Although the environment serves as a reservoir for a variety of microorganisms, it is rarely implicated in disease transmission except in the immunocompromised population. Inadvertent exposures to environmental opportunistic pathogens (e.g., Aspergillus spp. and Legionella spp.) or airborne pathogens (e.g., Mycobacterium tuberculosis and varicella-zoster virus) may result in infections with significant morbidity and/or mortality. Lack of adherence to established standards and guidance (e.g., water quality in dialysis, proper ventilation for specialized care areas such as operating rooms, and proper use of disinfectants) can result in adverse patient outcomes in health-care facilities.The objective is to develop an environmental infection-control guideline that reviews and reaffirms strategies for the prevention of environmentally-mediated infections, particularly among health-care workers and immunocompromised patients. The recommendations are evidence-based whenever possible.The contributors to this guideline reviewed predominantly English-language articles identified from MEDLINE literature searches, bibliographies from published articles, and infection-control textbooks.Articles dealing with outbreaks of infection due to environmental opportunistic microorganisms and epidemiological-or laboratory experimental studies were reviewed. Current editions of guidelines and standards from organizations (i.e.# Outcome Measures:
Infections caused by the microorganisms described in this guideline are rare events, and the effect of these recommendations on infection rates in a facility may not be readily measurable. Therefore, the following steps to measure performance are suggested to evaluate these recommendations:
1. Document whether infection-control personnel are actively involved in all phases of a healthcare facility's demolition, construction, and renovation. Activities should include performing a risk assessment of the necessary types of construction barriers, and daily monitoring and documenting of the presence of negative airflow within the construction zone or renovation area.
2. Monitor and document daily the negative airflow in airborne infection isolation rooms (AII) and positive airflow in protective environment rooms (PE), especially when patients are in these rooms.
3. Perform assays at least once a month by using standard quantitative methods for endotoxin in water used to reprocess hemodialyzers, and for heterotrophic, mesophilic bacteria in water used to prepare dialysate and for hemodialyzer reprocessing.

# Executive Summary
The Guidelines for Environmental Infection Control in Health-Care Facilities is a compilation of recommendations for the prevention and control of infectious diseases that are associated with healthcare environments. This document a. revises multiple sections from previous editions of the Centers for Disease Control and Prevention  document titled Guideline for Handwashing and Hospital Environmental Control; 1, 2 b. incorporates discussions of air and water environmental concerns from CDC's Guideline for the Prevention of Nosocomial Pneumonia; 3 c. consolidates relevant environmental infection-control measures from other CDC guidelines;  and d. includes two topics not addressed in previous CDC guidelines -infection-control concerns related to animals in health-care facilities and water quality in hemodialysis settings.
Part I of this report, Background Information: Environmental Infection Control in Health-Care Facilities, provides a comprehensive review of the scientific literature. Attention is given to engineering and infectioncontrol concerns during construction, demolition, renovation, and repairs of health-care facilities. Use of an infection-control risk assessment is strongly supported before the start of these or any other activities expected to generate dust or water aerosols. Also reviewed in Part I are infection-control measures used to recover from catastrophic events (e.g., flooding, sewage spills, loss of electricity and ventilation, and disruption of the water supply) and the limited effects of environmental surfaces, laundry, plants, animals, medical wastes, cloth furnishings, and carpeting on disease transmission in healthcare facilities.
Part II of this guideline, Recommendations for Environmental Infection Control in Health-Care Facilities, outlines environmental infection control in health-care facilities, describing measures for preventing infections associated with air, water, and other elements of the environment. These recommendations represent the views of different divisions within CDC's National Center for Infectious Diseases (NCID) (e.g., the Division of Healthcare Quality Promotion  and the Division of Bacterial and Mycotic Diseases ) and the consensus of the Healthcare Infection Control Practices Advisory Committee (HICPAC), a 12-member group that advises CDC on concerns related to the surveillance, prevention, and control of health-care associated infections, primarily in U.S. healthcare facilities.10 In 1999, HICPAC's infection-control focus was expanded from acute-care hospitals to all venues where health care is provided (e.g., outpatient surgical centers, urgent care centers, clinics, outpatient dialysis centers, physicians' offices, and skilled nursing facilities). The topics addressed in this guideline are applicable to the majority of health-care venues in the United States. This document is intended for use primarily by infection-control professionals (ICPs), epidemiologists, employee health and safety personnel, information system specialists, administrators, engineers, facility managers, environmental service professionals, and architects for health-care facilities.
Key recommendations include a. infection-control impact of ventilation system and water system performance; b. establishment of a multidisciplinary team to conduct infection-control risk assessment; c. use of dust-control procedures and barriers during construction, repair, renovation, or demolition; d. environmental infection-control measures for special care areas with patients at high risk; e. use of airborne particle sampling to monitor the effectiveness of air filtration and dust-control measures; f. procedures to prevent airborne contamination in operating rooms when infectious tuberculosis  patients require surgery g. guidance regarding appropriate indications for routine culturing of water as part of a comprehensive control program for legionellae; h. guidance for recovering from water system disruptions, water leaks, and natural disasters ; i. infection-control concepts for equipment that uses water from main lines ); j. environmental surface cleaning and disinfection strategies with respect to antibiotic-resistant microorganisms; k. infection-control procedures for health-care laundry; l. use of animals in health care for activities and therapy; m. managing the presence of service animals in health-care facilities; n. infection-control strategies for when animals receive treatment in human health-care facilities; and o. a call to reinstate the practice of inactivating amplified cultures and stocks of microorganisms on-site during medical waste treatment.
Whenever possible, the recommendations in Part II are based on data from well-designed scientific studies. However, certain of these studies were conducted by using narrowly defined patient populations or for specific health-care settings (e.g., hospitals versus long-term care facilities), making generalization of findings potentially problematic. Construction standards for hospitals or other healthcare facilities may not apply to residential home-care units. Similarly, infection-control measures indicated for immunosuppressed patient care are usually not necessary in those facilities where such patients are not present. Other recommendations were derived from knowledge gained during infectious disease investigations in health-care facilities, where successful termination of the outbreak was often the result of multiple interventions, the majority of which cannot be independently and rigorously evaluated. This is especially true for construction situations involving air or water.
Other recommendations are derived from empiric engineering concepts and may reflect an industry standard rather than an evidence-based conclusion. Where recommendations refer to guidance from the American Institute of Architects (AIA), (AIA guidance has been superseded by the Facilities Guidelines Institute ) the statements reflect standards intended for new construction or renovation. Existing structures and engineered systems are expected to be in continued compliance with the standards in effect at the time of construction or renovation. Also, in the absence of scientific confirmation, certain infectioncontrol recommendations that cannot be rigorously evaluated are based on a strong theoretical rationale and suggestive evidence. Finally, certain recommendations are derived from existing federal regulations.
The references and the appendices comprise Parts III and IV of this document, respectively.
Infections caused by the microorganisms described in these guidelines are rare events, and the effect of these recommendations on infection rates in a facility may not be readily measurable. Therefore, the following steps to measure performance are suggested to evaluate these recommendations (Box 1):
Box 1. Environmental infection control: performance measures 1. Document whether infection-control personnel are actively involved in all phases of a health-care facility's demolition, construction, and renovation. Activities should include performing a risk assessment of the necessary types of construction barriers, and daily monitoring and documenting of the presence of negative airflow within the construction zone or renovation area.
2. Monitor and document daily the negative airflow in airborne infection isolation (AII) rooms and positive airflow in protective environment (PE) rooms, especially when patients are in these rooms.
3. Perform assays at least once a month by using standard quantitative methods for endotoxin in water used to reprocess hemodialyzers, and for heterotrophic and mesophilic bacteria in water used to prepare dialysate and for hemodialyzer reprocessing.
4. Evaluate possible environmental sources (e.g., water, laboratory solutions, or reagents) of specimen contamination when nontuberculous mycobacteria (NTM) of unlikely clinical importance are isolated from clinical cultures. If environmental contamination is found, eliminate the probable mechanisms.
5. Document policies to identify and respond to water damage. Such policies should result in either repair and drying of wet structural or porous materials within 72 hours, or removal of the wet material if drying is unlikely with 72 hours.
Topics outside the scope of this document include a. noninfectious adverse events (e.g., sick building syndrome); b. environmental concerns in the home; c. home health care; d. bioterrorism; and e. healthcare-associated foodborne illness.
This document includes only limited discussion of handwashing/hand hygiene; standard precautions; and infection-control measures used to prevent instrument or equipment contamination during patient care (e.g., preventing waterborne contamination of nebulizers or ventilator humidifiers).
These topics are mentioned only if they are important in minimizing the transfer of pathogens to and from persons or equipment and the environment. Although the document discusses principles of cleaning and disinfection as they are applied to maintenance of environmental surfaces, the full discussion of sterilization and disinfection of medical instruments and direct patient-care devices is deferred for inclusion in the

# Part I. Background Information: Environmental Infection Control in Health-Care Facilities

# A. Introduction
The health-care environment contains a diverse population of microorganisms, but only a few are significant pathogens for susceptible humans. Microorganisms are present in great numbers in moist, organic environments, but some also can persist under dry conditions. Although pathogenic microorganisms can be detected in air and water and on fomites, assessing their role in causing infection and disease is difficult. 11 Only a few reports clearly delineate a "cause and effect" with respect to the environment and in particular, housekeeping surfaces.
Eight criteria are used to evaluate the strength of evidence for an environmental source or means of transmission of infectious agents (Box 2). 11,12 Applying these criteria to disease investigations allows scientists to assess the contribution of the environment to disease transmission. An example of this application is the identification of a pathogen (e.g., vancomycin-resistant enterococci ) on an environmental surface during an outbreak. The presence of the pathogen does not establish its causal role; its transmission from source to host could be through indirect means (e.g., via hand transferral). 11 The surface, therefore, would be considered one of a number of potential reservoirs for the pathogen, but not the "de facto" source of exposure. An understanding of how infection occurs after exposure, based on the principles of the "chain of infection," is also important in evaluating the contribution of the environment to health-care associated disease. 13 All of the components of the "chain" must be operational for infection to occur (Box 3).
Box 2. Eight criteria for evaluating the strength of evidence for environmental sources of infection*+
1. The organism can survive after inoculation onto the fomite.
2. The organism can be cultured from in-use fomites.
3. The organism can proliferate in or on the fomite.
4. Some measure of acquisition of infection cannot be explained by other recognized modes of transmission.
5. Retrospective case-control studies show an association between exposure to the fomite and infection.
Prospective case-control studies may be possible when more than one similar type of fomite is in use. 7. Prospective studies allocating exposure to the fomite to a subset of patients show an association between exposure and infection. The presence of the susceptible host is one of these components that underscores the importance of the health-care environment and opportunistic pathogens on fomites and in air and water. As a result of advances in medical technology and therapies (e.g., cytotoxic chemotherapy and transplantation medicine), more patients are becoming immunocompromised in the course of treatment and are therefore at increased risk for acquiring health-care associated opportunistic infections. Trends in health-care delivery (e.g., early discharge of patients from acute care facilities) also are changing the distribution of patient populations and increasing the number of immunocompromised persons in nonacute-care hospitals. According to the American Hospital Association (AHA), in 1998, the number of hospitals in the United States totaled 6,021; these hospitals had a total of 1,013,000 beds, 14 representing a 5.5% decrease in the number of acute-care facilities and a 10.2% decrease in the number of beds over the 5year period 1994-1998. 14 In addition, the total average daily number of patients receiving care in U.S. acute-care hospitals in 1998 was 662,000 (65.4%) -36.5% less than the 1978 average of 1,042,000. 14 As the number of acute-care hospitals declines, the length of stay in these facilities is concurrently decreasing, particularly for immunocompetent patients. Those patients remaining in acute-care facilities are likely to be those requiring extensive medical interventions who therefore at high risk for opportunistic infection. The growing population of severely immunocompromised patients is at odds with demands on the health-care industry to remain viable in the marketplace; to incorporate modern equipment, new diagnostic procedures, and new treatments; and to construct new facilities. Increasing numbers of health-care facilities are likely to be faced with construction in the near future as hospitals consolidate to reduce costs, defer care to ambulatory centers and satellite clinics, and try to create more "home-like" acute-care settings. In 1998, approximately 75% of health-care associated construction projects focused on renovation of existing outpatient facilities or the building of such facilities; 15 the number of projects associated with outpatient health care rose by 17% from 1998 through 1999. 16 An aging population is also creating increasing demand for assisted-living facilities and skilled nursing centers. Construction of assisted-living facilities in 1998 increased 49% from the previous year, with 138 projects completed at a cost of $703 million. 16 Overall, from 1998 to 1999, health-care associated construction costs increased by 28.5%, from $11.56 billion to $14.86 billion. 16 Environmental disturbances associated with construction activities near health-care facilities pose airborne and waterborne disease threats risks for the substantial number of patients who are at risk for health-care associated opportunistic infections. The increasing age of hospitals and other health-care facilities is also generating ongoing need for repair and remediation work (e.g., installing wiring for new information systems, removing old sinks, and repairing elevator shafts) that can introduce or increase contamination of the air and water in patient-care environments. Aging equipment, deferred maintenance, and natural disasters provide additional mechanisms for the entry of environmental pathogens into highrisk patient-care areas.
Architects, engineers, construction contractors, environmental health scientists, and industrial hygienists historically have directed the design and function of hospitals' physical plants. Increasingly, however, because of the growth in the number of susceptible patients and the increase in construction projects, the involvement of hospital epidemiologists and infection-control professionals is required. These experts help make plans for building, maintaining, and renovating health-care facilities to ensure that the adverse impact of the environment on the incidence of health-care associated infections is minimal. The following are examples of adverse outcomes that could have been prevented had such experts been involved in the planning process: transmission of infections caused by Mycobacterium tuberculosis, varicella-zoster virus (VZV), and measles (i.e., rubeola) facilitated by inappropriate air-handling systems in health-care facilities; 6 disease outbreaks caused by Aspergillus spp.,  Mucoraceae, 20 and Penicillium spp. associated with the absence of environmental controls during periods of health-care facility-associated construction; 21 infections and/or colonizations of patients and staff with vancomycin-resistant Enterococcus faecium  and Clostridium difficile acquired indirectly from contact with organisms present on environmental surfaces in health-care facilities;  and outbreaks and pseudoepidemics of legionellae, 26,27 Pseudomonas aeruginosa, 28-30 and the nontuberculous mycobacteria (NTM) 31,32 linked to water and aqueous solutions used in health-care facilities.
The purpose of this guideline is to provide useful information for both health-care professionals and engineers in efforts to provide a safe environment in which quality health care may be provided to patients. The recommendations herein provide guidance to minimize the risk for and prevent transmission of pathogens in the indoor environment.

# B. Key Terms Used in this Guideline
Although Appendix A provides definitions for terms discussed in Part I, several terms that pertain to specific patient-care areas and patients who are at risk for health-care associated opportunistic infections are presented here. Specific engineering parameters for these care areas are discussed more fully in the text. Airborne Infection Isolation (AII) refers to the isolation of patients infected with organisms spread via airborne droplet nuclei <5 m in diameter. This isolation area receives numerous air changes per hour (ACH) (12 ACH for new construction as of 2001; 6 ACH for construction before 2001), and is under negative pressure, such that the direction of the airflow is from the outside adjacent space (e.g., corridor) into the room. The air in an AII room is preferably exhausted to the outside, but may be recirculated provided that the return air is filtered through a high efficiency particulate air (HEPA) filter. The use of personal respiratory protection is also indicated for persons entering these rooms.
Protective Environment (PE) is a specialized patient-care area, usually in a hospital, with a positive airflow relative to the corridor (i.e., air flows from the room to the outside adjacent space). The combination of HEPA filtration, high numbers of air changes per hour (12 ACH), and minimal leakage of air into the room creates an environment that can safely accommodate patients who have undergone allogeneic hematopoietic stem cell transplant (HSCT).
Immunocompromised patients are those patients whose immune mechanisms are deficient because of immunologic disorders (e.g., human immunodeficiency virus  infection, congenital immune deficiency syndrome, chronic diseases ) or immunosuppressive therapy (e.g., radiation, cytotoxic chemotherapy, anti-rejection medication, and steroids). Immunocompromised patients who are identified as high-risk patients have the greatest risk of infection caused by airborne or waterborne microorganisms. Patients in this subset include those who are severely neutropenic for prolonged periods of time (i.e., an absolute neutrophil count  of 500 cells/mL), allogeneic HSCT patients, and those who have received intensive chemotherapy (e.g., childhood acute myelogenous leukemia patients).

