.287 Sensitive molecular typing methods (e.g., randomly amplified
polymorphic DNA (RAPD) techniques and a more recent DNA fingerprinting technique that detects
restriction fragment length polymorphisms in fungal genomic DNA) to identify strain differences
among Aspergillus spp., however, are becoming increasingly used in epidemiologic investigations of
health-care–acquired fungal infection (A.Streifel, University of Minnesota, 2000).68, 110, 286, 287, 292–296
During case cluster evaluation, microbiologic sampling may provide an isolate from the environment
for molecular typing and comparison with patient isolates. Therefore, it may be prudent for the clinical
laboratory to save Aspergillus spp. isolated from colonizations and invasive disease cases among
patients in PE, oncology, and transplant services for these purposes.
Box 6. Unresolved issues associated with microbiologic air sampling*
Lack of standards linking fungal spore levels with infection rates (i.e., no safe level of exposure)
Lack of standard protocols for testing (e.g., sampling intervals, number of samples, sampling
locations)
Need for substantial laboratory support
Culture issues (e.g., false negatives, insensitivity, lag time between sampling and recording the
results)
New, complex polymerase chain reaction (PCR) analytical methods
Unknown incubation period for Aspergillus spp. infection
Variability of sampler readings
Sensitivity of the sampler used (i.e., the volumes of air sampled)
Lack of details in the literature about describing sampling circumstances (e.g., unoccupied rooms
vs. ongoing activities in rooms, expected fungal concentrations, and rate of outdoor air
penetration)
Lack of correlation between fungal species and strains from the environment and clinical
specimens
Confounding variables with high-risk patients (e.g., visitors and time spent outside of protective
environment [PE] without respiratory protection)
Need for determination of ideal temperature for incubating fungal cultures (95°F [35°C] is the most
commonly used temperature)
* Material in this box is compiled from references 35, 100, 222, 289, and 297.
Sedimentation methods using settle plates and volumetric sampling methods using solid impactors are
commonly employed when sampling air for bacteria and fungi. Settle plates have been used by
numerous investigators to detect airborne bacteria or to measure air quality during medical procedures
(e.g., surgery).17, 60, 97, 151, 161, 287 Settle plates, because they rely on gravity during sampling, tend to
select for larger particles and lack sensitivity for respirable particles (e.g., individual fungal spores),
especially in highly-filtered environments. Therefore, they are considered impractical for general use.35,
289, 298–301
Settle plates, however, may detect fungi aerosolized during medical procedures (e.g., during
wound dressing changes), as described in a recent outbreak of aspergillosis among liver transplant
patients.302
The use of slit or sieve impactor samplers capable of collecting large volumes of air in short periods of
time are needed to detect low numbers of fungal spores in highly filtered areas.35, 289 In some
29
outbreaks, aspergillosis cases have occurred when fungal spore concentrations in PE ambient air ranged
as low as 0.9–2.2 colony-forming units per cubic meter (CFU/m3) of air.18, 94 On the basis of the
expected spore counts in the ambient air and the performance parameters of various types of volumetric
air samplers, investigators of a recent aspergillosis outbreak have suggested that an air volume of at
least 1000 L (1 m3) should be considered when sampling highly filtered areas.283 Investigators have
also suggested limits of 15 CFU/m3 for gross colony counts of fungal organisms and <0.1 CFU/m3 for
Aspergillus fumigatus and other potentially opportunistic fungi in heavily filtered areas (>12 ACH and
filtration of >99.97% efficiency).120 No correlation of these values with the incidence of health-care–
associated fungal infection rates has been reported.
Air sampling in health-care facilities, whether used to monitor air quality during construction, to verify
filter efficiency, or to commission new space prior to occupancy, requires careful notation of the
circumstances of sampling. Most air sampling is performed under undisturbed conditions. However,
when the air is sampled during or after human activity (e.g., walking and vacuuming), a higher number
of airborne microorganisms likely is detected.297 The contribution of human activity to the significance
of air sampling and its impact on health-care–associated infection rates remain to be defined.
Comparing microbiologic sampling results from a target area (e.g., an area of construction) to those
from an unaffected location in the facility can provide information about distribution and concentration
of potential airborne pathogens. A comparison of microbial species densities in outdoor air versus
indoor air has been used to help pinpoint fungal spore bursts. Fungal spore densities in outdoor air are
variable, although the degree of variation with the seasons appears to be more dramatic in the United
States than in Europe.92, 287, 303
Particulate and microbiologic air sampling have been used when commissioning new HVAC system
installations; however, such sampling is particularly important for newly constructed or renovated PE or
operating rooms. Particulate sampling is used as part of a battery of tests to determine if a new HVAC
system is performing to specifications for filtration and the proper number of ACH.268, 288, 304
Microbiologic air sampling, however, remains controversial in this application, because no standards for
comparison purposes have been determined. If performed, sampling should be limited to determining
the density of fungal spores per unit volume of air space. High numbers of spores may indicate
contamination of air-handling system components prior to installation or a system deficiency when
culture results are compared with known filter efficiencies and rates of air exchange.
e. External Demolition and Construction
External demolition, planned building implosions, and dirt excavation generate considerable dust and
debris that can contain airborne microorganisms. In one study, peak concentrations in outdoor air at
grade level and HVAC intakes during site excavation averaged 20,000 CFU/m3 for all fungi and 500
CFU/m3 for Aspergillus fumigatus, compared with 19 CFU/m3 and 4 CFU/m3, respectively, in the
absence of construction.280 Many health-care institutions are located in large, urban areas; building
implosions are becoming a more frequent concern. Infection-control risk assessment teams, particularly
those in facilities located in urban renewal areas, would benefit by developing risk management
strategies for external demolition and construction as a standing policy. In light of the events of 11
September 2001, it may be necessary for the team to identify those dust exclusion measures that can be
implemented rapidly in response to emergency situations (Table 8). Issues to be reviewed prior to
demolition include a) proximity of the air intake system to the work site, b) adequacy of window seals
and door seals, c) proximity of areas frequented by immunocompromised patients, and d) location of the
underground utilities (D. Erickson, ASHE, 2000).120, 250, 273, 276, 277, 280, 305
30
Table 8. Strategies to reduce dust and moisture intrusion during external demolition and
construction
Item
Recommendation
Demolition site
Shroud the site if possible to reduce environmental
contamination.
Prior to placing dust-generating equipment, evaluate the
location to ensure that dust produced by the equipment
will not enter the building through open doorways or
windows, or through ventilation air intakes.
Locate this storage away from the facility and ventilation air
intakes.
Seal off affected intakes, if possible, or move if funds permit.
Consult with the facility engineer about pressure differentials
and air recirculation options; keep facility air pressure
positive to outside air.
Ensure that filters are properly installed; change roughing
filters frequently to prevent dust build-up on high-efficiency
filters.
Seal and caulk to prevent entry of airborne fungal spores.
Keep closed as much as possible; do not prop open; seal and
caulk unused doors (i.e., those that are not designated as
emergency exits); use mats with tacky surfaces at outside
entrances.
Note location relative to construction area to prevent intrusion
of dust into water systems.*
Ensure that these lines/pipes are insulated during periods of
vibration.
Temporarily close off during active demolition/construction
those rooftop areas that are normally open to the public
(e.g., rooftop atrium).
Provide methods (e.g., misting the area with water) to
minimize dust.
Use walk-ways protected from demolition/construction sites;
avoid outside areas close to these sites; avoid rooftops.
Close off entry ways as needed to minimize dust intrusion.
Reroute if possible, or arrange for frequent street cleaning.
Encourage reporting of hazardous or unsafe incidents
associated with construction.
Dust-generating equipment
Construction materials storage
Adjacent air intakes
HVAC system
Filters
Windows
Doors
Water utilities
Medical gas piping
Rooftops
Dust generation
Immunocompromised patients
Pedestrian traffic
Truck traffic
Education and awareness+
* Contamination of water pipes during demolition activities has been associated with health-care–associated transmission of Legionella spp.305
+ When health-care facilities have immunosuppressed patients in their census, telephoning the city building department each month to find
out if buildings are scheduled for demolition is prudent.
Minimizing the entry of outside dust into the HVAC system is crucial in reducing the risk for airborne
contaminants. Facility engineers should be consulted about the potential impact of shutting down the
system or increasing the filtration. Selected air handlers, especially those located close to excavation
sites, may have to be shut off temporarily to keep from overloading the system with dust and debris.
Care is needed to avoid significant facility-wide reductions in pressure differentials that may cause the
building to become negatively pressured relative to the outside. To prevent excessive particulate
overload and subsequent reductions in effectiveness of intake air systems that cannot be shut off
temporarily, air filters must be inspected frequently for proper installation and function. Excessive dust
31
penetration can be avoided if recirculated air is maximally utilized while outdoor air intakes are shut
down. Scheduling demolition and excavation during the winter, when Aspergillus spp. spores may be
present in lower numbers, can help, although seasonal variations in spore density differ around the
world.92, 287, 303 Dust control can be managed by misting the dirt and debris during heavy dustgenerating activities. To decrease the amount of aerosols from excavation and demolition projects,
nearby windows, especially in areas housing immunocompromised patients, can be sealed and window
and door frames caulked or weather-stripped to prevent dust intrusion.50, 301, 306 Monitoring for
adherence to these control measures throughout demolition or excavation is crucial. Diverting
pedestrian traffic away from the construction sites decreases the amount of dust tracked back into the
health-care facility and minimizes exposure of high-risk patients to environmental pathogens.
Additionally, closing entrances near construction or demolition sites might be beneficial; if this is not
practical, creating an air lock (i.e., pressurizing the entry way) is another option.
f. Internal Demolition, Construction, Renovations, and Repairs
The focus of a properly implemented infection-control program during interior construction and repairs
is containment of dust and moisture. This objective is achieved by a) educating construction workers
about the importance of control measures; b) preparing the site; c) notifying and issuing advisories for
staff, patients, and visitors; d) moving staff and patients and relocating patients as needed; e) issuing
standards of practice and precautions during activities and maintenance; f) monitoring for adherence to
control measures during construction and providing prompt feedback about lapses in control; g)
monitoring HVAC performance; h) implementing daily clean-up, terminal cleaning and removal of
debris upon completion; and i) ensuring the integrity of the water system during and after construction.
These activities should be coordinated with engineering staff and infection-control professionals.
Physical barriers capable of containing smoke and dust will confine dispersed fungal spores to the
construction zone.279, 284, 307, 308 The specific type of physical barrier required depends on the project’s
scope and duration and on local fire codes. Short-term projects that result in minimal dust dispersion
(e.g., installation of new cables or wiring above ceiling tiles) require only portable plastic enclosures
with negative pressure and HEPA filtration of the exhaust air from the enclosed work area. The
placement of a portable industrial-grade HEPA filter device capable of filtration rate of 300–800 ft3/min.
adjacent to the work area will help to remove fungal spores, but its efficacy is dependent on the supplied
ACH and size of the area. If the project is extensive but short-term, dust-abatement, fire-resistant
plastic curtains (e.g., Visqueen®) may be adequate. These should be completely airtight and sealed
from ceiling to floor with overlapping curtains;276, 277, 309 holes, tears, or other perforations should be
repaired promptly with tape. A portable, industrial-grade HEPA filter unit on continuous operation is
needed within the contained area, with the filtered air exhausted to the outside of the work zone.
Patients should not remain in the room when dust-generating activities are performed. Tools to assist
the decision-making process regarding selection of barriers based on an ICRA approach are available.281
More elaborate barriers are indicated for long-term projects that generate moderate to large amounts of
dust. These barrier structures typically consist of rigid, noncombustible walls constructed from sheet
rock, drywall, plywood, or plaster board and covered with sheet plastic (e.g., Visqueen®). Barrier
requirements to prevent the intrusion of dust into patient-care areas include a) installing a plastic dust
abatement curtain before construction of the rigid barrier; b) sealing and taping all joint edges including
the top and bottom; c) extending the barrier from floor to floor, which takes into account the space
[approximately 2–8 ft.] above the finished, lay-down ceiling; and d) fitting or sealing any temporary
doors connecting the construction zone to the adjacent area. (See Box 7 for a list of the various
construction and repair activities that require the use of some type of barrier.)
32
Box 7. Construction/repair projects that require barrier structures*
Demolition of walls, wallboard, plaster, ceramic tiles, ceiling tiles, and ceilings
Removal of flooring and carpeting, windows and doors, and casework
Working with sinks and plumbing that could result in aerosolization of water in high-risk areas
Exposure of ceiling spaces for demolition and for installation or rerouting of utility services (e.g.,
rewiring, electrical conduction installation, HVAC ductwork, and piping)
Crawling into ceiling spaces for inspection in a manner that may dislodge dust
Demolition, repair, or construction of elevator shafts
Repairing water damage
* Material for this box was compiled from references 120, 250, 273, 276, and 277.
Dust and moisture abatement and control rely primarily on the impermeable barrier containment
approach; as construction continues, numerous opportunities can lead to dispersion of dust to other areas
of the health-care facility. Infection-control measures that augment the use of barrier containment
should be undertaken (Table 9).
Dust-control measures for clinical laboratories are an essential part of the infection-control strategy
during hospital construction or renovation. Use of plastic or solid barriers may be needed if the ICRA
determines that air flow from construction areas may introduce airborne contaminants into the
laboratory space. In one facility, pseudofungemia clusters attributed to Aspergillus spp. and Penicillium
spp. were linked to improper air flow patterns and construction projects adjacent to the laboratory;
intrusion of dust and spores into a biological safety cabinet from construction activity immediately next
to the cabinet resulted in a cluster of cultures contaminated with Aspergillus niger.310, 311 Reportedly,
no barrier containment was used and the HEPA filtration system was overloaded with dust. In addition,
an outbreak of pseudobacteremia caused by Bacillus spp. occurred in another hospital during
construction above a storage area for blood culture bottles.207 Airborne spread of Bacillus spp. spores
resulted in contamination of the bottles’ plastic lids, which were not disinfected or handled with proper
aseptic technique prior to collection of blood samples.
Table 9. Infection-control measures for internal construction and repair projects*+
Infection-control measure
Prepare for the project.
Educate staff and construction workers.
Issue hazard and warning notices.
Relocate high-risk patients as needed,
especially if the construction is in or
adjacent to a PE area.
Establish alternative traffic patterns for
staff, patients, visitors, and construction
workers.
Steps for implementation
1. Use a multi-disciplinary team approach to incorporate infection control into the
project.
2. Conduct the risk assessment and a preliminary walk-through with project
managers and staff.
1. Educate staff and construction workers about the importance of adhering to
infection-control measures during the project.
2. Provide educational materials in the language of the workers.
3. Include language in the construction contract requiring construction workers and
subcontractors to participate in infection-control training.
1. Post signs to identify construction areas and potential hazards.
2. Mark detours requiring pedestrians to avoid the work area.
1. Identify target patient populations for relocation based on the risk assessment.
2. Arrange for the transfer in advance to avoid delays.
3. At-risk patients should wear protective respiratory equipment (e.g., a highefficiency mask) when outside their PE rooms.
1. Determine appropriate alternate routes from the risk assessment.
2. Designate areas (e.g., hallways, elevators, and entrances/exits) for constructionworker use.
3. Do not transport patients on the same elevator with construction materials and
debris.
33
Infection-control measure
Erect appropriate barrier containment.
Establish proper ventilation.
Control solid debris.
Control water damage.
Control dust in air and on surfaces.
Steps for implementation
1. Use prefabricated plastic units or plastic sheeting for short-term projects that
will generate minimal dust.
2. Use durable rigid barriers for ongoing, long-term projects.
1. Shut off return air vents in the construction zone, if possible, and seal around
grilles.
2. Exhaust air and dust to the outside, if possible.
3. If recirculated air from the construction zone is unavoidable, use a pre-filter and
a HEPA filter before the air returns to the HVAC system.
4. When vibration-related work is being done that may dislodge dust in the
ventilation system or when modifications are made to ductwork serving
occupied spaces, install filters on the supply air grilles temporarily.
5. Set pressure differentials so that the contained work area is under negative
pressure.
6. Use air flow monitoring devices to verify the direction of the air pattern.
7. Exhaust air and dust to the outside, if possible.
8. Monitor temperature, air changes per hour (ACH), and humidity levels
(humidity levels should be <65%).
9. Use portable, industrial grade HEPA filters in the adjacent area and/or the
construction zone for additional ACH.
10. Keep windows closed, if possible.
1. When replacing filters, place the old filter in a bag prior to transport and dispose
as a routine solid waste.
2. Clean the construction zone daily or more often as needed.
3. Designate a removal route for small quantities of solid debris.
4. Mist debris and cover disposal carts before transport (i.e., leaving the
construction zone).
5. Designate an elevator for construction crew use.
6. Use window chutes and negative pressure equipment for removal of larger
pieces of debris while maintaining pressure differentials in the construction
zone.
7. Schedule debris removal to periods when patient exposures to dust is minimal.
1. Make provisions for dry storage of building materials.
2. Do not install wet, porous building materials (i.e., sheet rock).
3. Replace water-damaged porous building materials if they cannot be completely
dried out within 72 hours.
1. Monitor the construction area daily for compliance with the infection-control
plan.
2. Protective outer clothing for construction workers should be removed before
entering clean areas.
3. Use mats with tacky surfaces within the construction zone at the entry; cover
sufficient area so that both feet make contact with the mat while walking
through the entry.
4. Construct an anteroom as needed where coveralls can be donned and removed.
5. Clean the construction zone and all areas used by construction workers with a
wet mop.
6. If the area is carpeted, vacuum daily with a HEPA-filtered–equipped vacuum.
7. Provide temporary essential services (e.g., toilets) and worker conveniences
(e.g, vending machines) in the construction zone as appropriate.
8. Damp-wipe tools if removed from the construction zone or left in the area.
9. Ensure that construction barriers remain well sealed; use particle sampling as
needed.
10. Ensure that the clinical laboratory is free from dust contamination.
34
Infection-control measure
Complete the project.
Steps for implementation
1. Flush the main water system to clear dust-contaminated lines.
2. Terminally clean the construction zone before the construction barriers are
removed.
3. Check for visible mold and mildew and eliminate (i.e., decontaminate and
remove), if present.
4. Verify appropriate ventilation parameters for the new area as needed.
5. Do not accept ventilation deficiencies, especially in special care areas.
6. Clean or replace HVAC filters using proper dust-containment procedures.
7. Remove the barriers and clean the area of any dust generated during this work.
8. Ensure that the designated air balances in the operating rooms (OR) and
protective environments (PE) are achieved before occupancy.
9. Commission the space as indicated, especially in the OR and PE, ensuring that
the room’s required engineering specifications are met.
* Material in this table includes information from D. Erickson, ASHE, 2000.
+ Material in this table was compiled from references 19, 51, 67, 80, 106, 120, 250, 266, 273, 276–278, 280, 285, and 309, 312–315.
5. Environmental Infection-Control Measures for Special Health-Care
Settings
Areas in health-care facilities that require special ventilation include a) operating rooms; b) PE rooms
used by high-risk, immunocompromised patients; and c) AII rooms for isolation of patients with
airborne infections (e.g., those caused by M. tuberculosis, VZV, or measles virus). The number of
rooms required for PE and AII are determined by a risk assessment of the health-care facility.6
Continuous, visual monitoring of air flow direction is required for new or renovated pressurized
rooms.120, 256
a. Protective Environments (PE)
Although the exact configuration and specifications of PEs might differ among hospitals, these care
areas for high-risk, immunocompromised patients are designed to minimize fungal spore counts in air
by maintaining a) filtration of incoming air by using central or point-of-use HEPA filters; b) directed
room air flow [i.e., from supply on one side of the room, across the patient, and out through the exhaust
on the opposite side of the room]; c) positive room air pressure of 2.5 Pa [0.01" water gauge] relative to
the corridor; d) well-sealed rooms; and e) >12 ACH.44, 120, 251, 254, 316–319 Air flow rates must be adjusted
accordingly to ensure sufficient ACH, and these rates vary depending on certain factors (e.g., room air
leakage area). For example, to provide >12 ACH in a typical patient room with 0.5 sq. ft. air leakage,
the air flow rate will be minimally 125 cubic feet/min (cfm).320, 321 Higher air flow rates may be
needed. A general ventilation diagram for a positive-pressure room is given in Figure 2. Directed room
air flow in PE rooms is not laminar; parallel air streams are not generated. Studies attempting to
demonstrate patient benefit from laminar air flow in a PE setting are equivocal.316, 318, 319, 322 - 327
Air flow direction at the entrances to these areas should be maintained and verified, preferably on a
daily basis, using either a visual means of indication (e.g., smoke tubes and flutter strips) or
manometers. Permanent installation of a visual monitoring device is indicated for new PE construction
and renovation.120 Facility service structures can interfere with the proper unidirectional air flow from
the patients’ rooms to the adjacent corridor. In one outbreak investigation, Aspergillus spp. infections in
a critical care unit may have been associated with a pneumatic specimen transport system, a textile
disposal duct system, and central vacuum lines for housekeeping, all of which disrupted proper air flow
from the patients’ rooms to the outside and allowed entry of fungal spores into the unit (M.McNeil,
CDC, 2000).
35
Figure 2. Example of positive-pressure room control for protection from airborne
environmental microbes (PE)* + §
Monitor
r
Bathroom
Corridor
* Stacked black boxes represent patient’s bed. Long open box with cross-hatch represents supply air. Open boxes with single,
diagonal slashes represent air exhaust registers. Arrows indicate directions of air flow.
+ Possible uses include immunocompromised patient rooms (e.g., hematopoietic stem cell transplant or solid organ transplant
procedure rooms) and orthopedic operating rooms.
§ Positive-pressure room engineering features include
positive pressure (greater supply than exhaust air volume);
pressure differential range of 2.5–8 Pa (0.01–0.03-in. water gauge), ideal at 8 Pa;
air flow volume differential >125-cfm supply versus exhaust;
sealed room, approximately 0.5-sq. ft. leakage;
clean to dirty air flow;
monitoring;
>12 air changes per hour (ACH); and
return air if refiltered.
¶ This diagram is a generic illustration of air flow in a typical installation. Alternative air flow arrangements are recognized.
Adapted and used with permission from A. Streifel and the publisher of reference 328 (Penton Media, Inc.)
The use of surface fungicide treatments is becoming more common, especially for building materials.329
Copper-based compounds have demonstrated anti-fungal activity and are often applied to wood or paint.
Copper-8-quinolinolate was used on environmental surfaces contaminated with Aspergillus spp. to
control one reported outbreak of aspergillosis.310 The compound was also incorporated into the
fireproofing material of a newly constructed hospital to help decrease the environmental spore
burden.316
b. Airborne Infection Isolation (AII)
Acute-care inpatient facilities need at least one room equipped to house patients with airborne infectious
disease. Every health-care facility, including ambulatory and long-term care facilities, should undertake
an ICRA to identify the need for AII areas. Once the need is established, the appropriate ventilation
equipment can be identified. Air handling systems for this purpose need not be restricted to central
systems. Guidelines for the prevention of health-care–acquired TB have been published in response to
multiple reports of health-care–associated transmission of multi-drug resistant strains.4, 330 In reports
documenting health-care–acquired TB, investigators have noted a failure to comply fully with
prevention measures in established guidelines.331 - 345 These gaps highlight the importance of prompt
recognition of the disease, isolation of patients, proper treatment, and engineering controls. AII rooms
36
are also appropriate for the care and management of smallpox patients.6 Environmental infection
control with respect to smallpox is currently being revisited (see Appendix E).
Salient features of engineering controls for AII areas include a) use of negative pressure rooms with
close monitoring of air flow direction using manometers or temporary or installed visual indicators [e.g.,
smoke tubes and flutter strips] placed in the room with the door closed; b) minimum 6 ACH for existing
facilities, >12 ACH for areas under renovation or for new construction; and c) air from negative
pressure rooms and treatment rooms exhausted directly to the outside if possible.4, 120, 248 As with PE,
airflow rates need to be determined to ensure the proper numbers of ACH.320, 321 AII rooms can be
constructed either with (Figure 3) or without (Figure 4) an anteroom. When the recirculation of air from
AII rooms is unavoidable, HEPA filters should be installed in the exhaust duct leading from the room to
the general ventilation system. In addition to UVGI fixtures in the room, UVGI can be placed in the
ducts as an adjunct measure to HEPA filtration, but it can not replace the HEPA filter.4, 346 A UVGI
fixture placed in the upper room, coupled with a minimum of 6 ACH, also provides adequate air
cleaning.248
Figure 3. Example of negative-pressure room control for airborne infection isolation
(AII)* + §¶
Monitor
Bathroom
Corridor
* Stacked black boxes represent patient’s bed. Long open box with cross-hatch represents supply air. Open boxes with single,
diagonal slashes represent air exhaust registers. Arrows indicate direction of air flow.
+ Possible uses include treatment or procedure rooms, bronchoscopy rooms, and autopsy.
§ Negative-pressure room engineering features include
negative pressure (greater exhaust than supply air volume);
pressure differential of 2.5 Pa (0.01-in. water gauge);
air flow volume differential >125-cfm exhaust versus supply;
sealed room, approximately 0.5-sq. ft. leakage;
clean to dirty air flow;
monitoring;
>12 air changes per hour (ACH) new or renovation, 6 ACH existing; and
exhaust to outside or HEPA-filtered if recirculated.
¶ This diagram is a generic illustration of air flow in a typical installation. Alternative air flow arrangements are recognized.
Adapted and used with permission from A. Streifel and the publisher of reference 328 (Penton Media, Inc.)
One of the components of airborne infection isolation is respiratory protection for health-care workers
and visitors when entering AII rooms.4, 6, 347 Recommendations of the type of respiratory protection are
dependent on the patient’s airborne infection (indicating the need for AII) and the risk of infection to
37
persons entering the AII room. A more in-depth discussion of respiratory protection in this instance is
presented in the current isolation guideline;6 a revision of this guideline is in development. Coughinducing procedures (e.g., endotracheal intubation and suctioning of known or suspected TB patients,
diagnostic sputum induction, aerosol treatments, and bronchoscopy) require similar precautions.348–350
Additional engineering measures are necessary for the management of patients requiring PE (i.e.,
allogeneic HSCT patients) who concurrently have airborne infection. For this type of patient treatment,
an anteroom (Figure 4) is required in new construction and renovation as per AIA guidelines.120
Figure 4. Example of airborne infection isolation (AII) room with anteroom and neutral
anteroom* + §
Anteroom
Monitor
Bathroom
AII only
ƒ
Corridor
Neutral Anteroom
Monitor
Bathroom
AII and immunocompromised
ƒ
Corridor
Anteroom
Monitor
Bathroom
AII and immunocompromised
Corridor
y
* The top diagram indicates air flow patterns when patient with only airborne infectious disease occupies room. Middle and
bottom diagrams indicate recommended air flow patterns when room is occupied by immunocompromised patient with
airborne infectious disease. Stacked black boxes represent patient beds. Long open boxes with cross-hatches represent
supply air. Open boxes with single, diagonal slashes represent air exhaust registers. Arrows indicate directions of air flow.
+ AII isolation room with anteroom engineering features include
pressure differential of 2.5 Pa (0.01-in. water gauge) measured at the door between patient room and anteroom;
air flow volume differential >125-cfm. depending on anteroom air flow direction (pressurized versus depressurized);
38
sealed room with approximately 0.5-sq. ft. leakage;
clean to dirty air flow
monitoring;
>12 air changes per hour (ACH) new or renovation, 6 ACH existing; and
anteroom air flow patterns. The small ƒ in panels 1 and 2 indicate the anteroom is pressurized (supply versus exhaust),
while the small y in panel 3 indicates the anteroom is depressurized (exhaust versus supply).
§ Used with permission of A. Streifel, University of Minnesota
The pressure differential of an anteroom can be positive or negative relative to the patient in the room.120
An anteroom can act as an airlock (Figure 4). If the anteroom is positive relative to the air space in the
patient’s room, staff members do not have to mask prior to entry into the anteroom if air is directly
exhausted to the outside and a minimum of 10 ACH (Figure 4, top diagram).120 When an anteroom is
negative relative to both the AII room and the corridor, health-care workers must mask prior to entering
the anteroom (Figure 4, bottom diagram). If an AII room with an anteroom is not available, use of a
portable, industrial-grade HEPA filter unit may help to increase the number of ACHs while facilitating
the removal of fungal spores; however, a fresh air source must be present to achieve the proper air
exchange rate. Incoming ambient air should receive HEPA filtration.
c. Operating Rooms
Operating room air may contain microorganisms, dust, aerosol, lint, skin squamous epithelial cells, and
respiratory droplets. The microbial level in operating room air is directly proportional to the number of
people moving in the room.351 One study documented lower infection rates with coagulase-negative
staphylococci among patients when operating room traffic during the surgical procedure was limited.352
Therefore, efforts should be made to minimize personnel traffic during operations. Outbreaks of SSIs
caused by group A beta-hemolytic streptococci have been traced to airborne transmission from
colonized operating-room personnel to patients.150–154 Several potential health-care–associated
pathogens (e.g., Staphylococcus aureus and Staphylococcus epidermidis) and drug-resistant organisms
have also been recovered from areas adjacent to the surgical field,353 but the extent to which the
presence of bacteria near the surgical field influences the development of postoperative SSIs is not
clear.354
Proper ventilation, humidity (<68%), and temperature control in the operating room is important for the
comfort of surgical personnel and patients, but also in preventing environmental conditions that
encourage growth and transmission of microorganisms.355 Operating rooms should be maintained at
positive pressure with respect to corridors and adjacent areas.356 Operating rooms typically do not have
a variable air handling system. Variable air handling systems are permitted for use in operating rooms
only if they continue to provide a positive pressure with respect to the corridors and adjacent areas and
the proper ACHs are maintained when the room is occupied. Conventional operating-room ventilation
systems produce a minimum of about 15 ACH of filtered air for thermal control, three (20%) of which
must be fresh air.120, 357, 358 Air should be introduced at the ceiling and exhausted near the floor.357, 359
Laminar airflow and UVGI have been suggested as adjunct measures to reduce SSI risk for certain
operations. Laminar airflow is designed to move particle-free air over the aseptic operating field at a
uniform velocity (0.3–0.5 m/sec), sweeping away particles in its path. This air flow can be directed
vertically or horizontally, and recirculated air is passed through a HEPA filter.360–363 Neither laminar
airflow nor UV light, however, has been conclusively shown to decrease overall SSI risk.356, 364–370
Elective surgery on infectious TB patients should be postponed until such patients have received
adequate drug therapy. The use of general anesthesia in TB patients poses infection-control challenges
because intubation can induce coughing, and the anesthesia breathing circuit apparatus potentially can
become contaminated.371 Although operating room suites at 15 ACH exceed the air exchanges required
39
for TB isolation, the positive air flow relative to the corridor could result in health-care–associated
transmission of TB to operating-room personnel. If feasible, intubation and extubation of the TB
surgical patient should be performed in AII. AIA currently does not recommend changing pressure
from positive to negative or setting it to neutral; most facilities lack the capability to do so.120 When
emergency surgery is indicated for a suspected/diagnosed infectious TB patient, taking specific
infection-control measures is prudent (Box 8).
Box 8. Strategy for managing TB patients and preventing airborne transmission in
operating rooms*
1. If emergency surgery is indicated for a patient with active TB, schedule the TB patient as the last
surgical case to provide maximum time for adequate ACH.
2. Operating room personnel should use NIOSH-approved N95 respirators without exhalation valves.347
3. Keep the operating room door closed after the patient is intubated, and allow adequate time for
sufficient ACH to remove 99% of airborne particles (Appendix B, Table B.1.):
a) after the patient is intubated and particularly if intubation produces coughing;
b) if the door to the operating suite must be opened, and intubation induces coughing in the
patient; or
c) after the patient is extubated and suctioned [unless a closed suctioning system is present].
4. Extubate the patient in the operating room or allow the patient to recover in AII rather than in the
regular open recovery facilities.
5. Temporary use of a portable, industrial grade HEPA filter may expedite removal of airborne
contaminants (fresh-air exchange requirements for proper ventilation must still be met).+
6. Breathing circuit filters with 0.1–0.2 µm pore size can be used as an adjunct infection-control
measure.373, 374
* Material in this table was compiled from references 4, 347, and 372–374.
+ The placement of portable HEPA filter units in the operating room must be carefully evaluated for potential disruptions in normal air flow.
The portable unit should be turned off while the surgical procedure is underway and turned on following extubation. Portable HEPA filter
units previously placed in construction areas may be used in subsequent patient care, provided that all internal and external surfaces are
cleaned and the filter’s performance is verified with appropriate particle testing and is changed, if needed.
Table 10. Summary of ventilation specifications in selected areas of health-care facilities*
Specifications
AII room+
PE room
Critical care
room§
Isolation
anteroom
Operating
room
Air pressure¶
Negative
Positive
Positive, negative,
or neutral
Positive or
negative
Positive
>12 ACH
>6 ACH
>10 ACH
>15 ACH
Yes
No
Yes
Yes
99.97%++
>90%
>90%
90%
Yes
Yes
No
Yes
Room air changes
Sealed**
Filtration supply
Recirculation
>6 ACH (for
existing rooms);
>12 ACH (for
renovation or new
construction)
Yes
90% (dust-spot
ASHRAE 52.1
1992)
No§§
* Material in this table is compiled from references 35 and 120.
+ Includes bronchoscopy suites.
§ Positive pressure and HEPA filters may be preferred in some rooms in intensive care units (ICUs) caring for large numbers of
immunocompromised patients.
¶ Clean-to-dirty: negative to an infectious patient, positive away from an immunocompromised patient.
** Minimized infiltration for ventilation control; pertains to windows, closed doors, and surface joints.
++ Fungal spore filter at point of use (HEPA at 99.97% of 0.3 µm particles).
40
§§ Recirculated air may be used if the exhaust air is first processed through a HEPA filter.
¶¶ Table used with permission of the publisher of reference 35 (Lippincott Williams and Wilkins).
6. Other Aerosol Hazards in Health-Care Facilities
In addition to infectious bioaerosols, several crucial non-infectious, indoor air-quality issues must be
addressed by health-care facilities. The presence of sensitizing and allergenic agents and irritants in the
workplace (e.g., ethylene oxide, glutaraldehyde, formaldehyde, hexachlorophene, and latex allergens375)
is increasing. Asthma and dermatologic and systemic reactions often result with exposure to these
chemicals. Anesthetic gases and aerosolized medications (e.g., ribavirin, pentamidine, and
aminoglycosides) represent some of the emerging potentially hazardous exposures to health-care
workers. Containment of the aerosol at the source is the first level of engineering control, but personal
protective equipment (e.g., masks, respirators, and glove liners) that distances the worker from the
hazard also may be needed.
Laser plumes and surgical smoke represent another potential risk for health-care workers.376–378 Lasers
transfer electromagnetic energy into tissues, resulting in the release of a heated plume that includes
particles, gases, tissue debris, and offensive smells. One concern is that aerosolized infectious material
in the laser plume might reach the nasal mucosa of surgeons and adjacent personnel. Although some
viruses (i.e., varicella-zoster virus, pseudorabies virus, and herpes simplex virus) do not aerosolize
efficiently,379, 380 other viruses and bacteria (e.g., human papilloma virus [HPV], HIV, coagulasenegative Staphylococcus, Corynebacterium spp., and Neisseria spp.) have been detected in laser
plumes.381–387 The presence of an infectious agent in a laser plume may not, however, be sufficient to
cause disease from airborne exposure, especially if the normal mode of transmission for the agent is not
airborne. No evidence indicated that HIV or hepatitis B virus (HBV) has been transmitted via
aerosolization and inhalation.388
Although continuing studies are needed to fully evaluate the risk of laser plumes to surgical personnel,
the prevention measures in these other guidelines should be followed: a) NIOSH recommendations,378
b) the Recommended Practices for Laser Safety in Practice Settings developed by the Association of
periOperative Registered Nurses [AORN],389 c) the assessments of ECRI,390–392 and d) the ANSI
standard.393 These guidelines recommend the use of a) respirators (N95 or N100) or full face shields
and masks,260 b) central wall-suction units with in-line filters to collect particulate matter from minimal
plumes, and c) dedicated mechanical smoke exhaust systems with a high-efficiency filter to remove
large amounts of laser plume. Although transmission of TB has occurred as a result of abscess
management practices that lacked airborne particulate control measures and respiratory protection, use
of a smoke evacuator or needle aspirator and a high degree of clinical awareness can help protect healthcare workers when excising and draining an extrapulmonary TB abscess.137
D. Water
1. Modes of Transmission of Waterborne Diseases
Moist environments and aqueous solutions in health-care settings have the potential to serve as
reservoirs for waterborne microorganisms. Under favorable environmental circumstances (e.g., warm
temperature and the presence of a source of nutrition), many bacterial and some protozoal
microorganisms can either proliferate in active growth or remain for long periods in highly stable,
environmentally resistant (yet infectious) forms. Modes of transmission for waterborne infections
41
include a) direct contact [e.g., that required for hydrotherapy]; b) ingestion of water [e.g., through
consuming contaminated ice]; c) indirect-contact transmission [e.g., from an improperly reprocessed
medical device];6 d) inhalation of aerosols dispersed from water sources;3 and e) aspiration of
contaminated water. The first three modes of transmission are commonly associated with infections
caused by gram-negative bacteria and nontuberculous mycobacteria (NTM). Aerosols generated from
water sources contaminated with Legionella spp. often serve as the vehicle for introducing legionellae to
the respiratory tract.394
2. Waterborne Infectious Diseases in Health-Care Facilities
a. Legionellosis
Legionellosis is a collective term describing infection produced by Legionella spp., whereas
Legionnaires disease is a multi-system illness with pneumonia.395 The clinical and epidemiologic
aspects of these diseases (Table 11) are discussed extensively in another guideline.3 Although
Legionnaires disease is a respiratory infection, infection-control measures intended to prevent healthcare–associated cases center on the quality of water—the principal reservoir for Legionella spp.
Table 11. Clinical and epidemiologic characteristics of legionellosis/Legionnaires disease
References
Causative agent
Mode of transmission
Source of exposure
Clinical syndromes and
diseases
Populations at greatest
risk
Occurrence
Mortality rate
Legionella pneumophila (90% of infections); L. micdadei, L.
bozemanii, L. dumoffii, L. longbeachii, (14 additional species
can cause infection in humans)
Aspiration of water, direct inhalation or water aerosols
Exposure to environmental sources of Legionella spp. (i.e.,
water or water aerosols)
Two distinct illnesses: a) Pontiac fever [a milder, influenzalike illness]; and b) progressive pneumonia that may be
accompanied by cardiac, renal, and gastrointestinal
involvement
Immunosuppressed patients (e.g., transplant patients, cancer
patients, and patients receiving corticosteroid therapy);
immunocompromised patients (e.g., surgical patients,
patients with underlying chronic lung disease, and dialysis
patients); elderly persons; and patients who smoke
Proportion of community-acquired pneumonia caused by
Legionella spp. ranges from 1%–5%; estimated annual
incidence among the general population is 8,000–18,000
cases in the United States; the incidence of health-care–
associated pneumonia (0%–14%) may be underestimated if
appropriate laboratory diagnostic methods are unavailable.
Mortality declined markedly during 1980–1998, from 34% to
12% for all cases; the mortality rate is higher among persons
with health-care–associated pneumonia compared with the
rate among community-acquired pneumonia patients (14%
for health-care–associated pneumonia versus 10% for
community-acquired pneumonia [1998 data]).
395–399
3, 394–398, 400
31, 33, 401–414
3, 397–399, 415–422
395–397, 423–433
396, 397, 434–444
395–397, 445
Legionella spp. are commonly found in various natural and man-made aquatic environments446, 447 and
can enter health-care facility water systems in low or undetectable numbers.448, 449 Cooling towers,
evaporative condensers, heated potable water distribution systems, and locally-produced distilled water
can provide environments for multiplication of legionellae.450–454 In several hospital outbreaks, patients
have been infected through exposure to contaminated aerosols generated by cooling towers, showers,
faucets, respiratory therapy equipment, and room-air humidifiers.401–410, 455 Factors that enhance
42
colonization and amplification of legionellae in man-made water environments include a) temperatures
of 77°F–107.6°F [25°C–42°C],456–460 b) stagnation,461 c) scale and sediment, 462 and d) presence of
certain free-living aquatic amoebae that can support intracellular growth of legionellae.462, 463 The
bacteria multiply within single-cell protozoa in the environment and within alveolar macrophages in
humans.
b. Other Gram-Negative Bacterial Infections
Other gram-negative bacteria present in potable water also can cause health-care–associated infections.
Clinically important, opportunistic organisms in tap water include Pseudomonas aeruginosa,
Pseudomonas spp., Burkholderia cepacia, Ralstonia pickettii, Stenotrophomonas maltophilia, and
Sphingomonas spp. (Tables 12 and 13). Immunocompromised patients are at greatest risk of developing
infection. Medical conditions associated with these bacterial agents range from colonization of the
respiratory and urinary tracts to deep, disseminated infections that can result in pneumonia and
bloodstream bacteremia. Colonization by any of these organisms often precedes the development of
infection. The use of tap water in medical care (e.g., in direct patient care, as a diluent for solutions, as
a water source for medical instruments and equipment, and during the final stages of instrument
disinfection) therefore presents a potential risk for exposure. Colonized patients also can serve as a
source of contamination, particularly for moist environments of medical equipment (e.g., ventilators).
In addition to Legionella spp., Pseudomonas aeruginosa and Pseudomonas spp. are among the most
clinically relevant, gram-negative, health-care–associated pathogens identified from water. These and
other gram-negative, non-fermentative bacteria have minimal nutritional requirements (i.e., these
organisms can grow in distilled water) and can tolerate a variety of physical conditions. These attributes
are critical to the success of these organisms as health-care–associated pathogens. Measures to prevent
the spread of these organisms and other waterborne, gram-negative bacteria include hand hygiene, glove
use, barrier precautions, and eliminating potentially contaminated environmental reservoirs.464, 465
Table 12. Pseudomonas aeruginosa infections in health-care facilities
References
Clinical syndromes and
diseases
Modes of transmission
Environmental sources of
pseudomonads in healthcare settings
Environmental sources of
pseudomonads in the
community
Populations at greatest risk
Septicemia, pneumonia (particularly ventilator-associated),
chronic respiratory infections among cystic fibrosis patients,
urinary tract infections, skin and soft-tissue infections (e.g., tissue
necrosis and hemorrhage), burn-wound infections, folliculitis,
endocarditis, central nervous system infections (e.g., meningitis
and abscess), eye infections, and bone and joint infections
Direct contact with water, aerosols; aspiration of water and
inhalation of water aerosols; and indirect transfer from moist
environmental surfaces via hands of health-care workers
Potable (tap) water, distilled water, antiseptic solutions
contaminated with tap water, sinks, hydrotherapy pools,
whirlpools and whirlpool spas, water baths, lithotripsy therapy
tanks, dialysis water, eyewash stations, flower vases, and
endoscopes with residual moisture in the channels
Fomites (e.g., drug injection equipment stored in contaminated
water)
Intensive care unit (ICU) patients (including neonatal ICU),
transplant patients (organ and hematopoietic stem cell),
neutropenic patients, burn therapy and hydrotherapy patients,
patients with malignancies, cystic fibrosis patients, patients with
underlying medical conditions, and dialysis patients
466–503
28, 502–506
28, 29, 466, 468,
507–520
494, 495
28, 466, 467, 472,
477, 493, 506–508,
511, 512, 521–526
43
Table 13. Other gram-negative bacteria associated with water and moist environments
Implicated contaminated environmental vehicle
References
Burkholderia cepacia
Distilled water
Contaminated solutions and disinfectants
Dialysis machines
Nebulizers
Water baths
Intrinsically-contaminated mouthwash*
Ventilator temperature probes
527
528, 529
527
530–532
533
534
535
Stenotrophomonas maltophlia, Sphingomonas spp.
Distilled water
Contaminated solutions and disinfectants
Dialysis machines
Nebulizers
Water
Ventilator temperature probes
536, 537
529
527
530–532
538
539
Ralstonia pickettii
Fentanyl solutions
Chlorhexidine
Distilled water
Contaminated respiratory therapy solution
540
541
541
541, 542
Serratia marcescens
Potable water
Contaminated antiseptics (i.e., benzalkonium chloride
and chlorhexidine)
Contaminated disinfectants (i.e., quaternary ammonium
compounds and glutaraldehyde)
543
544–546
547, 548
Acinetobacter spp.
Medical equipment that collects moisture (e.g., mechanical
ventilators, cool mist humidifiers, vaporizers, and mist
tents)
Room humidifiers
Environmental surfaces
549–556
553, 555
557–564
Enterobacter spp.
Humidifier water
Intravenous fluids
Unsterilized cotton swabs
Ventilators
Rubber piping on a suctioning machine
Blood gas analyzers
565
566–578
573
565, 569
565, 569
570
* This report describes intrinsic contamination (i.e., occurring during manufacture) prior to use by the health-care facility staff. All other
entries reflect extrinsic sources of contamination.
Two additional gram-negative bacterial pathogens that can proliferate in moist environments are
Acinetobacter spp. and Enterobacter spp.571, 572 Members of both genera are responsible for healthcare–associated episodes of colonization, bloodstream infections, pneumonia, and urinary tract
infections among medically compromised patients, especially those in ICUs and burn therapy units.566,
572–583
Infections caused by Acinetobacter spp. represent a significant clinical problem. Average
infection rates are higher from July through October compared with rates from November through
June.584 Mortality rates associated with Acinetobacter bacteremia are 17%–52%, and rates as high as
71% have been reported for pneumonia caused by infection with either Acinetobacter spp. or
44
Pseudomonas spp.574–576 Multi-drug resistance, especially in third generation cephalosporins for
Enterobacter spp., contributes to increased morbidity and mortality.569, 572
Patients and health-care workers contribute significantly to the environmental contamination of surfaces
and equipment with Acinetobacter spp. and Enterobacter spp., especially in intensive care areas,
because of the nature of the medical equipment (e.g., ventilators) and the moisture associated with this
equipment.549, 571, 572, 585 Hand carriage and hand transfer are commonly associated with health-care–
associated transmission of these organisms and for S. marcescens.586 Enterobacter spp. are primarily
spread in this manner among patients by the hands of health-care workers.567, 587 Acinetobacter spp.
have been isolated from the hands of 4%–33% of health-care workers in some studies,585–590 and
transfer of an epidemic strain of Acinetobacter from patients’ skin to health-care workers’ hands has
been demonstrated experimentally.591 Acinetobacter infections and outbreaks have also been attributed
to medical equipment and materials (e.g., ventilators, cool mist humidifiers, vaporizers, and mist tents)
that may have contact with water of uncertain quality (e.g., rinsing a ventilator circuit in tap water).549–
556
Strict adherence to hand hygiene helps prevent the spread of both Acinetobacter spp. and
Enterobacter spp.577, 592
Acinetobacter spp. have also been detected on dry environmental surfaces (e.g., bed rails, counters,
sinks, bed cupboards, bedding, floors, telephones, and medical charts) in the vicinity of colonized or
infected patients; such contamination is especially problematic for surfaces that are frequently
touched.557–564 In two studies, the survival periods of Acinetobacter baumannii and Acinetobacter
calcoaceticus on dry surfaces approximated that for S. aureus (e.g., 26–27 days).593, 594 Because
Acinetobacter spp. may come from numerous sources at any given time, laboratory investigation of
health-care–associated Acinetobacter infections should involve techniques to determine biotype,
antibiotype, plasmid profile, and genomic fingerprinting (i.e., macrorestriction analysis) to accurately
identify sources and modes of transmission of the organism(s).595
c. Infections and Pseudo-Infections Due to Nontuberculous Mycobacteria
NTM are acid-fast bacilli (AFB) commonly found in potable water. NTM include both saprophytic and
opportunistic organisms. Many NTM are of low pathogenicity, and some measure of host impairment is
necessary to enhance clinical disease.596 The four most common forms of human disease associated
with NTM are a) pulmonary disease in adults; b) cervical lymph node disease in children; c) skin, soft
tissue, and bone infections; and d) disseminated disease in immunocompromised patients.596, 597
Person-to-person acquisition of NTM infection, especially among immunocompetent persons, does not
appear to occur, and close contacts of patients are not readily infected, despite the high numbers of
organisms harbored by such patients.596, 598–600 NTM are spread via all modes of transmission
associated with water. In addition to health-care–associated outbreaks of clinical disease, NTM can
colonize patients in health-care facilities through consumption of contaminated water or ice or through
inhalation of aerosols.601–605 Colonization following NTM exposure, particularly of the respiratory
tract, occurs when a patient’s local defense mechanisms are impaired; overt clinical disease does not
develop.606 Patients may have positive sputum cultures in the absence of clinical disease.
Using tap water during patient procedures and specimen collection and in the final steps of instrument
reprocessing can result in pseudo-outbreaks of NTM contamination.607– 609 NTM pseudo-outbreaks of
Mycobacterium chelonae, M. gordonae, and M. xenopi have been associated with both bronchoscopy
and gastrointestinal endoscopy when a) tap water is used to provide irrigation to the site or to rinse off
the viewing tip in situ or b) the instruments are inappropriately reprocessed with tap water in the final
steps.610– 612
45
Table 14. Nontuberculous mycobacteria—environmental vehicles
Vehicles associated with infections or colonizations
References
Mycobacterium abscessus
Inadequately sterilized medical instruments
613
Mycobacterium avium complex (MAC)
Potable water
614–616
Mycobacterium chelonae
Dialysis, reprocessed dialyzers
Inadequately-sterilized medical instruments, jet injectors
Contaminated solutions
Hydrotherapy tanks
31, 32
617, 618
619, 620
621
Mycobacterium fortuitum
Aerosols from showers or other water sources
Ice
Inadequately sterilized medical instruments
Hydrotherapy tanks
605, 606
602
603
622
Mycobacterium marinum
Hydrotherapy tanks
623
Mycobacterium ulcerans
Potable water
Vehicles associated with pseudo-outbreaks
624
References
Mycobacterium chelonae
Potable water used during bronchoscopy and instrument
reprocessing
610
Mycobacterium fortuitum
Ice
607
Mycobacterium gordonae
Deionized water
Ice
Laboratory solution (intrinsically contaminated)
Potable water ingestion prior to sputum specimen collection
611
603
625
626
Mycobacterium kansasii
Potable water
627
Mycobacterium terrae
Potable water
608
Mycobacterium xenopi
Potable water
609, 612, 627
NTM can be isolated from both natural and man-made environments. Numerous studies have identified
various NTM in municipal water systems and in hospital water systems and storage tanks.615, 616, 624, 627–
632
Some NTM species (e.g., Mycobacterium xenopi) can survive in water at 113°F (45°C), and can be
isolated from hot water taps, which can pose a problem for hospitals that lower the temperature of their
hot water systems.627 Other NTM (e.g., Mycobacterium kansasii, M. gordonae, M. fortuitum, and M.
chelonae) cannot tolerate high temperatures and are associated more often with cold water lines and
taps.629
NTM have a high resistance to chlorine; they can tolerate free chlorine concentrations of 0.05–0.2 mg/L
(0.05–0.2 ppm) found at the tap.598, 633, 634 They are 20–100 times more resistant to chlorine compared
with coliforms; slow-growing strains of NTM (e.g., Mycobacterium avium and M. kanasii) appear to be
46
more resistant to chorine inactivation compared to fast-growing NTM.635 Slow-growing NTM species
have also demonstrated some resistance to formaldehyde and glutaraldehyde, which has posed problems
for reuse of hemodialyzers.31 The ability of NTM to form biofilms at fluid-surface interfaces (e.g.,
interior surfaces of water pipes) contributes to the organisms’ resistance to chemical inactivation and
provides a microenvironment for growth and proliferation.636, 637
d. Cryptosporidiosis
Cryptosporidium parvum is a protozoan parasite that causes self-limiting gastroenteritis in normal hosts
but can cause severe, life-threatening disease in immunocompromised patients. First recognized as a
human pathogen in 1976, C. parvum can be present in natural and finished waters after fecal
contamination from either human or animal sources.638–641
The health risks associated with drinking potable water contaminated with minimal numbers of C.
parvum oocysts are unknown.642 It remains to be determined if immunosuppressed persons are more
susceptible to lower doses of oocysts than are immunocompetent persons. One study demonstrated that
a median 50% infectious dose (ID50) of 132 oocysts of calf origin was sufficient to cause infection
among healthy volunteers.643 In a second study, the same researchers found that oocysts obtained from
infected foals (newborn horses) were infectious for human volunteers at median ID50 of 10 oocysts,
indicating that different strains or species of Cryptosporidium may vary in their infectivity for
humans.644 In a small study population of 17 healthy adults with pre-existing antibody to C. parvum,
the ID50 was determined to be 1,880 oocysts, more than 20-fold higher than in seronegative persons.645
These data suggest that pre-existing immunity derived from previous exposures to Cryptosporidium
offers some protection from infection and illness that ordinarily would result from exposure to low
numbers of oocysts.645, 646
Oocysts, particularly those with thick walls, are environmentally resistant, but their survival under
natural water conditions is poorly understood. Under laboratory conditions, some oocysts remain viable
and infectious in cold (41°F [5°C]) for months.641 The prevalence of Cryptosporidium in the U.S.
drinking water supply is notable. Two surveys of approximately 300 surface water supplies revealed
that 55%–77% of the water samples contained Cryptosporidium oocysts.647, 648 Because the oocysts are
highly resistant to common disinfectants (e.g., chlorine) used to treat drinking water, filtration of the
water is important in reducing the risk of waterborne transmission. Coagulation-floculation and
sedimentation, when used with filtration, can collectively achieve approximately a 2.5 log10 reduction in
the number of oocysts.649 However, outbreaks have been associated with both filtered and unfiltered
drinking water systems (e.g., the 1993 outbreak in Milwaukee, Wisconsin that affected 400,000
people).641, 650–652 The presence of oocysts in the water is not an absolute indicator that infection will
occur when the water is consumed, nor does the absence of detectable oocysts guarantee that infection
will not occur. Health-care–associated outbreaks of cryptosporidiosis primarily have been described
among groups of elderly patients and immunocompromised persons.653
3. Water Systems in Health-Care Facilities
a. Basic Components and Point-of-Use Fixtures
Treated municipal water enters a health-care facility via the water mains and is distributed throughout
the building(s) by a network of pipes constructed of galvanized iron, copper, and polyvinylchloride
(PVC). The pipe runs should be as short as is practical. Where recirculation is employed, the pipe runs
should be insulated and long dead legs avoided in efforts to minimize the potential for water stagnation,
which favors the proliferation of Legionella spp. and NTM. In high-risk applications (e.g., PE areas for
severely immunosuppressed patients), insulated recirculation loops should be incorporated as a design
47
feature. Recirculation loops prevent stagnation and insulation maintains return water temperature with
minimal loss.
Each water service main, branch main, riser, and branch (to a group of fixtures) has a valve and a means
to reach the valves via an access panel.120 Each fixture has a stop valve. Valves permit the isolation of
a portion of the water system within a facility during repairs or maintenance. Vacuum breakers and
other similar devices in the lines prevent water from back-flowing into the system. All systems that
supply water should be evaluated to determine risk for potential back siphonage and cross connections.
Health-care facilities generate hot water from municipal water using a boiler system. Hot water heaters
and storage vessels for such systems should have a drainage facility at the lowest point, and the heating
element should be located as close as possible to the bottom of the vessel to facilitate mixing and to
prevent water temperature stratification. Those hot or cold water systems that incorporate an elevated
holding tank should be inspected and cleaned annually. Lids should fit securely to exclude foreign
materials.
The most common point-of-use fixtures for water in patient-care areas are sinks, faucets, aerators,
showers, and toilets; eye-wash stations are found primarily in laboratories. The potential for these
fixtures to serve as a reservoir for pathogenic microorganisms has long been recognized (Table 15).509,
654–656
Wet surfaces and the production of aerosols facilitate the multiplication and dispersion of
microbes. The level of risk associated with aerosol production from point-of-use fixtures varies.
Aerosols from shower heads and aerators have been linked to a limited number of clusters of gramnegative bacterial colonizations and infections, including Legionnaires disease, especially in areas
where immunocompromised patients are present (e.g., surgical ICUs, transplant units, and oncology
units).412, 415, 656–659 In one report, clinical infection was not evident among immunocompetent persons
(e.g., hospital staff) who used hospital showers when Legionella pneumophila was present in the water
system.660 Given the infrequency of reported outbreaks associated with faucet aerators, consensus has
not been reached regarding the disinfection of or removal of these devices from general use. If
additional clusters of infections or colonizations occur in high-risk patient-care areas, it may be prudent
to clean and decontaminate the aerators or to remove them.658, 659 ASHRAE recommends cleaning and
monthly disinfection of aerators in high-risk patient-care areas as part of Legionella control measures.661
Although aerosols are produced with toilet flushing,662, 663 no epidemiologic evidence suggests that
these aerosols pose a direct infection hazard.
Although not considered a standard point-of-use fixture, decorative fountains are being installed in
increasing numbers in health-care facilities and other public buildings. Aerosols from a decorative
fountain have been associated with transmission of Legionella pneumophila serogroup 1 infection to a
small cluster of older adults.664 This hotel lobby fountain had been irregularly maintained, and water in
the fountain may have been heated by submersed lighting, all of which favored the proliferation of
Legionella in the system.664 Because of the potential for generations of infectious aerosols, a prudent
prevention measure is to avoid locating these fixtures in or near high-risk patient-care areas and to
adhere to written policies for routine fountain maintenance.120
Table 15. Water and point-of-use fixtures as sources and reservoirs of waterborne
pathogens*
Reservoir
Potable water
Associated
pathogens
Pseudomonas, gramnegative bacteria,
NTM
Transmission
Strength of
evidence+
Contact
Moderate
Prevention and
control
Follow public health
guidelines.
References
(See Tables
12–14)
48
Reservoir
Associated
pathogens
Transmission
Strength of
evidence+
Prevention and
control
Aerosol inhalation
Moderate
Provide supplemental
treatment for water.
Avoid contact with
severe burn injuries.
Minimize use among
immunocompromised
patients.
Dialysate should be
<2,000 cfu/mL; water
should be <200 cfu/mL.
Use and maintain
equipment according to
instructions; eliminate
residual moisture by
drying the channels
(e.g., through alcohol
rinse and forced air
drying).
Add germicide to the
water; wrap transfusion
products in protective
plastic wrap if using the
bath to modulate the
temperature of these
products.
Drain and disinfect tub
after each use; consider
adding germicide to the
water; water in large
hydrotherapy pools
should be properly
disinfected and filtered.
Clean periodically; use
automatic dispenser
(avoid open chest
storage compartments
in patient areas).
Clean and disinfect
monthly in high-risk
patient areas; consider
removing if additional
infections occur.
No precautions are
necessary at present in
immunocompetent
patient-care areas.
Use separate sinks for
handwashing and
disposal of
contaminated fluids.
Provide sponge baths
for hematopoietic stem
cell transplant patients;
avoid shower use for
immunocompromised
patients when
Legionella is detected
in facility water.
