Aire (Annual Review of Immunology Book 27)

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The ACGME Annual Educational Conference offers multiple sessions focused on osteopathic medicine and accreditation and numerous opportunities for attendees from all corners of graduate medical education to learn and connect.

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HCPro writes about the three percent rise in the number of ACGME-accredited programs, the largest annual increase following a decade of growth. The newly organized and expanded Data Resource Book shows the largest number of newly-accredited ACGME programs in over a decade, driving an increase in future US physicians who will serve the nation's health care needs. About Us Contact Us Newsroom. Menu Login Search. Read More.

Collaboration and connection were front-and-center during the six pre-conferences today at to kick off the Annual Educational Conference. The pre-conferences, which are designed to appeal to those across experience levels from a first-year coord Media Coverage. Key Topics. 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 those 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 strong theoretic rationale and suggestive evidence. Finally, certain recommendations are derived from existing federal regulations. Performance Measurements. 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:. Contributors to this report reviewed primarily English-language manuscripts identified from reference searches using the National Library of Medicine's MEDLINE, bibliographies of published articles, and infection-control textbooks. All the recommendations may not reflect the opinions of all reviewers.

This report updates the following published guidelines and recommendations:. Guideline for handwashing and hospital environmental control. MMWR ;37 No. Replaces sections on microbiologic sampling, laundry, infective waste, and housekeeping. Guideline for prevention of nosocomial pneumonia.

Infect Control Hosp Epidemiol ; Updates and expands environmental infection-control information for aspergillosis and Legionnaires disease; online version incorporates Appendices B, C, and D addressing environmental control and detection of Legionella spp. Guidelines for preventing the transmission of mycobacterium tuberculosis in health-care facilities.

MMWR ;43 No. Provides supplemental information on engineering controls. MMWR ;44 No.

Guideline for isolation precautions in hospitals. Supplements and updates topics in Part II Recommendations for Isolation Precautions in Hospitals linen and laundry, routine and terminal cleaning, airborne precautions. Guideline for prevention of surgical site infection.

Infect Dis Obstet Gynecol ; Supplements information regarding patient interaction with pets and animals in the home. Guidelines for preventing opportunistic infections among hematopoietic stem cell transplant recipients. Cytotherapy ; Supplements and updates the section, Hospital Infection Control.

Key Terms. 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 when caring for TB or smallpox patients and for staff who lack immunity to airborne viral diseases e.

Protective environment PE is a specialized patient-care area, usually in a hospital, with a positive air flow relative to the corridor i. Immunocompromised patients are those patients whose immune mechanisms are deficient because of immunologic disorders e. 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 persons who are severely neutropenic for prolonged periods of time i.

As in previous CDC guidelines, each recommendation is categorized on the basis of existing scientific data, theoretic rationale, applicability, and possible economic effect. 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.

The HICPAC system for categorizing recommendations has been modified to include a category for engineering standards and actions required by state or federal regulations. These standards reflect a consensus of expert opinions and extensive consultation with agencies of the U.

Department of Health and Human Services. Compliance with these standards is usually voluntary. However, state and federal governments often adopt these standards as regulations. Certain recommendations have two category ratings e. Rating Categories. Category IA. Strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies. Category IB. Strongly recommended for implementation and supported by certain experimental, clinical, or epidemiologic studies and a strong theoretic 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 standards. Category II. Suggested for implementation and supported by suggestive clinical or epidemiologic studies, or a theoretic rationale.

Unresolved issue. No recommendation is offered. No consensus or insufficient evidence exists regarding efficacy. Recommendations Air.

Use of trade names and commercial sources is for identification only and does not imply endorsement by the U. CDC is not responsible for the content of pages found at these sites. This conversion may have resulted in character translation or format errors in the HTML version. An original paper copy of this issue can be obtained from the Superintendent of Documents, U. Contact GPO for current prices. Summary The health-care facility environment is rarely implicated in disease transmission, except among patients who are immunocompromised.

Relative to previous CDC guidelines, this report revises multiple sections e. Key recommendations include infection-control impact of ventilation system and water system performance; establishment of a multidisciplinary team to conduct infection-control risk assessment; use of dust-control procedures and barriers during construction, repair, renovation, or demolition; environmental infection-control measures for special areas with patients at high risk; use of airborne-particle sampling to monitor the effectiveness of air filtration and dust-control measures; procedures to prevent airborne contamination in operating rooms when infectious tuberculosis TB patients require surgery; guidance regarding appropriate indications for routine culturing of water as part of a comprehensive control program for legionellae; guidance for recovering from water-system disruptions, water leaks, and natural disasters e.

