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## Complete Summary

#### GUIDELINE TITLE

Guidelines for preventing health-care\--associated pneumonia, 2003:
recommendations of CDC and the Healthcare Infection Control Practices
Advisory Committee.

#### BIBLIOGRAPHIC SOURCE(S)

Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R. Guidelines for
preventing health-care\--associated pneumonia, 2003: recommendations of
CDC and the Healthcare Infection Control Practices Advisory Committee.
MMWR Recomm Rep 2004 Mar 26;53(RR-3):1-36. \[433 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15048056)

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Centers for Disease Control
and Prevention. Guidelines for prevention of nosocomial pneumonia. MMWR
Recomm Rep 1997 Jan 3;46(RR-1):1-79. \[140 references\]

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse**: This guideline
references a drug(s) for which important revised regulatory information
has been released:

-   [April 02, 2008, Relenza
    (zanamivir)](http://www.fda.gov/medwatch/safety/2008/safety08.htm#Relenza):
    GlaxoSmithKline informed healthcare professionals of changes to the
    warnings and precautions sections of prescribing information for
    Relenza. There have been reports (mostly from Japan) of delirium and
    abnormal behavior leading to injury in patients with influenza who
    are receiving neuraminidase inhibitors, including Relenza.

-   [March 4, 2008, Tamiflu (oseltamivir
    phosphate)](http://www.fda.gov/medwatch/safety/2008/safety08.htm#Tamiflu):
    Roche and the U.S. Food and Drug Administration (FDA) informed
    healthcare professionals of neuropsychiatric events associated with
    the use of Tamiflu, in patients with influenza. Roche has updated
    the PRECAUTIONS section of the package insert to include the new
    information and guidance under the Neuropsychiatric Events heading.

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Health-care associated infections, including bacterial pneumonia,
Legionnaires disease, pertussis, invasive pulmonary aspergillosis (IPA),
respiratory syncytial virus (RSV), parainfluenza and adenoviruses, and
influenza

**Note**: Lower respiratory tract infection caused by *Mycobacterium
tuberculosis* is not addressed in this document.

#### GUIDELINE CATEGORY

Evaluation\
Management\
Prevention

#### CLINICAL SPECIALTY

Critical Care\
Emergency Medicine\
Family Practice\
Infectious Diseases\
Internal Medicine\
Nursing\
Preventive Medicine\
Pulmonary Medicine

#### INTENDED USERS

Advanced Practice Nurses\
Allied Health Personnel\
Clinical Laboratory Personnel\
Health Care Providers\
Hospitals\
Nurses\
Physician Assistants\
Physicians\
Public Health Departments\
Respiratory Care Practitioners

#### GUIDELINE OBJECTIVE(S)

To provide appropriate recommendations for reducing the incidence of
pneumonia and other severe, acute lower respiratory tract infections in
acute-care hospitals and in other health-care settings (e.g., ambulatory
and long-term care institutions) and other facilities where health care
is provided

#### TARGET POPULATION

Patients at risk of pneumonia and other severe, acute lower respiratory
tract infections in acute-care hospitals and in other health-care
settings

#### INTERVENTIONS AND PRACTICES CONSIDERED

See the \"Major Recommendations\" field for additional context.

**Specific to Pneumonia**

1.  Sterilization or disinfection and maintenance of equipment and
    devices, specifically respiratory equipment, through cleaning steam
    sterilization

2.  Pneumococcal vaccination

3.  Prevention of aspiration by use of noninvasive ventilation, patient
    positioning, prevention or modulation of oropharyngeal colonization
    with an antiseptic agent, and oral rinsing with chlorhexidine
    gluconate

4.  Prevention of postoperative pneumonia by promoting deep breathing
    and ambulating and incentive spirometry

**Specific to Legionnaires Disease**

1.  Infection and environmental surveillance with appropriate laboratory
    diagnostic testing, including both culture of appropriate
    respiratory specimens and urine antigen testing

2.  Proper placement of cooling towers in new building construction

3.  Potable water temperature maintained at the outlet at
    [\>]{.underline}51Â°C (\>124Â°F) or \<20Â°C (\<68Â°F),

4.  Decontaminate heated water systems by superheating or
    hyperchlorination

**Specific to Pertussis**

1.  Pertussis vaccination

2.  Diagnostic laboratory tests and treatment for healthcare personnel
    with illness suggestive symptoms

3.  Antibiotic drug administration for persons in close contact with
    persons with pertussis: macrolides, erythromycin, azithromycin,
    clarithromycin, trimethoprim-sulfamethoxazole

**Specific to *Aspergillus***

1.  Minimization of fungal spore accumulation via high-efficiency
    particulate air (HEPA) filtration, directed room airflow, controlled
    environmental conditions (i.e., carpets, dust, water leaks), and use
    of antifungal biocides

2.  Plan to prevent exposure when planning construction, demolition, and
    renovations in and around the facility

**Specific to Respiratory Syncytial Virus (RSV)**

1.  Administration of monoclonal antibody (palivizumab)

**Specific to Influenza**

1.  Influenza vaccination

2.  Administration of amantadine, rimantadine, oseltamivir, and
    zanamivir

#### MAJOR OUTCOMES CONSIDERED

Incidence of pneumonia and other severe, acute lower respiratory tract
infections in acute-care hospitals and in other health-care settings

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Each recommendation is categorized on the basis of existing scientific
evidence, theoretical rationale, applicability, and potential economic
impact. In addition, a new category accommodates recommendations that
are made on the basis of existing national or state health regulations.

**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 clinical or epidemiologic studies and by strong theoretical
rationale

**Category IC**: Required for implementation, as mandated by federal or
state regulation or standard

**Category II**: Suggested for implementation and supported by
suggestive clinical or epidemiologic studies or by strong theoretical
rationale

**No recommendation; unresolved issue**: Practices for which
insufficient evidence or no consensus exists about efficacy

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

The document was reviewed by experts in infection control,
intensive-care medicine, pulmonology, respiratory therapy,
anesthesiology, internal medicine, and pediatrics; and approved by the
Healthcare Infection Control Practices Advisory Committee (HICPAC).

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

The rating scheme for the strength of recommendations (Category IA, IB,
IC, II, No recommendation) is provided at the end of the \"Major
Recommendations\" field.

**[Summary of Updated Recommendations]{.underline}**

The revised guidelines are designed to reduce the incidence of pneumonia
and other severe, acute lower respiratory tract infections in acute-care
hospitals and in other health-care settings (e.g., ambulatory and
long-term care institutions) and other facilities where health care is
provided.

Among the changes in the recommendations to prevent bacterial pneumonia,
especially ventilator-associated pneumonia, are the preferential use of
orotracheal rather than nasotracheal tubes in patients who receive
mechanically assisted ventilation, the use of noninvasive ventilation to
reduce the need for and duration of endotracheal intubation, changing
the breathing circuits of ventilators when they malfunction or are
visibly contaminated, and (when feasible) the use of an endotracheal
tube with a dorsal lumen to allow drainage of respiratory secretions; no
recommendations were made about the use of sucralfate, histamine-2
receptor antagonists, or antacids for stress-bleeding prophylaxis. For
prevention of health-care\--associated Legionnaires disease, the changes
include maintaining potable hot water at temperatures not suitable for
amplification of *Legionella* spp., considering routine culturing of
water samples from the potable water system of a facility\'s
organ-transplant unit when it is done as part of the facility\'s
comprehensive program to prevent and control health-care\--associated
Legionnaires disease, and initiating an investigation for the source of
*Legionella* spp. when one definite or one possible case of
laboratory-confirmed health-care\--associated Legionnaires disease is
identified in an inpatient hemopoietic stem-cell transplant (HSCT)
recipient or in two or more HSCT recipients who had visited an
outpatient HSCT unit during all or part of the 2 to 10 day period before
illness onset. In the section on aspergillosis, the revised
recommendations include the use of a room with high-efficiency
particulate air filters rather than laminar airflow as the protective
environment for allogeneic HSCT recipients and the use of
high-efficiency respiratory-protection devices (e.g., N95 respirators)
by severely immunocompromised patients when they leave their rooms when
dust-generating activities are ongoing in the facility. In the
respiratory syncytial virus (RSV) section, the new recommendation is to
determine, on a case-by-case basis, whether to administer monoclonal
antibody (palivizumab) to certain infants and children aged \<24 months
who were born prematurely and are at high risk for RSV infection. In the
section on influenza, the new recommendations include the addition of
oseltamivir (to amantadine and rimantadine) for prophylaxis of all
patients without influenza illness and oseltamivir and zanamivir (to
amantadine and rimantadine) as treatment for patients who are acutely
ill with influenza in a unit where an influenza outbreak is recognized.

In addition to the revised recommendations, the guideline contains new
sections on pertussis and lower respiratory tract infections caused by
adenovirus and human parainfluenza viruses, and refers readers to the
source of updated information about prevention and control of severe
acute respiratory syndrome.

**[Prevention of Health-Care--Associated Bacterial
Pneumonia]{.underline}**

I.  **Staff Education and Involvement in Infection Prevention**

> Educate health-care workers about the epidemiology of, and
> infection-control procedures for, preventing healthcare--associated
> bacterial pneumonia to ensure worker competency according to the
> worker\'s level of responsibility in the health-care setting, and
> involve the workers in the implementation of interventions to prevent
> healthcare--associated pneumonia by using performance improvement
> tools and techniques (**IA**) (Brooks, Whitten, & Quigley, 1998; Halm
> et al., 2000; Katz, 1999; Kaye et al., 2000; Kelleghan et al., 1993;
> Joiner, Salisbury, & Bollin, 1996; Nicotra & Ulrich, 1996; Zack et
> al., 2002).

II. **Infection and Microbiologic Surveillance**

    A.  Conduct surveillance for bacterial pneumonia in intensive care
        unit (ICU) patients who are at high risk for
        health-care--related bacterial pneumonia (e.g., patients with
        mechanically assisted ventilation or selected postoperative
        patients) to determine trends and help identify outbreaks and
        other potential infection-control problems (Haley, Culver et
        al., 1985; Haley, Morgan et al., 1985). The use of the new
        National Nosocomial Infection Surveillance (NNIS) system´s
        surveillance definition of pneumonia is recommended (CDC, \"NNIS
        criteria,\" 2003). Include data on the causative microorganisms
        and their antimicrobial susceptibility patterns (Horan et al.,
        1986). Express data as rates (e.g., number of infected patients
        or infections per 100 ICU days or per 1,000 ventilator days) to
        facilitate intrahospital comparisons and trend determination
        (Haley, Culver et al., 1985; Gaynes & Solomon, 1996; Josephson
        et al., 1991). Link monitored rates and prevention efforts and
        return data to appropriate health-care personnel (**IB**)
        (Gaynes et al., 2001).

    B.  In the absence of specific clinical, epidemiologic, or
        infection-control objectives, do not routinely perform
        surveillance cultures of patients or of equipment or devices
        used for respiratory therapy, pulmonary function testing, or
        delivery of inhalation anesthesia (**II**) (American Hospital
        Association Committee on Infection within hospitals, 1974;
        Eickhoff, 1970; Finelli, Livengood, & Saiman, 1994; Glupczynski,
        2001).

III. **Prevention of Transmission of Microorganisms**

     A.  Sterilization or Disinfection and Maintenance of Equipment and
         Devices

         1.  General measures

             a.  Thoroughly clean all equipment and devices to be
                 sterilized or disinfected (**IA**) (Favero & Bond,
                 1991; Rutala & Weber, in press).

             b.  Whenever possible, use steam sterilization (by
                 autoclaving) or high-level disinfection by wet heat
                 pasteurization at \>158 degrees F (\>70 degrees C) for
                 30 minutes for reprocessing semicritical equipment or
                 devices (i.e., items that come into direct or indirect
                 contact with mucous membranes of the lower respiratory
                 tract) that are not sensitive to heat and moisture (see
                 box on page 4 of the original guideline document). Use
                 low-temperature sterilization methods (as approved by
                 the Office of Device Evaluation, Center for Devices and
                 Radiologic Health, Food and Drug Administration
                 \[FDA\]) for equipment or devices that are heat- or
                 moisture-sensitive (Rutala & Weber, in press; Cefai et
                 al., 1990; Craig et al., 1975; McDonald, Welch, & Keet,
                 1955; Spaulding, 1939). After disinfection, proceed
                 with appropriate rinsing, drying, and packaging, taking
                 care not to contaminate the disinfected items in the
                 process (Favero & Bond, 1991; Rutala & Weber, in
                 press).

             c.  Preferentially use sterile water for rinsing reusable
                 semicritical respiratory equipment and devices when
                 rinsing is needed after they have been chemically
                 disinfected. If this is not feasible, rinse the device
                 with filtered water (i.e., water that has been through
                 a 0.2 micron filter) or tap water, and then rinse with
                 isopropyl alcohol and dry with forced air or in a
                 drying cabinet (**IB**) (Rutala & Weber, in press).

             d.  Adhere to provisions in FDA\'s enforcement document for
                 single-use devices that are reprocessed by third
                 parties (**IC**) (Rutala & Weber, in press; FDA, 2000)

         2.  Mechanical ventilators

> Do not routinely sterilize or disinfect the internal machinery of
> mechanical ventilators (**II**).

3.  Breathing circuits, humidifiers, and heat-and moisture exchangers
    (HMEs)

    a.  Breathing circuits with humidifiers

        1.  Do not change routinely, on the basis of duration of use,
            the breathing circuit (i.e., ventilator tubing and
            exhalation valve and the attached humidifier) that is in use
            on an individual patient. Change the circuit when it is
            visibly soiled or mechanically malfunctioning (**IA**)
            (Dreyfuss et al., 1991; Fink et al., 1998; Hess et al.,
            1995; Kollef et al., 1995; Kotilainen & Keroack, 1997; Long
            et al., 1996).