# C. Air 1. Modes of Transmission of Airborne Diseases
A variety of airborne infections in susceptible hosts can result from exposures to clinically significant microorganisms released into the air when environmental reservoirs (i.e., soil, water, dust, and decaying organic matter) are disturbed. Once these materials are brought indoors into a health-care facility by any of a number of vehicles (e.g., people, air currents, water, construction materials, and equipment), the attendant microorganisms can proliferate in various indoor ecological niches and, if subsequently disbursed into the air, serve as a source for airborne health-care associated infections.
Respiratory infections can be acquired from exposure to pathogens contained either in droplets or droplet nuclei. Exposure to microorganisms in droplets (e.g., through aerosolized oral and nasal secretions from infected patients 33 ) constitutes a form of direct contact transmission. When droplets are produced during a sneeze or cough, a cloud of infectious particles >5 m in size is expelled, resulting in the potential exposure of susceptible persons within 3 feet of the source person. 6 Examples of pathogens spread in this manner are influenza virus, rhinoviruses, adenoviruses, and respiratory syncytial virus (RSV). Because these agents primarily are transmitted directly and because the droplets tend to fall out of the air quickly, measures to control air flow in a health-care facility (e.g., use of negative pressure rooms) generally are not indicated for preventing the spread of diseases caused by these agents. Strategies to control the spread of these diseases are outlined in another guideline. 3 The spread of airborne infectious diseases via droplet nuclei is a form of indirect transmission. 34 Droplet nuclei are the residuals of droplets that, when suspended in air, subsequently dry and produce particles ranging in size from 1-5 m. These particles can a. contain potentially viable microorganisms, b. be protected by a coat of dry secretions, c. remain suspended indefinitely in air, and d. be transported over long distances.
The microorganisms in droplet nuclei persist in favorable conditions (e.g., a dry, cool atmosphere with little or no direct exposure to sunlight or other sources of radiation). Pathogenic microorganisms that can be spread via droplet nuclei include Mycobacterium tuberculosis, VZV, measles virus (i.e., rubeola), and smallpox virus (i.e., variola major). 6 Several environmental pathogens have life-cycle forms that are similar in size to droplet nuclei and may exhibit similar behavior in the air. The spores of Aspergillus fumigatus have a diameter of 2-3.5 m, with a settling velocity estimated at 0.03 cm/second (or about 1 meter/hour) in still air. With this enhanced buoyancy, the spores, which resist desiccation, can remain airborne indefinitely in air currents and travel far from their source. 35

# Airborne Infectious Diseases in Health-Care Facilities a. Aspergillosis and Other Fungal Diseases
Aspergillosis is caused by molds belonging to the genus Aspergillus. Aspergillus spp. are prototype health-care acquired pathogens associated with dusty or moist environmental conditions. Clinical and epidemiologic aspects of aspergillosis (Table 1) are discussed extensively in another guideline. 3 Format Change : The format of this section was changed to improve readability and accessibility. The content is unchanged.

# Table 1. Clinical and epidemiologic characteristics of aspergillosis

# Modes of transmission
Airborne transmission of fungal spores; direct inhalation; direct inoculation from environmental sources (rare)
and equipment can become contaminated with Aspergillus spp. spores and serve as sources of infection if stored in such areas. 57 Most cases of aspergillosis are caused by Aspergillus fumigatus, a thermotolerant/thermophilic fungus capable of growing over a temperature range from 53.6F-127.4F (12C-53C); optimal growth occurs at approximately 104F (40C), a temperature inhibitory to most other saprophytic fungi. 99 It can use cellulose or sugars as carbon sources; because its respiratory process requires an ample supply of carbon, decomposing organic matter is an ideal substrate. (For AIA guidance on Aspergillus spp. see Table 2.)
Other opportunistic fungi that have been occasionally linked with health-care associated infections are members of the order Mucorales (e.g., Rhizopus spp.) and miscellaneous moniliaceous molds (e.g., Fusarium spp. and Penicillium spp.) (Table 2). Many of these fungi can proliferate in moist environments (e.g., water-damaged wood and building materials). Some fungi (e.g., Fusarium spp. and Pseudoallescheria spp.) also can be airborne pathogens. 100 As with aspergillosis, a major risk factor for disease caused by any of these pathogens is the host's severe immunosuppression from either underlying disease or immunosuppressive therapy. 101,102 Format Change : The format of this section was changed to improve readability and accessibility. The content is unchanged.

# Table 2. Environmental fungal pathogens: entry into and contamination of the healthcare facility
Fungal pathogen Implicated environmental vehicle Aspergillus spp.
- Improperly functioning ventilation systems 20,46,47,97,98,103,104 - Air filters+ 17,18, Pigeons, their droppings and roosts are associated with spread of Aspergillus, Cryptococcus, and Histoplasma spp. There have been at least three outbreaks linked to contamination of the filtering systems from bird droppings 98,103,104 Pigeon mites may gain access into a health-care facility through the ventilation system. 119 - Air filter frames 17,18 - Window air conditioners 96 - Backflow of contaminated air 107
- Air exhaust contamination+ 104 - False ceilings 48,57,97,108 - Fibrous insulation and perforated metal ceilings 66 - Acoustic ceiling tiles, plasterboard 18,109 - Fireproofing material 48,49 - Damp wood building materials 49 - Opening doors to construction site 110

# Construction 69
- Open windows 20,108,111 105 - Topical anesthetic 117 Acremonium spp.
- Air filters 105 Cladosporium spp.
- Air filters 105

# Sporothrix
- Construction (pseudoepidemic) 118 + The American Institute of Architects (AIA) standards stipulate that for new or renovated construction o exhaust outlets are to be placed >25 feet from air intake systems, o the bottom of outdoor air intakes for HVAC systems should be 6 feet above ground or 3 feet above roof level, and o exhaust outlets from contaminated areas are situated above the roof level and arranged to minimize the recirculation of exhausted air back into the building. 120 Infections due Cryptococcus neoformans, Histoplasma capsulatum, or Coccidioides immitis can occur in health-care settings if nearby ground is disturbed and a malfunction of the facility's air-intake components allows these pathogens to enter the ventilation system. C. neoformans is a yeast usually 4-8 m in size. However, viable particles of <2 m diameter (and thus permissive to alveolar deposition) have been found in soil contaminated with bird droppings, particularly from pigeons. 98,103,104,121 H. capsulatum, with the infectious microconidia ranging in size from 2-5 m, is endemic in the soil of the central river valleys of the United States. Substantial numbers of these infectious particles have been associated with chicken coops and the roosts of blackbirds. 98,103,104,122 Several outbreaks of histoplasmosis have been associated with disruption of the environment; construction activities in an endemic area may be a potential risk factor for health-care acquired airborne infection. 123,124 C. immitis, with arthrospores of 3-5 m diameter, has similar potential, especially in the endemic southwestern United States and during seasons of drought followed by heavy rainfall. After the 1994 earthquake centered near Northridge, California, the incidence of coccidioidomycosis in the surrounding area exceeded the historical norm. 125 Emerging evidence suggests that Pneumocystis carinii, now classified as a fungus, may be spread via airborne, person-to-person transmission. 126 Controlled studies in animals first demonstrated that P. carinii could be spread through the air. 127 More recent studies in health-care settings have detected nucleic acids of P. carinii in air samples from areas frequented or occupied by P. carinii-infected patients but not in control areas that are not occupied by these patients. 128,129 Clusters of cases have been identified among immunocompromised patients who had contact with a source patient and with each other. Recent studies have examined the presence of P. carinii DNA in oropharyngeal washings and the nares of infected patients, their direct contacts, and persons with no direct contact. 130,131 Molecular analysis of the DNA by polymerase chain reaction (PCR) provides evidence for airborne transmission of P. carinii from infected patients to direct contacts, but immunocompetent contacts tend to become transiently colonized rather than infected. 131 The role of colonized persons in the spread of P. carinii pneumonia (PCP) remains to be determined. At present, specific modifications to ventilation systems to control spread of PCP in a health-care facility are not indicated. Current recommendations outline isolation procedures to minimize or eliminate contact of immunocompromised patients not on PCP prophylaxis with PCP-infected patients. 6,132

# b. Tuberculosis and Other Bacterial Diseases
The bacterium most commonly associated with airborne transmission is Mycobacterium tuberculosis. A comprehensive review of the microbiology and epidemiology of M. tuberculosis and guidelines for tuberculosis (TB) infection control have been published. 4,133,134 A summary of the clinical and epidemiologic information from these materials is provided in this guideline (Table 3).
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# Factors affecting severity and outcomes
- Concentration of droplet nuclei in air, duration of exposure - Age at infection - Immunosuppression due to therapy or disease, underlying chronic medical conditions, history of malignancies or lesions or the lungs Occurrence - Worldwide; incidence in the United States is 56 cases/100,000 population (2001) 136 Mortality rate - 930 deaths in the United States (1999) 136 Chemoprophylaxis / treatment - Treatment of latent infection includes isoniazid (INH) or rifampin (RIF) 4,134, - Directly observed therapy (DOT) for active cases as indicated: INH, RIF, pyrazinamide (PZA), ethambutol (EMB), streptomycin (SM) in various combinations determined by prevalent levels of specific resistance 4,134, - Consult therapy guidelines for specific treatment indications 139 - Material in this table is compiled from references 4, 133-141.
M. tuberculosis is carried by droplet nuclei generated when persons (primarily adults and adolescents) who have pulmonary or laryngeal TB sneeze, cough, speak, or sing; 139 normal air currents can keep these particles airborne for prolonged periods and spread them throughout a room or building. 142 However, transmission of TB has occurred from mycobacteria aerosolized during provision of care (e.g., wound/lesion care or during handling of infectious peritoneal dialysis fluid) for extrapulmonary TB patients. 135,140 Gram-positive cocci (i.e., Staphylococcus aureus, group A beta-hemolytic streptococci), also important health-care associated pathogens, are resistant to inactivation by drying and can persist in the environment and on environmental surfaces for extended periods. These organisms can be shed from heavily colonized persons and discharged into the air. Airborne dispersal of S. aureus is directly associated with the concentration of the bacterium in the anterior nares. 143 Approximately 10% of healthy carriers will disseminate S. aureus into the air, and some persons become more effective disseminators of S. aureus than others.  The dispersal of S. aureus into air can be exacerbated by concurrent viral upper respiratory infection, thereby turning a carrier into a "cloud shedder." 149 Outbreaks of surgical site infections (SSIs) caused by group A beta-hemolytic streptococci have been traced to airborne transmission from colonized operating-room personnel to patients.  In these situations, the strain causing the outbreak was recovered from the air in the operating room 150,151,154 or on settle plates in a room in which the carrier exercised.  S. aureus and group A streptococci have not been linked to airborne transmission outside of operating rooms, burn units, and neonatal nurseries. 155,156 Transmission of these agents occurs primarily via contact and droplets.
Other gram-positive bacteria linked to airborne transmission include Bacillus spp. which are capable of sporulation as environmental conditions become less favorable to support their growth. Outbreaks and pseudo-outbreaks have been attributed to Bacillus cereus in maternity, pediatric, intensive care, and bronchoscopy units; many of these episodes were secondary to environmental contamination.  Gram-negative bacteria rarely are associated with episodes of airborne transmission because they generally require moist environments for persistence and growth. The main exception is Acinetobacter spp., which can withstand the inactivating effects of drying. In one epidemiologic investigation of bloodstream infections among pediatric patients, identical Acinetobacter spp. were cultured from the patients, air, and room air conditioners in a nursery. 161 Aerosols generated from showers and faucets may potentially contain legionellae and other gram-negative waterborne bacteria (e.g., Pseudomonas aeruginosa). Exposure to these organisms is through direct inhalation. However, because water is the source of the organisms and exposure occurs in the vicinity of the aerosol, the discussion of the diseases associated with such aerosols and the prevention measures used to curtail their spread is discussed in another section of the Guideline (see Part I: Water).

# c. Airborne Viral Diseases
Some human viruses are transmitted from person to person via droplet aerosols, but very few viruses are consistently airborne in transmission (i.e., are routinely suspended in an infective state in air and capable of spreading great distances), and health-care associated outbreaks of airborne viral disease are limited to a few agents. Consequently, infection-control measures used to prevent spread of these viral diseases in health-care facilities primarily involve patient isolation, vaccination of susceptible persons, and antiviral therapy as appropriate rather than measures to control air flow or quality. 6 Infections caused by VZV frequently are described in health-care facilities. Health-care associated airborne outbreaks of VZV infections from patients with primary infection and disseminated zoster have been documented; patients with localized zoster have, on rare occasions, also served as source patients for outbreaks in health-care facilities.  VZV infection can be prevented by vaccination, although patients who develop a rash within 6 weeks of receiving varicella vaccine or who develop breakthrough varicella following exposure should be considered contagious. 167 Viruses whose major mode of transmission is via droplet contact rarely have caused clusters of infections in group settings through airborne routes. The factors facilitating airborne distribution of these viruses in an infective state are unknown, but a presumed requirement is a source patient in the early stage of infection who is shedding large numbers of viral particles into the air. Airborne transmission of measles has been documented in health-care facilities.  In addition, institutional outbreaks of influenza virus infections have occurred predominantly in nursing homes,  and less frequently in medical and neonatal intensive care units, chronic-care areas, HSCT units, and pediatric wards.  Some evidence supports airborne transmission of influenza viruses by droplet nuclei, 181,182 and case clusters in pediatric wards suggest that droplet nuclei may play a role in transmitting certain respiratory pathogens (e.g., adenoviruses and respiratory syncytial virus ). 177,183,184 Some evidence also supports airborne transmission of enteric viruses. An outbreak of a Norwalk-like virus infection involving more than 600 staff personnel over a 3-week period was investigated in a Toronto, Ontario hospital in 1985; common sources (e.g., food and water) were ruled out during the investigation, leaving airborne spread as the most likely mode of transmission. 185 Smallpox virus, a potential agent of bioterrorism, is spread predominantly via direct contact with infectious droplets, but it also can be associated with airborne transmission. 186,187 A German hospital study from 1970 documented the ability of this virus to spread over considerable distances and cause infection at low doses in a well-vaccinated population; factors potentially facilitating transmission in this situation included a patient with cough and an extensive rash, indoor air with low relative humidity, and faulty ventilation patterns resulting from hospital design (e.g., open windows). 188 Smallpox patients with extensive rash are more likely to have lesions present on mucous membranes and therefore have greater potential to disseminate virus into the air. 188 In addition to the smallpox transmission in Germany, two cases of laboratory-acquired smallpox virus infection in the United Kingdom in 1978 also were thought to be caused by airborne transmission. 189 Ebola Virus Disease Update : The recommendations in this guideline for Ebola has been superseded by these CDC documents:
- Infection Prevention and Control Recommendations for Hospitalized Patients with Known or Suspected Ebola Virus Disease in U.S. Hospitals () - Interim Guidance for Environmental Infection Control in Hospitals for Ebola Virus () See CDC's Ebola Virus Disease website () for current information on how Ebola virus is transmitted.
Airborne transmission may play a role in the natural spread of hantaviruses and certain hemorrhagic fever viruses (e.g., Ebola, Marburg, and Lassa), but evidence for airborne spread of these agents in health-care facilities is inconclusive. 190 Although hantaviruses can be transmitted when aerosolized from rodent excreta, 191,192 person-to-person spread of hantavirus infection from source patients has not occurred in healthcare facilities.  Nevertheless, health-care workers are advised to contain potentially infectious aerosols and wear National Institute of Occupational Safety and Health (NIOSH) approved respiratory protection when working with this agent in laboratories or autopsy suites. 196 Lassa virus transmission via aerosols has been demonstrated in the laboratory and incriminated in health-care associated infections in Africa,  but airborne spread of this agent in hospitals in developed nations likely is inefficient. 200,201 Yellow fever is considered to be a viral hemorrhagic fever agent with high aerosol infectivity potential, but health-care associated transmission of this virus has not been described. 202 Viral hemorrhagic fever diseases primarily occur after direct exposure to infected blood and body fluids, and the use of standard and droplet precautions prevents transmission early in the course of these illnesses. 203,204 However, whether these viruses can persist in droplet nuclei that might remain after droplet production from coughs or vomiting in the latter stages of illness is unknown. 205 Although the use of a negative-pressure room is not required during the early stages of illness, its use might be prudent at the time of hospitalization to avoid the need for subsequent patient transfer. Current CDC guidelines recommend negative-pressure rooms with anterooms for patients with hemorrhagic fever and use of HEPA respirators by persons entering these rooms when the patient has prominent cough, vomiting, diarrhea, or hemorrhage. 6,203 Face shields or goggles will help to prevent mucous-membrane exposure to potentially-aerosolized infectious material in these situations. If an anteroom is not available, portable, industrial-grade high efficiency particulate air (HEPA) filter units can be used to provide the equivalent of additional air changes per hour (ACH).

# Mycobacterium tuberculosis+
Measles (rubeola) virus  Varicella-zoster virus  Occasional reports in health-care facilities (atypical) Acremonium spp. 105,206 Fusarium spp. 102 Pseudoallescheria boydii 100 Scedosporium spp. 116 Sporothrix cyanescens  118 Acinetobacter spp. 161 Bacillus spp.  160,207 Brucella spp.  Staphylococcus aureus 148,156 Group A Streptococcus 151 Smallpox virus (variola)  188,189 Influenza viruses 181,182 Respiratory syncytial virus 183 Adenoviruses 184 Norwalk-like virus 185 No reports in health-care facilities; known to be airborne outside.
Coccidioides immitis 125 Cryptococcus spp. 121 Histoplasma capsulatum 124 Coxiella burnetii (Q fever) 212 Hantaviruses 193,195 Lassa virus 205 Marburg virus 205 Ebola virus  205 Crimean-Congo virus 205 Under investigation Pneumocystis carinii 131 n/a n/a - This list excludes microorganisms transmitted from aerosols derived from water.

# Heating, Ventilation, and Air Conditioning Systems in Health-Care Facilities

# a. Basic Components and Operations
Heating, ventilation, and air conditioning (HVAC) systems in health-care facilities are designed to maintain the indoor air temperature and humidity at comfortable levels for staff, patients, and visitors control odors; remove contaminated air; facilitate air-handling requirements to protect susceptible staff and patients from airborne health-care associated pathogens; and minimize the risk for transmission of airborne pathogens from infected patients. 35,120 An HVAC system includes an outside air inlet or intake; filters; humidity modification mechanisms (i.e., humidity control in summer, humidification in winter); heating and cooling equipment; fans; ductwork; air exhaust or out-takes; and registers, diffusers, or grilles for proper distribution of the air (Figure 1). 213,214 Decreased performance of healthcare facility HVAC systems, filter inefficiencies, improper installation, and poor maintenance can contribute to the spread of health-care associated airborne infections.
The American Institute of Architects (AIA) has published guidelines for the design and construction of new health-care facilities and for renovation of existing facilities. These AIA guidelines address indoor air-quality standards (e.g., ventilation rates, temperature levels, humidity levels, pressure relationships, and minimum air changes per hour ) specific to each zone or area in health-care facilities (e.g., operating rooms, laboratories, diagnostic areas, patient-care areas, and support departments). 120  ). More than 40 state agencies that license health-care facilities have either incorporated or adopted by reference these guidelines into their state standards. JCAHO, through its surveys, ensures that facilities are in compliance with the ventilation guidelines of this standard for new construction and renovation.