Potable water
Legionella
Holy water
Gram-negative
bacteria
Contact
Low
Dialysis water
Gram-negative
bacteria
Contact
Moderate
Automated
endoscope
reprocessors
and rinse water
Gram-negative
bacteria
Contact
Moderate
Water baths
Pseudomonas,
Burkholderia,
Acinetobacter
Contact
Moderate
Tub immersion
Pseudomonas,
Enterobacter,
Acinetobacter
Contact
Moderate
Ice and ice
machines
NTM, Enterobacter,
Pseudomonas,
Cryptosporidium
Ingestion, contact
Moderate
Aerosol inhalation
Low
Moderate
Contact, droplet
Low
Contact, droplet
Moderate
Aerosol inhalation
Low
Faucet aerators
Faucet aerators
Legionella
Legionella
Sinks
Pseudomonas,
Acinetobacter,
Stenotrophomonas,
Chryseobacterium
Pseudomonas
Showers
Legionella
References
(See Table
11)
665
2, 527, 666–
668
669–675
29, 533, 676,
677
678–683
601, 684–687
415, 661
658, 659,
688, 689
509, 653,
685–693
656
49
Reservoir
Dental unit
water lines
Ice baths for
thermodilution
catheters
Decorative
fountains
Eyewash
stations
Toilets
Flowers
Associated
pathogens
Transmission
Strength of
evidence+
Contact
Low
Contact
Low
Aerosol inhalation
Low
Pseudomonas,
amoebae,
Legionella
Contact
Low
Gram-negative
bacteria
Gram-negative
bacteria,
Aspergillus
–
Minimum
–
Minimum
Pseudomonas,
Legionella,
Sphingomonas,
Acinetobacter
Ewingella,
Staphylococcus
Legionella
Minimum
Prevention and
control
References
Clean water systems
according to system
manufacturer’s
instructions.
Use sterile water.
636, 694–696
Perform regular
maintenance, including
water disinfection;
avoid use in or near
high-risk patient-care
areas.
Flush eyewash stations
weekly; have sterile
water available for eye
flushes.
Clean regularly; use
good hand hygiene.
Avoid use in intensive
care units and in
immunocompromised
patient-care settings.
664
697, 698
518, 699, 700
662
515, 701, 702
* Modified from reference 654 and used with permission of the publisher (Slack, Inc.)
+ Moderate: occasional well-described outbreaks. Low: few well-described outbreaks. Minimal: actual infections not demonstrated.
b. Water Temperature and Pressure
Hot water temperature is usually measured at the point of use or at the point at which the water line
enters equipment requiring hot water for proper operation.120 Generally, the hot water temperature in
hospital patient-care areas is no greater than a temperature within the range of 105°F–120°F (40.6°C–
49°C), depending on the AIA guidance issued at the year in which the facility was built.120 Hot water
temperature in patient-care areas of skilled nursing-care facilities is set within a slightly lower range of
95°F–110°F (35°C–43.3°C) depending on the AIA guidance at the time of facility construction.120
Many states have adopted a temperature setting in these ranges into their health-care regulations and
building codes. ASHRAE, however, has recommended higher settings.661 Steam jets or booster heaters
are usually needed to meet the hot water temperature requirements in certain service areas of the
hospital (e.g., the kitchen [120°F (49°C)] or the laundry [160°F (71°C)]).120 Additionally, water lines
may need to be heated to a particular temperature specified by manufacturers of specific hospital
equipment. Hot-water distribution systems serving patient-care areas are generally operated under
constant recirculation to provide continuous hot water at each hot-water outlet.120 If a facility is or has
a hemodialysis unit, then continuously circulated, cold treated water is provided to that unit.120
To minimize the growth and persistence of gram-negative waterborne bacteria (e.g., thermophilic NTM
and Legionella spp.),627, 703–709 cold water in health-care facilities should be stored and distributed at
temperatures below 68°F (20°C); hot water should be stored above 140°F (60°C) and circulated with a
minimum return temperature of 124°F (51°C),661 or the highest temperature specified in state
regulations and building codes. If the return temperature setting of 124°F (51°C) is permitted, then
installation of preset thermostatic mixing valves near the point-of-use can help to prevent scalding.
Valve maintenance is especially important in preventing valve failure, which can result in scalding.
New shower systems in large buildings, hospitals, and nursing homes should be designed to permit
mixing of hot and cold water near the shower head. The warm water section of pipe between the control
valve and shower head should be self-draining. Where buildings can not be retrofitted, other
50
approaches to minimize the growth of Legionella spp. include a) periodically increasing the temperature
to at least 150°F [66°C] at the point of use [i.e., faucets] and b) adding additional chlorine and flushing
the water.661, 710, 711 Systems should be inspected annually to ensure that thermostats are functioning
properly.
Adequate water pressure ensures sufficient water supplies for a) direct patient care; b) operation of
water-cooled instruments and equipment [e.g., lasers, computer systems, telecommunications systems,
and automated endoscope reprocessors712]; c) proper function of vacuum suctioning systems; d) indoor
climate control; and e) fire-protection systems. Maintaining adequate pressure also helps to ensure the
integrity of the piping system.
c. Infection-Control Impact of Water System Maintenance and Repair
Corrective measures for water-system failures have not been studied in well-designed experiments;
these measures are instead based on empiric engineering and infection-control principles. Health-care
facilities can occasionally sustain both intentional cut-offs by the municipal water authority to permit
new construction project tie-ins and unintentional disruptions in service when a water main breaks as a
result of aging infrastructure or a construction accident. Vacuum breakers or other similar devices can
prevent backflow of water in the facility’s distribution system during water-disruption emergencies.11
To be prepared for such an emergency, all health-care facilities need contingency plans that identify a)
the total demand for potable water, b) the quantity of replacement water [e.g., bottled water] required for
a minimum of 24 hours when the water system is down, c) mechanisms for emergency water
distribution, and 4) procedures for correcting drops in water pressure that affect operation of essential
devices and equipment that are driven or cooled by a water system [Table 16].713
Table 16. Water demand in health-care facilities during water disruption emergencies
Potable water
Water use needs
Drinking water
Handwashing
Cafeteria services
Ice
Manual flushing of toilets
Patient baths, hygiene
Hemodialysis
Hydrotherapy
Fire prevention (e.g., sprinkler systems)
Surgery and critical care areas
Laboratory services
Laundry and central sterile services*
Cooling towers+
Steam generation
Bottled, sterile water
Surgical scrub
Emergency surgical procedures
Pharmaceutical preparations
Patient-care equipment (e.g., ventilators)§
* Arrange to have a contingency provision of these services from another resource, if possible (e.g., another health-care facility or contractor).
+ Some cooling towers may use a potable water source, but most units use non-potable water.
§ This item is included in the table under the assumption that electrical power is available during the water emergency.
Detailed, up-to-date plans for hot and cold water piping systems should be readily available for
maintenance and repair purposes in case of system problems. Opening potable water systems for repair
or construction and subjecting systems to water-pressure changes can result in water discoloration and
dramatic increases in the concentrations of Legionella spp. and other gram-negative bacteria. The
maintenance of a chlorine residual at all points within the piping system also offers some protection
from entry of contamination to the pipes in the event of inadvertent cross-connection between potable
and non-potable water lines. As a minimum preventive measure, ASHRAE recommends a thorough
flushing of the system.661 High-temperature flushing or hyperchlorination may also be appropriate
51
strategies to decrease potentially high concentrations of waterborne organisms. The decision to pursue
either of these remediation strategies, however, should be made on a case-by-case basis. If only a
portion of the system is involved, high temperature flushing or chlorination can be used on only that
portion of the system.661
When shock decontamination of hot water systems is necessary (e.g., after disruption caused by
construction and after cross-connections), the hot water temperature should be raised to 160°F–170°F
(71°C–77°C) and maintained at that level while each outlet around the system is progressively flushed.
A minimum flush time of 5 minutes has been recommended;3 the optimal flush time is not known,
however, and longer flush times may be necessary.714 The number of outlets that can be flushed
simultaneously depends on the capacity of the water heater and the flow capability of the system.
Appropriate safety procedures to prevent scalding are essential. When possible, flushing should be
performed when the fewest building occupants are present (e.g., during nights and weekends).
When thermal shock treatment is not possible, shock chlorination may serve as an alternative method.661
Experience with this method of decontamination is limited, however, and high levels of free chlorine
can corrode metals. Chlorine should be added, preferably overnight, to achieve a free chlorine residual
of at least 2 mg/L (2 ppm) throughout the system.661 This may require chlorination of the water heater
or tank to levels of 20–50 mg/L (20–50 ppm). The pH of the water should be maintained at 7.0–8.0.661
After completion of the decontamination, recolonization of the hot water system is likely to occur unless
proper temperatures are maintained or a procedure such as continuous supplemental chlorination is
continued.
Interruptions of the water supply and sewage spills are situations that require immediate recovery and
remediation measures to ensure the health and safety of patients and staff.715 When delivery of potable
water through the municipal distribution system has been disrupted, the public water supplier must issue
a “boil water” advisory if microbial contamination presents an immediate public health risk to
customers. The hospital engineer should oversee the restoration of the water system in the facility and
clear it for use when appropriate. Hospitals must maintain a high level of surveillance for waterborne
disease among patients and staff after the advisory is lifted.642
Flooding from either external (e.g., from a hurricane) or internal sources (e.g., a water system break)
usually results in property damage and a temporary loss of water and sanitation.716–718 JCAHO requires
all hospitals to have plans that address facility response for recovery from both internal and external
disasters.713, 719 The plans are required to discuss a) general emergency preparedness, b) staffing, c)
regional planning among area hospitals, d) emergency supply of potable water, e) infection control and
medical services needs, f) climate control, and g) remediation. The basic principles of structural
recovery from flooding are similar to those for recovery from sewage contamination (Box 9 and 10).
Following a major event (e.g., flooding), facilities may elect to conduct microbial sampling of water
after the system is restored to verify that water quality has been returned to safe levels (<500 CFU/mL,
heterotrophic plate count). This approach may help identify point-of-use fixtures that may harbor
contamination as a result of design or engineering features.720 Medical records should be allowed to
dry and then either photocopied or placed in plastic covers before returning them to the record.
Moisture meters can be used to assess water-damaged structural materials. If porous structural materials
for walls have a moisture content of >20% after 72 hours, the affected material should be removed.266,
278, 313
The management of water-damaged structural materials is not strictly limited to major water
catastrophes (e.g., flooding and sewage intrusions); the same principles are used to evaluate the damage
from leaking roofs, point-of-use fixtures, and equipment. Additional sources of moisture include
condensate on walls from boilers and poorly engineered humidification in HVAC systems.
52
Box 9. Recovery and remediation measures for water-related emergencies*
Potable water disruptions
Contingency plan items
Ensure access to plumbing network so that repairs can be easily made.
Provide sufficient potable water, either from bottled sources or truck delivery.
Post advisory notices against consuming tap water, ice, or beverages made with water.
Rope off or bag drinking fountains to designate these as being “out of service” until further notice.
Rinse raw foods as needed in disinfected water.
Disconnect ice machines whenever possible.+
Postpone laundry services until after the water system is restored.
Water treatment
Heat water to a rolling boil for >1 minute.
Remediation of the water system after the “boil water” advisory is rescinded
Flush fixtures (e.g., faucets and drinking fountains) and equipment for several minutes and restart.
Run water softeners through a regeneration cycle.
Drain, disinfect, and refill water storage tanks, if needed.
Change pretreatment filters and disinfect the dialysis water system.
Sewage spills/malfunction
Overall strategy
Move patients and clean/sterile supplies out of the area.
Redirect traffic away from the area.
Close the doors or use plastic sheeting to isolate the area prior to clean-up.
Restore sewage system function first, then the potable water system (if both are malfunctioning).
Remove sewage solids, drain the area, and let dry.
Remediation of the structure
Hard surfaces: clean with detergent/disinfectant after the area has been drained.
Carpeting, loose tiles, buckled flooring: remove and allow the support surface to dry; replace the items; wet down
carpeting with a low-level disinfectant or sanitizer prior to removal to minimize dust dispersion to the air.
Wallboard and other porous structural materials: remove and replace if they cannot be cleaned and dried within
72 hours.§
Furniture
Hard surface furniture (e.g., metal or plastic furniture): clean and allow to dry.
Wood furniture: let dry, sand the wood surface, and reapply varnish.
Cloth furniture: replace.
Electrical equipment
Replace if the item cannot be easily dismantled, cleaned, and reassembled.
* Material in this box is compiled from references 266, 278, 315, 713, 716–719, 721–729.
+ Ice machines should always be disconnected from the water source in advance of planned water disruptions.
§ Moisture meter readings should be <20% moisture content.
An exception to these recommendations is made for hemodialysis units where water is further
treated either by portable water treatment or large-scale water treatment systems usually involving
reverse osmosis (RO). In the United States, >97% of dialysis facilities use RO treatment for their
water.721 However, changing pre-treatment filters and disinfecting the system to prevent colonization
of the RO membrane and microbial contamination down-stream of the pre-treatment filter are prudent
measures.
53
Box 10. Contingency planning for flooding
General emergency preparedness
Ensure that emergency electrical generators are not located in flood-prone areas of the facility.
Develop alternative strategies for moving patients, water containers, medical records, equipment, and supplies in the
event that the elevators are inoperable.
Establish in advance a centralized base of operations with batteries, flashlights, and cellular phones.
Ensure sufficient supplies of sandbags to place at the entrances and the area around boilers, incinerators, and
generators.
Establish alternative strategies for bringing core employees to the facility if high water prevents travel.
Staffing Patterns
Temporarily reassign licensed staff as needed to critical care areas to provide manual ventilation and to perform
vital assessments on patients.
Designate a core group of employees to remain on site to keep all services operational if the facility remains open.
Train all employees in emergency preparedness procedures.
Regional planning among are facilities for disaster management
Incorporate community support and involvement (e.g., media alerts, news, and transportation).
Develop in advance strategies for transferring patients, as needed.
Develop strategies for sharing supplies and providing essential services among participating facilities (e.g., central
sterile department services, and laundry services).
Identify sources for emergency provisions (e.g., blood, emergency vehicles, and bottled water).
Medical services and infection control
Use alcohol-based hand rubs in general patient-care areas.
Postpone elective surgeries until full services are restored, or transfer these patients to other facilities.
Consider using portable dialysis machines.+
Provide an adequate supply of tetanus and hepatitis A immunizations for patients and staff.
Climate control
Provide adequate water for cooling towers.§
* Material in this box was compiled from references 713, 716–719.
+ Portable dialysis machines require less water compared to the larger units situated in dialysis settings.
§ Water for cooling towers may need to be trucked in, especially if the tower uses a potable water source.
4. Strategies for Controlling Waterborne Microbial Contamination
a. Supplemental Treatment of Water with Heat and/or Chemicals
In addition to using supplemental treatment methods as remediation measures after inadvertent
contamination of water systems, health-care facilities sometimes use special measures to control
waterborne microorganisms on a sustained basis. This decision is most often associated with outbreaks
of legionellosis and subsequent efforts to control legionellae,722 although some facilities have tried
supplemental measures to better control thermophilic NTM.627
The primary disinfectant for both cold and hot water systems is chlorine. However, chlorine residuals
are expected to be low, and possibly nonexistent, in hot water tanks because of extended retention time
in the tank and elevated water temperature. Flushing, especially that which removes sludge from the
bottom of the tank, probably provides the most effective treatment of water systems. Unlike the
situation for disinfecting cooling towers, no equivalent recommendations have been made for potable
water systems, although specific intervention strategies have been published.403, 723 The principal
approaches to disinfection of potable systems are heat flushing using temperatures 160°F–170°F (71°–
77°C), hyperchlorination, and physical cleaning of hot-water tanks.3, 403, 661 Potable systems are easily
recolonized and may require continuous intervention (e.g., raising of hot water temperatures or
continuous chlorination).403, 711 Chlorine solutions lose potency over time, thereby rendering the
stocking of large quantities of chlorine impractical.
54
Some hospitals with hot water systems identified as the source of Legionella spp. have performed
emergency decontamination of their systems by pulse (i.e., one-time) thermal disinfection/superheating
or hyperchlorination.711, 714, 724, 725 After either of these procedures, hospitals either maintain their
heated water with a minimum return temperature of 124°F (51°C) and cold water at <68°F (<20°C) or
chlorinate their hot water to achieve 1–2 mg/L (1–2 ppm) of free residual chlorine at the tap.26, 437, 709–711,
726, 727
Additional measures (e.g., physical cleaning or replacement of hot-water storage tanks, water
heaters, faucets, and shower heads) may be required to help eliminate accumulations of scale and
sediment that protect organisms from the biocidal effects of heat and chlorine.457, 711 Alternative
methods for controlling and eradicating legionellae in water systems (e.g., treating water with chlorine
dioxide, heavy metal ions [i.e., copper/silver ions], ozone, and UV light) have limited the growth of
legionellae under laboratory and operating conditions.728–742 Further studies on the long-term efficacy
of these treatments are needed before these methods can be considered standard applications.
Renewed interest in the use of chloramines stems from concerns about adverse health effects associated
with disinfectants and disinfection by-products.743 Monochloramine usage minimizes the formation of
disinfection by-products, including trihalomethanes and haloacetic acids. Monochloramine can also
reach distal points in a water system and can penetrate into bacterial biofilms more effectively than free
chlorine.744 However, monochloramine use is limited to municipal water treatment plants and is
currently not available to health-care facilities as a supplemental water-treatment approach. A recent
study indicated that 90% of Legionnaires disease outbreaks associated with drinking water could have
been prevented if monochloramine rather than free chlorine has been used for residual disinfection.745
In a retrospective comparison of health-care–associated Legionnaires disease incidence in central Texas
hospitals, the same research group documented an absence of cases in facilities located in communities
with monochloramine-treated municipal water.746 Additional data are needed regarding the
effectiveness of using monochloramine before its routine use as a disinfectant in water systems can be
recommended. No data have been published regarding the effectiveness of monochloramine installed at
the level of the health-care facility.
Additional filtration of potable water systems is not routinely necessary. Filters are used in water lines
in dialysis units, however, and may be inserted into the lines for specific equipment (e.g., endoscope
washers and disinfectors) for the purpose of providing bacteria-free water for instrument reprocessing.
Additionally, an RO unit is usually added to the distribution system leading to PE areas.
b. Primary Prevention of Legionnaires Disease (No Cases Identified)
The primary and secondary environmental infection-control strategies described in this section on the
guideline pertain to health-care facilities without transplant units. Infection-control measures specific to
PE or transplant units (i.e., patient-care areas housing patients at the highest risk for morbidity and
mortality from Legionella spp. infection) are described in the subsection titled Preventing Legionnaires
Disease in Protective Environments.
Health-care facilities use at least two general strategies to prevent health-care–associated legionellosis
when no cases or only sporadic cases have been detected. The first is an environmental surveillance
approach involving periodic culturing of water samples from the hospital’s potable water system to
monitor for Legionella spp.747–750 If any sample is culture-positive, diagnostic testing is recommended
for all patients with health-care–associated pneumonia.748, 749 In-house testing is recommended for
facilities with transplant programs as part of a comprehensive treatment/management program. If >30%
of the samples are culture-positive for Legionella spp., decontamination of the facility’s potable water
system is warranted.748 The premise for this approach is that no cases of health-care–associated
legionellosis can occur if Legionella spp. are not present in the potable water system, and, conversely,
cases of health-care–associated legionellosis could potentially occur if Legionella spp. are cultured from
the water.26, 751 Physicians who are informed that the hospital’s potable water system is culture-positive
55
for Legionella spp. are more likely to order diagnostic tests for legionellosis.
A potential advantage of the environmental surveillance approach is that periodic culturing of water is
less costly than routine laboratory diagnostic testing for all patients who have health-care–associated
pneumonia. The primary argument against this approach is that, in the absence of cases, the relationship
between water-culture results and legionellosis risk remains undefined.3 Legionnella spp. can be
present in the water systems of buildings752 without being associated with known cases of disease.437, 707,
753
In a study of 84 hospitals in Québec, 68% of the water systems were found to be colonized with
Legionella spp., and 26% were colonized at >30% of sites sampled; cases of Legionnaires disease,
however, were infrequently reported from these hospitals.707
Other factors also argue against environmental surveillance. Interpretation of results from periodic
water culturing might be confounded by differing results among the sites sampled in a single water
system and by fluctuations in the concentration of Legionella spp. at the same site.709, 754 In addition,
the risk for illness after exposure to a given source might be influenced by several factors other than the
presence or concentration of organisms, including a) the degree to which contaminated water is
aerosolized into respirable droplets, b) the proximity of the infectious aerosol to the potential host, c) the
susceptibility of the host, and d) the virulence properties of the contaminating strain.755–757 Thus, data
are insufficient to assign a level of disease risk even on the basis of the number of colony-forming units
detected in samples from areas for immunocompetent patients. Conducting environmental surveillance
would obligate hospital administrators to initiate water-decontamination programs if Legionella spp. are
identified. Therefore, periodic monitoring of water from the hospital's potable water system and from
aerosol-producing devices is not widely recommended in facilities that have not experienced cases of
health-care–associated legionellosis.661, 758
The second strategy to prevent and control health-care–associated legionellosis is a clinical approach, in
which providers maintain a high index of suspicion for legionellosis and order appropriate diagnostic
tests (i.e., culture, urine antigen, and direct fluorescent antibody [DFA] serology) for patients with
health-care–associated pneumonia who are at high risk for legionellosis and its complications.437, 759, 760
The testing of autopsy specimens can be included in this strategy should a death resulting from healthcare–associated pneumonia occur. Identification of one case of definite or two cases of possible healthcare–associated Legionnaires disease should prompt an epidemiologic investigation for a hospital
source of Legionella spp., which may involve culturing the facility’s water for Legionella. Routine
maintenance of cooling towers, and use of sterile water for the filling and terminal rinsing of
nebulization devices and ventilation equipment can help to minimize potential sources of contamination.
Circulating potable water temperatures should match those outlined in the subsection titled Water
Temperature and Pressure, as permitted by state code.
c. Secondary prevention of Legionnaires Disease (With Identified Cases)
The indications for a full-scale environmental investigation to search for and subsequently
decontaminate identified sources of Legionella spp. in health-care facilities without transplant units
have not been clarified; these indications would likely differ depending on the facility. Case categories
for health-care–associated Legionnaires disease in facilities without transplant units include definite
cases (i.e., laboratory-confirmed cases of legionellosis that occur in patients who have been hospitalized
continuously for >10 days before the onset of illness) and possible cases (i.e., laboratory-confirmed
infections that occur 2–9 days after hospital admission).3 In settings in which as few as one to three
health-care–associated cases are recognized over several months, intensified surveillance for
Legionnaires disease has frequently identified numerous additional cases.405, 408, 432, 453, 739, 759, 760 This
finding suggests the need for a low threshold for initiating an investigation after laboratory confirmation
of cases of health-care–associated legionellosis. When developing a strategy for responding to such a
finding, however, infection-control personnel should consider the level of risk for health-care–
56
associated acquisition of, and mortality from, Legionella spp. infection at their particular facility.
An epidemiologic investigation conducted to determine the source of Legionella spp. involves several
important steps (Box 11). Laboratory assessment is crucial in supporting epidemiologic evidence of a
link between human illness and a specific environmental source.761 Strain determination from subtype
analysis is most frequently used in these investigations.410, 762–764 Once the environmental source is
established and confirmed with laboratory support, supplemental water treatment strategies can be
initiated as appropriate.
Box 11. Steps in an epidemiologic investigation for legionellosis
Review medical and microbiologic records.
Initiate active surveillance to identify all recent or ongoing cases.
Develop a line listing of cases by time, place, and person.
Determine the type of epidemiologic investigation needed for assessing risk factors:
• Case-control study,
• Cohort study.
Gather and analyze epidemiologic information:
• Evaluate risk factors associated with potential environmental exposures (e.g., showers,
cooling towers, and respiratory-therapy equipment).
Collect water samples:
• Sample environmental sources implicated by epidemiologic investigation,
• Sample other potential source of water aerosols.
Subtype strains of Legionella spp. cultured from both patients and environmental sources.
Review autopsy records and include autopsy specimens in diagnostic testing.
The decision to search for hospital environmental sources of Legionella spp. and the choice of
procedures to eradicate such contamination are based on several considerations, as follows: a) the
hospital’s patient population; b) the cost of an environmental investigation and institution of control
measures to eradicate Legionella spp. from the water supply;765–768 and c) the differential risk, based on
host factors, for acquiring health-care–associated legionellosis and developing severe and fatal
infection.
d. Preventing Legionnaires Disease in Protective Environments
This subsection outlines infection-control measures applicable to those health-care facilities providing
care to severely immunocompromised patients. Indigenous microorganisms in the tap water of these
facilities may pose problems for such patients. These measures are designed to prevent the generation
of potentially infectious aerosols from water and the subsequent exposure of PE patients or other
immunocompromised patients (e.g., transplant patients) (Table 17). Infection-control measures that
address the use of water with medical equipment (e.g., ventilators, nebulizers, and equipment
humidifiers) are described in other guidelines and publications.3, 455
If one case of laboratory-confirmed, health-care–associated Legionnaires disease is identified in a
patient in a solid-organ transplant program or in PE (i.e., an inpatient in PE for all or part of the 2–10
days prior to onset of illness) or if two or more laboratory-confirmed cases occur among patients who
had visited an outpatient PE setting, the hospital should report the cases to the local and state health
departments. The hospital should then initiate a thorough epidemiologic and environmental
investigation to determine the likely environmental sources of Legionella spp.9 The source of
Legionella should be decontaminated or removed. Isolated cases may be difficult to investigate.
Because transplant recipients are at substantially higher risk for disease and death from legionellosis
57
compared with other hospitalized patients, periodic culturing for Legionella spp. in water samples from
the potable water in the solid-organ transplant and/or PE unit can be performed as part of an overall
strategy to prevent Legionnaires disease in PE units.9, 431, 710, 769 The optimal methodology (i.e.,
frequency and number of sites) for environmental surveillance cultures in PE units has not been
determined, and the cost-effectiveness of this strategy has not been evaluated. Because transplant
recipients are at high risk for Legionnaires disease and because no data are available to determine a safe
concentration of legionellae organisms in potable water, the goal of environmental surveillance for
Legionella spp. should be to maintain water systems with no detectable organisms.9, 431 Culturing for
legionellae may be used to assess the effectiveness of water treatment or decontamination methods, a
practice that provides benefits to both patients and health-care workers.767, 770
Table 17. Additional infection-control measures to prevent exposure of high-risk patients
to waterborne pathogens
Measures
• Restrict patients from taking showers if the water is contaminated with Legionella
spp.
• Use water that is not contaminated with Legionella spp. for patients’ sponge baths.
• Provide sterile water for drinking, tooth brushing, or for flushing nasogastric tubes.
• Perform supplemental treatment of the water for the unit.
• Consider periodic monitoring (i.e., culturing) of the unit water supply for
Legionella spp.
• Remove shower heads and faucet aerators monthly for cleaning.*
• Use a 500–600 ppm (1:100 v/v dilution) solution of sodium hypochlorite to
disinfect shower heads and faucet aerators.*
• Do not use large-volume room air humidifiers that create aerosols unless these are
subjected to cleaning and high-level disinfection daily and filled with distilled
water.
• Eliminate water-containing bath toys.+
References
• 407, 412, 654, 655, 658
•
•
•
•
9
9, 412
732
9, 431
• 661
• 661
• 3
• 30
* These measures can be considered in settings where legionellosis cases have occurred. These measures are not generally recommended in
routine patient-care setting..
+ These items have been associated with outbreaks of Pseudomonas.
Protecting patient-care devices and instruments from inadvertent tap water contamination during room
cleaning procedures is also important in any immunocompromised patient-care area. In a recent
outbreak of gram-negative bacteremias among open-heart-surgery patients, pressure-monitoring
equipment that was assembled and left uncovered overnight prior to the next day’s surgeries was
inadvertently contaminated with mists and splashing water from a hose-disinfectant system used for
cleaning.771
5. Cooling Towers and Evaporative Condensers
Modern health-care facilities maintain indoor climate control during warm weather by use of cooling
towers (large facilities) or evaporative condensers (smaller buildings). A cooling tower is a wet-type,
evaporative heat transfer device used to discharge to the atmosphere waste heat from a building’s air
conditioning condensers (Figure 5).772, 773 Warm water from air-conditioning condensers is piped to the
cooling tower where it is sprayed downward into a counter- or cross-current air flow. To accelerate heat
transfer to the air, the water passes over the fill, which either breaks water into droplets or causes it to
spread into a thin film.772, 773 Most systems use fans to move air through the tower, although some large
industrial cooling towers rely on natural draft circulation of air. The cooled water from the tower is
piped back to the condenser, where it again picks up heat generated during the process of chilling the
system’s refrigerant. The water is cycled back to the cooling tower to be cooled. Closed-circuit cooling
towers and evaporative condensers are also evaporative heat-transfer devices. In these systems, the
58
process fluid (e.g., water, ethylene glycol/water mixture, oil, or a condensing refrigerant) does not
directly contact the cooling air, but is contained inside a coil assembly.661
Figure 5. Diagram of a typical air conditioning (induced draft) cooling tower*
Water temperatures are approximate and may differ substantially according to system use and design. Warm water from the
condenser (or chiller) is sprayed downward into a counter- or cross-current air flow. Water passes over the fill (a component of
the system designed to increase the surface area of the water exposed to air), and heat from the water is transferred to the air.
Some of the water becomes aerosolized during this process, although the volume of aerosol discharged to the air can be
reduced by the placement of a drift eliminator. Water cooled in the tower returns to the heat source to cool refrigerant from the
air conditioning unit.
* This figure is reprinted with permission of the publisher of reference 773 (Plenum Medical).
Cooling towers and evaporative condensers incorporate inertial stripping devices called drift eliminators
to remove water droplets generated within the unit. Although the effectiveness of these eliminators
varies substantially depending on design and condition, some water droplets in the size range of <5 µm
will likely leave the unit, and some larger droplets leaving the unit may be reduced to <5 µm by
evaporation. Thus, even with proper operation, a cooling tower or evaporative condenser can generate
and expel respirable water aerosols. If either the water in the unit’s basin or the make-up water (added
to replace water lost to evaporation) contains Legionella spp. or other waterborne microorganisms, these
organisms can be aerosolized and dispersed from the unit.774 Clusters of both Legionnaires disease and
Pontiac fever have been traced to exposure to infectious water aerosols originating from cooling towers
and evaporative condensers contaminated with Legionella spp. Although most of these outbreaks have
been community-acquired episodes of pneumonia,775–782 health-care–associated Legionnaires disease
59
has been linked to cooling tower aerosol exposure.404, 405 Contaminated aerosols from cooling towers
on hospital premises gained entry to the buildings either through open windows or via air handling
system intakes located near the tower equipment.
Cooling towers and evaporative condensers provide ideal ecological niches for Legionella spp. The
typical temperature of the water in cooling towers ranges from 85°F–95°F (29°C–35°C), although
temperatures can be above 120°F (49°C) and below 70°F (21°C) depending on system heat load,
ambient temperature, and operating strategy.661 An Australian study of cooling towers found that
legionellae colonized or multiplied in towers with basin temperatures above 60.8°F (16°C), and
multiplication became explosive at temperatures above 73.4°F (23°C).783 Water temperature in closedcircuit cooling towers and evaporative condensers is similar to that in cooling towers. Considerable
variation in the piping arrangement occurs. In addition, stagnant areas or dead legs may be difficult to
clean or penetrate with biocides.
Several documents address the routine maintenance of cooling towers, evaporative condensers, and
whirlpool spas.661, 784–787 They suggest following manufacturer's recommendations for cleaning and
biocide treatment of these devices; all health-care facilities should ensure proper maintenance for their
cooling towers and evaporative condensers, even in the absence of Legionella spp (Appendix C).
Because cooling towers and evaporative condensers can be shut down during periods when air
conditioning is not needed, this maintenance cleaning and treatment should be performed before starting
up the system for the first time in the warm season.782 Emergency decontamination protocols
describing cleaning procedures and hyperchlorination for cooling towers have been developed for
towers implicated in the transmission of legionellosis.786, 787
6. Dialysis Water Quality and Dialysate
a. Rationale for Water Treatment in Hemodialysis
Hemodialysis, hemofiltration, and hemodiafiltration require special water-treatment processes to
prevent adverse patient outcomes of dialysis therapy resulting from improper formulation of dialysate
with water containing high levels of certain chemical or biological contaminants. The Association for
the Advancement of Medical Instrumentation (AAMI) has established chemical and microbiologic
standards for the water used to prepare dialysate, substitution fluid, or to reprocess hemodialyzers for
renal replacement therapy.788–792 The AAMI standards address: a) equipment and processes used to
purify water for the preparation of concentrates and dialysate and the reprocessing of dialyzers for
multiple use and b) the devices used to store and distribute this water. Future revisions to these
standards may include hemofiltration and hemodiafiltration.
Water treatment systems used in hemodialysis employ several physical and/or chemical processes either
singly or in combination (Figure 6). These systems may be portable units or large systems that feed
several rooms. In the United States, >97% of maintenance hemodialysis facilities use RO alone or in
combination with deionization.793 Many acute-care facilities use portable hemodialysis machines with
attached portable water treatment systems that use either deionization or RO. These machines were
exempted from earlier versions of AAMI recommendations, but given current knowledge about toxic
exposures to and inflammatory processes in patients new to dialysis, these machines should now come
into compliance with current AAMI recommendations for hemodialysis water and dialysate quality.788,
789
Previous recommendations were based on the assumption that acute-care patients did not
experience the same degree of adverse effects from short-term, cumulative exposures to either
chemicals or microbiologic agents present in hemodialysis fluids compared with the effects encountered
by patients during chronic, maintenance dialysis.788, 789 Additionally, JCAHO is reviewing inpatient
60
practices and record-keeping for dialysis (acute and maintenance) for adherence to AAMI standards and
recommended practices.
Figure 6. Dialysis water treatment system*
Product
water
Potable water
Blending
valve
Multimedia/
sand/depth
filtration
Softener
Carbon adsorption
media (2 beds in
series
Particulate/
1 µm filter
Reverse
osmosis
Storage tank and/or
optional additional
components:
deionization tanks
UV lamp
ultrafilters
* See text for description of the placement and function of these components.
Neither the water used to prepare dialysate nor the dialysate itself needs to be sterile, but tap water can
not be used without additional treatment. Infections caused by rapid-growing NTM (e.g.,
Mycobacterium chelonae and M. abscessus) present a potential risk to hemodialysis patients (especially
those in hemodialyzer reuse programs) if disinfection procedures to inactivate mycobacteria in the water
(low-level disinfection) and the hemodialyzers (high-level disinfection) are inadequate.31, 32, 633 Other
factors associated with microbial contamination in dialysis systems could involve the water treatment
system, the water and dialysate distribution systems, and the type of hemodialyzer.666, 667, 794–799
Understanding the various factors and their influence on contamination levels is the key to preventing
high levels of microbial contamination in dialysis therapy.
In several studies, pyrogenic reactions were demonstrated to have been caused by lipopolysaccharide or
endotoxin associated with gram-negative bacteria.794, 800–803 Early studies demonstrated that parenteral
exposure to endotoxin at a concentration of 1 ng/kg body weight/hour was the threshold dose for
producing pyrogenic reactions in humans, and that the relative potencies of endotoxin differ by bacterial
species.804, 805 Gram-negative water bacteria (e.g., Pseudomonas spp.) have been shown to multiply
rapidly in a variety of hospital-associated fluids that can be used as supply water for hemodialysis (e.g.,
distilled water, deionized water, RO water, and softened water) and in dialysate (a balanced salt solution
made with this water).806 Several studies have demonstrated that the attack rates of pyrogenic reactions
are directly associated with the number of bacteria in dialysate.666, 667, 807 These studies provided the
rationale for setting the heterotrophic bacteria standards in the first AAMI hemodialysis guideline at
<2,000 CFU/mL in dialysate and one log lower (<200 CFU/mL) for the water used to prepare
dialysate.668, 788 If the level of bacterial contamination exceeded 200 CFU/mL in water, this level could
be amplified in the system and effectively constitute a high inoculum for dialysate at the start of a
61
dialysis treatment.807, 808 Pyrogenic reactions did not appear to occur when the level of contamination
was below 2,000 CFU/mL in dialysate unless the source of the endotoxin was exogenous to the dialysis
system (i.e., present in the community water supply). Endotoxins in a community water supply have
been linked to the development of pyrogenic reactions among dialysis patients.794
Whether endotoxin actually crosses the dialyzer membrane is controversial. Several investigators have
shown that bacteria growing in dialysate-generated products that could cross the dialyzer membrane.809,
810
Gram-negative bacteria growing in dialysate have produced endotoxins that in turn stimulated the
production of anti-endotoxin antibodies in hemodialysis patients;801, 811 these data suggest that bacterial
endotoxins, although large molecules, cross dialyzer membranes either intact or as fragments. The use
of the very permeable membranes known as high-flux membranes (which allow large molecules [e.g.,
β2 microglobulin] to traverse the membrane) increases the potential for passage of endotoxins into the
blood path. Several studies support this contention. In one such study, an increase in plasma endotoxin
concentrations during dialysis was observed when patients were dialyzed against dialysate containing
103–104 CFU/mL Pseudomonas spp.812 In vitro studies using both radiolabeled lipopolysaccharide and
biologic assays have demonstrated that biologically active substances derived from bacteria found in
dialysate can cross a variety of dialyzer membranes.802, 813–816 Patients treated with high-flux
membranes have had higher levels of anti-endotoxin antibodies than subjects or patients treated with
conventional membranes.817 Finally, since 1989, 19%–22% of dialysis centers have reported pyrogenic
reactions in the absence of septicemia.818, 819
Investigations of adverse outcomes among patients using reprocessed dialyzers have demonstrated a
greater risk for developing pyrogenic reactions when the water used to reprocess these devices
contained >6 ng/mL endotoxin and >104 CFU/mL bacteria.820 In addition to the variability in
endotoxin assays, host factors also are involved in determining whether a patient will mount a response
to endotoxin.803 Outbreak investigations of pyrogenic reactions and bacteremias associated with
hemodialyzer reuse have demonstrated that pyrogenic reactions are prevented once the endotoxin level
in the water used to reprocess the dialyzers is returned to below the AAMI standard level.821
Reuse of dialyzers and use of bicarbonate dialysate, high-flux dialyzer membranes, or high-flux dialysis
may increase the potential for pyrogenic reactions if the water in the dialysis setting does not meet
standards.796–798 Although investigators have been unable to demonstrate endotoxin transfer across
dialyzer membranes,803, 822, 823 the preponderance of reports now supports the ability of endotoxin to
transfer across at least some high-flux membranes under some operating conditions. In addition to the
acute risk of pyrogenic reactions, indirect evidence in increasingly demonstrating that chronic exposure
to low amounts of endotoxin may play a role in some of the long-term complications of hemodialysis
therapy. Patients treated with ultrafiltered dialysate for 5–6 months have demonstrated a decrease in
serum β2 microglobulin concentrations and a decrease in markers of an inflammatory response.824–826 In
studies of longer duration, use of microbiologically ultrapure dialysate has been associated with a
decreased incidence of β2 microglobulin-associated amyloidosis.827, 828
Although patient benefit likely is associated with the use of ultrapure dialysate, no consensus has been
reached regarding the potential adoption of this as standard in the United States. Debate continues
regarding the bacterial and endotoxin limits for dialysate. As advances in water treatment and
hemodialysis processes occur, efforts are underway to move improved technology from the
manufacturer out into the user community. Cost-benefit studies, however, have not been done, and
substantially increased costs to implement newer water treatment modalities are anticipated.
To reconcile AAMI documents with current International Organization for Standardization (ISO)
format, AAMI has determined that its hemodialysis standards will be discussed in the following four
installments: RD 5 for hemodialysis equipment, RD 62 for product water quality, RD 47 for dialyzer
62
reprocessing, and RD 52 for dialysate quality. The Renal Diseases and Dialysis Committee of AAMI is
expected to finalize and promulgated the dialysate standard pertinent to the user community (RD 52),
adopting by reference the bacterial and endotoxin limits in product water as currently outlined in the
AAMI standard that applies to systems manufacturers (RD 62). At present, the user community should
continue to observe water quality and dialysate standards as outlined in AAMI RD 5 (Hemodialysis
Systems, 1992) and AAMI RD 47 (Reuse of Hemodialyzers, 1993) until the new RD 52 standard
becomes available (Table 18).789, 791
Table 18. Microbiologic limits for hemodialysis fluids*
Hemodialysis fluid
Maximum total heterotrophs
(CFU/mL)+
Maximum endotoxin level
(EU/mL)§
200
200
2,000
No standard
5
No standard
200
200
2
2
Present standard
Product water¶
Used to prepare dialysate
Used to reprocess dialyzers
Dialysate
Proposed standard**
Product water
Dialysate
* The material in this table was compiled from references 789 and 791 (ANSI/AAMI standards RD 5-1992 and ANSI/AAMI RD 47-1993).
+ Colony forming units per milliliter.
§ Endotoxin units per milliliter.
¶ Product water presently includes water used to prepare dialysate and water used to reprocess dialyzers.
** Dialysate for hemodialysis, RD 52, under development, American National Standards Institute, Association for the Advancement of
Medical Instrumentation (AAMI).
The current AAMI standard directed at systems manufacturers (RD 62 [Water Treatment Equipment for
Hemodialysis Applications, 2001]) now specifies that all product water used to prepare dialysate or to
reprocess dialyzers for multiple use should contain <2 endotoxin units per milliliter (EU/mL).792 A
level of 2 EU/mL was chosen as the upper limit for endotoxin because this level is easily achieved with
contemporary water treatment systems using RO and/or ultrafiltration. CDC has advocated monthly
endotoxin testing along with microbiologic assays of water, because endotoxin activity may not
correspond to the total heterotrophic plate counts.829 Additionally, the current AAMI standard RD 62
for manufacturers includes action levels for product water. Because 48 hours can elapse between the
time of sampling water for microbial contamination and the time when results are received, and because
bacterial proliferation can be rapid, action levels for microbial counts and endotoxin concentrations are
reported as 50 CFU/mL and 1 EU/mL, respectively, in this revision of the standard.792 These
recommendations will allow users to initiate corrective action before levels exceed the maximum levels
established by the standard.
In hemodialysis, the net movement of water is from the blood to the dialysate, although within the
dialyzer, local movement of water from the dialysate to the blood through the phenomenon of backfiltration may occur, particularly in dialyzers with highly permeable membranes.830 In contrast,
hemofiltration and hemodiaflltration feature infusion of large volumes of electrolyte solution (20–70 L)
into the blood. Increasingly, this electrolyte solution is being prepared on-line from water and
concentrate. Because of the large volumes of fluid infused, AAMI considered the necessity of setting
more stringent requirements for water to be used in this application, but this organization has not yet
established these because of lack of expert consensus and insufficient experience with on-line therapies
in the United States. On-line hemofiltration and hemodiafiltration systems use sequential ultrafiltration
as the final step in the preparation of infusion fluid. Several experts from AAMI concur that these
63
point-of-use ultrafiltration systems should be capable of further reducing the bacteria and endotoxin
burden of solutions prepared from water meeting the requirements of the AAMI standard to a safe level
for infusion.
b. Microbial Control Strategies
The strategy for controlling massive accumulations of gram-negative water bacteria and NTM in
dialysis systems primarily involves preventing their growth through proper disinfection of watertreatment systems and hemodialysis machines. Gram-negative water bacteria, their associated
lipopolysaccharides (bacterial endotoxins), and NTM ultimately come from the community water
supply, and levels of these bacteria can be amplified depending on the water treatment system, dialysate
distribution system, type of dialysis machine, and method of disinfection (Table 19).634, 794, 831 Control
strategies are designed to reduce levels of microbial contamination in water and dialysis fluid to
relatively low levels but not to completely eradicate it.
Table 19. Factors influencing microbial contamination in hemodialysis systems
Factors
Water supply
Source of community water
Ground water
Surface water
Water treatment at the dialysis center
None
Filtration
Prefilter
Absolute filter (depth or membrane filter)
Activated carbon filter
Water treatment devices
Deionization/ion-exchange softener
Reverse osmosis (RO)
Ultraviolet light
Ultrafilter
Water and dialysate distribution system
Distribution pipes
Size
Construction
Elevation
Storage tanks
Dialysis machines
Single-pass
Recirculating single-pass or recirculating
(batch)
Comments
Contains endotoxin and bacteria
Contains high levels of endotoxin and bacteria
Not recommended
Particulate filter to protect equipment; does not remove microorganisms
Removes bacteria, however, unless the filter is changed frequently or
disinfected, bacteria will accumulate and grow through the filter; acts
as a significant reservoir of bacteria and endotoxin
Removes organics and available chlorine or chloramines; acts as a
significant reservoir of bacteria and endotoxin
Both softeners and deionizers are significant reservoirs of bacteria and do
not remove endotoxin.
Removes bacteria and endotoxin, but must be disinfected; operates at high
water pressure
Kills some bacteria, but there is no residual; ultraviolet-resistant bacteria
can develop if the unit is not properly maintained
Removes bacteria and endotoxin; operates on normal line pressure; can be
positioned distal to deionizer; must be disinfected
Oversized diameter and length decrease fluid flow and increase bacterial
reservoir for both treated water and centrally-prepared dialysate.
Rough joints, dead ends, unused branches, and polyvinyl chloride (PVC)
piping can act as bacterial reservoirs.
Outlet taps should be located at the highest elevation to prevent loss of
disinfectant; keep a recirculation loop in the system; flush unused ports
routinely.
Tanks are undesirable because they act as a reservoir for water bacteria; if
tanks are present, they must be routinely scrubbed and disinfected.
Disinfectant should have contact with all parts of the machine that are
exposed to water or dialysis fluid.
Recirculating pumps and machine design allow for massive contamination
levels if not properly disinfected; overnight chemical germicide
treatment is recommended.
64
Two components of hemodialysis water distribution systems – pipes (particularly those made of
polyvinyl chloride [PVC]) and storage tanks – can serve as reservoirs of microbial contamination.
Hemodialysis systems frequently use pipes that are wider and longer than are needed to handle the
required flow, which slows the fluid velocity and increases both the total fluid volume and the wetted
surface area of the system. Gram-negative bacteria in fluids remaining in pipes overnight multiply
rapidly and colonize the wet surfaces, producing bacterial populations and endotoxin quantities in
proportion to the volume and surface area. Such colonization results in formation of protective biofilm
that is difficult to remove and protects the bacteria from disinfection.832 Routine (i.e., monthly), lowlevel disinfection of the pipes can help to control bacterial contamination of the distribution system.
Additional measures to protect pipes from contaminations include a) situating all outlet taps at equal
elevation and at the highest point of the system so that the disinfectant cannot drain from pipes by
gravity before adequate contact time has elapsed and b) eliminating rough joints, dead-end pipes, and
unused branches and taps that can trap fluid and serve as reservoirs of bacteria capable of continuously
inoculating the entire volume of the system.800 Maintain a flow velocity of 3–5 ft/sec.
A storage tank in the distribution system greatly increases the volume of fluid and surface area available
and can serve as a niche for water bacteria. Storage tanks are therefore not recommended for use in
dialysis systems unless they are frequently drained and adequately disinfected, including scrubbing the
sides of the tank to remove bacterial biofilm. An ultrafilter should be used distal to the storage tank.808,
833
Microbiologic sampling of dialysis fluids is recommended because gram-negative bacteria can
proliferate rapidly in water and dialysate in hemodialysis systems; high levels of these organisms place
patients at risk for pyrogenic reactions or health-care–associated infection.667, 668, 808
Health-care facilities are advised to sample dialysis fluids at least monthly using standard microbiologic
assay methods for waterborne microorganisms.788, 793, 799, 834–836 Product water used to prepare dialysate
and to reprocess hemodialyzers for reuse on the same patient should also be tested for bacterial
endotoxin on a monthly basis.792, 829, 837 (See Appendix C for information about water sampling
methods for dialysis.)
Cross-contamination of dialysis machines and inadequate disinfection measures can facilitate the spread
of waterborne organisms to patients. Steps should be taken to ensure that dialysis equipment is
performing correctly and that all connectors, lines, and other components are specific for the equipment,
in good repair, and properly in place. A recent outbreak of gram-negative bacteremias among dialysis
patients was attributed to faulty valves in a drain port of the machine that allowed backflow of saline
used to flush the dialyzer before patient use.838, 839 This backflow contaminated the drain priming
connectors, which contaminated the blood lines and exposed the patients to high concentrations of
gram-negative bacteria. Environmental infection control in dialysis settings also includes low-level
disinfection of housekeeping surfaces and spot decontamination of spills of blood (see Environmental
Services in Part I of this guideline for further information).
c. Infection-Control Issues in Peritoneal Dialysis
Peritoneal dialysis (PD), most commonly administered as continuous ambulatory peritoneal dialysis
(CAPD) and continual cycling peritoneal dialysis (CCPD), is the third most common treatment for endstage renal disease (ESRD) in the United States, accounting for 12% of all dialysis patients.840
Peritonitis is the primary complication of CAPD, with coagulase-negative staphylococci the most
clinically significant causative organisms.841 Other organisms that have been found to produce
peritonitis include Staphylococcus aureus, Mycobacterium fortuitum, M. mucogenicum,
Stenotrophomonas maltophilia, Burkholderia cepacia, Corynebacterium jeikeium, Candida spp., and
65
other fungi.842–850 Substantial morbidity is associated with peritoneal dialysis infections. Removal of
peritoneal dialysis catheters usually is required for treatment of peritonitis caused by fungi, NTM, or
other bacteria that are not cleared within the first several days of effective antimicrobial treatment.
Furthermore, recurrent episodes of peritonitis may lead to fibrosis and loss of the dialysis membrane.
Many reported episodes of peritonitis are associated with exit-site or tunneled catheter infections. Risk
factors for the development of peritonitis in PD patients include a) under dialysis, b) immune
suppression, c) prolonged antimicrobial treatment, d) patient age [more infections occur in younger
patients and older hospitalized patients], e) length of hospital stay, and f) hypoalbuminemia.844, 851, 852
Concern has been raised about infection risk associated with the use of automated cyclers in both
inpatient and outpatient settings; however, studies suggest that PD patients who use automated cyclers
have much lower infection rates.853 One study noted that a closed-drainage system reduced the
incidence of system-related peritonitis among intermittent peritoneal dialysis (IPD) patients from 3.6 to
1.5 cases/100 patient days.854 The association of peritonitis with management of spent dialysate fluids
requires additional study. Therefore, ensuring that the tip of the waste line is not submerged beneath the
water level in a toilet or in a drain is prudent.
7. Ice Machines and Ice
Microorganisms may be present in ice, ice-storage chests, and ice-making machines. The two main
sources of microorganisms in ice are the potable water from which it is made and a transferral of
organisms from hands (Table 20). Ice from contaminated ice machines has been associated with patient
colonization, blood stream infections, pulmonary and gastrointestinal illnesses, and pseudoinfections.602,
603, 683, 684, 854, 855
Microorganisms in ice can secondarily contaminate clinical specimens and medical
solutions that require cold temperatures for either transport or holding.601, 620 An outbreak of surgicalsite infections was interrupted when sterile ice was used in place of tap water ice to cool cardioplegia
solutions.601
Table 20. Microorganisms and their sources in ice and ice machines
Sources of microorganisms
References
From potable water
Legionella spp.
Nontuberculous mycobacteria (NTM)
Pseudomonas aeruginosa
Burkholderia cepacia
Stenotrophomonas maltophilia
Flavobacterium spp.
684, 685, 857, 858
602, 603, 859
859
859, 860
860
860
From fecally-contaminated water
Norwalk virus
Giardia lamblia
Cryptosporidium parvum
861–863
864
685
From hand-transfer of organisms
Acinetobacter spp.
Coagulase-negative staphylococci
Salmonella enteriditis
Cryptosporidium parvum
859
859
865
685
66
In a study comparing the microbial populations of hospital ice machines with organisms recovered from
ice samples gathered from the community, samples from 27 hospital ice machines yielded low numbers
(<10 CFU/mL) of several potentially opportunistic microorganisms, mainly gram-negative bacilli.859
During the survey period, no health-care–associated infections were attributed to the use of ice. Ice
from community sources had higher levels of microbial contamination (75%–95% of 194 samples had
total heterotrophic plate counts <500 CFU/mL, with the proportion of positive cultures dependent on the
incubation temperature) and showed evidence of fecal contamination from the source water.859 Thus,
ice machines in health-care settings are no more heavily contaminated compared with ice machines in
the community. If the source water for ice in a health-care facility is not fecally contaminated, then ice
from clean ice machines and chests should pose no increased hazard for immunocompetent patients.
Some waterborne bacteria found in ice could potentially be a risk to immunocompromised patients if
they consume ice or drink beverages with ice. For example, Burkholderia cepacia in ice could present
an infection risk for cystic fibrosis patients.859, 860 Therefore, protecting immunosuppressed and
otherwise medically at-risk patients from exposure to tap water and ice potentially contaminated with
opportunistic pathogens is prudent.9
No microbiologic standards for ice, ice-making machines, or ice storage equipment have been
established, although several investigators have suggested the need for such standards.859, 866 Culturing
of ice machines is not routinely recommended, but it may be useful as part of an epidemiologic
investigation.867–869 Sampling might also help determine the best schedule for cleaning open ice-storage
chests. Recommendations for a regular program of maintenance and disinfection have been
published.866–869 Health-care facilities are advised to clean ice-storage chests on a regular basis. Open
ice chests may require a more frequent cleaning schedule compared with chests that have covers.
Portable ice chests and containers require cleaning and low-level disinfection before the addition of ice
intended for consumption. Ice-making machines may require less frequent cleaning, but their
maintenance is important to proper performance. The manufacturer’s instructions for both the proper
method of cleaning and/or maintenance should be followed. These instructions may also recommend an
EPA-registered disinfectant to ensure chemical potency, materials compatibility, and safety. In the
event that instructions and suitable EPA-registered disinfectants are not available for this process, then a
generic approach to cleaning, disinfecting, and maintaining ice machines and dispensers can be used
(Box 12).
Ice and ice-making machines also may be contaminated via improper storage or handling of ice by
patients and/or staff.684–686, 855–858, 870 Suggested steps to avoid this means of contamination include a)
minimizing or avoiding direct hand contact with ice intended for consumption, b) using a hard-surface
scoop to dispense ice, and c) installing machines that dispense ice directly into portable containers at the
touch of a control.687, 869
Box 12. General steps for cleaning and maintaining ice machines, dispensers, and storage
chests*+
1.
2.
3.
4.
5.
6.
7.
8.
9.
Disconnect unit from power supply.
Remove and discard ice from bin or storage chest.
Allow unit to warm to room temperature.
Disassemble removable parts of machine that make contact with water to make ice.
Thoroughly clean machine and parts with water and detergent.
Dry external surfaces of removable parts before reassembling.
Check for any needed repair.
Replace feeder lines, as appropriate (e.g., when damaged, old, or difficult to clean).
Ensure presence of an air space in tubing leading from water inlet into water distribution system of
machine.
67
(Box 12. continued)
10. Inspect for rodent or insect infestations under the unit and treat, as needed.
11. Check door gaskets (open compartment models) for evidence of leakage or dripping into the
storage chest.
12. Clean the ice-storage chest or bin with fresh water and detergent; rinse with fresh tap water.
13. Sanitize machine by circulating a 50–100 parts per million (ppm) solution of sodium hypochlorite
(i.e., 4–8 mL sodium hypochlorite/gallon of water) through the ice-making and storage systems for
2 hours (100 ppm solution), or 4 hours (50 ppm solution).
14. Drain sodium hypochlorite solutions and flush with fresh tap water.
15. Allow all surfaces of equipment to dry before returning to service.
* Material in this box is adapted from reference 869.
+ These general guidelines should be used only where manufacturer-recommended methods and EPA-registered disinfectants are not
available.
8. Hydrotherapy Tanks and Pools
a. General Information
Hydrotherapy equipment (e.g., pools, whirlpools, whirlpool spas, hot tubs, and physiotherapy tanks)
traditionally has been used to treat patients with certain medical conditions (e.g., burns,871, 872 septic
ulcers, lesions, amputations,873 orthopedic impairments and injuries, arthritis,874 and kidney
lithotripsy).654 Wound-care medicine is increasingly moving away from hydrotherapy, however, in
favor of bedside pulsed-lavage therapy using sterile solutions for cleaning and irrigation.492, 875–878
Several episodes of health-care–associated infections have been linked to use of hydrotherapy
equipment (Table 21). Potential routes of infection include incidental ingestion of the water, sprays and
aerosols, and direct contact with wounds and intact skin (folliculitis). Risk factors for infection include
a) age and sex of the patient, b) underlying medical conditions, c) length of time spent in the
hydrotherapy water, and d) portals of entry.879
Table 21. Infections associated with use of hydrotherapy equipment
Microorganisms
Acinetobacter baumanii
Citrobacter freundii
Enterobacter cloacae
Legionella spp.
Mycobacterium abscessus, Mycobacterium
fortuitum, Mycobacterium marinum
Pseudomonas aeruginosa
Adenovirus, adeno-associated virus
Medical conditions
References
Sepsis
Cellulitis
Sepsis
Legionellosis
572
880
881
882
Skin ulcers and soft tissue infections
621–623, 883
Sepsis, soft tissue infections, folliculitis, and
wound infections
Conjunctivitis
492, 493, 506, 679, 884–888
889
Infection control for hydrotherapy tanks, pools, or birthing tanks presents unique challenges because
indigenous microorganisms are always present in the water during treatments. In addition, some studies
have found free living amoebae (i.e., Naegleria lovaniensis), which are commonly found in association
with Naegleria fowleri, in hospital hydrotherapy pools.890 Although hydrotherapy is at times
appropriate for patients with wounds, burns, or other types of non-intact skin conditions (determined on
a case-by-case basis), this equipment should not be considered “semi-critical” in accordance with the
Spaulding classification.891 Microbial data to evaluate the risk of infection to patients using
hydrotherapy pools and birthing tanks are insufficient. Nevertheless, health-care facilities should
maintain stringent cleaning and disinfection practices in accordance with the manufacturer’s instructions
68
and with relevant scientific literature until data supporting more rigorous infection-control measures
become available. Factors that should be considered in therapy decisions in this situation would include
a) availability of alternative aseptic techniques for wound management and b) a risk-benefit analysis of
using traditional hydrotherapy.
b. Hydrotherapy Tanks
Hydrotherapy tanks (e.g., whirlpools, Hubbard tanks and whirlpool bath tubs) are shallow tanks
constructed of stainless steel, plexiglass, or tile. They are closed-cycle water systems with hydrojets to
circulate, aerate, and agitate the water. The maximum water temperature range is 50°F–104°F (10°C–
40°C). The warm water temperature, constant agitation and aeration, and design of the hydrotherapy
tanks provide ideal conditions for bacterial proliferation if the equipment is not properly maintained,
cleaned, and disinfected. The design of the hydrotherapy equipment should be evaluated for potential
infection-control problems that can be associated with inaccessible surfaces that can be difficult to clean
and/or remain wet in between uses (i.e., recessed drain plates with fixed grill plates).887 Associated
equipment (e.g., parallel bars, plinths, Hoyer lifts, and wheelchairs) can also be potential reservoirs of
microorganisms, depending on the materials used in these items (i.e., porous vs. non-porous materials)
and the surfaces that may become wet during use. Patients with active skin colonizations and wound
infections can serve as sources of contamination for the equipment and the water. Contamination from
spilled tub water can extend to drains, floors, and walls.680–683 Health-care–associated colonization or
infection can result from exposure to endogenous sources of microorganisms (autoinoculation) or
exogenous sources (via cross-contamination from other patients previously receiving treatment in the
unit).