        2.  Breathing-circuit--tubing condensate

            a.  Periodically drain and discard any condensate that
                collects in the tubing of a mechanical ventilator,
                taking precautions not to allow condensate to drain
                toward the patient (**IB**) (Craven, Goularte, & Make,
                1984).

            b.  Wear gloves to perform the previous procedure and/or
                when handling the fluid (**IB**) (Garner, 1996; Gorman
                et al., 1993).

            c.  Decontaminate hands with soap and water (if hands are
                visibly soiled) or with an alcohol-based hand rub after
                performing the procedure or handling the fluid (**IA**)
                (Gorman et al., 1993; CDC, \"Guideline for hand
                hygiene,\" 2002).

        3.  No recommendation can be made for placing a filter or trap
            at the distal end of the expiratory-phase tubing of the
            breathing circuit to collect condensate (**Unresolved
            issue**).

        4.  Humidifier fluids

            a.  Use sterile (not distilled, nonsterile) water to fill
                bubbling humidifiers (**II**) (Craven, Goularte, & Make,
                1984; Arnow et al., 1982; Carson et al., 1973; Favero,
                Carson, & Bond, 1971; Rhame et al., 1986).

            b.  No recommendation can be made for the preferential use
                of a closed, continuous-feed humidification system
                (**Unresolved issue**).

    b.  Ventilator breathing circuits with HMEs

        1.  No recommendation can be made for the preferential use of
            either HMEs or heated humidifiers to prevent pneumonia in
            patients receiving mechanically assisted ventilation
            (**Unresolved issue**) (**IB**) (Cook et al., 1998; Dreyfuss
            et al., 1995; Hurni et al., 1997; Kirton et al., 1997;
            Roustan et al., 1992; Thomachot et al., 1998).

        2.  Changing HME

            a.  Change an HME that is in use on a patient when it
                malfunctions mechanically or becomes visibly soiled
                (**II**).

            b.  Do not routinely change more frequently than every 48
                hours an HME that is in use on a patient (**II**)
                (Boisson et al., 1999; Daumal et al., 1999; Thomachot et
                al., 1998).

        3.  Do not change routinely (in the absence of gross
            contamination or malfunction) the breathing circuit attached
            to an HME while it is in use on a patient (**II**) (Salemi
            et al., 2000).

4.  Oxygen humidifiers

    a.  Follow manufacturers\' instructions for use of oxygen
        humidifiers (**II**,**C**) (FDA, 2000; Golar, Sutherland, &
        Ford, 1993; Henderson et al., 1993; Seto et al., 1990).

    b.  Change the humidifier-tubing (including any nasal prongs or
        mask) that is in use on one patient when it malfunctions or
        becomes visibly contaminated (**II**).

5.  Small-volume medication nebulizers: in-line and hand-held nebulizers

    a.  Between treatments on the same patient clean, disinfect, rinse
        with sterile water (if rinsing is needed), and dry small-volume
        in-line or hand-held medication nebulizers (**IB**) (Craven et
        al., 1984; Mastro et al., 1991; Reboli et al., 1996).

    b.  Use only sterile fluid for nebulization, and dispense the fluid
        into the nebulizer aseptically (**IA**) (Arnow et al., 1982;
        Carson et al., 1973; Favero, Carson, & Bond, 1971; Mastro et
        al., 1991; Mertz, Scharer, & McClement, 1967; Moffet & Williams,
        1967; Sanders et al., 1970).

    c.  Whenever possible, use aerosolized medications in single-dose
        vials. If multidose medication vials are used, follow
        manufacturers´ instructions for handling, storing, and
        dispensing the medications (**IB**) (Mertz, Scharer, &
        McClement, 1967; Sanders et al., 1970; Hamill et al., 1995;
        Harbarth et al., 1999; Longfield et al., 1984; Ramsay et al.,
        2001; Sheth et al., 1983).

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6.  Mist tents

    a.  Between uses on different patients, replace mist tents and their
        nebulizers, reservoirs, and tubings with those that have been
        subjected to sterilization or high-level disinfection (**II**)
        (Moffet & Allan, 1967).

    b.  No recommendation can be made about the frequency of routinely
        changing mist-tent nebulizers, reservoirs, and tubings while in
        use on one patient (**Unresolved issue**).

    c.  Subject mist-tent nebulizers, reservoirs, and tubings that are
        used on the same patient to daily low-level disinfection (e.g.,
        with 2% acetic acid) or pasteurization followed by air drying
        (**II**) (Jakobsson, Hjelte, & Nystrom, 2000).

7.  Other devices used in association with respiratory therapy

    a.  Respirometer and ventilator thermometer: between their uses on
        different patients, sterilize or subject to high-level
        disinfection portable respirometers and ventilator thermometers
        (**IB**) (Cuhna et al., 1980; Irwin et al., 1980; Kaul et al.,
        1996; Rogues et al., 2001; Weems, 1993).

    b.  Resuscitation bags

        1.  Between their uses on different patients, sterilize or
            subject to high-level disinfection reusable hand-powered
            resuscitation bags (**IB**) (Fierer, Taylor, & Gezon, 1967;
            Stone & Das, 1986; Thompson, Wilder, & Powner, 1985; Weber
            et al., 1990; Van Der Zwet et al., 2000).

        2.  No recommendation can be made about the frequency of
            changing hydrophobic filters placed on the connection port
            of resuscitation bags (**Unresolved issue**).

8.  Anesthesia machines and breathing systems or patient circuits

    a.  Do not routinely sterilize or disinfect the internal machinery
        of anesthesia equipment (**IB**) (Du Moulin & Sauberman, 1977).

    b.  Between uses on different patients, clean reusable components of
        the breathing system or patient circuit (e.g., tracheal tube or
        face mask) inspiratory and expiratory breathing tubing, y-piece,
        reservoir bag, humidifier, and tubing, and then sterilize or
        subject them to high-level liquid chemical disinfection or
        pasteurization in accordance with the device manufacturers´
        instructions for their reprocessing (**IB**) (Rutala & Weber, in
        press; Craig et al., 1975).

    c.  No recommendation can be made about the frequency of routinely
        cleaning and disinfecting unidirectional valves and carbon
        dioxide absorber chambers (**Unresolved issue**) (Bengtson et
        al., 1989).

    d.  Follow published guidelines or manufacturers´ instructions about
        in-use maintenance, cleaning, and disinfection or sterilization
        of other components or attachments of the breathing system or
        patient circuit of anesthesia equipment (**IB**) (American
        Association of Nurse Anesthetists, 1993; American Society for
        Anesthesiologists, 1991).

    e.  No recommendation can be made for placing a bacterial filter in
        the breathing system or patient circuit of anesthesia equipment
        (**Unresolved issue**) (Brooks, Whitten, & Quigley, 1998; Berry
        & Nolte, 1991; Feeley et al., 1981; Garibaldi et al., 1981;
        Luttropp & Berntman, 1993; Ping et al., 1979; Vezina et al.,
        2001).

9.  Pulmonary-function testing equipment

    a.  Do not routinely sterilize or disinfect the internal machinery
        of pulmonary-function testing machines between uses on different
        patients (**II**) (Hiebert, Miles, & Okeson, 1999; Rutala et
        al., 1991).

    b.  Change the mouthpiece of a peak flow meter or the mouthpiece and
        filter of a spirometer between uses on different patients
        (**II**) (Rutala & Weber, in press; Ahmed et al., 1994).

10. Room-air \"humidifiers\" and faucet aerators

    a.  Do not use large-volume room-air humidifiers that create
        aerosols (e.g., by venturi principle, ultrasound, or spinning
        disk, and thus actually are nebulizers) unless they can be
        sterilized or subjected to high-level disinfection at least
        daily and filled only with sterile water (**II**) (Arnow et al.,
        1982; Grieble et al., 1970; Smith & Massanari, 1977).

    b.  Faucet aerators

        1.  No recommendation can be made about the removal of faucet
            aerators from areas for immunocompetent patients (see also
            section on Legionnaires Disease, Part II, Section I-C-1-d)
            (**Unresolved issue**).

        2.  If *Legionella* spp. are detected in the water of a
            transplant unit and until *Legionella* spp. are no longer
            detected by culture, remove faucet aerators in the unit (see
            also section on Legionnaires Disease, Part II, Section
            I-C-1-d) (**II**) (Sehulster & Chinn, 2003).

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A.  Prevention of Person-to-Person Transmission of Bacteria

    1.  Standard Precautions

        a.  Hand hygiene: Decontaminate hands by washing them with
            either antimicrobial soap and water or with nonantimicrobial
            soap and water (if hands are visibly dirty or contaminated
            with proteinaceous material or are soiled with blood or body
            fluids) or by using an alcohol-based waterless antiseptic
            agent (e.g., hand rub) if hands are not visibly soiled after
            contact with mucous membranes, respiratory secretions, or
            objects contaminated with respiratory secretions, whether or
            not gloves are worn. Decontaminate hands as described
            previously before and after contact with a patient who has
            an endotracheal or tracheostomy tube in place, and before
            and after contact with any respiratory device that is used
            on the patient, whether or not gloves are worn (**IA**)
            (Garner, 1996; CDC, \"Guideline for hand hygiene,\" 2002).

        b.  Gloving

            1.  Wear gloves for handling respiratory secretions or
                objects contaminated with respiratory secretions of any
                patient (**IB**) (Garner, 1996).

            2.  Change gloves and decontaminate hands as described
                previously between contacts with different patients;
                after handling respiratory secretions or objects
                contaminated with secretions from one patient and before
                contact with another patient, object, or environmental
                surface; and between contacts with a contaminated body
                site and the respiratory tract of, or respiratory device
                on, the same patient (**IA**) (Garner, 1996; CDC,
                \"Guideline for hand hygiene,\" 2002; Doebbeling et al.,
                1988; LeClair et al., 1987; Patterson et al., 1991).

        c.  When soiling with respiratory secretions from a patient is
            anticipated, wear a gown and change it after soiling occurs
            and before providing care to another patient (**IB**)
            (Garner, 1996; LeClair et al., 1987).

    2.  Care of patients with tracheostomy

        a.  Perform tracheostomy under aseptic conditions (**II**).

        b.  When changing a tracheostomy tube, wear a gown, use aseptic
            technique, and replace the tube with one that has undergone
            sterilization or high-level disinfection (**IB**) (Favero &
            Bond, 1991; Rutala & Weber, in press; Garner, 1996).

        c.  No recommendation can be made for the daily application of
            topical antimicrobial agent(s) at the tracheostoma
            (**Unresolved issue**) (Morar et al., 2000).

    3.  Suctioning of respiratory tract secretions (See also Section
        IV-B-1-d)

        a.  No recommendation can be made for the preferential use of
            either the multiuse closed system suction catheter or the
            single-use open system suction catheter for prevention of
            pneumonia (**Unresolved issue**) (Cook et al., 1998; Combes,
            Fauvage, & Oleyer, 2000; Deppe et al., 1990; Johnson et al.,
            1994).

        b.  No recommendation can be made about wearing sterile rather
            than clean gloves when performing endotracheal suctioning
            (**Unresolved issue**).

        c.  No recommendation can be made about the frequency of
            routinely changing the in-line suction catheter of a
            closed-suction system in use on one patient (**Unresolved
            issue**) (Kollef et al., 1997).

        d.  If the open-system suction is employed, use a sterile,
            single-use catheter (**II**).

        e.  Use only sterile fluid to remove secretions from the suction
            catheter if the catheter is to be used for re-entry into the
            patient´s lower respiratory tract (**II**).

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IV. **Modifying Host Risk for Infection**

    A.  Increasing Host Defense Against Infection: Administration of
        Immune Modulators

        1.  Pneumococcal vaccination. Vaccinate patients at high risk
            for severe pneumococcal infections

            a.  Administer the 23-valent pneumococcal polysaccharide
                vaccine to persons aged [\>]{.underline}65 years;
                persons aged 5 to 64 years who have chronic
                cardiovascular disease (e.g., congestive heart failure
                or cardiomyopathy), chronic pulmonary disease (e.g.,
                chronic obstructive pulmonary disease \[COPD\] or
                emphysema, but not asthma), diabetes mellitus,
                alcoholism, chronic liver disease (e.g., cirrhosis), or
                cerebrospinal fluid (CSF) leaks; persons aged 5 to 64
                years who have functional or anatomic asplenia; persons
                aged 5 to 64 years who are living in special
                environments or social settings; immunocompromised
                persons aged [\>]{.underline}5 years with human
                immunodeficiency virus (HIV) infection, leukemia,
                lymphoma, Hodgkin\'s disease, multiple myeloma,
                generalized malignancy, chronic renal failure, nephrotic
                syndrome, or other conditions associated with
                immunosuppression (e.g., receipt of hemopoietic
                stem-cell transplant \[HSCT\], solid-organ transplant,
                or immunosuppressive chemotherapy, including long-term
                systemic corticosteroids); and persons in
                long-term--care facilities (**IA**) (CDC 1997 & 2001;
                \"Preventing pneumococcal disease,\" 2000; Shapiro &
                Clemens, 1984; Williams et al, 1988; Nichol, Grimm, &
                Peterson, 1996).

            b.  Administer the 7-valent pneumococcal polysaccharide
                protein-conjugate vaccine to all children aged \<2 years
                and to children aged 24 to 59 months who are at
                increased risk for pneumococcal disease (e.g., children
                with sickle-cell disease or other hemoglobinopathies, or
                children who are functionally or anatomically asplenic;
                children with HIV infection; children who have chronic
                disease, including chronic cardiac or pulmonary disease
                \[except asthma\], diabetes mellitus, or CSF leak; and
                children with immunocompromising conditions including
                malignancies, chronic renal failure or nephrotic
                syndrome, receipt of immunosuppressive chemotherapy,
                including long-term corticosteroids, and receipt of
                solid organ transplant). Consider administering the
                vaccine to children aged 24 to 59 months, with priority
                to children aged 24 to 35 months, children who are
                American Indians/Alaska Natives or Black, and children
                who attend group child care centers (**IB**)
                (\"Preventing pneumococcal disease,\" 2000).

            c.  In nursing homes and other long-term--care facilities,
                establish a standing order program (SOP) for the
                administration of 23-valent vaccine to persons at high
                risk for acquiring severe pneumococcal infections,
                including pneumococcal pneumonia (**IA**) (CDC,
                \"Preventing,\" 1997; CDC, \"Use of standing orders,\"
                2000; \"Medicare and Medicaid programs,\" 2002).