Performance Measurements 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: 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. Monitor and document daily the negative airflow in AII rooms and positive airflow in PE rooms, especially when patients are in these rooms. 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.

Evaluate possible environmental sources e. If environmental contamination is found, eliminate the probable mechanisms. 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 within 72 hours. Updates to Previous Recommendations Contributors to this report reviewed primarily English-language manuscripts identified from reference searches using the National Library of Medicine's MEDLINE, bibliographies of published articles, and infection-control textbooks.

This report updates the following published guidelines and recommendations: CDC. Recommendations Air I. Air-Handling Systems in Health-Care Facilities 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 1. D, Ensure that heating, ventilation, air conditioning HVAC filters are properly installed and maintained to prevent air leakages and dust overloads 2,4,6,9.

Category IB 2. Monitor areas with special ventilation requirements e. C7, 7. Take into account the age and reliability of the system. Document these parameters, especially the pressure differentials. Engineer humidity controls into the HVAC system and monitor the controls to ensure adequate moisture removal 1.

Locate duct humidifiers upstream from the final filters. Incorporate a water-removal mechanism into the system. Locate all duct takeoffs sufficiently downstream 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 5. Ensure that air intakes and exhaust outlets are located properly in construction of new facilities and renovation of existing facilities 1, D3, 8. D3, 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 1,, Bag dust-filled filters immediately upon removal to prevent dispersion of dust and fungal spores during transport within the facility 4, Seal or close the bag containing the discarded filter.

Discard spent filters as regular solid waste, regardless of the area from which they were removed Remove bird roosts and nests near air intakes to prevent mites and fungal spores from entering the ventilation system 27 ,29, Category IB 9. Prevent dust accumulation by cleaning air-duct grilles in accordance with facility-specific procedures and schedules and when rooms are not occupied by patients 1, D10 Periodically measure output to monitor system function; clean ventilation ducts as part of routine HVAC maintenance to ensure optimum performance 1,31, Category II 1.

Category II 2. Category II 3. Situate portable HEPA units with the advice of facility engineers to ensure that all room air is filtered Category II 4. Ensure that fresh-air requirements for the area are met 33, D1, 8. D8, 9. D23, D18, D15 1. Do not use such areas as PE rooms 1.

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 are met 1, D When ultraviolet germicidal irradiation 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 area; or 3 in designated enclosed areas or booths for sputum induction 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 Emphasize restoration of appropriate air quality and ventilation conditions in AII rooms, PE rooms, operating rooms, emergency departments, and intensive care units 1, Deploy infection-control procedures to protect occupants until power and systems functions are restored 1,36, Coordinate HVAC system maintenance with infection-control staff and relocate immunocompromised patients if necessary 1.

For areas not served by installed emergency ventilation and backup systems, use portable units and monitor ventilation parameters and patients in those areas Coordinate system startups with infection-control staff to protect patients in PE rooms from bursts of fungal spores 1,3, 37 , Allow sufficient time for ACH to clean the air once the system is operational Table 1 1, A1 II.

Construction, Renovation, Remediation, Repair, and Demolition 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 1,9,,38, Category IB Incorporate mandatory adherence agreements for infection control into construction contracts, with penalties for noncompliance and mechanisms to ensure timely correction of problems 1,11,, 27 , Category IB 1.

Using active surveillance, monitor for airborne infections in immunocompromised patients 27 , 37 ,57, Periodically review the facility's microbiologic, histopathologic, and postmortem data to identify additional cases 27 , 37 ,57, Category IB 3. Before the project gets under way, perform an ICRA to define the scope of the activity and the need for barrier measures 1,11,,, Determine if immunocompromised patients may be at risk for exposure to fungal spores from dust generated during the project ,48, Develop a contingency plan to prevent such exposures ,48, Implement infection-control measures for external demolition and construction activities 11,,50,61, Determine if the facility can operate temporarily on recirculated air; if feasible, seal off adjacent air intakes.

If this is not possible or practical, check the low-efficiency roughing filter banks frequently and replace as needed to avoid buildup of particulates. Seal windows and reduce wherever possible other sources of outside air intrusion e. Avoid damaging the underground water system i. Implement infection-control measures for internal construction activities 1,11,, 50, Seal off and block return air vents if rigid barriers are used for containment 1,16, Implement dust-control measures on surfaces and divert pedestrian traffic away from work zones 1,48,49, Perform those engineering and work-site related infection-control measures as needed for internal construction, repairs, and renovations 1,48,49,51,64, 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 39,47,50, Create and maintain negative air pressure in work zones adjacent to patient-care areas and ensure that required engineering controls are maintained 1,48,49,51,64, Monitor negative airflow inside rigid barriers 1, Monitor barriers and ensure integrity of the construction barriers; repair gaps or breaks in barrier joints 1,65,66, Direct pedestrian traffic from construction zones away from patient-care areas to minimize dispersion of dust 1,,44,, Provide construction crews with 1 designated entrances, corridors, and elevators wherever practical; 2 essential services e.