Although some facilities have used tub liners to minimize environmental contamination of the tanks, the
use of a tub liner does not eliminate the need for cleaning and disinfection. Draining these small pools
and tanks after each patient use, thoroughly cleaning with a detergent, and disinfecting according to
manufacturers’ instructions have reduced bacterial contamination levels in the water from 104 CFU/mL
to <10 CFU/mL.892 A chlorine residual of 15 ppm in the water should be obtained prior to the patient’s
therapy session (e.g., by adding 15 grams of calcium hypochlorite 70% [e.g., HTH®] per 100 gallons of
water).892 A study of commercial and residential whirlpools found that superchlorination or draining,
cleaning, disinfection, and refilling of whirlpools markedly reduced densities of Pseudomonas
aeruginosa in whirlpool water.893 The bacterial populations were rapidly replenished, however, when
disinfectant concentrations dropped below recommended levels for recreational use (i.e., chlorine at 3.0
ppm or bromine at 6.0 ppm). When using chlorine, however, knowing whether the community
drinking-water system is disinfected with chloramine is important, because municipal utilities adjust the
pH of the water to the basic side to enhance chloramine formation. Because chlorine is not very
effective at pH levels above 8, it may be necessary to re-adjust the pH of the water to a more acidic
level.894
A few reports describe the addition of antiseptic chemicals to hydrotherapy tank water, especially for
burn patient therapy.895–897 One study involving a minimal number of participants demonstrated a
reduction in the number of Pseudomonas spp. and other gram-negative bacteria from both patients and
equipment surfaces when chloramine-T (“chlorazene”) was added to the water.898 Chloramine-T has
not, however, been approved for water treatment in the United States.
c. Hydrotherapy Pools
Hydrotherapy pools typically serve large numbers of patients and are usually heated to 91.4°F–98.6°F
(31°C–37°C). The temperature range is more narrow (94°F–96.8°F [35°C–36°C]) for pediatric and
geriatric patient use.899 Because the size of hydrotherapy pools precludes draining after patient use,
proper management is required to maintain the proper balance of water conditioning (i.e., alkalinity,
hardness, and temperature) and disinfection. The most widely used chemicals for disinfection of pools
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are chlorine and chlorine compounds – calcium hypochlorite, sodium hypochlorite, lithium
hypochlorite, chloroisocyanurates, and chlorine gas. Solid and liquid formulations of chlorine
chemicals are the easiest and safest to use.900 Other halogenated compounds have also been used for
pool-water disinfection, albeit on a limited scale. Bromine, which forms bactericidal bromamines in the
presence of ammonia, has limited use because of its association with contact dermatitis.901 Iodine does
not bleach hair, swim suits, or cause eye irritation, but when introduced at proper concentrations, it
gives water a greenish-yellowish cast.892
In practical terms, maintenance of large hydrotherapy pools (e.g., those used for exercise) is similar to
that for indoor public pools (i.e., continuous filtration, chlorine residuals no less than 0.4 ppm, and pH
of 7.2–7.6).902, 903 Supply pipes and pumps also need to be maintained to eliminate the possibility of
this equipment serving as a reservoir for waterborne organisms.904 Specific standards for chlorine
residual and pH of the water are addressed in local and state regulations. Patients who are fecally
incontinent or who have draining wounds should refrain from using these pools until their condition
improves.
d. Birthing Tanks and Other Equipment
The use of birthing tanks, whirlpool spas, and whirlpools is a recent addition to obstetrical practice.905
Few studies on the potential risks associated with these pieces of equipment have been conducted. In
one study of 32 women, a newborn contracted a Pseudomonas infection after being birthed in such a
tank, the strain of which was identical to the organism isolated from the tank water.906 Another report
documented identical strains of P. aeruginosa isolates from a newborn with sepsis and on the
environmental surfaces of a tub that the mother used for relaxation while in labor.907 Other studies have
shown no significant increases in the rates of post-immersion infections among mothers and infants.908,
909
Because the water and the tub surfaces routinely become contaminated with the mother’s skin flora and
blood during labor and delivery, birthing tanks and other tub equipment must be drained after each
patient use and the surfaces thoroughly cleaned and disinfected. Health-care facilities are advised to
follow the manufacturer’s instructions for selection of disinfection method and chemical germicide.
The range of chlorine residuals for public whirlpools and whirlpool spas is 2–5 ppm.910 Use of an
inflatable tub is an alternative solution, but this item must be cleaned and disinfected between patients if
it is not considered a single-use unit.
Recreational tanks and whirlpool spas are increasingly being used as hydrotherapy equipment.
Although such home equipment appears to be suitable for hydrotherapy, they are neither designed nor
constructed to function in this capacity. Additionally, manufacturers generally are not obligated to
provide the health-care facility with cleaning and disinfecting instructions appropriate for medical
equipment use, and the U.S. Food and Drug Administration (FDA) does not evaluate recreational
equipment. Health-care facilities should therefore carefully evaluate this “off-label” use of home
equipment before proceeding with a purchase.
9. Miscellaneous Medical/Dental Equipment Connected to Main Water
Systems
a. Automated Endoscope Reprocessors
The automated endoscopic reprocessor (AER) is classified by the FDA as an accessory for the flexible
endoscope.654 A properly operating AER can provide a more consistent, reliable method of
decontaminating and terminal reprocessing for endoscopes between patient procedures than manual
reprocessing methods alone.911 An endoscope is generally subjected to high-level disinfection using a
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liquid chemical sterilant or a high-level disinfectant. Because the instrument is a semi-critical device,
the optimal rinse fluid for a disinfected endoscope would be sterile water.3 Sterile water, however, is
expensive and difficult to produce in sufficient quantities and with adequate quality assurance for
instrument rinsing in an AER.912, 913 Therefore, one option to be used for AERs is rinse water that has
been passed through filters with a pore size of 0.1–0.2 µm to render the water “bacteria-free.” These
filters usually are located in the water line at or near the port where the mains water enters the
equipment. The product water (i.e., tap water passing through these filters) in these applications is not
considered equivalent in microbial quality to that for membrane-filtered water as produced by
pharmaceutical firms. Membrane filtration in pharmaceutical applications is intended to ensure the
microbial quality of polished product water.
Water has been linked to the contamination of flexible fiberoptic endoscopes in the following two
scenarios: a) rinsing a disinfected endoscope with unfiltered tap water, followed by storage of the
instrument without drying out the internal channels and b) contamination of AERs from tap water
inadvertently introduced into the equipment. In the latter instance, the machine’s water reservoirs and
fluid circuitry become contaminated with waterborne, heterotrophic bacteria (e.g., Pseudomonas
aeruginosa and NTM), which can survive and persist in biofilms attached to these components.914–917
Colonization of the reservoirs and water lines of the AER becomes problematic if the required cleaning,
disinfection, and maintenance are not performed on the equipment as recommended by the
manufacturer.669, 916, 917 Use of the 0.1–0.2-µm filter in the water line helps to keep bacterial
contamination to a minimum,670, 911, 917 but filters may fail and allow bacteria to pass through to the
equipment and then to the instrument undergoing reprocessing.671–674, 913, 918 Filters also require
maintenance for proper performance.670, 911, 912, 918, 919 Heightened awareness of the proper disinfection
of the connectors that hook the instrument to the AER may help to further reduce the potential for
contaminating endoscopes during reprocessing.920 An emerging issue in the field of endoscopy is that
of the possible role of rinse water monitoring and its potential to help reduce endoscopy/bronchoscopyassociated infections.918
Studies have linked deficiencies in endoscope cleaning and/or disinfecting processes to the incidence of
post-endoscopic adverse outcomes.921–924 Several clusters have been traced to AERs of older designs
and these were associated with water quality.675, 914–916 Regardless of whether manual or automated
terminal reprocessing is used for endoscopes, the internal channels of the instrument should be dried
before storage.925 The presence of residual moisture in the internal channels encourages the
proliferation of waterborne microorganisms, some of which may be pathogenic. One of the most
frequently used methods employs 70% isopropyl alcohol to flush the internal channels, followed by
forced air drying of these channels and hanging the endoscope vertically in a protected cabinet; this
method ensures internal drying of the endoscope, lessens the potential for proliferation of waterborne
microorganisms,669, 913, 917, 922, 926, 927 and is consistent with professional organization guidance for
endoscope reprocessing.928
An additional problem with waterborne microbial contamination of AERs centers on increased
microbial resistance to alkaline glutaraldehyde, a widely used liquid chemical sterilant/high-level
disinfectant.669, 929 Opportunistic waterborne microorganisms (e.g., Mycobacterium chelonae,
Methylobacterium spp.) have been associated with pseudo-outbreaks and colonization; infection caused
by these organisms has been associated with procedures conducted in clinical settings (e.g.,
bronchoscopy).669, 913, 929–931 Increasing microbial resistance to glutaraldehyde has been attributed to
improper use of the disinfectant in the equipment, allowing the dilution of glutaraldehyde to fall below
the manufacturer’s recommended minimal use concentration.929
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b. Dental Unit Water Lines
Dental unit water lines (DUWLs) consist of small-bore plastic tubing that delivers water used for
general, non-surgical irrigation and as a coolant to dental handpieces, sonic and ultrasonic scalers, and
air-water syringes; municipal tap water is the source water for these lines. The presence of biofilms of
waterborne bacteria and fungi (e.g., Legionella spp., Pseudomonas aeruginosa, and NTM) in DUWLs
has been established.636, 637, 694, 695, 932– 934 Biofilms continually release planktonic microorganisms into
the water, the titers of which can exceed 1H106 CFU/mL.694 However, scientific evidence indicates that
immunocompetent persons are only at minimal risk for substantial adverse health effects after contact
with water from a dental unit. Nonetheless, exposing patients or dental personnel to water of uncertain
microbiological quality is not consistent with universally accepted infection-control principles.935
In 1993, CDC issued guidelines relative to water quality in a dental setting. These guidelines
recommend that all dental instruments that use water (including high-speed handpieces) should be run to
discharge water for 20–30 seconds after each patient and for several minutes before the start of each
clinic day.936 This practice can help to flush out any patient materials that many have entered the
turbine, air, or waterlines.937, 938 The 1993 guidance also indicated that waterlines be flushed at the
beginning of the clinic day. Although these guidelines are designed to help reduce the number of
microorganisms present in treatment water, they do not address the issue of reducing or preventing
biofilm formation in the waterlines. Research published subsequent to the 1993 dental infection control
guideline suggests that flushing the lines at the beginning of the day has only minimal effect on the
status of the biofilm in the lines and does not reliably improve the quality of water during dental
treatment.939–941 Updated recommendations on infection-control practices for water line use in dentistry
will be available in late 2003.942
The numbers of microorganisms in water used as coolant or irrigant for non-surgical dental treatment
should be as low as reasonably achievable and, at a minimum, should meet nationally recognized
standards for safe drinking water.935, 943 Only minimal evidence suggests that water meeting drinking
water standards poses a health hazard for immunocompetent persons. The EPA, the American Public
Health Association (APHA), and the American Water Works Association (AWWA) have set a
maximum limit of 500 CFU/mL for aerobic, heterotrophic, mesophilic bacteria in drinking water in
municipal distribution systems.944, 945 This standard is achievable, given improvements in water-line
technology. Dentists should consult with the manufacturer of their dental unit to determine the best
equipment and method for maintaining and monitoring good water quality.935, 946
E. Environmental Services
1. Principles of Cleaning and Disinfecting Environmental Surfaces
Although microbiologically contaminated surfaces can serve as reservoirs of potential pathogens, these
surfaces generally are not directly associated with transmission of infections to either staff or patients.
The transferral of microorganisms from environmental surfaces to patients is largely via hand contact
with the surface.947, 948 Although hand hygiene is important to minimize the impact of this transfer,
cleaning and disinfecting environmental surfaces as appropriate is fundamental in reducing their
potential contribution to the incidence of healthcare-associated infections.
The principles of cleaning and disinfecting environmental surfaces take into account the intended use of
the surface or item in patient care. CDC retains the Spaulding classification for medical and surgical
instruments, which outlines three categories based on the potential for the instrument to transmit
infection if the instrument is microbiologically contaminated before use.949, 950 These categories are
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“critical,” “semicritical,” and “noncritical.” In 1991, CDC proposed an additional category designated
“environmental surfaces” to Spaulding’s original classification951 to represent surfaces that generally do
not come into direct contact with patients during care. Environmental surfaces carry the least risk of
disease transmission and can be safely decontaminated using less rigorous methods than those used on
medical instruments and devices. Environmental surfaces can be further divided into medical
equipment surfaces (e.g., knobs or handles on hemodialysis machines, x-ray machines, instrument carts,
and dental units) and housekeeping surfaces (e.g., floors, walls, and tabletops).951
The following factors influence the choice of disinfection procedure for environmental surfaces: a) the
nature of the item to be disinfected, b) the number of microorganisms present, c) the innate resistance of
those microorganisms to the inactivating effects of the germicide, d) the amount of organic soil present,
e) the type and concentration of germicide used, f) duration and temperature of germicide contact, and
g) if using a proprietary product, other specific indications and directions for use.952, 953
Cleaning is the necessary first step of any sterilization or disinfection process. Cleaning is a form of
decontamination that renders the environmental surface safe to handle or use by removing organic
matter, salts, and visible soils, all of which interfere with microbial inactivation.954–960 The physical
action of scrubbing with detergents and surfactants and rinsing with water removes large numbers of
microorganisms from surfaces.957 If the surface is not cleaned before the terminal reprocessing
procedures are started, the success of the sterilization or disinfection process is compromised.
Spaulding proposed three levels of disinfection for the treatment of devices and surfaces that do not
require sterility for safe use. These disinfection levels are “high-level,” “intermediate-level,” and “lowlevel.”949, 950 The basis for these levels is that microorganisms can usually be grouped according to their
innate resistance to a spectrum of physical or chemical germicidal agents (Table 22). This information,
coupled with the instrument/surface classification, determines the appropriate level of terminal
disinfection for an instrument or surface.
Table 22. Levels of disinfection by type of microorganism*
Disinfection
level
High
Intermediate
Low
Vegetative
+§
+
+
Bacteria
Tubercle
bacillus
+
+
–
Fungi+
Spores
+¶
–**
–
+
+
+
Viruses
Lipid and
Nonlipid and
medium size
small size
+
+
+
+
+++
+
* Material in this table compiled from references 2 and 951.
+ This class of microorganisms includes asexual spores but not necessarily chlamydospores or sexual spores.
§ The “plus” sign indicates that a killing effect can be expected when the normal use-concentrations of chemical disinfectants or pasteurization
are properly employed; a “negative” sign indicates little or no killing effect.
¶ Only with extended exposure times are high-level disinfectant chemicals capable of killing high numbers of bacterial spores in laboratory
tests; they are, however, capable of sporicidal activity.
** Some intermediate-level disinfectants (e.g., hypochlorites) can exhibit some sporicidal activity; others (e.g., alcohols and phenolics) have
no demonstrable sporicidal activity.
++ Some intermediate-level disinfectants, although they are tuberculocidal, may have limited virucidal activity.
The process of high-level disinfection, an appropriate standard of treatment for heat-sensitive, semicritical medical instruments (e.g., flexible, fiberoptic endoscopes), inactivates all vegetative bacteria,
mycobacteria, viruses, fungi, and some bacterial spores. High-level disinfection is accomplished with
powerful, sporicidal chemicals (e.g., glutaraldehyde, peracetic acid, and hydrogen peroxide) that are not
appropriate for use on housekeeping surfaces. These liquid chemical sterilants/high-level disinfectants
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are highly toxic.961–963 Use of these chemicals for applications other than those indicated in their label
instructions (i.e., as immersion chemicals for treating heat-sensitive medical instruments) is not
appropriate.964 Intermediate-level disinfection does not necessarily kill bacterial spores, but it does
inactivate Mycobacterium tuberculosis var. bovis, which is substantially more resistant to chemical
germicides than ordinary vegetative bacteria, fungi, and medium to small viruses (with or without lipid
envelopes). Chemical germicides with sufficient potency to achieve intermediate-level disinfection
include chlorine-containing compounds (e.g., sodium hypochlorite), alcohols, some phenolics, and some
iodophors. Low-level disinfection inactivates vegetative bacteria, fungi, enveloped viruses (e.g., human
immunodeficiency virus [HIV], and influenza viruses), and some non-enveloped viruses (e.g.,
adenoviruses). Low-level disinfectants include quaternary ammonium compounds, some phenolics, and
some iodophors. Sanitizers are agents that reduce the numbers of bacterial contaminants to safe levels
as judged by public health requirements, and are used in cleaning operations, particularly in food service
and dairy applications. Germicidal chemicals that have been approved by FDA as skin antiseptics are
not appropriate for use as environmental surface disinfectants.951
The selection and use of chemical germicides are largely matters of judgment, guided by product label
instructions, information, and regulations. Liquid sterilant chemicals and high-level disinfectants
intended for use on critical and semi-critical medical/dental devices and instruments are regulated
exclusively by the FDA as a result of recent memoranda of understanding between FDA and the EPA
that delineates agency authority for chemical germicide regulation.965, 966 Environmental surface
germicides (i.e., primarily intermediate- and low-level disinfectants) are regulated by the EPA and
labeled with EPA registration numbers. The labels and technical data or product literature of these
germicides specify indications for product use and provide claims for the range of antimicrobial activity.
The EPA requires certain pre-registration laboratory potency tests for these products to support product
label claims. EPA verifies (through laboratory testing) manufacturers’ claims to inactivate
microorganisms for selected products and organisms. Germicides labeled as “hospital disinfectant”
have passed the potency tests for activity against three representative microorganisms – Pseudomonas
aeruginosa, Staphylococcus aureus, and Salmonella cholerae suis. Low-level disinfectants are often
labeled “hospital disinfectant” without a tuberculocidal claim, because they lack the potency to
inactivate mycobacteria. Hospital disinfectants with demonstrated potency against mycobacteria (i.e.,
intermediate-level disinfectants) may list “tuberculocidal” on the label as well. Other claims (e.g.,
“fungicidal,” “pseudomonicidal,” and “virucidal”) may appear on labels of environmental surface
germicides, but the designations of “tuberculocidal hospital disinfectant” and “hospital disinfectant”
correlate directly to Spaulding’s assessment of intermediate-level disinfectants and low-level
disinfectants, respectively.951
A common misconception in the use of surface disinfectants in health-care settings relates to the
underlying purpose for use of proprietary products labeled as a “tuberculocidal” germicide. Such
products will not interrupt and prevent the transmission of TB in health-care settings because TB is not
acquired from environmental surfaces. The tuberculocidal claim is used as a benchmark by which to
measure germicidal potency. Because mycobacteria have the highest intrinsic level of resistance among
the vegetative bacteria, viruses, and fungi, any germicide with a tuberculocidal claim on the label (i.e.,
an intermediate-level disinfectant) is considered capable of inactivating a broad spectrum of pathogens,
including much less resistant organisms such the bloodborne pathogens (e.g., hepatitis B virus [HBV],
hepatitis C virus [HCV], and HIV). It is this broad spectrum capability, rather than the product’s
specific potency against mycobacteria, that is the basis for protocols and OSHA regulations indicating
the appropriateness of using tuberculocidal chemicals for surface disinfection.967
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2. General Cleaning Strategies for Patient-Care Areas
The number and types of microorganisms present on environmental surfaces are influenced by the
following factors: a) number of people in the environment, b) amount of activity, c) amount of moisture,
d) presence of material capable of supporting microbial growth, e) rate at which organisms suspended in
the air are removed, and f) type of surface and orientation [i.e., horizontal or vertical].968 Strategies for
cleaning and disinfecting surfaces in patient-care areas take into account a) potential for direct patient
contact, b) degree and frequency of hand contact, and c) potential contamination of the surface with
body substances or environmental sources of microorganisms (e.g., soil, dust, and water).
a. Cleaning of Medical Equipment
Manufacturers of medical equipment should provide care and maintenance instructions specific to their
equipment. These instructions should include information about a) the equipments’ compatibility with
chemical germicides, b) whether the equipment is water-resistant or can be safely immersed for
cleaning, and c) how the equipment should be decontaminated if servicing is required.967 In the
absence of manufacturers’ instructions, non-critical medical equipment (e.g., stethoscopes, blood
pressure cuffs, dialysis machines, and equipment knobs and controls) usually only require cleansing
followed by low- to intermediate-level disinfection, depending on the nature and degree of
contamination. Ethyl alcohol or isopropyl alcohol in concentrations of 60%–90% (v/v) is often used to
disinfect small surfaces (e.g., rubber stoppers of multiple-dose medication vials, and thermometers)952,
969
and occasionally external surfaces of equipment (e.g., stethoscopes and ventilators). However,
alcohol evaporates rapidly, which makes extended contact times difficult to achieve unless items are
immersed, a factor that precludes its practical use as a large-surface disinfectant.951 Alcohol may cause
discoloration, swelling, hardening, and cracking of rubber and certain plastics after prolonged and
repeated use and may damage the shellac mounting of lenses in medical equipment.970
Barrier protection of surfaces and equipment is useful, especially if these surfaces are a) touched
frequently by gloved hands during the delivery of patient care, b) likely to become contaminated with
body substances, or c) difficult to clean. Impervious-backed paper, aluminum foil, and plastic or fluidresistant covers are suitable for use as barrier protection. An example of this approach is the use of
plastic wrapping to cover the handle of the operatory light in dental-care settings.936, 942 Coverings
should be removed and discarded while the health-care worker is still gloved.936, 942 The health-care
worker, after ungloving and performing hand hygiene, must cover these surfaces with clean materials
before the next patient encounter.
b. Cleaning Housekeeping Surfaces
Housekeeping surfaces require regular cleaning and removal of soil and dust. Dry conditions favor the
persistence of gram-positive cocci (e.g., coagulase-negative Staphylococcus spp.) in dust and on
surfaces, whereas moist, soiled environments favor the growth and persistence of gram-negative
bacilli.948, 971, 972 Fungi are also present on dust and proliferate in moist, fibrous material.
Most, if not all, housekeeping surfaces need to be cleaned only with soap and water or a
detergent/disinfectant, depending on the nature of the surface and the type and degree of contamination.
Cleaning and disinfection schedules and methods vary according to the area of the health-care facility,
type of surface to be cleaned, and the amount and type of soil present. Disinfectant/detergent
formulations registered by EPA are used for environmental surface cleaning, but the actual physical
removal of microorganisms and soil by wiping or scrubbing is probably as important, if not more so,
than any antimicrobial effect of the cleaning agent used.973 Therefore, cost, safety, product-surface
compatibility, and acceptability by housekeepers can be the main criteria for selecting a registered
agent. If using a proprietary detergent/disinfectant, the manufacturers’ instructions for appropriate use
75
of the product should be followed.974 Consult the products’ material safety data sheets (MSDS) to
determine appropriate precautions to prevent hazardous conditions during product application. Personal
protective equipment (PPE) used during cleaning and housekeeping procedures should be appropriate to
the task.
Housekeeping surfaces can be divided into two groups – those with minimal hand-contact (e.g., floors,
and ceilings) and those with frequent hand-contact (“high touch surfaces”). The methods, thoroughness,
and frequency of cleaning and the products used are determined by health-care facility policy.6
However, high-touch housekeeping surfaces in patient-care areas (e.g., doorknobs, bedrails, light
switches, wall areas around the toilet in the patient’s room, and the edges of privacy curtains) should be
cleaned and/or disinfected more frequently than surfaces with minimal hand contact. Infection-control
practitioners typically use a risk-assessment approach to identify high-touch surfaces and then
coordinate an appropriate cleaning and disinfecting strategy and schedule with the housekeeping staff.
Horizontal surfaces with infrequent hand contact (e.g., window sills and hard-surface flooring) in
routine patient-care areas require cleaning on a regular basis, when soiling or spills occur, and when a
patient is discharged from the facility.6 Regular cleaning of surfaces and decontamination, as needed, is
also advocated to protect potentially exposed workers.967 Cleaning of walls, blinds, and window
curtains is recommended when they are visibly soiled.972, 973, 975 Disinfectant fogging is not
recommended for general infection control in routine patient-care areas.2, 976 Further,
paraformaldehyde, which was once used in this application, is no longer registered by EPA for this
purpose. Use of paraformaldehyde in these circumstances requires either registration or an exemption
issued by EPA under the Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA). Infection
control, industrial hygienists, and environmental services supervisors should assess the cleaning
procedures, chemicals used, and the safety issues to determine if a temporary relocation of the patient is
needed when cleaning in the room.
Extraordinary cleaning and decontamination of floors in health-care settings is unwarranted. Studies
have demonstrated that disinfection of floors offers no advantage over regular detergent/water cleaning
and has minimal or no impact on the occurrence of health-care–associated infections.947, 948, 977–980
Additionally, newly cleaned floors become rapidly recontaminated from airborne microorganisms and
those transferred from shoes, equipment wheels, and body substances.971, 975, 981 Nevertheless, healthcare institutions or contracted cleaning companies may choose to use an EPA-registered
detergent/disinfectant for cleaning low-touch surfaces (e.g., floors) in patient-care areas because of the
difficulty that personnel may have in determining if a spill contains blood or body fluids (requiring a
detergent/disinfectant for clean-up) or when a multi-drug resistant organism is likely to be in the
environment. Methods for cleaning non-porous floors include wet mopping and wet vacuuming, dry
dusting with electrostatic materials, and spray buffing.973, 982–984 Methods that produce minimal mists
and aerosols or dispersion of dust in patient-care areas are preferred.9, 20, 109, 272
Part of the cleaning strategy is to minimize contamination of cleaning solutions and cleaning tools.
Bucket solutions become contaminated almost immediately during cleaning, and continued use of the
solution transfers increasing numbers of microorganisms to each subsequent surface to be cleaned.971, 981,
985
Cleaning solutions should be replaced frequently. A variety of “bucket” methods have been devised
to address the frequency with which cleaning solutions are replaced.986, 987 Another source of
contamination in the cleaning process is the cleaning cloth or mop head, especially if left soaking in
dirty cleaning solutions.971, 988–990 Laundering of cloths and mop heads after use and allowing them to
dry before re-use can help to minimize the degree of contamination.990 A simplified approach to
cleaning involves replacing soiled cloths and mop heads with clean items each time a bucket of
detergent/disinfectant is emptied and replaced with fresh, clean solution (B. Stover, Kosair Children’s
Hospital, 2000). Disposable cleaning cloths and mop heads are an alternative option, if costs permit.
76
Another reservoir for microorganisms in the cleaning process may be dilute solutions of the detergents
or disinfectants, especially if the working solution is prepared in a dirty container, stored for long
periods of time, or prepared incorrectly.547 Gram-negative bacilli (e.g., Pseudomonas spp. and Serratia
marcescens) have been detected in solutions of some disinfectants (e.g., phenolics and quaternary
ammonium compounds).547, 991 Contemporary EPA registration regulations have helped to minimize
this problem by asking manufacturers to provide potency data to support label claims for
detergent/disinfectant properties under real- use conditions (e.g., diluting the product with tap water
instead of distilled water). Application of contaminated cleaning solutions, particularly from smallquantity aerosol spray bottles or with equipment that might generate aerosols during operation, should
be avoided, especially in high-risk patient areas.992, 993 Making sufficient fresh cleaning solution for
daily cleaning, discarding any remaining solution, and drying out the container will help to minimize the
degree of bacterial contamination. Containers that dispense liquid as opposed to spray-nozzle
dispensers (e.g., quart-sized dishwashing liquid bottles) can be used to apply detergent/disinfectants to
surfaces and then to cleaning cloths with minimal aerosol generation. A pre-mixed, “ready-to-use”
detergent/disinfectant solution may be used if available.
c. Cleaning Special Care Areas
Guidelines have been published regarding cleaning strategies for isolation areas and operating rooms.6, 7
The basic strategies for areas housing immunosuppressed patients include a) wet dusting horizontal
surfaces daily with cleaning cloths pre-moistened with detergent or an EPA-registered hospital
disinfectant or disinfectant wipes;94, 98463 b) using care when wet dusting equipment and surfaces above
the patient to avoid patient contact with the detergent/disinfectant; c) avoiding the use of cleaning
equipment that produces mists or aerosols; d) equipping vacuums with HEPA filters, especially for the
exhaust, when used in any patient-care area housing immunosuppressed patients;9, 94, 986 and e) regular
cleaning and maintenance of equipment to ensure efficient particle removal. When preparing the
cleaning cloths for wet-dusting, freshly prepared solutions of detergents or disinfectants should be used
rather than cloths that have soaked in such solutions for long periods of time. Dispersal of
microorganisms in the air from dust or aerosols is more problematic in these settings than elsewhere in
health-care facilities. Vacuum cleaners can serve as dust disseminators if they are not operating
properly.994 Doors to immunosuppressed patients’ rooms should be closed when nearby areas are being
vacuumed.9 Bacterial and fungal contamination of filters in cleaning equipment is inevitable, and these
filters should be cleaned regularly or replaced as per equipment manufacturer instructions.
Mats with tacky surfaces placed in operating rooms and other patient-care areas only slightly minimize
the overall degree of contamination of floors and have little impact on the incidence rate of health-care–
associated infection in general.351, 971, 983 An exception, however, is the use of tacky mats inside the
entry ways of cordoned-off construction areas inside the health-care facility; these mats help to
minimize the intrusion of dust into patient-care areas.
Special precautions for cleaning incubators, mattresses, and other nursery surfaces have been
recommended to address reports of hyperbilirubinemia in newborns linked to inadequately diluted
solutions of phenolics and poor ventilation.995–997 These medical conditions have not, however, been
associated with the use of properly prepared solutions of phenolics. Non-porous housekeeping surfaces
in neonatal units can be disinfected with properly diluted or pre-mixed phenolics, followed by rinsing
with clean water.997 However, phenolics are not recommended for cleaning infant bassinets and
incubators during the stay of the infant. Infants who remain in the nursery for an extended period
should be moved periodically to freshly cleaned and disinfected bassinets and incubators.997 If
phenolics are used for cleaning bassinets and incubators after they have been vacated, the surfaces
should be rinsed thoroughly with water and dried before either piece of equipment is reused. Cleaning
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and disinfecting protocols should allow for the full contact time specified for the product used. Bassinet
mattresses should be replaced, however, if the mattress cover surface is broken.997
3. Cleaning Strategies for Spills of Blood and Body Substances
Neither HBV, HCV, nor HIV has ever been transmitted from a housekeeping surface (i.e., floors, walls,
or countertops). Nonetheless, prompt removal and surface disinfection of an area contaminated by
either blood or body substances are sound infection-control practices and OSHA requirements.967
Studies have demonstrated that HIV is inactivated rapidly after being exposed to commonly used
chemical germicides at concentrations that are much lower than those used in practice.998–1003 HBV is
readily inactivated with a variety of germicides, including quaternary ammonium compounds.1004
Embalming fluids (e.g., formaldehyde) are also capable of completely inactivating HIV and HBV.1005,
1006
OSHA has revised its regulation for disinfecting spills of blood or other potentially infectious
material to include proprietary products whose label includes inactivation claims for HBV and HIV,
provided that such surfaces have not become contaminated with agent(s) or volumes of or
concentrations of agent(s) for which a higher level of disinfection is recommended.1007 These
registered products are listed in EPA’s List D – Registered Antimicrobials Effective Against Hepatitis B
Virus and Human HIV-1, which may include products tested against duck hepatitis B virus (DHBV) as a
surrogate for HBV.1008, 1009 Additional lists of interest include EPA’s List C –Registered Antimicrobials
Effective Against Human HIV-1 and EPA’s List E – Registered Antimicrobials Effective Against
Mycobacterium spp., Hepatitis B Virus, and Human HIV-1.
Sodium hypochlorite solutions are inexpensive and effective broad-spectrum germicidal solutions.1010,
1011
Generic sources of sodium hypochlorite include household chlorine bleach or reagent grade
chemical. Concentrations of sodium hypochlorite solutions with a range of 5,000–6,150 ppm (1:10 v/v
dilution of household bleaches marketed in the United States) to 500–615 ppm (1:100 v/v dilution) free
chlorine are effective depending on the amount of organic material (e.g., blood, mucus, and urine)
present on the surface to be cleaned and disinfected.1010, 1011 EPA-registered chemical germicides may
be more compatible with certain materials that could be corroded by repeated exposure to sodium
hypochlorite, especially the 1:10 dilution. Appropriate personal protective equipment (e.g., gloves and
goggles) should be worn when preparing and using hypochlorite solutions or other chemical
germicides.967
Despite laboratory evidence demonstrating adequate potency against bloodborne pathogens (e.g., HIV
and HBV), many chlorine bleach products available in grocery and chemical-supply stores are not
registered by the EPA for use as surface disinfectants. Use of these chlorine products as surface
disinfectants is considered by the EPA to be an “unregistered use.” EPA encourages the use of
registered products because the agency reviews them for safety and performance when the product is
used according to label instructions. When unregistered products are used for surface disinfection, users
do so at their own risk.
Strategies for decontaminating spills of blood and other body fluids differ based on the setting in which
they occur and the volume of the spill.1010 In patient-care areas, workers can manage small spills with
cleaning and then disinfecting using an intermediate-level germicide or an EPA-registered germicide
from the EPA List D or E.967, 1007 For spills containing large amounts of blood or other body
substances, workers should first remove visible organic matter with absorbent material (e.g., disposable
paper towels discarded into leak-proof, properly labeled containment) and then clean and decontaminate
the area.1002, 1003, 1012 If the surface is nonporous and a generic form of a sodium hypochlorite solution is
used (e.g., household bleach), a 1:100 dilution is appropriate for decontamination assuming that a) the
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worker assigned to clean the spill is wearing gloves and other personal protective equipment appropriate
to the task, b) most of the organic matter of the spill has been removed with absorbent material, and c)
the surface has been cleaned to remove residual organic matter. A recent study demonstrated that even
strong chlorine solutions (i.e., 1:10 dilution of chlorine bleach) may fail to totally inactivate high titers
of virus in large quantities of blood, but in the absence of blood these disinfectants can achieve complete
viral inactivation.1011 This evidence supports the need to remove most organic matter from a large spill
before final disinfection of the surface. Additionally, EPA-registered proprietary disinfectant label
claims are based on use on a pre-cleaned surface.951, 954
Managing spills of blood, body fluids, or other infectious materials in clinical, public health, and
research laboratories requires more stringent measures because of a) the higher potential risk of disease
transmission associated with large volumes of blood and body fluids and b) high numbers of
microorganisms associated with diagnostic cultures. The use of an intermediate-level germicide for
routine decontamination in the laboratory is prudent.954 Recommended practices for managing large
spills of concentrated infectious agents in the laboratory include a) confining the contaminated area, b)
flooding the area with a liquid chemical germicide before cleaning, and c) decontaminating with fresh
germicidal chemical of at least intermediate-level disinfectant potency.1010 A suggested technique when
flooding the spill with germicide is to lay absorbent material down on the spill and apply sufficient
germicide to thoroughly wet both the spill and the absorbent material.1013 If using a solution of
household chlorine bleach, a 1:10 dilution is recommended for this purpose. EPA-registered germicides
should be used according to the manufacturers’ instructions for use dilution and contact time. Gloves
should be worn during the cleaning and decontamination procedures in both clinical and laboratory
settings. PPE in such a situation may include the use of respiratory protection (e.g., an N95 respirator)
if clean-up procedures are expected to generate infectious aerosols. Protocols for cleaning spills should
be developed and made available on record as part of good laboratory practice.1013 Workers in
laboratories and in patient-care areas of the facility should receive periodic training in environmentalsurface infection-control strategies and procedures as part of an overall infection-control and safety
curriculum.
4. Carpeting and Cloth Furnishings
a. Carpeting
Carpeting has been used for more than 30 years in both public and patient-care areas of health-care
facilities. Advantages of carpeting in patient-care areas include a) its noise-limiting characteristics; b)
the “humanizing” effect on health care; and c) its contribution to reductions in falls and resultant
injuries, particularly for the elderly.1014–1016 Compared to hard-surface flooring, however, carpeting is
harder to keep clean, especially after spills of blood and body substances. It is also harder to push
equipment with wheels (e.g., wheelchairs, carts, and gurneys) on carpeting.
Several studies have documented the presence of diverse microbial populations, primarily bacteria and
fungi, in carpeting;111, 1017–1024 the variety and number of microorganisms tend to stabilize over time.
New carpeting quickly becomes colonized, with bacterial growth plateauing after about 4 weeks.1019
Vacuuming and cleaning the carpeting can temporarily reduce the numbers of bacteria, but these
populations soon rebound and return to pre-cleaning levels.1019, 1020, 1023 Bacterial contamination tends
to increase with higher levels of activity.1018–1020, 1025 Soiled carpeting that is or remains damp or wet
provides an ideal setting for the proliferation and persistence of gram-negative bacteria and fungi.1026
Carpeting that remains damp should be removed, ideally within 72 hours.
Despite the evidence of bacterial growth and persistence in carpeting, only limited epidemiologic
evidence demonstrates that carpets influence health-care–associated infection rates in areas housing
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immunocompetent patients.1023, 1025, 1027 This guideline, therefore, includes no recommendations against
the use of carpeting in these areas. Nonetheless, avoiding the use of carpeting is prudent in areas where
spills are likely to occur (e.g., laboratories, areas around sinks, and janitor closets) and where patients
may be at greater risk of infection from airborne environmental pathogens (e.g., HSCT units, burn units,
ICUs, and ORs).111, 1028 An outbreak of aspergillosis in an HSCT unit was recently attributed to carpet
contamination and a particular method of carpet cleaning.111 A window in the unit had been opened
repeatedly during the time of a nearby building fire, which allowed fungal spore intrusion into the unit.
After the window was sealed, the carpeting was cleaned using a “bonnet buffing” machine, which
dispersed Aspergillus spores into the air.111 Wet vacuuming was instituted, replacing the dry cleaning
method used previously; no additional cases of invasive aspergillosis were identified.
The care setting and the method of carpet cleaning are important factors to consider when attempting to
minimize or prevent production of aerosols and dispersal of carpet microorganisms into the air.94, 111
Both vacuuming and shampooing or wet cleaning with equipment can disperse microorganisms to the
air.111, 994 Vacuum cleaners should be maintained to minimize dust dispersal in general, and be
equipped with HEPA filters, especially for use in high-risk patient-care areas.9, 94, 986 Some
formulations of carpet-cleaning chemicals, if applied or used improperly, can be dispersed into the air as
a fine dust capable of causing respiratory irritation in patients and staff.1029 Cleaning equipment,
especially those that engage in wet cleaning and extraction, can become contaminated with waterborne
organisms (e.g., Pseudomonas aeruginosa) and serve as a reservoir for these organisms if this
equipment is not properly maintained. Substantial numbers of bacteria can then be transferred to
carpeting during the cleaning process.1030 Therefore, keeping the carpet cleaning equipment in good
repair and allowing such equipment to dry between uses is prudent.
Carpet cleaning should be performed on a regular basis determined by internal policy. Although spills
of blood and body substances on non-porous surfaces require prompt spot cleaning using standard
cleaning procedures and application of chemical germicides,967 similar decontamination approaches to
blood and body substance spills on carpeting can be problematic from a regulatory perspective.1031
Most, if not all, modern carpet brands suitable for public facilities can tolerate the activity of a variety of
liquid chemical germicides. However, according to OSHA, carpeting contaminated with blood or other
potentially infectious materials can not be fully decontaminated.1032 Therefore, facilities electing to use
carpeting for high-activity patient-care areas may choose carpet tiles in areas at high risk for spills.967,
1032
In the event of contamination with blood or other body substances, carpet tiles can be removed,
discarded, and replaced. OSHA also acknowledges that only minimal direct skin contact occurs with
carpeting, and therefore, employers are expected to make reasonable efforts to clean and sanitize
carpeting using carpet detergent/cleaner products.1032
Over the last few years, some carpet manufacturers have treated their products with fungicidal and/or
bactericidal chemicals. Although these chemicals may help to reduce the overall numbers of bacteria or
fungi present in carpet, their use does not preclude the routine care and maintenance of the carpeting.
Limited evidence suggests that chemically treated carpet may have helped to keep health-care–
associated aspergillosis rates low in one HSCT unit,111 but overall, treated carpeting has not been shown
to prevent the incidence of health-care–associated infections in care areas for immunocompetent
patients.
b. Cloth Furnishings
Upholstered furniture and furnishings are becoming increasingly common in patient-care areas. These
furnishings range from simple cloth chairs in patients’ rooms to a complete decorating scheme that
gives the interior of the facility more the look of an elegant hotel.1033 Even though pathogenic
microorganisms have been isolated from the surfaces of cloth chairs, no epidemiologic evidence
suggests that general patient-care areas with cloth furniture pose increased risks of health-care–
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associated infection compared with areas that contain hard-surfaced furniture.1034, 1035 Allergens (e.g.,
dog and cat dander) have been detected in or on cloth furniture in clinics and elsewhere in hospitals in
concentrations higher than those found on bed linens.1034, 1035 These allergens presumably are
transferred from the clothing of visitors. Researchers have therefore suggested that cloth chairs should
be vacuumed regularly to keep the dust and allergen levels to a minimum. This recommendation,
however, has generated concerns that aerosols created from vacuuming could place
immunocompromised patients or patients with preexisting lung disease (e.g., asthma) at risk for
development of health-care–associated, environmental airborne disease.9, 20, 109, 988 Recovering worn,
upholstered furniture (especially the seat cushion) with covers that are easily cleaned (e.g., vinyl), or
replacing the item is prudent; minimizing the use of upholstered furniture and furnishings in any patientcare areas where immunosuppressed patients are located (e.g., HSCT units) reduces the likelihood of
disease.9
5. Flowers and Plants in Patient-Care Areas
Fresh flowers, dried flowers, and potted plants are common items in health-care facilities. In 1974,
clinicians isolated an Erwinia sp. post mortem from a neonate diagnosed with fulminant septicemia,
meningitis, and respiratory distress syndrome.1038 Because Erwinia spp. are plant pathogens, plants
brought into the delivery room were suspected to be the source of the bacteria, although the case report
did not definitively establish a direct link. Several subsequent studies evaluated the numbers and
diversity of microorganisms in the vase water of cut flowers. These studies revealed that high
concentrations of bacteria, ranging from 104–1010 CFU/mL, were often present, especially if the water
was changed infrequently.515, 702, 1039 The major group of microorganisms in flower vase water was
gram-negative bacteria, with Pseudomonas aeruginosa the most frequently isolated organism.515, 702, 1039,
1040
P. aeruginosa was also the primary organism directly isolated from chrysanthemums and other
potted plants.1041, 1042 However, flowers in hospitals were not significantly more contaminated with
bacteria compared with flowers in restaurants or in the home.702 Additionally, no differences in the
diversity and degree of antibiotic resistance of bacteria have been observed in samples isolated from
hospital flowers versus those obtained from flowers elsewhere.702
Despite the diversity and large numbers of bacteria associated with flower-vase water and potted plants,
minimal or no evidence indicates that the presence of plants in immunocompetent patient-care areas
poses an increased risk of health-care–associated infection.515 In one study involving a limited number
of surgical patients, no correlation was observed between bacterial isolates from flowers in the area and
the incidence and etiology of postoperative infections among the patients.1040 Similar conclusions were
reached in a study that examined the bacteria found in potted plants.1042 Nonetheless, some precautions
for general patient-care settings should be implemented, including a) limiting flower and plant care to
staff with no direct patient contact, b) advising health-care staff to wear gloves when handling plants, c)
washing hands after handling plants, d) changing vase water every 2 days and discharging the water into
a sink outside the immediate patient environment, and e) cleaning and disinfecting vases after use.702
Some researchers have examined the possibility of adding a chemical germicide to vase water to control
bacterial populations. Certain chemicals (e.g., hydrogen peroxide and chlorhexidine) are well tolerated
by plants.1040, 1043, 1044 Use of these chemicals, however, was not evaluated in studies to assess impact on
health-care–associated infection rates. Modern florists now have a variety of products available to add
to vase water to extend the life of cut flowers and to minimize bacterial clouding of the water.
Flowers (fresh and dried) and ornamental plants, however, may serve as a reservoir of Aspergillus spp.,
and dispersal of conidiospores into the air from this source can occur.109 Health-care–associated
outbreaks of invasive aspergillosis reinforce the importance of maintaining an environment as free of
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Aspergillus spp. spores as possible for patients with severe, prolonged neutropenia. Potted plants, freshcut flowers, and dried flower arrangements may provide a reservoir for these fungi as well as other
fungal species (e.g., Fusarium spp.).109, 1045, 1046 Researchers in one study of bacteria and flowers
suggested that flowers and vase water should be avoided in areas providing care to medically at-risk
patients (e.g., oncology patients and transplant patients), although this study did not attempt to correlate
the observations of bacterial populations in the vase water with the incidence of health-care–associated
infections.515 Another study using molecular epidemiology techniques demonstrated identical
Aspergillus terreus types among environmental and clinical specimens isolated from infected patients
with hematological malignancies.1046 Therefore, attempts should be made to exclude flowers and plants
from areas where immunosuppressed patients are be located (e.g., HSCT units).9, 1046
6. Pest Control
Cockroaches, flies and maggots, ants, mosquitoes, spiders, mites, midges, and mice are among the
typical arthropod and vertebrate pest populations found in health-care facilities. Insects can serve as
agents for the mechanical transmission of microorganisms, or as active participants in the disease
transmission process by serving as a vector.1047–1049 Arthropods recovered from health-care facilities
have been shown to carry a wide variety of pathogenic microorganisms.1050–1056 Studies have suggested
that the diversity of microorganisms associated with insects reflects the microbial populations present in
the indoor health-care environment; some pathogens encountered in insects from hospitals were either
absent from or present to a lesser degree in insects trapped from residential settings.1057–1060 Some of
the microbial populations associated with insects in hospitals have demonstrated resistance to
antibiotics.1048, 1059, 1061–1063
Insect habitats are characterized by warmth, moisture, and availability of food.1064 Insects forage in and
feed on substrates, including but not limited to food scraps from kitchens/cafeteria, foods in vending
machines, discharges on dressings either in use or discarded, other forms of human detritis, medical
wastes, human wastes, and routine solid waste.1057–1061 Cockroaches, in particular, have been known to
feed on fixed sputum smears in laboratories.1065, 1066 Both cockroaches and ants are frequently found in
the laundry, central sterile supply departments, and anywhere in the facility where water or moisture is
present (e.g., sink traps, drains and janitor closets). Ants will often find their way into sterile packs of
items as they forage in a warm, moist environment.1057 Cockroaches and other insects frequent loading
docks and other areas with direct access to the outdoors.
Although insects carry a wide variety of pathogenic microorganisms on their surfaces and in their gut,
the direct association of insects with disease transmission (apart from vector transmission) is limited,
especially in health-care settings; the presence of insects in itself likely does not contribute substantially
to health-care–associated disease transmission in developed countries. However, outbreaks of infection
attributed to microorganisms carried by insects may occur because of infestation coupled with breaks in
standard infection-control practices.1063 Studies have been conducted to examine the role of houseflies
as possible vectors for shigellosis and other forms of diarrheal disease in non-health–care settings.1046,
1067
When control measures aimed at reducing the fly population density were implemented, a
concomitant reduction in the incidence of diarrheal infections, carriage of Shigella organisms, and
mortality caused by diarrhea among infants and young children was observed.
Myiasis is defined as a parasitosis in which the larvae of any of a variety of flies use living or necrotic
tissue or body substances of the host as a nutritional source.1068 Larvae from health-care–acquired
myiasis have been observed in nares, wounds, eyes, ears, sinuses, and the external urogenital
structures.1069–1071 Patients with this rare condition are typically older adults with underlying medical
conditions (e.g., diabetes, chronic wounds, and alcoholism) who have a decreased capacity to ward off
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the flies. Persons with underlying conditions who live or travel to tropical regions of the world are
especially at risk.1070, 1071 Cases occur in the summer and early fall months in temperate climates when
flies are most active.1071 An environmental assessment and review of the patient’s history are necessary
to verify that the source of the myiasis is health-care–acquired and to identify corrective measures.1069,
1072
Simple prevention measures (e.g., installing screens on windows) are important in reducing the
incidence of myiasis.1072
From a public health and hygiene perspective, arthropod and vertebrate pests should be eradicated from
all indoor environments, including health-care facilities.1073, 1074 Modern approaches to institutional
pest management usually focus on a) eliminating food sources, indoor habitats, and other conditions that
attract pests; b) excluding pests from the indoor environments; and c) applying pesticides as needed.1075
Sealing windows in modern health-care facilities helps to minimize insect intrusion. When windows
need to be opened for ventilation, ensuring that screens are in good repair and closing doors to the
outside can help with pest control. Insects should be kept out of all areas of the health-care facility,
especially ORs and any area where immunosuppressed patients are located. A pest-control specialist
with appropriate credentials can provide a regular insect-control program that is tailored to the needs of
the facility and uses approved chemicals and/or physical methods. Industrial hygienists can provide
information on possible adverse reactions of patients and staff to pesticides and suggest alternative
methods for pest control, as needed.
7. Special Pathogen Concerns
a. Antibiotic-Resistant Gram-Positive Cocci
Vancomycin-resistant enterococci (VRE), methicillin-resistant Staphylococcus aureus (MRSA), and S.
aureus with intermediate levels of resistance to glycopeptide antibiotics (vancomycin intermediate
resistant S. aureus [VISA] or glycopeptide intermediate resistant S. aureus [GISA]) represent crucial
and growing concerns for infection control. Although the term GISA is technically a more accurate
description of the strains isolated to date (most of which are classified as having intermediate resistance
to both vancomycin and teicoplanin), the term “glycopeptide” may not be recognized by many
clinicians. Thus, the label of VISA, which emphasizes a change in minimum inhibitory concentration
(MICs) to vancomycin, is similar to that of VRE and is more meaningful to clinicians.1076 According to
National Nosocomial Infection Surveillance (NNIS) statistics for infections acquired among ICU
patients in the United States in 1999, 52.3% of infections resulting from S. aureus were identified as
MRSA infections, and 25.2% of enterococcal infections were attributed to VRE. These figures reflect a
37% and a 43% increase, respectively, since 1994–1998.1077
People represent the primary reservoir of S. aureus.1078 Although S. aureus has been isolated from a
variety of environmental surfaces (e.g., stethoscopes, floors, charts, furniture, dry mops, and
hydrotherapy tanks), the role of environmental contamination in transmission of this organism in health
care appears to be minimal.1079–1082 S. aureus contamination of surfaces and tanks within burn therapy
units, however, may be a major factor in the transmission of infection among burn patients.1083
Colonized patients are the principal reservoir of VRE, and patients who are immunosuppressed (e.g.,
transplant patients) or otherwise medically at-risk (e.g., ICU patients, cardio-thoracic surgical patients,
patients previously hospitalized for extended periods, and those having received multi-antimicrobial or
vancomycin therapy) are at greatest risk for VRE colonization.1084–1087 The mechanisms by which
cross-colonization take place are not well defined, although recent studies have indicated that both
MRSA and VRE may be transmitted either a) directly from patient to patient, b) indirectly by transient
carriage on the hands of health-care workers,1088–1091 or c) by hand transfer of these gram-positive
organisms from contaminated environmental surfaces and patient-care equipment.1084, 1087, 1092–1097 In
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one survey, hand carriage of VRE in workers in a long-term care facility ranged from 13%–41%.1098
Many of the environmental surfaces found to be contaminated with VRE in outbreak investigations have
been those that are touched frequently by the patient or the health-care worker.1099 Such high-touch
surfaces include bedrails, doorknobs, bed linens, gowns, overbed tables, blood pressure cuffs, computer
table, bedside tables, and various medical equipment.22, 1087, 1094, 1095, 1100–1102 Contamination of
environmental surfaces with VRE generally occurs in clinical laboratories and areas where colonized
patients are present,1087, 1092, 1094, 1095, 1103 but the potential for contamination increases when such patients
have diarrhea1087 or have multiple body-site colonization.1104 Additional factors that can be important
in the dispersion of these pathogens to environmental surfaces are misuse of glove techniques by healthcare workers (especially when cleaning fecal contamination from surfaces) and patient, family, and
visitor hygiene.
Interest in the importance of environmental reservoirs of VRE increased when laboratory studies
demonstrated that enterococci can persist in a viable state on dry environmental surfaces for extended
periods of time (7 days to 4 months)1099, 1105 and multiple strains can be identified during extensive
periods of surveillance.1104 VRE can be recovered from inoculated hands of health-care workers (with
or without gloves) for up to 60 minutes.22 The presence of either MRSA, VISA, or VRE on
environmental surfaces, however, does not mean that patients in the contaminated areas will become
colonized. Strict adherence to hand hygiene/handwashing and the proper use of barrier precautions help
to minimize the potential for spread of these pathogens. Published recommendations for preventing the
spread of vancomycin resistance address isolation measures, including patient cohorting and
management of patient-care items.5 Direct patient-care items (e.g., blood pressure cuffs) should be
disposable whenever possible when used in contact isolation settings for patients with multiply resistant
microorganisms.1102
Careful cleaning of patient rooms and medical equipment contributes substantially to the overall control
of MRSA, VISA, or VRE transmission. The major focus of a control program for either VRE or MRSA
should be the prevention of hand transfer of these organisms. Routine cleaning and disinfection of the
housekeeping surfaces (e.g., floors and walls) and patient-care surfaces (e.g., bedrails) should be
adequate for inactivation of these organisms. Both MRSA and VRE are susceptible to several EPAregistered low- and intermediate-level disinfectants (e.g., alcohols, sodium hypochlorite, quaternary
ammonium compounds, phenolics, and iodophors) at recommended use dilutions for environmental
surface disinfection.1103, 1106–1109 Additionally, both VRE and vancomycin-sensitive enterococci are
equally sensitive to inactivation by chemical germicides,1106, 1107, 1109 and similar observations have been
made when comparing the germicidal resistance of MRSA to that of either methicillin-sensitive S.
aureus (MSSA) or VISA.1110 The use of stronger solutions of disinfectants for inactivation of either
VRE, MRSA, or VISA is not recommended based on the organisms’ resistance to antibiotics.1110–1112
VRE from clinical specimens have exhibited some measure of increased tolerance to heat inactivation in
temperature ranges <212ºF (<100ºC);1106, 1113 however, the clinical significance of these observations is
unclear because the role of cleaning the surface or item prior to heat treatment was not evaluated.
Although routine environmental sampling is not recommended, laboratory surveillance of
environmental surfaces during episodes when VRE contamination is suspected can help determine the
effectiveness of the cleaning and disinfecting procedures. Environmental culturing should be approved
and supervised by the infection-control program in collaboration with the clinical laboratory.1084, 1087, 1088,
1092, 1096
Two cases of wound infections associated with vancomycin-resistant Staphylococcus aureus (VRSA)
determined to be resistant by NCCLS standards for sensitivity/resistance testing were identified in
Michigan and Pennsylvania in 2002.1114, 1115 These represented isolated cases, and neither the family
members nor the health-care providers of these case-patients had evidence of colonization or infection
with VRSA. Conventional environmental infection-control measures (i.e., cleaning and then
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disinfecting surfaces using EPA-registered disinfectants with label claims for S. aureus) were used
during the environmental investigation of these two cases;1110–1112 however, studies have yet to evaluate
the potential intrinsic resistance of these VRSA strains to surface disinfectants.
Standard procedures during terminal cleaning and disinfection of surfaces, if performed incorrectly, may
be inadequate for the elimination of VRE from patient rooms.1113, 1116–1118 Given the sensitivity of VRE
to hospital disinfectants, current disinfecting protocols should be effective if they are diligently carried
out and properly performed. Health-care facilities should be sure that housekeeping staff use correct
procedures for cleaning and disinfecting surfaces in VRE-contaminated areas, which include using
sufficient amounts of germicide at proper use dilution and allowing adequate contact time.1118
b. Clostridium difficile
Clostridium difficile is the most frequent etiologic agent for health-care–associated diarrhea.1119, 1120 In
one hospital, 30% of adults who developed health-care–associated diarrhea were positive for C.
difficile.1121 One recent study employing PCR-ribotyping techniques demonstrated that cases of C.
difiicile-acquired diarrhea occurring in the hospital included patients whose infections were attributed to
endogenous C. difficile strains and patients whose illnesses were considered to be health-care–
associated infections.1122 Most patients remain asymptomatic after infection, but the organism
continues to be shed in their stools. Risk factors for acquiring C. difficile-associated infection include a)
exposure to antibiotic therapy, particularly with beta-lactam agents;1123 b) gastrointestinal procedures
and surgery;1124 c) advanced age; and d) indiscriminate use of antibiotics.1125–1128 Of all the measures
that have been used to prevent the spread of C. difficile-associated diarrhea, the most successful has
been the restriction of the use of antimicrobial agents.1129, 1130
C. difficile is an anaerobic, gram-positive bacterium. Normally fastidious in its vegetative state, it is
capable of sporulating when environmental conditions no longer support its continued growth. The
capacity to form spores enables the organism to persist in the environment (e.g., in soil and on dry
surfaces) for extended periods of time. Environmental contamination by this microorganism is well
known, especially in places where fecal contamination may occur.1131 The environment (especially
housekeeping surfaces) rarely serves as a direct source of infection for patients.1024, 1132–1136 However,
direct exposure to contaminated patient-care items (e.g., rectal thermometers) and high-touch surfaces in
patients’ bathrooms (e.g., light switches) have been implicated as sources of infection.1130, 1135, 1136, 1138
Transfer of the pathogen to the patient via the hands of health-care workers is thought to be the most
likely mechanism of exposure.24, 1133, 1139 Standard isolation techniques intended to minimize enteric
contamination of patients, health-care–workers’ hands, patient-care items, and environmental surfaces
have been published.1140 Handwashing remains the most effective means of reducing hand
contamination. Proper use of gloves is an ancillary measure that helps to further minimize transfer of
these pathogens from one surface to another.
The degree to which the environment becomes contaminated with C. difficile spores is proportional to
the number of patients with C. difficile-associated diarrhea,24, 1132, 1135 although asymptomatic, colonized
patients may also serve as a source of contamination. Few studies have examined the use of specific
chemical germicides for the inactivation of C. difficile spores, and no well-controlled trials have been
conducted to determine efficacy of surface disinfection and its impact on health-care–associated
diarrhea. Some investigators have evaluated the use of chlorine-containing chemicals (e.g., 1,000 ppm
hypochlorite at recommended use-dilution, 5,000 ppm sodium hypochlorite [1:10 v/v dilution], 1:100
v/v dilutions of unbuffered hypochlorite, and phosphate-buffered hypochlorite [1,600 ppm]). One of the
studies demonstrated that the number of contaminated environmental sites was reduced by half,1135
whereas another two studies demonstrated declines in health-care–associated C. difficile infections in a
HSCT unit1141 and in two geriatric medical units1142 during a period of hypochlorite use. The presence
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of confounding factors, however, was acknowledged in one of these studies.1142 The recommended
approach to environmental infection control with respect to C. difficile is meticulous cleaning followed
by disinfection using hypochlorite-based germicides as appropriate.952, 1130, 1143 However, because no
EPA-registered surface disinfectants with label claims for inactivation of C. difficile spores are
available, the recommendation is based on the best available evidence from the scientific literature.
c. Respiratory and Enteric Viruses in Pediatric-Care Settings
Although the viruses mentioned in this guideline are not unique to the pediatric-care setting in healthcare facilities, their prevalence in these areas, especially during the winter months, is substantial.