        2.  No recommendation can be made for the routine administration
            of preparations of granulocyte colony stimulating factor
            (GCSF) or intravenous gamma globulin for prophylaxis against
            healthcare--associated pneumonia (**Unresolved issue**)
            (Donta et al., 1996; Gruson et al., 2000; Heard et al.,
            1998; Maher et al., 1994; Mitchell et al., 1997; The
            Intravenous Immunoglobulin Collaborative Study Group, 1992).

        3.  No recommendation can be made for the routine enteral
            administration of glutamine for prevention of
            health-care--associated pneumonia (**Unresolved issue**)
            (Houdijk et al., 1998; van der Hulst et al., 1993).

    B.  Precautions for prevention of aspiration:

> As soon as the clinical indications for their use are resolved, remove
> devices such as endotracheal, tracheostomy, and/or enteral (i.e., oro-
> or nasogastric or jejunal) tubes from patients (**IB**) (Celis et al.,
> 1988; Craven et al., 1986; Kingston, Phang, & Leathley, 1991; Metheny,
> Eisenberg, & Spies, 1986; Pingleton, Hinthorn, & Liu, 1986; Treloar &
> Stechmiller, 1984).

1.  Prevention of aspiration associated with endotracheal intubation

    a.  Use of noninvasive ventilation (NIV) to reduce the need for and
        duration of endotracheal intubation

        1.  When feasible and not medically contraindicated, use
            noninvasive positive-pressure ventilation delivered
            continuously by face or nose mask, instead of performing
            endotracheal intubation in patients who are in respiratory
            failure and are not needing immediate intubation (e.g.,
            those who are in hypercapneic respiratory failure secondary
            to acute exacerbation of COPD or cardiogenic pulmonary
            edema) (**II**) (Brochard et al., 1995; Girou et al., 2000;
            Carlucci et al., 2001; Keenan, 2000).

        2.  When feasible and not medically contraindicated, use NIV as
            part of the weaning process (from mechanically assisted
            ventilation) to shorten the period of endotracheal
            intubation (**II**) (Nava et al., 1998).

    b.  As much as possible, avoid repeat endotracheal intubation in
        patients who have received mechanically assisted ventilation
        (**II**) (Torres et al., 1995).

    c.  Unless contraindicated by the patient\'s condition, perform
        orotracheal rather than nasotracheal intubation on patients
        (**IB**) (Cook et al., 1998; Holzapfel et al., 1993; Rouby et
        al., 1994).

    d.  If feasible, use an endotracheal tube with a dorsal lumen above
        the endotracheal cuff to allow drainage (by continuous or
        frequent intermittent suctioning) of tracheal secretions that
        accumulate in the patient´s subglottic area (**II**) (Cook et
        al., 1998; Kollef, Skubas, & Sundt, 1999; Mahul et al., 1992;
        Smulders et al., 2002; Valles et al., 1995).

    e.  Before deflating the cuff of an endotracheal tube in preparation
        for tube removal, or before moving the tube, ensure that
        secretions are cleared from above the tube cuff (**II**).

2.  Prevention of aspiration associated with enteral feeding

    a.  In the absence of medical contraindication(s), elevate at an
        angle of 30 to 45 degrees of the head of the bed of a patient at
        high risk for aspiration (e.g., a person receiving mechanically
        assisted ventilation and/or who has an enteral tube in place)
        (**II**) (Drakulovic et al., 1999; Orozco-Levi et al., 1995;
        Torres et al., 1992).

    b.  Routinely verify appropriate placement of the feeding tube
        (**IB**) (Gharpure et al., 2000; Hand et al., 1984; McClave et
        al., 2002).

    c.  No recommendation can be made for the preferential use of
        small-bore tubes for enteral feeding (**Unresolved issue**)
        (Ferrer et al., 1999).

    d.  No recommendation can be made for preferentially administering
        enteral feedings continuously or intermittently (**Unresolved
        issue**) (Bonten et al., 1996; Jacobs et al., 1990; Lee, Chang,
        & Jacobs, 1990; Skiest et al., 1996).

    e.  No recommendation can be made for preferentially placing the
        feeding tubes, (e.g., jejunal tubes) distal to the pylorus
        (**Unresolved issue**) (Heyland et al., 2001; Heyland et al.,
        2002; Kearns et al., 2000; Montecalvo et al., 1992; Montejo et
        al., 2002; Spain et al., 1995; Strong et al., 1992).

3.  Prevention or modulation of oropharyngeal colonization

    a.  Oropharyngeal cleaning and decontamination with an antiseptic
        agent: develop and implement a comprehensive oral-hygiene
        program (that might include the use of an antiseptic agent) for
        patients in acute-care settings or residents in long-term--care
        facilities who are at high risk for health-care--associated
        pneumonia (**II**) (Schleder, Stott, & Lloyd, 2002; Yoneyama et
        al., 2002).

    b.  Chlorhexidine oral rinse

        1.  No recommendation can be made for the routine use of an oral
            chlorhexidine rinse for the prevention of
            health-care--associated pneumonia in all postoperative or
            critically ill patients and/or other patients at high risk
            for pneumonia (**Unresolved issue**) (**II**) (DeRiso et
            al., 1996).

        2.  Use an oral chlorhexidine gluconate (0.12%) rinse during the
            perioperative period on adult patients who undergo cardiac
            surgery (**II**) (DeRiso et al., 1996).

    c.  Oral decontamination with topical antimicrobial agents.

        1.  No recommendation can be made for the routine use of topical
            antimicrobial agents for oral decontamination to prevent
            ventilator-associated pneumonia (VAP) (**Unresolved issue**)
            (Bergmans et al., 2001).

4.  Prevention of gastric colonization

    a.  No recommendation can be made for the preferential use of
        sucralfate, H2-antagonists, and/or antacids for stress-bleeding
        prophylaxis in patients receiving mechanically assisted
        ventilation (**Unresolved issue**) (Bonten et al., 1995; Cook et
        al., 1996 & 1998; Messori et al., 2000; Simms et al., 1991;
        Thomason et al., 1996; Tryba, 1987; Yildizdas, Yapicioglu, &
        Yilmaz, 2002).

    b.  No recommendation can be made for the routine selective
        decontamination of the digestive tract (SDD) of all critically
        ill, mechanically ventilated, or ICU patients (**Unresolved
        issue**) (Abele-Horn et al., 1997; D´Amico et al., 1998;
        Langlois-Karaga et al., 1995; Nathens & Marshall, 1999; Quinio
        et al., 1996; Stoutenbeek et al., 1984; Unertl et al., 1987;
        Kerver et al., 1988; Ledingham et al., 1988; Brun-Buisson et
        al., 1989; Ulrich et al., 1989; Flaherty et al., 1990; Godard et
        al., 1990; McClelland et al., 1990; Rodriguez-Roldan et al.,
        1990; Tetteroo et al., 1990; Aerdts et al., 1991; Blair et al.,
        1991; Fox et al., 1991; Hartenauer et al., 1991; Pugin et al.,
        1991; Vandenbroucke-Grauls & Vandenbrouke, 1991; Cockerill et
        al., 1992; Gastinne et al., 1992; Hammond et al., 1992; Rocha et
        al., 1992; Winter et al., 1992; Korinek et al., 1993; Selective
        Decontamination of the Digestive Tract Trialists´ Collaborative
        Group, 1993; Ferrer et al., 1994; Nau et al., 1990; Sanchez
        Garcia et al., 1998; Kreuger et al., 2002).

    c.  No recommendation can be made for routinely acidifying gastric
        feeding (**Unresolved issue**) (Heyland, Bradley, & Mandell,
        1992; Heyland et al., 1999).

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C.  Prevention of Postoperative Pneumonia

    1.  Instruct preoperative patients, especially those at high risk
        for contracting pneumonia, about taking deep breaths and
        ambulating as soon as medically indicated in the postoperative
        period. Patients at high risk include those who will have
        abdominal aortic aneurysm repair, thoracic surgery, or emergency
        surgery; those who will receive general anesthesia; those who
        are aged [\>]{.underline}60 years; those with totally dependent
        functional status; those who have had a weight loss \>10%; those
        using steroids for chronic conditions; those with recent history
        of alcohol use, history of COPD, or smoking during the preceding
        year; those with impaired sensorium, a history of
        cerebrovascular accident with residual neurologic deficit, or
        low (\<8 mg/dL) or high (\>22 mg/dL) blood urea nitrogen level;
        and those who will have received \>4 units of blood before
        surgery (**IB**) (Arozullah et al., 2001; Brooks-Brunn, 1997;
        Chumillas et al., 1998; Thomas & McIntosh, 1994).

    2.  Encourage all postoperative patients to take deep breaths, move
        about the bed, and ambulate unless medically contraindicated
        (**IB**) (Chumillas et al., 1998; Thomas & McIntosh, 1994; Hall
        et al., 1996).

    3.  Use incentive spirometry on postoperative patients at high risk
        for pneumonia (**IB**) (Chumillas et al., 1998; Thomas &
        McIntosh, 1994; Hall et al., 1996).

    4.  No recommendation can be made about the routine use of chest
        physiotherapy on all postoperative patients at high risk for
        pneumonia (**Unresolved issue**) (Chumillas et al., 1998; Thomas
        & McIntosh, 1994; Hall et al., 1996).

D.  Other Prophylactic Procedures for Pneumonia

    1.  Administration of antimicrobial agents other than in SDD

        a.  Systemic antimicrobial prophylaxis: No recommendation can be
            made about the routine administration of systemic
            antimicrobial agent(s) to prevent pneumonia in critically
            ill patients or in those receiving mechanically assisted
            ventilation (**Unresolved issue**) (Kreuger et al., 2002;
            Sirvent et al., 1997).

        b.  Scheduled changes in the class of antimicrobial agents used
            for empiric therapy: No recommendation can be made for
            scheduled changes in the class of antimicrobial agents used
            routinely for empiric treatment of suspected infections in a
            particular group of patients (**Unresolved issue**) (Gruson
            et al., 2000; Kollef et al., 1997).

    2.  Turning or rotational therapy: No recommendation can be made for
        the routine use of turning or rotational therapy, either by
        \"kinetic\" therapy or by continuous lateral rotational therapy
        (i.e., placing patients on beds that turn on their longitudinal
        axes intermittently or continuously) for prevention of
        health-care--associated pneumonia in critically ill and
        immobilized patients (**Unresolved issue**) (Cook et al., 1998;
        deBoisblanc et al., 1993; Fink et al., 1990; Gentilello et al.,
        1988; Kirschenbaum et al., 2002; Summer et al., 1989; Whiteman
        et al., 1995).

**[Prevention and Control of Health-Care\--Associated Legionnaires
Disease]{.underline}**

I.  **Primary Prevention (Preventing health-care--associated
    Legionnaires disease when no cases have been documented)**

    A.  Staff Education

        1.  Educate physicians to heighten their suspicion for cases of
            health-care--associated Legionnaires disease and to use
            appropriate methods for its diagnosis (**II**).

        2.  Educate patient-care, infection-control, and engineering
            personnel about measures to prevent and control
            health-care--associated legionellosis (**II**).

    B.  Infection and Environmental Surveillance

        1.  Maintain a high index of suspicion for the diagnosis of
            health-care--associated Legionnaires disease and perform
            laboratory diagnostic tests (both culture of appropriate
            respiratory specimen and the urine antigen test) for
            legionellosis on suspected cases, especially in patients who
            are at high risk for acquiring the disease (e.g., patients
            who are immunosuppressed, including HSCT or solid
            organ--transplant recipients; patients receiving systemic
            steroids; patients aged [\>]{.underline}65 years; or
            patients who have chronic underlying disease such as
            diabetes mellitus, congestive heart failure, and COPD)
            (**IA**) (Le Saux et al., 1989; Marston, Lipman, & Breiman,
            1994; Kirby et al., 1980; Haley et al., 1979; Bock et al.,
            1978; Brady, 1989; Jimenez et al., 1991; Chow & Yu, 1998;
            Brennen et al., 1987; Lepine et al., 1998)

        2.  Periodically review the availability and clinicians\' use of
            laboratory diagnostic tests for Legionnaires disease in the
            facility, and if clinicians do not routinely use the tests
            on patients with diagnosed or suspected pneumonia, implement
            measures to enhance clinicians´ use of the tests (e.g., by
            conducting educational programs) (**II**) (Fiore et al.,
            1999; Kool et al., 1998)

        3.  Routine culturing of water systems for *Legionella* spp.

            a.  No recommendation can be made about routinely culturing
                water systems for *Legionella* spp. in health-care
                facilities that do not have patient-care areas (i.e.,
                transplant units) for persons at high risk for
                Legionella infection (**Unresolved issue**) (Sehulster &
                Chinn, 2003; Alary & Joly, 1992; Best et al., 1983;
                Goetz & Yu, 1991; Johnson et al., 1985; Marrie et al.,
                1991 & 1992; Redd & Cohen, 1987; Tobin, Swann, &
                Bartlett, 1981; Yu, 1986; Yu et al., 1987)

            b.  In facilities with hemopoietic stem-cell- and/or
                solid-organ--transplantation programs, periodic
                culturing for legionellae in water samples from the
                transplant unit(s) can be performed as part of a
                comprehensive strategy to prevent Legionnaires disease
                in transplant recipients (**II**) (Sehulster & Chinn,
                2003; CDC, \"Guidelines,\" 2000; Pannuti, 1997;
                Patterson et al., 1997)

            c.  If such culturing (as in b) is undertaken:

                1.  No recommendation can be made about the optimal
                    methods (i.e., frequency or number of sites) for
                    environmental surveillance cultures in transplant
                    units (**Unresolved issue**).

                2.  Perform corrective measures aimed at maintaining
                    undetectable levels of *Legionella* spp. in the
                    unit\'s water system (**II**).

                3.  Maintain a high index of suspicion for legionellosis
                    in transplant patients with health-care--associated
                    pneumonia even when environmental surveillance
                    cultures do not yield legionellae (**IB**) (Chow &
                    Yu, 1998; Fiore et al., 1999).