Flush the water system to clear sediment from pipes to minimize waterborne microorganism proliferation 1, Restore appropriate ACH, humidity, and pressure differential; clean or replace air filters; dispose of spent filters 3,4,28, Use airborne-particle sampling as a tool to evaluate barrier integrity 3, 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 1, 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 40,48, Review pressure-differential monitoring documentation to verify that pressure differentials in the construction zone and in PE rooms are appropriate for their settings 1,40, Implement corrective engineering measures to restore proper pressure differentials as needed 1,40, Conduct a prospective search for additional cases and intensify retrospective epidemiologic review of the hospital's medical and laboratory records 27 ,48,76,79, Category IB 4.

If no epidemiologic evidence of ongoing transmission exists, continue routine maintenance in the area to prevent health-care--acquired fungal disease 27 , Use an EPA-registered antifungal biocide e. Category IB 5. If possible, perform molecular subtyping of Aspergillus spp. Infection Control and Ventilation Requirements for PE rooms Minimize exposures of severely immunocompromised patients e. Category IB Minimize the length of time that immunocompromised patients in PE are outside their rooms for diagnostic procedures and other activities 37 , Category IB Provide respiratory protection for severely immunocompromised patients when they must leave PE for diagnostic procedures and other activities; consult the most recent revision of CDC's Guideline for Prevention of Health-Care--Associated Pneumonia for information regarding the appropriate type of respiratory protection.

Category II Incorporate ventilation engineering specifications and dust-controlling processes into the planning and construction of new PE units Figure 1. Category IB, IC 1. Install central or point-of-use HEPA filters for supply incoming air 1,2, 27 ,48,56,70, 80,82,85, Document the monitoring results 1, Install self-closing devices on all room exit doors in PE rooms 1. Category II Take measures to protect immunocompromised patients who would benefit from a PE room and who also have an airborne infectious disease e.

Ensure that the patient's room is designed to maintain positive pressure. D1, A7. If an anteroom is not available, place the patient in AII and use portable, industrial-grade HEPA filters to enhance filtration of spores in the room Maintain continuous negative air pressure 2. C7, Table 7. Install self-closing devices on all AII room exit doors 1. 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 1, Category II Implement environmental infection-control measures for persons with diagnosed or suspected airborne infectious diseases. D23, 9. 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.

Place smallpox patients in negative pressure rooms at the onset of their illness, preferably using a room with an anteroom, if available Maintain backup ventilation equipment e. Infection-Control and Ventilation Requirements for Operating Rooms Implement environmental infection-control and ventilation measures for operating rooms. Maintain positive-pressure ventilation with respect to corridors and adjacent areas 1,, In rooms not engineered for horizontal laminar airflow, introduce air at the ceiling and exhaust air near the floor 1,, Do not use ultraviolet UV lights to prevent surgical-site infections , Category IB 6.

Keep operating room doors closed except for the passage of equipment, personnel, and patients, and limit entry to essential personnel , Use an N95 respirator approved by the National Institute for Occupational Safety and Health without exhalation valves in the operating room , Extubate and allow the patient to recover in an AII room 34 , Position the units appropriately so that all room air passes through the filter; obtain engineering consultation to determine the appropriate placements Switch the portable unit off during the surgical procedure.

Provide fresh air as per ventilation standards for operating rooms; portable units do not meet the requirements for the number of fresh ACH 1,33, Category II No recommendation is offered for performing orthopedic implant operations in rooms supplied with laminar airflow , Unresolved issue Maintain backup ventilation equipment e. Other Potential Infectious Aerosol Hazards in Health-Care Facilities In settings where surgical lasers are used, wear appropriate personal protective equipment PPE , including N95 or N respirators, to minimize exposure to laser plumes ,, Category II 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 34 ,,, Controlling the Spread of Waterborne Microorganisms Practice hand hygiene to prevent the hand transfer of waterborne pathogens, and use barrier precautions e.