Children (particularly neonates) are more likely to develop infection and substantial clinical disease
from these agents compared with adults and therefore are more likely to require supportive care during
their illness.
Common respiratory viruses in pediatric-care areas include rhinoviruses, respiratory syncytial virus
(RSV), adenoviruses, influenza viruses, and parainfluenza viruses. Transmission of these viruses occurs
primarily via direct contact with small-particle aerosols or via hand contamination with respiratory
secretions that are then transferred to the nose or eyes. Because transmission primarily requires close
personal contact, contact precautions are appropriate to interrupt transmission.6 Hand contamination
can occur from direct contact with secretions or indirectly from touching high-touch environmental
surfaces that have become contaminated with virus from large droplets. The indirect transfer of virus
from one persion to other via hand contact with frequently-touched fomites was demonstrated in a study
using a bacteriophage whose environmental stability approximated that of human viral pathogens (e.g.,
poliovirus and parvovirus).1144 The impact of this mode of transmission with respect to human
respiratory- and enteric viruses is dependent on the ability of these agents to survive on environmental
surfaces. Infectious RSV has been recovered from skin, porous surfaces, and non-porous surfaces after
30 minutes, 1 hour, and 7 hours, respectively.1145 Parainfluenza viruses are known to persist for up to 4
hours on porous surfaces and up to 10 hours on non-porous surfaces.1146 Rhinoviruses can persist on
porous surfaces and non-porous surfaces for approximately 1 and 3 hours respectively; study
participants in a controlled environment became infected with rhinoviruses after first touching a surface
with dried secretions and then touching their nasal or conjunctival mucosa.1147 Although the efficiency
of direct transmission of these viruses from surfaces in uncontrolled settings remains to be defined,
these data underscore the basis for maintaining regular protocols for cleaning and disinfecting of hightouch surfaces.
The clinically important enteric viruses encountered in pediatric care settings include enteric
adenovirus, astroviruses, caliciviruses, and rotavirus. Group A rotavirus is the most common cause of
infectious diarrhea in infants and children. Transmission of this virus is primarily fecal-oral, however,
the role of fecally contaminated surfaces and fomites in rotavirus transmission is unclear. During one
epidemiologic investigation of enteric disease among children attending day care, rotavirus
contamination was detected on 19% of inanimate objects in the center.1148, 1149 In an outbreak in a
pediatric unit, secondary cases of rotavirus infection clustered in areas where children with rotaviral
diarrhea were located.1150 Astroviruses cause gastroenteritis and diarrhea in newborns and young
children and can persist on fecally contaminated surfaces for several months during periods of relatively
low humidity.1151, 1152 Outbreaks of small round-structured viruses (i.e., caliciviruses [Norwalk virus
and Norwalk-like viruses]) can affect both patients and staff, with attack rates of >50%.1153 Routes of
person-to-person transmission include fecal-oral spread and aerosols generated from vomiting.1154–1156
Fecal contamination of surfaces in care settings can spread large amounts of virus to the environment.
Studies that have attempted to use low- and intermediate-level disinfectants to inactivate rotavirus
suspended in feces have demonstrated a protective effect of high concentrations of organic matter.1157,
1158
Intermediate-level disinfectants (e.g., alcoholic quaternary ammonium compounds, and chlorine
solutions) can be effective in inactivating enteric viruses provided that a cleaning step to remove most of
86
the organic matter precedes terminal disinfection.1158 These findings underscore the need for proper
cleaning and disinfecting procedures where contamination of environmental surfaces with body
substances is likely. EPA-registered surface disinfectants with label claims for these viral agents should
be used in these settings. Using disposable, protective barrier coverings may help to minimize the
degree of surface contamination.936
d. Severe Acute Respiratory Syndrome (SARS) Virus
In November 2002 an atypical pneumonia of unknown etiology emerged in Asia and subsequently
developed into an international outbreak of respiratory illness among persons in 29 countries during the
first six months of 2003. “Severe acute respiratory syndrome” (SARS) is a viral upper respiratory
infection associated with a newly described coronavirus (SARS-associated Co-V [SARS-CoV]).
SARS-CoV is an enveloped RNA virus. It is present in high titers in respiratory secretions, stool, and
blood of infected persons. The modes of transmission determined from epidemiologic investigations
were primarily forms of direct contact (i.e., large droplet aerosolization and person-to-person contact).
Respiratory secretions were presumed to be the major source of virus in these situations; airborne
transmission of virus has not been completely ruled out. Little is known about the impact of fecal-oral
transmission and SARS.
The epidemiology of SARS-CoV infection is not completely understood, and therefore recommended
infection control and prevention measures to contain the spread of SARS will evolve as new
information becomes available.1159 At present there is no indication that established strategies for
cleaning (i.e., to remove the majority of bioburden) and disinfecting equipment and environmental
surfaces need to be changed for the environmental infection control of SARS. In-patient rooms housing
SARS patients should be cleaned and disinfected at least daily and at the time of patient transfer or
discharge. More frequent cleaning and disinfection may be indicated for high-touch surfaces and
following aerosol-producing procedures (e.g., intubation, bronchoscopy, and sputum production).
While there are presently no disinfectant products registered by EPA specifically for inactivation of
SARS-CoV, EPA-registered hospital disinfectants that are equivalent to low- and intermediate-level
germicides may be used on pre-cleaned, hard, non-porous surfaces in accordance with manufacturer’s
instructions for environmental surface disinfection. Monitoring adherence to guidelines established for
cleaning and disinfection is an important component of environmental infection control to contain the
spread of SARS.
e. Creutzfeldt-Jakob Disease (CJD) in Patient-Care Areas
Creutzfeldt-Jakob disease (CJD) is a rare, invariably fatal, transmissible spongiform encephalopathy
(TSE) that occurs worldwide with an average annual incidence of 1 case per million population.1160–1162
CJD is one of several TSEs affecting humans; other diseases in this group include kuru, fatal familial
insomnia, and Gerstmann-Sträussler-Scheinker syndrome. A TSE that affects a younger population
(compared to the age range of CJD cases) has been described primarily in the United Kingdom since
1996.1163 This variant form of CJD (vCJD) is clinically and neuropathologically distinguishable from
classic CJD; epidemiologic and laboratory evidence suggests a causal association for bovine spongiform
encephalopathy (BSE [Mad Cow disease]) and vCJD.1163–1166
The agent associated with CJD is a prion, which is an abnormal isoform of a normal protein constituent
of the central nervous system.1167–1169 The mechanism by which the normal form of the protein is
converted to the abnormal, disease-causing prion is unknown. The tertiary conformation of the
abnormal prion protein appears to confer a heightened degree of resistance to conventional methods of
sterilization and disinfection.1170, 1171
Although about 90% of CJD cases occur sporadically, a limited number of cases are the result of a
direct exposure to prion-containing material (usually central nervous system tissue or pituitary
87
hormones) acquired as a result of health care (iatrogenic cases). These cases have been linked to a)
pituitary hormone therapy [from human sources as opposed to hormones prepared through the use of
recombinant technology],1170–1174 b) transplants of either dura mater or corneas,1175–1181 and c)
neurosurgical instruments and depth electrodes.1182–1185 In the cases involving instruments and depth
electrodes, conventional cleaning and terminal reprocessing methods of the day failed to fully inactivate
the contaminating prions and are considered inadequate by today’s standards.
Prion inactivation studies involving whole tissues and tissue homogenates have been conducted to
determine the parameters of physical and chemical methods of sterilization or disinfection necessary for
complete inactivation;1170, 1186–1191 however, the application of these findings to environmental infection
control in health-care settings is problematic. No studies have evaluated the effectiveness of medical
instrument reprocessing in inactivating prions. Despite a consensus that abnormal prions display some
extreme measure of resistance to inactivation by either physical or chemical methods, scientists disagree
about the exact conditions needed for sterilization. Inactivation studies utilizing whole tissues present
extraordinary challenges to any sterilizing method.1192 Additionally, the experimental designs of these
studies preclude the evaluation of surface cleaning as a part of the total approach to pathogen
inactivation.951, 1192
Some researchers have recommended the use of either a 1:2 v/v dilution of sodium hypochorite
(approximately 20,000 ppm), full-strength sodium hypochlorite (50,000–60,000 ppm), or 1–2 N sodium
hydroxide (NaOH) for the inactivation of prions on certain surfaces (e.g., those found in the pathology
laboratory).1170, 1188 Although these chemicals may be appropriate for the decontamination of
laboratory, operating-room, or autopsy-room surfaces that come into contact with central nervous
system tissue from a known or suspected patient, this approach is not indicated for routine or terminal
cleaning of a room previously occupied by a CJD patient. Both chemicals pose hazards for the healthcare worker doing the decontamination. NaOH is caustic and should not make contact with the skin.
Sodium hypochlorite solutions (i.e., chlorine bleach) can corrode metals (e.g., aluminum). MSDS
information should be consulted when attempting to work with concentrated solutions of either
chemical. Currently, no EPA-registered products have label claims for prion inactivation; therefore, this
guidance is based on the best available evidence from the scientific literature.
Environmental infection-control strategies must based on the principles of the “chain of infection,”
regardless of the disease of concern.13 Although CJD is transmissible, it is not highly contagious. All
iatrogenic cases of CJD have been linked to a direct exposure to prion-contaminated central nervous
system tissue or pituitary hormones. The six documented iatrogenic cases associated with instruments
and devices involved neurosurgical instruments and devices that introduced residual contamination
directly to the recipient’s brain. No evidence suggests that vCJD has been transmitted iatrogenically or
that either CJD or vCJD has been transmitted from environmental surfaces (e.g., housekeeping
surfaces). Therefore, routine procedures are adequate for terminal cleaning and disinfection of a CJD
patient’s room. Additionally, in epidemiologic studies involving highly transfused patients, blood was
not identified as a source for prion transmission.1193–1198 Routine procedures for containing,
decontaminating, and disinfecting surfaces with blood spills should be adequate for proper infection
control in these situations.951, 1199
Guidance for environmental infection control in ORs and autopsy areas has been published.1197, 1199
Hospitals should develop risk-assessment procedures to identify patients with known or suspected CJD
in efforts to implement prion-specific infection-control measures for the OR and for instrument
reprocessing.1200 This assessment also should be conducted for older patients undergoing non-lesionous
neurosurgery when such procedures are being done for diagnosis. Disposable, impermeable coverings
should be used during these autopsies and neurosurgeries to minimize surface contamination. Surfaces
that have become contaminated with central nervous system tissue or cerebral spinal fluid should be
88
cleaned and decontaminated by a) removing most of the tissue or body substance with absorbent
materials, b) wetting the surface with a sodium hypochlorite solution containing >5,000 ppm or a 1 N
NaOH solution, and c) rinsing thoroughly.951, 1197–1199, 1201 The optimum duration of contact exposure in
these instances is unclear. Some researchers recommend a 1-hour contact time on the basis of tissueinactivation studies,1197, 1198, 1201 whereas other reviewers of the subject draw no conclusions from this
research.1199 Factors to consider before cleaning a potentially contaminated surface are a) the degree to
which gross tissue/body substance contamination can be effectively removed and b) the ease with which
the surface can be cleaned.
F. Environmental Sampling
This portion of Part I addresses the basic principles and methods of sampling environmental surfaces
and other environmental sources for microorganisms. The applied strategies of sampling with respect to
environmental infection control have been discussed in the appropriate preceding subsections.
1. General Principles: Microbiologic Sampling of the Environment
Before 1970, U.S. hospitals conducted regularly scheduled culturing of the air and environmental
surfaces (e.g., floors, walls, and table tops).1202 By 1970, CDC and the American Hospital Association
(AHA) were advocating the discontinuation of routine environmental culturing because rates of healthcare–associated infection had not been associated with levels of general microbial contamination of air
or environmental surfaces, and because meaningful standards for permissible levels of microbial
contamination of environmental surfaces or air did not exist.1203–1205 During 1970–1975, 25% of U.S.
hospitals reduced the extent of such routine environmental culturing — a trend that has continued.1206,
1207
Random, undirected sampling (referred to as “routine” in previous guidelines) differs from the current
practice of targeted sampling for defined purposes.2, 1204 Previous recommendations against routine
sampling were not intended to discourage the use of sampling in which sample collection, culture, and
interpretation are conducted in accordance with defined protocols.2 In this guideline, targeted
microbiologic sampling connotes a monitoring process that includes a) a written, defined,
multidisciplinary protocol for sample collection and culturing; b) analysis and interpretation of results
using scientifically determined or anticipatory baseline values for comparison; and c) expected actions
based on the results obtained. Infection control, in conjunction with laboratorians, should assess the
health-care facility’s capability to conduct sampling and determine when expert consultation and/or
services are needed.
Microbiologic sampling of air, water, and inanimate surfaces (i.e., environmental sampling) is an
expensive and time-consuming process that is complicated by many variables in protocol, analysis, and
interpretation. It is therefore indicated for only four situations.1208 The first is to support an
investigation of an outbreak of disease or infections when environmental reservoirs or fomites are
implicated epidemiologically in disease transmission.161, 1209, 1210 It is important that such culturing be
supported by epidemiologic data. Environmental sampling, as with all laboratory testing, should not be
conducted if there is no plan for interpreting and acting on the results obtained.11, 1211, 1212 Linking
microorganisms from environmental samples with clinical isolates by molecular epidemiology is crucial
whenever it is possible to do so.
The second situation for which environmental sampling may be warranted is in research. Well-designed
and controlled experimental methods and approaches can provide new information about the spread of
health-care–associated diseases.126, 129 A classic example is the study of environmental microbial
89
contamination that compared health-care–associated infection rates in an old hospital and a new facility
before and shortly after occupancy.947
The third indication for sampling is to monitor a potentially hazardous environmental condition,
confirm the presence of a hazardous chemical or biological agent, and validate the successful abatement
of the hazard. This type of sampling can be used to: a) detect bioaerosols released from the operation of
health-care equipment (e.g., an ultrasonic cleaner) and determine the success of repairs in containing the
hazard,1213 b) detect the release of an agent of bioterrorism in an indoor environmental setting and
determine its successful removal or inactivation, and c) sample for industrial hygiene or safety purposes
(e.g., monitoring a “sick building”).
The fourth indication is for quality assurance to evaluate the effects of a change in infection-control
practice or to ensure that equipment or systems perform according to specifications and expected
outcomes. Any sampling for quality-assurance purposes must follow sound sampling protocols and
address confounding factors through the use of properly selected controls. Results from a single
environmental sample are difficult to interpret in the absence of a frame of reference or perspective.
Evaluations of a change in infection-control practice are based on the assumption that the effect will be
measured over a finite period, usually of short duration. Conducting quality-assurance sampling on an
extended basis, especially in the absence of an adverse outcome, is usually unjustified. A possible
exception might be the use of air sampling during major construction periods to qualitatively detect
breaks in environmental infection-control measures. In one study, which began as part of an
investigation of an outbreak of health-care–associated aspergillosis, airborne concentrations of
Aspergillus spores were measured in efforts to evaluate the effectiveness of sealing hospital doors and
windows during a period of construction of a nearby building.50 Other examples of sampling for
quality-assurance purposes may include commissioning newly constructed space in special care areas
(i.e., ORs and units for immunosuppressed patients) or assessing a change in housekeeping practice.
However, the only types of routine environmental microbiologic sampling recommended as part of a
quality-assurance program are a) the biological monitoring of sterilization processes by using bacterial
spores1214 and b) the monthly culturing of water used in hemodialysis applications and for the final
dialysate use dilution. Some experts also advocate periodic environmental sampling to evaluate the
microbial/particulate quality for regular maintenance of the air handling system (e.g., filters) and to
verify that the components of the system meet manufacturer’s specifications (A. Streifel, University of
Minnesota, 2000). Certain equipment in health-care settings (e.g., biological safety cabinets) may also
be monitored with air flow and particulate sampling to determine performance or as part of adherence to
a certification program; results can then be compared with a predetermined standard of performance.
These measurements, however, usually do not require microbiologic testing.
2. Air Sampling
Biological contaminants occur in the air as aerosols and may include bacteria, fungi, viruses, and
pollens.1215, 1216 Aerosols are characterized as solid or liquid particles suspended in air. Talking for 5
minutes and coughing each can produce 3,000 droplet nuclei; sneezing can generate approximately
40,000 droplets which then evaporate to particles in the size range of 0.5–12 µm.137, 1217 Particles in a
biological aerosol usually vary in size from <1 µm to >50 µm. These particles may consist of a single,
unattached organism or may occur in the form of clumps composed of a number of bacteria. Clumps
can also include dust and dried organic or inorganic material. Vegetative forms of bacterial cells and
viruses may be present in the air in a lesser number than bacterial spores or fungal spores. Factors that
determine the survival of microorganisms within a bioaerosol include a) the suspending medium, b)
temperature, c) relative humidity, d) oxygen sensitivity, and e) exposure to UV or electromagnetic
radiation.1215 Many vegetative cells will not survive for lengthy periods of time in the air unless the
90
relative humidity and other factors are favorable for survival and the organism is enclosed within some
protective cover (e.g., dried organic or inorganic matter).1216 Pathogens that resist drying (e.g.,
Staphylococcus spp., Streptococcus spp., and fungal spores) can survive for long periods and can be
carried considerable distances via air and still remain viable. They may also settle on surfaces and
become airborne again as secondary aerosols during certain activities (e.g., sweeping and bed
making).1216, 1218
Microbiologic air sampling is used as needed to determine the numbers and types of microorganisms, or
particulates, in indoor air.289 Air sampling for quality control is, however, problematic because of lack
of uniform air-quality standards. Although airborne spores of Aspergillus spp. can pose a risk for
neutropenic patients, the critical number (i.e., action level) of these spores above which outbreaks of
aspergillosis would be expected to occur has not been defined. Health-care professionals considering
the use of air sampling should keep in mind that the results represent indoor air quality at singular points
in time, and these may be affected by a variety of factors, including a) indoor traffic, b) visitors entering
the facility, c) temperature, d) time of day or year, e) relative humidity, f) relative concentration of
particles or organisms, and g) the performance of the air-handling system components. To be
meaningful, air-sampling results must be compared with those obtained from other defined areas,
conditions, or time periods.
Several preliminary concerns must be addressed when designing a microbiologic air sampling strategy
(Box 13). Because the amount of particulate material and bacteria retained in the respiratory system is
largely dependent on the size of the inhaled particles, particle size should be determined when studying
airborne microorganisms and their relation to respiratory infections. Particles >5 µm are efficiently
trapped in the upper respiratory tract and are removed primarily by ciliary action.1219 Particles <5 µm
in diameter reach the lung, but the greatest retention in the alveoli is of particles 1–2 µm in
diameter.1220–1222
Box 13. Preliminary concerns for conducting air sampling
• Consider the possible characteristics and conditions of the aerosol, including size range of particles,
relative amount of inert material, concentration of microorganisms, and environmental factors.
• Determine the type of sampling instruments, sampling time, and duration of the sampling program.
• Determine the number of samples to be taken.
• Ensure that adequate equipment and supplies are available.
• Determine the method of assay that will ensure optimal recovery of microorganisms.
• Select a laboratory that will provide proper microbiologic support.
• Ensure that samples can be refrigerated if they cannot be assayed in the laboratory promptly.
Bacteria, fungi, and particulates in air can be identified and quantified with the same methods and
equipment (Table 23). The basic methods include a) impingement in liquids, b) impaction on solid
surfaces, c) sedimentation, d) filtration, e) centrifugation, f) electrostatic precipitation, and g) thermal
precipitation.1218 Of these, impingement in liquids, impaction on solid surfaces, and sedimentation (on
settle plates) have been used for various air-sampling purposes in health-care settings.289
Several instruments are available for sampling airborne bacteria and fungi (Box 14). Some of the
samplers are self-contained units requiring only a power supply and the appropriate collecting medium,
but most require additional auxiliary equipment (e.g., a vacuum pump and an airflow measuring device
[i.e., a flowmeter or anemometer]). Sedimentation or depositional methods use settle plates and
91
therefore need no special instruments or equipment. Selection of an instrument for air sampling requires
a clear understanding of the type of information desired and the particular determinations that must be
made (Box 14). Information may be needed regarding a) one particular organism or all organisms that
may be present in the air, b) the concentration of viable particles or of viable organisms, c) the change in
concentration with time, and d) the size distribution of the collected particles. Before sampling begins,
decisions should be made regarding whether the results are to be qualitative or quantitative. Comparing
quantities of airborne microorganisms to those of outdoor air is also standard operating procedure.
Infection-control professionals, hospital epidemiologists, industrial hygienists, and laboratory
supervisors, as part of a multidisciplinary team, should discuss the potential need for microbial air
sampling to determine if the capacity and expertise to conduct such sampling exists within the facility
and when it is appropriate to enlist the services of an environmental microbiologist consultant.
Table 23. Air sampling methods and examples of equipment*
Suitable for
measuring:
Collection
media or
surface
Method
Principle
Impingement in
liquids
Air drawn
through a
small jet and
directed
against a
liquid surface
Viable
organisms, and
concentration
over time.
Example use:
sampling water
aerosols to
Legionella spp.
Buffered
gelatin,
tryptose
saline,
peptone,
nutrient
broth
Impaction on
solid surfaces
Air drawn
into the
sampler;
particles
deposited on
a dry surface
Dry surface,
coated
surfaces, and
agar
Sedimentation
Particles and
microorganisms
settle onto
surfaces via
gravity
Viable
particles; viable
organisms (on
non-nutrient
surfaces,
limited to
organisms that
resist drying
and spores);
size
measurement,
and
concentration
over time.
Example use:
sampling air for
Aspergillus
spp., fungal
spores
Viable
particles.
Example uses:
sampling air for
bacteria in the
vicinity of and
during a
medical
procedure;
general
measurements
of microbial air
quality.
Nutrient
media
(agars) on
plates or
slides
Rate of
collection
(L/min.)
Auxilliary
equipment
needed+
12.5
Yes
28 (sieve)
30–800
(slit)
Yes
–
No
Points to
consider
Prototype
samplers§
Antifoaming
agent may be
needed.
Ambient
temperature
and humidity
will influence
length of
collection time
Available as
sieve
impactors or
slit impactors.
Sieve
impactors can
be set up to
measure
particle size.
Slit impactors
have a rotating
support stage
for agar plates
to allow for
measurement
of
concentration
over time.
Chemical
Corps. All
Glass
Impinger
(AGI)
Simple and
inexpensive;
best suited for
qualitative
sampling;
significant
airborne
fungal spores
are too
buoyant to
settle
efficiently for
collection
using this
Settle plates
method.
Andersen Air
Sampler
(sieve
impactor);
TDL,
Cassella MK2 (slit
impactors)
92
Method
Principle
Filtration
Air drawn
through a
filter unit;
particles
trapped;
0.2 µm pore
size
Centrifugation
Aerosols
subjected to
centrifugal
force;
particles
impacted
onto a solid
surface
Electrostatic
precipitation
Air drawn
over an
electrostatically
charged
surface;
particles
become
charged
Thermal
precipitation
Air drawn
over a
thermal
gradient;
particles
repelled from
hot surfaces,
settle on
colder
surfaces
Suitable for
measuring:
Viable
particles; viable
organisms (on
non-nutrient
surfaces,
limited to
spores and
organisms that
resist drying);
concentration
over time.
Example use:
air sampling for
Aspergillus
spp., fungal
spores, and dust
Viable
particles; viable
organisms (on
non-nutrient
surfaces,
limited to
spores and
organisms that
resist drying);
concentration
over time.
Example use:
air sampling for
Aspergillus
spp., and
fungal spores
Viable
particles; viable
organisms (on
non-nutrient
surfaces,
limited to
spores and
organisms that
resist drying);
concentration
over time
Size
measurements
Collection
media or
surface
Rate of
collection
(L/min.)
Auxilliary
equipment
needed+
Paper,
cellulose,
glass wool,
gelatin foam,
and
membrane
filters
1–50
Yes
Filter must be
agitated first
in rinse fluid
to remove and
disperse
trapped microorganisms;
rinse fluid is
assayed; used
more for
sampling dust
and chemicals.
–
Coated glass
or plastic
slides, and
agar surfaces
40–50
Yes
Calibration is
difficult and is
done only by
the factory;
relative
comparison of
airborne
contamination
is its general
use.
Biotest RCS
Plus
85
Yes
High volume
sampling rate,
but equipment
is complex
and must be
handled
carefully; not
practical for
use in healthcare settings.
–
0.003–0.4
Yes
Determine
particle size
by direct
observation;
not frequently
used because
of complex
adjustments
and low
sampling
rates.
Solid
collecting
surfaces
(glass, and
agar)
Glass
coverslip,
and electron
microscope
grid
Points to
consider
Prototype
samplers§
* Material in this table is compiled from references 289, 1218, 1223, and 1224.
+ Most samplers require a flow meter or anemometer and a vacuum source as auxiliary equipment.
§ Trade names listed are for identification purposes only and are not intended as endorsements by the U.S. Public Health Service.
–
93
Box 14. Selecting an air sampling device*
The following factors must be considered when choosing an air sampling instrument:
•
•
•
•
•
•
•
•
•
•
•
•
Viability and type of the organism to be sampled
Compatibility with the selected method of analysis
Sensitivity of particles to sampling
Assumed concentrations and particle size
Whether airborne clumps must be broken (i.e., total viable organism count vs. particle count)
Volume of air to be sampled and length of time sampler is to be continuously operated
Background contamination
Ambient conditions
Sampler collection efficiency
Effort and skill required to operate sampler
Availability and cost of sampler, plus back-up samplers in case of equipment malfunction
Availability of auxiliary equipment and utilities (e.g., vacuum pumps, electricity, and water)
* Material in this box is compiled from reference 1218.
Liquid impinger and solid impactor samplers are the most practical for sampling bacteria, particles, and
fungal spores, because they can sample large volumes of air in relatively short periods of time.289 Solid
impactor units are available as either “slit” or “sieve” designs. Slit impactors use a rotating disc as
support for the collecting surface, which allows determinations of concentration over time. Sieve
impactors commonly use stages with calibrated holes of different diameters. Some impactor-type
samplers use centrifugal force to impact particles onto agar surfaces. The interior of either device must
be made sterile to avoid inadvertent contamination from the sampler. Results obtained from either
sampling device can be expressed as organisms or particles per unit volume of air (CFU/m3).
Sampling for bacteria requires special attention, because bacteria may be present as individual
organisms, as clumps, or mixed with or adhering to dust or covered with a protective coating of dried
organic or inorganic substances. Reports of bacterial concentrations determined by air sampling
therefore must indicate whether the results represent individual organisms or particles bearing multiple
cells. Certain types of samplers (e.g., liquid impingers) will completely or partially disintegrate clumps
and large particles; the sampling result will therefore reflect the total number of individual organisms
present in the air.
The task of sizing a bioaerosol is simplified through the use of sieves or slit impactors because these
samplers will separate the particles and microorganisms into size ranges as the sample is collected.
These samplers must, however, be calibrated first by sampling aerosols under similar use conditions.1225
The use of settle plates (i.e., the sedimentation or depositional method) is not recommended when
sampling air for fungal spores, because single spores can remain suspended in air indefinitely.289 Settle
plates have been used mainly to sample for particulates and bacteria either in research studies or during
epidemiologic investigations.161, 1226–1229 Results of sedimentation sampling are typically expressed as
numbers of viable particles or viable bacteria per unit area per the duration of sampling time (i.e.,
CFU/area/time); this method can not quantify the volume of air sampled. Because the survival of
microorganisms during air sampling is inversely proportional to the velocity at which the air is taken
into the sampler,1215 one advantage of using a settle plate is its reliance on gravity to bring organisms
and particles into contact with its surface, thus enhancing the potential for optimal survival of collected
organisms. This process, however, takes several hours to complete and may be impractical for some
situations.
94
Air samplers are designed to meet differing measurement requirements. Some samplers are better
suited for one form of measurement than others. No one type of sampler and assay procedure can be
used to collect and enumerate 100% of airborne organisms. The sampler and/or sampling method
chosen should, however, have an adequate sampling rate to collect a sufficient number of particles in a
reasonable time period so that a representative sample of air is obtained for biological analysis. Newer
analytical techniques for assaying air samples include PCR methods and enzyme-linked immunosorbent
assays (ELISAs).
3. Water Sampling
A detailed discussion of the principles and practices of water sampling has been published.945 Water
sampling in health-care settings is used detect waterborne pathogens of clinical significance or to
determine the quality of finished water in a facility’s distribution system. Routine testing of the water in
a health-care facility is usually not indicated, but sampling in support of outbreak investigations can
help determine appropriate infection-control measures. Water-quality assessments in dialysis settings
have been discussed in this guideline (see Water, Dialysis Water Quality and Dialysate, and Appendix
C).
Health-care facilities that conduct water sampling should have their samples assayed in a laboratory that
uses established methods and quality-assurance protocols. Water specimens are not “static specimens”
at ambient temperature; potential changes in both numbers and types of microbial populations can occur
during transport. Consequently, water samples should be sent to the testing laboratory cold (i.e., at
approximately 39.2°F [4°C]) and testing should be done as soon as practical after collection (preferably
within 24 hours).
Because most water sampling in health-care facilities involves the testing of finished water from the
facility’s distribution system, a reducing agent (i.e., sodium thiosulfate [Na2S2O3]) needs to be added to
neutralize residual chlorine or other halogen in the collected sample. If the water contains elevated
levels of heavy metals, then a chelating agent should be added to the specimen. The minimum volume
of water to be collected should be sufficient to complete any and all assays indicated; 100 mL is
considered a suitable minimum volume. Sterile collection equipment should always be used.
Sampling from a tap requires flushing of the water line before sample collection. If the tap is a mixing
faucet, attachments (e.g., screens and aerators) must be removed, and hot and then cold water must be
run through the tap before collecting the sample.945 If the cleanliness of the tap is questionable,
disinfection with 500–600 ppm sodium hypochlorite (1:100 v/v dilution of chlorine bleach) and flushing
the tap should precede sample collection.
Microorganisms in finished or treated water often are physically damaged (“stressed”) to the point that
growth is limited when assayed under standard conditions. Such situations lead to false-negative
readings and misleading assessments of water quality. Appropriate neutralization of halogens and
chelation of heavy metals are crucial to the recovery of these organisms. The choice of recovery media
and incubation conditions will also affect the assay. Incubation temperatures should be closer to the
ambient temperature of the water rather than at 98.6°F (37°C), and recovery media should be formulated
to provide appropriate concentrations of nutrients to support organisms exhibiting less than rigorous
growth.945 High-nutrient content media (e.g., blood agar and tryptic soy agar [TSA]) may actually
inhibit the growth of these damaged organisms. Reduced nutrient media (e.g., diluted peptone and
R2A) are preferable for recovery of these organisms.945
95
Use of aerobic, heterotrophic plate counts allows both a qualitative and quantitative measurement for
water quality. If bacterial counts in water are expected to be high in number (e.g., during waterborne
outbreak investigations), assaying small quantities using pour plates or spread plates is appropriate.945
Membrane filtration is used when low-count specimens are expected and larger sampling volumes are
required (>100 mL). The sample is filtered through the membrane, and the filter is applied directly
face-up onto the surface of the agar plate and incubated.
Unlike the testing of potable water supplies for coliforms (which uses standardized test and specimen
collection parameters and conditions), water sampling to support epidemiologic investigations of
disease outbreaks may be subjected to modifications dictated by the circumstances present in the
facility. Assay methods for waterborne pathogens may also not be standardized. Therefore, control or
comparison samples should be included in the experimental design. Any departure from a standard
method should be fully documented and should be considered when interpreting results and developing
strategies. Assay methods specific for clinically significant waterborne pathogens (e.g., Legionella spp.,
Aeromonas spp, Pseudomonas spp., and Acinetobacter spp.) are more complicated and costly compared
with both methods used to detect coliforms and other standard indicators of water quality.
4. Environmental Surface Sampling
Routine environmental-surface sampling (e.g., surveillance cultures) in health-care settings is neither
cost-effective nor warranted.951, 1225 When indicated, surface sampling should be conducted with
multidisciplinary approval in adherence to carefully considered plans of action and policy (Box 15).
Box 15. Undertaking environmental-surface sampling*
The following factors should be considered before engaging in environmental-surface sampling:
• Background information from the literature and present activities (i.e., preliminary results from an
epidemiologic investigation)
• Location of surfaces to be sampled
• Method of sample collection and the appropriate equipment for this task
• Number of replicate samples needed and which control or comparison samples are required
• Parameters of the sample assay method and whether the sampling will be qualitative,
quantitative, or both
• An estimate of the maximum allowable microbial numbers or types on the surface(s) sampled
(refer to the Spaulding classification for devices and surfaces)
• Some anticipation of a corrective action plan
* The material in this box is compiled from reference 1214.
Surface sampling is used currently for research, as part of an epidemiologic investigation, or as part of a
comprehensive approach for specific quality assurance purposes. As a research tool, surface sampling
has been used to determine a) potential environmental reservoirs of pathogens,564, 1230–1232 b) survival of
microorganisms on surfaces,1232, 1233 and c) the sources of the environmental contamination.1023 Some
or all of these approaches can also be used during outbreak investigations.1232 Discussion of surface
sampling of medical devices and instruments is beyond the scope of this document and is deferred to
future guidelines on sterilization and disinfection issues.
Meaningful results depend on the selection of appropriate sampling and assay techniques.1214 The
media, reagents, and equipment required for surface sampling are available from any well-equipped
96
microbiology laboratory and laboratory supplier. For quantitative assessment of surface organisms,
non-selective, nutrient-rich agar media and broth (e.g., TSA and brain-heart infusion broth [BHI] with
or without 5% sheep or rabbit blood supplement) are used for the recovery of aerobic bacteria. Broth
media are used with membrane-filtration techniques. Further sample work-up may require the use of
selective media for the isolation and enumeration of specific groups of microorganisms. Examples of
selective media are MacConkey agar (MAC [selects for gram-negative bacteria]), Cetrimide agar
(selects for Pseudomonas aeruginosa), or Sabouraud dextrose- and malt extract agars and broths (select
for fungi). Qualitative determinations of organisms from surfaces require only the use of selective or
non-selective broth media.
Effective sampling of surfaces requires moisture, either already present on the surface to be sampled or
via moistened swabs, sponges, wipes, agar surfaces, or membrane filters.1214, 1234–1236 Dilution fluids
and rinse fluids include various buffers or general purpose broth media (Table 24). If disinfectant
residuals are expected on surfaces being sampled, specific neutralizer chemicals should be used in both
the growth media and the dilution or rinse fluids. Lists of the neutralizers, the target disinfectant active
ingredients, and the use concentrations have been published.1214, 1237 Alternatively, instead of adding
neutralizing chemicals to existing culture media (or if the chemical nature of the disinfectant residuals is
unknown), the use of either a) commercially available media including a variety of specific and nonspecific neutralizers or b) double-strength broth media will facilitate optimal recovery of
microorganisms. The inclusion of appropriate control specimens should be included to rule out both
residual antimicrobial activity from surface disinfectants and potential toxicity caused by the presence
of neutralizer chemicals carried over into the assay system.1214
Table 24. Examples of eluents and diluents for environmental-surface sampling* +
Solutions
Ringer
Peptone water
Buffered peptone water
Phosphate-buffered saline
Sodium chloride (NaCl)
Calgon Ringer§
Thiosulfate Ringer¶
Water
Tryptic soy broth (TSB)
Brain-heart infusion broth (BHI) supplemented with 0.5%
beef extract
Concentration in water
¼ strength
0.1%–1.0%
0.067 M phosphate, 0.43% NaCl, 0.1% peptone
0.02 M phosphate, 0.9% NaCl
0.25%–0.9%
¼ strength
¼ strength
–
–
–
* Material in this table is compiled from references 1214 and 1238.
+ A surfactant (e.g., polysorbate [i.e., Tween® 80]) may be added to eluents and diluents. A concentration ranging from 0.01%–0.1% is
generally used, depending on the specific application. Foaming may occur during use.
§ This solution is used for dissolution of calcium alginate swabs.
¶ This solution is used for neutralization of residual chlorine.
Several methods can be used for collecting environmental surface samples (Table 25). Specific step-bystep discussions of each of the methods have been published.1214, 1239 For best results, all methods
should incorporate aseptic techniques, sterile equipment, and sterile recovery media.
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Table 25. Methods of environmental-surface sampling
Method
Sample/rinse
Moistened
swab/rinse
Suitable for
appropriate
surface(s)
Assay
technique
Procedural
notes
Points of
interpretation
Available
standards
References
Non-absorbent
surfaces, corners,
crevices, devices,
and instruments
Dilutions;
qualitative or
quantitative
assays
Assay multiple
measures areas
or devices with
separate swabs
Report results per
measured areas or if
assaying an object,
per the entire sample
site
YES – food
industry;
NO – heath
care
1214, 1239–
1242
Moistened
sponge/rinse
Large areas and
housekeeping
surfaces (e.g.,
floors or walls)
Dilutions;
qualitative or
quantitative
assays
Vigorously rub a
sterile sponge
over the surface
Report results per
measured area
YES – food
industry;
NO – health
care
1214, 1239–
1242
Moistened
wipe/rinse
Large areas and
housekeeping
surfaces (e.g.,
countertops)
Small items
capable of being
immersed
Dilutions;
qualitative or
quantitative
assays
Dilutions;
qualitative or
quantitative
assays
Use a sterile
wipe
Report results per
measured area
1214, 1239–
1242
Report results per
item
Containment
Interior surfaces
of containers,
tubes, or bottles
Dilutions;
qualitative or
quantitative
assays
Use membrane
filtration if rinse
volume is large
and anticipated
microbiological
concentration is
low
Use membrane
filtration if rinse
volume is large
YES – food
industry;
NO – health
care
NO
RODAC*
Previously
cleaned and
sanitized flat,
non-absorbent
surfaces; not
suitable for
irregular surfaces
Direct assay
Overgrowth
occurs if used on
heavily
contaminated
surfaces; use
neutralizers in
the agar if
surface
disinfectant
residuals are
present
Provides direct,
quantitative results;
use a minimum of
15 plates per an
average hospital
room
Direct
immersion
Evaluate both the
types and numbers
of microorganisms
YES – food and
industrial
applications for
containers prior
to fill
NO
1214
1214
1214, 1237,
1239, 1243,
1244
* RODAC stands for “replicate organism direct agar contact.”
Sample/rinse methods are frequently chosen because of their versatility. However, these sampling
methods are the most prone to errors caused by manipulation of the swab, gauze pad, or sponge.1238
Additionally, no microbiocidal or microbiostatic agents should be present in any of these items when
used for sampling.1238 Each of the rinse methods requires effective elution of microorganisms from the
item used to sample the surface. Thorough mixing of the rinse fluids after elution (e.g., via manual or
mechanical mixing using a vortex mixer, shaking with or without glass beads, and ultrasonic bath) will
help to remove and suspend material from the sampling device and break up clumps of organisms for a
more accurate count.1238 In some instances, the item used to sample the surface (e.g., gauze pad and
sponge) may be immersed in the rinse fluids in a sterile bag and subjected to stomaching.1238 This
technique, however, is suitable only for soft or absorbent items that will not puncture the bag during the
elution process.
If sampling is conducted as part of an epidemiologic investigation of a disease outbreak, identification
of isolates to species level is mandatory, and characterization beyond the species level is preferred.1214
When interpreting the results of the sampling, the expected degree of microbial contamination
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associated with the various categories of surfaces in the Spaulding classification must be considered.
Environmental surfaces should be visibly clean; recognized pathogens in numbers sufficient to result in
secondary transfer to other animate or inanimate surfaces should be absent from the surface being
sampled.1214 Although the interpretation of a sample with positive microbial growth is self-evident, an
environmental surface sample, especially that obtained from housekeeping surfaces, that shows no
growth does not represent a “sterile” surface. Sensitivities of the sampling and assay methods (i.e., level
of detection) must be taken into account when no-growth samples are encountered. Properly collected
control samples will help rule out extraneous contamination of the surface sample.
G. Laundry and Bedding
1. General Information
Laundry in a health-care facility may include bed sheets and blankets, towels, personal clothing, patient
apparel, uniforms, scrub suits, gowns, and drapes for surgical procedures.1245 Although contaminated
textiles and fabrics in health-care facilities can be a source of substantial numbers of pathogenic
microorganisms, reports of health-care–associated diseases linked to contaminated fabrics are so few in
number that the overall risk of disease transmission during the laundry process likely is negligible.
When the incidence of such events are evaluated in the context of the volume of items laundered in
health-care settings (estimated to be 5 billion pounds annually in the United States),1246 existing control
measures (e.g., standard precautions) are effective in reducing the risk of disease transmission to
patients and staff. Therefore, use of current control measures should be continued to minimize the
contribution of contaminated laundry to the incidence of health-care–associated infections. The control
measures described in this section of the guideline are based on principles of hygiene, common sense,
and consensus guidance; they pertain to laundry services utilized by health-care facilities, either inhouse or contract, rather than to laundry done in the home.
2. Epidemiology and General Aspects of Infection Control
Contaminated textiles and fabrics often contain high numbers of microorganisms from body substances,
including blood, skin, stool, urine, vomitus, and other body tissues and fluids. When textiles are heavily
contaminated with potentially infective body substances, they can contain bacterial loads of 106–108
CFU/100 cm2 of fabric.1247 Disease transmission attributed to health-care laundry has involved
contaminated fabrics that were handled inappropriately (i.e., the shaking of soiled linens). Bacteria
(Salmonella spp., Bacillus cereus), viruses (hepatitis B virus [HBV]), fungi (Microsporum canis), and
ectoparasites (scabies) presumably have been transmitted from contaminated textiles and fabrics to
workers via a) direct contact or b) aerosols of contaminated lint generated from sorting and handling
contaminated textiles.1248–1252 In these events, however, investigations could not rule out the possibility
that some of these reported infections were acquired from community sources. Through a combination
of soil removal, pathogen removal, and pathogen inactivation, contaminated laundry can be rendered
hygienically clean. Hygienically clean laundry carries negligible risk to health-care workers and
patients, provided that the clean textiles, fabric, and clothing are not inadvertently contaminated before
use.
OSHA defines contaminated laundry as “laundry which has been soiled with blood or other potentially
infectious materials or may contain sharps.”967 The purpose of the laundry portion of the standard is to
protect the worker from exposure to potentially infectious materials during collection, handling, and
sorting of contaminated textiles through the use of personal protective equipment, proper work
practices, containment, labeling, hazard communication, and ergonomics.
99
Experts are divided regarding the practice of transporting clothes worn at the workplace to the healthcare worker’s home for laundering. Although OSHA regulations prohibit home laundering of items that
are considered personal protective apparel or equipment (e.g., laboratory coats),967 experts disagree
about whether this regulation extends to uniforms and scrub suits that are not contaminated with blood
or other potentially infectious material. Health-care facility policies on this matter vary and may be
inconsistent with recommendations of professional organizations.1253, 1254 Uniforms without blood or
body substance contamination presumably do not differ appreciably from street clothes in the degree
and microbial nature of soilage. Home laundering would be expected to remove this level of soil
adequately. However, if health-care facilities require the use of uniforms, they should either make
provisions to launder them or provide information to the employee regarding infection control and
cleaning guidelines for the item based on the tasks being performed at the facility. Health-care
facilities should address the need to provide this service and should determine the frequency for
laundering these items. In a recent study examining the microbial contamination of medical students’
white coats, the students perceived the coats as “clean” as long as the garments were not visibly
contaminated with body substances, even after wearing the coats for several weeks.1255 The heaviest
bacterial load was found on the sleeves and the pockets of these garments; the organisms most
frequently isolated were Staphylococcus aureus, diphtheroids, and Acinetobacter spp.1255 Presumably,
the sleeves of the coat may make contact with a patient and potentially serve to transfer environmentally
stable microorganisms among patients. In this study, however, surveillance was not conducted among
patients to detect new infections or colonizations. The students did, however, report that they would
likely replace their coats more frequently and regularly if clean coats were provided.1255 Apart from
this study, which documents the presence of pathogenic bacteria on health-care facility clothing, reports
of infections attributed to either the contact with such apparel or with home laundering have been
rare.1256, 1257
Laundry services for health-care facilities are provided either in-house (i.e., on-premise laundry [OPL]),
co-operatives (i.e., those entities owned and operated by a group of facilities), or by off-site commercial
laundries. In the latter, the textiles may be owned by the health-care facility, in which case the
processor is paid for laundering only. Alternatively, the textiles may be owned by the processor who is
paid for every piece laundered on a “rental” fee. The laundry facility in a health-care setting should be
designed for efficiency in providing hygienically clean textiles, fabrics, and apparel for patients and
staff. Guidelines for laundry construction and operation for health-care facilities, including nursing
facilities, have been published.120, 1258 The design and engineering standards for existing facilities are
those cited in the AIA edition in effect during the time of the facility’s construction.120 A laundry
facility is usually partitioned into two separate areas - a “dirty” area for receiving and handling the
soiled laundry and a “clean” area for processing the washed items.1259 To minimize the potential for
recontaminating cleaned laundry with aerosolized contaminated lint, areas receiving contaminated
textiles should be at negative air pressure relative to the clean areas.1260–1262 Laundry areas should have
handwashing facilities readily available to workers. Laundry workers should wear appropriate personal
protective equipment (e.g., gloves and protective garments) while sorting soiled fabrics and textiles.967
Laundry equipment should be used and maintained according to the manufacturer’s instructions to
prevent microbial contamination of the system.1250, 1263 Damp textiles should not be left in machines
overnight.1250
3. Collecting, Transporting, and Sorting Contaminated Textiles and Fabrics
The laundry process starts with the removal of used or contaminated textiles, fabrics, and/or clothing
from the areas where such contamination occurred, including but not limited to patients’ rooms,
surgical/operating areas, and laboratories. Handling contaminated laundry with a minimum of agitation
100
can help prevent the generation of potentially contaminated lint aerosols in patient-care areas.967, 1259
Sorting or rinsing contaminated laundry at the location where contamination occurred is prohibited by
OSHA.967 Contaminated textiles and fabrics are placed into bags or other appropriate containment in
this location; these bags are then securely tied or otherwise closed to prevent leakage.967 Single bags of
sufficient tensile strength are adequate for containing laundry, but leak-resistant containment is needed
if the laundry is wet and capable of soaking through a cloth bag.1264 Bags containing contaminated
laundry must be clearly identified with labels, color-coding, or other methods so that health-care
workers handle these items safely, regardless of whether the laundry is transported within the facility or
destined for transport to an off-site laundry service.967
Typically, contaminated laundry originating in isolation areas of the hospital is segregated and handled
with special practices; however, few, if any, cases of health-care–associated infection have been linked
to this source.1265 Single-blinded studies have demonstrated that laundry from isolation areas is no
more heavily contaminated with microorganisms than laundry from elsewhere in the hospital.1266
Therefore, adherence to standard precautions when handling contaminated laundry in isolation areas and
minimizing agitation of the contaminated items are considered sufficient to prevent the dispersal of
potentially infectious aerosols.6
Contaminated textiles and fabrics in bags can be transported by cart or chute.1258, 1262 Laundry chutes
require proper design, maintenance, and use, because the piston-like action of a laundry bag traveling in
the chute can propel airborne microbial contaminants throughout the facility.1267–1269 Laundry chutes
should be maintained under negative air pressure to prevent the spread of microorganisms from floor to
floor. Loose, contaminated pieces of laundry should not be tossed into chutes, and laundry bags should
be closed or otherwise secured to prevent the contents from falling out into the chute.1270 Health-care
facilities should determine the point in the laundry process at which textiles and fabrics should be
sorted. Sorting after washing minimizes the exposure of laundry workers to infective material in soiled
fabrics, reduces airborne microbial contamination in the laundry area, and helps to prevent potential
percutaneous injuries to personnel.1271 Sorting laundry before washing protects both the machinery and
fabrics from hard objects (e.g., needles, syringes, and patients’ property) and reduces the potential for
recontamination of clean textiles.1272 Sorting laundry before washing also allows for customization of
laundry formulas based on the mix of products in the system and types of soils encountered.
Additionally, if work flow allows, increasing the amount of segregation by specific product types will
usually yield the greatest amount of work efficiency during inspection, folding, and pack-making
operations.1253 Protective apparel for the workers and appropriate ventilation can minimize these
exposures.967, 1258–1260 Gloves used for the task of sorting laundry should be of sufficient thickness to
minimize sharps injuries.967 Employee safety personnel and industrial hygienists can help to determine
the appropriate glove choice.
4. Parameters of the Laundry Process
Fabrics, textiles, and clothing used in health-care settings are disinfected during laundering and
generally rendered free of vegetative pathogens (i.e., hygienically clean), but they are not sterile.1273
Laundering cycles consist of flush, main wash, bleaching, rinsing, and souring.1274 Cleaned wet
textiles, fabrics, and clothing are then dried, pressed as needed, and prepared (e.g., folded and packaged)
for distribution back to the facility. Clean linens provided by an off-site laundry must be packaged prior
to transport to prevent inadvertent contamination from dust and dirt during loading, delivery, and
unloading. Functional packaging of laundry can be achieved in several ways, including a) placing clean
linen in a hamper lined with a previously unused liner, which is then closed or covered; b) placing clean
linen in a properly cleaned cart and covering the cart with disposable material or a properly cleaned
reusable textile material that can be secured to the cart; and c) wrapping individual bundles of clean
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textiles in plastic or other suitable material and sealing or taping the bundles.
The antimicrobial action of the laundering process results from a combination of mechanical, thermal,
and chemical factors.1271, 1275, 1276 Dilution and agitation in water remove substantial quantities of
microorganisms. Soaps and detergents function to suspend soils and also exhibit some microbiocidal
properties. Hot water provides an effective means of destroying microorganisms.1277 A temperature of
at least 160°F (71°C) for a minimum of 25 minutes is commonly recommended for hot-water washing.2
Water of this temperature can be provided by steam jet or separate booster heater.120 The use of
chlorine bleach assures an extra margin of safety.1278, 1279 A total available chlorine residual of 50–150
ppm is usually achieved during the bleach cycle.1277 Chlorine bleach becomes activated at water
temperatures of 135°F–145°F (57.2°C–62.7°C). The last of the series of rinse cycles is the addition of a
mild acid (i.e., sour) to neutralize any alkalinity in the water supply, soap, or detergent. The rapid shift
in pH from approximately 12 to 5 is an effective means to inactivate some microorganisms.1247
Effective removal of residual alkali from fabrics is an important measure in reducing the risk for skin
reactions among patients.
Chlorine bleach is an economical, broad-spectrum chemical germicide that enhances the effectiveness
of the laundering process. Chlorine bleach is not, however, an appropriate laundry additive for all
fabrics. Traditionally, bleach was not recommended for laundering flame-retardant fabrics, linens, and
clothing because its use diminished the flame-retardant properties of the treated fabric.1273 However,
some modern-day flame retardant fabrics can now tolerate chlorine bleach. Flame-retardant fabrics,
whether topically treated or inherently flame retardant, should be thoroughly rinsed during the rinse
cycles, because detergent residues are capable of supporting combustion. Chlorine alternatives (e.g.,
activated oxygen-based laundry detergents) provide added benefits for fabric and color safety in
addition to antimicrobial activity. Studies comparing the antimicrobial potencies of chlorine bleach and
oxygen-based bleach are needed. Oxygen-based bleach and detergents used in health-care settings
should be registered by EPA to ensure adequate disinfection of laundry. Health-care workers should
note the cleaning instructions of textiles, fabrics, drapes, and clothing to identify special laundering
requirements and appropriate hygienic cleaning options.1278
Although hot-water washing is an effective laundry disinfection method, the cost can be substantial.
Laundries are typically the largest users of hot water in hospitals. They consume 50%–75% of the total
hot water,1280 representing an average of 10%–15% of the energy used by a hospital. Several studies
have demonstrated that lower water temperatures of 71°F–77°F (22°C–25°C) can reduce microbial
contamination when the cycling of the washer, the wash detergent, and the amount of laundry additive
are carefully monitored and controlled.1247, 1281–1285 Low-temperature laundry cycles rely heavily on the
presence of chlorine- or oxygen-activated bleach to reduce the levels of microbial contamination. The
selection of hot- or cold-water laundry cycles may be dictated by state health-care facility licensing
standards or by other regulation. Regardless of whether hot or cold water is used for washing, the
temperatures reached in drying and especially during ironing provide additional significant
microbiocidal action.1247 Dryer temperatures and cycle times are dictated by the materials in the
fabrics. Man-made fibers (i.e., polyester and polyester blends) require shorter times and lower
temperatures.
After washing, cleaned and dried textiles, fabrics, and clothing are pressed, folded, and packaged for
transport, distribution, and storage by methods that ensure their cleanliness until use.2 State regulations
and/or accrediting standards may dictate the procedures for this activity. Clean/sterile and contaminated
textiles should be transported from the laundry to the health-care facility in vehicles (e.g., trucks, vans,
and carts) that allow for separation of clean/sterile and contaminated items. Clean/sterile textiles and
contaminated textiles may be transported in the same vehicle, provided that the use of physical barriers
and/or space separation can be verified to be effective in protecting the clean/sterile items from
102
contamination. Clean, uncovered/unwrapped textiles stored in a clean location for short periods of time
(e.g., uncovered and used within a few hours) have not been demonstrated to contribute to increased
levels of health-care–acquired infection. Such textiles can be stored in convenient places for use during
the provision of care, provided that the textiles can be maintained dry and free from soil and bodysubstance contamination.
In the absence of microbiologic standards for laundered textiles, no rationale exists for routine
microbiologic sampling of cleaned health-care textiles and fabrics.1286 Sampling may be used as part of
an outbreak investigation if epidemiologic evidence suggests that textiles, fabrics, or clothing are a
suspected vehicle for disease transmission. Sampling techniques include aseptically macerating the
fabric into pieces and adding these to broth media or using contact plates (RODAC plates) for direct
surface sampling.1271, 1286 When evaluating the disinfecting properties of the laundering process
specifically, placing pieces of fabric between two membrane filters may help to minimize the
contribution of the physical removal of microorganisms.1287
Washing machines and dryers in residential-care settings are more likely to be consumer items rather
than the commercial, heavy-duty, large volume units typically found in hospitals and other institutional
health-care settings. Although all washing machines and dryers in health-care settings must be properly
maintained for performance according to the manufacturer’s instructions, questions have been raised
about the need to disinfect washers and dryers in residential-care settings. Disinfection of the tubs and
tumblers of these machines is unnecessary when proper laundry procedures are followed; these
procedures involve a) the physical removal of bulk solids (e.g., feces) before the wash/dry cycle and b)
proper use of temperature, detergent, and laundry additives. Infection has not been linked to laundry
procedures in residential-care facilities, even when consumer versions of detergents and laundry
additives are used.
5. Special Laundry Situations
Some textile items (e.g., surgical drapes and reusable gowns) must be sterilized before use and therefore
require steam autoclaving after laundering.7 Although the American Academy of Pediatrics in previous
guidelines recommended autoclaving for linens in neonatal intensive care units (NICUs), studies on the
microbial quality of routinely cleaned NICU linen have not identified any increased risk for infection
among the neonates receiving care.1288 Consequently, hygienically clean linens are suitable for use in
this setting.997 The use of sterile linens in burn therapy units remains unresolved.
Coated or laminated fabrics are often used in the manufacture of PPE. When these items become
contaminated with blood or other body substances, the manufacturer’s instructions for decontamination
and cleaning take into account the compatibility of the rubber backing with the chemical germicides or
detergents used in the process. The directions for decontaminating these items should be followed as
indicated; the item should be discarded when the backing develops surface cracks.
Dry cleaning, a cleaning process that utilizes organic solvents (e.g., perchloroethylene) for soil removal,
is an alternative means of cleaning fabrics that might be damaged in conventional laundering and
detergent washing. Several studies, however, have shown that dry cleaning alone is relatively
ineffective in reducing the numbers of bacteria and viruses on contaminated linens;1289, 1290 microbial
populations are significantly reduced only when dry-cleaned articles are heat pressed. Dry cleaning
should therefore not be considered a routine option for health-care facility laundry and should be
reserved for those circumstances in which fabrics can not be safely cleaned with water and detergent.1291
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6. Surgical Gowns, Drapes, and Disposable Fabrics
An issue of recent concern involves the use of disposable (i.e., single use) versus reusable (i.e., multiple
use) surgical attire and fabrics in health-care settings.1292 Regardless of the material used to
manufacture gowns and drapes, these items must be resistant to liquid and microbial penetration.7, 1293–
1297
Surgical gowns and drapes must be registered with FDA to demonstrate their safety and
effectiveness. Repellency and pore size of the fabric contribute to gown performance, but performance
capability can be influenced by the item’s design and construction.1298, 1299 Reinforced gowns (i.e.,
gowns with double-layered fabric) generally are more resistant to liquid strike-through.1300, 1301
Reinforced gowns may, however, be less comfortable. Guidelines for selection and use of barrier
materials for surgical gowns and drapes have been published.1302 When selecting a barrier product,
repellency level and type of barrier should be compatible for the exposure expected.967 However, data
are limited regarding the association between gown or drape characteristics and risk for surgical site
infections.7, 1303 Health-care facilities must ensure optimal protection of patients and health-care
workers. Not all fabric items in health care lend themselves to single-use. Facilities exploring options
for gowns and drapes should consider the expense of disposable items and the impact on the facility’s
waste-management costs once these items are discarded. Costs associated with the use of durable goods
involve the fabric or textile items; staff expenses to collect, sort, clean, and package the laundry; and
energy costs to operate the laundry if on-site or the costs to contract with an outside service.1304, 1305
7. Antimicrobial-Impregnated Articles and Consumer Items Bearing
Antimicrobial Labeling
Manufacturers are increasingly incorporating antibacterial or antimicrobial chemicals into consumer and
health-care items. Some consumer products bearing labels that indicate treatment with antimicrobial
chemicals have included pens, cutting boards, toys, household cleaners, hand lotions, cat litter, soaps,
cotton swabs, toothbrushes, and cosmetics. The “antibacterial” label on household cleaning products, in
particular, gives consumers the impression that the products perform “better” than comparable products
without this labeling, when in fact all household cleaners have antibacterial properties.
In the health-care setting, treated items may include children’s pajamas, mattresses, and bed linens with
label claims of antimicrobial properties. These claims require careful evaluation to determine whether
they pertain to the use of antimicrobial chemicals as preservatives for the fabric or other components or
whether they imply a health claim.1306, 1307 No evidence is available to suggest that use of these
products will make consumers and patients healthier or prevent disease. No data support the use of
these items as part of a sound infection-control strategy, and therefore, the additional expense of
replacing a facility’s bedding and sheets with these treated products is unwarranted.