# Figure 1. Diagram of a ventilation system*
Outdoor air and recirculated air pass through air cleaners (e.g., filter banks) designed to reduce the concentration of airborne contaminants. Air is conditioned for temperature and humidity before it enters the occupied space as supply air. Infiltration is air leakage inward through cracks and interstitial spaces of walls, floors, and ceilings. Exfiltration is air leakage outward through these same cracks and spaces. Return air is largely exhausted from the system, but a portion is recirculated with fresh, incoming air.
- Used with permission of the publisher of reference 214 (ASHRAE)
Engineering controls to contain or prevent the spread of airborne contaminants center on local exhaust ventilation , general ventilation, and air cleaning. 4 General ventilation encompasses dilution and removal of contaminants via well-mixed air distribution of filtered air, directing contaminants toward exhaust registers and grilles via uniform, non-mixed airflow patterns, pressurization of individual spaces relative to all other spaces, and pressurization of buildings relative to the outdoors and other attached buildings.
A centralized HVAC system operates as follows. Outdoor air enters the system, where low-efficiency or "roughing" filters remove large particulate matter and many microorganisms. The air enters the distribution system for conditioning to appropriate temperature and humidity levels, passes through an additional bank of filters for further cleaning, and is delivered to each zone of the building. After the conditioned air is distributed to the designated space, it is withdrawn through a return duct system and delivered back to the HVAC unit. A portion of this "return air" is exhausted to the outside while the remainder is mixed with outdoor air for dilution and filtered for removal of contaminants. 215 Air from toilet rooms or other soiled areas is usually exhausted directly to the atmosphere through a separate duct exhaust system. Air from rooms housing tuberculosis patients is exhausted to the outside if possible, or passed through a HEPA filter before recirculation. Ultraviolet germicidal irradiation (UVGI) can be used as an adjunct air-cleaning measure, but it cannot replace HEPA filtration. 15 b. Filtration i. Filter Types and Methods of Filtration Filtration, the physical removal of particulates from air, is the first step in achieving acceptable indoor air quality. Filtration is the primary means of cleaning the air. Five methods of filtration can be used (Table 5). During filtration, outdoor air passes through two filter beds or banks (with efficiencies of 20%-40% and 90%, respectively) for effective removal of particles 1-5 m in diameter. 35,120 The low-to-medium efficiency filters in the first bank have low resistance to airflow, but this feature allows some small particulates to pass onto heating and air conditioning coils and into the indoor environment. 35 Incoming air is mixed with recirculated air and reconditioned for temperature and humidity before being filtered by the second bank of filters. The performance of filters with 90% efficiency is measured using either the dust-spot test or the weight-arrestance test. 35,216  The second filter bank usually consists of high-efficiency filters. This filtration system is adequate for most patient-care areas in ambulatory-care facilities and hospitals, including the operating room environment and areas providing central services. 120 Nursing facilities use 90% dust-spot efficient filters as the second bank of filters, 120 whereas a HEPA filter bank may be indicated for special-care areas of hospitals. HEPA filters are at least 99.97% efficient for removing particles 0.3 m in diameter. (As a reference, Aspergillus spores are 2.5-3.0 m in diameter.) Examples of care areas where HEPA filters are used include PE rooms and those operating rooms designated for orthopedic implant procedures. 35 Maintenance costs associated with HEPA filters are high compared with other types of filters, but use of in-line disposable prefilters can increase the life of a HEPA filter by approximately 25%. Alternatively, if a disposable prefilter is followed by a filter that is 90% efficient, the life of the HEPA filter can be extended ninefold. This concept, called progressive filtration, allows HEPA filters in special care areas to be used for 10 years. 213 Although progressive filtering will extend the mechanical ability of the HEPA filter, these filters may absorb chemicals in the environment and later desorb those chemicals, thereby necessitating a more frequent replacement program. HEPA filter efficiency is monitored with the dioctylphthalate (DOP) particle test using particles that are 0.3 m in diameter. 218 HEPA filters are usually framed with metal, although some older versions have wood frames. A metal frame has no advantage over a properly fitted wood frame with respect to performance, but wood can compromise the air quality if it becomes and remains wet, allowing the growth of fungi and bacteria. Hospitals are therefore advised to phase out water-damaged or spent wood-framed filter units and replace them with metal-framed HEPA filters.
HEPA filters are usually fixed into the HVAC system; however, portable, industrial grade HEPA units are available that can filter air at the rate of 300-800 ft 3 /min. Portable HEPA filters are used to a. temporarily recirculate air in rooms with no general ventilation, b. augment systems that cannot provide adequate airflow, and c. provide increased effectiveness in airflow. 4 Portable HEPA units are useful engineering controls that help clean the air when the central HVAC system is undergoing repairs 219 but these units do not satisfy fresh-air requirements. 214 The effectiveness of the portable unit for particle removal is dependent on a. the configuration of the room, b. the furniture and persons in the room, c. the placement of the units relative to the contents and layout of the room, and d. the location of the supply and exhaust registers or grilles.
If portable, industrial-grade units are used, they should be capable of recirculating all or nearly all of the room air through the HEPA filter, and the unit should be designed to achieve the equivalent of 12 ACH. 4 (An average room has approximately 1,600 ft 3 of airspace.) The hospital engineering department should be contacted to provide ACH information in the event that a portable HEPA filter unit is necessary to augment the existing fixed HVAC system for air cleaning.
ii. Filter Maintenance Efficiency of the filtration system is dependent on the density of the filters, which can create a drop in pressure unless compensated by stronger and more efficient fans, thus maintaining air flow. For optimal performance, filters require monitoring and replacement in accordance with the manufacturer's recommendations and standard preventive maintenance practices. 220 Upon removal, spent filters can be bagged and discarded with the routine solid waste, regardless of their patient-care area location. 221 Excess accumulation of dust and particulates increases filter efficiency, requiring more pressure to push the air through. The pressure differential across filters is measured by use of manometers or other gauges. A pressure reading that exceeds specifications indicates the need to change the filter. Filters also require regular inspection for other potential causes of decreased performance. Gaps in and around filter banks and heavy soil and debris upstream of poorly maintained filters have been implicated in health-care associated outbreaks of aspergillosis, especially when accompanied by construction activities at the facility. 17,18,106,222

# c. Ultraviolet Germicidal Irradiation (UVGI)
As a supplemental air-cleaning measure, UVGI is effective in reducing the transmission of airborne bacterial and viral infections in hospitals, military housing, and classrooms, but it has only a minimal inactivating effect on fungal spores.  UVGI is also used in air handling units to prevent or limit the growth of vegetative bacteria and fungi. Most commercially available UV lamps used for germicidal purposes are low-pressure mercury vapor lamps that emit radiant energy predominantly at a wave-length of 253.7 nm. 229,230 Two systems of UVGI have been used in health-care settings -duct irradiation and upper-room air irradiation. In duct irradiation systems, UV lamps are placed inside ducts that remove air from rooms to disinfect the air before it is recirculated. When properly designed, installed, and maintained, high levels of UVGI can be attained in the ducts with little or no exposure of persons in the rooms. 231,232 In upper-room air irradiation, UV lamps are either suspended from the ceiling or mounted on the wall. 4 Upper air UVGI units have two basic designs: a. a "pan" fixture with UVGI unshielded above the unit to direct the irradiation upward and b. a fixture with a series of parallel plates to columnize the irradiation outward while preventing the light from getting to the eyes of the room's occupants.
The germicidal effect is dependent on air mixing via convection between the room's irradiated upper zone and the lower patient-care zones. 233,234 Bacterial inactivation studies using BCG mycobacteria and Serratia marcescens have estimated the effect of UVGI as equivalent to 10 ACH-39 ACH. 235,236 Another study, however, suggests that UVGI may result in fewer equivalent ACH in the patient-care zone, especially if the mixing of air between zones is insufficient. 234 The use of fans or HVAC systems to generate air movement may increase the effectiveness of UVGI if airborne microorganisms are exposed to the light energy for a sufficient length of time. 233,235, The optimal relationship between ventilation and UVGI is not known.
Because the clinical effectiveness of UV systems may vary, UVGI is not recommended for air management prior to air recirculation from airborne isolation rooms. It is also not recommended as a substitute for HEPA filtration, local exhaust of air to the outside, or negative pressure. 4 The use of UV lamps and HEPA filtration in a single unit offers only minimal infection-control benefits over those provided by the use of a HEPA filter alone. 240 Duct systems with UVGI are not recommended as a substitute for HEPA filters if the air from isolation rooms must be recirculated to other areas of the facility. 4 Regular maintenance of UVGI systems is crucial and usually consists of keeping the bulbs free of dust and replacing old bulbs as necessary. Safety issues associated with the use of UVGI systems are described in other guidelines. 4

# d. Conditioned Air in Occupied Spaces
Temperature and humidity are two essential components of conditioned air. After outside air passes through a low-or medium-efficiency filter, the air undergoes conditioning for temperature and humidity control before it passes through high-efficiency or HEPA filtration.
i. Temperature HVAC systems in health-care facilities are often single-duct or dual-duct systems. 35,241 A single-duct system distributes cooled air (55F ) throughout the building and uses thermostatically controlled reheat boxes located in the terminal ductwork to warm the air for individual or multiple rooms. The dual-duct system consists of parallel ducts, one with a cold air stream and the other with a hot air stream. A mixing box in each room or group of rooms mixes the two air streams to achieve the desired temperature. Temperature standards are given as either a single temperature or a range, depending on the specific health-care zone. Cool temperature standards (68F-73F ) usually are associated with operating rooms, clean workrooms, and endoscopy suites. 120 A warmer temperature (75F ) is needed in areas requiring greater degrees of patient comfort. Most other zones use a temperature range of 70F-75F (21C-24C). 120 Temperatures outside of these ranges may be needed occasionally in limited areas depending on individual circumstances during patient care (e.g., cooler temperatures in operating rooms during specialized operations).
ii. Humidity Four measures of humidity are used to quantify different physical properties of the mixture of water vapor and air. The most common of these is relative humidity, which is the ratio of the amount of water vapor in the air to the amount of water vapor air can hold at that temperature. 242 The other measures of humidity are specific humidity, dew point, and vapor pressure. 242 Relative humidity measures the percentage of saturation. At 100% relative humidity, the air is saturated. For most areas within health-care facilities, the designated comfort range is 30%-60% relative humidity. 120,214 Relative humidity levels >60%, in addition to being perceived as uncomfortable, promote fungal growth. 243 Humidity levels can be manipulated by either of two mechanisms. 244 In a water-wash unit, water is sprayed and drops are taken up by the filtered air; additional heating or cooling of this air sets the humidity levels. The second mechanism is by means of water vapor created from steam and added to filtered air in humidifying boxes. Reservoir-type humidifiers are not allowed in health-care facilities as per AIA guidelines and many state codes. 120 Cool-mist humidifiers should be avoided, because they can disseminate aerosols containing allergens and microorganisms. 245 Additionally, the small, personal-use versions of this equipment can be difficult to clean.

# iii. Ventilation
The control of air pollutants (e.g., microorganisms, dust, chemicals, and smoke) at the source is the most effective way to maintain clean air. The second most effective means of controlling indoor air pollution is through ventilation. Ventilation rates are voluntary unless a state or local government specifies a standard in health-care licensing or health department requirements. These standards typically apply to only the design of a facility, rather than its operation. 220,246 Health-care facilities without specific ventilation standards should follow the AIA guideline specific to the year in which the building was 120, 214, 241 built or the ANSI/ASHRAE Standard 62, Ventilation for Acceptable Indoor Air Quality.
Ventilation guidelines are defined in terms of air volume per minute per occupant and are based on the assumption that occupants and their activities are responsible for most of the contaminants in the conditioned space. 215 Most ventilation rates for health-care facilities are expressed as room ACH. Peak efficiency for particle removal in the air space occurs between 12 ACH-15 ACH. 35,247,248 Ventilation rates vary among the different patient-care areas of a health-care facility (Appendix B). 120 Health-care facilities generally use recirculated air. 35,120,241,249,250 Fans create sufficient positive pressure to force air through the building duct work and adequate negative pressure to evacuate air from the conditioned space into the return duct work and/or exhaust, thereby completing the circuit in a sealed system (Figure 1). However, because gaseous contaminants tend to accumulate as the air recirculates, a percentage of the recirculated air is exhausted to the outside and replaced by fresh outdoor air. In hospitals, the delivery of filtered air to an occupied space is an engineered system design issue, the full discussion of which is beyond the scope of this document.
Hospitals with areas not served by central HVAC systems often use through-the-wall or fan coil air conditioning units as the sole source of room ventilation. AIA guidelines for newly installed systems stipulate that through-the-wall fan-coil units be equipped with permanent (i.e., cleanable) or replaceable filters with a minimum efficiency of 68% weight arrestance. 120 These units may be used only as recirculating units; all outdoor air requirements must be met by a separate central air handling system with proper filtration, with a minimum of two outside air changes in general patient rooms (D. Erickson, ASHE, 2000). 120 If a patient room is equipped with an individual through-the-wall fan coil unit, the room should not be used as either AII or as PE. 120 These requirements, although directed to new HVAC installations also are appropriate for existing settings. Non-central air-handling systems are prone to problems associated with excess condensation accumulating in drip pans and improper filter maintenance; health-care facilities should clean or replace the filters in these units on a regular basis while the patient is out of the room.
Laminar airflow ventilation systems are designed to move air in a single pass, usually through a bank of HEPA filters either along a wall or in the ceiling, in a one-way direction through a clean zone with parallel streamlines. Laminar airflow can be directed vertically or horizontally; the unidirectional system optimizes airflow and minimizes air turbulence. 63,241 Delivery of air at a rate of 0.5 meters per second (90  20 ft/min) helps to minimize opportunities for microorganism proliferation. 63,251,252 Laminar airflow systems have been used in PE to help reduce the risk for health-care associated airborne infections (e.g., aspergillosis) in high-risk patients. 63,93,253,254 However, data that demonstrate a survival benefit for patients in PE with laminar airflow are lacking. Given the high cost of installation and apparent lack of benefit, the value of laminar airflow in this setting is questionable. 9,37 Few data support the use of laminar airflow systems elsewhere in a hospital. 255 iv. Pressurization Positive and negative pressures refer to a pressure differential between two adjacent air spaces (e.g., rooms and hallways). Air flows away from areas or rooms with positive pressure (pressurized), while air flows into areas with negative pressure (depressurized). AII rooms are set at negative pressure to prevent airborne microorganisms in the room from entering hallways and corridors. PE rooms housing severely neutropenic patients are set at positive pressure to keep airborne pathogens in adjacent spaces or corridors from coming into and contaminating the airspace occupied by such high-risk patients. Selfclosing doors are mandatory for both of these areas to help maintain the correct pressure differential. 4,6,120 Older health-care facilities may have variable pressure rooms (i.e., rooms in which the ventilation can be manually switched between positive and negative pressure). These rooms are no longer permitted in the construction of new facilities or in renovated areas of the facility, 120 and their use in existing facilities has been discouraged because of difficulties in assuring the proper pressure differential, especially for the negative pressure setting, and because of the potential for error associated with switching the pressure differentials for the room. Continued use of existing variable pressure rooms depends on a partnership between engineering and infection control. Both positive-and negativepressure rooms should be maintained according to specific engineering specifications (Table 6). Health-care professionals (e.g., infection control, hospital epidemiologists) must perform a risk assessment to determine the appropriate number of AII rooms (negative pressure) and/or PE rooms (positive pressure) to serve the patient population. The AIA guidelines require a certain number of AII rooms as a minimum, and it is important to refer to the edition under which the building was built for appropriate guidance. 120 In large health-care facilities with central HVAC systems, sealed windows help to ensure the efficient operation of the system, especially with respect to creating and maintaining pressure differentials. Sealing the windows in PE areas helps minimize the risk of airborne contamination from the outside. One outbreak of aspergillosis among immunosuppressed patients in a hospital was attributed in part to an open window in the unit during a time when both construction and a fire happened nearby; sealing the window prevented further entry of fungal spores into the unit from the outside air. 111 Additionally, all emergency exits (e.g., fire escapes and emergency doors) in PE wards should be kept closed (except during emergencies) and equipped with alarms.