Category IA Eliminate contaminated water or fluid environmental reservoirs e. 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. Category IB Avoid placing decorative fountains and fish tanks in patient-care areas; ensure disinfection and fountain maintenance if decorative fountains are used in public areas of the health-care facility Category IB II. Alternatively, chlorinate the water and then flush it through the system Remediation Strategies for Distribution System Repair or Emergencies Whenever possible, disconnect the ice machine before planned water disruptions.

Category II Prepare a contingency plan to estimate water demands for the entire facility in advance of significant water disruptions i. Category II Corrective decontamination of the hot water system might be necessary after a disruption in service or a cross-connection with sewer lines has occurred. Decontaminate the system when the fewest occupants are present in the building e. Flush each outlet until chlorine odor is detected. Use a thorough flushing of the water system instead of chlorination if a highly chlorine-resistant microorganism e. Category II Change the pretreatment filter and disinfect the dialysis water system with an EPA-registered product to prevent colonization of the reverse osmosis membrane and downstream microbial contamination 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 procedures to manage a sewage system failure or flooding e. Relocate patients and clean or sterilize supplies from affected areas. If hands are visibly soiled or contaminated with proteinaceous material, use soap and bottled water for handwashing If the potable water system is not affected by flooding or sewage contamination, process surgical instruments for sterilization according to standard procedures.

Contact the manufacturer of the automated endoscope reprocessor AER for specific instructions on the use of this equipment during a water advisory. Close off affected areas during cleanup procedures. Ensure that the sewage system is fully functional before beginning remediation so contaminated solids and standing water can be removed.

If hard-surfaced equipment, floors, and walls remain in good repair, ensure that these are dry within 72 hours; clean with detergent according to standard cleaning procedures. Clean wood furniture and materials if still in good repair ; allow them to dry thoroughly before restoring varnish or other surface coatings. Contain dust and debris during remediation and repair as outlined in air recommendations Air: IIG 4, 5. Category IB IV. Category II No recommendation is offered for treating water in the facility's distribution system with chlorine dioxide, heavy-metal ions e.

Unresolved issue V. General Infection-Control Strategies for Preventing Legionnaires Disease Conduct an infection-control risk assessment of the facility to determine if patients at risk or severely immunocompromised patients are present 27 ,, Category IB Implement general strategies for detecting and preventing Legionnaires disease in facilities that do not provide care for severely immunocompromised patients i.

Establish a surveillance process to detect health-care--associated Legionnaires disease 27 ,, Inform health-care personnel e. Establish mechanisms to provide clinicians with laboratory tests e. 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.

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 ,,,,, Report the cases to state and local health departments where required. Category IC States 2. Collect water samples from potential aerosolized water sources Box 1 and Box 2 Save and subtype isolates of Legionella spp.

If a source is identified, promptly institute water system decontamination measures per recommendations see Water IV , If Legionella spp. Either defer decontamination pending identification of the source of Legionella spp. Category II No recommendation is offered regarding routine culturing of water systems in health-care facilities that do not have patient-care areas i. 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 VI. Preventing Legionnaires Disease in Protective Environments and Transplant Units When implementing strategies for preventing Legionnaires disease among severely immunocompromised patients housed in facilities with HSCT or solid-organ transplant programs, incorporate these specific surveillance and epidemiologic measures in addition to the steps outlined previously see Appendix.

Maintain a high index of suspicion for legionellosis in transplant patients even when environmental surveillance cultures do not yield legionellae , If a case occurs in a severely immunocompromised patient, or if severely immunocompromised patients are present in high-risk areas of the hospital e. No recommendation is offered regarding the optimal methodology i. Unresolved issue 4.

In areas with patients at risk, when Legionella spp. Decontaminate the water supply as outlined previously Water: IV 27 , 37 ,,, Do not use water from the faucets in patient-care rooms to avoid creating infectious aerosols 37 , Restrict severely immunocompromised patients from taking showers 37 , Use water that is not contaminated with Legionella spp. Provide patients with sterile water for tooth brushing, drinking, and for flushing nasogastric tubing during legionellosis outbreaks 37 , Cooling Towers and Evaporative Condensers 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 ,, Install drift eliminators ,, Use an effective EPA-registered biocide on a regular basis Dialysis Water Quality and Dialysate 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 Unresolved issue Conduct microbiologic testing specific to water in dialysis settings ,, Perform bacteriologic assays of water and dialysis fluids at least once a month and during outbreaks by using standard quantitative methods Assay for heterotrophic, mesophilic bacteria e.