EPA has reaffirmed its position that manufacturers who make public health claims for articles
containing antimicrobial chemicals must provide evidence to support those claims as part of the
registration process.1308 Current EPA regulations outlined in the Treated Articles Exemption of the
Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA) require manufacturers to register both the
antimicrobial chemical used in or on the product and the finished product itself if a public health claim
is maintained for the item. The exemption applies to the use of antimicrobial chemicals for the purpose
of preserving the integrity of the product’s raw material(s). The U.S. Federal Trade Commission (FTC)
is evaluating manufacturer advertising of products with antimicrobial claims.1309
104
8. Standard Mattresses, Pillows, and Air-Fluidized Beds
Standard mattresses and pillows can become contaminated with body substances during patient care if
the integrity of the covers of these items is compromised. The practice of sticking needles into the
mattress should be avoided. A mattress cover is generally a fitted, protective material, the purpose of
which is to prevent the mattress from becoming contaminated with body fluids and substances. A linen
sheet placed on the mattress is not considered a mattress cover. Patches for tears and holes in mattress
covers do not provide an impermeable surface over the mattress. Mattress covers should be replaced
when torn; the mattress should be replaced if it is visibly stained. Wet mattresses, in particular, can be a
substantial environmental source of microorganisms. Infections and colonizations caused by
Acinetobacter spp., MRSA, and Pseudomonas aeruginosa have been described, especially among burn
patients.1310–1315 In these reports, the removal of wet mattresses was an effective infection-control
measure. Efforts were made to ensure that pads and covers were cleaned and disinfected between
patients using disinfectant products compatible with mattress-cover materials to ensure that these covers
remained impermeable to fluids.1310–1314 Pillows and their covers should be easily cleanable, preferably
in a hot water laundry cycle.1315 These should be laundered between patients or if contaminated with
body substances.
Air-fluidized beds are used for the care of patients immobilized for extended periods of time because of
therapy or injury (e.g., pain, decubitus ulcers, and burns).1316 These specialized beds consist of a base
unit filled with microsphere beads fluidized by warm, dry air flowing upward from a diffuser located at
the bottom of the unit. A porous, polyester filter sheet separates the patient from direct contact with the
beads but allows body fluids to pass through to the beads. Moist beads aggregate into clumps which
settle to the bottom where they are removed as part of routine bed maintenance.
Because the beads become contaminated with the patient’s body substances, concerns have been raised
about the potential for these beds to serve as an environmental source of pathogens. Certain pathogens
(e.g., Enterococcus spp., Serratia marcescens, Staphylococcus aureus, and Streptococcus fecalis) have
been recovered either from the microsphere beads or the polyester sheet after cleaning.1317, 1318 Reports
of cross-contamination of patients, however, are few.1318 Nevertheless, routine maintenance and
between-patient decontamination procedures can minimize potential risks to patients. Regular removal
of bead clumps, coupled with the warm, dry air of the bed, can help to minimize bacterial growth in the
unit.1319–1321 Beads are decontaminated between patients by high heat (113°F–194°F [45°C–90°C],
depending on the manufacturer’s specifications) for at least 1 hour; this procedure is particularly
important for the inactivation of Enterococcus spp. which are relatively resistant to heat.1322, 1323 The
polyester filter sheet requires regular changing and thorough cleaning and disinfection, especially
between patients.1317, 1318, 1322, 1323
Microbial contamination of the air space in the immediate vicinity of a properly maintained air-fluidized
bed is similar to that found in air around conventional bedding, despite the air flow out of the base unit
and around the patient.1320, 1324, 1325 An operational air-fluidized bed can, however, interfere with proper
pressure differentials, especially in negative-pressure rooms;1326 the effect varies with the location of
the bed relative to the room’s configuration and supply and exhaust vent locations. Use of an airfluidized bed in a negative-pressure room requires consultation with a facility engineer to determine
appropriate placement of the bed.
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H. Animals in Health-Care Facilities
1. General Information
Animals in health-care facilities traditionally have been limited to laboratories and research areas.
However, their presence in patient-care areas is now more frequent, both in acute-care and long-term
care settings, prompting consideration for the potential transmission of zoonotic pathogens from animals
to humans in these settings. Although dogs and cats may be commonly encountered in health-care
settings, other animals (e.g., fish, birds, non-human primates, rabbits, rodents, and reptiles) also can be
present as research, resident, or service animals. These animals can serve as sources of zoonotic
pathogens that could potentially infect patients and health-care workers (Table 26).1327–1340 Animals
potentially can serve as reservoirs for antibiotic-resistant microorganisms, which can be introduced to
the health-care setting while the animal is present. VRE have been isolated from both farm animals and
pets,1341 and a cat in a geriatric care center was found to be colonized with MRSA.1342
Table 26. Examples of diseases associated with zoonotic transmission*+
Infectious disease
Cats
Dogs
+
+
+
+
+
+
Fish
Birds
Rabbits
Reptiles§
Primates
Virus
Lymphocytic choriomeningitis
Rabies
Bacteria
Campylobacteriosis
Capnocytophaga canimorsus
infection
Cat scratch disease (Bartonella
henselae)
Leptospirosis
+¶
+
+
Pasteurellosis
+
Plague
+
+
+
+
+
+
+
+
+
+
+
+
Psittacosis
Q fever (Coxiella burnetti)
Rat bite fever (Spirrillum minus,
Streptobacillus monliformis)
Salmonellosis
+
Tularemia
+
+
+
+
+
+
+
Cryptosporidiosis
+
Giardiasis
Toxocariasis
Toxoplasmosis
Fungi
Blastomycosis
+
+
+
+
+
+
+
+
Yersiniosis
Parasites
Ancylostomiasis
*
+
§
¶
+
+
Mycobacteriosis
Dermatophytosis
Rodents§
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
Material in this table is adapted from reference 1331 and used with permission of the publisher (Lippincott Williams and Wilkins).
This table does not include vectorborne diseases.
Reptiles include lizards, snakes, and turtles. Rodents include hamsters, mice, and rats.
The + symbol indicates that the pathogen associated with the infection has been isolated from animals and is considered to pose potential
risk to humans.
106
Zoonoses can be transmitted from animals to humans either directly or indirectly via bites, scratches,
aerosols, ectoparasites, accidental ingestion, or contact with contaminated soil, food, water, or
unpasteurized milk.1331, 1332, 1343–1345 Colonization and hand transferral of pathogens acquired from pets
in health-care workers’ homes represent potential sources and modes of transmission of zoonotic
pathogens in health-care settings. An outbreak of infections caused by a yeast (Malassezia
pachydermatis) among newborns was traced to transfer of the yeast from the hands of health-care
workers with pet dogs at home.1346 In addition, an outbreak of ringworm in a NICU caused by
Microsporum canis was associated with a nurse and her cat,1347 and an outbreak of Rhodococcus
(Gordona) bronchialis sternal SSIs after coronary-artery bypass surgery was traced to a colonized nurse
whose dogs were culture-positive for the organism.1348 In the latter outbreak, whether the dogs were
the sole source of the organism and whether other environmental reservoirs contributed to the outbreak
are unknown. Nonetheless, limited data indicate that outbreaks of infectious disease have occurred as a
result of contact with animals in areas housing immunocompetent patients. However, the low frequency
of outbreaks may result from a) the relatively limited presence of the animals in health-care facilities
and b) the immunocompetency of the patients involved in the encounters. Formal scientific studies to
evaluate potential risks of transmission of zoonoses in health-care settings outside of the laboratory are
lacking.
2. Animal-Assisted Activities, Animal-Assisted Therapy, and Resident
Animals
Animal-Assisted Activities (AAA) are those programs that enhance the patients’ quality of life. These
programs allow patients to visit animals in either a common, central location in the facility or in
individual patient rooms. A group session with the animals enhances opportunities for ambulatory
patients and facility residents to interact with caregivers, family members, and volunteers.1349–1351
Alternatively, allowing the animals access to individual rooms provides the same opportunity to nonambulatory patients and patients for whom privacy or dignity issues are a consideration. The decision
to allow this access to patients’ rooms should be made on a case-by-case basis, with the consultation and
consent of the attending physician and nursing staff.
Animal-Assisted Therapy (AAT) is a goal-directed intervention that incorporates an animal into the
treatment process provided by a credentialed therapist.1330, 1331 The concept for AAT arose from the
observation that some patients with pets at home recover from surgical and medical procedures more
rapidly than patients without pets.1352, 1353 Contact with animals is considered beneficial for enhancing
wellness in certain patient populations (e.g., children, the elderly, and extended-care hospitalized
patients).1349, 1354–1357 However, evidence supporting this benefit is largely derived from anecdotal
reports and observations of patient/animal interactions.1357–1359 Guidelines for establishing AAT
programs are available for facilities considering this option.1360
The incorporation of non-human primates into an AAA or AAT program is not encouraged because of
concerns regarding potential disease transmission from and unpredictable behavior of these animals.1361,
1362
Animals participating in either AAA or AAT sessions should be in good health and up-to-date with
recommended immunizations and prophylactic medications (e.g., heartworm prevention) as determined
by a licensed veterinarian based on local needs and recommendations. Regular re-evaluation of the
animal’s health and behavior status is essential.1360 Animals should be routinely screened for enteric
parasites and/or have evidence of a recently completed antihelminthic regimen.1363 They should also be
free of ectoparasites (e.g., fleas and ticks) and should have no sutures, open wounds, or obvious
dermatologic lesions that could be associated with bacterial, fungal, or viral infections or parasitic
infestations. Incorporating young animals (i.e., those aged <1 year) into these programs is not
encouraged because of issues regarding unpredictable behavior and elimination control. Additionally,
107
the immune systems of very young puppies and kittens is not completely developed, thereby placing the
health of these animals at risk. Animals should be clean and well-groomed. The visits must be
supervised by persons who know the animals and their behavior. Animal handlers should be trained in
these activities and receive site-specific orientation to ensure that they work efficiently with the staff in
the specific health-care environment.1360 Additionally, animal handlers should be in good health.1360
The most important infection-control measure to prevent potential disease transmission is strict
enforcement of hand-hygiene measures (e.g., using either soap and water or an alcohol-based hand rub)
for all patients, staff, and residents after handling the animals.1355, 1364 Care should also be taken to
avoid direct contact with animal urine or feces. Clean-up of these substances from environmental
surfaces requires gloves and the use of leak-resistant plastic bags to discard absorbent material used in
the process.2 The area must be cleaned after visits according to standard cleaning procedures.
The American Academy of Allergy, Asthma, and Immunology estimates that dog or cat allergies occur
in approximately 15% of the population.1365 Minimizing contact with animal saliva, dander, and/or
urine helps to mitigate allergic responses.1365–1367 Some facilities may not allow animal visitation for
patients with a) underlying asthma, b) known allergies to cat or dog hair, c) respiratory allergies of
unknown etiology, and d) immunosuppressive disorders. Hair shedding can be minimized by processes
that remove dead hair (e.g., grooming) and that prevent the shedding of dead hair (e.g., therapy capes
for dogs). Allergens can be minimized by bathing therapy animals within 24 hours of a visit.1333, 1368
Animal therapists and handlers must take precautions to prevent animal bites. Common pathogens
associated with animal bites include Capnocytophaga canimorsus, Pasteurella spp., Staphylococcus
spp., and Streptococcus spp. Selecting well-behaved and well-trained animals for these programs
greatly decreases the incidence of bites. Rodents, exotic species, wild/domestic animals (i.e., wolf-dog
hybrids), and wild animals whose behavior is unpredictable should be excluded from AAA or AAT
programs. A well-trained animal handler should be able to recognize stress in the animal and to
determine when to terminate a session to minimize risk. When an animal bites a person during AAA or
AAT, the animal is to be permanently removed from the program. If a bite does occur, the wound must
be cleansed immediately and monitored for subsequent infection. Most infections can be treated with
antibiotics, and antibiotics often are prescribed prophylactically in these situations.
The health-care facility’s infection-control staff should participate actively in planning for and
coordinating AAA and AAT sessions. Many facilities do not offer AAA or AAT programs for severely
immunocompromised patients (e.g., HSCT patients and patients on corticosteroid therapy).1339 The
question of whether family pets or companion animals can visit terminally-ill HSCT patients or other
severely immunosuppressed patients is best handled on a case-by-case basis, although animals should
not be brought into the HSCT unit or any other unit housing severely immunosuppressed patients. An
in-depth discussion of this issue is presented elsewhere.1366
Immunocompromised patients who have been discharged from a health-care facility may be at higher
risk for acquiring some pet-related zoonoses. Although guidelines have been developed to minimize the
risk of disease transmission to HIV-infected patients,8 these recommendations may be applicable for
patients with other immunosuppressive disorders. In addition to handwashing or hand hygiene, these
recommendations include avoiding contact with a) animal feces and soiled litter box materials, b)
animals with diarrhea, c) very young animals (i.e., dogs <6 months of age and cats <1 year of age), and
d) exotic animals and reptiles.8 Pets or companion animals with diarrhea should receive veterinary care
to resolve their condition.
Many health-care facilities are adopting more home-like environments for residential-care or extendedstay patients in acute-care settings, and resident animals are one element of this approach.1369 One
108
concept, the “Eden Alternative,” incorporates children, plants, and animals (e.g., dogs, cats, fish, birds,
rabbits, and rodents) into the daily care setting.1370, 1371 The concept of working with resident animals
has not been scientifically evaluated. Several issues beyond the benefits of therapy must be considered
before embarking on such a program, including a) whether the animals will come into direct contact
with patients and/or be allowed to roam freely in the facility; b) how the staff will provide care for the
animals; c) the management of patients’ or residents’ allergies, asthma, and phobias; d) precautionary
measures to prevent bites and scratches; and e) measures to properly manage the disposal of animal
feces and urine, thereby preventing environmental contamination by zoonotic microorganisms (e.g.,
Toxoplasma spp., Toxocara spp., and Ancylostoma spp.).1372, 1373 Few data document a link between
health-care–acquired infection rates and frequency of cleaning fish tanks or rodent cages. Skin
infections caused by Mycobacterium marinum have been described among persons who have fish
aquariums at home.1374, 1375 Nevertheless, immunocompromised patients should avoid direct contact
with fish tanks and cages and the aerosols that these items produce. Further, fish tanks should be kept
clean on a regular basis as determined by facility policy, and this task should be performed by gloved
staff members who are not responsible for patient care. The use of the infection-control risk assessment
can help determine whether a fish tank poses a risk for patient or resident safety and health in these
situations. No evidence, however, links the incidence of health-care–acquired infections among
immunocompetent patients or residents with the presence of a properly cleaned and maintained fish
tank, even in dining areas. As a general preventive measure, resident animal programs are advised to
restrict animals from a) food preparation kitchens, b) laundries, c) central sterile supply and any storage
areas for clean supplies, and d) medication preparation areas. Resident-animal programs in acute-care
facilities should not allow the animals into the isolation areas, protective environments, ORs, or any area
where immunocompromised patients are housed. Patients and staff routinely should wash their hands or
use waterless, alcohol-based hand-hygiene products after contact with animals.
3. Service Animals
Although this section provides an overview about service animals in health-care settings, it cannot
address every situation or question that may arise (see Appendix E - Information Resources). A service
animal is any animal individually trained to do work or perform tasks for the benefit of a person with a
disability.1366, 1376 A service animal is not considered a pet but rather an animal trained to provide
assistance to a person because of a disability. Title III of the “Americans with Disabilities Act” (ADA)
of 1990 mandates that persons with disabilities accompanied by service animals be allowed access with
their service animals into places of public accommodation, including restaurants, public transportation,
schools, and health-care facilities.1366, 1376 In health-care facilities, a person with a disability requiring a
service animal may be an employee, a visitor, or a patient.
An overview of the subject of service animals and their presence in health-care facilities has been
published.1366 No evidence suggests that animals pose a more significant risk of transmitting infection
than people; therefore, service animals should not be excluded from such areas, unless an individual
patient’s situation or a particular animal poses greater risk that cannot be mitigated through reasonable
measures. If health-care personnel, visitors, and patients are permitted to enter care areas (e.g., inpatient rooms, some ICUs, and public areas) without taking additional precautions to prevent
transmission of infectious agents (e.g., donning gloves, gowns, or masks), a clean, healthy, wellbehaved service animal should be allowed access with its handler.1366 Similarly, if
immunocompromised patients are able to receive visitors without using protective garments or
equipment, an exclusion of service animals from this area would not be justified.1366
Because health-care facilities are covered by the ADA or the Rehabilitation Act, a person with a
disability may be accompanied by a service animal within the facility unless the animal’s presence or
109
behavior creates a fundamental alteration in the nature of a facility’s services in a particular area or a
direct threat to other persons in a particular area.1366 A “direct threat” is defined as a significant risk to
the health or safety of others that cannot be mitigated or eliminated by modifying policies, practices, or
procedures.1376 The determination that a service animal poses a direct threat in any particular healthcare setting must be based on an individualized assessment of the service animal, the patient, and the
health-care situation. When evaluating risk in such situations, health-care personnel should consider the
nature of the risk (including duration and severity); the probability that injury will occur; and whether
reasonable modifications of policies, practices, or procedures will mitigate the risk (J. Wodatch, U.S.
Department of Justice, 2000). The person with a disability should contribute to the risk-assessment
process as part of a pre-procedure health-care provider/patient conference.
Excluding a service animal from an OR or similar special care areas (e.g., burn units, some ICUs, PE
units, and any other area containing equipment critical for life support) is appropriate if these areas are
considered to have “restricted access” with regards to the general public. General infection-control
measures that dictate such limited access include a) the area is required to meet environmental criteria to
minimize the risk of disease transmission, b) strict attention to hand hygiene and absence of
dermatologic conditions, and c) barrier protective measures [e.g., using gloves, wearing gowns and
masks] are indicated for persons in the affected space. No infection-control measures regarding the use
of barrier precautions could be reasonably imposed on the service animal. Excluding a service animal
that becomes threatening because of a perceived danger to its handler during treatment also is
appropriate; however, exclusion of such an animal must be based on the actual behavior of the particular
animal, not on speculation about how the animal might behave.
Another issue regarding service animals is whether to permit persons with disabilities to be
accompanied by their service animals during all phases of their stay in the health-care facility. Healthcare personnel should discuss all aspects of anticipatory care with the patient who uses a service animal.
Health-care personnel may not exclude a service animal because health-care staff may be able to
perform the same services that the service animal does (e.g., retrieving dropped items and guiding an
otherwise ambulatory person to the restroom). Similarly, health-care personnel can not exclude service
animals because the health-care staff perceive a lack of need for the service animal during the person’s
stay in the health-care facility. A person with a disability is entitled to independent access (i.e., to be
accompanied by a service animal unless the animal poses a direct threat or a fundamental alteration in
the nature of services); “need” for the animal is not a valid factor in either analysis. For some forms of
care (e.g., ambulation as physical therapy following total hip replacement or knee replacement), the
service animal should not be used in place of a credentialed health-care worker who directly provides
therapy. However, service animals need not be restricted from being in the presence of its handler
during this time; in addition, rehabilitation and discharge planning should incorporate the patient’s
future use of the animal. The health-care personnel and the patient with a disability should discuss both
the possible need for the service animal to be separated from its handler for a period of time during nonemergency care and an alternate plan of care for the service animal in the event the patient is unable or
unwilling to provide that care. This plan might include family members taking the animal out of the
facility several times a day for exercise and elimination, the animal staying with relatives, or boarding
off-site. Care of the service animal, however, remains the obligation of the person with the disability,
not the health-care staff.
Although animals potentially carry zoonotic pathogens transmissible to man, the risk is minimal with a
healthy, clean, vaccinated, well-behaved, and well-trained service animal, the most common of which
are dogs and cats. No reports have been published regarding infectious disease that affects humans
originating in service dogs. Standard cleaning procedures are sufficient following occupation of an area
by a service animal.1366 Clean-up of spills of animal urine, feces, or other body substances can be
accomplished with blood/body substance procedures outlined in the Environmental Services section of
110
this guideline. No special bathing procedures are required prior to a service animal accompanying its
handler into a health-care facility.
Providing access to exotic animals (e.g., reptiles and non-human primates) that are used as service
animals is problematic. Concerns about these animals are discussed in two published reviews.1331, 1366
Because some of these animals exhibit high-risk behaviors that may increase the potential for zoonotic
disease transmission (e.g., herpes B infection), providing health-care facility access to nonhuman
primates used as service animals is discouraged, especially if these animals might come into contact
with the general public.1361, 1362 Health-care administrators should consult the Americans with
Disabilities Act for guidance when developing policies about service animals in their facilities.1366, 1376
Requiring documentation for access of a service animal to an area generally accessible to the public
would impose a burden on a person with a disability. When health-care workers are not certain that an
animal is a service animal, they may ask the person who has the animal if it is a service animal required
because of a disability; however, no certification or other documentation of service animal status can be
required.1377
4. Animals as Patients in Human Health-Care Facilities
The potential for direct and indirect transmission of zoonoses must be considered when rooms and
equipment in human health-care facilities are used for the medical or surgical treatment or diagnosis of
animals.1378 Inquiries should be made to veterinary medical professionals to determine an appropriate
facility and equipment to care for an animal.
The central issue associated with providing medical or surgical care to animals in human health-care
facilities is whether cross-contamination occurs between the animal patient and the human health-care
workers and/or human patients. The fundamental principles of infection control and aseptic practice
should differ only minimally, if at all, between veterinary medicine and human medicine. Health-care–
associated infections can and have occurred in both patients and workers in veterinary medical facilities
when lapses in infection-control procedures are evident.1379–1384 Further, veterinary patients can be at
risk for acquiring infection from veterinary health-care workers if proper precautions are not taken.1385
The issue of providing care to veterinary patients in human health-care facilities can be divided into the
following three areas of infection-control concerns: a) whether the room/area used for animal care can
be made safe for human patients, b) whether the medical/surgical instruments used on animals can be
subsequently used on human patients, and c) which disinfecting or sterilizing procedures need to be
done for these purposes. Studies addressing these concerns are lacking. However, with respect to
disinfection or sterilization in veterinary settings, only minimal evidence suggests that zoonotic
microbial pathogens are unusually resistant to inactivation by chemical or physical agents (with the
exception of prions). Ample evidence supports the contrary observation (i.e., that pathogens from
human- and animal sources are similar in their relative instrinsic resistance to inactivation).1386–1391
Further, no evidence suggests that zoonotic pathogens behave differently from human pathogens with
respect to ventilation. Despite this knowledge, an aesthetic and sociologic perception that animal care
must remain separate from human care persists. Health-care facilities, however, are increasingly faced
with requests from the veterinary medical community for access to human health-care facilities for
reasons that are largely economical (e.g., costs of acquiring sophisticated diagnostic technology and
complex medical instruments). If hospital guidelines allow treatment of animals, alternate veterinary
resources (including veterinary hospitals, clinics, and universities) should be exhausted before using
human health-care settings. Additionally, the hospital’s public/media relations should be notified of the
situation. The goal is to develop policies and procedures to proactively and positively discuss and
111
disclose this activity to the general public.
An infection-control risk assessment (ICRA) must be undertaken to evaluate the circumstances specific
to providing care to animals in a human health-care facility. Individual hospital policies and guidelines
should be reviewed before any animal treatment is considered in such facilities. Animals treated in
human health-care facilities should be under the direct care and supervision of a licensed veterinarian;
they also should be free of known infectious diseases, ectoparasites, and other external contaminants
(e.g., soil, urine, and feces). Measures should be taken to avoid treating animals with a known or
suspected zoonotic disease in a human health-care setting (e.g., lambs being treated for Q fever).
If human health-care facilities must be used for animal treatment or diagnostics, the following general
infection-control actions are suggested: a) whenever possible, the use of ORs or other rooms used for
invasive procedures should be avoided [e.g., cardiac catheterization labs and invasive nuclear medicine
areas]; b) when all other space options are exhausted and use of the aforementioned rooms is
unavoidable, the procedure should be scheduled late in the day as the last procedure for that particular
area such that patients are not present in the department/unit/area; c) environmental surfaces should be
thoroughly cleaned and disinfected using procedures discussed in the Environmental Services portion of
this guideline after the animal is removed from the care area; d) sufficient time should be allowed for
ACH to help prevent allergic reactions by human patients [Table B.1. in Appendix B]; e) only
disposable equipment or equipment that can be thoroughly and easily cleaned, disinfected, or sterilized
should be used; f) when medical or surgical instruments, especially those invasive instruments that are
difficult to clean [e.g., endoscopes], are used on animals, these instruments should be reserved for future
use only on animals; and g) standard precautions should be followed.
5. Research Animals in Health-Care Facilities
The risk of acquiring a zoonotic infection from research animals has decreased in recent years because
many small laboratory animals (e.g., mice, rats, and rabbits) come from quality stock and have defined
microbiologic profiles.1392 Larger animals (e.g., nonhuman primates) are still obtained frequently from
the wild and may harbor pathogens transmissible to humans. Primates, in particular, benefit from
vaccinations to protect their health during the research period provided the vaccination does not
interfere with the study of the particular agent. Animals serving as models for human disease studies
pose some risk for transmission of infection to laboratory or health-care workers from percutaneous or
mucosal exposure. Exposures can occur either through a) direct contact with an infected animal or its
body substances and secretions or b) indirect contact with infectious material on equipment,
instruments, surfaces, or supplies.1392 Uncontained aerosols generated during laboratory procedures can
also transmit infection.
Infection-control measures to prevent transmission of zoonotic infections from research animals are
largely derived from the following basic laboratory safety principles: a) purchasing pathogen-free
animals, b) quarantining incoming animals to detect any zoonotic pathogens, c) treating infected
animals or removing them from the facility, d) vaccinating animal carriers and high-risk contacts if
possible, e) using specialized containment caging or facilities, and f) using protective clothing and
equipment [e.g., gloves, face shields, gowns, and masks].1392 An excellent resource for detailed
discussion of these safety measures has been published.1013
The animal research unit within a health-care facility should be engineered to provide a) adequate
containment of animals and pathogens; b) daily decontamination and transport of equipment and waste;
c) proper ventilation and air filtration, which prevents recirculation of the air in the unit to other areas of
the facility; and d) negative air pressure in the animal rooms relative to the corridors. To ensure
112
adequate security and containment, no through traffic to other areas of the health-care facility should
flow through this unit; access should be restricted to animal-care staff, researchers, environmental
services, maintenance, and security personnel.
Occupational health programs for animal-care staff, researchers, and maintenance staff should take into
consideration the animals’ natural pathogens and research pathogens. Components of such programs
include a) prophylactic vaccines, b) TB skin testing when primates are used, c) baseline serums, and d)
hearing and respiratory testing. Work practices, PPE, and engineering controls specific for each of the
four animal biosafety levels have been published.1013, 1393 The facility’s occupational or employee
health clinic should be aware of the appropriate post-exposure procedures involving zoonoses and have
available the appropriate post-exposure biologicals and medications.
Animal-research-area staff should also develop standard operating procedures for a) daily animal
husbandry [e.g., protection of the employee while facilitating animal welfare]; b) pathogen containment
and decontamination; c) management, cleaning, disinfecting and/or sterilizing equipment and
instruments; and d) employee training for laboratory safety and safety procedures specific to animal
research worksites.1013 The federal Animal Welfare Act of 1966 and its amendments serve as the
regulatory basis for ensuring animal welfare in research.1394, 1395
I. Regulated Medical Waste
1. Epidemiology
No epidemiologic evidence suggests that most of the solid- or liquid wastes from hospitals, other healthcare facilities, or clinical/research laboratories is any more infective than residential waste. Several
studies have compared the microbial load and the diversity of microorganisms in residential wastes and
wastes obtained from a variety of health-care settings.1399–1402 Although hospital wastes had a greater
number of different bacterial species compared with residential waste, wastes from residences were
more heavily contaminated.1397, 1398 Moreover, no epidemiologic evidence suggests that traditional
waste-disposal practices of health-care facilities (whereby clinical and microbiological wastes were
decontaminated on site before leaving the facility) have caused disease in either the health-care setting
or the general community.1400, 1401 This statement excludes, however, sharps injuries sustained during
or immediately after the delivery of patient care before the sharp is “discarded.” Therefore, identifying
wastes for which handling and disposal precautions are indicated is largely a matter of judgment about
the relative risk of disease transmission, because no reasonable standards on which to base these
determinations have been developed. Aesthetic and emotional considerations (originating during the
early years of the HIV epidemic) have, however, figured into the development of treatment and disposal
policies, particularly for pathology and anatomy wastes and sharps.1402–1405 Public concerns have
resulted in the promulgation of federal, state, and local rules and regulations regarding medical waste
management and disposal.1406–1414
2. Categories of Medical Waste
Precisely defining medical waste on the basis of quantity and type of etiologic agents present is virtually
impossible. The most practical approach to medical waste management is to identify wastes that
represent a sufficient potential risk of causing infection during handling and disposal and for which
some precautions likely are prudent.2 Health-care facility medical wastes targeted for handling and
disposal precautions include microbiology laboratory waste (e.g., microbiologic cultures and stocks of
microorganisms), pathology and anatomy waste, blood specimens from clinics and laboratories, blood
113
products, and other body-fluid specimens.2 Moreover, the risk of either injury or infection from certain
sharp items (e.g., needles and scalpel blades) contaminated with blood also must be considered.
Although any item that has had contact with blood, exudates, or secretions may be potentially infective,
treating all such waste as infective is neither practical nor necessary. Federal, state, and local guidelines
and regulations specify the categories of medical waste that are subject to regulation and outline the
requirements associated with treatment and disposal. The categorization of these wastes has generated
the term “regulated medical waste.” This term emphasizes the role of regulation in defining the actual
material and as an alternative to “infectious waste,” given the lack of evidence of this type of waste’s
infectivity. State regulations also address the degree or amount of contamination (e.g., blood-soaked
gauze) that defines the discarded item as a regulated medical waste. The EPA’s Manual for Infectious
Waste Management identifies and categorizes other specific types of waste generated in health-care
facilities with research laboratories that also require handling precautions.1406
3. Management of Regulated Medical Waste in Health-Care Facilities
Medical wastes require careful disposal and containment before collection and consolidation for
treatment. OSHA has dictated initial measures for discarding regulated medical-waste items. These
measures are designed to protect the workers who generate medical wastes and who manage the wastes
from point of generation to disposal.967 A single, leak-resistant biohazard bag is usually adequate for
containment of regulated medical wastes, provided the bag is sturdy and the waste can be discarded
without contaminating the bag’s exterior. The contamination or puncturing of the bag requires
placement into a second biohazard bag. All bags should be securely closed for disposal. Punctureresistant containers located at the point of use (e.g., sharps containers) are used as containment for
discarded slides or tubes with small amounts of blood, scalpel blades, needles and syringes, and unused
sterile sharps.967 To prevent needlestick injuries, needles and other contaminated sharps should not be
recapped, purposefully bent, or broken by hand. CDC has published general guidelines for handling
sharps.6, 1415 Health-care facilities may need additional precautions to prevent the production of
aerosols during the handling of blood-contaminated items for certain rare diseases or conditions (e.g.,
Lassa fever and Ebola virus infection).203
Transporting and storing regulated medical wastes within the health-care facility prior to terminal
treatment is often necessary. Both federal and state regulations address the safe transport and storage of
on- and off-site regulated medical wastes.1406–1408 Health-care facilities are instructed to dispose
medical wastes regularly to avoid accumulation. Medical wastes requiring storage should be kept in
labeled, leak-proof, puncture-resistant containers under conditions that minimize or prevent foul odors.
The storage area should be well ventilated and be inaccessible to pests. Any facility that generates
regulated medical wastes should have a regulated medical waste management plan to ensure health and
environmental safety as per federal, state, and local regulations.
4. Treatment of Regulated Medical Waste
Regulated medical wastes are treated or decontaminated to reduce the microbial load in or on the waste
and to render the by-products safe for further handling and disposal. From a microbiologic standpoint,
waste need not be rendered “sterile” because the treated waste will not be deposited in a sterile site. In
addition, waste need not be subjected to the same reprocessing standards as are surgical instruments.
Historically, treatment methods involved steam-sterilization (i.e., autoclaving), incineration, or
interment (for anatomy wastes). Alternative treatment methods developed in recent years include
chemical disinfection, grinding/shredding/disinfection methods, energy-based technologies (e.g.,
microwave or radiowave treatments), and disinfection/encapsulation methods.1409 State medical waste
regulations specify appropriate treatment methods for each category of regulated medical waste.
114
Of all the categories comprising regulated medical waste, microbiologic wastes (e.g., untreated cultures,
stocks, and amplified microbial populations) pose the greatest potential for infectious disease
transmission, and sharps pose the greatest risk for injuries. Untreated stocks and cultures of
microorganisms are subsets of the clinical laboratory or microbiologic waste stream. If the
microorganism must be grown and amplified in culture to high concentration to permit work with the
specimen, this item should be considered for on-site decontamination, preferably within the laboratory
unit. Historically, this was accomplished effectively by either autoclaving (steam sterilization) or
incineration. If steam sterilization in the health-care facility is used for waste treatment, exposure of the
waste for up to 90 minutes at 250°F (121°C) in a autoclave (depending on the size of the load and type
container) may be necessary to ensure an adequate decontamination cycle.1416–1418 After steam
sterilization, the residue can be safely handled and discarded with all other nonhazardous solid waste in
accordance with state solid-waste disposal regulations. On-site incineration is another treatment option
for microbiologic, pathologic, and anatomic waste, provided the incinerator is engineered to burn these
wastes completely and stay within EPA emissions standards.1410 Improper incineration of waste with
high moisture and low energy content (e.g., pathology waste) can lead to emission problems. State
medical-waste regulatory programs identify acceptable methods for inactivating amplified stocks and
cultures of microorganisms, some of which may employ technology rather than steam sterilization or
incineration.
Concerns have been raised about the ability of modern health-care facilities to inactivate microbiologic
wastes on-site, given that many of these institutions have decommissioned their laboratory autoclaves.
Current laboratory guidelines for working with infectious microorganisms at biosafety level (BSL) 3
recommend that all laboratory waste be decontaminated before disposal by an approved method,
preferably within the laboratory.1013 These same guidelines recommend that all materials removed
from a BSL 4 laboratory (unless they are biological materials that are to remain viable) are to be
decontaminated before they leave the laboratory.1013 Recent federal regulations for laboratories that
handle certain biological agents known as “select agents” (i.e., those that have the potential to pose a
severe threat to public health and safety) require these agents (and those obtained from a clinical
specimen intended for diagnostic, reference, or verification purposes) to be destroyed on-site before
disposal.1412 Although recommendations for laboratory waste disposal from BSL 1 or 2 laboratories
(e.g., most health-care clinical and diagnostic laboratories) allow for these materials to be
decontaminated off-site before disposal, on-site decontamination by a known effective method is
preferred to reduce the potential of exposure during the handling of infectious material.
A recent outbreak of TB among workers in a regional medical-waste treatment facility in the United
States demonstrated the hazards associated with aerosolized microbiologic wastes.1419, 1420 The facility
received diagnostic cultures of Mycobacterium tuberculosis from several different health-care facilities
before these cultures were chemically disinfected; this facility treated this waste with a
grinding/shredding process that generated aerosols from the material. 1419, 1420 Several operational
deficiencies facilitated the release of aerosols and exposed workers to airborne M. tuberculosis. Among
the suggested control measures was that health-care facilities perform on-site decontamination of
laboratory waste containing live cultures of microorganisms before release of the waste to a waste
management company.1419, 1420 This measure is supported by recommendations found in the CDC/NIH
guideline for laboratory workers.1013 This outbreak demonstrates the need to avoid the use of any
medical-waste treatment method or technology that can aerosolize pathogens from live cultures and
stocks (especially those of airborne microorganisms) unless aerosols can be effectively contained and
workers can be equipped with proper PPE.1419–1421 Safe laboratory practices, including those addressing
waste management, have been published.1013, 1422
In an era when local, state, and federal health-care facilities and laboratories are developing bioterrorism
115
response strategies and capabilities, the need to reinstate in-laboratory capacity to destroy cultures and
stocks of microorganisms becomes a relevant issue.1423 Recent federal regulations require health-care
facility laboratories to maintain the capability of destroying discarded cultures and stocks on-site if these
laboratories isolate from a clinical specimen any microorganism or toxin identified as a “select agent”
from a clinical specimen (Table 27).1412, 1413 As an alternative, isolated cultures of select agents can be
transferred to a facility registered to accept these agents in accordance with federal regulations.1412
State medical waste regulations can, however, complicate or completely prevent this transfer if these
cultures are determined to be medical waste, because most states regulate the inter-facility transfer of
untreated medical wastes.
Table 27. Microorganisms and biologicals identified as select agents*+
HHS Non-overlap select agents and toxins (42 CFR Part 73 §73.4)
Viruses
Exclusions¶
Bacteria
Fungi
Toxins
Exclusions¶
Genetic elements,
recombinant nucleic
acids, and recombinant
organisms¶
Crimean-Congo hemorrhagic fever virus; Ebola viruses; Cercopithecine herpesvirus 1 (herpes B
virus); Lassa fever virus; Marburg virus; monkeypox virus; South American hemorrhagic fever
viruses (Junin, Machupo, Sabia, Flexal, Guanarito); tick-borne encephalitis complex (flavi)
viruses (Central European tick-borne encephalitis, Far Eastern tick-borne encephalitis [Russian
spring and summer encephalitis, Kyasnaur Forest disease, Omsk hemorrhagic fever]); variola
major virus (smallpox virus); and variola minor virus (alastrim)
Vaccine strain of Junin virus (Candid. #1)
Rickettsia prowazekii, R. rickettsii, Yersinia pestis
Coccidioides posadasii
Abrin; conotoxins; diacetoxyscirpenol; ricin; saxitoxin; Shiga-like ribosome inactivating
proteins; tetrodotoxin
The following toxins (in purified form or in combinations of pure and impure forms) if the
aggregate amount under the control of a principal investigator does not, at any time, exceed the
amount specified: 100 mg of abrin; 100 mg of conotoxins; 1,000 mg of diacetoxyscirpenol; 100
mg of ricin; 100 mg of saxitoxin; 100 mg of Shiga-like ribosome inactivating proteins; or 100
mg of tetrodotoxin
• Select agent viral nucleic acids (synthetic or naturally-derived, contiguous or fragmented, in
host chromosomes or in expression vectors) that can encode infectious and/or replication
competent forms of any of the select agent viruses;
• Nucleic acids (synthetic or naturally-derived) that encode for the functional form(s) of any of
the toxins listed in this table if the nucleic acids: a) are in a vector or host chromosome;
b) can be expressed in vivo or in vitro; or c) are in a vector or host chromosome and can be
expressed in vivo or in vitro;
• Viruses, bacteria, fungi, and toxins listed in this table that have been genetically modified.
High consequence livestock pathogens and toxins/select agents (overlap agents) (42 CFR Part 73 §73.5 and
USDA regulation 9 CFR Part 121)
Viruses
Exclusions¶
Bacteria
Fungi
Toxins
Exclusions¶
Eastern equine encephalitis virus; Nipah and Hendra complex viruses; Rift Valley fever virus;
Venezuelan equine encephalitis virus
MP-12 vaccine strain of Rift Valley fever virus; TC-83 vaccine strain of Venezuelan equine
encephalitis virus
Bacillus anthracis; Brucella abortus, B. melitensis, B. suis; Burkholderia mallei (formerly
Pseudomonas mallei), B. pseudomallei (formerly P. pseudomallei); botulinum neurotoxinproducing species of Clostridium; Coxiella burnetii; Francisella tularensis
Coccidioides immitis
Botulinum neurotoxins; Clostridium perfringens epsilon toxin; Shigatoxin; staphylococcal
enterotoxins; T-2 toxin
The following toxins (in purified form or in combinations of pure and impure forms) if the
aggregate amount under the control of a principal investigator does not, at any time, exceed the
amount specified: 0.5 mg of botulinum neurotoxins; 100 mg of Clostridium perfringens epsilon
toxin; 100 mg of Shigatoxin; 5 mg of staphylococcal enterotoxins; or 1,000 mg of T-2 toxin
116
High consequence livestock pathogens and toxins/select agents (overlap agents) (42 CFR Part 73 §73.5 and
USDA regulation 9 CFR Part 121) (continued)
Genetic elements,
recombinant nucleic
acids, and recombinant
organisms¶
• Select agent viral nuclei acids (synthetic or naturally derived, contiguous or fragmented, in
host chromosomes or in expression vectors) thatcan encode infectious and/or replication
competent forms of any of the select agent viruses;
• Nucleic acids (synthetic or naturally derived) that encode for the functional form(s) of any of
the toxins listed in this table if the nucleic acids: a) are in a vector or host chromosome;
b) can be expressed in vivo or in vitro; or c) are in a vector or host chromosome and can be
expressed in vivo or in vitro;
• Viruses, bacteria, fungi, and toxins listed in this table that have been genetically modified
* Material in this table is compiled from references 1412, 1413, and 1424. Reference 1424 also contains lists of select agents that include
plant pathogens and pathogens affecting livestock.
+ 42 CFR 73 §§73.4 and 73.5 do not include any select agent or toxin that is in its naturally-occurring environment, provided it has not been
intentionally introduced, cultivated, collected, or otherwise extracted from its natural source. These sections also do not include non-viable
select agent organisms or nonfunctional toxins. This list of select agents is current as of 3 October 2003 and is subject to change pending
the final adoption of 42 CFR Part 73.
¶ These table entries are listed in reference 1412 and 1413, but were not included in reference 1424.
5. Discharging Blood, Fluids to Sanitary Sewers or Septic Tanks
The contents of all vessels that contain more than a few milliliters of blood remaining after laboratory
procedures, suction fluids, or bulk blood can either be inactivated in accordance with state-approved
treatment technologies or carefully poured down a utility sink drain or toilet.1414 State regulations may
dictate the maximum volume allowable for discharge of blood/body fluids to the sanitary sewer. No
evidence indicates that bloodborne diseases have been transmitted from contact with raw or treated
sewage. Many bloodborne pathogens, particularly bloodborne viruses, are not stable in the environment
for long periods of time;1425, 1426 therefore, the discharge of small quantities of blood and other body
fluids to the sanitary sewer is considered a safe method of disposing of these waste materials.1414 The
following factors increase the likelihood that bloodborne pathogens will be inactivated in the disposal
process: a) dilution of the discharged materials with water; b) inactivation of pathogens resulting from
exposure to cleaning chemicals, disinfectants, and other chemicals in raw sewage; and c) effectiveness
of sewage treatment in inactivating any residual bloodborne pathogens that reach the treatment facility.
Small amounts of blood and other body fluids should not affect the functioning of a municipal sewer
system. However, large quantities of these fluids, with their high protein content, might interfere with
the biological oxygen demand (BOD) of the system. Local municipal sewage treatment restrictions may
dictate that an alternative method of bulk fluid disposal be selected. State regulations may dictate what
quantity constitutes a small amount of blood or body fluids.
Although concerns have been raised about the discharge of blood and other body fluids to a septic tank
system, no evidence suggests that septic tanks have transmitted bloodborne infections. A properly
functioning septic system is adequate for inactivating bloodborne pathogens. System manufacturers’
instructions specify what materials may be discharged to the septic tank without jeopardizing its proper
operation.
6. Medical Waste and CJD
Concerns also have been raised about the need for special handling and treatment procedures for wastes
generated during the care of patients with CJD or other transmissible spongiform encephalopathies
(TSEs). Prions, the agents that cause TSEs, have significant resistance to inactivation by a variety of
physical, chemical, or gaseous methods.1427 No epidemiologic evidence, however, links acquisition of
CJD with medical-waste disposal practices. Although handling neurologic tissue for pathologic
examination and autopsy materials with care, using barrier precautions, and following specific
117
procedures for the autopsy are prudent measures,1197 employing extraordinary measures once the
materials are discarded is unnecessary. Regulated medical wastes generated during the care of the CJD
patient can be managed using the same strategies as wastes generated during the care of other patients.
After decontamination, these wastes may then be disposed in a sanitary landfill or discharged to the
sanitary sewer, as appropriate.
Part II. Recommendations for Environmental
Infection Control in Health-Care Facilities
A. Rationale for Recommendations
As in previous CDC guidelines, each recommendation is categorized on the basis of existing scientific
data, theoretic rationale, applicability, and possible economic benefit. The recommendations are
evidence-based wherever possible. However, certain recommendations are derived from empiric
infection-control or engineering principles, theoretic rationale, or from experience gained from events
that cannot be readily studied (e.g., floods).
The HICPAC system for categorizing recommendations has been modified to include a category for
engineering standards and actions required by state or federal regulations. Guidelines and standards
published by the American Institute of Architects (AIA), American Society of Heating, Refrigeration,
and Air-Conditioning Engineers (ASHRAE), and the Association for the Advancement in Medical
Instrumentation (AAMI) form the basis of certain recommendations. These standards reflect a
consensus of expert opinions and extensive consultation with agencies of the U.S. Department of Health
and Human Services. Compliance with these standards is usually voluntary. However, state and federal
governments often adopt these standards as regulations. For example, the standards from AIA regarding
construction and design of new or renovated health-care facilities, have been adopted by reference by
>40 states. Certain recommendations have two category ratings (e.g., Categories IA and IC or
Categories IB and IC), indicating the recommendation is evidence-based as well as a standard or
regulation.
B. Rating Categories
Recommendations are rated according to the following categories:
•
•
•
•
•
Category IA. Strongly recommended for implementation and strongly supported by welldesigned experimental, clinical, or epidemiologic studies.
Category IB. Strongly recommended for implementation and supported by certain
experimental, clinical, or epidemiologic studies and a strong theoretical rationale.
Category IC. Required by state or federal regulation, or representing an established association
standard. (Note: Abbreviations for governing agencies and regulatory citations are listed, where
appropriate. Recommendations from regulations adopted at state levels are also noted.
Recommendations from AIA guidelines cite the appropriate sections of the standard).
Category II. Suggested for implementation and supported by suggestive clinical or
epidemiologic studies, or a theoretical rationale.
Unresolved Issue. No recommendation is offered. No consensus or insufficient evidence
exists regarding efficacy.
118
C. Recommendations—Air
I.
Air-Handling Systems in Health-Care Facilities
A. Use AIA guidelines as minimum standards where state or local regulations are not in place
for design and construction of ventilation systems in new or renovated health-care facilities.
Ensure that existing structures continue to meet the specifications in effect at the time of
construction.120 Category IC (AIA: 1.1.A, 5.4)
B.
Monitor ventilation systems in accordance with engineers’ and manufacturers’
recommendations to ensure preventive engineering, optimal performance for removal of
particulates, and elimination of excess moisture.18, 35, 106, 120, 220, 222, 333, 336 Category IB, IC
(AIA: 7.2, 7.31.D, 8.31.D, 9.31.D, 10.31.D, 11.31.D, EPA guidance)
1.
2.
Ensure that heating, ventilation, air conditioning (HVAC) filters are properly installed
and maintained to prevent air leakages and dust overloads.17, 18, 106, 222 Category IB
Monitor areas with special ventilation requirements (e.g., AII or PE) for ACH,
filtration, and pressure differentials.21, 120, 249, 250, 273–275, 277, 333–344 Category IB, IC
(AIA: 7.2.C7, 7.2.D6)
a.
3.
4.
5.
Develop and implement a maintenance schedule for ACH, pressure
differentials, and filtration efficiencies using facility-specific data as part of the
multidisciplinary risk assessment. Take into account the age and reliability of
the system.
b.
Document these parameters, especially the pressure differentials.
Engineer humidity controls into the HVAC system and monitor the controls to ensure
proper moisture removal.120 Category IC (AIA: 7.31.D9)
a.
Locate duct humidifiers upstream from the final filters.
b.
Incorporate a water-removal mechanism into the system.
c.
Locate all duct takeoffs sufficiently down-stream from the humidifier so that
moisture is completely absorbed.
Incorporate steam humidifiers, if possible, to reduce potential for microbial
proliferation within the system, and avoid use of cool mist humidifiers. Category II
Ensure that air intakes and exhaust outlets are located properly in construction of new
facilities and renovation of existing facilities.3, 120 Category IC (AIA: 7.31.D3, 8.31.D3,
9.31.D3, 10.31.D3, 11.31.D3)
a.
b.
c.
6.
7.
8.
9.
Locate exhaust outlets >25 ft. from air-intake systems.
Locate outdoor air intakes >6 ft. above ground or >3 ft. above roof level.
Locate exhaust outlets from contaminated areas above roof level to minimize
recirculation of exhausted air.
Maintain air intakes and inspect filters periodically to ensure proper operation.3, 120, 249,
250, 273–275, 277
Category IC (AIA: 7.31.D8)
Bag dust-filled filters immediately upon removal to prevent dispersion of dust and
fungal spores during transport within the facility.106, 221 Category IB
a.
Seal or close the bag containing the discarded filter.
b.
Discard spent filters as regular solid waste, regardless of the area from which
they were removed.221
Remove bird roosts and nests near air intakes to prevent mites and fungal spores from
entering the ventilation system.3, 98, 119 Category IB
Prevent dust accumulation by cleaning air-duct grilles in accordance with facilityspecific procedures and schedules when rooms are not occupied by patients.21, 120, 249,
250, 273–275, 277
Category IC, II (AIA: 7.31.D10)
119
10.
C.
D.
E.
F.
G.
H.
I.
Periodically measure output to monitor system function; clean ventilation ducts as
part of routine HVAC maintenance to ensure optimum performance.120, 263, 264
Category II (AIA: 7.31.D10)
Use portable, industrial-grade HEPA filter units capable of filtration rates in the range of
300–800 ft3/min. to augment removal of respirable particles as needed.219 Category II
1.
Select portable HEPA filters that can recirculate all or nearly all of the room air and
provide the equivalent of >12 ACH.4 Category II
2.
Portable HEPA filter units previously placed in construction zones can be used later
in patient-care areas, provided all internal and external surfaces are cleaned, and the
filter’s performance verified by appropriate particle testing. Category II
3.
Situate portable HEPA units with the advice of facility engineers to ensure that all
room air is filtered.4 Category II
4.
Ensure that fresh-air requirements for the area are met.214, 219 Category II
Follow appropriate procedures for use of areas with through-the-wall ventilation units.120
Category IC (AIA: 8.31.D1, 8.31.D8, 9.31.D23, 10.31.D18, 11.31.D15)
1.
Do not use such areas as PE rooms.120 Category IC (AIA: 7.2.D3)
2.
Do not use a room with a through-the-wall ventilation unit as an AII room unless it
can be demonstrated that all required AII engineering controls required are met.4, 120
Category IC (AIA: 7.2.C3)
Conduct an infection-control risk assessment (ICRA) and provide an adequate number of
AII and PE rooms (if required) or other areas to meet the needs of the patient population.4, 6,
9, 18, 19, 69, 94, 120, 142, 331–334, 336–338
Category IA, IC (AIA: 7.2.C, 7.2.D)
When UVGI is used as a supplemental engineering control, install fixtures 1) on the wall
near the ceiling or suspended from the ceiling as an upper air unit; 2) in the air-return duct
of an AII room; or 3) in designated enclosed areas or booths for sputum induction.4
Category II
Seal windows in buildings with centralized HVAC systems and especially with PE areas.35,
111, 120
Category IB, IC (AIA: 7.2.D3)
Keep emergency doors and exits from PE rooms closed except during an emergency; equip
emergency doors and exits with alarms. Category II
Develop a contingency plan for backup capacity in the event of a general power failure.713
Category IC (Joint Commission on Accreditation of Healthcare Organizations [JCAHO]: Environment of Care [EC]
1.4)
1.
J.
Emphasize restoration of proper air quality and ventilation conditions in AII rooms,
PE rooms, operating rooms, emergency departments, and intensive care units.120, 713
Category IC (AIA: 1.5.A1; JCAHO: EC 1.4)
2.
Deploy infection-control procedures to protect occupants until power and systems
functions are restored.6, 120, 713 Category IC (AIA: 5.1, 5.2; JCAHO: EC 1.4)
Do not shut down HVAC systems in patient-care areas except for maintenance, repair,
testing of emergency backup capacity, or new construction.120, 206 Category IB, IC (AIA:
5.1, 5.2.B, C)
1.
Coordinate HVAC system maintenance with infection-control staff to allow for
relocation of immunocompromised patients if necessary.120 Category IC (AIA: 5.1,
5.2)
2.
3.
4.
Provide backup emergency power and air-handling and pressurization systems to
maintain filtration, constant ACH, and pressure differentials in PE rooms, AII rooms,
operating rooms, and other critical-care areas.9, 120, 278 Category IC (AIA: 1.5, 5.1, 5.2)
For areas not served by installed emergency ventilation and backup systems, use
portable units and monitor ventilation parameters and patients in those areas.219
Category II
Coordinate system startups with infection-control staff to protect patients in PE rooms
from bursts of fungal spores.9, 35, 120, 278 Category IC (AIA: 5.1, 5.2)
120
5.
K.
L.
M.
II.
Allow sufficient time for ACH to clean the air once the system is operational
(Appendix B, Table B.1).4, 120 Category IC (AIA: 5.1, 5.2)
HVAC systems serving offices and administration areas may be shut down for energy
conservation purposes, but the shutdown must not alter or adversely affect pressure
differentials maintained in laboratories or critical-care areas with specific ventilation
requirements (i.e., PE rooms, AII rooms, operating rooms). Category II
Whenever possible, avoid inactivating or shutting down the entire HVAC system at one
time, especially in acute-care facilities. Category II
Whenever feasible, design and install fixed backup ventilation systems for new or renovated
construction for PE rooms, AII rooms, operating rooms, and other critical care areas
identified by ICRA.120 Category IC (AIA: 1.5.A1)
Construction, Renovation, Remediation, Repair, and Demolition
A. Establish a multidisciplinary team that includes infection-control staff to coordinate
demolition, construction, and renovation projects and consider proactive preventive
measures at the inception; produce and maintain summary statements of the team’s
activities.17, 19, 20, 97, 109, 120, 249, 250, 273–277 Category IB, IC (AIA: 5.1)
B.
Educate both the construction team and the health-care staff in immunocompromised
patient-care areas regarding the airborne infection risks associated with construction
projects, dispersal of fungal spores during such activities, and methods to control the
dissemination of fungal spores.3, 249, 250, 273–277, 1428–1432 Category IB
C.
Incorporate mandatory adherence agreements for infection control into construction
contracts, with penalties for noncompliance and mechanisms to ensure timely correction of
problems.3, 120, 249, 273–277 Category IC (AIA: 5.1)
D. Establish and maintain surveillance for airborne environmental disease (e.g., aspergillosis)
as appropriate during construction, renovation, repair, and demolition activities to ensure
the health and safety of immunocompromised patients.3, 64, 65, 79 Category IB
1.
Using active surveillance, monitor for airborne fungal infections in
immunocompromised patients.3, 9, 64, 65 Category IB
2.
Periodically review the facility’s microbiologic, histopathologic, and postmortem data
to identify additional cases.3, 9, 64, 65 Category IB
3.
If cases of aspergillosis or other health-care–associated airborne fungal infections
occur, aggressively pursue the diagnosis with tissue biopsies and cultures as feasible.3,
64, 65, 79, 249, 273–277
Category IB
E.
Implement infection-control measures relevant to construction, renovation, maintenance,
demolition, and repair.96, 97, 120, 276, 277 Category IB, IC (AIA: 5.1, 5.2)
1.
Before the project gets underway, perform an ICRA to define the scope of the project
and the need for barrier measures.96, 97, 120, 249, 273–277
Category IB, IC (AIA: 5.1)
a.
Determine if immunocompromised patients may be at risk for exposure to
fungal spores from dust generated during the project.20, 109, 273–275, 277
b.
Develop a contingency plan to prevent such exposures.20, 109, 273–275, 277
2.
Implement infection-control measures for external demolition and construction
activities.50, 249, 273–277, 283 Category IB
a.
Determine if the facility can operate temporarily on recirculated air; if feasible,
seal off adjacent air intakes.
b.
If this is not possible or practical, check the low-efficiency (roughing) filter
banks frequently and replace as needed to avoid buildup of particulates.
c.
Seal windows and reduce wherever possible other sources of outside air
intrusion (e.g., open doors in stairwells and corridors), especially in PE areas.
3.
Avoid damaging the underground water distribution system (i.e., buried pipes) to
prevent soil and dust contamination of the water.120, 305 Category IB, IC (AIA: 5.1)
121
4.
Implement infection-control measures for internal construction activities.20, 49, 97, 120,
249, 273–277
Category IB, IC (AIA: 5.1, 5.2)
a.
Construct barriers to prevent dust from construction areas from entering
patient-care areas; ensure that barriers are impermeable to fungal spores and in
compliance with local fire codes.20, 49, 97, 120, 284, 312, 713, 1431
b.
Block and seal off return air vents if rigid barriers are used for containment.120,
276, 277
c.
5.
Implement dust control measures on surfaces and by diverting pedestrian traffic
away from work zones.20, 49, 97, 120
d.
Relocate patients whose rooms are adjacent to work zones, depending upon
their immune status, the scope of the project, the potential for generation of
dust or water aerosols, and the methods used to control these aerosols.49, 120, 281
Perform those engineering and work-site related infection-control measures as needed
for internal construction, repairs, and renovations:20, 49, 97, 109, 120, 312 Category IB, IC
(AIA: 5.1, 5.2)
a.
b.
Ensure proper operation of the air-handling system in the affected area after
erection of barriers and before the room or area is set to negative pressure.49, 69,
276, 278
Category IB
Create and maintain negative air pressure in work zones adjacent to patient-care
areas and ensure that required engineering controls are maintained.20, 49, 97, 109, 120,
312
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
Monitor negative air flow inside rigid barriers.120, 281
Monitor barriers and ensure the integrity of the construction barriers; repair
gaps or breaks in barrier joints.120, 284, 307, 312
Seal windows in work zones if practical; use window chutes for disposal of
large pieces of debris as needed, but ensure that the negative pressure
differential for the area is maintained.20, 120, 273
Direct pedestrian traffic from construction zones away from patient-care areas
to minimize the dispersion of dust.20, 49, 97, 109, 111, 120, 273–277
Provide construction crews with 1) designated entrances, corridors, and
elevators whenever practical; 2) essential services [e.g., toilet facilities], and
convenience services [e.g., vending machines]; 3) protective clothing [e.g.,
coveralls, footgear, and headgear] for travel to patient-care areas; and 4) a space
or anteroom for changing clothing and storing equipment.120, 249, 273–277
Clean work zones and their entrances daily by 1) wet-wiping tools and tool
carts before their removal from the work zone; 2) placing mats with tacky
surfaces inside the entrance; and 3) covering debris and securing this covering
before removing debris from the work zone.120, 249, 273–277
In patient-care areas, for major repairs that include removal of ceiling tiles and
disruption of the space above the false ceiling, use plastic sheets or
prefabricated plastic units to contain dust; use a negative pressure system
within this enclosure to remove dust; and either pass air through an industrial
grade, portable HEPA filter capable of filtration rates ranging from 300–800
ft3/min., or exhaust air directly to the outside.49, 276, 277, 281, 309
Upon completion of the project, clean the work zone according to facility
procedures, and install barrier curtains to contain dust and debris before
removal of rigid barriers.20, 97, 120, 249, 273–277
Flush the water system to clear sediment from pipes to minimize waterborne
microorganism proliferation.120, 305
Restore appropriate ACH, humidity, and pressure differential; clean or replace
air filters; dispose of spent filters.35, 106, 221, 278
122
F.
G.
Use airborne-particle sampling as a tool to evaluate barrier integrity.35, 100 Category II
Commission the HVAC system for newly constructed health-care facilities and renovated
spaces before occupancy and use, with emphasis on ensuring proper ventilation for
operating rooms, AII rooms, and PE areas.100, 120, 288, 304 Category IC (AIA: 5.1; ASHRAE: 11996)
H.
I.
J.
K.
III.
