depar depar depar depar department of health and human ser tment of health and human ser tment of health and human ser tment of health and human ser tment of health and human services vices vices vices vices# Introduction
Because of the high morbidity and mortality associated with health-care-associated pneumonia, several guidelines for its prevention and control have been published. The first CDC Guideline for Prevention of Nosocomial Pneumonia was published in 1981 and addressed the main infection-control problems related to hospital-acquired pneumonia at the time: the use of large-volume nebulizers that were attached to mechanical ventilators and improper reprocessing (i.e., cleaning and disinfection or sterilization) of respiratory-care equipment. The document also covered the prevention and control of hospital-acquired influenza and respiratory syncytial virus (RSV) infection.
In 1994, the Healthcare Infection Control Practices Advisory Committee (HICPAC) (then known as the Hospital Infection Control Practices Advisory Committee) revised and expanded the CDC Guideline for Prevention of Nosocomial Pneumonia to include Legionnaires disease and pulmonary aspergillosis (1). HICPAC advises the secretary of Health and Human Services and the directors of CDC about the prevention and control of health-care-associated infections and related adverse events. The 1994 guideline addressed concerns related to preventing ventilator-associated pneumonia (VAP) (e.g., the role of stress-ulcer prophylaxis in the causation of pneumonia and the contentious roles of selective gastrointestinal decontamination and periodic changes of ventilator tubings in the prevention of the infection). The report also presented major changes in the recommendations to prevent and control hospital-acquired pneumonia caused by Legionnella spp. and aspergilli.
In recent years, demand has increased for guidance on preventing and controlling pneumonia and other lower respiratory tract infections in health-care settings other than the acute-care hospital, probably resulting in part from the progressive shift in the burden and focus of health care in the United States away from inpatient care in the acute-care hospital and towards outpatient and long-term care in other health-care settings. In response to this demand, HICPAC revised the guideline to cover these other settings. However, infection-control data about the acute-care hospital setting are more abundant and well-analyzed; in comparison, data are limited from long-term care, ambulatory, and psychiatric facilities and other health-care settings.
This report consists of Parts II and III of a three-part document (2) and contains the consensus HICPAC recommendations for the prevention of the following infections: bacterial pneumonia, Legionnaires disease, pertussis, invasive pulmonary aspergillosis (IPA), lower respiratory tract infections caused by RSV, parainfluenza and adenoviruses, and influenza. Part III provides suggested performance indicators to assist infection-control personnel in monitoring the implementation of the guideline recommendations in their facilities.
Part I of the guideline provides the background for the recommendations and includes a discussion of the epidemiology, diagnosis, pathogenesis, modes of transmission, and prevention and control of the infections (3). Part I can be an important resource for educating health-care personnel. Because education of health-care personnel is the cornerstone of an effective infection-control program, health-care agencies should give high priority to continuing infection-control education programs for their staff members.
HICPAC recommendations address such issues as education of health-care personnel about the prevention and control of health-care-associated pneumonia and other lower respiratory tract infections, surveillance and reporting of diagnosed cases of infections, prevention of person-to-person transmission of each disease, and reduction of host risk for infection.
Lower respiratory tract infection caused by Mycobacterium tuberculosis is not addressed in this document; however, it is covered in a separate publication (3).
The document was prepared by CDC; reviewed by experts in infection control, intensive-care medicine, pulmonology, respiratory therapy, anesthesiology, internal medicine, and pediatrics; and approved by HICPAC. The recommendations are endorsed by the American College of Chest Physicians, American Healthcare Association, Association for Professionals of Infection Control and Epidemiology, Infectious Diseases Society of America, Society for Healthcare Epidemiology of America, and Society of Critical Care Medicine.

# Key Terms Used In the Guideline
Protective environment (PE) is a specialized patient-care area, usually in a hospital, with a positive air flow relative to the corridor (i.e., air flows from the room to the outside adjacent space). The combination of high-efficiency particulate air (HEPA) filtration, high numbers (>12) of air changes per hour (ACH), and minimal leakage of air into the room creates an environment that can safely accommodate patients who have received allogeneic hemopoietic stem-cell transplant (HSCT).
Immunocompromised patients are those patients whose immune mechanisms are deficient because of immunologic disorders (e.g., human immunodeficiency virus  infection, congenital immune deficiency syndrome, and chronic diseases ), or immunosuppressive therapy (e.g., radiation, cytotoxic chemotherapy, anti-rejection medication, and steroids). Immunocompromised patients who are identified as patients at high risk have the greatest risk for infection and include persons with severe neutropenia (i.e., an absolute neutrophil count  of <500 cells/mL) for prolonged periods of time, recipients of allogeneic HSCT, and those who receive the most intensive chemotherapy (e.g., patients with childhood acute myelogenous leukemia).

# Abbreviations Used In the Guideline
ACIP

# Categorization of Recommendations
In this document, 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. The following categorization scheme is applied in this guideline:
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.

# Prevention of Health-Care-Associated
Bacterial Pneumonia

# 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 performanceimprovement tools and techniques (IA) (4-11).

# 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 (12,13). The use of the new National Nosocomial Infection Surveillance (NNIS) system's surveillance definition of pneumonia is recommended (14). Include data on the causative microorganisms and their antimicrobial susceptibility patterns (15). 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 (12,16,17). Link monitored rates and prevention efforts and return data to appropriate health-care personnel (IB) (18). 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, pulmonaryfunction testing, or delivery of inhalation anesthesia (II) (19)(20)(21)(22).

# III. Prevention of Transmission of Microorganisms

# Prevention and Control of Health-Care-Associated Influenza

# 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) (109,(387)(388)(389).

# 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) (390). 2. Arrange for laboratory tests to be available to clinicians for prompt diagnosis of influenza, especially during November-April (II) (391)(392)(393)(394).

# III. Modifying Host Risk for Infection

# Severe Acute Respiratory Syndrome
Updated information about prevention and control of severe acute respiratory syndrome in health-care facilities is available in a separate publication (433).

# Part III: Performance Indicators
To assist infection-control personnel in assessing personnel adherence to the recommendations, the following performance measures are suggested: 1. Monitor rates of VAP; can use established benchmarks and definitions of pneumonia (e.g., NNIS definitions and rates) (14). 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 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 ACIP. 4. Monitor the number of cases of health-care-associated RSV infections by geographic location within the facility and give prompt feedback to appropriate staff members to improve adherence to recommended infectioncontrol 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 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 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.
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