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Do not use nutrient-rich media e. In conjunction with microbiologic testing, perform endotoxin testing on product water used to reprocess dialyzers for multiple use ,, Ensure that water does not exceed the limits for microbial counts and endotoxin concentrations Table 2 Ice Machines and Ice Do not handle ice directly by hand, and wash hands before obtaining ice.

Category II Use a smooth-surface ice scoop to dispense ice , Keep the ice scoop on a chain short enough that the scoop cannot touch the floor or keep the scoop on a clean, hard surface when not in use , Do not store the ice scoop in the ice bin. Category IB Machines that dispense ice are preferred to those that require ice to be removed from bins or chests with a scoop , Category II Limit access to ice-storage chests, and keep container doors closed except when removing ice Category II Clean, disinfect, and maintain ice-storage chests on a regular basis.

Follow the manufacturer's instructions for cleaning. Use an EPA-registered disinfectant suitable for use on ice machines, dispensers, or storage chests in accordance with label instructions. Flush and clean ice machines and dispensers if they have not been disconnected before anticipated lengthy water disruptions. Conduct microbiologic sampling of ice, ice chests, and ice-making machines and dispensers where indicated during an epidemiologic investigation ,, Category IB X.

Hydrotherapy Tanks and Pools Drain and clean hydrotherapy equipment e. Maintain a ppm chlorine residual in the water of small hydrotherapy tanks, Hubbard tanks, and tubs Maintain a ppm chlorine residual in the water of whirlpools and whirlpool spas If the pH of the municipal water is in the basic range e. Category II Clean and disinfect inflatable tubs unless they are single-use equipment. Category II No recommendation is offered regarding the use of antiseptic chemicals e. Unresolved issue Conduct a risk assessment of patients before their use of large hydrotherapy pools, deferring patients with draining wounds or fecal incontinence from pool use until their condition resolves.

Category II 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 No recommendation is offered regarding the use in health-care settings of whirlpool or spa equipment manufactured for home or recreational use.

Unresolved issue XI. Miscellaneous Medical Equipment Connected to Water Systems 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 To rinse disinfected endoscopes and bronchoscopes, use water of the highest quality practical for the system's engineering and design e. Dry the internal channels of the reprocessed endoscope or bronchoscope by using a proven method e.

After each patient, discharge water and air for a minimum of seconds from any dental device connected to the dental water system that enters a patient's mouth e. Consult with the dental unit manufacturer regarding the need for periodic maintenance of antiretraction mechanisms , Cleaning and Disinfecting Strategies for Environmental Surfaces in Patient-Care Areas Select EPA-registered disinfectants, if available, and use them in accordance with the manufacturer's instructions Category II In the absence of a manufacturer's cleaning instructions, follow certain procedures. Do not use alcohol to disinfect large environmental surfaces Detergent and water are adequate for cleaning surfaces in nonpatient-care areas e.

Clean and disinfect high-touch surfaces e. Clean walls, blinds, and window curtains in patient-care areas when they are visibly dusty or soiled , Category IB Avoid large-surface cleaning methods that produce mists or aerosols, or disperse dust in patient-care areas 37 ,48,51, Category IB Follow proper procedures for effective uses of mops, cloths, and solutions.

Prepare cleaning solutions daily or as needed, and replace with fresh solution frequently according to facility policies and procedures , Change the mop head at the beginning of each day and also as required by facility policy, or after cleaning up large spills of blood or other body substances. Clean mops and cloths after use and allow to dry before reuse; or use single-use, disposable mop heads and cloths , Category IB Do not use mats with tacky surfaces at the entrances to operating rooms or infection-control suites Category IB Use appropriate dusting methods for patient-care areas designated for immunocompromised patients e.

Avoid dusting methods that disperse dust e. Category IB Close the doors of immunocompromised patients' rooms when vacuuming, waxing, or buffing corridor floors to minimize exposure to airborne dust 37 ,40, 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 these surfaces by using EPA-registered germicides in accordance with manufacturers' instructions and safety advisories , Do not use phenolics or any other chemical germicide to disinfect bassinets or incubators during an infant's stay , Rinse disinfectant-treated surfaces, especially those treated with phenolics, with water Cleaning Spills of Blood and Body Substances Promptly clean and decontaminate spills of blood or other potentially infectious materials A Follow proper procedures for site decontamination of spills of blood or blood-containing body fluids Use protective gloves and other PPE appropriate for this task Swab the area with a cloth or paper towels moderately wetted with disinfectant, and allow the surface to dry , Use a dilution ppm available chlorine to decontaminate nonporous surfaces after cleaning a spill of either blood or body fluids in patient-care settings , Carpeting and Cloth Furnishings 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 Category II 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 residue Category II Avoid use of carpeting in high-traffic zones in patient-care areas or where spills are likely e.