No recommendation is offered on routine microbiologic air sampling before, during, or
after construction or before or during occupancy of areas housing immunocompromised
patients.17, 20, 49, 97, 109, 272, 1433 Unresolved issue
If a case of health-care–acquired aspergillosis or other opportunistic environmental airborne
fungal disease occurs during or immediately after construction, implement appropriate
follow-up measures.20, 55, 62, 77, 94, 95 Category IB
1.
Review pressure differential monitoring documentation to verify that pressure
differentials in the construction zone and in PE rooms were appropriate for their
settings.94, 95, 120 Category IB, IC (AIA: 5.1)
2.
Implement corrective engineering measures to restore proper pressure differentials as
needed.94, 95, 120 Category IB, IC (AIA: 5.1)
3.
Conduct a prospective search for additional cases and intensify retrospective
epidemiologic review of the hospital’s medical and laboratory records.3, 20, 62, 63, 104
Category IB
4.
If there is no evidence of ongoing transmission, continue routine maintenance in the
area to prevent health-care–acquired fungal disease.3, 55 Category IB
If there is epidemiologic evidence of ongoing transmission of fungal disease, conduct an
environmental assessment to determine and eliminate the source.3, 96, 97, 109, 111, 115, 249, 273–277
Category IB
1.
Collect environmental samples from potential sources of airborne fungal spores,
preferably using a high-volume air sampler rather than settle plates.3, 18, 44, 48, 49, 97, 106,
111, 112, 115, 249, 254, 273–277, 292, 312
Category IB
2.
If either an environmental source of airborne fungi or an engineering problem with
filtration or pressure differentials is identified, promptly perform corrective measures
to eliminate the source and route of entry.96, 97 Category IB
3.
Use an EPA-registered anti-fungal biocide (e.g., copper-8-quinolinolate) for
decontaminating structural materials.50, 277, 312, 329 Category IB
4.
If an environmental source of airborne fungi is not identified, review infection control
measures, including engineering controls, to identify potential areas for correction or
improvement.73, 117 Category IB
5.
If possible, perform molecular subtyping of Aspergillus spp. isolated from patients
and the environment to establish strain identities.252, 293–296 Category II
If air-supply systems to high-risk areas (e.g., PE rooms) are not optimal, use portable,
industrial-grade HEPA filters on a temporary basis until rooms with optimal air-handling
systems become available.3, 120, 273–277 Category II
Infection-Control and Ventilation Requirements for PE Rooms
A. Minimize exposures of severely immunocompromised patients (e.g., solid organ transplant
patients or allogeneic neutropenic patients) to activities that might cause aerosolization of
fungal spores (e.g., vacuuming or disruption of ceiling tiles).9, 20, 109, 272 Category IB
B.
Minimize the length of time that immunocompromised patients in PE are outside their
rooms for diagnostic procedures and other activities.9, 283 Category IB
C.
Provide respiratory protection for severely immunocompromised patients when they must
leave PE for diagnostic studies and other activities; consult the most recent revision of
CDC’s Guidelines for Prevention of Health-Care–Associated Pneumonia for information
regarding the appropriate type of respiratory protection.3, 9 Category II
123
D.
E.
F.
Incorporate ventilation engineering specifications and dust-controlling processes into the
planning and construction of new PE units. Category IB, IC
1.
Install central or point-of-use HEPA filters for supply (incoming) air.3, 18, 20, 44, 99–104,
120, 254, 316–318, 1432, 1434
Category IB, IC (AIA: 5.1, 5.2, 7.2.D)
2.
Ensure that rooms are well sealed by 1) properly constructing windows, doors, and
intake and exhaust ports; 2) maintaining ceilings that are smooth and free of fissures,
open joints, and crevices; 3) sealing walls above and below the ceiling, and 4)
monitoring for leakage and making necessary repairs.3, 111, 120, 317, 318
Category IB,
IC (AIA: 7.2.D3)
3.
Ventilate the room to maintain >12 ACH.3, 9, 120, 241, 317, 318 Category IC (AIA: 7.2.D)
4.
Locate air supply and exhaust grilles so that clean, filtered air enters from one side of
the room, flows across the patient’s bed, and exits from the opposite side of the
room.3, 120, 317, 318 Category IC (AIA: 7.31.D1)
5.
Maintain positive room air pressure (>2.5 Pa [0.01-inch water gauge]) in relation to
the corridor.3, 35, 120, 317, 318 Category IB, IC (AIA: Table 7.2)
6.
Maintain airflow patterns and monitor these on a daily basis by using permanently
installed visual means of detecting airflow in new or renovated construction, or using
other visual methods (e.g., flutter strips, or smoke tubes) in existing PE units.
Document the monitoring results.120, 273 Category IC (AIA: 7.2.D6)
7.
Install self-closing devices on all room exit doors in protective environments.120
Category IC (AIA: 7.2.D4)
Do not use laminar air flow systems in newly constructed PE rooms.316, 318 Category II
Take measures to protect immunocompromised patients who would benefit from a PE room
and who also have an airborne infectious disease (e.g., acute VZV infection or
tuberculosis).
1.
Ensure that the patient’s room is designed to maintain positive pressure.
2.
Use an anteroom to ensure appropriate air balance relationships and provide
independent exhaust of contaminated air to the outside, or place a HEPA filter in the
exhaust duct if the return air must be recirculated.120, 317 Category IC (AIA: 7.2.D1,
A7.2.D)
3.
G.
IV.
If an anteroom is not available, place the patient in AII and use portable, industrialgrade HEPA filters to enhance filtration of spores in the room.219 Category II
Maintain backup ventilation equipment (e.g., portable units for fans or filters) for
emergency provision of ventilation requirements for PE areas and take immediate steps to
restore the fixed ventilation system function.9, 120, 278 Category IC (AIA: 5.1)
Infection-Control and Ventilation Requirements for AII Rooms
A. Incorporate certain specifications into the planning, and construction or renovation of AII
units.4, 107, 120, 317, 318 Category IB, IC
1.
Maintain continuous negative air pressure (2.5 Pa [0.01-inch water gauge]) in relation
to the air pressure in the corridor; monitor air pressure periodically, preferably daily,
with audible manometers or smoke tubes at the door (for existing AII rooms) or with
a permanently installed visual monitoring mechanism. Document the results of
monitoring.120, 317, 318 Category IB, IC (AIA: 7.2.C7, Table 7.2)
2.
Ensure that rooms are well-sealed by properly constructing windows, doors, and airintake and exhaust ports; when monitoring indicates air leakage, locate the leak and
make necessary repairs.120, 317, 318 Category IB, IC (AIA: 7.2.C3)
3.
Install self-closing devices on all AII room exit doors.120 Category IC (AIA: 7.2.C4)
4.
Provide ventilation to ensure >12 ACH for renovated rooms and new rooms, and >6
ACH for existing AII rooms.4, 107, 120 Category IC (AIA: Table 7.2)
124
5.
B.
C.
D.
E.
V.
Direct exhaust air to the outside, away from air-intake and populated areas. If this is
not practical, air from the room can be recirculated after passing through a HEPA
filter.4, 120 Category IC (AIA: Table 7.2)
Where supplemental engineering controls for air cleaning are indicated from a risk
assessment of the AII area, install UVGI units in the exhaust air ducts of the HVAC system
to supplement HEPA filtration or install UVGI fixtures on or near the ceiling to irradiate
upper room air.4 Category II
Implement environmental infection-control measures for persons with known or suspected
airborne infectious diseases.
1.
Use AII rooms for patients with or suspected of having an airborne infection who also
require cough-inducing procedures, or use an enclosed booth that is engineered to
provide 1) >12 ACH; 2) air supply and exhaust rate sufficient to maintain a 2.5 Pa
[0.01-inch water gauge] negative pressure difference with respect to all surrounding
spaces with an exhaust rate of >50 ft3/min.; and 3) air exhausted directly outside away
from air intakes and traffic or exhausted after HEPA filtration prior to recirculation.4,
120, 348–350
Category IB, IC (AIA: 7.15.E, 7.31.D23, 9.10, Table 7.2)
2.
Although airborne spread of viral hemorrhagic fever (VHF) has not been documented
in a health-care setting, prudence dictates placing a VHF patient in an AII room,
preferably with an anteroom to reduce the risk of occupational exposure to
aerosolized infectious material in blood, vomitus, liquid stool, and respiratory
secretions present in large amounts during the end stage of a patient’s illness.202–204
Category II
a.
If an anteroom is not available, use portable, industrial-grade HEPA filters in
the patient’s room to provide additional ACH equivalents for removing
airborne particulates.
b.
Ensure that health-care workers wear face shields or goggles with appropriate
respirators when entering the rooms of VHF patients with prominent cough,
vomiting, diarrhea, or hemorrhage.203
3.
Place smallpox patients in negative pressure rooms at the onset of their illness,
preferably using a room with an anteroom if available.6 Category II
No recommendation is offered regarding negative pressure or isolation rooms for patients
with Pneumocystis carinii pneumonia.126, 131, 132 Unresolved issue
Maintain back-up ventilation equipment (e.g., portable units for fans or filters) for
emergency provision of ventilation requirements for AII rooms and take immediate steps to
restore the fixed ventilation system function.4, 120, 278 Category IC (AIA: 5.1)
Infection-Control and Ventilation Requirements for Operating Rooms
A. Implement environmental infection-control and ventilation measures for operating rooms.
1.
Maintain positive-pressure ventilation with respect to corridors and adjacent areas.7,
120, 356
Category IB, IC (AIA: Table 7.2)
2.
Maintain >15 ACH, of which >3 ACH should be fresh air.120, 357, 358 Category IC
(AIA: Table 7.2)
3.
B.
Filter all recirculated and fresh air through the appropriate filters, providing 90%
efficiency (dust-spot testing) at a minimum.120, 362 Category IC (AIA: Table 7.3)
4.
In rooms not engineered for horizontal laminar airflow, introduce air at the ceiling
and exhaust air near the floor.120, 357, 359 Category IC (AIA: 7.31.D4)
5.
Do not use UV lights to prevent surgical-site infections.356, 364–370 Category IB
6.
Keep operating room doors closed except for the passage of equipment, personnel,
and patients, and limit entry to essential personnel.351, 352 Category IB
Follow precautionary procedures for TB patients who also require emergency surgery.4, 347,
371
Category IB, IC
125
1.
Use an N95 respirator approved by the National Institute for Occupational Safety and
Health (NIOSH) without exhalation valves in the operating room.347, 372 Category
IC (Occupational Safety and Health Administration [OSHA]; 29 Code of Federal Regulations [CFR]
1910.134,139)
2.
C.
D.
E.
F.
Intubate the patient in either the AII room or the operating room; if intubating the
patient in the operating room, do not allow the doors to open until 99% of the
airborne contaminants are removed (Appendix B, Table B.1).4, 358 Category IB
3.
When anesthetizing a patient with confirmed or suspected TB, place a bacterial filter
between the anesthesia circuit and patient’s airway to prevent contamination of
anesthesia equipment or discharge of tubercle bacilli into the ambient air.371, 373
Category IB
4.
Extubate and allow the patient to recover in an AII room.4, 358 Category IB
5.
If the patient has to be extubated in the operating room, allow adequate time for ACH
to clean 99% of airborne particles from the air (Appendix B, Table B.1) because
extubation is a cough-producing procedure.4, 358 Category IB
Use portable, industrial-grade HEPA filters temporarily for supplemental air cleaning
during intubation and extubation for infectious TB patients who require surgery.4, 219, 358
Category II
1.
Position the units appropriately so that all room air passes through the filter; obtain
engineering consultation to determine the appropriate placement of the unit.4
Category II
2.
Switch the portable unit off during the surgical procedure. Category II
3.
Provide fresh air as per ventilation standards for operating rooms; portable units do
not meet the requirements for the number of fresh ACH.120, 215, 219 Category II
If possible, schedule infectious TB patients as the last surgical cases of the day to maximize
the time available for removal of airborne contamination. Category II
No recommendation is offered for performing orthopedic implant operations in rooms
supplied with laminar airflow.362, 364 Unresolved issue
Maintain backup ventilation equipment (e.g., portable units for fans or filters) for
emergency provision of ventilation requirements for operating rooms, and take immediate
steps to restore the fixed ventilation system function.68, 120, 278,372 Category IB, IC (AIA:
5.1)
VI. Other Potential Infectious Aerosol Hazards in Health-Care Facilities
A. In settings where surgical lasers are used, wear appropriate personal protective equipment,
including N95 or N100 respirators, to minimize exposure to laser plumes.347, 378, 389
Category IC (OSHA; 29 CFR 1910.134,139)
B.
Use central wall suction units with in-line filters to evacuate minimal laser plumes.378, 382, 386,
389
Category II
C.
Use a mechanical smoke evacuation system with a high-efficiency filter to manage the
generation of large amounts of laser plume, when ablating tissue infected with human
papilloma virus (HPV) or performing procedures on a patient with extrapulmonary TB.4, 382,
389– 392
Category II
D. Recommendations—Water
I.
Controlling the Spread of Waterborne Microoganisms
A. Practice hand hygiene to prevent the hand transfer of waterborne pathogens, and use barrier
precautions (e.g., gloves) as defined by other guidelines.6, 464, 577, 586, 592, 1364 Category IA
126
B.
C.
D.
E.
Eliminate contaminated water or fluid environmental reservoirs (e.g., in equipment or
solutions) wherever possible.464, 465 Category IB
Clean and disinfect sinks and wash basins on a regular basis by using an EPA-registered
product as set by facility policies. Category II
Evaluate for possible environmental sources (e.g., potable water) of specimen
contamination when waterborne microorganisms (e.g., NTM) of unlikely clinical
importance are isolated from clinical cultures (e.g., specimens collected aseptically from
sterile sites or, if post-procedural, colonization occurs after use of tap water in patient
care).607, 610–612 Category IB
Avoid placing decorative fountains and fish tanks in patient-care areas; ensure disinfection
and fountain maintenance if decorative fountains are used in the public areas of the healthcare facility.664 Category IB
II.
Routine Prevention of Waterborne Microbial Contamination Within the Distribution
System
A. Maintain hot water temperature at the return at the highest temperature allowable by state
regulations or codes, preferably >124°F (>51°C), and maintain cold water temperature at
<68°F (<20°C).3, 661 Category IC (States; ASHRAE: 12:2000)
B.
If the hot water temperature can be maintained at >124°F (>51°C), explore engineering
options (e.g., install preset thermostatic valves in point-of-use fixtures) to help minimize the
risk of scalding.661 Category II
C.
When state regulations or codes do not allow hot water temperatures above the range of
105°F–120°F (40.6°C–49°C) for hospitals or 95°F–110°F (35°C–43.3°C) for nursing care
facilities or when buildings cannot be retrofitted for thermostatic mixing valves, follow
either of these alternative preventive measures to minimize the growth of Legionella spp. in
water systems. Category II
1.
Periodically increase the hot water temperature to >150°F (>66°C) at the point of
use.661 Category II
2.
Alternatively, chlorinate the water and then flush it through the system.661, 710, 711
Category II
D. Maintain constant recirculation in hot-water distribution systems serving patient-care
areas.120 Category IC (AIA: 7.31.E.3)
III.
Remediation Strategies for Distribution System Repair or Emergencies
A. Whenever possible, disconnect the ice machine before planned water disruptions.
Category II
B.
Prepare a contingency plan to estimate water demands for the entire facility in advance of
significant water disruptions (i.e., those expected to result in extensive and heavy microbial
or chemical contamination of the potable water), sewage intrusion, or flooding.713, 719
Category IC (JCAHO: EC 1.4)
C.
When a significant water disruption or an emergency occurs, adhere to any advisory to boil
water issued by the municipal water utility.642 Category IB, IC (Municipal order)
1.
Alert patients, families, staff, and visitors not to consume water from drinking
fountains, ice, or drinks made from municipal tap water, while the advisory is in
effect, unless the water has been disinfected (e.g., by bringing to a rolling boil for >1
minute).642 Category IB, IC (Municipal order)
2.
After the advisory is lifted, run faucets and drinking fountains at full flow for >5
minutes, or use high-temperature water flushing or chlorination.642, 661 Category IC,
II (Municipal order; ASHRAE 12:2000)
D. Maintain a high level of surveillance for waterborne disease among patients after a boil
water advisory is lifted. Category II
127
E.
Corrective decontamination of the hot water system might be necessary after a disruption in
service or a cross-connection with sewer lines has occurred.
1.
Decontaminate the system when the fewest occupants are present in the building (e.g.,
nights or weekends).3, 661 Category IC (ASHRAE: 12:2000)
2.
If using high-temperature decontamination, raise the hot-water temperature to 160°F–
170°F (71°C–77°C) and maintain that level while progressively flushing each outlet
around the system for >5 minutes.3, 661 Category IC (ASHRAE: 12:2000)
3.
If using chlorination, add enough chlorine, preferably overnight, to achieve a free
chlorine residual of >2 mg/L (>2 ppm) throughout the system.661 Category IC
(ASHRAE: 12:2000)
a.
b.
F.
G.
H.
I.
J.
K.
L.
Flush each outlet until chlorine odor is detected.
Maintain the elevated chlorine concentration in the system for >2 hrs (but <24
hrs).
4.
Use a very thorough flushing of the water system instead of chlorination if a highly
chlorine-resistant microorganism (e.g., Cryptosporidium spp.) is suspected as the
water contaminant.
Category II
Flush and restart equipment and fixtures according to manufacturers’ instructions.
Category II
Change the pretreatment filter and disinfect the dialysis water system with an EPAregistered product to prevent colonization of the reverse osmosis membrane and
downstream microbial contamination.721 Category II
Run water softeners through a regeneration cycle to restore their capacity and function.
Category II
If the facility has a water-holding reservoir or water-storage tank, consult the facility
engineer or local health department to determine whether this equipment needs to be
drained, disinfected with an EPA-registered product, and refilled. Category II
Implement facility management procedures to manage a sewage system failure or flooding
(e.g., arranging with other health-care facilities for temporary transfer of patients or
provision of services), and establish communications with the local municipal water utility
and the local health department to ensure that advisories are received in a timely manner
upon release.713, 719 Category IC (JCAHO: EC 1.4; Municipal order)
Implement infection-control measures during sewage intrusion, flooding, or other waterrelated emergencies.
1.
Relocate patients and clean or sterilize supplies from affected areas. Category II
2.
If hands are not visibly soiled or contaminated with proteinaceous material, include
an alcohol-based hand rub in the hand hygiene process 1) before performing invasive
procedures; 2) before and after each patient contact; and 3) whenever hand hygiene is
indicated.1364 Category II
3.
If hands are visibly soiled or contaminated with proteinaceous material, use soap and
bottled water for handwashing.1364 Category II
4.
If the potable water system is not affected by flooding or sewage contamination,
process surgical instruments for sterilization according to standard procedures.
Category II
5.
Contact the manufacturer of the automated endoscope reprocessor (AER) for specific
instructions on the use of this equipment during a water advisory. Category II
Remediate the facility after sewage intrusion, flooding, or other water-related emergencies.
1.
Close off affected areas during cleanup procedures. Category II
2.
Ensure that the sewage system is fully functional before beginning remediation so
contaminated solids and standing water can be removed. Category II
128
3.
M.
IV.
If hard-surface equipment, floors, and walls remain in good repair, ensure that these
are dry within 72 hours; clean with detergent according to standard cleaning
procedures. Category II
4.
Clean wood furniture and materials (if still in good repair); allow them to dry
thoroughly before restoring varnish or other surface coatings. Category II
5.
Contain dust and debris during remediation and repair as outlined in air
recommendations (Air: II G 4, 5). Category II
Regardless of the original source of water damage (e.g., flooding versus water leaks from
point-of-use fixtures or roofs), remove wet, absorbent structural items (e.g., carpeting,
wallboard, and wallpaper) and cloth furnishings if they cannot be easily and thoroughly
cleaned and dried within 72 hours (e.g., moisture content <20% as determined by moisture
meter readings); replace with new materials as soon as the underlying structure is declared
by the facility engineer to be thoroughly dry.18, 266, 278, 1026 Category IB
Additional Engineering Measures as Indicated by Epidemiologic Investigation for
Controlling Waterborne, Health-Care–Associated Legionnaires Disease
A. When using a pulse or one-time decontamination method, superheat the water by flushing
each outlet for >5 minutes with water at 160°F–170°F (71°C–77°C) or hyperchlorinate the
system by flushing all outlets for >5 minutes with water containing >2 mg/L (>2 ppm) free
residual chlorine using a chlorine-based product registered by the EPA for water treatment
(e.g., sodium hypochlorite [chlorine bleach]).661, 711, 714, 724, 764, 766 Category IB (ASHRAE:
12:2000)
B.
After a pulse treatment, maintain both the heated water temperature at the return and the
cold water temperature as per the recommendation (Water: IIA) wherever practical and
permitted by state codes, or chlorinate heated water to achieve 1–2 mg/L (1–2 ppm) free
residual chlorine at the tap using a chlorine-based product registered by the EPA for water
treatment (e.g., sodium hypochlorite [bleach]).26, 437, 661, 709, 726, 727 Category IC (States;
ASHRAE: 12:2000)
C.
D.
V.
Explore engineering or educational options (e.g., install preset thermostatic mixing valves
in point-of-use fixtures or post warning signs at each outlet) to minimize the risk of scalding
for patients, visitors, and staff.
Category II
No recommendation is offered for treating water in the facility’s distribution system with
chlorine dioxide, heavy-metal ions (e.g., copper or silver), monochloramine, ozone, or UV
light.728–746 Unresolved issue
General Infection-Control Strategies for Preventing Legionnaires Disease
A. Conduct an infection-control risk assessment of the facility to determine if patients at risk or
severely immunocompromised patients are present.3, 431, 432 Category IB
B.
Implement general strategies for detecting and preventing Legionnaires disease in facilities
that do not provide care for severely immunocompromised patients (i.e., facilities that do
not have HSCT or solid organ transplant programs).3, 431, 432 Category IB
1.
Establish a surveillance process to detect health-care–associated Legionnaires
disease.3, 431, 432 Category IB
2.
Inform health-care personnel (e.g., infection control, physicians, patient-care staff,
and engineering) regarding the potential for Legionnaires disease to occur and
measures to prevent and control health-care–associated legionellosis.437, 759
Category IB
3.
Establish mechanisms to provide clinicians with laboratory tests (e.g., culture, urine
antigen, direct fluorescence assay [DFA], and serology) for the diagnosis of
Legionnaires disease.3, 431 Category IB
129
C.
D.
E.
F.
G.
H.
I.
J.
Maintain a high index of suspicion for health-care–associated Legionnaires disease, and
perform laboratory diagnostic tests for legionellosis on suspected cases, especially in
patients at risk who do not require a PE for care (e.g., patients receiving systemic steroids;
patients aged >65 years; or patients with chronic underlying disease [e.g., diabetes mellitus,
congestive heart failure, or chronic obstructive lung disease]).3, 395, 417, 423–425, 432, 435, 437, 453
Category IA
Periodically review the availability and clinicians’ use of laboratory diagnostic tests for
Legionnaires disease in the facility; if clinicians’ use of the tests on patients with diagnosed
or suspected pneumonia is limited, implement measures (e.g., an educational campaign) to
enhance clinicians’ use of the test(s).453 Category IB
If one case of laboratory-confirmed, health-care–associated Legionnaires disease is
identified, or if two or more cases of laboratory-suspected, health-care–associated
Legionnaires disease occur during a 6-month period, certain activities should be initiated.405,
408, 431, 453, 739, 759
Category IB
1.
Report the cases to the state and local health departments where required. Category
IC (States)
2.
If the facility does not treat severely immunocompromised patients, conduct an
epidemiologic investigation, including retrospective review of microbiologic,
serologic, and postmortem data to look for previously unidentified cases of healthcare–associated Legionnaires disease, and begin intensive prospective surveillance for
additional cases.3, 405, 408, 431, 453, 739, 759 Category IB
3.
If no evidence of continued health-care–associated transmission exists, continue
intensive prospective surveillance for >2 months after the initiation of surveillance.3,
405, 408, 431, 453, 739, 759
Category IB
If there is evidence of continued health-care–associated transmission (i.e., an outbreak),
conduct an environmental assessment to determine the source of Legionella spp.403–410, 455
Category IB
1.
Collect water samples from potential aerosolized water sources (Appendix C).1209
Category IB
2.
Save and subtype isolates of Legionella spp. obtained from patients and the
environment.403–410, 453, 763, 764 Category IB
3.
If a source is identified, promptly institute water system decontamination measures
per recommendations (see Water IV).766, 767 Category IB
4.
If Legionella spp. are detected in >1cultures (e.g., conducted at 2-week intervals
during 3 months), reassess the control measures, modify them accordingly, and repeat
the decontamination procedures; consider intensive use of techniques used for initial
decontamination, or a combination of superheating and hyperchlorination.3, 767, 768
Category IB
If an environmental source is not identified during a Legionnaires disease outbreak,
continue surveillance for new cases for >2 months. Either defer decontamination pending
identification of the source of Legionella spp., or proceed with decontamination of the
hospital's water distribution system, with special attention to areas involved in the outbreak.
Category II
No recommendation is offered regarding routine culturing of water systems in health-care
facilities that do not have patient-care areas (i.e., PE or transplant units) for persons at high
risk for Legionella spp. infection.26, 453, 707, 709, 714, 747, 753 Unresolved issue
No recommendation is offered regarding the removal of faucet aerators in areas for
immunocompetent patients. Unresolved issue
Keep adequate records of all infection-control measures and environmental test results for
potable water systems. Category II
130
VI.
Preventing Legionnaires Disease in Protective Environments and Transplant Units
A. When implementing strategies for preventing Legionnaires disease among severely
immunosuppressed patients housed in facilities with HSCT or solid-organ transplant
programs, incorporate these specific surveillance and epidemiologic measures in addition to
the steps previously outlined (Water: V and Appendix C).
1.
Maintain a high index of suspicion for legionellosis in transplant patients even when
environmental surveillance cultures do not yield legionellae.430, 431 Category IB
2.
If a case occurs in a severely immunocompromised patient, or if severely
immunocompromised patients are present in high-risk areas of the hospital (e.g., PE
or transplant units) and cases are identified elsewhere in the facility, conduct a
combined epidemiologic and environmental investigation to determine the source of
Legionella spp.431, 767 Category IB
B.
Implement culture strategies and potable water and fixture treatment measures in addition to
those previously outlined (Water: V). Category II
1.
Depending on state regulations on potable water temperature in public buildings,725
hospitals housing patients at risk for health-care–associated legionellosis should either
maintain heated water with a minimum return temperature of >124°F [>51°C] and
cold water at <68°F [<20°C]), or chlorinate heated water to achieve 1–2 mg/L (1–2
ppm) of free residual chlorine at the tap.26, 441, 661, 709–711, 726, 727 Category II
2.
Periodic culturing for legionellae in potable water samples from HSCT or solid-organ
transplant units can be performed as part of a comprehensive strategy to prevent
Legionnaires disease in these units.9, 431, 710, 769 Category II
3.
No recommendation is offered regarding the optimal methodology (i.e., frequency
or number of sites) for environmental surveillance cultures in HSCT or solid organ
transplant units. Unresolved issue
4.
In areas with patients at risk, when Legionella spp. are not detectable in unit water,
remove, clean, and disinfect shower heads and tap aerators monthly by using a
chlorine-based, EPA-registered product. If an EPA-registered chlorine disinfectant is
not available, use a chlorine bleach solution (500–615 ppm [1:100 v/v dilution]).661, 745
Category II
C.
If Legionella spp. are determined to be present in the water of a transplant unit, implement
certain measures until Legionella spp. are no longer detected by culture.
1.
Decontaminate the water supply as outlined previously (Water: IV).3, 9, 661, 766, 767
Category IB
2.
Do not use water from the faucets in patient-care rooms to avoid creating infectious
aerosols.9, 412 Category IB
3.
Restrict severely immunocompromised patients from taking showers.9, 412 Category
IB
4.
Use water that is not contaminated with Legionella spp. for HSCT patients’ sponge
baths.9, 412 Category IB
5.
Provide patients with sterile water for tooth brushing, drinking, and for flushing
nasogastric tubing during legionellosis outbreaks.9, 412 Category IB
D. Do not use large-volume room air humidifiers that create aerosols (e.g., by Venturi
principle, ultrasound, or spinning disk) unless they are subjected to high-level disinfection
and filled only with sterile water.3, 9, 402, 455 Category IB
VII. Cooling Towers and Evaporative Condensers
A. When planning construction of new health-care facilities, locate cooling towers so that the
drift is directed away from the air-intake system, and design the towers to minimize the
volume of aerosol drift.404, 661, 786 Category IC (ASHRAE: 12:2000)
131
B.
Implement infection-control procedures for operational cooling towers.404, 661, 784
Category IC (ASHRAE: 12:2000)
1.
Install drift eliminators.404, 661, 784 Category IC (ASHRAE: 12:2000)
2.
Use an effective EPA-registered biocide on a regular basis.661 Category IC
(ASHRAE: 12:2000)
3.
C.
Maintain towers according to manufacturers’ recommendations, and keep detailed
maintenance and infection control records, including environmental test results from
legionellosis outbreak investigations.661 Category IC (ASHRAE: 12:2000)
If cooling towers or evaporative condensers are implicated in health-care–associated
legionellosis, decontaminate the cooling-tower system.404, 405, 786, 787 Category IB
VIII. Dialysis Water Quality and Dialysate
A. Adhere to current AAMI standards for quality assurance performance of devices and
equipment used to treat, store, and distribute water in hemodialysis centers (both acute and
maintenance [chronic] settings) and for the preparation of concentrates and dialysate.31, 32,
666–668, 789, 791, 800, 807, 809, 1454, 1455
Category IA, IC (AAMI: ANSI/AAMI RD5:1992, ANSI/AAMI RD
47:1993)
B.
C.
No recommendation is offered regarding whether more stringent requirements for water
quality should be imposed in hemofiltration and hemodiafiltration. Unresolved issue
Conduct microbiological testing specific to water in dialysis settings.789, 791, 792, 834, 835
Category IA, IC (AAMI: ANSI/AAMI RD 5: 1992, ANSI/AAMI RD 47: 1993, ANSI/AAMI RD 62:2001)
1.
Perform bacteriologic assays of water and dialysis fluids at least once a month and
during outbreaks using standard quantitative methods.792, 834, 835 Category IA, IC
(AAMI: ANSI/AAMI RD 62:2001)
2.
3.
a.
Assay for heterotrophic, mesophilic bacteria (e.g., Pseudomonas spp).
b.
Do not use nutrient-rich media (e.g., blood agar or chocolate agar).
In conjunction with microbiological testing, perform endotoxin testing on product
water used to reprocess dialyzers for multiple use.789, 791, 806, 811, 816, 829 Category IA,
IC (AAMI: ANSI/AAMI RD 5:1992, ANSI/AAMI RD 47:1993)
Ensure that water does not exceed the limits for microbial counts and endotoxin
concentrations outlined in Table 18.789, 791, 800 Category IA, IC (AAMI: ANSI/AAMI RD
5:1992, ANSI/AAMI RD 47:1993)
D.
E.
F.
Disinfect water distribution systems in dialysis settings on a regular schedule. Monthly
disinfection is recommended.666–668, 792, 800 Category IA, IC (AAMI: ANSI/AAMI RD62:2001)
Whenever practical, design and engineer water systems in dialysis settings to avoid
incorporating joints, dead-end pipes, and unused branches and taps that can harbor
bacteria.666–668, 792, 800 Category IA, IC (AAMI: ANSI/AAMI RD62:2001)
When storage tanks are used in dialysis systems, they should be routinely drained,
disinfected with an EPA-registered product, and fitted with an ultrafilter or pyrogenic filter
(membrane filter with a pore size sufficient to remove small particles and molecules >1
kilodalton) installed in the water line distal to the storage tank.792 Category IC (AAMI:
ANSI/AAMI RD62:2001)
IX.
Ice Machines and Ice
A. Do not handle ice directly by hand, and wash hands before obtaining ice. Category II
B.
Use a smooth-surface ice scoop to dispense ice.680, 863 Category II
1.
Keep the ice scoop on a chain short enough the scoop cannot touch the floor, or keep
the scoop on a clean, hard surface when not in use.680, 863 Category II
2.
Do not store the ice scoop in the ice bin. Category II
C.
Do not store pharmaceuticals or medical solutions on ice intended for consumption; use
sterile ice to keep medical solutions cold, or use equipment specifically manufactured for
this purpose.600, 863 Category IB
132
D.
E.
F.
G.
H.
Machines that dispense ice are preferred to those that require ice to be removed from bins or
chests with a scoop.687, 869 Category II
Limit access to ice-storage chests, and keep the container doors closed except when
removing ice.863 Category II
Clean, disinfect, and maintain ice-storage chests on a regular basis. Category II
1.
Follow the manufacturer’s instructions for cleaning. Category II
2.
Use an EPA-registered disinfectant suitable for use on ice machines, dispensers, or
storage chests in accordance with label instructions.
Category II
3.
If instructions and EPA-registered disinfectants suitable for use on ice machines are
not available, use a general cleaning/disinfecting regimen as outlined in Box 12.863
Category II
4.
Flush and clean the ice machines and dispensers if they have not been disconnected
before anticipated lengthy water disruptions. Category II
Install proper air gaps where the condensate lines meet the waste lines. Category II
Conduct microbiologic sampling of ice, ice chests, and ice-making machines and dispensers
where indicated during an epidemiologic investigation.861–863 Category IB
X.
Hydrotherapy Tanks and Pools
A. Drain and clean hydrotherapy equipment (e.g., Hubbard tanks, tubs, whirlpools, whirlpool
spas, or birthing tanks) after each patient’s use, and disinfect equipment surfaces and
components by using an EPA-registered product in accordance with the manufacturer’s
instructions. Category II
B.
In the absence of an EPA-registered product for water treatment, add sodium hypochlorite
to the water:
1.
Maintain a 15-ppm chlorine residual in the water of small hydrotherapy tanks,
Hubbard tanks, and tubs.889 Category II
2.
Maintain a 2–5 ppm chlorine residual in the water of whirlpools and whirlpool
spas.905 Category II
3.
If the pH of the municipal water is in the basic range (e.g., when chloramine is used
as the primary drinking water disinfectant in the community), consult the facility
engineer regarding the possible need to adjust the pH of the water to a more acid level
before disinfection, to enhance the biocidal activity of chlorine.894 Category II
C.
Clean and disinfect hydrotherapy equipment after using tub liners. Category II
D. Clean and disinfect inflatable tubs unless they are single-use equipment.
Category II
E.
No recommendation is offered regarding the use of antiseptic chemicals (e.g., chloramineT) in the water during hydrotherapy sessions. Unresolved issue
F.
Conduct a risk assessment of patients prior to their use of large hydrotherapy pools,
deferring patients with draining wounds or fecal incontinence from pool use until their
condition resolves. Category II
G. For large hydrotherapy pools, use pH and chlorine residual levels appropriate for an indoor
pool as provided by local and state health agencies. Category IC (States)
H. No recommendation is offered regarding the use in health care of whirlpools or spa
equipment manufactured for home or recreational use. Unresolved issue
XI.
Miscellaneous Medical Equipment Connected to Water Systems
A. Clean, disinfect, and maintain AER equipment according to the manufacturer’s instructions
and relevant scientific literature to prevent inadvertent contamination of endoscopes and
bronchoscopes with waterborne microorganisms.911–915 Category IB
1.
To rinse disinfected endoscopes and bronchoscopes, use water of the highest quality
practical for the system’s engineering and design (e.g., sterile water or
133
bacteriologically-filtered water [water filtered through 0.1–0.2-µm filters]).912, 914, 915,
Category IB
2.
Dry the internal channels of the reprocessed endoscope or bronchoscope using a
proven method (e.g., 70% alcohol followed by forced-air treatment) to lessen the
potential for the proliferation of waterborne microorganisms and to help prevent
biofilm formation.671, 921, 923, 925, 928 Category IB
Use water that meets nationally recognized standards set by the EPA for drinking water
(<500 CFU/mL for heterotrophic plate count) for routine dental treatment output water.935,
936, 943, 944
Category IB, IC (EPA: 40 CFR 1 Part 141, Subpart G).
Take precautions to prevent waterborne contamination of dental unit water lines and
instruments.
1.
After each patient, discharge water and air for a minimum of 20–30 seconds from any
dental device connected to the dental water system that enters the patient’s mouth
(e.g., handpieces, ultrasonic scalers, and air/water syringe).936, 937 Category II
2.
Consult with dental water-line manufacturers to 1) determine suitable methods and
equipment to obtain the recommended water quality; and 2) determine appropriate
methods for monitoring the water to ensure quality is maintained.936, 946 Category II
3.
Consult with the dental unit manufacturer on the need for periodic maintenance of
anti-retraction mechanisms.937, 946 Category IB
918
B.
C.
E. Recommendations—Environmental Services
I.
Cleaning and Disinfecting Strategies for Environmental Surfaces in Patient-Care Areas
A. Select EPA-registered disinfectants, if available, and use them in accordance with the
manufacturer’s instructions.2, 974, 983 Category IB, IC (EPA: 7 United States Code [USC] § 136 et
seq)
B.
Do not use high-level disinfectants/liquid chemical sterilants for disinfection of either
noncritical instrument/devices or any environmental surfaces; such use is counter to label
instructions for these toxic chemicals.951, 952, 961–964 Category IB, IC (FDA: 21 CFR 801.5,
807.87.e)
C.
D.
E.
Follow manufacturers’ instructions for cleaning and maintaining noncritical medical
equipment. Category II
In the absence of a manufacturer’s cleaning instructions, follow certain procedures.
1.
Clean noncritical medical equipment surfaces with a detergent/disinfectant. This may
be followed with an application of an EPA-registered hospital disinfectant with or
without a tuberculocidal claim (depending on the nature of the surface and the degree
of contamination), in accordance with disinfectant label instructions.952 Category II
2.
Do not use alcohol to disinfect large environmental surfaces.951 Category II
3.
Use barrier protective coverings as appropriate for noncritical equipment surfaces that
are 1) touched frequently with gloved hands during the delivery of patient care; 2)
likely to become contaminated with blood or body substances; or 3) difficult to clean
(e.g., computer keyboards).936 Category II
Keep housekeeping surfaces (e.g., floors, walls, and tabletops) visibly clean on a regular
basis and clean up spills promptly.954 Category II
1.
Use a one-step process and an EPA-registered hospital disinfectant/detergent
designed for general housekeeping purposes in patient-care areas when 1) uncertainty
exists as to the nature of the soil on these surfaces [e.g., blood or body fluid
contamination versus routine dust or dirt]; or 2) uncertainty exists regarding the
presence or absence of multi-drug resistant organisms on such surfaces.952, 983, 986, 987
Category II
134
2.
F.
G.
H.
I.
J.
K.
L.
M.
N.
Detergent and water are adequate for cleaning surfaces in nonpatient-care areas (e.g.,
administrative offices). Category II
3.
Clean and disinfect high-touch surfaces (e.g., doorknobs, bed rails, light switches, and
surfaces in and around toilets in patients’ rooms) on a more frequent schedule than
minimal touch housekeeping surfaces. Category II
4.
Clean walls, blinds, and window curtains in patient-care areas when they are visibly
dusty or soiled.2, 971, 972, 982 Category II
Do not perform disinfectant fogging in patient-care areas.2, 976 Category IB
Avoid large-surface cleaning methods that produce mists or aerosols or disperse dust in
patient-care areas.9, 20, 109, 272 Category IB
Follow proper procedures for effective use of mops, cloths, and solutions. Category II
1.
Prepare cleaning solutions daily or as needed, and replace with fresh solution
frequently according to facility policies and procedures.986, 987 Category II
2.
Change the mop head at the beginning of the day and also as required by facility
policy, or after cleaning up large spills of blood or other body substances. Category
II
3.
Clean mops and cloths after use and allow to dry before reuse; or use single-use,
disposable mop heads and cloths.971, 988–990 Category II
After the last surgical procedure of the day or night, wet vacuum or mop operating room
floors with a single-use mop and an EPA-registered hospital disinfectant.7
Category IB
Do not use mats with tacky surfaces at the entrance to operating rooms or infection-control
suites.7
Category IB
Use appropriate dusting methods for patient-care areas designated for immunocompromised
patients (e.g., HSCT patients):9, 94, 986 Category IB
1.
Wet-dust horizontal surfaces daily by moistening a cloth with a small amount of an
EPA-registered hospital detergent/disinfectant.9, 94, 986 Category IB
2.
Avoid dusting methods that disperse dust (e.g., feather-dusting).94 Category IB
Keep vacuums in good repair, and equip vacuums with HEPA filters for use in areas with
patients at risk.9, 94, 986, 994 Category IB
Close the doors of immunocompromised patients’ rooms when vacuuming, waxing, or
buffing corridor floors to minimize exposure to airborne dust.9, 94, 994 Category IB
When performing low- or intermediate-level disinfection of environmental surfaces in
nurseries and neonatal units, avoid unnecessary exposure of neonates to disinfectant
residues on environmental surfaces by using EPA-registered disinfectants in accordance
with manufacturers’ instructions and safety advisories.974, 995–997 Category IB, IC (EPA: 7
USC § 136 et seq.)
1.
O.
II.
Do not use phenolics or any other chemical germicide to disinfect bassinets or
incubators during an infant’s stay.952, 995–997 Category IB
2.
Rinse disinfectant-treated surfaces, especially those treated with phenolics, with
water.995–997 Category IB
When using phenolic disinfectants in neonatal units, prepare solutions to correct
concentrations in accordance with manufacturers’ instructions, or use premixed
formulations.974, 995–997 Category IB, IC (EPA: 7 USC § 136 et seq.)
Cleaning Spills of Blood and Body Substances
A. Promptly clean and decontaminate spills of blood or other potentially infectious
materials.967, 998–1004 Category IB, IC (OSHA: 29 CFR 1910.1030 §d.4.ii.A)
B.
Follow proper procedures for site decontamination of spills of blood or blood-containing
body fluids.967, 998–1004 Category IC (OSHA: 29 CFR 1910.1030 § d.4.ii.A)
1.
Use protective gloves and other PPE appropriate for this task.967 Category IC
(OSHA: 29 CFR 1910.1030 § d.3.i, ii)
135
2.
If the spill contains large amounts of blood or body fluids, clean the visible matter
with disposable absorbent material, and discard the contaminated materials in
appropriate, labeled containment.967, 1002, 1003, 1010, 1012 Category IC (OSHA: 29 CFR
1910.1030 § d.4.iii.B)
3.
C.
Swab the area with a cloth or paper towels moderately wetted with disinfectant, and
allow the surface to dry.967, 1010 Category IC (OSHA: 29 CFR 1910.1030 § d.4.ii.A)
Use EPA-registered hospital disinfectants labeled tuberculocidal or registered germicides on
the EPA Lists D and E (products with specific label claims for HIV or hepatitis B virus
[HBV]) in accordance with label instructions to decontaminate spills of blood and other
body fluids.967, 1007, 1010 Category IC (OSHA 29 CFR 1910.1030 § d.4.ii.A memorandum 2/28/97;
compliance document CPL 2-2.44D [11/99])
D.
III.
An EPA-registered sodium hypochlorite product is preferred, but if such products are not
available, generic versions of sodium hypochlorite solutions (e.g., household chlorine
bleach) may be used.
1.
Use a 1:100 dilution (500–615 ppm available chlorine) to decontaminate nonporous
surfaces after cleaning a spill of either blood or body fluids in patient-care
settings.1010, 1011 Category II
2.
If a spill involves large amounts of blood or body fluids, or if a blood or culture spill
occurs in the laboratory, use a 1:10 dilution (5,000–6,150 ppm available chlorine) for
the first application of germicide before cleaning.954, 1010
Category II
Carpeting and Cloth Furnishings
A. Vacuum carpeting in public areas of health-care facilities and in general patient-care areas
regularly with well-maintained equipment designed to minimize dust dispersion.986
Category II
B.
Periodically perform a thorough, deep cleaning of carpeting as determined by facility policy
by using a method that minimizes the production of aerosols and leaves little or no
Category II
residue.111
C.
Avoid use of carpeting in high-traffic zones in patient-care areas or where spills are likely
(e.g., burn therapy units, operating rooms, laboratories, and intensive care units).111, 1023, 1028
Category IB
D. Follow proper procedures for managing spills on carpeting.
1.
Spot-clean blood or body substance spills promptly.967, 1010, 1011, 1032 Category IC
(OSHA: 29 CFR 1910.1030 § d.4.ii.A, interpretation)
2.
E.
F.
G.
H.
I.
J.
If a spill occurs on carpet tiles, replace any tiles contaminated by blood and body
fluids or body substances.1032 Category IC (OSHA 29 CFR 1910.1030 § d.4.ii interpretation)
Thoroughly dry wet carpeting to prevent the growth of fungi; replace carpeting that remains
wet after 72 hours.9, 1026 Category IB
No recommendation is offered regarding the routine use of fungicidal or bactericidal
treatments for carpeting in public areas of a health-care facility or in general patient-care
areas. Unresolved issue
Do not use carpeting in hallways and patient rooms in areas housing immunosuppressed
patients (e.g., PE areas).9, 111 Category IB
Avoid the use of upholstered furniture and furnishings in high-risk patient-care areas and in
areas with increased potential for body substance contamination (e.g., pediatrics units).9
Category II
No recommendation is offered regarding whether upholstered furniture and furnishings
should be avoided in general patient-care areas. Unresolved issue
Maintain upholstered furniture in good repair. Category II
1.
Maintain the surface integrity of the upholstery by repairing tears and holes.
Category II
136
2.
If upholstered furniture in a patient’s room requires cleaning to remove visible soil or
body substance contamination, move that item to a maintenance area where it can be
adequately cleaned with a process appropriate for the type of upholstery and the
nature of the soil. Category II
IV.
Flowers and Plants in Patient-Care Areas
A. Flowers and potted plants need not be restricted from areas for immunocompetent
patients.515, 702, 1040, 1042 Category II
B.
Designate care and maintenance of flowers and potted plants to staff not directly involved
with patient care.702 Category II
C.
If plant or flower care by patient-care staff is unavoidable, instruct the staff to wear gloves
when handling the plants and flowers and perform hand hygiene after glove removal.702
Category II
D. Do not allow fresh or dried flowers, or potted plants in patient-care areas for
immunosuppressed patients.9, 109, 515, 1046 Category II
V.
Pest Control
A. Develop pest-control strategies, with emphasis on kitchens, cafeterias, laundries, central
sterile supply areas, operating rooms, loading docks, construction activities, and other areas
prone to infestations.1050, 1072, 1075 Category II
B.
Install screens on all windows that open to the outside; keep screens in good repair.1072
Category IB
C.
Contract for routine pest control service by a credentialed pest-control specialist who will
tailor the application to the needs of a health-care facility.1075 Category II
D. Place laboratory specimens (e.g., fixed sputum smears) in covered containers for overnight
storage.1065, 1066 Category II
VI.
Special Pathogens
A. Use appropriate hand hygiene, PPE (e.g., gloves), and isolation precautions during cleaning
and disinfecting procedures.5, 952, 1130, 1364 Category IB
B.
Use standard cleaning and disinfection protocols to control environmental contamination
with antibiotic-resistant gram-positive cocci (e.g., methicillin-resistant Staphylococcus
aureus, vancomycin intermediate-resistant Staphylococcus aureus, or vancomycin-resistant
Enterococcus [VRE] ).5, 1116–1118 Category IB
1.
Pay close attention to cleaning and disinfection of high-touch surfaces in patient-care
areas (e.g., bed rails, carts, bedside commodes, bedrails, doorknobs, or faucet
handles).5, 1116–1118 Category IB
2.
Ensure compliance by housekeeping staff with cleaning and disinfection procedures.5,
1116–1118
Category IB
3.
Use EPA-registered hospital disinfectants appropriate for the surface to be disinfected
(e.g., either low- or intermediate-level disinfection) as specified by the manufacturers’
instructions.974, 1106–1110, 1118 Category IB, IC (EPA: 7 USC § 136 et seq.)
4.
When contact precautions are indicated for patient care, use disposable patient-care
items (e.g., blood pressure cuffs) whenever possible to minimize cross-contamination
with multiple-resistant microorganisms.1102 Category IB
5.
Follow these same surface cleaning and disinfecting measures for managing the
environment of VRSA patients.1110, 1116–1118 Category II
C.
Environmental-surface culturing can be used to verify the efficacy of hospital policies and
procedures before and after cleaning and disinfecting rooms that house patients with VRE.5,
1084, 1087, 1088, 1092, 1096
Category II
137
1.
D.
E.
F.
G.
H.
I.
J.
Obtain prior approval from infection-control staff and the clinical laboratory before
performing environmental surface culturing. Category II
2.
Infection-control staff, with clinical laboratory consultation, must supervise all
environmental culturing. Category II
Thoroughly clean and disinfect environmental and medical equipment surfaces on a regular
basis using EPA-registered disinfectants in accordance with manufacturers’ instructions.952,
974, 1130, 1143
Category IB, IC (EPA: 7 USC § 136 et seq.)
Advise families, visitors, and patients about the importance of hand hygiene to minimize the
spread of body substance contamination (e.g., respiratory secretions or fecal matter) to
surfaces.952 Category II
Do not use high-level disinfectants (i.e., liquid chemical sterilants) on environmental
surfaces; such use is inconsistent with label instructions and because of the toxicity of the
chemicals.2, 951, 952, 964 Category IC (FDA: 21 CFR 801.5, 807.87.e)
Because no EPA-registered products are specific for inactivating Clostridium difficile
spores, use hypochlorite-based products for disinfection of environmental surfaces in those
patient-care areas where surveillance and epidemiology indicate ongoing transmission of C.
difficile.952, 1130, 1141
Category II
No recommendation is offered regarding the use of specific EPA-registered hospital
disinfectants with respect to environmental control of C. difficile. Unresolved issue
Apply standard cleaning and disinfection procedures to control environmental
contamination with respiratory and enteric viruses in pediatric-care units and care areas for
immunocompromised patients.986, 1158 Category IC (EPA: 7 USC § 136 et seq.)
Clean surfaces that have been contaminated with body substances; perform low- to
intermediate-level disinfection on cleaned surfaces with an EPA-registered disinfectant in
accordance with the manufacturer’s instructions.967, 974, 1158 Category IC (OSHA: 29 CFR
1910.1030 § d.4.ii.A; EPA: 7 USC § 136 et seq.)
K.
L.
Use disposable barrier coverings as appropriate to minimize surface contamination.
Category II
Develop and maintain cleaning and disinfection procedures to control environmental
contamination with agents of Creutzfeldt-Jakob disease (CJD), for which no EPA-registered
product exists. Category II
1.
In the absence of contamination with central nervous system tissue, extraordinary
measures (e.g., use of 2N sodium hydroxide [NaOH] or applying full-strength sodium
hypochlorite) are not needed for routine cleaning or terminal disinfection of a room
housing a confirmed or suspected CJD patient.951, 1199 Category II
2.
After removing gross tissue from the surface, use either 1N NaOH or a sodium
hypochlorite solution containing approximately 10,000–20,000 ppm available
chlorine (dilutions of 1:5 to 1:3 v/v, respectively, of U.S. household chlorine bleach;
contact the manufacturers of commercially available sodium hypochlorite products
for advice) to decontaminate operating room or autopsy surfaces with central nervous
system or cerebral spinal fluid contamination from a diagnosed or suspected CJD
patient.951, 1170, 1188, 1191, 1197–1199, 1201 Category II
a.
The contact time for the chemical used during this process should be 30 min–1
hour.1191, 1197, 1201
b.
Blot up the chemical with absorbent material and rinse the treated surface
thoroughly with water.
c.
Discard the used, absorbent material into appropriate waste containment.
3.
Use disposable, impervious covers to minimize body substance contamination to
autopsy tables and surfaces.1197, 1201 Category IB
138
M.
Use standard procedures for containment, cleaning, and decontamination of blood spills on
surfaces as previously described (Environmental Services: II).967 Category IC (OSHA: 29
CFR 1910.1030 §d.4.ii.A)
1.
2.
Wear PPE appropriate for a surface decontamination and cleaning task.967, 1199
Category IC (OSHA 29 CFR 1910.1030 §d.3.i, ii)
Discard used PPE by using routine disposal procedures or decontaminate reusable
PPE as appropriate.967, 1199 Category IC (OSHA 29 CFR 1910.1030 §d.3.viii)
F. Recommendations—Environmental Sampling
I.
General Information
A. Do not conduct random, undirected microbiologic sampling of air, water, and
environmental surfaces in health-care facilities.2, 1214 Category IB
B.
When indicated, conduct microbiologic sampling as part of an epidemiologic investigation
or during assessment of hazardous environmental conditions to detect contamination and
verify abatement of a hazard.2, 1214 Category IB
C.
Limit microbiologic sampling for quality assurance purposes to 1) biological monitoring of
sterilization processes; 2) monthly cultures of water and dialysate in hemodialysis units; and
3) short-term evaluation of the impact of infection-control measures or changes in infectioncontrol protocols.2, 1214 Category IB
II.
Air, Water, and Environmental-Surface Sampling
A. When conducting any form of environmental sampling, identify existing comparative
standards and fully document departures from standard methods.945, 1214, 1223, 1224, 1238
Category II
B.
Select a high-volume air sampling device if anticipated levels of microbial airborne
contamination are expected to be low.290, 1218, 1223, 1224 Category II
C.
Do not use settle plates to quantify the concentration of airborne fungal spores.290
Category II
D. When sampling water, choose growth media and incubation conditions that will facilitate
the recovery of waterborne organisms.945 Category II
E.
When using a sample/rinse method for sampling an environmental surface, develop and
document a procedure for manipulating the swab, gauze, or sponge in a reproducible
manner so that results are comparable.1238 Category II
F.
When environmental samples and patient specimens are available for comparison, perform
the laboratory analysis on the recovered microorganisms down to the species level at a
minimum and beyond the species level if possible.1214 Category II
G. Recommendations—Laundry and Bedding
I.
Employer Responsibilities
A. Employers must launder workers’ personal protective garments or uniforms that are
contaminated with blood or other potentially infectious materials.967 Category IC
29 CFR 1910.1030 § d.3.iv)
(OSHA:
139
II.
Laundry Facilities and Equipment
A. Maintain the receiving area for contaminated textiles at negative pressure compared with
the clean areas of the laundry in accordance with AIA construction standards in effect
during the time of facility construction.120, 1260–1262 Category IC (AIA: 7.23.B1, B2)
B.
Ensure that laundry areas have handwashing facilities and products and appropriate PPE
available for workers.120, 967 Category IC (AIA: 7.23.D4; OSHA: 29 CFR 1910.1030 § d.2.iii)
C.
Use and maintain laundry equipment according to manufacturers’ instructions.1250, 1263
Category II
D. Do not leave damp textiles or fabrics in machines overnight.1250 Category II
E.
Disinfection of washing and drying machines in residential care is not needed as long as
gross soil is removed before washing and proper washing and drying procedures are used.
Category II
III.
Routine Handling of Contaminated Laundry
A. Handle contaminated textiles and fabrics with minimum agitation to avoid contamination of
air, surfaces, and persons.6, 967, 1258, 1259 Category IC (OSHA: 29 CFR 1910.1030 § d.4.iv)
B.
Bag or otherwise contain contaminated textiles and fabrics at the point of use.967
Category IC (OSHA: 29 CFR 1910.1030 § d.4.iv)
1.
Do not sort or prerinse contaminated textiles or fabrics in patient-care areas.967
Category IC (OSHA: 29 CFR 1910.1030 §d.4.iv)
2.
Use leak-resistant containment for textiles and fabrics contaminated with blood or
body substances.967, 1258 Category IC (OSHA: 29 CFR 1910.1030 § d.4.iv)
3.
Identify bags or containers for contaminated textiles with labels, color coding, or
other alternative means of communication as appropriate.967 Category IC (OSHA:
29 CFR 1910.1030 § d.4.iv)
C.
D.
E.
Covers are not needed on contaminated textile hampers in patient-care areas. Category II
If laundry chutes are used, ensure that they are properly designed, maintained, and used in a
manner to minimize dispersion of aerosols from contaminated laundry.1253, 1267–1270
Category IC (AAMI: ANSI/AAMI ST65:2000)
1.
Ensure that laundry bags are closed before tossing the filled bag into the chute.
Category II
2.
Do not place loose items in the chute. Category II
Establish a facility policy to determine when textiles or fabrics should be sorted in the
laundry facility (i.e., before or after washing).1271, 1272 Category II
IV.
Laundry Process
A. If hot-water laundry cycles are used, wash with detergent in water >160°F (>71°C) for >25
minutes.2, 120 Category IC (AIA: 7.31.E3)
B.
No recommendation is offered regarding a hot-water temperature setting and cycle
duration for items laundered in residence-style health-care facilities. Unresolved issue
C.
Follow fabric-care instructions and special laundering requirements for items used in the
facility.1278 Category II
D. Choose chemicals suitable for low-temperature washing at proper use concentration if lowtemperature (<160°F [<71°C]) laundry cycles are used.1247, 1281–1285 Category II
E.
Package, transport, and store clean textiles and fabrics by methods that will ensure their
cleanliness and protect them from dust and soil during interfacility loading, transport, and
unloading.2 Category II
V.
Microbiologic Sampling of Textiles
A. Do not conduct routine microbiological sampling of clean textiles.2, 1286
Category IB
140
B.
VI.
Use microbiological sampling during outbreak investigations if epidemiologic evidence
suggests a role for health-care textiles and clothing in disease transmission.1286 Category
IB
Special Laundry Situations
A. Use sterilized textiles, surgical drapes, and gowns for situations requiring sterility in patient
care.7 Category IB
B.
Use hygienically clean textiles (i.e., laundered, but not sterilized) in neonatal intensive care
units.997, 1288 Category IB
C.
Follow manufacturers’ recommendations for cleaning fabric products including those with
coated or laminated surfaces. Category II
D. Do not use dry cleaning for routine laundering in health-care facilities.1289–1291 Category
II
E.
Use caution when considering the use of antimicrobial mattresses, textiles, and clothing as
replacements for standard bedding and other fabric items; EPA has not approved public
health claims asserting protection against human pathogens for treated articles.1306
Category II
F.
No recommendation is offered regarding using disposable fabrics and textiles versus
durable goods. Unresolved issue
VII. Mattresses and Pillows
A. Keep mattresses dry; discard them if they become and remain wet or stained, particularly in
burn units.1310–1315 Category IB
B.
Clean and disinfect mattress covers using EPA-registered disinfectants, if available, that are
compatible with the cover materials to prevent the development of tears, cracks, or holes in
the cover.1310–1315 Category IB
C.
Maintain the integrity of mattress and pillow covers. Category II
1.
Replace mattress and pillow covers if they become torn or otherwise in need of repair.
Category II
2.
Do not stick needles into the mattress through the cover. Category II
D. Clean and disinfect moisture-resistant mattress covers between patients using an EPAregistered product, if available.1310–1315 Category IB
E.
If using a mattress cover completely made of fabric, change these covers and launder
between patients.1310–1315 Category IB
F.
Launder pillow covers and washable pillows in the hot-water cycle between patients or
when they become contaminated with body substances.1315 Category IB
VIII. Air-Fluidized Beds
A. Follow manufacturers’ instructions for bed maintenance and decontamination. Category
II
B.