    C.  Use and Care of Medical Devices, Equipment, and Environment

        1.  Nebulizers and other devices

            a.  Preferentially use sterile water for rinsing
                nebulization devices and other semicritical
                respiratory-care equipment after they have been cleaned
                or disinfected (Mastro et al., 1991; Woo, Yu, & Goetz,
                1986). If this is not feasible, rinse the device with
                filtered water (i.e., water that has been through a 0.2
                micro filter) or tap water and then rinse with isopropyl
                alcohol and dry with forced air or in a drying cabinet
                (**IB**) (Rutala & Weber, in press).

            b.  Use only sterile (not distilled, nonsterile) water to
                fill reservoirs of devices used for nebulization
                (**IA**) (Arnow et al., 1982; Mastro et al., 1991; Alary
                & Joly, 1992; (Woo, Yu, & Goetz, 1986; Zuravleff et al.,
                1983).

            c.  Do not use large-volume room-air humidifiers that create
                aerosols (e.g., by venturi principle, ultrasound, or
                spinning disk and thus are really nebulizers) unless
                they can be sterilized or subjected to high-level
                disinfection at least daily and filled only with sterile
                water (**II**) Woo, Yu, & Goetz, 1986; Zuravleff et al.,
                1983).

            d.  Faucet aerators

                1.  No recommendation can be made for the removal of
                    faucet aerators from areas for immunocompetent
                    patients (see also Bacterial Pneumonia, Part II,
                    section III-A-10-b in the original guideline
                    document) (**Unresolved issue**).

                2.  If *Legionella* spp. are detected in the water of a
                    transplant unit and until *Legionella* spp. are no
                    longer detected by culture, remove faucet aerators
                    in areas for severely immunocompromised patients
                    (**II**) (Sehulster & Chinn, 2003).

        2.  Cooling towers

            a.  When a new building is constructed, place cooling towers
                in such a way that the tower drift is directed away from
                the facility´s air intake system, and design the cooling
                towers such that the volume of aerosol drift is
                minimized (**IB**) (Sehulster & Chinn, 2003; American
                Society for Heating, Refrigerating, and Air-Conditioning
                Engineers, 2000; Department of Health and Social
                Security and the Welsh Office, 1991).

            b.  For cooling towers, install drift eliminators, regularly
                use an effective biocide, maintain the tower according
                to manufacturers´ recommendations, and keep adequate
                maintenance records (**IB**) (Sehulster & Chinn, 2003;
                American Society for Heating, Refrigerating, and
                Air-Conditioning Engineers, 2000; Department of Health
                and Social Security and the Welsh Office, 1991).

        3.  Water-distribution system

            a.  Where practical and allowed by state law, maintain
                potable water at the outlet at [\>]{.underline}51
                degrees C ([\>]{.underline}124 degrees F) or \<20
                degrees C (\<68 degrees F), especially in facilities
                housing organ-transplant recipients or other patients at
                high-risk (American Society for Heating, Refrigerating,
                and Air-Conditioning Engineers, 2000; Department of
                Health and Social Security and the Welsh Office, 1991;
                Ezzeddine et al., 1989; Mandel et al., 1993; Snyder et
                al., 1990). If water is maintained at [\>]{.underline}51
                degrees C ([\>]{.underline}124 degrees F), use
                thermostatic mixing valves to prevent scalding (**II**)
                (Health and Safety Commission, 2000).

            b.  No recommendation can be made about the treatment of
                water with chlorine dioxide, heavy-metal ions, ozone, or
                ultraviolet light (Biurrun et al., 1999; Domingue et
                al., 1988; Edelstein et al., 1982; Goetz & Yu, 1997;
                Hall et al., 2003; Landeen, Yahya, & Gerba, 1989; Lin et
                al., 1998; Liu et al., 1994; Matulonis, Rosenfield, &
                Shadduck, 1993; Mietzner et al., 1997; Muraca, Stout, &
                Yu, 1987; Muraca, Yu, & Goetz, 1990; Rohr et al., 1999;
                Srinivasan et al., 2003; Stout et al., 1998; Stout & Yu,
                2003; Heffelfinger et al., 2003). Hospitals served by
                municipalities with monochloramine-treated water have
                had success in controlling legionella (**Unresolved
                issue**) (Walker et al., 1995; Kool, Carpenter, &
                Fields, 1999).

        4.  Health-care facilities with hemopoietic stem-cell or
            solid-organ transplantation programs: If legionellae are
            detected in the potable water supply of a transplant unit,
            and until legionellae are no longer detected by culture:

            a.  Decontaminate the water supply as per section
                II-B-2-b-3)-a)-i to v of the guidelines (**IB**).

            b.  Restrict severely immunocompromised patients from taking
                showers (**IB**) (CDC, \"Guidelines,\" 2000; Bollin et
                al., 1985).

            c.  Use water that is not contaminated with *Legionella*
                spp. for HSCT patients´ sponge baths (**IB**) (Breiman
                et al., 1991; Marrie et al., 1991).

            d.  Provide HSCT patients with sterile water for tooth
                brushing or drinking or for flushing nasogastric tubes
                (**IB**) (CDC, \"Guidelines,\" 2000; Marrie et al.,
                1991).

            e.  Do not use water from faucets with
                *Legionella*-contaminated water in patients´ rooms to
                avoid creating infectious aerosols (**II**) (Bollin et
                al., 1985).

II. **Secondary Prevention (Response to identification of
    laboratory-confirmed health-care--associated Legionellosis)**

    A.  In Facilities with HSCT or Solid-Organ Transplant Recipients:
        When one inpatient of an HSCT or solid-organ transplant unit
        develops a case of laboratory-confirmed definite (i.e., after
        [\>]{.underline}10 days of continuous inpatient stay) or
        possible (i.e., within 2--9 days of inpatient stay)
        health-care--associated Legionnaires disease, or when two or
        more patients develop laboratory-confirmed Legionnaires disease
        within 6 months of each other and after having visited an
        outpatient transplant unit during part of the 2--10 day period
        before illness onset:

        1.  Contact the local or state health department or Centers for
            Disease Control and Prevention (CDC) if the disease is
            reportable in the state or if assistance is needed (**II**,
            **IC**).

        2.  In consultation with the facility\'s infection control team,
            conduct a combined epidemiologic and environmental
            investigation (as outlined from II-B-2-b-1 through
            II-B-2-b-5) to determine the source(s) of *Legionella* spp.
            (Sehulster & Chinn, 2003; CDC, \"Guidelines,\" 2000).
            Include but do not limit the investigation to such potential
            sources as showers, water faucets, cooling towers, hot-water
            tanks, and carpet-cleaner water tanks (Lepine et al., 1998;
            Kool et al., 1998; Fiore et al., 1998). On its
            identification, decontaminate or remove the source of
            *Legionella* spp (**II**).

        3.  If the health-care facility\'s potable water system is found
            to be the source of *Legionella* spp., observe the measures
            outlined in Section I-C-4-b to e, about the nonuse of the
            facility´s potable water by recipients of HSCT or
            solid-organ transplants and decontaminate the water supply
            as per Section II-B-2-b-3)-a)-i to v (**IB**).

        4.  Do not conduct an extensive facility investigation when an
            isolated case of possible health-care--associated
            Legionnaires disease occurs in a patient who has had little
            contact with the inpatient transplant unit during most of
            the incubation period of the disease (**II**).

    B.  In Facilities That Do Not House Severely Immunocompromised
        Patients (e.g., HSCT or Solid-Organ Transplant Recipients): When
        a single case of laboratory-confirmed definite
        health-care--associated Legionnaires disease is identified, or
        when two or more cases of laboratory confirmed, possible
        health-care--associated Legionnaires disease occur within 6
        months of each other:

        1.  Contact the local or state health department or CDC if the
            disease is reportable in the state or if assistance is
            needed (**II**, **IC**).

        2.  Conduct an epidemiologic investigation through a
            retrospective review of microbiologic, serologic, and
            postmortem data to identify previous cases, and begin an
            intensive prospective surveillance for additional cases of
            health-care--associated Legionnaires disease (**II**).

            a.  If no evidence of continued nosocomial transmission
                exists, continue the intensive prospective surveillance
                for cases for [\>]{.underline}2 months after
                surveillance is begun (**II**).

            b.  If evidence of continued transmission exists:

                1.  Conduct an environmental investigation to determine
                    the source(s) of *Legionella* spp. by collecting
                    water samples from potential sources of aerosolized
                    water and saving and subtyping isolates of
                    *Legionella* spp. obtained from patients and the
                    environment (**IB**) (Arnow et al., 1982; Mastro et
                    al., 1991; Breiman et al., 1990 & 1991; Dondero et
                    al., 1980; Garbe et al., 1985; Hanrahan et al.,
                    1987; Johnston et al., 1987; O\'Mahony et al., 1990;
                    Pruckler et al., 1995; Schoonmaker, Heimberger, &
                    Birkhead, 1992; Struelens et al., 1992; Whitney et
                    al., 1997).

                2.  If a source is not identified, continue surveillance
                    for new cases for [\>]{.underline}2 months and,
                    depending on the scope of the outbreak, decide to
                    either defer decontamination pending identification
                    of the source(s) of *Legionella* spp. or proceed
                    with decontamination of the hospital\'s water
                    distribution system, with special attention to the
                    specific hospital areas involved in the outbreak
                    (**II**).

                3.  If a source of infection is identified by the
                    epidemiologic and environmental investigations,
                    promptly decontaminate the source (**IB**).

                    a.  If the heated water system is implicated:

                        i.  Decontaminate the heated water system either
                            by superheating or by hyperchlorination. To
                            superheat, raise the hot water temperature
                            to 71 to 77 degrees C (160--170 degrees F)
                            and maintain at that level while
                            progressively flushing each outlet around
                            the system. A minimum flush time of 5
                            minutes has been recommended; however, the
                            optimal flush time is not known and longer
                            flush times might be required. Post warning
                            signs at each outlet being flushed to
                            prevent scald injury to patients, staff, or
                            visitors. If possible, perform flushing when
                            the building has the fewest occupants (e.g.,
                            nights and weekends). For systems on which
                            thermal shock treatment is not possible, use
                            shock chlorination as an alternative. Add
                            chlorine, preferably overnight, to achieve a
                            free chlorine residual of [\>]{.underline}2
                            mg/L ([\>]{.underline}2 ppm) throughout the
                            system. This might require chlorination of
                            the water heater or tank to levels of 20 to
                            50 mg/L (20--50 ppm). Maintain the water pH
                            between 7.0 and 8.0 (**IB**) (Best et al.,
                            1983; American Society for Heating,
                            Refrigerating, and Air-Conditioning
                            Engineers, 2000; Ezzeddine et al., 1989;
                            Snyder et al., 1990; Johnston et al., 1987;
                            Best, Goetz, & Yu, 1984; \"Sustained
                            transmission,\" 1997; Helms et al., 1988).

                        ii. Depending on local and state regulations
                            about potable water temperature in public
                            buildings (Mandel et al., 1993), circulate
                            potable water at temperatures not conducive
                            to amplification of *Legionella*; store and
                            distribute cold water at \<20 degrees C
                            (\<68 degrees F); and store hot water at
                            \>60 degrees C (\>140 degrees F) and
                            circulate it at a minimum return temperature
                            of 51 degrees C (124 degrees F) (**II**)
                            (Sehulster & Chinn, 2003; Department of
                            Health and Social Security and the Welsh
                            Office, 1991; Ezzeddine et al., 1989; Mandel
                            et al., 1993; Snyder et al., 1990).

                        iii. If the methods described in 3a-i and 3a-ii
                             are not successful in decontaminating the
                             hospital´s water, seek expert consultation
                             for review of decontamination procedures
                             and assistance with further efforts
                             (**II**).

                        iv. No recommendation can be made for the
                            treatment of water with chlorine dioxide,
                            heavy-metal ions, ozone, or ultraviolet
                            light (Biurrun et al., 1999; Domingue et
                            al., 1988; Edelstein et al., 1982; Goetz &
                            Yu, 1997; Hall et al., 2003; Landeen, Yahya,
                            & Gerba, 1989; Lin et al., 1998; Liu et al.,
                            1994; Matulonis, Rosenfield, & Shadduck,
                            1993; Mietzner et al., 1997; Muraca, Stout,
                            & Yu, 1987; Muraca, Yu, & Goetz, 1990; Rohr
                            et al., 1999; Srinivasan et al., 2003; Stout
                            et al., 1998; Stout & Yu, 2003; Heffelfinger
                            et al., 2003). Hospitals have reported
                            successful decontamination using each of
                            these methods (**Unresolved issue**).

                        v.  Clean hot-water storage tanks and water
                            heaters to remove accumulated scale and
                            sediment (**IB**) (Sehulster & Chinn, 2003).

                    b.  If cooling towers or evaporative condensers are
                        implicated, decontaminate the cooling-tower
                        system (**IB**) (Sehulster & Chinn, 2003;
                        American Society for Heating, Refrigerating, and
                        Air-Conditioning Engineers, 2000).

                4.  Assess the efficacy of implemented measures in
                    reducing or eliminating *Legionella* spp. by
                    collecting specimens for culture at 2-week intervals
                    for 3 months (**II**).

                    a.  If *Legionella* spp. are not detected in
                        cultures during 3 months of monitoring at 2-week
                        intervals, collect cultures monthly for another
                        3 months (**II**).

                    b.  If *Legionella* spp. are detected in one or more
                        cultures, reassess the implemented control
                        measures, modify them accordingly, and repeat
                        decontamination procedures. Options for repeat
                        decontamination include the intensive use of the
                        same technique used for the initial
                        decontamination or a combination of superheating
                        and hyperchlorination (**II**) (\"Sustained
                        transmission,\" 1997).

                5.  Keep adequate records of all infection control
                    measures, including maintenance procedures, and of
                    environmental test results for cooling towers and
                    potable water systems (**II**).

**[Prevention and Control of Health-Care--Associated
Pertussis]{.underline}**

I.  **Staff Education**:

> Educate appropriate personnel in accordance with their level of
> responsibility in the health-care setting about the epidemiology,
> modes of transmission, and means of preventing the spread of pertussis
> (**IB**) (Christie et al., 1995; Haiduven et al., 1998).