# e. Infection Control Impact of HVAC System Maintenance and Repair
A failure or malfunction of any component of the HVAC system may subject patients and staff to discomfort and exposure to airborne contaminants. Only limited information is available from formal studies on the infection-control implications of a complete air-handling system failure or shutdown for maintenance. Most experience has been derived from infectious disease outbreaks and adverse outcomes among high-risk patients when HVAC systems are poorly maintained. (See Table 7 for potential ventilation hazards, consequences, and correction measures.)
AIA guidelines prohibit U.S. hospitals and surgical centers from shutting down their HVAC systems for purposes other than required maintenance, filter changes, and construction. 120 Airflow can be reduced; however, sufficient supply, return, and exhaust must be provided to maintain required pressure relationships when the space is not occupied. Maintaining these relationships can be accomplished with special drives on the air-handling units (i.e., a variable air ventilation  system).
Microorganisms proliferate in environments wherever air, dust, and water are present, and air-handling systems can be ideal environments for microbial growth. 35 Properly engineered HVAC systems require routine maintenance and monitoring to provide acceptable indoor air quality efficiently and to minimize conditions that favor the proliferation of health-care associated pathogens. 35,249 Performance monitoring of the system includes determining pressure differentials across filters, regular inspection of system filters, DOP testing of HEPA filters, testing of low-or medium efficiency filters, and manometer tests for positive-and negative-pressure areas in accordance with nationally recognized standards, guidelines, and manufacturers' recommendations. The use of hand-held, calibrated equipment that can provide a numerical reading on a daily basis is preferred for engineering purposes (A.Streifel, University of Minnesota, 2000). 256 Several methods that provide a visual, qualitative measure of pressure differentials (i.e., airflow direction) include smoke-tube tests or placing flutter strips, ping-pong balls, or tissue in the air stream.
Preventive filter and duct maintenance (e.g., cleaning ductwork vents, replacing filters as needed, and properly disposing spent filters into plastic bags immediately upon removal) is important to prevent potential exposures of patients and staff during HVAC system shut-down. The frequency of filter inspection and the parameters of this inspection are established by each facility to meet their unique needs. Ductwork in older health-care facilities may have insulation on the interior surfaces that can trap contaminants. This insulation material tends to break down over time to be discharged from the HVAC system. Additionally, a malfunction of the air-intake system can overburden the filtering system and permit aerosolization of fungal pathogens. Keeping the intakes free from bird droppings, especially those from pigeons, helps to minimize the concentration of fungal spores entering from the outside. 98 Accumulation of dust and moisture within HVAC systems increases the risk for spread of health-careassociated environmental fungi and bacteria. Clusters of infections caused by Aspergillus spp., P. aeruginosa, S. aureus, and Acinetobacter spp. have been linked to poorly maintained and/or malfunctioning air conditioning systems. 68,161,257,258 Efforts to limit excess humidity and moisture in the infrastructure and on air-stream surfaces in the HVAC system can minimize the proliferation and dispersion of fungal spores and waterborne bacteria throughout indoor air.  Within the HVAC system, water is present in water-wash units, humidifying boxes, or cooling units. The dual-duct system may also create conditions of high humidity and excess moisture that favor fungal growth in drain pans as well as in fibrous insulation material that becomes damp as a result of the humid air passing over the hot stream and condensing.
If moisture is present in the HVAC system, periods of stagnation should be avoided. Bursts of organisms can be released upon system start-up, increasing the risk of airborne infection. 206 Proper engineering of the HVAC system is critical to preventing dispersal of airborne organisms. In one hospital, endophthalmitis caused by Acremonium kiliense infection following cataract extraction in an ambulatory surgical center was traced to aerosols derived from the humidifier water in the ventilation system. 206 The organism proliferated because the ventilation system was turned off routinely when the center was not in operation; the air was filtered before humidification, but not afterwards.
Most health-care facilities have contingency plans in case of disruption of HVAC services. These plans include back-up power generators that maintain the ventilation system in high-risk areas (e.g., operating rooms, intensive-care units, negative-and positive-pressure rooms, transplantation units, and oncology units). Alternative generators are required to engage within 10 seconds of a loss of main power. If the ventilation system is out of service, rendering indoor air stagnant, sufficient time must be allowed to clean the air and re-establish the appropriate number of ACH once the HVAC system begins to function again.
Air filters may also need to be changed, because reactivation of the system can dislodge substantial amounts of dust and create a transient burst of fungal spores.
Duct cleaning in health-care facilities has benefits in terms of system performance, but its usefulness for infection control has not been conclusively determined. Duct cleaning typically involves using specialized tools to dislodge dirt and a high-powered vacuum cleaner to clean out debris. 263 Some duct-cleaning services also apply chemical biocides or sealants to the inside surfaces of ducts to minimize fungal growth and prevent the release of particulate matter. The U.S. Environmental Protection Agency (EPA), however, has concerns with the use of sanitizers and/or disinfectants to treat the surfaces of ductwork, because the label indications for most of these products may not specifically include the use of the product in HVAC systems. 264 Further, EPA has not evaluated the potency of disinfectants in such applications, nor has the agency examined the potential attendant health and safety risks. The EPA recommends that companies use only those chemical biocides that are registered for use in HVAC systems. 264 Although infrequent cleaning of the exhaust ducts in AII areas has been documented as a cause of diminishing negative pressure and a decrease in the air exchange rates, 214 no data indicate that duct cleaning, beyond what is recommended for optimal performance, improves indoor air quality or reduces the risk of infection. Exhaust return systems should be cleaned as part of routine system maintenance. Duct cleaning has not been shown to prevent any health problems, 265 and EPA studies indicate that airborne particulate levels do not increase as a result of dirty air ducts, nor do they diminish after cleaning, presumably because much of the dirt inside air ducts adheres to duct surfaces and does not enter the conditioned space. 265 Additional research is needed to determine if air-duct contamination can significantly increase the airborne infection risk in general areas of health-care facilities.

# Construction, Renovation, Remediation, Repair, and Demolition

# a. General Information
Environmental disturbances caused by construction and/or renovation and repair activities (e.g., disruption of the above-ceiling area, running cables through the ceiling, and structural repairs) in and near health-care facilities markedly increase the airborne Aspergillus spp. spore counts in the indoor air of such facilities, thereby increasing the risk for health-care associated aspergillosis among high-risk patients.
Although one case of health-care associated aspergillosis is often difficult to link to a specific environmental exposure, the occurrence of temporarily clustered cases increase the likelihood that an environmental source within the facility may be identified and corrected. Construction, renovation, repair, and demolition activities in health-care facilities require substantial planning and coordination to minimize the risk for airborne infection both during projects and after their completion. Several organizations and experts have endorsed a multi-disciplinary team approach (Box 4) to coordinate the various stages of construction activities (e.g., project inception, project implementation, final walk-through, and completion). 120,249,250, Environmental services, employee health, engineering, and infection control must be represented in construction planning and design meetings should be convened with architects and design engineers. The number of members and disciplines represented is a function of the complexity of a project. Smaller, less complex projects and maintenance may require a minimal number of members beyond the core representation from engineering, infection control, environmental services, and the directors of the specialized departments.

# Box 4. Suggested members and functions of a multi-disciplinary coordination team for construction, renovation, repair, and demolition projects

# Members
- Infection-control personnel, including hospital epidemiologists - Laboratory personnel - Facility administrators or their designated representatives, facility managers - Director of engineering - Risk-management personnel - Directors of specialized programs (e.g., transplantation, oncology and ICU  programs) - Employee safety personnel, industrial hygienists, and regulatory affairs personnel - Environmental services personnel Information systems personnel - Construction administrators or their designated representatives - Architects, design engineers, project managers, and contractors

# Functions and responsibilities
Coordinate members' input in developing a comprehensive project management plan.
Conduct a risk assessment of the project to determine potential hazards to susceptible patients.
Prevent unnecessary exposures of patients, visitors, and staff to infectious agents.
Oversee all infection-control aspects of construction activities.
Establish site-specific infection-control protocols for specialized areas.
Provide education about the infection-control impact of construction to staff and construction workers.
Ensure compliance with technical standards, contract provisions, and regulations.
Establish a mechanism to address and correct problems quickly.
Develop contingency plans for emergency response to power failures, water supply disruptions, and fires.
Provide a water-damage management plan (including drying protocols) for handling water intrusion from floods, leaks, and condensation.
Develop a plan for structural maintenance.
Education of maintenance and construction workers, health-care staff caring for high-risk patients, and persons responsible for controlling indoor air quality heightens awareness that minimizing dust and moisture intrusion from construction sites into high-risk patient-care areas helps to maintain a safe environment. 120,250,271, Visual and printed educational materials should be provided in the language spoken by the workers. Staff and construction workers also need to be aware of the potentially catastrophic consequences of dust and moisture intrusion when an HVAC system or water system fails during construction or repair; action plans to deal quickly with these emergencies should be developed in advance and kept on file. Incorporation of specific standards into construction contracts may help to prevent departures from recommended practices as projects progress. Establishing specific lines of communication is important to address problems (e.g., dust control, indoor air quality, noise levels, and vibrations), resolve complaints, and keep projects moving toward completion. Health-care facility staff should develop a mechanism to monitor worker adherence to infection-control guidelines on a daily basis in and around the construction site for the duration of the project.

# b. Preliminary Considerations
The three major topics to consider before initiating any construction or repair activity are as follows: a. design and function of the new structure or area, b. assessment of environmental risks for airborne disease and opportunities for prevention, and c. measures to contain dust and moisture during construction or repairs.
A checklist of design and function considerations can help to ensure that a planned structure or area can be easily serviced and maintained for environmental infection control (Box 5) . 17,250,273, Specifications for the construction, renovation, remodeling, and maintenance of health-care facilities are outlined in the AIA document, Guidelines for Design and Construction of Hospitals and Health Care Facilities. 120,275 Box 5. Construction design and function considerations for environmental infection control Proactive strategies can help prevent environmentally mediated airborne infections in health-care facilities during demolition, construction, and renovation. The potential presence of dust and moisture and their contribution to health-care associated infections must be critically evaluated early in the planning of any demolition, construction, renovation, and repairs. 120,250,251,273,274, Consideration must extend beyond dust generated by major projects to include dust that can become airborne if disturbed during routine maintenance and minor renovation activities (e.g., exposure of ceiling spaces for inspection; installation of conduits, cable, or sprinkler systems; rewiring; and structural repairs or replacement). 273,276,277 Other projects that can compromise indoor air quality include construction and repair jobs that inadvertently allow substantial amounts of raw, unfiltered outdoor air to enter the facility (e.g., repair of elevators and elevator shafts) and activities that dampen any structure, area, or item made of porous materials or characterized by cracks and crevices (e.g., sink cabinets in need of repair, carpets, ceilings, floors, walls, vinyl wall coverings, upholstery, drapes, and countertops). 18,273,277 Molds grow and proliferate on these surfaces when they become and remain wet. 21,120,250,266,270,272,280 Scrubbable materials are preferred for use in patient-care areas.
Containment measures for dust and/or moisture control are dictated by the location of the construction site. Outdoor demolition and construction require actions to keep dust and moisture out of the facility (e.g., sealing windows and vents and keeping doors closed or sealed). Containment of dust and moisture generated from construction inside a facility requires barrier structures (either pre-fabricated or constructed of more durable materials as needed) and engineering controls to clean the air in and around the construction or repair site.

# c. Infection-Control Risk Assessment
An infection-control risk assessment (ICRA) conducted before initiating repairs, demolition, construction, or renovation activities can identify potential exposures of susceptible patients to dust and moisture and determine the need for dust and moisture containment measures. This assessment centers on the type and extent of the construction or repairs in the work area but may also need to include adjacent patient-care areas, supply storage, and areas on levels above and below the proposed project. An example of designing an ICRA as a matrix, the policy for performing an ICRA and implementing its results, and a sample permit form that streamlines the communication process are available. 281 Knowledge of the air flow patterns and pressure differentials helps minimize or eliminate the inadvertent dispersion of dust that could contaminate air space, patient-care items, and surfaces. 57,282,283 A recent aspergillosis outbreak among oncology patients was attributed to depressurization of the building housing the HSCT unit while construction was underway in an adjacent building. Pressure readings in the affected building (including 12 of 25 HSCT-patient rooms) ranged from 0.1 Pa-5.8 Pa. Unfiltered outdoor air flowed into the building through doors and windows, exposing patients in the HSCT unit to fungal spores. 283 During long-term projects, providing temporary essential services (e.g., toilet facilities) and conveniences (e.g., vending machines) to construction workers within the site will help to minimize traffic in and out of the area. The type of barrier systems necessary for the scope of the project must be defined. 12,120,250,279,284 Depending on the location and extent of the construction, patients may need to be relocated to other areas in the facility not affected by construction dust. 51,285 Such relocation might be especially prudent when construction takes place within units housing immunocompromised patients (e.g., severely neutropenic patients and patients on corticosteroid therapy). Advance assessment of high-risk locations and planning for the possible transport of patients to other departments can minimize delays and waiting time in hallways. 51 Although hospitals have provided immunocompromised patients with some form of respiratory protection for use outside their rooms, the issue is complex and remains unresolved until more research can be done. Previous guidance on this issue has been inconsistent. 9 Protective respirators (i.e., N95) were well tolerated by patients when used to prevent further cases of construction-related aspergillosis in a recent outbreak. 283 The routine use of the N95 respirator by patients, however, has not been evaluated for preventing exposure to fungal spores during periods of non-construction. Although health-care workers who would be using the N95 respirator for personal respiratory protect must be fittested, there is no indication that either patients or visitors should undergo fit-testing.
Surveillance activities should augment preventive strategies during construction projects. 3,4,20,110,286,287 By determining baseline levels of health-care acquired airborne and waterborne infections, infectioncontrol staff can monitor changes in infection rates and patterns during and immediately after construction, renovations, or repairs. 3

# d. Air Sampling
Air sampling in health-care facilities may be conducted both during periods of construction and on a periodic basis to determine indoor air quality, efficacy of dust-control measures, or air-handling system performance via parametric monitoring. Parametric monitoring consists of measuring the physical periodic assessment of the system (e.g., air flow direction and pressure, ACH, and filter efficiency) can give assurance of proper ventilation, especially for special care areas and operating rooms. 288 Air sampling is used to detect aerosols (i.e., particles or microorganisms). Particulate sampling (i.e., total numbers and size range of particulates) is a practical method for evaluating the infection-control performance of the HVAC system, with an emphasis on filter efficiency in removing respirable particles (<5 m in diameter) or larger particles from the air. Particle size is reported in terms of the mass median aerodynamic diameter (MMAD), whereas count median aerodynamic diameter (CMAD) is useful with respect to particle concentrations.
Particle counts in a given air space within the health-care facility should be evaluated against counts obtained in a comparison area. Particle counts indoors are commonly compared with the particulate levels of the outdoor air. This approach determines the "rank order" air quality from "dirty" (i.e., the outdoor air) to "clean" (i.e., air filtered through high-efficiency filters ) to "cleanest" (i.e., HEPA-filtered air). 288 Comparisons from one indoor area to another may also provide useful information about the magnitude of an indoor air-quality problem. Making rank-order comparisons between clean, highly-filtered areas and dirty areas and/or outdoors is one way to interpret sampling results in the absence of air quality and action level standards. 35,289 In addition to verifying filter performance, particle counts can help determine if barriers and efforts to control dust dispersion from construction are effective. This type of monitoring is helpful when performed at various times and barrier perimeter locations during the project. Gaps or breaks in the barriers' joints or seals can then be identified and repaired. The American Conference of Governmental Industrial Hygienists (ACGIH) has set a threshold limit value-time weighted average (TLV-TWA) of 10 mg/m 3 for nuisance dust that contains no asbestos and <1% crystalline silica. 290 Alternatively, OSHA has set permissible exposure limits (PELs) for inert or nuisance dust as follows: respirable fraction at 5 mg/m 3 and total dust at 15 mg/m 3 . 291 Although these standards are not measures of a bioaerosol, they are used for indoor air quality assessment in occupational settings and may be useful criteria in construction areas. Application of ACGIH guidance to health-care settings has not been standardized, but particulate counts in health-care facilities are likely to be well below this threshold value and approaching cleanroom standards in certain care areas (e.g., operating rooms). 100 Particle counters and anemometers are used in particulate evaluation. The anemometer measures air flow velocity, which can be used to determine sample volumes. Particulate sampling usually does not require microbiology laboratory services for the reporting of results.
Microbiologic sampling of air in health-care facilities remains controversial because of currently unresolved technical limitations and the need for substantial laboratory support (Box 6). Infection-control professionals, laboratorians, and engineers should determine if microbiologic and/or particle sampling is warranted and assess proposed methods for sampling. The most significant technical limitation of air sampling for airborne fungal agents is the lack of standards linking fungal spore levels with infection rates. Despite this limitation, several health-care institutions have opted to use microbiologic sampling when construction projects are anticipated and/or underway in efforts to assess the safety of the environment for immunocompromised patients. 35,289 Microbiologic air sampling should be limited to assays for airborne fungi; of those, the thermotolerant fungi (i.e., those capable of growing at 95F-98.6F ) are of particular concern because of their pathogenicity in immunocompromised hosts. 35 Use of selective media (e.g., Sabouraud dextrose agar and inhibitory mold agar) helps with the initial identification of recovered organisms.
Microbiologic sampling for fungal spores performed as part of various airborne disease outbreak investigations has also been problematic. 18,49,106,111,112,289 The precise source of a fungus is often difficult to trace with certainty, and sampling conducted after exposure may neither reflect the circumstances that were linked to infection nor distinguish between health-care acquired and community-acquired infections.
Because fungal strains may fluctuate rapidly in the environment, health-care acquired Aspergillus spp. infection cannot be confirmed or excluded if the infecting strain is not found in the health-care setting. 287 Sensitive molecular typing methods (e.g., randomly amplified polymorphic DNA (RAPD) techniques and a more recent DNA fingerprinting technique that detects restriction fragment length polymorphisms in fungal genomic DNA) to identify strain differences among Aspergillus spp., however, are becoming increasingly used in epidemiologic investigations of health-care acquired fungal infection (A.Streifel, University of Minnesota, 2000). 68,110,286,287, During case cluster evaluation, microbiologic sampling may provide an isolate from the environment for molecular typing and comparison with patient isolates.
Therefore, it may be prudent for the clinical laboratory to save Aspergillus spp. isolated from colonizations and invasive disease cases among patients in PE, oncology, and transplant services for these purposes. Sedimentation methods using settle plates and volumetric sampling methods using solid impactors are commonly employed when sampling air for bacteria and fungi. Settle plates have been used by numerous investigators to detect airborne bacteria or to measure air quality during medical procedures (e.g., surgery). 17,60,97,151,161,287 Settle plates, because they rely on gravity during sampling, tend to select for larger particles and lack sensitivity for respirable particles (e.g., individual fungal spores), especially in highly-filtered environments. Therefore, they are considered impractical for general use. 35,289, Settle plates, however, may detect fungi aerosolized during medical procedures (e.g., during wound dressing changes), as described in a recent outbreak of aspergillosis among liver transplant patients. 302 The use of slit or sieve impactor samplers capable of collecting large volumes of air in short periods of time are needed to detect low numbers of fungal spores in highly filtered areas. 35,289 In some outbreaks, aspergillosis cases have occurred when fungal spore concentrations in PE ambient air ranged as low as 0.9-2.2 colony-forming units per cubic meter (CFU/m 3 ) of air. 18,94 On the basis of the expected spore counts in the ambient air and the performance parameters of various types of volumetric air samplers, investigators of a recent aspergillosis outbreak have suggested that an air volume of at least 1000 L (1 m 3 ) should be considered when sampling highly filtered areas. 283 Investigators have also suggested limits of 15 CFU/m 3 for gross colony counts of fungal organisms and <0.1 CFU/m 3 for Aspergillus fumigatus and other potentially opportunistic fungi in heavily filtered areas (12 ACH and filtration of 99.97% efficiency). 120 No correlation of these values with the incidence of health-care-associated fungal infection rates has been reported.
Air sampling in health-care facilities, whether used to monitor air quality during construction, to verify filter efficiency, or to commission new space prior to occupancy, requires careful notation of the circumstances of sampling. Most air sampling is performed under undisturbed conditions. However, when the air is sampled during or after human activity (e.g., walking and vacuuming), a higher number of airborne microorganisms likely is detected. 297 The contribution of human activity to the significance of air sampling and its impact on health-care associated infection rates remain to be defined. Comparing microbiologic sampling results from a target area (e.g., an area of construction) to those from an unaffected location in the facility can provide information about distribution and concentration of potential airborne pathogens. A comparison of microbial species densities in outdoor air versus indoor air has been used to help pinpoint fungal spore bursts. Fungal spore densities in outdoor air are variable, although the degree of variation with the seasons appears to be more dramatic in the United States than in Europe. 92,287,303 Particulate and microbiologic air sampling have been used when commissioning new HVAC system installations; however, such sampling is particularly important for newly constructed or renovated PE or operating rooms. Particulate sampling is used as part of a battery of tests to determine if a new HVAC system is performing to specifications for filtration and the proper number of ACH. 268,288,304 Microbiologic air sampling, however, remains controversial in this application, because no standards for comparison purposes have been determined. If performed, sampling should be limited to determining the density of fungal spores per unit volume of air space. High numbers of spores may indicate contamination of air-handling system components prior to installation or a system deficiency when culture results are compared with known filter efficiencies and rates of air exchange.