Category IB Follow appropriate procedures for managing spills on carpeting.

12222 CIS Annual Meeting: Immune Deficiency & Dysregulation North American Conference

Spot-clean blood or body substance spills promptly ,,, A, interpretation 2. If a spill occurs on carpet tiles, replace any tiles contaminated by blood and body fluids or body substances 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. Category IB Avoid using upholstered furniture and furnishings in high-risk patient-care areas and in areas with increased potential for body substance contamination e. Category II No recommendation is offered regarding whether upholstered furniture and furnishings should be avoided in general patient-care areas.

Unresolved issue 1. Maintain upholstered furniture in good repair. Maintain the surface integrity of the upholstery by repairing tears and holes. Category II IV. Flowers and Plants in Patient-Care Areas Flowers and potted plants need not be restricted from areas for immunocompetent patients Category II Designate care and maintenance of flowers and potted plants to staff not directly involved with patient care Category II If plant or flower care by patient-care staff is unavoidable, instruct the staff to wear gloves when handling plants and flowers and perform hand hygiene after glove removal Category II Do not allow fresh or dried flowers, or potted plants, in patient-care areas for immunosuppressed patients 37 ,51,, Category II V.

Pest Control 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 Category II Install screens on all windows that open to the outside; keep screens in good repair Category IB 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 Category II Place laboratory specimens e. Category IB Use standard cleaning and disinfection protocols to control environmental contamination with antibiotic-resistant, gram-positive cocci e.

Pay close attention to cleaning and disinfection of high-touch surfaces in patient-care areas e. Ensure compliance by housekeeping staff with cleaning and disinfection procedures , Use EPA-registered chemical germicides appropriate for the surface to be disinfected e. When contact precautions are indicated for patient care, use disposable patient-care items e.

Follow these same surface-cleaning and disinfecting measures for managing the environment of VRSA patients , Obtain prior approval from infection-control staff and the clinical laboratory before performing environmental-surface culturing. Infection-control staff, with clinical laboratory staff consultation, must supervise all environmental culturing.

Advise families, visitors, and patients regarding the importance of hand hygiene to minimize the spread of body substance contamination e. Category II Do not use high-level disinfectants i. Category II No recommendation is offered regarding the use of specific EPA-registered hospital disinfectants with respect to environmental control of C. 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 , 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 ,, Use disposable barrier coverings as appropriate to minimize surface contamination.

Category II Develop and maintain cleaning and disinfection procedures in patient-care areas to control environmental contamination with agents of Creutzfeldt-Jakob disease CJD , for which no EPA-registered product exists. In the absence of contamination with central nervous system tissue, extraordinary measures e.

The contact time for the chemical used during this process should be 30 min hour ,, Blot up the chemical with absorbent material and rinse the treated surface thoroughly with water. Discard the used, absorbent material into appropriate waste containers. Use disposable, impervious covers to minimize body substance contamination to autopsy tables and surfaces , Wear PPE appropriate for a surface decontamination and cleaning task , General Information Do not conduct random, undirected, microbiologic sampling of air, water, and environmental surfaces in health-care facilities , Category IB When indicated, conduct microbiologic sampling as part of an epidemiologic investigation or during assessment of hazardous environmental conditions to detect contamination or verify abatement of a hazard , Category IB Limit microbiologic sampling for quality assurance purposes to 1 biologic 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 infection-control protocols , Air, Water, and Environmental Surface Sampling When conducting any form of environmental sampling, identify existing comparative standards and fully document departures from standard methods Category II Select a high-volume air sampling device if anticipated levels of microbial airborne contamination are expected to be low ,,, Category II Do not use settle plates to quantify the concentration of airborne fungal spores Category II When sampling water, choose growth media and incubation conditions that will facilitate recovery of waterborne organisms Category II 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 Employer Responsibilities Employers must launder workers' personal protective garments or uniforms that are contaminated with blood or other potentially infectious materials Laundry Facilities and Equipment 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 1, B1, B2 Ensure that laundry areas have handwashing facilities and products and appropriate PPE available for workers 1, Category II Do not leave damp textiles or fabrics in machines overnight Category II Disinfection of washing and drying machines in residential care is not needed as long as gross soil is removed from items before washing and proper washing and drying procedures are used.