II. **Case-Reporting, Disease Surveillance, and Case Contact
    Notification**

    A.  Report to the local and/or state health department all confirmed
        and suspected cases of pertussis (**II**, **IC**) (Christie et
        al., 1995).

    B.  Conduct active surveillance for cases of pertussis until 42 days
        after the onset of the last pertussis case (**II**) (CDC,
        \"Guidelines for the control of pertussis outbreaks,\" 2002)

    C.  Notify persons who have had close contact with a case of
        pertussis in the health-care setting so that they can be
        monitored for symptoms of pertussis and/or administered
        appropriate chemoprophylaxis. Close contact includes
        face-to-face contact with a patient who is symptomatic (e.g., in
        the catarrhal or paroxysmal period of illness); sharing a
        confined space in close proximity for a prolonged period of time
        (e.g., [\>]{.underline}1 hour) with a symptomatic patient; or
        direct contact with respiratory, oral, or nasal secretions from
        a symptomatic patient (e.g., an explosive cough or sneeze on the
        face, sharing food, sharing eating utensils during a meal,
        kissing, mouth-to-mouth resuscitation, or performing a full
        medical examination of the nose and throat) (**II**) (CDC,
        \"Guidelines for the control of pertussis outbreaks,\" 2002).

III. **Prevention of Pertussis Transmission**

     A.  Vaccination for Primary Prevention

         1.  No recommendation can be made for routinely vaccinating
             adults, including health-care workers, with the acellular
             pertussis vaccine at regular intervals (e.g., every 10
             years) (**Unresolved issue**) (CDC, \"Guidelines for the
             control of pertussis outbreaks,\" 2002; Gardner, 1999;
             Linnemann et al., 1975; Orenstein, 1999; Wright, Decker, &
             Edwards, 1999).

         2.  In long-term--care facilities for children and for children
             with prolonged stay in acute-care facilities, follow the
             recommendations of the Advisory Committee on Immunization
             Practices (ACIP) for vaccinating children according to
             their chronologic age (**IB**) (CDC, \"Guidelines for the
             control of pertussis outbreaks,\" 2002; \"Pertussis
             vaccination,\" 1997).

     B.  Vaccination for Secondary Prevention

         1.  No recommendation can be made for vaccinating adults,
             including health-care workers, during an institutional
             outbreak of pertussis (**Unresolved issue**) (CDC,
             \"Guidelines for the control of pertussis outbreaks,\"
             2002; Shefer et al., 1995).

         2.  During an institutional outbreak of pertussis, accelerate
             scheduled vaccinations to infants and children aged \<7
             years who have not completed their primary vaccinations, as
             follows:

             a.  Infants aged \<2 months who are receiving their initial
                 vaccination: Administer the first dose of the
                 diphtheria, tetanus, and acellular pertussis (DTaP)
                 vaccine as early as age 6 weeks and the second and
                 third doses at a minimum of 4-week intervals between
                 doses. Give the fourth dose on or after age 1 year and
                 at least 6 months after the third dose (**II**) (CDC,
                 \"Guidelines for the control of pertussis outbreaks,\"
                 2002; CDC, \"Recommended childhood immunization
                 schedule,\" 2002; Halsey & Galazka, 1985).

             b.  Other children aged \<7 years: Administer DTaP vaccine
                 to all patients who are aged \<7 years and are not
                 up-to-date with their pertussis vaccinations, as
                 follows: administer a fourth dose of DTaP if the child
                 has had 3 doses of DTaP or diphtheria, tetanus and
                 pertussis (DTP) vaccine, is [\>]{.underline}12 months
                 old, and \>6 months have passed since the third dose of
                 DTaP or DTP; administer a fifth dose of DTaP if the
                 child has had four doses of DTaP or DTP, is aged 4 to 6
                 years, and received the fourth vaccine dose before the
                 fourth birthday (**IB**) (Haiduven et al., 1998; CDC,
                 \"Guidelines for the control of pertussis outbreaks,\"
                 2002; \"Pertussis vaccination,\" 1997; CDC,
                 \"Recommended childhood immunization schedule,\" 2002).

         3.  Vaccination of children with a history of well documented
             pertussis disease: No recommendation can be made for
             administering additional dose(s) of pertussis vaccine to
             children who have a history of well-documented pertussis
             disease (i.e., pertussis illness with either a *B.
             pertussis*-positive culture or epidemiologic linkage to a
             culture-positive case) (**Unresolved issue**) (CDC,
             \"Guidelines for the control of pertussis outbreaks,\"
             2002; \"Pertussis vaccination,\" 1997).

     C.  Patient Placement and Management

         1.  Patients with confirmed pertussis: Place a patient with
             diagnosed pertussis in a private room or, if known not to
             have any other respiratory infection, in a room with other
             patient(s) with pertussis until after the first 5 days of a
             full course of antimicrobial treatment or 21 days after the
             onset of cough if unable to take antimicrobial treatment
             for pertussis (**IB**) (Garner, 1996; CDC, \"Guidelines for
             the control of pertussis outbreaks,\" 2002).

         2.  Patients with suspected pertussis

             a.  Place a patient with suspected pertussis in a private
                 room. After pertussis and no other infection is
                 confirmed, the patient can be placed in a room with
                 other patient(s) who have pertussis until after the
                 first 5 days of a full course of antimicrobial
                 treatment or 21 days after the onset of cough if unable
                 to take antimicrobial treatment for pertussis (**IB**)
                 (Garner, 1996; CDC, \"Guidelines for the control of
                 pertussis outbreaks,\" 2002).

             b.  Perform diagnostic laboratory tests (for confirmation
                 or exclusion of pertussis) on patients who are admitted
                 with or who develop signs and symptoms of pertussis to
                 allow for the earliest possible downgrading of
                 infection control precautions to the minimum required
                 for each patient´s specific infection(s) (**IB**)
                 (Christie et al., 1995; Grimprel et al., 1993;
                 Mastrantonio et al., 1996; Matlow et al., 1997; van der
                 Zee et al., 1996).

     D.  Management of Symptomatic Health-Care Personnel

         1.  In conjunction with employee-health personnel, perform
             diagnostic laboratory tests for pertussis in health-care
             personnel with illness suggestive of pertussis (i.e.,
             unexplained cough illness of \>1 week duration and
             paroxysmal cough) (**IB**) (Christie et al., 1995; Haiduvan
             et al., 1998; Grimprel et al., 1993; Mastrantonio et al.,
             1996; Matlow et al., 1997; van der Zee et al., 1996).

         2.  In conjunction with employee-health personnel, treat
             symptomatic health-care personnel who are proven to have
             pertussis or personnel who are highly suspected of having
             pertussis with the same antimicrobial regimen, as detailed
             for chemoprophylaxis of case-contacts, in F-1 to F-2
             (**IB**) (Christie et al., 1995; Gehanno et al., 1999).

         3.  Restrict symptomatic pertussis-infected healthcare workers
             from work during the first 5 days of their receipt of
             antimicrobial therapy (**IB**) (Haiduvan et al., 1998; CDC,
             \"Guidelines for the control of pertussis outbreaks,\"
             2002; Gehanno et al., 1999).

     E.  Masking

> In addition to observing standard precautions, wear a surgical mask
> when within 3 feet of a patient with confirmed or suspected pertussis,
> when performing procedures or patient-care activities that are likely
> to generate sprays of respiratory secretions, or on entering the room
> of a patient with confirmed or suspected pertussis (**IB**) (Garner,
> 1996).

F.  Use of a Prophylactic Antibiotic Regimen for Contacts of Persons
    with Pertussis

    1.  Administer a macrolide to any person who has had close contact
        with persons with pertussis and who does not have
        hypersensitivity or intolerance to macrolides (**IB**) (Haiduven
        et al., 1998; Halperin et al., 1999).

        a.  Except in infants aged [\<]{.underline}2 weeks, use
            erythromycin (i.e., erythromycin estolate, 500 mg four times
            daily or erythromycin delayed-release tablets, 333 mg three
            times daily for adults, and 40 to 50 mg/kg day for children)
            for 14 days (**IB**) (Haiduven et al., 1998; \"Diphtheria,
            tetanus, and pertussis,\" 1991; Cooper et al., 2002;
            Halperin et al., 1997; Honein et al., 1999).

        b.  For patients who are intolerant to erythromycin or for
            infants aged [\<]{.underline}2 weeks, use any of the
            following regimens: azithromycin for 5 to 7 days (at 10--12
            mg/kg/day) or for 5 days (at 10 mg/kg on day one followed by
            4 days at 5 mg/kg/day) for infants and young children
            (Halperin, 2003); or clarithromycin for 10 to 14 days (at
            500 mg twice a day for adults or 15--20 mg/kg/day in two
            divided doses for children) (**II**) (Haiduven et al., 1998;
            Aoyama et al., 1996; Hoppe & Bryskier, 1998).

    2.  For chemoprophylaxis of persons who have hypersensitivity or
        intolerance to macrolides, use (except in the case of a pregnant
        woman at term, a nursing mother, or an infant aged \<2 months)
        trimethoprim-sulfamethoxazole (TMP-SXT) for 14 days (at one
        double-strength tablet twice a day for adults and 8 mg/kg/day
        TMP, 40 mg/kg/day SXT a day in 2 divided doses for children)
        (**II**) (\"Diphtheria, tetanus, and pertussis,\" 1991; Hoppe et
        al., 1989).

G.  Work Exclusion of Asymptomatic Health-Care Workers Exposed to
    Pertussis

    1.  Do not exclude from patient care a health-care worker who
        remains asymptomatic and is receiving chemoprophylaxis after an
        exposure to a case of pertussis (i.e., by direct contact of
        one\'s nasal or buccal mucosa with the respiratory secretions of
        an untreated person who is in the catarrhal or paroxysmal stage
        of pertussis) (**II**) (Haiduven et al., 1998).

    2.  If mandated by state law or where feasible, exclude an exposed,
        asymptomatic health-care worker who is unable to receive
        chemoprophylaxis from providing care to a child aged \<4 years
        during the period starting 7 days after the worker\'s first
        possible exposure until 14 days after his last possible exposure
        to a case of pertussis (**II**, **IC**) (Haiduven et al., 1998).

H.  Other measures

    1.  Limiting patient movement or transport: Limit the movement and
        transport of a patient with diagnosed or suspected pertussis
        from his room to those for essential purposes only. If the
        patient is transported out of the room, ensure that precautions
        are maintained to minimize the risk for disease transmission to
        other patients and contamination of environmental surfaces or
        equipment (**IB**) (Garner, 1996).

    2.  Limiting visitors: Do not allow persons who have symptoms of
        respiratory infection to visit pediatric, immunosuppressed, or
        cardiac patients (**IB**) (Garner, 1996; Christie et al., 1995;
        Valenti, Pincus, & Messner, 1980).

**[Prevention and Control of Health-Care--Associated Pulmonary
Aspergillosis]{.underline}**

I.  **Staff Education and Infection Surveillance**

    A.  Staff Education

> Educate health-care personnel according to their level of
> responsibility about infection-control procedures to decrease the
> occurrence of health-care--associated pulmonary aspergillosis
> (**II**).

B.  Surveillance

    1.  Maintain a high index of suspicion for healthcare--associated
        pulmonary aspergillosis in severely immunocompromised patients
        (i.e., patients with severe, prolonged neutropenia \[absolute
        neutrophil count (ANC) \<500/mm^3^ for 2 weeks or \<100/mm^3^
        for 1 week\], most notably HSCT recipients, and including
        recipients of solid-organ transplants or patients with
        hematologic malignancies who are receiving chemotherapy, when
        they are severely neutropenic as defined previously) and persons
        receiving prolonged high-dose steroids (**IA**) (Gerson et al.,
        1984; Marr et al., 2002; Pannuti et al., 1992; Paterson & Singh,
        1999; Wald et al., 1997; Wingard et al., 1987; Kramer et al.,
        1993; Gustafson et al., 1983).

    2.  Maintain surveillance for cases of health-care--associated
        pulmonary aspergillosis by establishing a system by which the
        facility\'s infection control personnel are promptly informed
        when *Aspergillus* sp. is isolated from cultures of specimens
        from patient\'s respiratory tract and by periodically reviewing
        the hospital´s microbiologic, histopathologic, and postmortem
        data (**II**).

    3.  Surveillance cultures

        a.  Do not perform routine, periodic cultures of the nasopharynx
            of asymptomatic patients at high risk (**IB**) (Riley et
            al., 1995; Walsh, 1990).

        b.  Do not perform routine, periodic cultures of equipment or
            devices used for respiratory therapy, pulmonary function
            testing, or delivery of inhalation anesthesia in the HSCT
            unit, nor of dust in rooms of HSCT recipients (**IB**)
            (Walsh, 1990).

        c.  No recommendation can be made about routine microbiologic
            air sampling before, during, or after facility construction
            or renovation or before or during occupancy of areas housing
            immunocompromised patients (**Unresolved issue**) (Sehulster
            & Chinn, 2003; Richardson et al., 2000).

    4.  In facilities with protective environments (PEs), perform
        surveillance of the ventilation status of these areas either by
        continuous monitoring or periodic analysis of the following
        parameters: room air exchanges, pressure relations, and
        filtration efficacy to ensure that appropriate levels are
        maintained (**IB**) (Sehulster & Chinn, 2003; Streifel, 1999).

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II. **Prevention of Transmission of *Aspergillus* spp. Spores**

    A.  Planning New Specialized-Care Units for High-Risk Patients

        1.  Protective environment (PE) for allogeneic HSCT recipients

            a.  When constructing new specialized-care units with PE for
                HSCT recipients, ensure that patient rooms have adequate
                capacity to minimize accumulation of fungal spores via

                1.  High-efficiency particulate air (HEPA) filtration of
                    incoming air (Oren et al., 2001),

                2.  directed room airflow,

                3.  positive air pressure in patient´s room in relation
                    to the corridor,

                4.  well-sealed room, and

                5.  high ([\>]{.underline}12) air changes per hour
                    (**IB**, **IC**) (Sehulster & Chinn, 2003; Rice,
                    Streifel, & Velsey, 2001; Sherertz et al., 1987;
                    Thio et al., 2000).

            b.  Do not use laminar airflow (LAF) routinely in PE
                (**IB**) (Sehulster & Chinn, 2003; Buckner et al., 1978;
                Loo et al., 1996; Walter & Bowden, 1995; Walsh et al.,
                1989).