# e. External Demolition and Construction
External demolition, planned building implosions, and dirt excavation generate considerable dust and debris that can contain airborne microorganisms. In one study, peak concentrations in outdoor air at grade level and HVAC intakes during site excavation averaged 20,000 CFU/m 3 for all fungi and 500 CFU/m 3 for Aspergillus fumigatus, compared with 19 CFU/m 3 and 4 CFU/m 3 , respectively, in the absence of construction. 280 Many health-care institutions are located in large, urban areas; building implosions are becoming a more frequent concern. Infection-control risk assessment teams, particularly those in facilities located in urban renewal areas, would benefit by developing risk management strategies for external demolition and construction as a standing policy. In light of the events of 11 September 2001, it may be necessary for the team to identify those dust exclusion measures that can be implemented rapidly in response to emergency situations (Table 8). Issues to be reviewed prior to demolition include a. proximity of the air intake system to the work site, b. adequacy of window seals and door seals, c. proximity of areas frequented by immunocompromised patients, and d. location of the underground utilities (D. Erickson, ASHE, 2000). 120,250,273,276,277,280,305  Minimizing the entry of outside dust into the HVAC system is crucial in reducing the risk for airborne contaminants. Facility engineers should be consulted about the potential impact of shutting down the system or increasing the filtration. Selected air handlers, especially those located close to excavation sites, may have to be shut off temporarily to keep from overloading the system with dust and debris. Care is needed to avoid significant facility-wide reductions in pressure differentials that may cause the building to become negatively pressured relative to the outside. To prevent excessive particulate overload and subsequent reductions in effectiveness of intake air systems that cannot be shut off temporarily, air filters must be inspected frequently for proper installation and function. Excessive dust penetration can be avoided if recirculated air is maximally utilized while outdoor air intakes are shut down. Scheduling demolition and excavation during the winter, when Aspergillus spp. spores may be present in lower numbers, can help, although seasonal variations in spore density differ around the world. 92,287,303 Dust control can be managed by misting the dirt and debris during heavy dust-generating activities. To decrease the amount of aerosols from excavation and demolition projects, nearby windows, especially in areas housing immunocompromised patients, can be sealed and window and door frames caulked or weatherstripped to prevent dust intrusion. 50,301,306 Monitoring for adherence to these control measures throughout demolition or excavation is crucial. Diverting pedestrian traffic away from the construction sites decreases the amount of dust tracked back into the health-care facility and minimizes exposure of high-risk patients to environmental pathogens. Additionally, closing entrances near construction or demolition sites might be beneficial; if this is not practical, creating an air lock (i.e., pressurizing the entry way) is another option.

# f. Internal Demolition, Construction, Renovations, and Repairs
The focus of a properly implemented infection-control program during interior construction and repairs is containment of dust and moisture. This objective is achieved by a. educating construction workers about the importance of control measures b. preparing the site; c. notifying and issuing advisories for staff, patients, and visitors; d. moving staff and patients and relocating patients as needed; e. issuing standards of practice and precautions during activities and maintenance; f. monitoring for adherence to control measures during construction and providing prompt feedback about lapses in control g. monitoring HVAC performance; h. implementing daily clean-up, terminal cleaning and removal of debris upon completion; and i. ensuring the integrity of the water system during and after construction. These activities should be coordinated with engineering staff and infection-control professionals.
Physical barriers capable of containing smoke and dust will confine dispersed fungal spores to the construction zone. 279,284,307,308 The specific type of physical barrier required depends on the project's scope and duration and on local fire codes. Short-term projects that result in minimal dust dispersion (e.g., installation of new cables or wiring above ceiling tiles) require only portable plastic enclosures with negative pressure and HEPA filtration of the exhaust air from the enclosed work area. The placement of a portable industrial-grade HEPA filter device capable of filtration rate of 300-800 ft 3 /min. adjacent to the work area will help to remove fungal spores, but its efficacy is dependent on the supplied ACH and size of the area. If the project is extensive but short-term, dust-abatement, fire-resistant plastic curtains (e.g., Visqueen) may be adequate. These should be completely airtight and sealed from ceiling to floor with overlapping curtains; 276,277,309 holes, tears, or other perforations should be repaired promptly with tape. A portable, industrial-grade HEPA filter unit on continuous operation is needed within the contained area, with the filtered air exhausted to the outside of the work zone. Patients should not remain in the room when dust-generating activities are performed. Tools to assist the decision-making process regarding selection of barriers based on an ICRA approach are available. 281 More elaborate barriers are indicated for long-term projects that generate moderate to large amounts of dust. These barrier structures typically consist of rigid, noncombustible walls constructed from sheet rock, drywall, plywood, or plaster board and covered with sheet plastic (e.g., Visqueen). Barrier requirements to prevent the intrusion of dust into patient-care areas include a. installing a plastic dust abatement curtain before construction of the rigid barrier b. sealing and taping all joint edges including the top and bottom; c. extending the barrier from floor to floor, which takes into account the space  above the finished, lay-down ceiling; and d. fitting or sealing any temporary doors connecting the construction zone to the adjacent area. (See Box 7 for a list of the various construction and repair activities that require the use of some type of barrier.) Dust and moisture abatement and control rely primarily on the impermeable barrier containment approach; as construction continues, numerous opportunities can lead to dispersion of dust to other areas of the health-care facility. Infection-control measures that augment the use of barrier containment should be undertaken (Table 9).
Dust-control measures for clinical laboratories are an essential part of the infection-control strategy during hospital construction or renovation. Use of plastic or solid barriers may be needed if the ICRA determines that air flow from construction areas may introduce airborne contaminants into the laboratory space. In one facility, pseudofungemia clusters attributed to Aspergillus spp. and Penicillium spp. were linked to improper air flow patterns and construction projects adjacent to the laboratory; intrusion of dust and spores into a biological safety cabinet from construction activity immediately next to the cabinet resulted in a cluster of cultures contaminated with Aspergillus niger. 310,311 Reportedly, no barrier containment was used and the HEPA filtration system was overloaded with dust. In addition, an outbreak of pseudobacteremia caused by Bacillus spp. occurred in another hospital during construction above a storage area for blood culture bottles. 207 Airborne spread of Bacillus spp. spores resulted in contamination of the bottles' plastic lids, which were not disinfected or handled with proper aseptic technique prior to collection of blood samples. 1. Monitor the construction area daily for compliance with the infection-control plan. 2. Protective outer clothing for construction workers should be removed before entering clean areas. 3. Use mats with tacky surfaces within the construction zone at the entry; cover sufficient area so that both feet make contact with the mat while walking through the entry. 4. Construct an anteroom as needed where coveralls can be donned and removed. 5. Clean the construction zone and all areas used by construction workers with a wet mop. 6. If the area is carpeted, vacuum daily with a HEPA-filtered-equipped vacuum. 7. Provide temporary essential services (e.g., toilets) and worker conveniences (e.g, vending machines) in the construction zone as appropriate. 8. Damp-wipe tools if removed from the construction zone or left in the area. 9. Ensure that construction barriers remain well sealed; use particle sampling as needed. 10. Ensure that the clinical laboratory is free from dust contamination.

# Infection-control measure
Steps for implementation Complete the project.
1. Flush the main water system to clear dust-contaminated lines.

# Environmental Infection-Control Measures for Special Health-Care Settings
Areas in health-care facilities that require special ventilation include a. operating rooms b. PE rooms used by high-risk, immunocompromised patients; and c. AII rooms for isolation of patients with airborne infections (e.g., those caused by M. tuberculosis, VZV, or measles virus).
The number of rooms required for PE and AII are determined by a risk assessment of the health-care facility. 6 Continuous, visual monitoring of air flow direction is required for new or renovated pressurized rooms. 120,256

# a. Protective Environments (PE)
Although the exact configuration and specifications of PEs might differ among hospitals, these care areas for high-risk, immunocompromised patients are designed to minimize fungal spore counts in air by maintaining a. filtration of incoming air by using central or point-of-use HEPA filters b. directed room air flow ; c. positive room air pressure of 2.5 Pa  relative to the corridor; d. well-sealed rooms; and e. 12 ACH. 44,120,251,254, Air flow rates must be adjusted accordingly to ensure sufficient ACH, and these rates vary depending on certain factors (e.g., room air leakage area). For example, to provide 12 ACH in a typical patient room with 0.5 sq. ft. air leakage, the air flow rate will be minimally 125 cubic feet/min (cfm). 320,321 Higher air flow rates may be needed. A general ventilation diagram for a positive-pressure room is given in Figure 2. Directed room air flow in PE rooms is not laminar; parallel air streams are not generated. Studies attempting to demonstrate patient benefit from laminar air flow in a PE setting are equivocal. 316, 318, 319, 322 -327 Air flow direction at the entrances to these areas should be maintained and verified, preferably on a daily basis, using either a visual means of indication (e.g., smoke tubes and flutter strips) or manometers. Permanent installation of a visual monitoring device is indicated for new PE construction and renovation. 120 Facility service structures can interfere with the proper unidirectional air flow from the patients' rooms to the adjacent corridor. In one outbreak investigation, Aspergillus spp. infections in a critical care unit may have been associated with a pneumatic specimen transport system, a textile disposal duct system, and central vacuum lines for housekeeping, all of which disrupted proper air flow from the patients' rooms to the outside and allowed entry of fungal spores into the unit (M. McNeil, CDC, 2000). The use of surface fungicide treatments is becoming more common, especially for building materials. 329 Copper-based compounds have demonstrated anti-fungal activity and are often applied to wood or paint.
Copper-8-quinolinolate was used on environmental surfaces contaminated with Aspergillus spp. to control one reported outbreak of aspergillosis.310 The compound was also incorporated into the fireproofing material of a newly constructed hospital to help decrease the environmental spore burden. 316

# b. Airborne Infection Isolation (AII)
Acute-care inpatient facilities need at least one room equipped to house patients with airborne infectious disease. Every health-care facility, including ambulatory and long-term care facilities, should undertake an ICRA to identify the need for AII areas. Once the need is established, the appropriate ventilation equipment can be identified. Air handling systems for this purpose need not be restricted to central systems. Guidelines for the prevention of health-care acquired TB have been published in response to multiple reports of health-care associated transmission of multi-drug resistant strains. 4,330 In reports documenting health-care acquired TB, investigators have noted a failure to comply fully with prevention measures in established guidelines. 331 -345 These gaps highlight the importance of prompt recognition of the disease, isolation of patients, proper treatment, and engineering controls. AII rooms are also appropriate for the care and management of smallpox patients. 6 Environmental infection control with respect to smallpox is currently being revisited (see Appendix E).
Salient features of engineering controls for AII areas include a. use of negative pressure rooms with close monitoring of air flow direction using manometers or temporary or installed visual indicators  placed in the room with the door closed b. minimum 6 ACH for existing facilities, 12 ACH for areas under renovation or for new construction; and c. air from negative pressure rooms and treatment rooms exhausted directly to the outside if possible. 4,120,248 As with PE, airflow rates need to be determined to ensure the proper numbers of ACH. 320,321 AII rooms can be constructed either with (Figure 3) or without (Figure 4) an anteroom. When the recirculation of air from AII rooms is unavoidable, HEPA filters should be installed in the exhaust duct leading from the room to the general ventilation system. In addition to UVGI fixtures in the room, UVGI can be placed in the ducts as an adjunct measure to HEPA filtration, but it can not replace the HEPA filter. 4 One of the components of airborne infection isolation is respiratory protection for health-care workers and visitors when entering AII rooms. 4,6,347 Recommendations of the type of respiratory protection are dependent on the patient's airborne infection (indicating the need for AII) and the risk of infection to persons entering the AII room. A more in-depth discussion of respiratory protection in this instance is presented in the current isolation guideline; 6 a revision of this guideline is in development. Coughinducing procedures (e.g., endotracheal intubation and suctioning of known or suspected TB patients, diagnostic sputum induction, aerosol treatments, and bronchoscopy) require similar precautions.  Additional engineering measures are necessary for the management of patients requiring PE (i.e., allogeneic HSCT patients) who concurrently have airborne infection. For this type of patient treatment, an anteroom (Figure 4) is required in new construction and renovation as per AIA guidelines. 120 The pressure differential of an anteroom can be positive or negative relative to the patient in the room. 120 An anteroom can act as an airlock (Figure 4). If the anteroom is positive relative to the air space in the patient's room, staff members do not have to mask prior to entry into the anteroom if air is directly exhausted to the outside and a minimum of 10 ACH (Figure 4, top diagram). 120 When an anteroom is negative relative to both the AII room and the corridor, health-care workers must mask prior to entering the anteroom (Figure 4, bottom diagram). If an AII room with an anteroom is not available, use of a portable, industrial-grade HEPA filter unit may help to increase the number of ACHs while facilitating the removal of fungal spores; however, a fresh air source must be present to achieve the proper air exchange rate. Incoming ambient air should receive HEPA filtration.

# c. Operating Rooms
Operating room air may contain microorganisms, dust, aerosol, lint, skin squamous epithelial cells, and respiratory droplets. The microbial level in operating room air is directly proportional to the number of people moving in the room. 351 One study documented lower infection rates with coagulase-negative staphylococci among patients when operating room traffic during the surgical procedure was limited. 352 Therefore, efforts should be made to minimize personnel traffic during operations. Outbreaks of SSIs caused by group A beta-hemolytic streptococci have been traced to airborne transmission from colonized operating-room personnel to patients.  Several potential health-care associated pathogens (e.g., Staphylococcus aureus and Staphylococcus epidermidis) and drug-resistant organisms have also been recovered from areas adjacent to the surgical field, 353 but the extent to which the presence of bacteria near the surgical field influences the development of postoperative SSIs is not clear. 354 Proper ventilation, humidity (<68%), and temperature control in the operating room is important for the comfort of surgical personnel and patients, but also in preventing environmental conditions that encourage growth and transmission of microorganisms. 355 Operating rooms should be maintained at positive pressure with respect to corridors and adjacent areas. 356 Operating rooms typically do not have a variable air handling system. Variable air handling systems are permitted for use in operating rooms only if they continue to provide a positive pressure with respect to the corridors and adjacent areas and the proper ACHs are maintained when the room is occupied. Conventional operating-room ventilation systems produce a minimum of about 15 ACH of filtered air for thermal control, three (20%) of which must be fresh air. 120,357,358 Air should be introduced at the ceiling and exhausted near the floor. 357,359 Laminar airflow and UVGI have been suggested as adjunct measures to reduce SSI risk for certain operations. Laminar airflow is designed to move particle-free air over the aseptic operating field at a uniform velocity (0.3-0.5 m/sec), sweeping away particles in its path. This air flow can be directed vertically or horizontally, and recirculated air is passed through a HEPA filter.  Neither laminar airflow nor UV light, however, has been conclusively shown to decrease overall SSI risk. 356, Elective surgery on infectious TB patients should be postponed until such patients have received adequate drug therapy. The use of general anesthesia in TB patients poses infection-control challenges because intubation can induce coughing, and the anesthesia breathing circuit apparatus potentially can become contaminated. 371 Although operating room suites at 15 ACH exceed the air exchanges required transmission of TB to operating-room personnel. If feasible, intubation and extubation of the TB surgical patient should be performed in AII. AIA currently does not recommend changing pressure from positive to negative or setting it to neutral; most facilities lack the capability to do so. 120 When emergency surgery is indicated for a suspected/diagnosed infectious TB patient, taking specific infection-control measures is prudent (Box 8). + The placement of portable HEPA filter units in the operating room must be carefully evaluated for potential disruptions in normal air flow. The portable unit should be turned off while the surgical procedure is underway and turned on following extubation. Portable HEPA filter units previously placed in construction areas may be used in subsequent patient care, provided that all internal and external surfaces are cleaned and the filter's performance is verified with appropriate particle testing and is changed, if needed.