Routine Handling of Contaminated Laundry Handle contaminated textiles and fabrics with minimum agitation to avoid contamination of air, surfaces, and persons 36,,, Do not sort or prerinse contaminated textiles or fabrics in patient-care areas Use leak-resistant containment for textiles and fabrics contaminated with blood or body substances , Identify bags or containers for contaminated textiles with labels, color coding, or other alternative means of communication as appropriate 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 Ensure that laundry bags are closed before tossing the filled bag into the chute.

Do not place loose items in the laundry chute. E3 No recommendation is offered regarding a hot-water temperature setting and cycle duration for items laundered in residence-style health-care facilities. Unresolved issue Follow fabric-care instructions and special laundering requirements for items used in the facility Category II 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 Microbiologic Sampling of Textiles Do not conduct routine microbiologic sampling of clean textiles , Category IB Use microbiologic sampling during outbreak investigations if epidemiologic evidence indicates a role for health-care textiles and clothing in disease transmission Category IB VI.

Special Laundry Situations Use sterilized textiles, surgical drapes, and gowns for situations requiring sterility in patient care Category IB Use hygienically clean textiles i. Category IB Follow manufacturers' recommendations for cleaning fabric products, including those with coated or laminated surfaces. Category II Do not use dry cleaning for routine laundering in health-care facilities Category II Use caution when considering 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 such treated items Category II No recommendation is offered regarding using disposable fabrics and textiles versus durable goods.

Unresolved issue VII. Mattresses and Pillows Keep mattresses dry; discard them if they remain wet or stained, particularly in burn units Category IB Clean and disinfect mattress covers by using EPA-registered disinfectants that are compatible with the materials to prevent the development of tears, cracks, or holes in the covers Category IB Maintain the integrity of mattress and pillow covers. Replace mattress and pillow covers if they become torn or otherwise in need of repair. Do not stick needles into a mattress through the cover.

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Category IB If using a mattress cover completely made of fabric, change these covers and launder between patient use Category IB Launder pillow covers and washable pillows in the hot-water cycle between patients or when they become contaminated with body substances Air-Fluidized Beds Follow manufacturers' instructions for air-fluidized bed maintenance and decontamination.

Category II Change the polyester filter sheet at least weekly or as indicated by the manufacturer Category II Clean and disinfect the polyester filter sheet thoroughly, especially between patients, using an EPA-registered product Category IB Consult the facility engineer to determine the proper placement of air-fluidized beds in negative-pressure rooms General Infection-Control Measures for Animal Encounters Minimize contact with animal saliva, dander, urine, and feces Category II Practice hand hygiene after any animal contact , Wash hands with soap and water, especially if hands are visibly soiled or contaminated with proteinaceous material Use either soap and water or alcohol-based hand rubs when hands are not visibly soiled or contaminated Category II II.

Animal-Assisted Activities and Resident Animal Programs Avoid selection of nonhuman primates and reptiles in animal-assisted activities, animal-assisted therapy, or resident animal programs Category IB 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 anthelmintic treatment under the regular care of a veterinarian , Category II Enroll animals that are trained with the assistance or under the direction of persons who are experienced in this field Category II Ensure that animals are controlled by persons trained in providing activities or therapies safely, and who know the animal's health status and behavior traits , Category II Take prompt action when an incident of biting or scratching by an animal occurs during an animal-assisted activity or therapy.

Remove the animal permanently from these programs Report the incident promptly to appropriate authorities e. Promptly clean and treat scratches, bites, or other breaks in the skin. Category II Take precautions to mitigate allergic responses to animals. Groom animals to remove loose hair before a visit, or use a therapy animal cape Category II Restrict resident animals, including fish in tanks, from access to 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 Establish a facility policy for regular cleaning of fish tanks, rodent cages, and 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. Protective Measures for Immunocompromised Patients Advise patients to avoid contact with animal feces, saliva, urine, or solid litter box material Category II Promptly clean and treat scratches, bites, or other wounds that break the skin Category II Advise patients to avoid direct or indirect contact with reptiles Category IB Conduct a case-by-case assessment to determine if animal-assisted activities or animal-assisted therapy programs are appropriate for immunocompromised patients Category II No recommendation is offered regarding permitting pet visits to terminally ill immunocompromised patients outside their PE units.

Bibliography – Meta Science: Research as a Complex System

Service Animals Avoid providing facility access to nonhuman primates and reptiles as service animals , Category IB Allow service animals access to the facility in accordance with the Americans with Disabilities Act of , unless the presence of the animal creates a direct threat to other persons or a fundamental alteration in the nature of services , Category IC U. Animals as Patients in Human Health-Care Facilities Develop health-care facility policies to address the treatment of animals in human health-care facilities.