        2.  Units for autologous HSCT and solid-organ transplant
            recipients: No recommendation can be made for constructing
            PE for recipients of autologous HSCTs or
            solid-organ-transplants (e.g., heart, liver, lung, kidney)
            (**Unresolved issue**) (Sehulster & Chinn, 2003; Walsh et
            al., 1989).

    B.  In Existing Facilities with HSCT Units and No Cases of
        Health-Care--Associated Aspergillosis

        1.  Placement of patients in PE

            a.  Place an allogeneic HSCT recipient in a PE that meets
                the conditions outlined in Section II-A-1 (**IB**).

            b.  No recommendation can be made for routinely placing a
                recipient of autologous HSCT or solid-organ transplant
                in a PE. (**Unresolved issue**)

        2.  Maintain air-handling systems in PE and other high-risk
            patient-care areas according to previously published CDC
            recommendations (**IB**, **IC**) (Sehulster & Chinn, 2003;
            Rice, Streifel, & Velsey, 2001; Thio et al., 2000)

        3.  Develop a water-damage response plan for immediate execution
            when water leaks, spills, and moisture accumulation occur to
            prevent fungal growth in the involved areas (**IB**)
            (Sehulster & Chinn, 2003; Velsey & Streifel, 1999).

        4.  Use proper dusting methods for patient-care areas designated
            for severely immunocompromised patients (e.g., HSCT
            recipients) (**IB**) (Sehulster & Chinn, 2003; Rice,
            Streifel, & Velsey, 2001; Thio et al., 2000; Buckner et al.,
            1978; Anderson et al., 1996).

            a.  Wet-dust horizontal surfaces daily using cloth that has
                been moistened with an Environmental Protection Agency
                (EPA)-registered hospital disinfectant (**IB**) (Rhame
                et al., 1984).

            b.  Avoid dusting methods that disperse dust (e.g., feather
                dusting) (**IB**) (Rhame et al., 1984).

            c.  Keep vacuums in good repair and equip them with HEPA
                filters for use in areas with patients at high risk
                (**IB**) (Anderson et al., 1996; Rhame et al., 1984).

            d.  Use vacuum cleaners that are equipped with HEPA filters
                in patient-care areas for the severely immunocompromised
                (**IB**) (Anderson et al., 1996; Rhame et al., 1984).

        5.  Do not use carpeting in hallways and rooms occupied by
            severely immunocompromised patients (**IB**) (Sehulster &
            Chinn, 2003; CDC, \"Guidelines,\" 2000; Gerson et al., 1994)

        6.  Avoid using upholstered furniture or furnishings in rooms
            occupied by severely immunocompromised patients (**II**).

        7.  Minimize the length of time that immunocompromised patients
            in PEs are outside their rooms for diagnostic procedures and
            other activities (**II**).

            a.  Instruct severely immunocompromised patients to wear a
                high-efficiency respiratory protection device (e.g., an
                N95 respirator) when they leave the PE during periods
                when construction, renovation, or other dust-generating
                activities are ongoing in and around the health-care
                facility (**II**) (Raad et al., 2002).

            b.  No recommendation can be made about the specific type of
                respiratory-protection device (e.g., surgical mask, N95
                respirator) for use by a severely immunocompromised
                patient who leaves the PE during periods when there is
                no construction, renovation, or other dust-generating
                activity in progress in or around the health-care
                facility (**Unresolved issue**).

        8.  Systematically review and coordinate infection control
            strategies with personnel in charge of the facility´s
            engineering, maintenance, central supply and distribution,
            and catering services (**IB**) (Sehulster & Chinn, 2003;
            CDC, \"Guidelines,\" 2000; Walsh & Dixon, 1989; Weems et
            al., 1987).

        9.  When planning construction, demolition, and renovation
            activities in and around the facility, assess whether
            patients at high risk for aspergillosis are likely to be
            exposed to high ambient-air spore counts of *Aspergillus*
            spp. from construction, demolition, and renovation sites,
            and if so, develop a plan to prevent such exposures (**IA**)
            (Sehulster & Chinn, 2003; CDC, \"Guidelines,\" 2000; Weems
            et al., 1987).

        10. During construction, demolition, or renovation activities,
            construct impermeable barriers between patient-care and
            construction areas to prevent dust from entering the
            patient-care areas (**IB**) (Sehulster & Chinn, 2003;
            Sherertz et al., 1987; Arnow et al., 1978).

        11. Direct pedestrian traffic that come from construction areas
            away from patient-care areas to limit the opening and
            closing of doors or other barriers that might cause dust
            dispersion, entry of contaminated air, or tracking of dust
            into patient-care areas (**IB**) (Sehulster & Chinn, 2003;
            CDC, \"Guidelines,\" 2000; Weems et al., 1987; Arnow et al.,
            1978; Krasinski et al., 1985).

        12. Do not allow fresh or dried flowers or potted plants in
            patient-care areas for severely immunocompromised patients
            (**II**) (Lass-Flörl et al., 2000).

    C.  When a Case of Aspergillosis Occurs

        1.  Assess whether the infection is health-care--related or
            community-acquired.

            a.  Obtain and use the following information to help in the
                investigation: background rate of disease at the
                facility; presence of concurrent or recent cases, as
                determined by a review of the facility\'s microbiologic,
                histopathologic, and postmortem records; length of
                patient\'s stay in the facility before onset of
                aspergillosis; patient\'s stay at, visit of, or transfer
                from, other health-care facilities or other locations
                within the facility; and the period the patient was
                exposed outside the health-care facility after the onset
                of immunosuppression and before onset of aspergillosis
                (**II**).

            b.  Determine if any ventilation deficiency exists in PEs
                (**IB**) (Sehulster & Chinn, 2003).

        2.  If no evidence exists that the patient\'s aspergillosis is
            facility-acquired, continue routine maintenance procedures
            to prevent health-care-- associated aspergillosis, as in
            Section II-B-1 through II-B-12 (**IB**).

        3.  If evidence of possible facility-acquired infection with
            *Aspergillus* spp. exists, conduct an epidemiologic
            investigation and an environmental assessment to determine
            and eliminate the source of *Aspergillus* spp. (Sehulster &
            Chinn, 2003) (**IB**). If assistance is needed, contact the
            local or state health department (**IB**).

        4.  Use an antifungal biocide (e.g., copper-8-quinolinolate)
            that is registered with the Environmental Protection Agency
            for decontamination of structural materials (**IB**)
            (Sehulster & Chinn, 2003; Loo et al., 1996; Aisner et al.,
            1976; Opal et al., 1986; Streifel et al., 1989).

III. **Chemoprophylaxis**

     A.  No recommendation can be made for the routine administration of
         antifungal agents such as itraconazole oral solution (5
         mg/kg/day) or capsules (500 mg twice a day), low-dose
         parenteral amphotericin B (0.1 mg/kg/day), lipid-based
         formulations of amphotericin B (1 mg/kg/day), or nebulized
         amphotericin B administered by inhalation as prophylaxis for
         pulmonary aspergillosis in patients at high-risk for this
         infection (**Unresolved issue**) (CDC, \"Guidelines,\" 2000;
         Bow et al., 2002; Conneally et al., 1990; Gotzsche & Krogh
         Johansen, 1997; Gubbins, Bowman, & Penzak, 1998; Harousseau et
         al., 2000; Kelsey et al., 1999; Minari et al., 2002;
         Morgenstern et al., 1999; Nucci et al., 2000; Rousey et al.,
         1991; Schwartz et al., 1999; Tsourounis & Guglielmo, 1996).

     B.  No recommendation can be made for any specific strategy (e.g.,
         deferral of hematopoietic stem-cell transplantation for a
         particular length of time or routine prophylaxis with
         absorbable or intravenous antifungal medications) to prevent
         recurrence of pulmonary aspergillosis in patients undergoing
         hematopoietic stem-cell transplantation who have a history of
         pulmonary aspergillosis (**Unresolved issue**) (Karp, Burch, &
         Merz, 1988; Lupinetti et al., 1992; Martino et al., 1997;
         McWhinney et al., 1993; Michailov et al., 1996; Offner et al.,
         1998; Richard et al., 1993).

**[Prevention and Control of Health-Care--Associated Respiratory
Syncytial Virus, Parainfluenza Virus, and Adenovirus
Infections]{.underline}**

I.  **Staff Education and Monitoring and Infection Surveillance**

    A.  Staff Education and Monitoring

        1.  Staff education

            a.  Educate personnel in accordance with their level of
                responsibility in the health-care setting about the
                epidemiology, modes of transmission, and means of
                preventing the transmission of respiratory syncytial
                virus (RSV) within health-care facilities (**IB**)
                (Macartney et al., 2000).

            b.  Educate personnel in accordance with their level of
                responsibility in the health-care setting about the
                epidemiology, modes of transmission, and means of
                preventing the spread of parainfluenza virus and
                adenovirus within health-care facilities (**II**).

        2.  In acute-care facilities, establish mechanisms by which the
            infection-control staff can monitor personnel compliance
            with the facility\'s infection control policies about these
            viruses (**II**) (Macartney et al, 2000).

    B.  Surveillance

        1.  Establish mechanisms by which the appropriate health-care
            personnel are promptly alerted to any increase in the
            activity of RSV, parainfluenza virus, adenovirus, or other
            respiratory viruses in the local community. Establish
            mechanisms by which the appropriate health-care personnel
            can promptly inform the local and state health departments
            of any increase in the activity of the above-named viruses
            or of influenza-like illness in their facility (**IB**).

        2.  In acute-care facilities during periods of increased
            prevalence of symptoms of viral respiratory illness in the
            community or health-care facility and during the RSV and
            influenza season (i.e., December--March), attempt prompt
            diagnosis of respiratory infections caused by RSV,
            influenza, parainfluenza, or other respiratory viruses. Use
            rapid diagnostic techniques as clinically indicated in
            patients who are admitted to the health-care facility with
            respiratory illness and are at high risk for serious
            complications from viral respiratory infections (e.g.,
            pediatric patients, especially infants, and those with
            compromised cardiac, pulmonary, or immune function) (**IA**)
            (Macartney et al., 2000; Beekman et al., 1996; Glezen et
            al., 2000; Krasinski et al., 1990; Madge et al., 1992).

        3.  No recommendation can be made for routinely conducting
            surveillance cultures for RSV or other respiratory viruses
            in respiratory secretions of patients (including
            immunocompromised patients, such as recipients of HSCT)
            (**Unresolved issue**) (CDC, \"Guidelines,\" 2000).

        4.  In long-term--care facilities, establish mechanism(s) for
            continuing surveillance to allow rapid identification of a
            potential outbreak in the facility (**II**).

II. **Prevention of Transmission of RSV, Parainfluenza Virus, or
    Adenovirus**

    A.  Prevention of Person-to-Person Transmission

        1.  Standard and contact precautions for RSV and parainfluenza
            virus and standard, contact, and droplet precautions for
            adenovirus

            a.  Hand hygiene

                1.  Decontaminate hands after contact with a patient or
                    after touching respiratory secretions or fomites
                    potentially contaminated with respiratory
                    secretions, whether or not gloves are worn. Use soap
                    and water when hands are visibly dirty or
                    contaminated with proteinaceous material or are
                    visibly soiled with blood or other body fluids, and
                    use an alcohol-based hand rub if hands are not
                    visibly soiled (**IA**) (Garner, 1996; Macartney et
                    al., 2000; Hall et al., 1978 & 1981; Hall & Douglas,
                    1981; Hall, Douglas, & Geiman, 1980; Hall, 1983;
                    Korniewicz et al., 1990; Lowbury, Lilly, & Bull,
                    1964).

            b.  Gloving

                1.  Wear gloves when entering the room of patients with
                    confirmed or suspected RSV, parainfluenza, or
                    adenovirus infection, or before handling the
                    patients or their respiratory secretions or fomites
                    potentially contaminated with the patients´
                    secretions (**IA**) (Garner, 1996; LeClair et al.,
                    1987; Macartney et al., 2000; Madge et al., 1992;
                    Hall & Douglas, 1981; Hall, Douglas, & Geiman, 1980;
                    Hall, 1983; Garcia et al., 1997; Snydman et al.,
                    1988).

                2.  Change gloves between patients or after handling
                    respiratory secretions or fomites contaminated with
                    secretions from one patient before contact with
                    another patient (Garner, 1996; Doebbeling et al.,
                    1988; LeClair et al., 1987; Macartney et al., 2000).
                    Decontaminate hands after removing gloves (see
                    II-A-1-a). (**IA**)

                3.  After glove removal and hand decontamination, do not
                    touch potentially contaminated environmental
                    surfaces or items in the patient´s room (**IB**)
                    (Garner, 1996).

            c.  Gowning

                1.  Wear a gown when entering the room of a patient
                    suspected or proven to have RSV, parainfluenza
                    virus, or adenovirus infection and when soiling with
                    respiratory secretions from a patient is anticipated
                    (e.g., when handling infants with suspected or
                    proven RSV, parainfluenza, or adenovirus infection).
                    Change the gown after such contact and before giving
                    care to another patient or when leaving the
                    patient´s room. After gown removal, ensure that
                    clothing does not come into contact with potentially
                    contaminated environmental surfaces (**IB**)
                    (Garner, 1996; LeClair et al., 1987).

            d.  Masking and wearing eye protection

                1.  Wear a surgical mask and eye protection or a face
                    shield when performing procedures or patient-care
                    activities that might generate sprays of respiratory
                    secretions from any patient whether or not the
                    patient has confirmed or suspected viral respiratory
                    tract infection (**IB**) (Garner, 1996).