Change the polyester filter sheet at least weekly or as indicated by the manufacturer.1317, 1318,
1322, 1323
Category II
C.
Clean and disinfect the polyester filter sheet thoroughly, especially between patients, using
an EPA-registered product, if available.1317, 1318, 1322, 1323 Category IB
D. Consult the facility engineer to determine the proper location of air-fluidized beds in
negative-pressure rooms.1326 Category II
141
H. Recommendations—Animals in Health-Care Facilities
I.
General Infection-Control Measures for Animal Encounters
A. Minimize contact with animal saliva, dander, urine, and feces.1365–1367 Category II
B.
Practice hand hygiene after any animal contact.2, 1364 Category IB
1.
Wash hands with soap and water, especially if hands are visibly soiled.1364
Category IB
2.
Use either soap and water or alcohol-based hand rubs when hands are not visibly
soiled.1364 Category IB
II.
Animal-Assisted Activities, Animal-Assisted Therapy, and Resident Animal Programs
A. Avoid selection of nonhuman primates and reptiles in animal-assisted activities, animalassisted therapy, or resident animal programs.1360–1362 Category IB
B.
Enroll animals that are fully vaccinated for zoonotic diseases and that are healthy, clean,
well-groomed, and negative for enteric parasites or otherwise have completed recent
antihelminthic treatment under the regular care of a veterinarian.1349, 1360
Category II
C.
Enroll animals that are trained with the assistance or under the direction of individuals who
are experienced in this field.1360 Category II
D. Ensure that animals are handled by persons trained in providing activities or therapies
safely, and who know the animals’ health status and behavior traits.1349, 1360 Category II
E.
Take prompt action when an incident of biting or scratching by an animal occurs during an
animal-assisted activity or therapy.
1.
Remove the animal permanently from these programs.1360 Category II
2.
Report the incident promptly to appropriate authorities (e.g., infection-control staff,
animal program coordinator, or local animal control).1360 Category II
3.
Promptly clean and treat scratches, bites, or other accidental breaks in the skin.
Category II
F.
Perform an ICRA and work actively with the animal handler prior to conducting an animalassisted activity or therapy to determine if the session should be held in a public area of the
facility or in individual patient rooms. 1349, 1360 Category II
G. Take precautions to mitigate allergic responses to animals. Category II
1.
Minimize shedding of animal dander by bathing animals <24 hours before a visit.1360
Category II
2.
Groom animals to remove loose hair before a visit, or using a therapy animal cape.1358
Category II
H. Use routine cleaning protocols for housekeeping surfaces after therapy sessions.
Category II
I.
Restrict resident animals, including fish in fish tanks, from access to or placement in
patient-care areas, food preparation areas, dining areas, laundry, central sterile supply areas,
sterile and clean supply storage areas, medication preparation areas, operating rooms,
isolation areas, and PE areas. Category II
J.
Establish a facility policy for regular cleaning of fish tanks, rodent cages, bird cages, and
any other animal dwellings and assign this cleaning task to a nonpatient-care staff member;
avoid splashing tank water or contaminating environmental surfaces with animal bedding.
Category II
III.
Protective Measures for Immunocompromised Patients
A. Advise patients to avoid contact with animal feces and body fluids such as saliva, urine, or
solid litter box material.8 Category II
142
B.
C.
D.
E.
IV.
Promptly clean and treat scratches, bites, or other wounds that break the skin.8 Category
II
Advise patients to avoid direct or indirect contact with reptiles.1340
Category IB
Conduct a case-by-case assessment to determine if animal-assisted activities or animalassisted therapy programs are appropriate for immunocompromised patients.1349 Category
II
No recommendation is offered regarding permitting pet visits to terminally ill
immunosuppressed patients outside their PE units. Unresolved issue
Service Animals
A. Avoid providing access to nonhuman primates and reptiles as service animals.1340, 1362
Category IB
B.
Allow service animals access to the facility in accordance with the Americans with
Disabilities Act of 1990, unless the presence of the animal creates a direct threat to other
persons or a fundamental alteration in the nature of services.1366, 1376 Category IC (U.S.
Department of Justice: 28 CFR § 36.302)
C.
D.
V.
When a decision must be made regarding a service animal’s access to any particular area of
the health-care facility, evaluate the service animal, the patient, and the health-care situation
on a case-by-case basis to determine whether significant risk of harm exists and whether
reasonable modifications in policies and procedures will mitigate this risk.1376
Category
IC (Justice: 28 CFR § 36.208 and App.B)
If a patient must be separated from his or her service animal while in the health-care facility
1) ascertain from the person what arrangements have been made for supervision or care of
the animal during this period of separation; and 2) make appropriate arrangements to
address the patient’s needs in the absence of the service animal. Category II
Animals as Patients in Human Health-Care Facilities
A. Develop health-care facility policies to address the treatment of animals in human healthcare facilities.
1.
Use the multidisciplinary team approach to policy development, including public
media relations in order to disclose and discuss these activities. Category II
2.
Exhaust all veterinary facility, equipment, and instrument options before undertaking
the procedure. Category II
3.
Ensure that the care of the animal is supervised by a licensed veterinarian.
Category II
B.
When animals are treated in human health-care facilities, avoid treating animals in
operating rooms or other patient-care areas where invasive procedures are performed (e.g.,
cardiac catheterization laboratories, or invasive nuclear medicine areas). Category II
C.
Schedule the animal procedure for the last case of the day for the area, at a time when
human patients are not scheduled to be in the vicinity. Category II
D. Adhere strictly to standard precautions. Category II
E.
Clean and disinfect environmental surfaces thoroughly using an EPA-registered product in
the room after the animal is removed. Category II
F.
Allow sufficient ACH to clean the air and help remove airborne dander, microorganisms,
and allergens [Appendix B, Table B.1.]). Category II
G. Clean and disinfect using EPA-registered products or sterilize equipment that has been in
contact with animals, or use disposable equipment. Category II
H. If reusable medical or surgical instruments are used in an animal procedure, restrict future
use of these instruments to animals only. Category II
143
VI.
Research Animals in Health-Care Facilities
A. Use animals obtained from quality stock, or quarantine incoming animals to detect zoonotic
diseases. Category II
B.
Treat sick animals or remove them from the facility. Category II
C.
Provide prophylactic vaccinations, as available, to animal handlers and contacts at high risk.
Category II
D. Ensure proper ventilation through appropriate facility design and location.1395 Category
IC (U.S. Department of Agriculture [USDA]: 7 USC 2131)
1.
Keep animal rooms at negative pressure relative to corridors.1395 Category IC
(USDA: 7 USC 2131)
2.
E.
F.
G.
Prevent air in animal rooms from recirculating elsewhere in the health-care
facility.1395 Category IC (USDA: 7 USC 2131)
Keep doors to animal research rooms closed. Category II
Restrict access to animal facilities to essential personnel. Category II
Establish employee occupational health programs specific to the animal research facility,
and coordinate management of postexposure procedures specific for zoonoses with
occupational health clinics in the health-care facility.1013, 1378 Category IC (U.S. Department
of Health and Human Services [DHHS]: BMBL; OSHA: 29 CFR 1910.1030.132-139)
H.
I.
Document standard operating procedures for the unit.1013 Category IC (DHHS: BMBL)
Conduct routine employee training on worker safety issues relevant to the animal research
facility (e.g., working safely with animals and animal handling).1013, 1393 Category IC
(DHHS: BMBL; OSHA: 29 CFR 1910.1030.132-139)
J.
Use precautions to prevent the development of animal-induced asthma in animal
workers.1013 Category IC (DHHS: BMBL)
I. Recommendations—Regulated Medical Waste
I.
Categories of Regulated Medical Waste
A. Designate the following as major categories of medical waste that require special handling
and disposal precautions: 1) microbiology laboratory wastes [e.g., cultures and stocks of
microorganisms]; 2) bulk blood, blood products, blood, and bloody body fluid specimens;
3) pathology and anatomy waste; and 4) sharps [e.g., needles and scalpels].2 Category II
B.
Consult federal, state, and local regulations to determine if other waste items are considered
regulated medical wastes.967, 1407, 1408 Category IC (States; Authorities having jurisdiction [AHJ];
OSHA: 29 CFR 1910.1030 §g.2.1; U.S. Department of Transportation [DOT]: 49 CFR 171-180; U.S. Postal Service: CO23.8)
II.
Disposal Plan for Regulated Medical Wastes
A. Develop a plan for the collection, handling, predisposal treatment, and terminal disposal of
regulated medical wastes.967, 1409 Category IC (States; AHJ; OSHA: 29 CFR 1910.1030 §g.2.i;)
B.
Designate a person or persons to be responsible for establishing, monitoring, reviewing, and
administering the plan. Category II
III.
Handling, Transporting, and Storing Regulated Medical Wastes
A. Inform personnel involved in the handling and disposal of potentially infective waste of the
possible health and safety hazards; ensure that they are trained in appropriate handling and
disposal methods.967 Category IC (OSHA: 29 CFR 1910.1030 § g.2.i)
B.
Manage the handling and disposal of regulated medical wastes generated in isolation areas
by using the same methods as for regulated medical wastes from other patient-care areas.2
Category II
C.
Use proper sharps disposal strategies.967 Category IC (OSHA: 29 CFR 1910.1030 § d.4.iii.A)
144
1.
2.
Use a sharps container capable of maintaining its impermeability after waste
treatment to avoid subsequent physical injuries during final disposal.967 Category
IC (OSHA: 29 CFR 1910.1030 § d.4.iii.A)
Place disposable syringes with needles, including sterile sharps that are being
discarded, scalpel blades, and other sharp items into puncture-resistant containers
located as close as practical to the point of use.967 Category IC (OSHA: 29 CFR
1910.1030 § d.4.iii.A)
3.
D.
E.
IV.
Do not bend, recap, or break used syringe needles before discarding them into a
container.6, 967, 1415 Category IC (OSHA: 29 CFR 1910.1030 § d.2.vii and § d.2.vii.A)
Store regulated medical wastes awaiting treatment in a properly ventilated area that is
inaccessible to vertebrate pests; use waste containers that prevent the development of
noxious odors. Category IC (States; AHJ)
If treatment options are not available at the site where the medical waste is generated,
transport regulated medical wastes in closed, impervious containers to the on-site treatment
location or to another facility for treatment as appropriate. Category IC (States; AHJ)
Treatment and Disposal of Regulated Medical Wastes
A. Treat regulated medical wastes by using a method (e.g., steam sterilization, incineration,
interment, or an alternative treatment technology) approved by the appropriate authority
having jurisdiction (AHJ) (e.g., states, Indian Health Service [IHS], Veterans Affairs [VA])
before disposal in a sanitary landfill. Category IC (States, AHJ)
B.
Follow precautions for treating microbiological wastes (e.g., amplified cultures and stocks
of microorganisms).1013 Category IC (DHHS: BMBL)
1.
Biosafety level 4 laboratories must inactivate microbiological wastes in the laboratory
by using an approved inactivation method (e.g., autoclaving) before transport to and
disposal in a sanitary landfill.1013 Category IC (DHHS: BMBL)
2.
Biosafety level 3 laboratories must inactivate microbiological wastes in the laboratory
by using an approved inactivation method (e.g., autoclaving) or incinerate them at the
facility before transport to and disposal in a sanitary landfill.1013 Category IC
(DHHS: BMBL)
C.
D.
E.
V.
Biosafety levels 1 and 2 laboratories should develop strategies to inactivate amplified
microbial cultures and stocks onsite by using an approved inactivation method (e.g.,
autoclaving) instead of packaging and shipping untreated wastes to an offsite facility for
treatment and disposal.1013, 1419–1421 Category II
Laboratories that isolate select agents from clinical specimens must comply with federal
regulations for the receipt, transfer, management, and appropriate disposal of these
agents.1412 Category IC (DHHS: 42 CFR 73 § 73.6)
Sanitary sewers may be used for the safe disposal of blood, suctioned fluids, ground tissues,
excretions, and secretions, provided that local sewage discharge requirements are met and
that the state has declared this to be an acceptable method of disposal.1414 Category II
Special Precautions for Wastes Generated During Care of Patients with Rare Diseases
A. When discarding items contaminated with blood and body fluids from VHF patients,
contain these regulated medical wastes with minimal agitation during handling.6, 203
Category II
B.
Manage properly contained wastes from areas providing care to VHF patients in accordance
with recommendations for other isolation areas (Regulated Medical Waste: III B).2, 6, 203
Category II
C.
Decontaminate bulk blood and body fluids from VHF patients using approved inactivation
methods (e.g., autoclaving or chemical treatment) before disposal.6, 203 Category IC, II
(States; AHJ)
145
D.
E.
When discarding regulated medical waste generated during the routine (i.e., non-surgical)
care of CJD patients, contain these wastes and decontaminate them using approved
inactivation methods (e.g., autoclaving or incineration) appropriate for the medical waste
category (e.g., blood, sharps, pathological waste).2, 6, 948, 1199 Category IC, II (States; AHJ)
Incinerate medical wastes (e.g., central nervous system tissues or contaminated disposable
materials) from brain autopsy or biopsy procedures of diagnosed or suspected CJD
patients.1197, 1201 Category IB
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listed in the MMWR version of this guideline.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
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16.
17.
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(Box 2) Flournoy DJ, Belobraydic KA, Silberg SL, Lawrence CH, Guthrie PJ. False postive Legionella
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(Box 2) Bej AK, Majbubani MH, Atlas RM. Detection of viable Legionella pneumophila in water by
polymerase chain reaction and gene probe methods. Appl Environ Microbiol 1991;57:597–600.
Schulze-Röbbecke R, Jung KD, Pullman H, Hundgeburth J. Control of Legionella pneumophila in a
hospital hot water system. Zbl Hyg 1990;190:84–100.
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Part IV. Appendices
Appendix A. Glossary of Terms
Acceptable indoor air quality: air in which there are no known contaminants at harmful
concentrations as determined by knowledgeble authorities and with which a substantial majority (>80%)
of the people exposed do not express dissatisfaction.
ACGIH: American Conference of Governmental Industrial Hygienists.
Action level: the concentration of a contaminant at which steps should be taken to interrupt the trend
toward higher, unacceptable levels.
Aerosol: particles of respirable size generated by both humans and environmental sources and that
have the capability of remaining viable and airborne for extended periods in the indoor environment.
AIA: American Institute of Architects, a professional group responsible for publishing the Guidelines
for Design and Construction of Hospitals and Healthcare Facilities, a consensus document for design
and construction of health-care facilities endorsed by the U.S. Department of Health and Human
Services, health-care professionals, and professional organizations.
Air changes per hour (ACH): the ratio of the volume of air flowing through a space in a certain
period of time (the airflow rate) to the volume of that space (the room volume). This ratio is expressed
as the number of air changes per hour (ACH).
Air mixing: the degree to which air supplied to a room mixes with the air already in the room, usually
expressed as a mixing factor. This factor varies from 1 (for perfect mixing) to 10 (for poor mixing). It
is used as a multiplier to determine the actual airflow required (i.e., the recommended ACH multiplied
by the mixing factor equals the actual ACH required).
Airborne transmission: a means of spreading infection when airborne droplet nuclei (small particle
residue of evaporated droplets <5 µm in size containing microorganisms that remain suspended in air
for long periods of time) are inhaled by the susceptible host.
Air-cleaning system: a device or combination of devices applied to reduce the concentration of
airborne contaminants (e.g., microorganisms, dusts, fumes, aerosols, other particulate matter, and
gases).
Air conditioning: the process of treating air to meet the requirements of a conditioned space by
controlling its temperature, humidity, cleanliness, and distribution.
Allogeneic: non-twin, non-self. The term refers to transplanted tissue from a donor closely matched to
a recipient but not related to that person.
Ambient air: the air surrounding an object.
Anemometer: a flow meter which measures the wind force and velocity of air. An anemometer is
often used as a means of determining the volume of air being drawn into an air sampler.
Anteroom: a small room leading from a corridor into an isolation room. This room can act as an
airlock, preventing the escape of contaminants from the isolation room into the corridor.
ASHE: American Society for Healthcare Engineering, an association affiliated with the American
Hospital Association.
ASHRAE: American Society of Heating, Refrigerating, and Air-Conditioning Engineers Inc.
Autologous: self. The term refers to transplanted tissue whose source is the same as the recipient, or
an identical twin.
Automated cycler: a machine used during peritoneal dialysis which pumps fluid into and out of the
patient while he/she sleeps.
Biochemical oxygen demand (BOD): a measure of the amount of oxygen removed from aquatic
environments by aerobic microorganisms for their metabolic requirements. Measurement of BOD is
used to determine the level of organic pollution of a stream or lake. The greater the BOD, the greater
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the degree of water pollution. The term is also referred to as Biological Oxygen Demand (BOD).
Biological oxygen demand (BOD): an indirect measure of the concentration of biologically
degradable material present in organic wastes (pertaining to water quality). It usually reflects the
amount of oxygen consumed in five days by biological processes breaking down organic waste (BOD5).
Biosafety level: a combination of microbiological practices, laboratory facilities, and safety equipment
determined to be sufficient to reduce or prevent occupational exposures of laboratory personnel to the
microbiological agents they work with. There are four biosafety levels based on the hazards associated
with the various microbiological agents.
BOD5: the amount of dissolved oxygen consumed in five days by biological processes breaking down
organic matter.
Bonneting: a floor cleaning method for either carpeted or hard surface floors that uses a circular
motion of a large fibrous disc to lift and remove soil and dust from the surface.
Capped spur: a pipe leading from the water recirculating system to an outlet that has been closed off
(“capped”). A capped spur cannot be flushed, and it might not be noticed unless the surrounding wall is
removed.
CFU/m3: colony forming units per cubic meter (of air).
Chlamydospores: thick-walled, typically spherical or ovoid resting spores asexually produced by
certain types of fungi from cells of the somatic hyphae.
Chloramines: compounds containing nitrogen, hydrogen, and chlorine. These are formed by the
reaction between hypochlorous acid (HOCl) and ammonia (NH3) and/or organic amines in water. The
formation of chloramines in drinking water treatment extends the disinfecting power of chlorine. The
term is also referred to as Combined Available Chlorine.
Cleaning: the removal of visible soil and organic contamination from a device or surface, using either
the physical action of scrubbing with a surfactant or detergent and water, or an energy-based process
(e.g., ultrasonic cleaners) with appropriate chemical agents.
Coagulation-flocculation: coagulation is the clumping of particles that results in the settling of
impurities. It may be induced by coagulants (e.g., lime, alum, and iron salts). Flocculation in water and
wastewater treatment is the agglomeration or clustering of colloidal and finely-divided suspended matter
after coagulation by gentle stirring by either mechanical or hydraulic means, such that they can be
separated from water or sewage.
Commissioning (a room): testing a system or device to ensure that it meets the pre-use specifications
as indicated by the manufacturer or predetermined standard, or air sampling in a room to establish a preoccupancy baseline standard of microbial or particulate contamination. The term is also referred to as
benchmarking at 77°F (25°C).
Completely packaged: functionally packaged, as for laundry.
Conidia: asexual spores of fungi borne externally.
Conidiophores: specialized hyphae that bear conidia in fungi.
Conditioned space: that part of a building that is heated or cooled, or both, for the comfort of the
occupants.
Contaminant: an unwanted airborne constituent that may reduce the acceptibility of air.
Convection: the transfer of heat or other atmospheric properties within the atmosphere or in the
airspace of an enclosure by the circulation of currents from one region to another, especially by such
motion directed upward.
Cooling tower: a structure engineered to receive accumulated heat from ventilation systems and
equipment and transfer this heat to water, which then releases the stored heat to the atmosphere through
evaporative cooling.
Critical item (medical instrument): a medical instrument or device that contacts normally sterile
areas of the body or enters the vascular system. There is a high risk of infection from such devices if
they are microbiologically contaminated prior to use. These devices must be sterilized before use.
Dead legs: areas in the water system where water stagnates. A dead leg is a pipe or spur, leading from
the water recirculating system to an outlet that is used infrequently, resulting in inadequate flow of
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water from the recirculating system to the outlet. This inadequate flow reduces the perfusion of heat or
chlorine into this part of the water distribution system, thereby adversely affecting the disinfection of the
water system in that area.
Deionization: removal of ions from water by exchange with other ions associated with fixed charges
on a resin bed. Cations are usually removed and H+ ions are exchanged; OH- ions are exchanged for
anions.
Detritis: particulate matter produced by or remaining after the wearing away or disintegration of a
substance or tissue.
Dew point: the temperature at which a gas or vapor condenses to form a liquid; the point at which
moisture begins to condense out of the air. At dew point, air is cooled to the point where it is at 100%
relative humidity or saturation.
Dialysate: the aqueous electrolyte solution, usually containing dextrose, used to make a concentration
gradient between the solution and blood in the hemodialyzer (dialyzer).
Dialyzer: a device that consists of two compartments (blood and dialysate) separated by a
semipermeable membrane. A dialyzer is usually referred to as an artificial kidney.
Diffuser: the grille plate that disperses the air stream coming into the conditioned air space.
Direct transmission: involves direct body surface-to-body surface contact and physical transfer of
microorganisms between a susceptible host and an infected/colonized person, or exposure to cloud of
infectious particles within 3 feet of the source; the aerosolized particles are >5 µm in size.
Disability: as defined by the Americans with Disabilities Act, a disability is any physical or mental
impairment that substantially limits one or more major life activities, including but not limited to
walking, talking, seeing, breathing, hearing, or caring for oneself.
Disinfection: a generally less lethal process of microbial inactivation (compared to sterilization) that
eliminates virtually all recognized pathogenic microorganisms but not necessarily all microbial forms
(e.g., bacterial spores).
Drain pans: pans that collect water within the HVAC system and remove it from the system.
Condensation results when air and steam come together.
Drift: circulating water lost from the cooling tower in the form as liquid droplets entrained in the
exhaust air stream (i.e., exhaust aerosols from a cooling tower).
Drift eliminators: an assembly of baffles or labyrinth passages through which the air passes prior to its
exit from the cooling tower. The purpose of a drift eliminator is to remove entrained water droplets
from the exhaust air.
Droplets: particles of moisture, such as are generated when a person coughs or sneezes, or when water
is converted to a fine mist by a device such as an aerator or shower head. These particles may contain
infectious microorganisms. Intermediate in size between drops and droplet nuclei, these particles tend
to quickly settle out from the air so that any risk of disease transmission is generally limited to persons
in close proximity to the droplet source.
Droplet nuclei: sufficiently small particles (1–5 µm in diameter) that can remain airborne indefinitely
and cause infection when a susceptible person is exposed at or beyond 3 feet of the source of these
particles.
Dual duct system: an HVAC system that consists of parallel ducts that produce a cold air stream in
one and a hot air stream in the other.
Dust: an air suspension of particles (aerosol) of any solid material, usually with particle sizes <100 µm
in diameter.
Dust-spot test: a procedure that uses atmospheric air or a defined dust to measure a filter’s ability to
remove particles. A photometer is used to measure air samples on either side of the filter, and the
difference is expressed as a percentage of particles removed.
Effective leakage area: the area through which air can enter or leave the room. This does not include
supply, return, or exhaust ducts. The smaller the effective leakage area, the better isolated the room.
Endotoxin: the lipopolysaccharides of gram-negative bacteria, the toxic character of which resides in
the lipid portion. Endotoxins generally produce pyrogenic reactions in persons exposed to these
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bacterial components.
Enveloped virus: a virus whose outer surface is derived from a membrane of the host cell (either
nuclear or the cell’s outer membrane) during the budding phase of the maturation process. This
membrane-derived material contains lipid, a component that makes these viruses sensitive to the action
of chemical germicides.
Evaporative condenser: a wet-type, heat-rejection unit that produces large volumes of aerosols during
the process of removing heat from conditioned space air.
Exhaust air: air removed from a space and not reused therein.
Exposure: the condition of being subjected to something (e.g., infectious agents) that could have a
harmful effect.
Fastidious: having complex nutritional requirements for growth, as in microorganisms.
Fill: that portion of a cooling tower which makes up its primary heat transfer surface. Fill is
alternatively known as “packing.”
Finished water: treated, or potable water.
Fixed room-air HEPA recirculation systems: nonmobile devices or systems that remove airborne
contaminants by recirculating air through a HEPA filter. These may be built into the room and
permanently ducted or may be mounted to the wall or ceiling within the room. In either situation, they
are fixed in place and are not easily movable.
Fomite: an inanimate object that may be contaminated with microorganisms and serves in their
transmission.
Free and available chlorine: the term applied to the three forms of chlorine that may be found in
solution (i.e., chlorine [Cl2] , hypochlorite [OCl–], and hypochlorous acid [HOCl]).
Germicide: a chemical that destroys microorganisms. Germicides may be used to inactivate
microorganisms in or on living tissue (antiseptics) or on environmental surfaces (disinfectants).
Health-care–associated: an outcome, usually an infection, that occurs in any health-care facility as a
result of medical care. The term “health-care–associated” replaces “nosocomial,” the latter term being
limited to adverse infectious outcomes occurring only in hospitals.
Hemodiafiltration: a form of renal replacement therapy in which waste solutes in the patient’s blood
are removed by both diffusion and convection through a high-flux membrane.
Hemodialysis: a treatment for renal replacement therapy in which waste solutes in the patient’s blood
are removed by diffusion and/or convection through the semipermeable membrane of an artificial
kidney or dialyzer.
Hemofiltration: cleansing of waste products or other toxins from the blood by convection across a
semipermeable, high-flux membrane where fluid balance is maintained by infusion of sterile, pyrogenfree substitution fluid pre- or post-hemodialyzer.
HEPA filter: High Efficiency Particulate Air filters capable of removing 99.97% of particles 0.3 µm in
diameter and may assist in controlling the transmission of airborne disease agents. These filters may be
used in ventilation systems to remove particles from the air or in personal respirators to filter air before
it is inhaled by the person wearing the respirator. The use of HEPA filters in ventilation systems
requires expertise in installation and maintenance. To test this type of filter, 0.3 µm particles of
dioctylphthalate (DOP) are drawn through the filter. Efficiency is calculated by comparing the
downstream and upstream particle counts. The optimal HEPA filter allows only three particles to pass
through for every 10,000 particles that are fed to the filter.
Heterotrophic (heterotroph): that which requires some nutrient components from exogenous sources.
Heterotrophic bacteria cannot synthesize all of their metabolites and therefore require certain nutrients
from other sources.
High-efficiency filter: a filter with a particle-removal efficiency of 90%–95%.
High flux: a type of dialyzer or hemodialysis treatment in which large molecules (>8,000 daltons [e.g.,
β2 microglobulin]) are removed from blood.
High-level disinfection: a disinfection process that inactivates vegetative bacteria, mycobacteria, fungi,
and viruses, but not necessarily high numbers of bacterial spores.
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Housekeeping surfaces: environmental surfaces (e.g., floors, walls, ceilings, and tabletops) that are not
involved in direct delivery of patient care in health-care facilities.
Hoyer lift: an apparatus that facilitates the repositioning of the non-ambulatory patient from bed to
wheelchair or gurney and subsequently to therapy equipment (immersion tanks).
Hubbard tank: a tank used in hydrotherapy that may accomodate whole-body immersion (e.g., as may
be indicated for burn therapy). Use of a Hubbard tank has been replaced largely by bedside post-lavage
therapy for wound care management.
HVAC: Heating, Ventilation, Air Conditioning.
Iatrogenic: induced in a patient by a physician’s activity, manner, or therapy. The term is used
especially in reference to an infectious complication or other adverse outcome of medical treatment.
Impactor: an air-sampling device in which particles and microorganisms are directed onto a solid
surface and retained there for assay.
Impingement: an air-sampling method during which particles and microorganisms are directed into a
liquid and retained there for assay.
Indirect transmission: involves contact of a susceptible host with a contaminated intermediate object,
usually inanimate (a fomite).
Induction unit: the terminal unit of an in-room ventilation system. Induction units take centrally
conditioned air and further moderate its temperature. Induction units are not appropriate for areas with
high exhaust requirements (e.g., research laboratories).
Intermediate-level disinfection: a disinfection process that inactivates vegetative bacteria, most fungi,
mycobacteria, and most viruses (particularly the enveloped viruses), but does not inactivate bacterial
spores.
Isoform: a possible configuration (tertiary structure) of a protein molecule. With respect to prion
proteins, the molecules with large amounts of α-conformation are the normal isoform of that particular
protein, whereas those prions with large amounts of β-sheet conformation are the proteins associated
with the development of spongiform encephalopathy (e.g., Creutzfeldt-Jakob disease [CJD]).
Laminar flow: HEPA-filtered air that is blown into a room at a rate of 90 ± 10 feet/min in a
unidirectional pattern with 100 ACH–400 ACH.
Large enveloped virus: viruses whose particle diameter is >50 nm and whose outer surface is covered
by a lipid-containing structure derived from the membranes of the host cells. Examples of large
enveloped viruses include influenza viruses, herpes simplex viruses, and poxviruses.
Laser plume: the transfer of electromagnetic energy into tissues which results in a release of particles,
gases, and tissue debris.
Lipid-containing viruses: viruses whose particle contains lipid components. The term is generally
synonymous with enveloped viruses whose outer surface is derived from host cell membranes. Lipidcontaining viruses are sensitive to the inactivating effects of liquid chemical germicides.
Lithotriptors: instruments used for crushing caliculi (i.e., calcified stones, and sand) in the bladder or
kidneys.
Low efficiency filter: the prefilter with a particle-removal efficiency of approximately 30% through
which incoming air first passes. See also Prefilter.
Low-level disinfection: a disinfection process that will inactivate most vegetative bacteria, some fungi,
and some viruses, but cannot be relied upon to inactivate resistant microorganisms (e.g., mycobacteria
or bacterial spores).
Makeup air: outdoor air supplied to the ventilation system to replace exhaust air.
Makeup water: a cold water supply source for a cooling tower.
Manometer: a device that measures the pressure of liquids and gases. A manometer is used to verify
air filter performance by measuring pressure differentials on either side of the filter.
Membrane filtration: an assay method suitable for recovery and enumeration of microorganisms from
liquid samples. This method is used when sample volume is large and anticipated microbial
contamination levels are low.
Mesophilic: that which favors a moderate temperature. For mesophilic bacteria, a temperature range of
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68°F–131°F (20°C–55°C) is favorable for their growth and proliferation.
Mixing box: the site where the cold and hot air streams mix in the HVAC system, usually situated
close to the air outlet for the room.
Mixing faucet: a faucet that mixes hot and cold water to produce water at a desired temperature.
MMAD: Mass Median Aerodynamic Diameter. This is the unit used by ACGIH to describe the size of
particles when particulate air sampling is conducted.
Moniliaceous: hyaline or brightly colored. This is a laboratory term for the distinctive characteristics
of certain opportunistic fungi in culture (e.g., Aspergillus spp. and Fusarium spp.).
Monochloramine: the result of the reaction between chlorine and ammonia that contains only one
chlorine atom. Monochloramine is used by municipal water systems as a water treatment.
Natural ventilation: the movement of outdoor air into a space through intentionally provided openings
(i.e., windows, doors, or nonpowered ventilators).
Negative pressure: air pressure differential between two adjacent airspaces such that air flow is
directed into the room relative to the corridor ventilation (i.e., room air is prevented from flowing out of
the room and into adjacent areas).
Neutropenia: a medical condition in which the patient’s concentration of neutrophils is substantially
less than that in the normal range. Severe neutropenia occurs when the concentration is <1,000
polymorphonuclear cells/µL for 2 weeks or <100 polymorphonuclear cells /mL for 1 week, particularly
for hematopoietic stem cell transplant (HSCT) recipients.
Noncritical devices: medical devices or surfaces that come into contact with only intact skin. The risk
of infection from use of these devices is low.
Non-enveloped virus: a virus whose particle is not covered by a structure derived from a membrane of
the host cell. Non-enveloped viruses have little or no lipid compounds in their biochemical
composition, a characteristic that is significant to their inherent resistance to the action of chemical
germicides.
Nosocomial: an occurrence, usually an infection, that is acquired in a hospital as a result of medical
care.
NTM: nontuberculous mycobacteria. These organisms are also known as atypical mycobacteria, or as
“Mycobacteria other than tuberculosis” (MOTT). This descriptive term refers to any of the fast- or
slow-growing Mycobacterium spp. found in primarily in natural or man-made waters, but it excludes
Mycobacterium tuberculosis and its variants.
Nuisance dust: generally innocuous dust, not recognized as the direct cause of serious pathological
conditions.
Oocysts: a cyst in which sporozoites are formed; a reproductive aspect of the life cycle of a number of
parasitic agents (e.g., Cryptosporidium spp., and Cyclospora spp.).
Outdoor air: air taken from the external atmosphere and, therefore, not previously circulated through
the ventilation system.
Parallel streamlines: a unidirectional airflow pattern achieved in a laminar flow setting, characterized
by little or no mixing of air.
Particulate matter (particles): a state of matter in which solid or liquid substances exist in the form of
aggregated molecules or particles. Airborne particulate matter is typically in the size range of 0.01–100
µm diameter.
Pasteurization: a disinfecting method for liquids during which the liquids are heated to 140°F (60EC)
for a short time (>30 mins.) to significantly reduce the numbers of pathogenic or spoilage
microorganisms.
Plinth: a treatment table or a piece of equipment used to reposition the patient for treatment.
Portable room-air HEPA recirculation units: free-standing portable devices that remove airborne
contaminants by recirculating air through a HEPA filter.
Positive pressure: air pressure differential between two adjacent air spaces such that air flow is
directed from the room relative to the corridor ventilation (i.e., air from corridors and adjacent areas is
prevented from entering the room).
207
Potable (drinking) water: water that is fit to drink. The microbiological quality of this water as
defined by EPA microbiological standards from the Surface Water Treatment Rule: a) Giardia lamblia:
99.9% killed/inactivated; b) viruses: 99.9% inactivated; c) Legionella spp.: no limit, but if Giardia and
viruses are inactivated, Legionella will also be controlled; d) heterotrophic plate count [HPC]: <500
CFU/mL; and e) >5% of water samples total coliform-positive in a month.
PPE: Personal Protective Equipment.
ppm: parts per million. The term is a measure of concentration in solution. Chlorine bleaches
(undiluted) that are available in the U.S. (5.25%–6.15% sodium hypochlorite) contain approximately
50,000–61,500 parts per million of free and available chlorine.
Prefilter: the first filter for incoming fresh air in a HVAC system. This filter is approximately 30%
efficient in removing particles from the air. See also Low-Efficiency Filter.
Prion: a class of agent associated with the transmission of diseases knowns as transmissible
spongiform encephalopathies (TSEs). Prions are considered to consist of protein only, and the abnormal
isoform of this protein is thought to be the agent that causes diseases such as Creutzfeldt-Jakob disease
(CJD), kuru, scrapie, bovine spongiform encephalopathy (BSE), and the human version of BSE which is
variant CJD (vCJD).
Product water: water produced by a water treatment system or individual component of that system.
Protective environment: a special care area, usually in a hospital, designed to prevent transmission of
opportunistic airborne pathogens to severely immunosuppressed patients.
Pseudoepidemic (pseudo-outbreak): a cluster of positive microbiologic cultures in the absence of
clinical disease. A pseudoepidemic usually results from contamination of the laboratory apparatus and
process used to recover microorganisms.
Pyrogenic: an endotoxin burden such that a patient would receive >5 endotoxin units (EU) per
kilogram of body weight per hour, thereby causing a febrile response. In dialysis this usually refers to
water or dialysate having endotoxin concentrations of >5 EU/mL.
Rank order: a strategy for assessing overall indoor air quality and filter performance by comparing
airborne particle counts from lowest to highest (i.e., from the best filtered air spaces to those with the
least filtration).
RAPD: a method of genotyping microorganisms by randomly amplified polymorphic DNA. This is
one version of the polymerase chain reaction method.
Recirculated air: air removed from the conditioned space and intended for reuse as supply air.
Relative humidity: the ratio of the amount of water vapor in the atmosphere to the amount necessary
for saturation at the same temperature. Relative humidity is expressed in terms of percent and measures
the percentage of saturation. At 100% relative humidity, the air is saturated. The relative humidity
decreases when the temperature is increased without changing the amount of moisture in the air.
Reprocessing (of medical instruments): the procedures or steps taken to make a medical instrument
safe for use on the next patient. Reprocessing encompasses both cleaning and the final or terminal step
(i.e., sterilization or disinfection) which is determined by the intended use of the instrument according to
the Spaulding classification.
Residuals: the presence and concentration of a chemical in media (e.g., water) or on a surface after the
chemical has been added.
Reservoir: a nonclinical source of infection.
Respirable particles: those particles that penetrate into and are deposited in the nonciliated portion of
the lung. Particles >10 µm in diameter are not respirable.
Return air: air removed from a space to be then recirculated.
Reverse osmosis (RO): an advanced method of water or wastewater treatment that relies on a semipermeable membrane to separate waters from pollutants. An external force is used to reverse the
normal osmotic process resulting in the solvent moving from a solution of higher concentration to one
of lower concentration.
Riser: water piping that connects the circulating water supply line, from the level of the base of the
tower or supply header, to the tower’s distribution system.
208
RODAC: Replicate Organism Direct Agar Contact. This term refers to a nutrient agar plate whose
convex agar surface is directly pressed onto an environmental surface for the purpose of microbiologic
sampling of that surface.
Room-air HEPA recirculation systems and units: devices (either fixed or portable) that remove
airborne contaminants by recirculating air through a HEPA filter.
Routine sampling: environmental sampling conducted without a specific, intended purpose and with
no action plan dependent on the results obtained.
Sanitizer: an agent that reduces microbial contamination to safe levels as judged by public health
standards or requirements.
Saprophytic: a naturally-occurring microbial contaminant.
Sedimentation: the act or process of depositing sediment from suspension in water. The term also
refers to the process whereby solids settle out of wastewater by gravity during treatment.
Semicritical devices: medical devices that come into contact with mucous membranes or non-intact
skin.
Service animal: any animal individually trained to do work or perform tasks for the benefit of a person
with a disability.
Shedding: the generation and dispersion of particles and spores by sources within the patient area,
through activities such as patient movement and airflow over surfaces.
Single-pass ventilation: ventilation in which 100% of the air supplied to an area is exhausted to the
outside.
Small, non-enveloped viruses: viruses whose particle diameter is <50 nm and whose outer surface is
the protein of the particle itself and not that of host cell membrane components. Examples of small,
non-enveloped viruses are polioviruses and hepatitis A virus.
Spaulding Classification: the categorization of inanimate medical device surfaces in the medical
environment as proposed in 1972 by Dr. Earle Spaulding. Surfaces are divided into three general
categories, based on the theoretical risk of infection if the surfaces are contaminated at time of use. The
categories are “critical,” “semicritical,” and “noncritical.”
Specific humidity: the mass of water vapor per unit mass of moist air. It is expressed as grains of
water per pound of dry air, or pounds of water per pound of dry air. The specific humidity changes as
moisture is added or removed. However, temperature changes do not change the specific humidity
unless the air is cooled below the dew point.
Splatter: visible drops of liquid or body fluid that are expelled forcibly into the air and settle out
quickly, as distinguished from particles of an aerosol which remain airborne indefinitely.
Steady state: the usual state of an area.
Sterilization: the use of a physical or chemical procedure to destroy all microbial life, including large
numbers of highly-resistant bacterial endospores.
Stop valve: a valve that regulates the flow of fluid through a pipe. The term may also refer to a faucet.
Substitution fluid: fluid that is used for fluid management of patients receiving hemodiafiltration.
This fluid can be prepared on-line at the machine through a series of ultrafilters or with the use of sterile
peritoneal dialysis fluid.
Supply air: air that is delivered to the conditioned space and used for ventilation, heating, cooling,
humidification, or dehumidification.
Tensile strength: the resistance of a material to a force tending to tear it apart, measured as the
maximum tension the material can withstand without tearing.
Therapy animal: an animal (usually a personal pet) that, with their owners or handlers, provide
supervised, goal-directed intervention to clients in hospitals, nursing homes, special-population schools,
and other treatment sites.
Thermophilic: capable of growing in environments warmer than body temperature.
Thermotolerant: capable of withstanding high temperature conditions.
TLV®: an exposure level under which most people can work consistently for 8 hours a day, day after
day, without adverse effects. The term is used by the ACGIH to designate degree of exposure to
209
contaminants. TLV® can be expressed as approximate milligrams of particulate per cubic meter of air
(mg/m3). TLVs® are listed as either an 8-hour TWA (time weighted average) or a 15-minute STEL
(short term exposure limit).
TLV-TWA: Threshold Limit Value-Time Weighted Average. The term refers to the time-weighted
average concentration for a normal 8-hour workday and a 40-hour workweek to which nearly all
workers may be exposed repeatedly, day after day, without adverse effects. The TLV-TWA for
“particulates (insoluble) not otherwise classified” (PNOC) - (sometimes referred to as nuisance dust) are those particulates containing no asbestos and <1% crystalline silica. A TLV-TWA of 10 mg/m3 for
inhalable particulates and a TLV-TWA of 3 mg/m3 for respirable particulates (particulates <5 µm in
aerodynamic diameter) have been established.
Total suspended particulate matter: the mass of particles suspended in a unit of volume of air when
collected by a high-volume air sampler.
Transient: a change in the condition of the steady state that takes a very short time compared with the
steady state. Opening a door, and shaking bed linens are examples of transient activities.
TWA: average exposure for an individual over a given working period, as determined by sampling at
given times during the period. TWA is usually presented as the average concentration over an 8-hour
workday for a 40-hour workweek.
Ultraclean air: air in laminar flow ventilation that has also passed through a bank of HEPA filters.
Ultrafilter: a membrane filter with a pore size in the range of 0.001–0.05 µm, the performance of
which is usually rated in terms of a nominal molecular weight cut-off (defined as the smallest molecular
weight species for which the filter membrance has more than 90% rejection).
Ultrafiltered dialysate: the process by which dialysate is passed through a filter having a molecular
weight cut-off of approximately 1 kilodalton for the purpose of removing bacteria and endotoxin from
the bath.
Ultraviolet germicidal irradiation (UVGI): the use of ultraviolet radiation to kill or inactivate
microorganisms.
Ultraviolet germicidal irradiation lamps: lamps that kill or inactivate microorganisms by emitting
ultraviolet germicidal radiation, predominantly at a wavelength of 254 nm. UVGI lamps can be used in
ceiling or wall fixtures or within air ducts of ventilation systems.
Vapor pressure: the pressure exerted by free molecules at the surface of a solid or liquid. Vapor
pressure is a function of temperature, increasing as the temperature rises.
Vegetative bacteria: bacteria that are actively growing and metabolizing, as opposed to a bacterial
state of quiescence that is achieved when certain bacteria (gram-positive bacilli) convert to spores when
the environment can no longer support active growth.
Vehicle: any object, person, surface, fomite, or media that may carry and transfer infectious
microorganisms from one site to another.
Ventilation: the process of supplying and removing air by natural or mechanical means to and from
any space. Such air may or may not be conditioned.
Ventilation air: that portion of the supply air consisting of outdoor air plus any recirculated air that has
been treated for the purpose of maintaining acceptable indoor air quality.
Ventilation, dilution: an engineering control technique to dilute and remove airborne contaminants by
the flow of air into and out of an area. Air that contains droplet nuclei is removed and replaced by
contaminant-free air. If the flow is sufficient, droplet nuclei become dispersed, and their concentration
in the air is diminished.
Ventilation, local exhaust: ventilation used to capture and removed airborne contaminants by
enclosing the contaminant source (the patient) or by placing an exhaust hood close to the contaminant
source.
v/v: volume to volume. This term is an expression of concentration of a percentage solution when the
principle component is added as a liquid to the diluent.
w/v: weight to volume. This term is an expression of concentration of a percentage solution when the
principle component is added as a solid to the diluent.
210
Weight-arrestance: a measure of filter efficiency, used primarily when describing the performance of
low- and medium-efficiency filters. The measurement of weight-arrestance is performed by feeding a
standardized synthetic dust to the filter and weighing the fraction of the dust removed.
Appendix B. Air
1. Airborne Contaminant Removal
Table B.1. Air changes/hour (ACH) and time required for airborne-contaminant removal
efficiencies of 99% and 99.9%*
Time (mins.) required for removal:
99% efficiency
99.9% efficiency
138
207
69
104
46
69
35
52
28
41
23
35
18
28
14
21
6
8
ACH+ § ¶
2
4
6
8
10
12
15
20
50
* This table is revised from Table S3-1 in reference 4 and has been adapted from the formula for the rate of purging airborne
contaminants presented in reference 1435.
+ Shaded entries denote frequently cited ACH for patient-care areas.
§ Values were derived from the formula:
t2 – t1 = – [ln (C2 / C1) / (Q / V)] H 60, with t1 = 0 and where
t1 = initial timepoint in minutes
C1 = initial concentration of contaminant
C2 / C1 = 1 – (removal efficiency / 100)
V = room volume in cubic feet
t2 = final timepoint in minutes
C2 = final concentration of contaminant
Q = air flow rate in cubic feet/hour
Q / V = ACH
¶ Values apply to an empty room with no aerosol-generating source. With a person present and generating
aerosol, this table would not apply. Other equations are available that include a constant generating source.
However, certain diseases (e.g., infectious tuberculosis) are not likely to be aerosolized at a constant rate. The
times given assume perfect mixing of the air within the space (i.e., mixing factor = 1). However, perfect mixing
usually does not occur. Removal times will be longer in rooms or areas with imperfect mixing or air stagnation.213
Caution should be exercised in using this table in such situations. For booths or other local ventilation enclosures,
manufacturers’ instructions should be consulted.
2. Air Sampling for Aerosols Containing Legionellae
Air sampling is an insensitive means of detecting Legionella pneumophila, and is of limited practical
value in environmental sampling for this pathogen. In certain instances, however, it can be used to a)
demonstrate the presence of legionellae in aerosol droplets associated with suspected bacterial
211
reservoirs; b) define the role of certain devices [e.g., showers, faucets, decorative fountains, or evaporate
condensers] in disease transmission; and c) quantitate and determine the size of the droplets containing
legionellae.1436 Stringent controls and calibration are necessary when sampling is used to determine
particle size and numbers of viable bacteria.1437 Samplers should be placed in locations where human
exposure to aerosols is anticipated, and investigators should wear a NIOSH-approved respirator (e.g.,
N95 respirator) if sampling involves exposure to potentially infectious aerosols.
Methods used to sample air for legionellae include impingement in liquid, impaction on solid medium,
and sedimentation using settle plates.1436 The Chemical Corps.-type all-glass impingers (AGI) with the
stem 30 mm from the bottom of the flask have been used successfully to sample for legionellae.1436
Because of the velocity at which air samples are collected, clumps tend to become fragmented, leading
to a more accurate count of bacteria present in the air. The disadvantages of this method are a) the
velocity of collection tends to destroy some vegetative cells; b) the method does not differentiate
particle sizes; and c) AGIs are easily broken in the field. Yeast extract broth (0.25%) is the
recommended liquid medium for AGI sampling of legionellae;1437 standard methods for water samples
can be used to culture these samples.
Andersen samplers are viable particle samplers in which particles pass through jet orifices of decreasing
size in cascade fashion until they impact on an agar surface.1218 The agar plates are then removed and
incubated. The stage distribution of the legionellae should indicate the extent to which the bacteria
would have penetrated the respiratory system. The advantages of this sampling method are a) the
equipment is more durable during use; b) the sampler can cetermine the number and size of droplets
containing legionellae; c) the agar plates can be placed directly in an incubator with no further
manipulations; and d) both selective and nonselective BCYE agar can be used. If the samples must be
shipped to a laboratory, they should be packed and shipped without refrigeration as soon as possible.
3. Calculation of Air Sampling Results
Assuming that each colony on the agar plate is the growth from a single bacteria-carrying particle, the
contamination of the air being sampled is determined from the number of colonies counted. The
airborne microorganisms may be reported in terms of the number per cubic foot of air sampled. The
following formulas can be applied to convert colony counts to organisms per cubic foot of air
sampled.1218
For solid agar impactor samplers:
C / (R H P) = N
where
For liquid impingers:
(C H V) / (Q H P H R) = N
where
N = number of organisms collected per cubic foot of air sampled
C = total plate count
R = airflow rate in cubic feet per minute
P = duration of sampling period in minutes
C = total number of colonies from all aliquots plated
V = final volume in mL of collecting media
Q = total number of mL plated
P, R, and N are defined as above
212
4. Ventilation Specifications for Health-Care Facilities
The following tables from the AIA Guidelines for Design and Construction of Hospitals and Health-Care Facilities, 2001 are reprinted with permission of the American Institute
of Architects and the publisher (The Facilities Guidelines Institute).120
Table B.2. Ventilation requirements for areas affecting patient care in hospitals and outpatient facilities1
Notes: This table is Table 7.2 in the AIA guidelines, 2001 edition. Superscripts used in this table refer to notes following the table.
Area designation
Surgeru and critical care
Operating/surgical cystoscopic rooms10, 11
Delivery room10
Recovery room10
Critical and intensive care
Newborn intensive care
Treatment room13
Trauma room13
Anesthesia gas storage
Endoscopy
Bronchoscopy11
ER waiting rooms
Triage
Radiology waiting rooms
Procedure room
Nursing
Patient room
Toilet room
Newborn nursery suite
Protective environment room11, 17
Airborne infection isolation room17, 18
Isolation alcove or anteroom17, 18
Labor/delivery/recovery
Labor/delivery/recovery/postpartum
Patient corridor
Air movement
relationship
to adjacent
area2
Minimum
air changes
of outdoor
air per hour3
Minimum
total air
changes per
hour4, 5
AII air
exhausted
directly to
outdoors6
Out
Out
–
–
–
–
Out
In
In
In
In
In
In
Out
3
3
2
2
2
–
3
–
2
2
2
2
2
3
15
15
6
6
6
6
15
8
6
12
12
12
12
15
–
–
–
–
–
–
–
Yes
–
Yes
Yes14, 15
Yes14
Yes14, 15
–
No
No
No
No
No
–
No
–
No
No
–
–
–
No
30–60
30–60
30–60
30–60
30–60
–
30–60
–
30–60
30–60
–
–
–
30–60
68–73 (20–23)12
68–73 (20–23)
70–75 (21–24)
70–75 (21–24)
72–78 (22–26)
75 (24)
70–75 (21–24)
–
68–73 (20–23)
68–73 (20–23)
70–75 (21–24)
70–75 (21–24)
70–75 (21–24)
70–75 (21–24)
–
In
–
Out
In
In/Out
–
–
–
2
–
2
2
2
–
2
2
–
616
10
6
12
12
10
616
616
2
–
Yes
–
–
Yes15
Yes
–
–
–
–
–
No
No
No
No
–
–
–
–
–
30–60
–
–
–
–
–
–
70–75 (21–24)
–
72–78 (22–26)
75 (24)
75 (24)
–
70–75 (21–24)
70–75 (21–24)
–
Recirculated
by means of
room units7
Relative
humidity8
(%)
Design
temperature9
(degrees F [C])
213
Area designation
Air movement
relationship
to adjacent
area2
Minimum
air changes
of outdoor
air per hour3
Minimum
total air
changes per
hour4, 5
AII air
exhausted
directly to
outdoors6
Recirculated
by means of
room units7
Relative
humidity8
(%)
Design
temperature9
(degrees F [C])
Ancillary
Radiology19
X-ray (surgical/critical care and
catheterization)
X-ray (diagnostic & treatment)
Darkroom
Laboratory
General19
Biochemistry19
Cytology
Glass washing
Histology
Microbiology19
Nuclear medicine
Pathology
Serology
Sterilizing
Autopsy room11
Nonrefrigerated body-holding room
Pharmacy
Out
–
In
3
–
–
15
6
10
–
–
Yes
No
–
No
30-60
–
–
70–75 (21–24)
75 (24)
–
–
Out
In
In
In
In
In
In
Out
In
In
In
Out
–
–
–
–
–
–
–
–
–
–
–
–
–
6
6
6
10
6
6
6
6
6
10
12
10
4
–
–
Yes
Yes
Yes
Yes
Yes
Yes
–
Yes
Yes
Yes
–
–
No
No
–
No
No
No
No
No
–
No
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
75 (24)
75 (24)
75 (24)
–
75 (24)
75 (24)
75 (24)
75 (24)
75 (24)
–
–
70 (21)
–
Diagnostic and treatment
Examination room
Medication room
Treatment room
Physical therapy and hydrotherapy
Soiled workroom or soiled holding
Clean workroom or clean holding
–
Out
–
In
In
Out
–
–
–
–
–
–
6
4
6
6
10
4
–
–
–
–
Yes
–
–
–
–
–
No
–
–
–
–
–
–
–
75 (24)
–
75 (24)
75 (24)
–
–
In
In
–
–
10
10
Yes
Yes
No
–
30-60
–
75 (24)
–
In
Out
Out
–
–
–
6
4
4
Yes
–
–
No
No
–
–
30-60
(Max.) 70
68–73 (20–23)
75 (24)
–
Sterilizing and supply
ETO-sterilizer room
Sterilizer equipment room
Central medical and surgical supply
Soiled or decontamination room
Clean workroom
Sterile storage
214
Area designation
Service
Food preparation center20
Ware washing
Dietary day storage
Laundry, general
Soiled linen (sorting and storage)
Clean linen storage
Soiled linen and trash chute room
Bedpan room
Bathroom
Janitor’s closet
Air movement
relationship
to adjacent
area2
Minimum
air changes
of outdoor
air per hour3
Minimum
total air
changes per
hour4, 5
AII air
exhausted
directly to
outdoors6
Recirculated
by means of
room units7
Relative
humidity8
(%)
Design
temperature9
(degrees F [C])
–
In
In
–
In
Out
In
In
In
In
–
–
–
–
–
–
–
–
–
–
10
10
2
10
10
2
10
10
10
10
–
Yes
–
Yes
Yes
–
Yes
Yes
–
Yes
No
No
–
–
No
–
No
–
–
No
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
75 (24)
–
Notes:
1. The ventilation rates in this table cover ventilation for comfort, as well as for asepsis and odor control in areas of acute care hospitals that directly affect patient care and are
determined based on health-care facilities being predominantly “No Smoking” facilities. Where smoking may be allowed, ventilation rates will need adjustment. Areas where
specific ventilation rates are not given in the table shall be ventilated in accordance with ASHRAE Standard 62, Ventilation for Acceptable Indoor Air Quality, and ASHRAE
Handbook - HVAC Applications. Specialized patient care areas, including organ transplant units, burn units, specialty procedure rooms, etc., shall have additional ventilation
provisions for air quality control as may be appropriate. OSHA standards and/or NIOSH criteria require special ventilation requirements for employee health and safety within
health-care facilities.
2. Design of the ventilation system shall provide air movement which is generally from clean to less clean areas. If any form of variable air volume or load shedding system is
used for energy conservation, it must not compromise the corridor-to-room pressure balancing relationships or the minimum air changes required by the table.
3. To satisfy exhaust needs, replacement air from the outside is necessary. Table B2 does not attempt to describe specific amounts of outside air to be supplied to individual
spaces except for certain areas such as those listed. Distribution of the outside air, added to the system to balance required exhaust, shall be as required by good engineering
practice. Minimum outside air quantities shall remain constant while the system is in operation.
4. Number of air changes may be reduced when the room is unoccupied if provisions are made to ensure that the number of air changes indicated is reestablished any time the
space is being utilized. Adjustments shall include provisions so that the direction of air movement shall remain the same when the number of air changes is reduced. Areas not
indicated as having continuous directional control may have ventilation systems shut down when space is unoccupied and ventilation is not otherwise needed, if the maximum
infiltration or exfiltration permitted in Note 2 is not exceeded and if adjacent pressure balancing relationships are not compromised. Air quantity calculations must account for
filter loading such that the indicated air change rates are provided up until the time of filter change-out.
5. Air change requirements indicated are minimum values. Higher values should be used when required to maintain indicated room conditions (temperature and jumidity), based
on the cooling load of the space (lights, equipment, people, exterior walls and windows, etc.).
215
6. Air from areas with contamination and/or odor problems shall be exhausted to the outside and not recirculated to other areas. Note that individual circumstances may require
special consideration for air exhaust to the outside, (e.g., in intensive care units in which patients with pulmonary infection are treated) and rooms for burn patients.
7. Recirculating room HVAC units refer to those local units that are used primarily for heating and cooling of air, and not disinfection of air. Because of cleaning difficulty and
potential for buildup of contamination, recirculating room units shall not be used in areas marked “No.” However, for airborne infection control, air may be recirculated within
individual isolation rooms if HEPA filters are used. Isolation and intensive care unit rooms may be ventilated by reheat induction units in which only the primary air supplied from
a central system passes through the reheat unit. Gravity-type heating or cooling units such as radiators or convectors shall not be used in operating rooms and other special care
areas. See this table’s Appendix I for a description of recirculation units to be used in isolation rooms (A7).
8. The ranges listed are the minimum and maximum limits where control is specifically needed. The maximum and minimum limits are not intended to be independent of a
space’s associated temperature. The humidity is expected to be at the higher end of the range when the temperature is also at the higher end, and vice versa.
9. Where temperature ranges are indicated, the systems shall be capable of maintaining the rooms at any point within the range during normal operation. A single figure indicates
a heating or cooling capacity of at least the indicated temperature. This is usually applicable when patients may be undressed and require a warmer environment. Nothing in these
guidelines shall be construed as precluding the use of temperatures lower than those noted when the patients' comfort and medical conditions make lower temperatures desirable.
Unoccupied areas such as storage rooms shall have temperatures appropriate for the function intended.
10. National Institute for Occupational Safety and Health (NIOSH) criteria documents regarding “Occupational Exposure to Waste Anesthetic Gases and Vapors,” and “Control of
Occupational Exposure to Nitrous Oxide” indicate a need for both local exhaust (scavenging) systems and general ventilation of the areas in which the respective gases are utilized.
11. Differential pressure shall be a minimum of 0.01" water gauge (2.5 Pa). If alarms are installed, allowances shall be made to prevent nuisance alarms of monitoring devices.
12. Some surgeons may require room temperatures which are outside of the indicated range. All operating room design conditions shall be developed in consultation with
surgeons, anesthesiologists, and nursing staff.
13. The term “trauma room” as used here is the operating room space in the emergency department or other trauma reception area that is used for emergency surgery. The “first
aid room” and/or “emergency room” used for initial treatment of accident victims may be ventilated as noted for the “treatment room.” Treatment rooms used for bronchoscopy
shall be treated as Bronchoscopy rooms. Treatment rooms used for cryosurgery procedures with nitrous oxide shall contain provisions for exhausting waste gases.
14. In a ventilation system that recirculates air, HEPA filters can be used in lieu of exhausting the air from these spaces to the outside. In this application, the return air shall be
passed through the HEPA filters before it is introduced into any other spaces.
15. If it is not practical to exhaust the air from the airborne infection isolation room to the outside, the air may be returned through HEPA filters to the air-handling system
exclusively serving the isolation room.
16. Total air changes per room for patient rooms, labor/delivery/recovery rooms, and labor/delivery/recovery/postpartum rooms may be reduced to 4 when supplemental heating
and/or cooling systems (radiant heating and cooling, baseboard heating, etc.) are used.