# Other Aerosol Hazards in Health-Care Facilities
In addition to infectious bioaerosols, several crucial non-infectious, indoor air-quality issues must be addressed by health-care facilities. The presence of sensitizing and allergenic agents and irritants in the workplace (e.g., ethylene oxide, glutaraldehyde, formaldehyde, hexachlorophene, and latex allergens 375 ) is increasing. Asthma and dermatologic and systemic reactions often result with exposure to these chemicals. Anesthetic gases and aerosolized medications (e.g., ribavirin, pentamidine, and aminoglycosides) represent some of the emerging potentially hazardous exposures to health-care workers. Containment of the aerosol at the source is the first level of engineering control, but personal protective equipment (e.g., masks, respirators, and glove liners) that distances the worker from the hazard also may be needed.
Laser plumes and surgical smoke represent another potential risk for health-care workers.  Lasers transfer electromagnetic energy into tissues, resulting in the release of a heated plume that includes particles, gases, tissue debris, and offensive smells. One concern is that aerosolized infectious material in the laser plume might reach the nasal mucosa of surgeons and adjacent personnel. Although some viruses (i.e., varicella-zoster virus, pseudorabies virus, and herpes simplex virus) do not aerosolize efficiently, 379,380 other viruses and bacteria (e.g., human papilloma virus , HIV, coagulasenegative Staphylococcus, Corynebacterium spp., and Neisseria spp.) have been detected in laser plumes.  The presence of an infectious agent in a laser plume may not, however, be sufficient to cause disease from airborne exposure, especially if the normal mode of transmission for the agent is not airborne. No evidence indicated that HIV or hepatitis B virus (HBV) has been transmitted via aerosolization and inhalation. 388 Although continuing studies are needed to fully evaluate the risk of laser plumes to surgical personnel, the prevention measures in these other guidelines should be followed: a. NIOSH recommendations, 378 b. the Recommended Practices for Laser Safety in Practice Settings developed by the Association of periOperative Registered Nurses , 389 c. the assessments of ECRI, 390-392 and d. the ANSI standard. 393 These guidelines recommend the use of a. respirators (N95 or N100) or full face shields and masks, 260 b. central wall-suction units with in-line filters to collect particulate matter from minimal plumes, and c. dedicated mechanical smoke exhaust systems with a high-efficiency filter to remove large amounts of laser plume.
Although transmission of TB has occurred as a result of abscess management practices that lacked airborne particulate control measures and respiratory protection, use of a smoke evacuator or needle aspirator and a high degree of clinical awareness can help protect healthcare workers when excising and draining an extrapulmonary TB abscess. 137

# D. Water 1. Modes of Transmission of Waterborne Diseases
Moist environments and aqueous solutions in health-care settings have the potential to serve as reservoirs for waterborne microorganisms. Under favorable environmental circumstances (e.g., warm temperature and the presence of a source of nutrition), many bacterial and some protozoal microorganisms can either proliferate in active growth or remain for long periods in highly stable, environmentally resistant (yet infectious) forms. Modes of transmission for waterborne infections include direct contact ; ingestion of water ; indirect-contact transmission ; 6 inhalation of aerosols dispersed from water sources; 3 and aspiration of contaminated water.
The first three modes of transmission are commonly associated with infections caused by gram-negative bacteria and nontuberculous mycobacteria (NTM). Aerosols generated from water sources contaminated with Legionella spp. often serve as the vehicle for introducing legionellae to the respiratory tract. 394

# Waterborne Infectious Diseases in Health-Care Facilities a. Legionellosis
Legionellosis is a collective term describing infection produced by Legionella spp., whereas Legionnaires disease is a multi-system illness with pneumonia. 395 The clinical and epidemiologic aspects of these diseases (Table 11) are discussed extensively in another guideline. 3 Although Legionnaires disease is a respiratory infection, infection-control measures intended to prevent healthcare-associated cases center on the quality of water-the principal reservoir for Legionella spp.

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# Table 11. Clinical and epidemiologic characteristics of legionellosis/Legionnaires disease

# Modes of transmission
- Aspiration of water, direct inhalation or water aerosols. 3,400 Causative agent - Legionella pneumophila (90% of infections); L. micdadei, L. bozemanii, L. dumoffii, L. longbeachii, (14 additional species can cause infection in humans).  Source of exposure - Exposure to environmental sources of Legionella spp. (i.e., water or water aerosols). 31,33, Clinical syndromes and diseases Two distinct illnesses:  - Pontiac fever ; and - progressive pneumonia that may be accompanied by cardiac, renal, and gastrointestinal involvement 3
Patient populations at greatest risk - Immunosuppressed patients (e.g., transplant patients, cancer patients, and patients receiving corticosteroid therapy); - Immunocompromised patients (e.g., surgical patients, patients with underlying chronic lung disease, and dialysis patients); - Elderly persons; and - Patients who smoke. 

# Occurrence
- Proportion of community-acquired pneumonia caused by Legionella spp. ranges from 1%-5%; estimated annual incidence among the general population is 8,000-18,000 cases in the United States; the incidence of healthcare-associated pneumonia (0%-14%) may be underestimated if appropriate laboratory diagnostic methods are unavailable. 396,397, Mortality rate - Mortality declined markedly during 1980-1998, from 34% to 12% for all cases; the mortality rate is higher among persons with health-care associated pneumonia compared with the rate among community-acquired pneumonia patients (14% for health-care associated pneumonia versus 10% for community-acquired pneumonia ). 445 Legionella spp. are commonly found in various natural and man-made aquatic environments 446,447 and can enter health-care facility water systems in low or undetectable numbers. 448,449 Cooling towers, evaporative condensers, heated potable water distribution systems, and locally-produced distilled water can provide environments for multiplication of legionellae.  In several hospital outbreaks, patients have been infected through exposure to contaminated aerosols generated by cooling towers, showers, faucets, respiratory therapy equipment, and room-air humidifiers. 455 Factors that enhance colonization and amplification of legionellae in man-made water environments include a. temperatures of 77F-107.6F ,  b. stagnation, 461 c. scale and sediment, 462 and d. presence of certain free-living aquatic amoebae that can support intracellular growth of legionellae. 462,463 The bacteria multiply within single-cell protozoa in the environment and within alveolar macrophages in humans.

# b. Other Gram-Negative Bacterial Infections
Other gram-negative bacteria present in potable water also can cause health-care associated infections.
Clinically important, opportunistic organisms in tap water include Pseudomonas aeruginosa, Pseudomonas spp., Burkholderia cepacia, Ralstonia pickettii, Stenotrophomonas maltophilia, and Sphingomonas spp.
(Tables 12 and 13). Immunocompromised patients are at greatest risk of developing infection. Medical conditions associated with these bacterial agents range from colonization of the respiratory and urinary tracts to deep, disseminated infections that can result in pneumonia and bloodstream bacteremia. Colonization by any of these organisms often precedes the development of infection. The use of tap water in medical care (e.g., in direct patient care, as a diluent for solutions, as a water source for medical instruments and equipment, and during the final stages of instrument disinfection) therefore presents a potential risk for exposure. Colonized patients also can serve as a source of contamination, particularly for moist environments of medical equipment (e.g., ventilators).
In addition to Legionella spp., Pseudomonas aeruginosa and Pseudomonas spp. are among the most clinically relevant, gram-negative, health-care associated pathogens identified from water. These and other gram-negative, non-fermentative bacteria have minimal nutritional requirements (i.e., these organisms can grow in distilled water) and can tolerate a variety of physical conditions. These attributes are critical to the success of these organisms as health-care associated pathogens. Measures to prevent the spread of these organisms and other waterborne, gram-negative bacteria include hand hygiene, glove use, barrier precautions, and eliminating potentially contaminated environmental reservoirs. 464,465 Format Change : The format of this section was changed to improve readability and accessibility. The content is unchanged.

# Table 12. Pseudomonas aeruginosa infections

# Modes of transmission
- Direct contact with water, aerosols; aspiration of water and inhalation of water aerosols; and indirect transfer from moist environmental surfaces via hands of health-care workers. 28, Clinical syndromes and diseases - Septicemia, pneumonia (particularly ventilator-associated), chronic respiratory infections among cystic fibrosis patients, urinary tract infections, skin and soft-tissue infections (e.g., tissue necrosis and hemorrhage), burn-wound infections, folliculitis, endocarditis, central nervous system infections (e.g., meningitis and abscess), eye infections, and bone and joint infections.  Environmental sources of pseudomonads in healthcare settings - Potable (tap) water, distilled water, antiseptic solutions contaminated with tap water, sinks, hydrotherapy pools, whirlpools and whirlpool spas, water baths, lithotripsy therapy tanks, dialysis water, eyewash stations, flower vases, and endoscopes with residual moisture in the channels. 28,29,466,468, Environmental sources of pseudomonads in the community - Fomites (e.g., drug injection equipment stored in contaminated water). 494,495 Patient populations at greatest risk - Intensive care unit (ICU) patients (including neonatal ICU), transplant patients (organ and hematopoietic stem cell), neutropenic patients, burn therapy and hydrotherapy patients, patients with malignancies, cystic fibrosis patients, patients with underlying medical conditions, and dialysis patients. 28, 466, 467, 472, 477, 493, 506-508, 511, 512, 521-526 Format Change : The format of this section was changed to improve readability and accessibility. The content is unchanged.  527 - Contaminated solutions and disinfectants 528,529 - Dialysis machines 527 - Nebulizers  - Water baths 533 - Intrinsically-contaminated mouthwash 534 (This report describes contamination occurring during manufacture prior to use by the health-care facility staff. All other entries reflect extrinsic sources of contamination.) - Ventilator temperature probes 535

# Stenotrophomonas maltophlia, Sphingomonas spp.
- Distilled water 536,537 - Contaminated solutions and disinfectants 529 - Dialysis machines 527 - Nebulizers  - Water 538 - Ventilator temperature probes 539

# Ralstonia pickettii
- Fentanyl solutions 540 - Chlorhexidine 541
- Distilled water 541 - Contaminated respiratory therapy solution 541,542 Serratia marcescens
- Potable water 543 - Contaminated antiseptics (i.e., benzalkonium chloride and chlorhexidine)  - Contaminated disinfectants (i.e., quaternary ammonium compounds and glutaraldehyde) 547,548 Acinetobacter spp.
- Medical equipment that collects moisture (e.g., mechanical ventilators, cool mist humidifiers, vaporizers, and mist tents)  - Room humidifiers 553,555 - Environmental surfaces  Enterobacter spp.
- Humidifier water 565 - Intravenous fluids  - Unsterilized cotton swabs 573 - Ventilators 565,569 - Rubber piping on a suctioning machine 565,569 - Blood gas analyzers 570 Two additional gram-negative bacterial pathogens that can proliferate in moist environments are Acinetobacter spp. and Enterobacter spp. 571,572 Members of both genera are responsible for healthcareassociated episodes of colonization, bloodstream infections, pneumonia, and urinary tract infections among medically compromised patients, especially those in ICUs and burn therapy units. 566, Infections caused by Acinetobacter spp. represent a significant clinical problem. Average infection rates are higher from July through October compared with rates from November through June. 584 Mortality rates associated with Acinetobacter bacteremia are 17%-52%, and rates as high as 71% have been reported for pneumonia caused by infection with either Acinetobacter spp. or Pseudomonas spp.Multidrug resistance, especially in third generation cephalosporins for Enterobacter spp., contributes to increased morbidity and mortality. 569,572 Patients and health-care workers contribute significantly to the environmental contamination of surfaces and equipment with Acinetobacter spp. and Enterobacter spp., especially in intensive care areas, because of the nature of the medical equipment (e.g., ventilators) and the moisture associated with this equipment. 549,571,572,585 Hand carriage and hand transfer are commonly associated with health-care-associated transmission of these organisms and for S. marcescens. 586 Enterobacter spp. are primarily spread in this manner among patients by the hands of health-care workers. 567,587 Acinetobacter spp. have been isolated from the hands of 4%-33% of health-care workers in some studies,  and transfer of an epidemic strain of Acinetobacter from patients' skin to health-care workers' hands has been demonstrated experimentally. 591 Acinetobacter infections and outbreaks have also been attributed to medical equipment and materials (e.g., ventilators, cool mist humidifiers, vaporizers, and mist tents) that may have contact with water of uncertain quality (e.g., rinsing a ventilator circuit in tap water).  Strict adherence to hand hygiene helps prevent the spread of both Acinetobacter spp. and Enterobacter spp. 577,592 Acinetobacter spp. have also been detected on dry environmental surfaces (e.g., bed rails, counters, sinks, bed cupboards, bedding, floors, telephones, and medical charts) in the vicinity of colonized or infected patients; such contamination is especially problematic for surfaces that are frequently touched.  In two studies, the survival periods of Acinetobacter baumannii and Acinetobacter calcoaceticus on dry surfaces approximated that for S. aureus (e.g., 26-27 days). 593,594 Because Acinetobacter spp. may come from numerous sources at any given time, laboratory investigation of health-care associated Acinetobacter infections should involve techniques to determine biotype, antibiotype, plasmid profile, and genomic fingerprinting (i.e., macrorestriction analysis) to accurately identify sources and modes of transmission of the organism(s). 595

# c. Infections and Pseudo-Infections Due to Nontuberculous Mycobacteria
NTM are acid-fast bacilli (AFB) commonly found in potable water. NTM include both saprophytic and opportunistic organisms. Many NTM are of low pathogenicity, and some measure of host impairment is necessary to enhance clinical disease. 596 The four most common forms of human disease associated with NTM are pulmonary disease in adults; cervical lymph node disease in children; skin, soft tissue, and bone infections; and disseminated disease in immunocompromised patients. 596,597 Person-to-person acquisition of NTM infection, especially among immunocompetent persons, does not appear to occur, and close contacts of patients are not readily infected, despite the high numbers of organisms harbored by such patients. 596, NTM are spread via all modes of transmission associated with water. In addition to health-care associated outbreaks of clinical disease, NTM can colonize patients in health-care facilities through consumption of contaminated water or ice or through inhalation of aerosols.  Colonization following NTM exposure, particularly of the respiratory tract, occurs when a patient's local defense mechanisms are impaired; overt clinical disease does not develop. 606   The format of this section was changed to improve readability and accessibility. The content is unchanged.