                2.  Wear a surgical mask and eye protection or a face
                    shield when within 3 feet of a patient with
                    suspected or confirmed adenovirus infection (**IB**)
                    (Garner, 1996).

            e.  Patient placement in acute-care facilities

                1.  Place a patient with diagnosed RSV, parainfluenza,
                    adenovirus, or other viral respiratory tract
                    infection in a private room when possible or in a
                    room with other patients with the same infection and
                    no other infection (**IB**) (Garner, 1996; Krasinski
                    et al., 1990; Madge et al., 1992; Hall et al, 1978;
                    Garcia et al., 1997; Snydman et al., 1988).

                2.  Place a patient with suspected RSV, parainfluenza,
                    adenovirus, or other viral respiratory tract
                    infection in a private room (**II**).

                    a.  Promptly perform rapid diagnostic laboratory
                        tests on patients who are admitted with or who
                        have symptoms of RSV infection after admission
                        to the health-care facility to facilitate early
                        downgrading of infection-control precautions to
                        the minimum required for each patient\'s
                        specific viral infection (**IB**) (Macartney et
                        al., 2000; Garcia et al., 1997).

                    b.  Promptly perform rapid diagnostic laboratory
                        tests on patients who are admitted with or who
                        have symptoms of parainfluenza or adenovirus
                        infection after admission to the health-care
                        facility to facilitate early downgrading of
                        infection-control precautions to the minimum
                        required for each patient´s specific viral
                        infection and early initiation of treatment when
                        indicated (**II**).

            f.  Limiting patient movement or transport in acute-care
                facilities

                1.  Limit to essential purposes only the movement or
                    transport of patients from their rooms when they are
                    diagnosed or suspected to be infected with RSV,
                    parainfluenza virus, or adenovirus (**IB**) (Garner,
                    1996).

                2.  If transport or movement from the room is necessary

                    a.  For a patient with diagnosed or suspected RSV or
                        parainfluenza virus infection, ensure that
                        precautions are maintained to minimize the risk
                        for transmission of the virus to other patients
                        and contamination of environmental surfaces or
                        equipment by ensuring that the patient does not
                        touch other persons´ hands or environmental
                        surfaces with hands that have been contaminated
                        with his/her respiratory secretions (**IB**)
                        (Garner, 1996).

                    b.  For a patient with diagnosed or suspected
                        adenovirus infection, minimize patient dispersal
                        of droplets by having the patient wear a
                        surgical mask, and ensure that contact
                        precautions are maintained to minimize the risk
                        for transmission of the virus to other patients
                        and contamination of environmental surfaces or
                        equipment (**IB**) (Garner, 1996).

        2.  Other measures in acute-care facilities

            a.  Staffing

                1.  Restrict health-care personnel in the acute stages
                    of an upper respiratory tract infection from caring
                    for infants and other patients at high risk for
                    complications from viral respiratory tract
                    infections (e.g., children with severe underlying
                    cardio-pulmonary conditions, children receiving
                    chemotherapy for malignancy, premature infants, and
                    patients who are otherwise immunocompromised)
                    (**II**) (Garner, 1996; CDC, \"Guidelines,\" 2000;
                    Macartney et al., 2000; Madge et al., 1992; Hall et
                    al., 1978).

                2.  When feasible, perform rapid diagnostic testing on
                    health-care personnel with symptoms of respiratory
                    tract infection, especially those who provide care
                    to patients at high-risk for acquiring or developing
                    severe complications from RSV, parainfluenza, or
                    adenovirus infection, so that their work status can
                    be determined promptly (**II**).

            b.  Limiting visitors: Do not allow persons who have
                symptoms of respiratory infection to visit pediatric,
                immunosuppressed, or cardiac patients (**IB**) (Garner,
                1996; CDC, \"Guidelines,\" 2000; Macartney et al., 2000;
                Garcia et al., 1997; Snydman et al., 1988).

            c.  Use of monoclonal antibody (palivizumab) for attenuation
                of RSV infection: Follow the recommendation of the
                American Academy of Pediatrics to consider monthly
                administration of palivizumab, an RSV
                monoclonal-antibody preparation, to the following
                infants and children aged \<24 months:

                1.  Those born prematurely at [\<]{.underline}32 weeks
                    of gestational age that have bronchopulmonary
                    dysplasia and those born prematurely at \<32 weeks
                    gestation without chronic lung disease who will be
                    aged \<6 months at the beginning of the RSV season.

                2.  Those born at 32 to 35 weeks\' gestation if two or
                    more of the following risk factors are present:
                    child-care attendance, school-aged siblings,
                    exposure to environmental pollutants, congenital
                    abnormalities of the airways, or severe
                    neuromuscular disease (**II**) (American Academy of
                    Pediatrics, 2003; Groothuis et al., 1993;
                    \"Palivizumab,\" 1998; \"Reduction of RSV
                    hospitalization,\" 1997).

        3.  Control of outbreaks in acute-care facilities

            a.  Perform rapid screening diagnostic tests for the
                particular virus(es) known or suspected to be causing
                the outbreak on patients who are admitted with symptoms
                of viral respiratory illness. Promptly cohort the
                patients (according to their specific infections) as
                soon as the results of the screening tests are available
                (Macartney et al., 2000; Beekmann et al., 1996;
                Krasinski et al., 1990; Madge et al., 1992; Hall et al.,
                1978; Garcia et al., 1997; Snydman et al., 1988). In the
                interim, when possible, admit patients with symptoms of
                viral respiratory infections to private rooms (**IB**).

            b.  Personnel cohorting

                1.  During an outbreak of health-care--associated RSV
                    infection, cohort personnel as much as practical
                    (e.g., restrict personnel who give care to infected
                    patients from giving care to uninfected patients)
                    (**II**) (Madge et al., 1992; Hall et al., 1978;
                    Snydman et al., 1988).

                2.  No recommendation can be made for routinely
                    cohorting personnel during an outbreak of
                    health-care--associated adenovirus or parainfluenza
                    virus infection (**Unresolved issue**).

            c.  Use of RSV immune globulin or monoclonal antibody

                1.  No recommendation can be made for the use of RSV
                    immune globulin or monoclonal antibody to control
                    outbreaks of RSV infection in the health-care
                    setting (**Unresolved issue**) (American Academy of
                    Pediatrics, 2003; Groothuis et al., 1993;
                    \"Palivizumab,\" 1998; \"Reduction of RSV
                    hospitalization,\" 1997; \"Prevention of respiratory
                    syncytial virus,\" 1998; Clark et al., 2000;
                    Kamal-Bahl, Doshi, & Campbell, 2002; Lofland et al.,
                    2000; Robbins et al., 1998).

**[Prevention and Control of Health-Care--Associated
Influenza]{.underline}**

I.  **Staff Education**

> Provide health-care personnel continuing education or access to
> continuing education about the epidemiology, modes of transmission,
> diagnosis, and means of preventing the spread of influenza, in
> accordance with their level of responsibility in preventing
> health-care--associated influenza (**II**) (Nichol, Grimm, & Peterson,
> 1996; Kim et al., 1999; Nichol, 1992; Pachucki, Lentino, & Jackson,
> 1985).

II. **Surveillance**

    A.  Establish mechanisms by which facility personnel are promptly
        alerted about increased influenza activity in the community
        (**II**).

    B.  Establish protocols for intensifying efforts to promptly
        diagnose cases of facility-acquired influenza.

        1.  Determine the threshold incidence or prevalence of influenza
            or influenza-like illness in the facility at which
            laboratory testing of patients with influenza-like illness
            is to be undertaken and outbreak control measures are to be
            initiated (**II**) (Weingarten et al., 1988).

        2.  Arrange for laboratory tests to be available to clinicians
            for prompt diagnosis of influenza, especially during
            November--April (**II**) (\"Rapid diagnostic tests,\" 1999;
            Covalciuc, Webb, & Carlson, 1999; Leonardi et al., 1994;
            Noyola et al., 2000).

III. **Modifying Host Risk for Infection**

     A.  Vaccination

         1.  In acute-care settings (including acute-care hospitals,
             emergency rooms, and walk-in clinics) or ongoing-care
             facilities (including physicians´ offices, public health
             clinics, employee health clinics, hemodialysis centers,
             hospital specialty-care clinics, outpatient rehabilitation
             programs, and mobile clinics), offer vaccine to inpatients
             and outpatients at high risk for complications from
             influenza beginning in September and throughout the
             influenza season (Williams et al., 1988; Bridges et al.,
             2003; Arden, Patriarca, & Kendall, 1985; Fedson, 1987).
             Groups at high risk for influenza-related complications
             include those aged [\>]{.underline}65 years; residents of
             nursing homes and other chronic-care facilities that house
             persons of any age who have chronic medical conditions;
             adults and children aged \>6 months who have chronic
             disorders of the pulmonary or cardiovascular system,
             including asthma; adults and children who have required
             regular medical follow-up or hospitalization during the
             preceding year because of chronic metabolic diseases
             (including diabetes mellitus), renal dysfunction, or
             hemoglobinopathies, or immunosuppression (including
             immunosuppression caused by medications or HIV); children
             and adolescents (aged 6 months--18 years) who are receiving
             long-term aspirin therapy; and women who will be in the
             second or third trimester of pregnancy during the influenza
             season (Bridges et al., 2003; Fraund et al., 1999; Gross et
             al., 1995; Neuzil et al., 1998; Nichol, Baken, & Nelson,
             1999; Ohmit, Arden, & Monto, 1999; Tasker et al., 1999). In
             addition, offer annual influenza vaccination to all persons
             aged 50 to 64 years, close contacts of children aged \<24
             months, and healthy children aged 6 to 23 months (**IA**)
             (Bridges et al., 2003).

         2.  In nursing homes and other long-term--care facilities,
             establish an SOP for timely administration of the
             inactivated influenza vaccine to persons at high risk as
             identified in Section III-A-1 (**IA**) (Nichol, Grimm, &
             Peterson, 1996; \"Medicare and Medicaid programs,\" 2002;
             CDC, \"Use of standing orders programs,\" 2000; Bridges et
             al., 2003).

             a.  Obtain consent for influenza vaccination (if such is
                 required by local or state law) from every resident (or
                 his/her guardian) at the time the resident is admitted
                 to the facility or anytime afterwards before the next
                 influenza season (**IB**) (Nichol, Grimm, & Peterson,
                 1996; Bridges et al., 2003; McArthur et al., 1999).

             b.  Routinely vaccinate all residents, except those with
                 medical contraindication(s) to receipt of influenza
                 vaccine (under an SOP or with the concurrence of the
                 residents\' respective attending physicians) at one
                 time, annually, before the influenza season. To
                 residents who are admitted during the winter months
                 after completion of the facility\'s vaccination
                 program, offer the vaccine at the time of their
                 admission (**IA**) (Bridges et al., 2003; Ohmit, Arden,
                 & Monto, 1999; McArthur et al., 1999; Libow et al.,
                 1996).

             c.  In settings not included in sections II-A-1 and -2,
                 where health care is given (e.g., in homes visited by
                 personnel from home health-care agencies), vaccinate
                 patients for whom vaccination is indicated, as listed
                 in section III-A-1, and refer patient\'s household
                 members and care givers for vaccination, before the
                 influenza season (**IA**) (Bridges et al., 2003).

         3.  Personnel

             a.  Beginning in October each year, provide inactivated
                 influenza vaccine for all personnel including night and
                 weekend staff (Bridges et al., 2003; Carman et al.,
                 2000; Nichol et al., 1995; Potter et al., 1997; Saxen &
                 Virtanen, 1999; Wilde et al., 1999). Throughout the
                 influenza season, continue to make the vaccine
                 available to newly hired personnel and to those who
                 initially refuse vaccination. If vaccine supply is
                 limited, give highest priority to staff caring for
                 patients at greatest risk for severe complications from
                 influenza infection, as listed in section III-A-1
                 (**IA**) (Bridges et al., 2003).

             b.  Educate health-care personnel about the benefits of
                 vaccination and the potential health consequences of
                 influenza illness for themselves and their patients
                 (**IB**) (Bridges et al., 2003).

             c.  Take measures to provide all health-care personnel
                 convenient access to inactivated influenza vaccine at
                 the work site, free of charge, as part of employee
                 health program (**IB**) (Bridges et al., 2003).

     B.  Use of Antiviral Agents (See Section V-C)

IV. **Prevention of Person-to-Person Transmission**

    A.  Droplet Precautions

        1.  Place a patient who is diagnosed with influenza in a private
            room or in a room with other patients with confirmed
            influenza, unless medical contraindications exist (**IB**)
            (Garner, 1996).

        2.  Place a patient who is suspected to have influenza in a
            private room, and promptly perform rapid diagnostic
            laboratory tests to facilitate early downgrading of
            infection-control precautions to the minimum required for
            the patient´s infection (**II**) (Garner, 1996).

        3.  Wear a surgical mask upon entering the patient\'s room or
            when working within 3 feet of the patient (**IB**) (Garner,
            1996).

        4.  Limit the movement and transport of the patient from the
            room to those for essential purposes only. If patient
            movement or transport is necessary, have the patient wear a
            surgical mask, if possible, to minimize droplet dispersal by
            the patient (**II**) (Garner, 1996).

    B.  Eye Protection

> No recommendation can be made for wearing an eye protective device
> upon entering the room of a patient with confirmed or suspected
> influenza or when working within 3 feet of the patient (**Unresolved
> issue**).

C.  Contact Precautions

> No recommendation can be made for the observance of contact
> precautions (in addition to droplet precautions) for patients with
> confirmed or suspected influenza (**Unresolved issue**) (Garner, 1996;
> Bean et al., 1982).

D.  Standard Precautions

    1.  Decontaminate hands before and after giving care to or touching
        a patient or after touching a patient\'s respiratory secretions,
        whether or not gloves are worn. If hands are visibly dirty or
        contaminated with proteinaceous material or are visibly soiled
        with blood or body fluids, wash them with either a
        nonantimicrobial soap and water or an antimicrobial soap and
        water. If hands are not visibly soiled, use an alcohol-based
        hand rub for their decontamination (**IA**) (CDC, \"Guideline
        for hand hygiene,\" 2000).