17. The protective environment airflow design specifications protect the patient from common environmental airborne infectious microbes (i.e., Aspergillus spores). These special
ventilation areas shall be designed to provide directed airflow from the cleanest patient care area to less clean areas. These rooms shall be protected with HEPA filters at 99.97
percent efficiency for a 0.3 µm sized particle in the supply airstream. These interrupting filters protect patient rooms from maintenance-derived release of environmental microbes
from the ventilation system components. Recirculation HEPA filters can be used to increase the equivalent room air exchanges. Constant volume airflow is required for consistent
ventilation for the protected environment. If the facility determines that airborne infection isolation is necessary for protective environment patients, an anteroom should be
216
provided. Rooms with reversible airflow provisions for the purpose of switching between protective environment and airborne infection isolation functions are not acceptable.
18. The infectious disease isolation room described in these guidelines is to be used for isolating the airborne spread of infectious diseases, such as measles, varicella, or
tuberculosis. The design of airborne infection isolation (AII) rooms should include the provision for normal patient care during periods not requiring isolation precautions.
Supplemental recirculating devices may be used in the patient room to increase the equivalent room air exchanges; however, such recirculating devices do not provide the outside
air requirements. Air may be recirculated within individual isolation rooms if HEPA filters are used. Rooms with reversible airflow provisions for the purpose of switching
between protective environment and AII functions are not acceptable.
19. When required, appropriate hoods and exhaust devices for the removal of noxious gases or chemical vapors shall be provided (see Section 7.31.D14 and 7.31.D15 in the AIA
guideline [reference 120] and NFPA 99).
20. Food preparation centers shall have ventilation systems whose air supply mechanisms are interfaced appropriately with exhaust hood controls or relief vents so that exfiltration
or infiltration to or from exit corridors does not compromise the exit corridor restrictions of NFPA 90A, the pressure requirements of NFPA 96, or the maximum defined in the
table. The number of air changes may be reduced or varied to any extent required for odor control when the space is not in use. See Section 7.31.D1.p in the AIA guideline
(reference 120).
Appendix I:
A7. Recirculating devices with HEPA filters may have potential uses in existing facilities as interim, supplemental environmental controls to meet requirements for the control of
airborne infectious agents. Limitations in design must be recognized. The design of either portable or fixed systems should prevent stagnation and short circuiting of airflow. The
supply and exhaust locations should direct clean air to areas where health-care workers are likely to work, across the infectious source, and then to the exhaust, so that the healthcare worker is not in position between the infectious source and the exhaust location. The design of such systems should also allow for easy access for scheduled preventative
maintenance and cleaning.
A11. The verification of airflow direction can include a simple visual method such as smoke trail, ball-in-tube, or flutterstrip. These devices will require a minimum differential
air pressure to indicate airflow direction.
217
Table B.3. Pressure relationships and ventilation of certain areas of nursing facilities1
Notes: This table is Table 8.1 in the AIA guidelines, 2001 edition. Superscripts used in this table refer to notes following the table.
Area designation
Resident room
Resident unit corridor
Resident gathering areas
Toilet room
Dining rooms
Activity rooms, if provided
Physical therapy
Occupational therapy
Soiled workroom or soiled holding
Clean workroom or clean holding
Sterilizer exhaust room
Linen and trash chute room, if provided
Laundry, general, if provided
Soiled linen sorting and storage
Clean linen storage
Food preparation facilities10
Dietary warewashing
Dietary storage areas
Housekeeping rooms
Bathing rooms
Air movement
relationship
to adjacent
area2
Minimum
air changes
of outdoor
air per hour3
–
–
–
In
–
–
In
In
In
Out
In
In
–
In
Out
–
In
–
In
In
2
–
4
–
2
4
2
2
2
2
–
–
2
–
–
2
–
–
–
–
Minimum
total air
changes per
hour4
2
4
4
10
4
4
6
6
10
4
10
10
10
10
2
10
10
2
10
10
AII air
exhausted
directly to
outdoors5
–
–
–
Yes
–
–
–
–
Yes
–
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Recirculated
by means of
room units6
Relative
humidity7
(%)
Design
temperature8
(degrees F [C])
–
–
–
No
–
–
–
–
No
–
No
No
No
No
No
No
No
No
No
No
9
70–75 (21–24)
–
–
–
75 (24)
–
75 (24)
75.(24)
–
75 (24)
–
–
–
–
–
–
–
–
–
75 (24)
9
–
–
–
–
–
–
–
(Max. 70)
–
–
–
–
–
–
–
–
–
–
Notes:
1. The ventilation rates in this table cover ventilation for comfort, as well as for asepsis and odor control in areas of nursing facilities that directly affect resident care and are
determined based on nursing facilities being predominantly “No Smoking” facilities. Where smoking may be allowed, ventilation rates will need adjustment. Areas where
specific ventilation rates are not given in the table shall be ventilated in accordance with ASHRAE Standard 62, Ventilation for Acceptable Indoor Air Quality, and ASHRAE
Handbook - HVAC Applications. OSHA standards and/or NIOSH criteria require special ventilation requirements for employee health and safety within nursing facilities.
2. Design of the ventilation system shall, insofar as possible, provide that air movement is from clean to less clean areas. However, continuous compliance may be impractical
with full utilization of some forms of variable air volume and load shedding systems that may be used for energy conservation. Areas that do require positive and continuous
control are noted with “Out” or “In” to indicate the required direction of air movement in relation to the space named. Rate of air movement may, of course, be varied as needed
218
within the limits required for positive control. Where indication of air movement direction is enclosed in parentheses, continuous directional control is required only when the
specialized equipment or device is in use or where room use may otherwise compromise the intent of movement from clean to less clean. Air movement for rooms with dashes
and nonpatient areas may vary as necessary to satisfy the requirements of those spaces. Additional adjustments may be needed when space is unused or unoccupied and air
systems are deenergized or reduced.
3. To satisfy exhaust needs, replacement air from outside is necessary. Table B.3 does not attempt to describe specific amounts of outside air to be supplied to individual spaces
except for certain areas such as those listed. Distribution of the outside air, added to the system to balance required exhaust, shall be as required by good engineering practice.
4. Number of air changes may be reduced when the room is unoccupied if provisions are made to ensure that the number of air changes indicated is reestablished any time the
space is being utilized. Adjustments shall include provisions so that the direction of air movement shall remain the same when the number of air changes is reduced. Areas not
indicated as having continuous directional control may have ventilation systems shut down when space is unoccupied and ventilation is not otherwise needed.
5. Air from areas with contamination and/or odor problems shall be exhausted to the outside and not recirculated to other areas. Note that individual circumstances may require
special consideration for air exhaust to outside.
6. Because of cleaning difficulty and potential for buildup of contamination, recirculating room units shall not be used in areas marked “No.” Isolation rooms may be ventilated
by reheat induction units in which only the primary air supplied from a central system passes through the reheat unit. Gravity-type heating or cooling units such as radiators or
convectors shall not be used in special care areas.
7. The ranges listed are the minimum and maximum limits where control is specifically needed. See A8.31.D in the AIA guideline (reference 120) for additional information.
8. Where temperature ranges are indicated, the systems shall be capable of maintaining the rooms at any point within the range. A single figure indicates a heating or cooling
capacity of at least the indicated temperature. This is usually applicable where residents may be undressed and require a warmer environment. Nothing in these guidelines shall be
construed as precluding the use of temperatures lower than those noted when the residents’ comfort and medical conditions make lower temperatures desirable. Unoccupied areas
such as storage rooms shall have temperatures appropriate for the function intended.
9. See A8.31.D1 in the AIA guideline (reference 120).
10. Food preparation facilities shall have ventilation systems whose air supply mechanisms are interfaced appropriately with exhaust hood controls or relief vents so that
exfiltration or infiltration to or from exit corridors does not compromise the exit corridor restrictions of NFPA 90A, the pressure requirements of NFPA 96, or the maximum
defined in the table. The number of air changes may be reduced or varied to any extent required for odor control when the space is not in use.
219
Table B.4. Filter efficiencies for central ventilation and air conditioning systems in
general hospitals*
Note: This table is Table 7.3 in the AIA guidelines, 2001 edition.
Number of
filter beds
Filter bed
No.1
(%)
Filter bed
No. 2
(%)
All areas for inpatient care, treatment, and
diagnosis, and those areas providing direct
service or clean supplies, such as sterile and
clean processing, etc.
2
30
90
Protective environment room
2
30
99.97
Laboratories
1
80
–
Administrative, bulk storage, soiled holding areas,
food preparation areas, and laundries
1
30
–
Area designation
* Additional roughing or prefilters should be considered to reduce maintenance required for filters with efficiency higher
than 75 percent. The filtration efficiency ratings are based on average dust sopt efficiency per ASHRAE 52.1–1992.
Table B.5. Filter efficiencies for central ventilation and air conditioning systems in
outpatient facilities*
Note: This table is Table 9.1 in the AIA guidelines, 2001 edition.
Number of
filter beds
Filter bed
No. 1
(%)
Filter bed
No. 2+
(%)
All areas for patient care, treatment, and/or
diagnosis, and those areas providing direct service
or clean supplies such as sterile and clean processing,
etc.
2
30
90
Laboratories
1
80
–
Administrative, bulk storage, soiled holding areas,
food preparation areas, and laundries
1
30
–
Area designation
* Additional roughing or prefilters should be considered to reduce maintenance required for main filters. The filtration
efficiency ratings are based on dust spot efficiency per ASHRAE 52.1–1992.
+ These requirements do not apply to small primary (e.g., neighborhood) outpatient facilities or outpatient facilities that do
not perform invasive applications or procedures.
220
Table B.6. Filter efficiencies for central ventilation and air conditioning systems in
nursing facilities
Note: This table is Table 8.2 in the AIA guidelines, 2001 edition.
Minimum
number of
filter beds
Filter bed
No. 1
(%)*
Filter bed
No. 2
(%)*
All areas for inpatient care, treatment, and/or
diagnosis, and those areas providing direct
service or clean supplies
2
30
80
Administrative, bulk storage, soiled holding,
laundries, and food preparation areas
1
30
–
Area designation
* The filtration efficiency ratings are based on average dust spot efficiency as per ASHRAE 52.1–1992.
Table B.7. Filter efficiencies for central ventilation and air conditioning systems in
psychiatric hospitals
Note: This table is Table 11.1 in the AIA guidelines, 2001 edition.
Minimum
number of
filter beds
Filter bed
No. 1
(%)*
Filter bed
No. 2
(%)*
All areas for inpatient care, treatment, and
diagnosis, and those areas providing direct
services
2
30
90
Administrative, bulk storage, soiled holding,
laundries, and food preparation areas
1
30
–
Area designation
* The filtration efficiency ratings are based on average dust spot efficiency as per ASHRAE 52.1–1992.
Appendix C. Water
1. Biofilms
Microorganisms have a tendency to associate with and stick to surfaces. These adherent organisms can
initiate and develop biofilms, which are comprised of cells embedded in a matrix of extracellularly
produced polymers and associated abiotic particles.1438 It is inevitable that biofilms will form in most
water systems. In the health-care facility environment, biofilms may be found in the potable water
supply piping, hot water tanks, air conditioning cooling towers, or in sinks, sink traps, aerators, or
shower heads. Biofilms, especially in water systems, are not present as a continuous slime or film, but
221
are more often scanty and heterogeneous in nature.1439 Biofilms may form under stagnant as well as
flowing conditions, so storage tanks, in addition to water system piping, may be vulnerable to the
development of biofilm, especially if water temperatures are low enough to allow the growth of
thermophilic bacteria (e.g., Legionella spp.). Favorable conditions for biofilm formation are present if
these structures and equipment are not cleaned for extended periods of time.1440
Algae, protozoa, and fungi may be present in biofilms, but the predominant microorganisms of water
system biofilms are gram-negative bacteria. Although most of these organisms will not normally pose a
problem for healthy individuals, certain biofilm bacteria (e.g., Pseudomonas aeruginosa, Klebsiella
spp., Pantoea agglomerans, and Enterobacter cloacae) all may be agents for opportunistic infections for
immunocompromised individuals.1441, 1442 These biofilm organisms may easily contaminate indwelling
medical devices or intravenous (IV) fluids, and they could be transferred on the hands of health-care
workers.1441–1444 Biofilms may potentially provide an environment for the survival of pathogenic
organisms, such as Legionella pneumophila and E. coli O157:H7. Although the association of biofilms
and medical devices provides a plausible explanation for a variety of health-care–associated infections,
it is not clear how the presence of biofilms in the water system may influence the rates of health-care–
associated waterborne infection.
Organisms within biofilms behave quite differently than their planktonic (i.e., free floating)
counterparts. Research has shown that biofilm-associated organisms are more resistant to antibiotics
and disinfectants than are planktonic organisms, either because the cells are protected by the polymer
matrix, or because they are physiologically different.1445–1450 Nevertheless, municipal water utilities
attempt to maintain a chlorine residual in the distribution system to discourage microbiological growth.
Though chlorine in its various forms is a proven disinfectant, it has been shown to be less effective
against biofilm bacteria.1448 Higher levels of chlorine for longer contact times are necessary to
eliminate biofilms.
Routine sampling of health-care facility water systems for biofilms is not warranted. If an
epidemiologic investigation points to the water supply system as a possible source of infection, then
water sampling for biofilm organisms should be considered so that prevention and control strategies can
be developed. An established biofilm is is difficult to remove totally in existing piping. Strategies to
remediate biofilms in a water system would include flushing the system piping, hot water tank, dead
legs, and those areas of the facility’s water system subject to low or intermittent flow. The benefits of
this treatment would include a) elimination of corrosion deposits and sludge from the bottom of hot
water tanks, b) removal of biofilms from shower heads and sink aerators, and c) circulation of fresh
water containing elevated chlorine residuals into the health-care facility water system.
The general strategy for evaluating water system biofilm depends on a comparision of the
bacteriological quality of the incoming municipal water and that of water sampled from within facility’s
distribution system. Heterotrophic plate counts and coliform counts, both of which are routinely run by
the municipal water utility, will at least provide in indication of the potential for biofilm formation.
Heterotrophic plate count levels in potable water should be <500 CFU/mL. These levels may increase
on occasion, but counts consistently >500 CFU/mL would indicate a general decrease in water quality.
A direct correlation between heterotrophic plate count and biofilm levels has been demonstrated.1450
Therefore, an increase in heterotrophic plate count would suggest a greater rate and extent of biofilm
formation in a health-care facility water system. The water supplied to the facility should also contain
<1 coliform bacteria/100 mL. Coliform bacteria are organisms whose presence in the distribution
system could indicate fecal contamination. It has been shown that coliform bacteria can colonize
biofilms within drinking water systems. Intermittant contamination of a water system with these
organisms could lead to colonization of the system.
222
Water samples can be collected from throughout the health-care facility system, including both hot and
cold water sources; samples should be cultured by standard methods.945 If heterotrophic plate counts in
samples from the facility water system are higher than those from samples collected at the point of
water entry to the building, it can be concluded that the facility water quality has diminished. If
biofilms are detected in the facility water system and determined by an epidemiologic and
environmental investigation to be a reservoir for health-care–associated pathogens, the municipal water
supplier could be contacted with a request to provide higher chlorine residuals in the distribution
system, or the health-care facility could consider installing a supplemental chlorination system.
Sample collection sites for biofilm in health-care facilities include a) hot water tanks; b) shower heads;
and c) faucet aerators, especially in immunocompromised patient-care areas. Swabs should be placed
into tubes containing phosphate buffered water, pH 7.2 or phosphate buffered saline, shipped to the
laboratory under refrigeration and processed within 24 hrs. of collection. Samples are suspended by
vortexing with sterile glass beads and plated onto a nonselective medium (e.g., Plate Count Agar or
R2A medium) and selective media (e.g., media for Legionella spp. isolation) after serial dilution. If the
plate counts are elevated above levels in the water (i.e. comparing the plate count per square centimeter
of swabbed surface to the plate count per milliliter of water), then biofilm formation can be suspected.
In the case of an outbreak, it would be advisable to isolate organisms from these plates to determine
whether the suspect organisms are present in the biofilm or water samples and compare them to the
organisms isolated from patient specimens.
2. Water and Dialysate Sampling Strategies in Dialysis
In order to detect the low, total viable heterotrophic plate counts outlined by the current AAMI
standards for water and dialysate in dialysis settings, it is necessary to use standard quantitative culture
techniques with appropriate sensitivity levels.792, 832, 833 The membrane filter technique is particularly
suited for this application because it permits large volumes of water to be assayed.792, 834 Since the
membrane filter technique may not be readily available in clinical laboratories, the spread plate assay
can be used as an alternative.834 If the spread plate assay is used, however, the standard prohibits the
use of a calibrated loop when applying sample to the plate.792 The prohibition is based on the low
sensitivity of the calibrated loop. A standard calibrated loop transfers 0.001 mL of sample to the culture
medium, so that the minimum sensitivity of the assay is 1,000 CFU/mL. This level of sensitivity is
unacceptable when the maximum allowable limit for microorganisms is 200 CFU/mL. Therefore, when
the spread plate method is used, a pipette must be used to place 0.1–0.5 mL of water on the culture
medium.
The current AAMI standard specifically prohibits the use of nutrient-rich media (e.g., blood agar, and
chocolate agar) in dialysis water and dialysate assays because these culture media are too rich for
growth of the naturally occurring organisms found in water.792 Debate continues within AAMI,
however, as to the most appropriate culture medium and incubation conditions to be used. The original
clinical observations on which the microbiological requirements of this standard were based used
Standard Methods Agar (SMA), a medium containing relatively few nutrients.666 The use of tryptic soy
agar (TSA), a general purpose medium for isolating and cultivating microorganisms was recommended
in later versions of the standard because it was thought to be more appropriate for culturing bicarbonatecontaining dialysate.788, 789, 835 Moreover, culturing systems based on TSA are readily available from
commercial sources. Several studies, however, have shown that the use of nutrient-poor media, such as
R2A, results in an increased recovery of bacteria from water.1451, 1452 The original standard also
specified incubation for 48 hours at 95°F–98.6°F (35°C–37°C) before enumeration of bacterial colonies.
Extending the culturing time up to 168 hours, or 7 days and using incubation temperatures of 73.4°F–
82.4°F (23°C–28°C) have also been shown to increase the recovery of bacteria.1451, 1452 Other
223
investigators, however, have not found such clear cut differences between culturing techniques.835, 1453
After considerable discussion, the AAMI Committee has not reached a consensus regarding changes in
the assay technique, and the use of TSA or its equivalent for 48 hours at 95°F–98.6°F (35°C–37°C)
remains the recommended method. It should be recognized, however, that these culturing conditions
may underestimate the bacterial burden in the water and fail to identify the presence of some organisms.
Specifically, the recommended method may not detect the presence of various NTM that have been
associated with several outbreaks of infection in dialysis units.31, 32 In these instances, however, the
high numbers of mycobacteria in the water were related to the total heterotrophic plate counts, each of
which was significantly greater than that allowable by the AAMI standard. Additionally, the
recommended method will not detect fungi and yeast, which have been shown to contaminate water
used for hemodialysis applications.1454 Biofilm on the surface of the pipes may hide viable bacterial
colonies, even though no viable colonies are detected in the water using sensitive culturing
techniques.1455 Many disinfection processes remove biofilm poorly, and a rapid increase in the level of
bacteria in the water following disinfection may indicate significant biofilm formation. Therefore,
although the results of microbiological surveillance obtained using the test methods outlined above may
be useful in guiding disinfection schedules and in demonstrating compliance with AAMI standards, they
should not be taken as an indication of the absolute microbiological purity of the water.792
Endotoxin can be tested by one of two types of assays a) a kinetic test method [e.g., colorimetric or
turbidimetric] or b) a gel-clot assay. Endotoxin units are assayed by the Limulus Amebocyte Lysate
(LAL) method. Because endotoxins differ in their activity on a mass basis, their activity is referred to a
standard Escherichia coli endotoxin. The current standard (EC-6) is prepared from E. coli O113:H10.
The relationship between mass of endotoxin and its activity varies with both the lot of LAL and the lot
of control standard endotoxin used. Since standards for endotoxin were harmonized in 1983 with the
introduction of EC-5, the relationship between mass and activity of endotoxin has been approximately
5–10 EU/ng. Studies to harmonize standards have led to the measurement of endotoxin units (EU)
where 5 EU is equivalent to 1 ng E. coli O55:B5 endotoxin.1456
In summary, water used to prepare dialysate and to reprocess hemodialyzers should not contain a total
microbial count >200 CFU/mL as determined by assay on TSA agar for 48 hrs. at 96.8°F (36°C), and
<2 endotoxin units (EU) per mL. The dialysate at the end of a dialysis treatment should not contain
>2,000 CFU/mL.31, 32, 668, 789, 792
3. Water Sampling Strategies and Culture Techniques for Detecting
Legionellae
Legionella spp. are ubiquitous and can be isolated from 20%–40% of freshwater environments,
including man-made water systems.1457, 1458 In health-care facilities, where legionellae in potable water
rarely result in disease among immunocompromised patients, courses of remedial action are unclear.
Scheduled microbiologic monitoring for legionellae remains controversial because the presence of
legionellae is not necessarily evidence of a potential for causing disease.1459 CDC recommends
aggressive disinfection measures for cleaning and maintaining devices known to transmit legionellae,
but does not recommend regularly scheduled microbiologic assays for the bacteria.396 However,
scheduled monitoring of potable water within a hospital might be considered in certain settings where
persons are highly susceptible to illness and mortality from Legionella infection (e.g., hematopoietic
stem cell transplantation units and solid organ transplant units).9 Also, after an outbreak of
224
legionellosis, health officials agree monitoring is necessary to identify the source and to evaluate the
efficacy of biocides or other prevention measures.
Examination of water samples is the most efficient microbiologic method for identifying sources of
legionellae and is an integral part of an epidemiologic investigation into health-care–associated
Legionnaires disease. Because of the diversity of plumbing and HVAC systems in health-care facilities,
the number and types of sites to be tested must be determined before collection of water samples. One
environmental sampling protocol that addresses sampling site selection in hospitals might serve as a
prototype for sampling in other institutions.1209 Any water source that might be aerosolized should be
considered a potential source for transmission of legionellae. The bacteria are rarely found in municipal
water supplies and tend to colonize plumbing systems and point-of-use devices. To colonize,
legionellae usually require a temperature range of 77°F–108°F (25°C–42.2°C) and are most commonly
located in hot water systems.1460 Legionellae do not survive drying. Therefore, air-conditioning
equipment condensate, which frequently evaporates, is not a likely source.1461
Water samples and swabs from point-of-use devices or system surfaces should be collected when
sampling for legionellae (Box C.1).1437 Swabs of system surfaces allow sampling of biofilms, which
frequently contain legionellae. When culturing faucet aerators and shower heads, swabs of surface areas
should be collected first; water samples are collected after aerators or shower heads are removed from
their pipes. Collection and culture techniques are outlined (Box C.2). Swabs can be streaked directly
onto buffered charcoal yeast extract agar (BCYE) plates if the pates are available at the collection site.
If the swabs and water samples must be transported back to a laboratory for processing, immersing
individual swabs in sample water minimizes drying during transit. Place swabs and water samples in
insulated coolers to protect specimens from temperature extremes.
Box C.1. Potential sampling sites for Legionella spp. in health-care facilities*
• Potable water systems
incoming water main, water softener unit, holding tanks, cisterns, water heater tanks
(at the inflows and outflows)
• Potable water outlets, especially those in or near patient rooms
faucets or taps, showers
• Cooling towers and evaporative condensers
makeup water (e.g., added to replace water lost because of evaporation, drift, or leakage),
basin (i.e., area under the tower for collection of cooled water), sump (i.e., section of basin
from which cooled water returns to heat source), heat sources (e.g., chillers)
• Humidfiers (e.g., nebullizers)
bubblers for oxygen, water used for respiratory therapy equipment
• Other sources
decorative fountains, irrigation equipment, fire sprinkler system (if recently used), whirlpools,
spas
* Material in this box is adapted from reference 1209.
225
Box C.2. Procedures for collecting and processing environmental specimens for
Legionella spp.*
1.
2.
3.
4.
Collect water (1-liter samples, if possible) in sterile, screw-top bottles.
Collect culture swabs of internal surfaces of faucets, aerators, and shower heads in a sterile,
screw-top container (e.g., 50 mL plastic centrifuge tube). Submerge each swab in 5–10 mL of
sample water taken from the same device from which the sample was obtained.
Transport samples and process in a laboratory proficient at culturing water specimens for
Legionella spp. as soon as possible after collection.+
Test samples for the presence of Legionella spp. by using semiselective culture media using
procedures specific to the cultivation and detection of Legionella spp.§¶
* Material in this table is compiled from references1209, 1437, 1462–1465.
+ Samples may be transported at room temperature but must be protected from temperature extremes. Samples not processed
within 24 hours of collection should be refrigerated.
§ Detection of Legionella spp. antigen by the direct fluorescent antibody technique is not suitable for environmental samples.
¶ Use of polymerase chain reaction for identification of Legionella spp. is not recommended until more data regading the
sensitivity and specificity of this procedure are available.
4. Procedure for Cleaning Cooling Towers and Related Equipment
I.
Perform these steps prior to chemical disinfection and mechanical cleaning.
A. Provide protective equipment to workers who perform the disinfection, to prevent their exposure
to chemicals used for disinfection and aerosolized water containing Legionella spp. Protective
equipment may include full-length protective clothing, boots, gloves, goggles, and a full- or
half-face mask that combines a HEPA filter and chemical cartridges to protect against airborne
chlorine levels of up to 10 mg/L.
B. Shut off cooling tower.
1. Shut off the heat source, if possible.
2. Shut off fans, if present, on the cooling tower/evaporative condenser (CT/EC).
3. Shut off the system blowdown (i.e., purge) valve.
4. Shut off the automated blowdown controller, if present, and set the system controller to
manual.
5. Keep make-up water valves open.
6. Close building air-intake vents within at least 30 meters of the CT/EC until after the cleaning
procedure is complete.
7. Continue operating pumps for water circulation through the CT/EC.
II. Perform these chemical disinfection procedures.
A. Add fast-release, chlorine-containing disinfectant in pellet, granular, or liquid form, and follow
safety instructions on the product label. Use EPA-registered products, if available. Examples
of disinfectants include sodium hypochlorite (NaOCl) or calcium hypochlorite (Ca[OCl]2),
calculated to achieve initial free residual chlorine (FRC) of 50 mg/L: either a) 3.0 lbs [1.4 kg]
industrial grade NaOCl [12%–15% available Cl] per 1,000 gallons of CT/EC water; b) 10.5 lbs
[4.8 kg] domestic grade NaOCl [3%–5% available Cl] per 1,000 gallons of CT/EC water; or c)
226
B.
C.
D.
E.
F.
G.
0.6 lb [0.3 kg] Ca[OCl]2 per 1,000 gallons of CT/EC water. If significant biodeposits are
present, additional chlorine may be required. If the volume of water in the CT/EC is unknown,
it can be estimated (in gallons) by multiplying either the recirculation rate in gallons per minute
by 10 or the refrigeration capacity in tons by 30. Other appropriate compounds may be
suggested by a water-treatment specialist.
Record the type and quality of all chemicals used for disinfection, the exact time the chemicals
were added to the system, and the time and results of FRC and pH measurements.
Add dispersant simultaneously with or within 15 minutes of adding disinfectant. The dispersant
is best added by first dissolving it in water and adding the solution to a turbulent zone in the
water system. Automatic-dishwasher compounds are examples of low- or nonfoaming, silicatebased dispersants. Dispersants are added at 10–25 lbs (4.5–11.25 kg) per 1,000 gallons of
CT/EC water.
After adding disinfectant and dispersant, continue circulating the water through the system.
Monitor the FRC by using an FRC-measuring device with the DPD method (e.g., a swimmingpool test kit), and measure the pH with a pH meter every 15 minutes for 2 hours. Add chlorine
as needed to maintain the FRC at >10 mg/L. Because the biocidal effect of chlorine is reduced
at a higher pH, adjust the pH to 7.5–8.0. The pH may be lowered by using any acid (e.g.,
nuriatic acid or sulfuric acid used for maintenance of swimming pools) that is compatible with
the treatment chemicals.
Two hours after adding disinfectant and dispersant or after the FRC level is stable at >10 mg/L,
monitor at 2-hour intervals and maintain the FRC at >10 mg/L for 24 hours.
After the FRC level has been maintained at >10 mg/L for 24 hours, drain the system. CT/EC
water may be drained safely into the sanitary sewer. Municipal water and sewerage authorities
should be contacted regarding local regulations. If a sanitary sewer is not available, consult
local or state authorities (e.g., a department of natural resources or environmental protection)
regarding disposal of water. If necessary, the drain-off may be dechlorinated by dissipation or
chemical neutralization with sodium bisulfite.
Refill the system with water and repeat the procedure outline in steps 2–7 in I-B above.
III. Perform mechanical cleaning.
A. After water from the second chemical disinfection has been drained, shut down the CT/EC.
B. Inspect all water-contact areas for sediment, sludge, and scale. Using brushes and/or a lowpressure water hose, thoroughly clean all CT/EC water-contact areas, including the basin, sump,
fill, spray nozzles, and fittings. Replace components as needed.
C. If possible, clean CT/EC water-contact areas within the chillers.
IV. Perform these procedures after mechanical cleaning.
A. Fill the system with water and add chlorine to achieve an FRC level of 10 mg/L.
B. Circulate the water for 1 hour, then open the blowdown valve and flush the entire system until
the water is free of turbidity.
C. Drain the system.
D. Open any air-intake vents that were closed before cleaning.
E. Fill the system with water. The CT/EC may be put back into service using an effective watertreatment program.
227
5. Maintenance Procedures Used to Decrease Survival and Multiplications
of Legionella spp. in Potable-Water Distribution Systems
Wherever allowable by state code, provide water at >124°F (>51°C) at all points in the heated water
system, including the taps. This requires that water in calorifiers (e.g., water heaters) be maintained at
>140°F (>60°C). In the United Kingdom, where maintenance of water temperatures at >122°F (>50°C)
in hospitals has been mandated, installation of blending or mixing valves at or near taps to reduce the
water temperature to <109.4°F (<63°C) has been recommended in certain settings to reduce the risk for
scald injury to patients, visitors, and health care workers.726 However, Legionella spp. can multiply
even in short segments of pipe containing water at this temperature. Increasing the flow rate from the
hot-water-circulation system may help lessen the likelihood of water stagnation and cooling.711, 1465
Insulation of plumbing to ensure delivery of cold (<68°F [<20°C]) water to water heaters (and to coldwater outlets) may diminish the opportunity for bacterial multiplication.456 Both dead legs and capped
spurs within the plumbing system provide areas of stagnation and cooling to <122°F (<50°C) regardless
of the circulating water temperature; these segments may need to be removed to prevent colonization.704
Rubber fittings within plumbing systems have been associated with persistent colonization, and
replacement of these fittings may be required for Legionella spp. eradication.1467
Continuous chlorination to maintain concentrations of free residual chlorine at 1–2 mg/L (1–2 ppm) at
the tap is an alternative option for treatment. This requires the placement of flow-adjusted, continuous
injectors of chlorine throughout the water distribution system. Adverse effects of continuous
chlorination can include accelerated corrosion of plumbing (resulting in system leaks) and production of
potentially carcinogenic trihalomethanes. However, when levels of free residual chlorine are below 3
mg/L (3 ppm), trihalomethane levels are kept below the maximum safety level recommended by the
EPA.727, 1468, 1469
228
Appendix D. Insects and Microorganisms
Table D.1. Microorganisms isolated from arthropods in health-care settings
Insect
Microorganism category
Gram-negative bacteria
Cockroaches
Gram-positive bacteria
Acid-fast bacteria
Fungi
Parasites
Gram-negative bacteria
Houseflies
Gram-positive bacteria
Fungi / yeasts
Parasites
Viruses
Gram-negative bacteria
Ants
Gram-positive bacteria
Gram-negative bacteria
Spiders
Gram-positive bacteria
Bram-negative bacteria
Mites, midges
Gram-positive bacteria
Gram-negative bacteria
Mosquitoes
Gram-positive bacteria
Microorganisms
Acinetobacter spp.; Citrobacter freundii;
Enterobacter spp., E. cloacae; Escherichia
coli; Flavobacterium spp.; Klebsiella spp.;
Proteus spp.; Pseudomonas spp., P.
aeruginosa, P. fluorescens, P. putida;
Salmonella spp.; Serratia spp., S.
marcescens; Shigella boydii
Bacillus spp.; Enterococcus faecalis;
Micrococcus spp.; Staphylococcus aureus,
S. epidermidis; Streptococcus spp., S.
viridans
Mycobacterium tuberculosis
Aspergillus niger; Mucor spp.; Rhizopus
spp.
Endolimax nana; Entamoeba coli
Acinetobacter spp.; Campulobacter fetus
subsp. Jejuni; Chlamydia spp.; Citrobacter
fruendii; Enterobacter spp.; Escherichia
coli; Helicobacter pylori; Klebsiella spp.;
Proteus spp.; Pseudomonas aeruginosa;
Serratia marcescens; Shigella spp.
Bacillus spp.; Enterococcus faecalis;
Micrococcus spp.; Staphylococcus spp.
(coagulase-negative), S. aureus;
Streptococcus spp., S. viridans
Candida spp.; Geotrichum spp.
Endolimax nana; Entamoeba coli
Rotaviruses
Acinetobacter spp.; Escherichia coli;
Klebsiella spp.; Neisseria sicca; Proteus
spp.; Providencia spp.; Pseudomonas
aeruginosa, P. fluorescens
Bacillus spp., B. cereus, B. pumilis;
Clostridium cochlearium, C. welchii;
Enterococcus faecalis; Staphylococcus spp.
(coagulase-negative), S. aureus;
Streptococcus pyrogenes
Acinetobacter spp.; Citrobacter freundii;
Enterobacteraerogenes; Morganella
morganii
Staphylococcus spp. (coagulase-negative)
Acinetobacter spp.; Burkholderia cepacia;
Enterbacter agglomerans, E. aerogenes;
Hafnia alvei; Pseudomonas aeruginosa
Staphylococcus spp. (coagulase-negative)
Acinetobacter calcoaceticus; Enteobacter
cloacae
Enterococcus spp.; Staphylococcus spp.
(coagulase-negative)
References
1048, 1051, 1056,
1058, 1059, 1062
1056, 1058, 1059
1065
1052, 1059
1059
1047, 1048, 1050,
1053–1055, 1060
1048, 1060
1060
1060
1049
1057
1057
1048
1048
1048
1048
1048
1048
229
Appendix E. Information Resources
The following sources of information may be helpful to the reader. Some of these are available at no
charge, while others are available for purchase from the publisher.
Air andWater
•
•
•
•
•
Jensen PA, Schafer MP. Sampling and characterization of bioaerosols. NIOSH Manual of
Analytical Methods; revised 6/99. www.cdc.gov/niosh/nmam/pdfs/chapter-j.pdf
American Institutes of Architects. Guidelines for Design and Construction of Hospital and
Health Care Facilities. Washington DC; American Institute of Architects Press; 2001. AIA,
1735 New York Avenue, NW, Washington DC 20006. 1-800-AIA-3837 or (202) 626-7541
ASHRAE. Standard 62, and Standard 12-2000. These documents may be purchased from:
American Society of Heating, Refrigerating, and Air-Conditioning Engineers, Inc. 1791 Tullie
Circle, NE, Atlanta GA 30329 1-800-527-4723 or (404) 636-8400.
University of Minnesota websites: www.dehs.umn.edu
Indoor air quality site:
www.dehs.umn.edu/resources.htm#indoor
Water infiltration and use of the wet test
(moisture) meter: www.dehs.umn.edu/remangi.html
The CDC website for bioterrorism information contains the interim intervention plan for
smallpox. The plan discusses infection control issues both for home-based care and hospitalbased patient management. www.bt.cdc.gov/agent/smallpox/response-plan/index.asp
Environmental Sampling
•
ISO. Sterilization of medical devices – microbiological methods, Part 1. ISO standard 117371. Paramus NJ; International Organization for Standardization; 1995.
Animals in Health-Care Facilities
•
Service animal information with respect to the Americans with Disabilities Act. Contact the
U.S. Department of Justice ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383
(TDD), or visit the ADA website at: www.usdoj.gov/crt/ada/adahom1.htm
Regulated Medical Waste
•
U.S. Environmental Protection Agency. This is the Internet address on their Internet web site
that will link to any state for information about medical waste rules and regulations at the state
level: www.epa.gov/epaoswer/other/medical/stregs.htm
General Resources
•
•
•
APIC Text of Infection Control and Epidemiology. Association for Professionals in Infection
Control and Epidemiology, Inc. Washington DC; 2000. (Two binder volumes, or CD-ROM)
Abrutyn E, Goldmann DA, Scheckler WE. Saunders Infection Control Reference Service, 2nd
Edition. Philadelphia PA; WB Saunders; 2000.
ECRI publications are available on a variety of healthcare topics. Contact ECRI at (610) 8256000. CRI, 5200 Butler Pike, Plymouth Meeting, PA 19462-1298.
230
Appendix F. Areas of Future Research
Air
• Standardize the methodology and interpretation of microbiologic air sampling (e.g., determine action
levels or minimum infectious dose for aspergillosis, and evaluate the significance of airborne
bacteria and fungi in the surgical field and the impact on postoperative SSI).
• Develop new molecular typing methods to better define the epidemiology of health-care–associated
outbreaks of aspergillosis and to associate isolates recovered from both clinical and environmental
sources.
• Develop new methods for the diagnosis of aspergillosis that can lead reliably to early recognition of
infection.
• Assess the value of laminar flow technology for surgeries other than for joint replacement surgery.
• Determine if particulate sampling can be routinely performed in lieu of microbiologic sampling for
purposes such as determining air quality of clean environments (e.g., operating rooms, HSCT units).
Water
• Evaluate new methods of water treatment, both in the facility and at the water utility (e.g., ozone,
chlorine dioxide, copper/silver/monochloramine) and perform cost-benefit analyses of treatment in
preventing health-care–associated legionellosis.
• Evaluate the role of biofilms in overall water quality and determine the impact of water treatments
for the control of biofilm in distribution systems.
• Determine if the use of ultrapure fluids in dialysis is feasible and warranted, and determine the action
level for the final bath.
• Develop quality assurance protocols and validated methods for sampling filtered rinse water used
with AERs and determine acceptable microbiologic quality of AER rinse water.
Environmental Services
•
Evaluate the innate resistance of microorganisms to the action of chemical germicides, and
determine what, if any, linkage there may be between antibiotic resistance and resistance to
disinfectants.
Laundry and Bedding
• Evaluate the microbial inactivation capabilities of new laundry detergents, bleach substitutes, other
laundry additives, and new laundry technologies.
Animals in Health-Care Facilities
• Conduct surveillance to monitor incidence of infections among patients in facilities that use animal
programs, and conduct investigations to determine new infection control strategies to prevent these
infections.
• Evaluate the epidemiologic impact of performing procedures on animals (e.g., surgery or imaging) in
human health-care facilities.
Regulated Medical Waste
• Determine the efficiency of current medical waste treatment technologies to inactivate emerging
pathogens that may be present in medical waste (e.g., SARS-coV).
• Explore options to enable health-care facilities to reinstate the capacity to inactivate microbiological
cultures and stocks on-site.
231
Index—Parts I and IV
A
AAMI standards ..................................59, 60, 62, 222, 223
Acinetobacter spp. ...........................11, 20, 43, 44, 99, 104
aerators ................................47, 48, 94, 220–222, 224, 225
aerosols... 12, 27, 41, 47, 56, 59, 67, 75, 76, 78, 80, 85, 89,
90, 98, 106, 111, 113, 114
AIA guidelines.............................17, 18, 19, 25, 37, 39, 99
AII rooms ................................................................. 35–37
air changes per hour (ACH).......6, 12, 16, 18, 31, 111, 210
air conditioners ........................................................... 8, 22
air conditioning systems ............................... 13, 20, 57, 59
air filtration................................................................... 111
air intakes ............................................................... 31, 226
air sampling ...............................26, 29, 89, 90, 91, 93, 210
airborne infection isolation (AII) ................................ 6, 19
airborne transmission...................................................... 12
air-fluidized beds .......................................................... 104
alcohol-based hand rubs ................................................. 53
alkaline glutaraldehyde................................................... 70
allergens............................................................ 17, 80, 107
American Institute of Architects (AIA) .......................... 13
Americans with Disabilities Act ........................... 108, 110
amplified stocks and cultures................................ 114, 115
Animal Assisted Activities ................................... 106, 107
Animal Assisted Therapy ..................................... 106, 107
animal bites................................................................... 107
animal handler .............................................................. 107
animal patient ............................................................... 110
Animal Welfare Act...................................................... 112
anterooms ................................................12, 25, 33, 36–38
ants ................................................................................. 81
ASHRAE ............................................................ 13, 47, 49
aspergillosis ...............................7, 8, 16, 19, 21, 35, 79, 80
Aspergillus fumigatus ............................................. 7, 8, 29
Aspergillus spp. .........................5, 7, 20, 21, 28, 32, 34, 81
automated cyclers ........................................................... 65
automated endoscope reprocessor....................... 50, 69, 70
autopsy suites/rooms................................................. 12, 87
B
bacterial spores ................................................... 73, 84, 89
bank of filters.................................................................. 14
barrier ............................................................................. 34
barrier precautions/protection ......................... 74, 109, 116
barriers................................................................ 27, 31, 33
bassinets.......................................................................... 76
biofilms..................................46, 54, 64, 71, 220–222, 224
biosafety level............................................................... 114
bioterrorism ............................................................ 89, 114
bird droppings....................................................... 9, 20, 22
birthing tanks ............................................................ 67, 69
blood.. 12, 64, 69, 75, 77–79, 86, 87, 98, 99, 102, 113, 116
bloodborne pathogens............................................. 73, 116
boil water advisory ................................................... 51, 52
C
calibrated loop .............................................................. 222
carpet cleaning................................................................ 79
carpet tiles....................................................................... 79
carpeting ..................................................22, 25, 52, 78, 79
cats.........................................................105, 106, 108, 109
chain of infection ........................................................ 4, 87
chemical germicides ................................73, 74, 77, 80, 84
chloramine/chloramine-T ............................................... 68
chlorine....................................46, 50, 53, 69, 84, 221, 226
chlorine bleach........................................................ 78, 101
chlorine residual ............................50, 68, 69, 94, 101, 221
cleaning .. 68, 70–72, 74, 78, 80, 83, 85, 86, 107, 109, 112,
225
cleaning cloths ................................................................ 75
cleaning solutions ..................................................... 75, 76
Clostridium difficile .................................................... 5, 84
cloth chairs...................................................................... 79
cockroaches .................................................................... 81
coliform bacteria........................................................... 221
colonization .......................42–44, 68, 70, 83, 99, 106, 227
colony counts................................................................ 211
commissioning.......................................................... 29, 89
construction ..... 7, 13, 14, 21, 23, 26, 27, 29, 31, 37, 76, 89
construction workers........................................... 24, 26, 31
contact precautions ......................................................... 85
contact time ................................................ 74, 84, 88, 221
contaminants..........................................14, 18, 19, 59, 210
contaminated fabrics....................................... 98, 101, 102
contingency plans ..................................................... 21, 50
continuous chlorination ................................................ 227
cooling tower ...........................41, 53, 55, 57–59, 220, 225
copper/silver ions............................................................ 54
copper-8-quinolinolate.................................................... 35
Creutzfeldt-Jakob disease ....................................... 86, 116
Cryptosporidium parvum................................................ 46
D
dead legs ........................................................... 59, 64, 221
decorative fountains.......................................... 47, 49, 224
demolition..................................................... 23, 25, 26, 29
dental unit water lines..................................................... 71
detergent/disinfectant................................................ 74–76
dialysate.................................................................... 59–62
dialysis machines............................................................ 64
dialysis water ................................................................ 222
dialyzer ........................................................................... 62
dialyzer membranes ........................................................ 61
232
dialyzer reprocessing ...................................................... 59
dioctylphthalate (DOP) particle test................................ 15
direct contact........................6, 41, 67, 85, 86, 98, 108, 111
direct threat ................................................................... 109
disinfectant fogging ........................................................ 75
disinfectant residuals ...................................................... 96
disinfectants ...................................................... 21, 76, 225
disinfecting ........................71, 74, 80, 83, 85, 86, 112, 226
disinfection ................................................... 63, 64, 68, 70
dispersant ...................................................................... 226
disposal (of medical waste)........................................... 113
distribution system.................................................. 94, 221
dogs ...................................................... 105, 106, 108, 109
drift eliminators .............................................................. 58
drinking water................................................................. 71
droplet nuclei .............................................. 6, 7, 10, 12, 89
droplets ..................................................... 6, 55, 85, 86, 89
dry cleaning .................................................................. 102
drying.............................................................................. 11
dual-duct system ............................................................. 20
duct cleaning................................................................... 21
ductwork ................................................................... 20, 22
dust ....................................8, 20, 24, 27, 30, 32, 74, 79, 93
dust-spot test ................................................................... 15
E
education......................................................................... 24
electrical generators ........................................................ 53
emergency....................................................................... 53
endotoxin .................................................... 60–62, 64, 223
engineering controls........................................................ 36
enteric viruses ................................................................. 85
environmental cultures.............................................. 83, 88
Environmental Protection Agency (EPA) .... 21, 73–75, 77,
103, 227
environmental sampling............................................ 88, 95
environmental surfaces ...11, 44, 71, 72, 74, 82–86, 88, 98,
107
environmental surveillance ....................................... 54, 55
EPA registration.................................................. 73, 76, 83
EPA-registered germicides ........................... 75, 78, 85, 86
evaporative condensers ....................................... 41, 57–59
exclusion (of a service animal) ..................................... 109
exotic animals ............................................................... 110
F
fan-coil units ................................................................... 18
faucets..........................................47, 54, 94, 222, 224, 225
fecal contamination......................................................... 84
FIFRA..................................................................... 75, 103
filter efficiency ......................................................... 27, 29
filtration .......................................................................... 15
fire codes ........................................................................ 31
fish ........................................................................ 105, 108
fish tanks....................................................................... 108
flies ................................................................................. 81
flooding........................................................................... 51
floors............................................................. 25, 75, 82, 83
flowers ............................................................................ 80
flush times....................................................................... 51
flutter strips......................................................... 20, 34, 36
fomites ................................................................ 3, 4, 7, 85
Food and Drug Administration (FDA).............. 69, 73, 103
free residual chlorine ................................ 51, 54, 225–227
fungal spores... 8, 15, 16, 19–21, 26–28, 31, 34, 38, 79, 89,
93
fungi.................................................................................. 8
furniture .............................................................. 52, 79, 82
G
gram-negative bacteria...11, 41, 42, 48, 50, 60, 63, 64, 221
gram-positive bacteria............................................... 11, 84
H
hand hygiene............................................. 25, 71, 107, 109
hand transferral ..........................3, 44, 65, 82–84, 106, 221
handwashing ......................................... 25, 80, 84, 99, 107
hantaviruses .................................................................... 12
hematopoietic stem cell transplant .................................... 6
hemodiafiltration............................................................. 62
hemodialysis ......................................... 59, 60, 62, 64, 223
hemodialysis patients........................................................ 7
hemofiltration ................................................................. 62
HEPA filtration/filters........6, 12, 14, 15, 17, 31, 32, 36, 76
hepatitis B virus .................................................. 40, 73, 98
heterotrophic plate counts ............. 51, 62, 66, 95, 221–223
high-flux membranes ...................................................... 61
high-level disinfectants ................................................... 73
high-level disinfection ........................................ 60, 69, 72
high-temperature flushing............................................... 50
high-touch surfaces ............................................. 75, 83–85
holding tank .................................................................... 47
hospital disinfectant ........................................................ 73
hot water system ....................................................... 51, 54
hot water tanks................................................ 53, 220–222
hot water temperature ..................................................... 49
housekeeping surfaces ........................ 3, 64, 72, 74–77, 83
HSCT patients............................................................. 6, 37
HSCT units ........................................... 11, 26, 79, 80, 107
Hubbard tanks................................................................. 68
human health-care facilities .................................. 110, 111
human immunodeficiency virus...................................... 73
humidifiers.......................................................... 17, 23, 41
humidity............................................ 13, 14, 17, 20, 38, 90
HVAC systems ................13, 14, 16, 17, 19–21, 27, 30, 51
hydrotherapy equipment ........................................... 67–69
hydrotherapy pools ......................................................... 68
hydrotherapy tanks.............................................. 67, 68, 82
hygienically-clean laundry.............................. 98–100, 102
hyperchlorination .......................................... 50, 53, 54, 59
233
I, J
M
iatrogenic cases............................................................... 87
ice machines and ice ..................................... 25, 48, 65, 66
ice-storage chests............................................................ 66
immunocompromised patients....6, 7, 9, 26, 29–31, 34, 42,
47, 56, 66, 80, 107, 108, 223
impaction ................................................................ 90, 211
impactors .................................................................. 28, 93
impingement ..................................................... 90, 93, 211
impingers ...................................................................... 211
inactivation studies ......................................................... 87
incineration ........................................................... 113, 114
incubators (nursery)........................................................ 76
indirect transmission......................................................... 6
indirect contact ............................................................... 41
indoor air .................................................21, 24, 26, 27, 90
industrial-grade HEPA filter......................... 16, 31, 38, 39
infection-control risk assessment (ICRA).... 26, 29, 31, 35,
108, 111
influenza viruses............................................. 6, 12, 73, 85
innate resistance.................................................. 72, 73, 84
insects ....................................................................... 67, 81
insulation material .......................................................... 20
intermediate-level disinfectants ...............73, 78, 83, 85, 86
intermediate-level disinfection ....................................... 72
isolation/isolation areas .................................... 11, 36, 100
manufacturer’s instructions...........67, 69, 74, 86, 102, 116
material safety data sheets (MSDS) .......................... 75, 87
mattress cover ......................................................... 77, 104
mattresses ............................................................... 77, 104
medical equipment.................................................... 74, 83
medical equipment surfaces............................................ 72
medical gas piping .......................................................... 30
medical records............................................................... 51
medical waste ............................................... 112, 113, 117
medical waste management .......................................... 112
membrane filtration .................................... 70, 95, 96, 222
methicillin-resistant Staphylococcus aureus (MRSA) ... 82,
83, 104, 105
microbial inactivation ..................................................... 72
microbial resistance ........................................................ 70
microbiologic air sampling ............................................. 27
microbiologic cultures and stocks................................. 112
microbiologic sampling .................................................. 64
microbiologic sampling of laundry............................... 102
microbiological wastes ......................................... 112, 114
moisture .............................................20, 24, 32, 51, 70, 96
moisture meters............................................................... 51
molecular typing ............................................................. 28
monochloramine ............................................................. 54
mop heads....................................................................... 75
multidisciplinary team .............................................. 23, 91
municipal water ................................................ 47, 50, 224
municipal water systems/utilities............................ 45, 221
Mycobacterium tuberculosis..................... 5, 7, 10, 73, 114
myiasis............................................................................ 81
JCAHO ......................................................... 13, 14, 51, 59
L
laboratories . 12, 13, 32, 47, 78, 79, 83, 105, 111, 112, 114,
222
laboratory confirmation .................................................. 55
laminar airflow ................................................... 18, 34, 38
laser plumes .................................................................... 40
laundry............................................................................ 49
laundry bags ................................................................. 100
laundry chutes............................................................... 100
laundry cycles............................................................... 101
laundry disinfection ...................................................... 101
laundry facility................................................................ 99
laundry packaging................................................. 100, 101
laundry process................................................. 98, 99, 102
laundry services .............................................................. 99
laundry transport................................................... 100, 101
Legionella pneumophila ....................................... 210, 221
Legionella spp. ... 41, 42, 50, 54–57, 59, 71, 222, 223, 225,
227
legionellae .................................................41, 54, 211, 223
legionellosis...................................................... 53–56, 224
Legionnaires disease..............................41, 47, 57, 58, 224
liquid chemical sterilant.................................................. 70
low-level disinfectants .................................. 72, 73, 83, 86
low-level disinfection ............................................... 60, 64
N
negative air pressure .....6, 12, 18, 19, 21, 36, 99, 100, 104,
111
neutralizer chemicals ...................................................... 96
NIOSH............................................................................ 40
nontuberculous mycobacteria (NTM).5, 41, 44–46, 60, 63,
70, 71, 223
O
operating rooms ..... 13, 15, 17, 34, 38, 76, 82, 87, 109, 111
opportunistic infections ................................................ 4, 5
organic matter ................................................................. 78
OSHA ......................................13, 73, 77, 79, 98, 100, 113
outdoor air ...............................................14, 15, 18, 25, 91
oxygen-based laundry detergents.................................. 101
P
particle sampling................................................. 27, 33, 89
performance measures ...................................................... 2
periodic culturing............................................................ 57
peritoneal dialysis ..................................................... 64, 65
234
personal protective equipment .....77, 98, 99, 112, 114, 225
persons with disabilities........................................ 108, 109
person-to-person transmission .................................. 12, 85
pest control ..................................................................... 82
phenolics......................................................................... 76
pillows .......................................................................... 104
pipes.................................................. 64, 69, 221, 223, 224
planktonic organisms .................................................... 221
plastic enclosures ............................................................ 31
plastic wrapping.............................................................. 74
Pneumocystis carinii......................................................... 9
pneumonia ................................................................ 42, 55
point-of-use fixtures.......................................... 47, 51, 224
polyvinylchloride (PVC)........................................... 46, 64
pools ............................................................................... 67
positive air pressure .................................................. 18, 38
potable water................................................................. 220
potted plants................................................................ 8, 80
pressure differentials............................... 18, 19, 25, 30, 38
primates ........................................................ 105, 106, 111
prions ...................................................................... 86, 116
privacy curtains............................................................... 75
product water ............................................................ 64, 70
protective environment (PE) ............. 6, 18, 19, 34, 56, 108
Pseudomonas aeruginosa .5, 11, 20, 42, 68, 70, 71, 73, 79,
80, 96, 104, 221
pseudo-outbreaks ...................................................... 44, 70
pyrogenic reactions ................................................... 60, 61
Q
quality assurance................................................. 89, 94, 95
R
R2A media.................................................................... 222
rank order........................................................................ 27
recirculation .............................................................. 16, 18
recirculation loops .......................................................... 46
recreational equipment.................................................... 69
reduced nutrient media.................................................... 94
reducing agent................................................................. 94
relative humidity............................................................. 17
renovation ..................................................... 13, 14, 23, 37
repairs ............................................................................. 31
reprocess hemodialyzers ......................................... 61, 223
research animals............................................................ 111
reservoirs ...................3, 6, 41, 42, 71, 79, 83, 95, 105, 211
resident animals ............................................................ 107
respirable particles .............................................. 27, 28, 90
respirators ................................................................. 26, 40
respiratory protection................................................ 36, 78
respiratory syncytial virus (RSV) ......................... 6, 12, 85
respiratory therapy equipment ...................................... 224
return air ......................................................................... 14
return temperature........................................................... 54
reverse osmosis (RO).............................. 52, 54, 59, 60, 63
rewiring........................................................................... 25
rinse water monitoring .................................................... 70
RODAC plates .............................................................. 102
rodents ............................................................................ 67
rooftops........................................................................... 30
S
Sabouraud dextrose agar ................................................. 96
sample/rinse methods...................................................... 97
sanitary sewer ....................................................... 116, 117
SARS .............................................................................. 86
SARS-CoV ..................................................................... 86
scalding..................................................................... 49, 51
screens ............................................................................ 82
scrub suits ................................................................. 98, 99
sealed windows............................................. 19, 26, 29, 89
sedimentation.................................................... 90, 93, 211
select agents.......................................................... 114, 115
self-closing doors............................................................ 19
semicritical device .......................................................... 70
service animal ............................................... 105, 108–110
settle plates ................................................. 28, 90, 93, 211
sewage spills ................................................................... 51
sharps containers........................................................... 113
shock decontamination ................................................... 51
shower heads................47, 49, 54, 220, 221, 222, 224, 225
showers ..................................................................... 47, 48
skin antiseptics................................................................ 73
smallpox.......................................................................... 36
smallpox virus............................................................. 7, 12
smoke tubes ........................................................ 20, 34, 36
sodium hydroxide ........................................................... 87
sodium hypochlorite 67, 69, 73, 77, 83, 84, 87, 88, 94, 225
solid-organ transplant program ....................................... 56
sorting (laundry) ..................................................... 98, 100
Spaulding classification ............................................ 71, 98
spills.................................................................... 75, 77, 79
standard precautions ............................................. 100, 111
standards ....................................2, 14, 71, 88, 90, 112, 223
Staphylococcus aureus...............10, 11, 38, 64, 73, 99, 104
state codes/regulations .............................................. 55, 69
steam jet........................................................................ 101
steam sterilization (of medical waste)................... 113, 114
sterile water..................................................................... 55
storage tanks ............................................................. 63, 64
streptococci............................................................... 10, 38
supplemental treatment methods..................................... 53
surgical gowns and drapes ............................................ 103
surgical site infections (SSI) ............................... 11, 38, 65
surgical smoke ................................................................ 40
surveillance........................................... 26, 51, 57, 99, 223
swabs ............................................................................ 224
T
tacky mats ....................................................................... 76
tap water ........................................... 42, 44, 57, 65, 66, 70
TB patients...................................................................... 38
temperature (air) ........................................... 13, 14, 17, 89
temperature (water)................40, 45, 49, 68, 101, 221, 227
235
thermostatic mixing valves ............................................. 49
transport and storage (of medical waste) ...................... 113
treated items/products............................................. 79, 103
tryptic soy agar ................................................. 94, 96, 222
tub liners ......................................................................... 68
tuberculocidal claim ....................................................... 73
tuberculosis (TB) ............................................................ 35
U
ultrapure dialysate........................................................... 61
ultraviolet germicidal irradiation (UVGI)14, 16, 17, 36, 38
uniforms.................................................................... 98, 99
V
vacuum breakers....................................................... 47, 50
vacuum cleaners ....................................................... 76, 79
vacuuming ...................................................................... 79
vancomycin-resistant enterococci (VRE) ..3, 5, 82, 83, 105
vancomycin-resistant Staphylococcus aureus (VRSA)... 83
variable air ventilation .............................................. 20, 38
varicella-zoster virus (VZV)................................... 5, 7, 40
vase water ....................................................................... 81
vegetative bacteria .......................................................... 73
ventilation rates .............................................................. 18
ventilation systems ............................................... 8, 9, 111
viable particles............................................................ 9, 91
viral hemorrhagic fever................................................... 12
viral particles .................................................................. 11
viruses....................................................................... 11, 85
visual monitoring device................................................. 34
volumetric air samplers................................................... 29
volumetric sampling methods......................................... 28
W
wallboard .............................................................. 8, 22, 52
walls ............................................................................... 25
washing machines and dryers ....................................... 102
water conditioning .......................................................... 68
water distribution systems .............................. 64, 221, 227
water droplets ................................................................. 58
water pipes...................................................................... 46
water pressure ................................................................. 50
water quality ............................................................. 71, 94
water sampling.......................................... 54, 94, 221, 224
water stagnation............................................................ 227
water treatment system ................................................... 63
waterborne transmission ................................................. 46
weight-arrestance test ..................................................... 15
wet cleaning.................................................................... 79
whirlpool spas..................................................... 59, 67, 69
whirlpools ................................................................. 68, 69
window chutes ................................................................ 33
windows.................................................................... 22, 59
wood ................................................................. 8, 9, 15, 35

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