# Table 14a. Infections or colonizations

# Pathogen Vehicles associated with infections or colonizations

# Mycobacterium abscessus
- Inadequately sterilized medical instruments 613

# Mycobacterium avium complex (MAC)
- Potable water 

# Mycobacterium chelonae
- Dialysis, reprocessed dialyzers 31,32 - Inadequately-sterilized medical instruments, jet injectors 617,618 - Contaminated solutions 619,620 - Hydrotherapy tanks 621

# Mycobacterium fortuitum
- Aerosols from showers or other water sources 605,606 - Ice 602
- Inadequately sterilized medical instruments 603 - Hydrotherapy tanks 622

# Mycobacterium marinum
- Hydrotherapy tanks 623

# Mycobacterium ulcerans
- Potable water 624 - Laboratory solution (intrinsically contaminated 625 - Potable water ingestion prior to sputum specimen collection 626

# Mycobacterium kansasii
- Potable water 627

# Mycobacterium terrae
- Potable water 608

# Mycobacterium xenopi
- Potable water 609,612,627 NTM can be isolated from both natural and man-made environments. Numerous studies have identified 632 Some NTM species (e.g., Mycobacterium xenopi) can survive in water at 113F (45C), and can be isolated from hot water taps, which can pose a problem for hospitals that lower the temperature of their hot water systems. 627 Other NTM (e.g., Mycobacterium kansasii, M. gordonae, M. fortuitum, and M. chelonae) cannot tolerate high temperatures and are associated more often with cold water lines and taps. 629 NTM have a high resistance to chlorine; they can tolerate free chlorine concentrations of 0.05-0.2 mg/L (0.05-0.2 ppm) found at the tap. 598,633,634 They are 20-100 times more resistant to chlorine compared with coliforms; slow-growing strains of NTM (e.g., Mycobacterium avium and M. kanasii) appear to be more resistant to chorine inactivation compared to fast-growing NTM. 635 Slow-growing NTM species have also demonstrated some resistance to formaldehyde and glutaraldehyde, which has posed problems for reuse of hemodialyzers. 31 The ability of NTM to form biofilms at fluid-surface interfaces (e.g., interior surfaces of water pipes) contributes to the organisms' resistance to chemical inactivation and provides a microenvironment for growth and proliferation. 636,637

# d. Cryptosporidiosis
Cryptosporidium parvum is a protozoan parasite that causes self-limiting gastroenteritis in normal hosts but can cause severe, life-threatening disease in immunocompromised patients. First recognized as a human pathogen in 1976, C. parvum can be present in natural and finished waters after fecal contamination from either human or animal sources.  The health risks associated with drinking potable water contaminated with minimal numbers of C. parvum oocysts are unknown. 642 It remains to be determined if immunosuppressed persons are more susceptible to lower doses of oocysts than are immunocompetent persons. One study demonstrated that a median 50% infectious dose (ID50) of 132 oocysts of calf origin was sufficient to cause infection among healthy volunteers. 643 In a second study, the same researchers found that oocysts obtained from infected foals (newborn horses) were infectious for human volunteers at median ID50 of 10 oocysts, indicating that different strains or species of Cryptosporidium may vary in their infectivity for humans. 644 In a small study population of 17 healthy adults with pre-existing antibody to C. parvum, the ID50 was determined to be 1,880 oocysts, more than 20-fold higher than in seronegative persons. 645 These data suggest that pre-existing immunity derived from previous exposures to Cryptosporidium offers some protection from infection and illness that ordinarily would result from exposure to low numbers of oocysts. 645,646 Oocysts, particularly those with thick walls, are environmentally resistant, but their survival under natural water conditions is poorly understood. Under laboratory conditions, some oocysts remain viable and infectious in cold (41F ) for months. 641 The prevalence of Cryptosporidium in the U.S. drinking water supply is notable. Two surveys of approximately 300 surface water supplies revealed that 55%-77% of the water samples contained Cryptosporidium oocysts. 647,648 Because the oocysts are highly resistant to common disinfectants (e.g., chlorine) used to treat drinking water, filtration of the water is important in reducing the risk of waterborne transmission. Coagulation-floculation and sedimentation, when used with filtration, can collectively achieve approximately a 2.5 log10 reduction in the number of oocysts. 649 However, outbreaks have been associated with both filtered and unfiltered drinking water systems (e.g., the 1993 outbreak in Milwaukee, Wisconsin that affected 400,000 people). 641, The presence of oocysts in the water is not an absolute indicator that infection will occur when the water is consumed, nor does the absence of detectable oocysts guarantee that infection will not occur. Healthcare associated outbreaks of cryptosporidiosis primarily have been described among groups of elderly patients and immunocompromised persons. 653

# Water Systems in Health-Care Facilities a. Basic Components and Point-of-Use Fixtures
Treated municipal water enters a health-care facility via the water mains and is distributed throughout the building(s) by a network of pipes constructed of galvanized iron, copper, and polyvinylchloride (PVC). The pipe runs should be as short as is practical. Where recirculation is employed, the pipe runs should be insulated and long dead legs avoided in efforts to minimize the potential for water stagnation, which favors the proliferation of Legionella spp. and NTM. In high-risk applications (e.g., PE areas for severely immunosuppressed patients), insulated recirculation loops should be incorporated as a design minimal loss.
Each water service main, branch main, riser, and branch (to a group of fixtures) has a valve and a means to reach the valves via an access panel. 120 Each fixture has a stop valve. Valves permit the isolation of a portion of the water system within a facility during repairs or maintenance. Vacuum breakers and other similar devices in the lines prevent water from back-flowing into the system. All systems that supply water should be evaluated to determine risk for potential back siphonage and cross connections.
Health-care facilities generate hot water from municipal water using a boiler system. Hot water heaters and storage vessels for such systems should have a drainage facility at the lowest point, and the heating element should be located as close as possible to the bottom of the vessel to facilitate mixing and to prevent water temperature stratification. Those hot or cold water systems that incorporate an elevated holding tank should be inspected and cleaned annually. Lids should fit securely to exclude foreign materials.
The most common point-of-use fixtures for water in patient-care areas are sinks, faucets, aerators, showers, and toilets; eye-wash stations are found primarily in laboratories. The potential for these fixtures to serve as a reservoir for pathogenic microorganisms has long been recognized (Table 15). 509, Wet surfaces and the production of aerosols facilitate the multiplication and dispersion of microbes. The level of risk associated with aerosol production from point-of-use fixtures varies. Aerosols from shower heads and aerators have been linked to a limited number of clusters of gram-negative bacterial colonizations and infections, including Legionnaires disease, especially in areas where immunocompromised patients are present (e.g., surgical ICUs, transplant units, and oncology units). 412, 415,
In one report, clinical infection was not evident among immunocompetent persons (e.g., hospital staff) who used hospital showers when Legionella pneumophila was present in the water system. 660 Given the infrequency of reported outbreaks associated with faucet aerators, consensus has not been reached regarding the disinfection of or removal of these devices from general use. If additional clusters of infections or colonizations occur in high-risk patient-care areas, it may be prudent to clean and decontaminate the aerators or to remove them. 658,659 ASHRAE recommends cleaning and monthly disinfection of aerators in high-risk patient-care areas as part of Legionella control measures. 661 Although aerosols are produced with toilet flushing, 662,663 no epidemiologic evidence suggests that these aerosols pose a direct infection hazard.
Although not considered a standard point-of-use fixture, decorative fountains are being installed in increasing numbers in health-care facilities and other public buildings. Aerosols from a decorative fountain have been associated with transmission of Legionella pneumophila serogroup 1 infection to a small cluster of older adults. 664 This hotel lobby fountain had been irregularly maintained, and water in the fountain may have been heated by submersed lighting, all of which favored the proliferation of Legionella in the system. 664 Because of the potential for generations of infectious aerosols, a prudent prevention measure is to avoid locating these fixtures in or near high-risk patient-care areas and to adhere to written policies for routine fountain maintenance. 120 Follow public health guidelines.
(See Tables 12-14)

# Potable water Legionella Aerosol inhalation
Moderate: occasional welldescribed outbreaks.
Provide supplemental treatment for water.
(See

# b. Water Temperature and Pressure
Hot water temperature is usually measured at the point of use or at the point at which the water line enters equipment requiring hot water for proper operation. 120 Generally, the hot water temperature in hospital patient-care areas is no greater than a temperature within the range of 105F-120F (40.6C-49C), depending on the AIA guidance issued at the year in which the facility was built. 120 Hot water temperature in patient-care areas of skilled nursing-care facilities is set within a slightly lower range of 95F-110F (35C-43.3C) depending on the AIA guidance at the time of facility construction. 120 Many states have adopted a temperature setting in these ranges into their health-care regulations and building codes. ASHRAE, however, has recommended higher settings. 661 Steam jets or booster heaters are usually needed to meet the hot water temperature requirements in certain service areas of the hospital (e.g., the kitchen  or the laundry ). 120 Additionally, water lines may need to be heated to a particular temperature specified by manufacturers of specific hospital equipment. Hot-water distribution systems serving patient-care areas are generally operated under constant recirculation to provide continuous hot water at each hot-water outlet. 120 If a facility is or has a hemodialysis unit, then continuously circulated, cold treated water is provided to that unit. 120 To minimize the growth and persistence of gram-negative waterborne bacteria (e.g., thermophilic NTM and Legionella spp.), 627, cold water in health-care facilities should be stored and distributed at temperatures below 68F (20C); hot water should be stored above 140F (60C) and circulated with a minimum return temperature of 124F (51C), 661 or the highest temperature specified in state regulations and building codes. If the return temperature setting of 124F (51C) is permitted, then installation of preset thermostatic mixing valves near the point-of-use can help to prevent scalding. Valve maintenance is especially important in preventing valve failure, which can result in scalding. New shower systems in large buildings, hospitals, and nursing homes should be designed to permit mixing of hot and cold water near the shower head. The warm water section of pipe between the control valve and shower head should be self-draining. Where buildings can not be retrofitted, other approaches to minimize the growth of Legionella spp. include periodically increasing the temperature to at least 150F  at the point of use  and adding additional chlorine and flushing the water. 661,710,711 Systems should be inspected annually to ensure that thermostats are functioning properly. Maintaining adequate pressure also helps to ensure the integrity of the piping system.

# c. Infection-Control Impact of Water System Maintenance and Repair
Corrective measures for water-system failures have not been studied in well-designed experiments; these measures are instead based on empiric engineering and infection-control principles. Health-care facilities can occasionally sustain both intentional cut-offs by the municipal water authority to permit new construction project tie-ins and unintentional disruptions in service when a water main breaks as a result of aging infrastructure or a construction accident. Vacuum breakers or other similar devices can prevent backflow of water in the facility's distribution system during water-disruption emergencies. 11 To be prepared for such an emergency, all health-care facilities need contingency plans that identify the total demand for potable water, the quantity of replacement water  required for a minimum of 24 hours when the water system is down, mechanisms for emergency water distribution, and procedures for correcting drops in water pressure that affect operation of essential devices and equipment that are driven or cooled by a water system . 713

# Format Change :
The format of this section was changed to improve readability and accessibility. The content is unchanged. Detailed, up-to-date plans for hot and cold water piping systems should be readily available for maintenance and repair purposes in case of system problems. Opening potable water systems for repair or construction and subjecting systems to water-pressure changes can result in water discoloration and dramatic increases in the concentrations of Legionella spp. and other gram-negative bacteria. The maintenance of a chlorine residual at all points within the piping system also offers some protection from entry of contamination to the pipes in the event of inadvertent cross-connection between potable and nonpotable water lines. As a minimum preventive measure, ASHRAE recommends a thorough flushing of the system. 661 High-temperature flushing or hyperchlorination may also be appropriate strategies to decrease potentially high concentrations of waterborne organisms. The decision to pursue either of these remediation strategies, however, should be made on a case-by-case basis. If only a portion of the system is involved, high temperature flushing or chlorination can be used on only that portion of the system. 661 When shock decontamination of hot water systems is necessary (e.g., after disruption caused by construction and after cross-connections), the hot water temperature should be raised to 160F-170F (71C-77C) and maintained at that level while each outlet around the system is progressively flushed. A minimum flush time of 5 minutes has been recommended; 3 the optimal flush time is not known, however, and longer flush times may be necessary. 714 The number of outlets that can be flushed simultaneously depends on the capacity of the water heater and the flow capability of the system. Appropriate safety procedures to prevent scalding are essential. When possible, flushing should be performed when the fewest building occupants are present (e.g., during nights and weekends).
When thermal shock treatment is not possible, shock chlorination may serve as an alternative method. 661 Experience with this method of decontamination is limited, however, and high levels of free chlorine can corrode metals. Chlorine should be added, preferably overnight, to achieve a free chlorine residual of at least 2 mg/L (2 ppm) throughout the system. 661 This may require chlorination of the water heater or tank to levels of 20-50 mg/L (20-50 ppm). The pH of the water should be maintained at 7.0-8.0. 661 After completion of the decontamination, recolonization of the hot water system is likely to occur unless proper temperatures are maintained or a procedure such as continuous supplemental chlorination is continued.
Interruptions of the water supply and sewage spills are situations that require immediate recovery and remediation measures to ensure the health and safety of patients and staff. 715 When delivery of potable water through the municipal distribution system has been disrupted, the public water supplier must issue a "boil water" advisory if microbial contamination presents an immediate public health risk to customers. The hospital engineer should oversee the restoration of the water system in the facility and clear it for use when appropriate. Hospitals must maintain a high level of surveillance for waterborne disease among patients and staff after the advisory is lifted. 642 Flooding from either external (e.g., from a hurricane) or internal sources (e.g., a water system break) usually results in property damage and a temporary loss of water and sanitation.  JCAHO requires all hospitals to have plans that address facility response for recovery from both internal and external disasters. 713,719 The plans are required to discuss a. general emergency preparedness, b. staffing, c. regional planning among area hospitals, d. emergency supply of potable water, e. infection control and medical services needs, f. climate control, and g. remediation.
The basic principles of structural recovery from flooding are similar to those for recovery from sewage contamination (Box 9 and 10). Following a major event (e.g., flooding), facilities may elect to conduct microbial sampling of water after the system is restored to verify that water quality has been returned to safe levels (<500 CFU/mL, heterotrophic plate count). This approach may help identify point-of-use fixtures that may harbor contamination as a result of design or engineering features. 720 Medical records should be allowed to dry and then either photocopied or placed in plastic covers before returning them to the record.
Moisture meters can be used to assess water-damaged structural materials. If porous structural materials for walls have a moisture content of >20% after 72 hours, the affected material should be removed. 266,278,313 The management of water-damaged structural materials is not strictly limited to major water catastrophes (e.g., flooding and sewage intrusions); the same principles are used to evaluate the damage from leaking roofs, point-of-use fixtures, and equipment. Additional sources of moisture include condensate on walls from boilers and poorly engineered humidification in HVAC systems. An exception to these recommendations is made for hemodialysis units where water is further treated either by portable water treatment or large-scale water treatment systems usually involving reverse osmosis (RO). In the United States, >97% of dialysis facilities use RO treatment for their water. 721 However, changing pre-treatment filters and disinfecting the system to prevent colonization of the RO membrane and microbial contamination down-stream of the pre-treatment filter are prudent measures.

# Box 10. Contingency planning for flooding
General emergency preparedness - Ensure that emergency electrical generators are not located in flood-prone areas of the facility.
- Develop alternative strategies for moving patients, water containers, medical records, equipment, and supplies in the event that the elevators are inoperable. - Establish in advance a centralized base of operations with batteries, flashlights, and cellular phones.
- Ensure sufficient supplies of sandbags to place at the entrances and the area around boilers, incinerators, and generators. - Establish alternative strategies for bringing core employees to the facility if high water prevents travel.

# Staffing Patterns
- Temporarily reassign licensed staff as needed to critical care areas to provide manual ventilation and to perform vital assessments on patients. - Designate a core group of employees to remain on site to keep all services operational if the facility remains open. - Train all employees in emergency preparedness procedures.

# Regional planning among are facilities for disaster management
- Incorporate community support and involvement (e.g., media alerts, news, and transportation).
- Develop in advance strategies for transferring patients, as needed.
- Develop strategies for sharing supplies and providing essential services among participating facilities (e.g., central sterile department services, and laundry services). - Identify sources for emergency provisions (e.g., blood, emergency vehicles, and bottled water).

# Medical services and infection control
- Use alcohol-based hand rubs in general patient-care areas.
- Postpone elective surgeries until full services are restored, or transfer these patients to other facilities.
- Consider using portable dialysis machines. (Portable dialysis machines require less water compared to the larger units situated in dialysis settings.) - Provide an adequate supply of tetanus and hepatitis A immunizations for patients and staff.

# Climate control
- Provide adequate water for cooling towers. (Water for cooling towers may need to be trucked in, especially if the tower uses a potable water source.) - Material in this box was compiled from references 713, 716-719.

# Strategies for Controlling Waterborne Microbial Contamination a. Supplemental Treatment of Water with Heat and/or Chemicals
In addition to using supplemental treatment methods as remediation measures after inadvertent contamination of water systems, health-care facilities sometimes use special measures to control waterborne microorganisms on a sustained basis. This decision is most often associated with outbreaks of legionellosis and subsequent efforts to control legionellae, 722 although some facilities have tried supplemental measures to better control thermophilic NTM. 627 The primary disinfectant for both cold and hot water systems is chlorine. However, chlorine residuals are expected to be low, and possibly nonexistent, in hot water tanks because of extended retention time in the tank and elevated water temperature. Flushing, especially that which removes sludge from the bottom of the tank, probably provides the most effective treatment of water systems. Unlike the situation for disinfecting cooling towers, no equivalent recommendations have been made for potable water systems, although specific intervention strategies have been published. 403,723 The principal approaches to disinfection of potable systems are heat flushing using temperatures 160F-170F (71-77C), hyperchlorination, and physical cleaning of hot-water tanks. 3,403,661 Potable systems are easily recolonized and may require continuous intervention (e.g., raising of hot water temperatures or continuous chlorination). 403,711 Chlorine solutions lose potency over time, thereby rendering the stocking of large quantities of chlorine impractical.
Some hospitals with hot water systems identified as the source of Legionella spp. have performed emergency decontamination of their systems by pulse (i.e., one-time) thermal disinfection/superheating or hyperchlorination. 711,714,724,725 After either of these procedures, hospitals either maintain their heated water with a minimum return temperature of 124F (51C) and cold water at <68F (<20C) or chlorinate their hot water to achieve 1-2 mg/L (1-2 ppm) of free residual chlorine at the tap. 26, 437, 709-711, 726, 727 Additional measures (e.g., physical cleaning or replacement of hot-water storage tanks, water heaters, faucets, and shower heads) may be required to help eliminate accumulations of scale and sediment that protect organisms from the biocidal effects of heat and chlorine. 457,711 Alternative methods for controlling and eradicating legionellae in water systems (e.g., treating water with chlorine dioxide, heavy metal ions , ozone, and UV light) have limited the growth of legionellae under laboratory and operating conditions.  Further studies on the long-term efficacy of these treatments are needed before these methods can be considered standard applications.
Renewed interest in the use of chloramines stems from concerns about adverse health effects associated with disinfectants and disinfection by-products. 743 Monochloramine usage minimizes the formation of disinfection by-products, including trihalomethanes and haloacetic acids. Monochloramine can also reach distal points in a water system and can penetrate into bacterial biofilms more effectively than free chlorine. 744 However, monochloramine use is limited to municipal water treatment plants and is currently not available to health-care facilities as a supplemental water-treatment approach. A recent study indicated that 90% of Legionnaires disease outbreaks associated with drinking water could have been prevented if monochloramine rather than free chlorine has been used for residual disinfection. 745 In a retrospective comparison of health-care associated Legionnaires disease incidence in central Texas hospitals, the same research group documented an absence of cases in facilities located in communities with monochloramine-treated municipal water. 746 Additional data are needed regarding the effectiveness of using monochloramine before its routine use as a disinfectant in water systems can be recommended.
No data have been published regarding the effectiveness of monochloramine installed at the level of the health-care facility.
Additional filtration of potable water systems is not routinely necessary. Filters are used in water lines in dialysis units, however, and may be inserted into the lines for specific equipment (e.g., endoscope washers and disinfectors) for the purpose of providing bacteria-free water for instrument reprocessing. Additionally, an RO unit is usually added to the distribution system leading to PE areas.