    2.  Wear gloves if hand contact with patient´s respiratory
        secretions is expected (**II**) (Garner, 1996; Bean et al.,
        1982).

    3.  Wear a gown if soiling of clothes with patient´s respiratory
        secretions is expected (**II**) (Garner, 1996).

E.  Air Handling

> No recommendation can be made for maintaining negative air pressure in
> rooms of patients in whom influenza is suspected or diagnosed, or in
> placing together persons with influenza-like illness in a hospital
> area with an independent air-supply and exhaust system (**Unresolved
> issue**) (Alford et al., 1966; Blumenfeld et al., 1959; Moser et al.,
> 1979).

F.  Personnel Restrictions

> In acute-care facilities, use the facility\'s employee health service
> or its equivalent to evaluate personnel with influenza-like illness
> and determine whether they should be removed from duties that involve
> direct patient contact. Use more stringent criteria for personnel who
> work in certain patient-care areas (e.g., intensive care units,
> nurseries, and organ-transplant \[especially HSCT\]) where patients
> who are most susceptible to influenza-related complications are
> located (**IB**) (Berlinberg et al., 1989; Valenti et al., 1980;
> Whimbey et al., 1994).

V.  **Control of Influenza Outbreaks**

    A.  Determining the Outbreak Strain

> Early in the outbreak, perform rapid influenza virus testing on
> nasopharyngeal swab or nasal-wash specimens from patients with recent
> onset of symptoms suggestive of influenza. In addition, obtain viral
> cultures from a subset of patients to determine the infecting virus
> type and subtype (**IB**) (\"Rapid diagnostic tests,\" 1999;
> Covalciuc, Webb, & Carlson, 1999; Leonardi et al., 1994; Noyola et
> al., 2000).

B.  Vaccination of Patients and Personnel

> Administer current inactivated influenza vaccine to unvaccinated
> patients and health-care personnel (**IA**) (Bridges et al., 2003;
> Ohmit, Arden, & Monto, 1999; Carman et al., 2000; Potter et al.,
> 1997).

C.  Antiviral Agent Administration

    1.  When a facility outbreak of influenza is suspected or
        recognized:

        a.  Administer amantadine, rimantadine, or oseltamivir as
            prophylaxis to all patients without influenza illness in the
            involved unit for whom the antiviral agent is not
            contraindicated (regardless of whether they received
            influenza vaccinations during the previous fall) for a
            minimum of 2 weeks or until approximately 1 week after the
            end of the outbreak. Do not delay administration of the
            antiviral agent(s) for prophylaxis unless the results of
            diagnostic tests to identify the infecting strain(s) can be
            obtained within 12 to 24 hours after specimen collection
            (**IA**) (Bridges et al., 2003; Libow et al., 1996; Dolin et
            al., 1982; Welliver et al., 2001).

        b.  Administer amantadine, rimantadine, oseltamivir, or
            zanamivir to patients acutely ill with influenza within 48
            hours of illness onset. Choose the agent appropriate for the
            type of influenza virus circulating in the community
            (**IA**) (Bridges et al., 2003; Libow et al., 1996; Dolin et
            al., 1982; Welliver et al., 2001; Hayden et al., \"Use of
            oral neuraminidase,\" 1999; \"Randomised trial of
            efficacy,\" 1998).

        c.  Offer antiviral agent(s) (amantadine, rimantadine, or
            oseltamivir) for prophylaxis to unvaccinated personnel for
            whom the antiviral agent is not contraindicated and who are
            in the involved unit or taking care of patients at high risk
            (**IB**) (Bridges et al., 2003; Libow et al., 1996; Dolin et
            al., 1982; Welliver et al., 2001; Hayden et al., \"Use of
            the selective,\" 1999).

        d.  Consider prophylaxis for all health-care personnel,
            regardless of their vaccination status, if the outbreak is
            caused by a variant of influenza that is not well matched by
            the vaccine (**IB**) (Bridges et al., 2003).

        e.  No recommendation can be made about the prophylactic
            administration of zanamivir to patients or personnel
            (**Unresolved issue**) (Bridges et al., 2003; Lee et al.,
            2000; Monto et al., 1999; Schilling et al., 1998).

        f.  Discontinue the administration of influenza antiviral agents
            to patients or personnel if laboratory tests confirm or
            strongly suggest that influenza is not the cause of the
            facility outbreak (**IA**) (Tominack & Hayden, 1987).

        g.  If the cause of the outbreak is confirmed or believed to be
            influenza and vaccine has been administered only recently to
            susceptible patients and personnel, continue prophylaxis
            with an antiviral agent until 2 weeks after the vaccination
            (**IB**) (Bridges et al., 2003; Askonas, McMichael, &
            Webster, 1982).

    2.  To reduce the potential for transmission of drug resistant
        virus, do not allow contact between persons at high risk for
        complications from influenza and patients or personnel who are
        taking an antiviral agent for treatment of confirmed or
        suspected influenza during and for 2 days after the latter
        discontinue treatment (**IB**) (Hall et al., 1987; Hayden &
        Couch, 1992; Hayden et al., 1991; Mast et al., 1991; Monto &
        Arden, 1992).

D.  Other Measures in Acute-Care Facilities

> When influenza outbreaks, especially those characterized by high
> attack rates and severe illness, occur in the community and/or
> facility:

1.  Curtail or eliminate elective medical and surgical admissions
    (**II**) (Valenti et al., 1980).

2.  Restrict cardiovascular and pulmonary surgery to emergency cases
    only (**II**) (Valenti et al., 1980).

3.  Restrict persons with influenza or influenza-like illness from
    visiting patients in the health-care facility (**II**) (Valenti et
    al., 1980).

4.  Restrict personnel with influenza or influenza-like illness from
    patient care (**IB**) (Valenti et al., 1980).

**[Severe Acute Respiratory Syndrome]{.underline}**

Updated information about prevention and control of severe acute
respiratory syndrome in health-care facilities is available in a
separate publication (\"Update: outbreak of severe acute respiratory
syndrome,\" 2003).

**[Rating Scheme for Strength of Recommendations]{.underline}**

**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 clinical or epidemiologic studies and by strong theoretical
rationale

**Category IC**. Required for implementation, as mandated by federal or
state regulation or standard

**Category II**. Suggested for implementation and supported by
suggestive clinical or epidemiologic studies or by strong theoretical
rationale

**No recommendation; unresolved issue**. Practices for which
insufficient evidence or no consensus exists about efficacy

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### REFERENCES SUPPORTING THE RECOMMENDATIONS

[References open in a new
window](http://www.guideline.gov/summary/select_ref.aspx?doc_id=4872)

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for selected
recommendation (see \"Major Recommendations\").

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   Prevention of transmission of microorganisms resulting in a
    reduction of the incidence of pneumonia and other severe, acute
    lower respiratory tract infections in acute-care hospitals and in
    other health-care settings (e.g., ambulatory and long-term care
    institutions) and other facilities where health care is provided

-   Heightened awareness and understanding of health-care workers about
    the epidemiology of, and infection-control procedures for preventing
    health-care---associated pneumonia

#### POTENTIAL HARMS

Not stated

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

**Performance Indicators**

To assist infection-control personnel in assessing personnel adherence
to the recommendations, the following performance measures are
suggested:

1.  Monitor rates of ventilator-associated pneumonia (VAP); can use
    established benchmarks and definitions of pneumonia (e.g., National
    Nosocomial Infection Surveillance \[NNIS\] definitions and rates).
    Provide feedback to the staff about the facility\'s VAP rates and
    reminders about the need for personnel to adhere to
    infection-control practices that reduce the incidence of VAP.

2.  Establish a standing orders program (SOP) for influenza vaccination
    and monitor the percentage of eligible patients in acute-care
    settings or patients or residents in long-term--care settings who
    receive the vaccine.

3.  Before and during the influenza season, monitor and record the
    number of eligible health-care personnel who receive the influenza
    vaccine and determine the desired unit- and facility-specific
    vaccination rates as recommended by the Advisory Committee on
    Immunizations Practices (ACIP).

4.  Monitor the number of cases of health-care--associated respiratory
    syncytial virus (RSV) infections by geographic location within the
    facility and give prompt feedback to appropriate staff members to
    improve adherence to recommended infection-control precautions.

5.  Periodically review clinicians´ use of laboratory diagnostic tests
    (both culture of appropriate respiratory specimen and the urine
    antigen test) for legionellosis, especially in patients who are at
    high risk for acquiring the disease (e.g., patients who are
    immunosuppressed, including recipients of hemopoietic stem-cell
    transplant \[HSCT\] or solid-organ transplant, or patients receiving
    systemic steroids; patients aged \>65 years; or patients who have
    chronic underlying disease such as diabetes mellitus, congestive
    heart failure, and chronic obstructive pulmonary disease \[COPD\]).
    Provide feedback on the use of these tests to clinicians.

6.  During construction or renovation activities in the facility,
    monitor personnel adherence to infection-control measures (e.g., use
    of barriers, maintenance of negative room pressure) that are aimed
    at minimizing dust dispersion in patient-care areas. Review all
    cases of healthcare--associated aspergillosis to determine the
    presence of remediable environmental risks.

7.  Periodically monitor the frequency of diagnostic testing for
    pertussis and the time interval between suspicion of the infection
    and initiation of isolation precautions for patients in whom
    pertussis is suspected.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Staying Healthy

#### IOM DOMAIN

Effectiveness\
Safety

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R. Guidelines for
preventing health-care\--associated pneumonia, 2003: recommendations of
CDC and the Healthcare Infection Control Practices Advisory Committee.
MMWR Recomm Rep 2004 Mar 26;53(RR-3):1-36. \[433 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15048056)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2004 Mar 26

#### GUIDELINE DEVELOPER(S)

Centers for Disease Control and Prevention - Federal Government Agency
\[U.S.\]

#### SOURCE(S) OF FUNDING

United States Government

#### GUIDELINE COMMITTEE

Healthcare Infection Control Practices Committee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Report prepared by*: Ofelia C. Tablan, MD, Division of Healthcare
Quality Promotion, National Center for Infectious Diseases; Larry J.
Anderson, MD, Division of Viral and Rickettsial Diseases, National
Center for Infectious Diseases; Richard Besser, MD, Division of
Bacterial and Mycotic Diseases, National Center for Infectious Diseases;
Carolyn Bridges, MD, Division of Viral and Rickettsial Diseases,
National Center for Infectious Diseases; Rana Hajjeh, MD, Division of
Bacterial and Mycotic Diseases, National Center for Infectious Diseases

*Healthcare Infection Control Practices Committee Members*

**Chair**: Robert A. Weinstein, MD, Cook County Hospital Chicago,
Illinois

**Co-Chair**: Jane D. Siegel, MD, University of Texas Southwestern
Medical Center, Dallas, Texas

**Executive Secretary**: Michele L. Pearson, MD, CDC, Atlanta, Georgia

**Members**: Alfred DeMaria, Jr., MD, Massachusetts Department of Public
Health, Jamaica Plain, Massachusetts; Raymond Y.W. Chinn, MD, Sharp
Memorial Hospital, San Diego, California; Elaine L. Larson, RN, PhD,
Columbia University School of Nursing, New York, New York; James T.
Lee., MD, Veterans Affairs Medical Center, University of Minnesota, St.
Paul, Minnesota; Ramon E. Moncada, MD, Coronado Physician\'s Medical
Center, Coronado, California; William A. Rutala, PhD, University of
North Carolina School of Medicine, Chapel Hill, North Carolina; William
E. Scheckler, MD, University of Wisconsin Medical School, Madison,
Wisconsin; Beth H. Stover, Kosair Children\'s Hospital, Louisville,
Kentucky; Marjorie A. Underwood, Mt. Diablo Medical Center, Concord,
California

**Liaison Representatives**: Loretta L. Fauerbach, MS, CIC, Association
for Professionals of Infection Control and Epidemiology, Inc., Shands
Hospital at University of Florida, Gainesville, Florida; Sandra L.
Fitzler, RN, American Healthcare Association, Washington, DC; Dorothy M.
Fogg, RN, BSN, MA, Association of Peri-Operative Registered Nurses,
Denver, Colorado; Stephen F. Jencks, MD, MPH, Center for Medicare and
Medicaid Services, Baltimore, Maryland; Chiu S. Lin, PhD, Food and Drug
Administration, Rockville, Maryland; James P. Steinberg, Society for
Healthcare Epidemiology of America, Inc., Crawford Long Hospital,
Atlanta, Georgia; Michael L. Tapper, MD, Advisory Committee for the
Elimination of Tuberculosis, Lennox Hill Hospital, New York, New York

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### ENDORSER(S)

American College of Chest Physicians - Medical Specialty Society\
American Health Care Association - Professional Association\
Association for Professionals in Infection Control and Epidemiology,
Inc. - Professional Association\
Infectious Diseases Society of America - Medical Specialty Society\
Society for Healthcare Epidemiology of America - Professional
Association\
Society of Critical Care Medicine - Professional Association

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Centers for Disease Control
and Prevention. Guidelines for prevention of nosocomial pneumonia. MMWR
Recomm Rep 1997 Jan 3;46(RR-1):1-79. \[140 references\]

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the Centers for Disease Control and
Prevention (CDC) Web site:

-   [HTML Format](http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm)

-   [Portable Document Format
    (PDF)](http://www.cdc.gov/mmwr/PDF/rr/rr5303.pdf)

Print copies: Available from the Centers for Disease Control and
Prevention, MMWR, Atlanta, GA 30333. Additional copies can be purchased
from the Superintendent of Documents, U.S. Government Printing Office,
Washington, DC 20402-9325; (202) 783-3238.

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on June 15, 2004. This summary
was updated by ECRI on November 21, 2006 following the FDA advisory on
Tamiflu. This summary was updated by ECRI Institute on March 10, 2008
following the U.S. Food and Drug Administration (FDA) advisory on
Tamiflu (oseltamivir phosphate). This summary was updated by ECRI
Institute on April 9, 2008 following the U.S. Food and Drug
Administration (FDA) advisory on Relenza (zanamivir).

#### COPYRIGHT STATEMENT

No copyright restrictions apply.

### DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008