Use the multidisciplinary team approach to policy development, including public media relations efforts to disclose and discuss these activities. Exhaust all veterinary facility, equipment, and instrument options before undertaking the procedure. Ensure that the care of the animal is supervised by a licensed veterinarian. Category II Schedule the animal procedure for the last procedure of the day in the area, at a time when human patients are not scheduled to be in the vicinity.

Category II Adhere strictly to standard precautions. Category II Clean and disinfect environmental surfaces thoroughly by using an EPA-registered product in the room after the animal has been removed. Category II Clean and disinfect using EPA-registered products or sterilize equipment that has been in contact with the animal; or use disposable equipment. Category II If reusable medical or surgical instruments are used in an animal procedure, restrict future use of these instruments to animals only.

Research Animals in Health-Care Facilities Use animals obtained from quality stock, or quarantine incoming animals to detect zoonotic diseases. Category II Treat sick animals or remove them from the facility. Category II Provide prophylactic vaccinations, as available, to animal handlers and contacts at high risk. Category II Ensure proper ventilation through appropriate facility design and location Keep animal rooms at negative pressure relative to corridors Prevent air in animal rooms from recirculating elsewhere in the health-care facility 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 to zoonoses with occupational health clinics in the health-care facility , Categories of Regulated Medical Waste Designate the following as major categories of medical waste that require special handling and disposal precautions: 1 microbiology laboratory wastes [e. Category II Consult federal, state, and local regulations to determine if other waste items are considered regulated medical wastes ,, Postal Service: CO Disposal Plan for Regulated Medical Wastes Develop a plan for the collection, handling, predisposal treatment, and terminal disposal of regulated medical wastes , Handling, Transporting, and Storing Regulated Medical Wastes Inform personnel involved in handling and disposal of potentially infective waste of possible health and safety hazards; ensure that they are trained in appropriate handling and disposal methods Category II Use proper sharps disposal strategies Use a sharps container capable of maintaining its impermeability after waste treatment to avoid subsequent physical injuries during final disposal Do not bend, recap, or break used syringe needles before discarding them into a container 36,, Category IC States 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.

Treatment and Disposal of Regulated Medical Wastes Treat regulated medical wastes by using a method e. Biosafety level 4 laboratories must inactivate microbiologic wastes in the laboratory by using an approved inactivation method e. Biosafety level 3 laboratories must inactivate microbiologic wastes in the laboratory by using an approved inactivation method e. Category II Laboratories that isolate select agents from clinical specimens must comply with federal regulations for receipt, transfer, management, and appropriate disposal of these agents Special Precautions for Wastes Generated During Care of Patients with Rare Diseases When discarding items contaminated with blood and body fluids from VHF patients, contain these regulated medical wastes with minimal agitation during handling 36, Guidelines for design and construction of hospital and health care facilities, Endemic and epidemic aspergillosis associated with in-hospital replication of Aspergillus organisms.

J Infect Dis ; Streifel AJ. Design and maintenance of hospital ventilation systems and the prevention of airborne nosocomial infections [Chapter 80]. In: Mayhall, CG, ed. Hospital epidemiology and infection control. Unusual cause of lethal pulmonary aspergillosis in patients with chronic obstructive pulmonary disease. Building air quality: a guide for building owners and facility managers. Review of quantitative standards and guidelines for fungi in indoor air.

Hospital outbreak of multidrug-resistant Mycobacterium tuberculosis infections: factors in transmission to staff and HIV-infected patients. JAMA ; Nosocomial transmission of tuberculosis in a hospital unit for HIV-infected patients. Increased recovery of Aspergillus flavus from respiratory specimens during hospital construction.

Am Rev Respir Dis ; In-hospital source of airborne Penicillium species spores. J Clin Microbiol ; Hansen W. The need for an integrated indoor air quality program. In: Hansen W, ed. A guide to managing indoor air quality in health care organizations. Bartley J. In: Pfeiffer J, ed. APIC text of infection control and epidemiology. Construction and renovation. Harvey MA. Critical-care--unit bedside design and furnishing: impact on nosocomial infections.

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Infection Control Focus Group. Patient care focus groups assessing organizational readiness for infection control issues related to construction, renovation, and physical plant projects. Infection control issues in construction and renovation. Transmission of multidrug-resistant Mycobacterium tuberculosis among persons with human immunodeficiency virus infection in an urban hospital: epidemiologic and restriction fragment length polymorphism analysis.

Nosocomial transmission of multidrug-resistant Mycobacterium tuberculosis among intravenous drug users with human immunodeficiency virus infection [Abstract S50].

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