# b. Primary Prevention of Legionnaires Disease (No Cases Identified)
The primary and secondary environmental infection-control strategies described in this section on the guideline pertain to health-care facilities without transplant units. Infection-control measures specific to PE or transplant units (i.e., patient-care areas housing patients at the highest risk for morbidity and mortality from Legionella spp. infection) are described in the subsection titled Preventing Legionnaires Disease in Protective Environments.
Health-care facilities use at least two general strategies to prevent health-care associated legionellosis when no cases or only sporadic cases have been detected. The first is an environmental surveillance approach involving periodic culturing of water samples from the hospital's potable water system to monitor for Legionella spp.  If any sample is culture-positive, diagnostic testing is recommended for all patients with health-care associated pneumonia. 748,749 In-house testing is recommended for facilities with transplant programs as part of a comprehensive treatment/management program. If 30% of the samples are culture-positive for Legionella spp., decontamination of the facility's potable water system is warranted. 748 The premise for this approach is that no cases of health-care associated legionellosis can occur if Legionella spp. are not present in the potable water system, and, conversely, cases of health-care associated legionellosis could potentially occur if Legionella spp. are cultured from the water. 26,751 Physicians who are informed that the hospital's potable water system is culture-positive for Legionella spp. are more likely to order diagnostic tests for legionellosis.
A potential advantage of the environmental surveillance approach is that periodic culturing of water is less costly than routine laboratory diagnostic testing for all patients who have health-care associated pneumonia. The primary argument against this approach is that, in the absence of cases, the relationship between water-culture results and legionellosis risk remains undefined. 3 Legionnella spp. can be present in the water systems of buildings 752 without being associated with known cases of disease. 437,707,753 In a study of 84 hospitals in Quebec, 68% of the water systems were found to be colonized with Legionella spp., and 26% were colonized at >30% of sites sampled; cases of Legionnaires disease, however, were infrequently reported from these hospitals. 707 Other factors also argue against environmental surveillance. Interpretation of results from periodic water culturing might be confounded by differing results among the sites sampled in a single water system and by fluctuations in the concentration of Legionella spp. at the same site. 709,754 In addition, the risk for illness after exposure to a given source might be influenced by several factors other than the presence or concentration of organisms, including a. the degree to which contaminated water is aerosolized into respirable droplets, b. the proximity of the infectious aerosol to the potential host, c. the susceptibility of the host, and d. the virulence properties of the contaminating strain.  Thus, data are insufficient to assign a level of disease risk even on the basis of the number of colonyforming units detected in samples from areas for immunocompetent patients. Conducting environmental surveillance would obligate hospital administrators to initiate water-decontamination programs if Legionella spp. are identified. Therefore, periodic monitoring of water from the hospital's potable water system and from aerosol-producing devices is not widely recommended in facilities that have not experienced cases of health-care associated legionellosis. 661,758 The second strategy to prevent and control health-care associated legionellosis is a clinical approach, in which providers maintain a high index of suspicion for legionellosis and order appropriate diagnostic tests (i.e., culture, urine antigen, and direct fluorescent antibody  serology) for patients with health-care associated pneumonia who are at high risk for legionellosis and its complications. 437,759,760 The testing of autopsy specimens can be included in this strategy should a death resulting from healthcare-associated pneumonia occur. Identification of one case of definite or two cases of possible healthcare-associated Legionnaires disease should prompt an epidemiologic investigation for a hospital source of Legionella spp., which may involve culturing the facility's water for Legionella. Routine maintenance of cooling towers, and use of sterile water for the filling and terminal rinsing of nebulization devices and ventilation equipment can help to minimize potential sources of contamination. Circulating potable water temperatures should match those outlined in the subsection titled Water Temperature and Pressure, as permitted by state code.

# c. Secondary Prevention of Legionnaires Disease (With Identified Cases)
The indications for a full-scale environmental investigation to search for and subsequently decontaminate identified sources of Legionella spp. in health-care facilities without transplant units have not been clarified; these indications would likely differ depending on the facility. Case categories for health-care associated Legionnaires disease in facilities without transplant units include definite cases (i.e., laboratory-confirmed cases of legionellosis that occur in patients who have been hospitalized continuously for 10 days before the onset of illness) and possible cases (i.e., laboratory-confirmed infections that occur 2-9 days after hospital admission). 3 In settings in which as few as one to three health-care associated cases are recognized over several months, intensified surveillance for Legionnaires disease has frequently identified numerous additional cases. 405,408,432,453,739,759,760 This finding suggests the need for a low threshold for initiating an investigation after laboratory confirmation of cases of healthcare associated legionellosis. When developing a strategy for responding to such a finding, however, infection-control personnel should consider the level of risk for health-care-associated acquisition of, and mortality from, Legionella spp. infection at their particular facility.
An epidemiologic investigation conducted to determine the source of Legionella spp. involves several important steps (Box 11). Laboratory assessment is crucial in supporting epidemiologic evidence of a link between human illness and a specific environmental source. 761 Strain determination from subtype analysis is most frequently used in these investigations. 410, Once the environmental source is established and confirmed with laboratory support, supplemental water treatment strategies can be initiated as appropriate.

# Box 11. Steps in an epidemiologic investigation for legionellosis
- Review medical and microbiologic records.

# d. Preventing Legionnaires Disease in Protective Environments
This subsection outlines infection-control measures applicable to those health-care facilities providing care to severely immunocompromised patients. Indigenous microorganisms in the tap water of these facilities may pose problems for such patients. These measures are designed to prevent the generation of potentially infectious aerosols from water and the subsequent exposure of PE patients or other immunocompromised patients (e.g., transplant patients) (Table 17). Infection-control measures that address the use of water with medical equipment (e.g., ventilators, nebulizers, and equipment humidifiers) are described in other guidelines and publications. 3,455 If one case of laboratory-confirmed, health-care associated Legionnaires disease is identified in a patient in a solid-organ transplant program or in PE (i.e., an inpatient in PE for all or part of the 2-10 days prior to onset of illness) or if two or more laboratory-confirmed cases occur among patients who had visited an outpatient PE setting, the hospital should report the cases to the local and state health departments. The hospital should then initiate a thorough epidemiologic and environmental investigation to determine the likely environmental sources of Legionella spp. 9 The source of Legionella should be decontaminated or removed. Isolated cases may be difficult to investigate. Because transplant recipients are at substantially higher risk for disease and death from legionellosis compared with other hospitalized patients, periodic culturing for Legionella spp. in water samples from the potable water in the solid-organ transplant and/or PE unit can be performed as part of an overall strategy to prevent Legionnaires disease in PE units. 9,431,710,769 The optimal methodology (i.e., frequency and number of sites) for environmental surveillance cultures in PE units has not been determined, and the cost-effectiveness of this strategy has not been evaluated. Because transplant recipients are at high risk for Legionnaires disease and because no data are available to determine a safe concentration of legionellae organisms in potable water, the goal of environmental surveillance for Legionella spp. should be to maintain water systems with no detectable organisms. 9,431 Culturing for legionellae may be used to assess the effectiveness of water treatment or decontamination methods, a practice that provides benefits to both patients and health-care workers. 767,770 Format Change : The format of this section was changed to improve readability and accessibility. The content is unchanged. - Use water that is not contaminated with Legionella spp. for patients' sponge baths. 9 - Provide sterile water for drinking, tooth brushing, or for flushing nasogastric tubes. 9,412 - Perform supplemental treatment of the water for the unit. 732 - Consider periodic monitoring (i.e., culturing) of the unit water supply for Legionella spp. Protecting patient-care devices and instruments from inadvertent tap water contamination during room cleaning procedures is also important in any immunocompromised patient-care area. In a recent outbreak of gram-negative bacteremias among open-heart-surgery patients, pressure-monitoring equipment that was assembled and left uncovered overnight prior to the next day's surgeries was inadvertently contaminated with mists and splashing water from a hose-disinfectant system used for cleaning. 771

# Cooling Towers and Evaporative Condensers
Modern health-care facilities maintain indoor climate control during warm weather by use of cooling towers (large facilities) or evaporative condensers (smaller buildings). A cooling tower is a wet-type, evaporative heat transfer device used to discharge to the atmosphere waste heat from a building's air conditioning condensers (Figure 5). 772,773 Warm water from air-conditioning condensers is piped to the cooling tower where it is sprayed downward into a counter-or cross-current air flow. To accelerate heat transfer to the air, the water passes over the fill, which either breaks water into droplets or causes it to spread into a thin film. 772,773 Most systems use fans to move air through the tower, although some large industrial cooling towers rely on natural draft circulation of air. The cooled water from the tower is piped back to the condenser, where it again picks up heat generated during the process of chilling the system's refrigerant. The water is cycled back to the cooling tower to be cooled. Closed-circuit cooling towers and evaporative condensers are also evaporative heat-transfer devices. In these systems, the process fluid (e.g., water, ethylene glycol/water mixture, oil, or a condensing refrigerant) does not directly contact the cooling air, but is contained inside a coil assembly. 661 Water temperatures are approximate and may differ substantially according to system use and design. Warm water from the condenser (or chiller) is sprayed downward into a counter-or cross-current air flow. Water passes over the fill (a component of the system designed to increase the surface area of the water exposed to air), and heat from the water is transferred to the air. Some of the water becomes aerosolized during this process, although the volume of aerosol discharged to the air can be reduced by the placement of a drift eliminator. Water cooled in the tower returns to the heat source to cool refrigerant from the air conditioning unit.
Cooling towers and evaporative condensers incorporate inertial stripping devices called drift eliminators to remove water droplets generated within the unit. Although the effectiveness of these eliminators varies substantially depending on design and condition, some water droplets in the size range of <5 m will likely leave the unit, and some larger droplets leaving the unit may be reduced to 5 m by evaporation. Thus, even with proper operation, a cooling tower or evaporative condenser can generate and expel respirable water aerosols. If either the water in the unit's basin or the make-up water (added to replace water lost to evaporation) contains Legionella spp. or other waterborne microorganisms, these organisms can be aerosolized and dispersed from the unit. 774 Clusters of both Legionnaires disease and Pontiac fever have been traced to exposure to infectious water aerosols originating from cooling towers and evaporative condensers contaminated with Legionella spp. Although most of these outbreaks have been community-acquired episodes of pneumonia,  health-care associated Legionnaires disease has been linked to cooling tower aerosol exposure. 404,405 Contaminated aerosols from cooling towers on hospital premises gained entry to the buildings either through open windows or via air handling system intakes located near the tower equipment.
Cooling towers and evaporative condensers provide ideal ecological niches for Legionella spp. The typical temperature of the water in cooling towers ranges from 85F-95F (29C-35C), although temperatures can be above 120F (49C) and below 70F (21C) depending on system heat load, ambient temperature, and operating strategy. 661 An Australian study of cooling towers found that legionellae colonized or multiplied in towers with basin temperatures above 60.8F (16C), and multiplication became explosive at temperatures above 73.4F (23C). 783 Water temperature in closed-circuit cooling towers and evaporative condensers is similar to that in cooling towers. Considerable variation in the piping arrangement occurs. In addition, stagnant areas or dead legs may be difficult to clean or penetrate with biocides.
Several documents address the routine maintenance of cooling towers, evaporative condensers, and whirlpool spas. 661, 784-787 They suggest following manufacturer's recommendations for cleaning and biocide treatment of these devices; all health-care facilities should ensure proper maintenance for their cooling towers and evaporative condensers, even in the absence of Legionella spp (Appendix C). Because cooling towers and evaporative condensers can be shut down during periods when air conditioning is not needed, this maintenance cleaning and treatment should be performed before starting up the system for the first time in the warm season. 782 Emergency decontamination protocols describing cleaning procedures and hyperchlorination for cooling towers have been developed for towers implicated in the transmission of legionellosis. 786, 787

# Dialysis Water Quality and Dialysate

# a. Rationale for Water Treatment in Hemodialysis
Hemodialysis, hemofiltration, and hemodiafiltration require special water-treatment processes to prevent adverse patient outcomes of dialysis therapy resulting from improper formulation of dialysate with water containing high levels of certain chemical or biological contaminants. The Association for the Advancement of Medical Instrumentation (AAMI) has established chemical and microbiologic standards for the water used to prepare dialysate, substitution fluid, or to reprocess hemodialyzers for renal replacement therapy.  The AAMI standards address: a. equipment and processes used to purify water for the preparation of concentrates and dialysate and the reprocessing of dialyzers for multiple use and b. the devices used to store and distribute this water. Future revisions to these standards may include hemofiltration and hemodiafiltration.
Water treatment systems used in hemodialysis employ several physical and/or chemical processes either singly or in combination (Figure 6). These systems may be portable units or large systems that feed several rooms. In the United States, >97% of maintenance hemodialysis facilities use RO alone or in combination with deionization. 793 Many acute-care facilities use portable hemodialysis machines with attached portable water treatment systems that use either deionization or RO. These machines were exempted from earlier versions of AAMI recommendations, but given current knowledge about toxic exposures to and inflammatory processes in patients new to dialysis, these machines should now come into compliance with current AAMI recommendations for hemodialysis water and dialysate quality. 788,789 Previous recommendations were based on the assumption that acute-care patients did not experience the same degree of adverse effects from short-term, cumulative exposures to either chemicals or microbiologic agents present in hemodialysis fluids compared with the effects encountered by patients during chronic, maintenance dialysis. 788,789 Additionally, JCAHO is reviewing inpatient practices and record-keeping for dialysis (acute and maintenance) for adherence to AAMI standards and recommended practices. Neither the water used to prepare dialysate nor the dialysate itself needs to be sterile, but tap water can not be used without additional treatment. Infections caused by rapid-growing NTM (e.g., Mycobacterium chelonae and M. abscessus) present a potential risk to hemodialysis patients (especially those in hemodialyzer reuse programs) if disinfection procedures to inactivate mycobacteria in the water (lowlevel disinfection) and the hemodialyzers (high-level disinfection) are inadequate. 31,32,633 Other factors associated with microbial contamination in dialysis systems could involve the water treatment system, the water and dialysate distribution systems, and the type of hemodialyzer. 666,667, Understanding the various factors and their influence on contamination levels is the key to preventing high levels of microbial contamination in dialysis therapy.
In several studies, pyrogenic reactions were demonstrated to have been caused by lipopolysaccharide or endotoxin associated with gram-negative bacteria. 794, Early studies demonstrated that parenteral exposure to endotoxin at a concentration of 1 ng/kg body weight/hour was the threshold dose for producing pyrogenic reactions in humans, and that the relative potencies of endotoxin differ by bacterial species. 804,805 Gram-negative water bacteria (e.g., Pseudomonas spp.) have been shown to multiply rapidly in a variety of hospital-associated fluids that can be used as supply water for hemodialysis (e.g., distilled water, deionized water, RO water, and softened water) and in dialysate (a balanced salt solution made with this water). 806 Several studies have demonstrated that the attack rates of pyrogenic reactions are directly associated with the number of bacteria in dialysate. 666,667,807 These studies provided the rationale for setting the heterotrophic bacteria standards in the first AAMI hemodialysis guideline at 2,000 CFU/mL in dialysate and one log lower (200 CFU/mL) for the water used to prepare dialysate. 668,788 If the level of bacterial contamination exceeded 200 CFU/mL in water, this level could be amplified in the system and effectively constitute a high inoculum for dialysate at the start of a dialysis treatment. 807,808 Pyrogenic reactions did not appear to occur when the level of contamination was below 2,000 CFU/mL in dialysate unless the source of the endotoxin was exogenous to the dialysis system (i.e., present in the community water supply). Endotoxins in a community water supply have been linked to the development of pyrogenic reactions among dialysis patients. 794 Whether endotoxin actually crosses the dialyzer membrane is controversial. Several investigators have shown that bacteria growing in dialysate-generated products that could cross the dialyzer membrane. 809,810 Gram-negative bacteria growing in dialysate have produced endotoxins that in turn stimulated the production of anti-endotoxin antibodies in hemodialysis patients; 801,811 these data suggest that bacterial endotoxins, although large molecules, cross dialyzer membranes either intact or as fragments. The use of the very permeable membranes known as high-flux membranes (which allow large molecules  to traverse the membrane) increases the potential for passage of endotoxins into the blood path. Several studies support this contention. In one such study, an increase in plasma endotoxin concentrations during dialysis was observed when patients were dialyzed against dialysate containing 10 3 -10 4 CFU/mL Pseudomonas spp. 812 In vitro studies using both radiolabeled lipopolysaccharide and biologic assays have demonstrated that biologically active substances derived from bacteria found in dialysate can cross a variety of dialyzer membranes. 802, Patients treated with high-flux membranes have had higher levels of anti-endotoxin antibodies than subjects or patients treated with conventional membranes. 817 Finally, since 1989, 19%-22% of dialysis centers have reported pyrogenic reactions in the absence of septicemia. 818,819 Investigations of adverse outcomes among patients using reprocessed dialyzers have demonstrated a greater risk for developing pyrogenic reactions when the water used to reprocess these devices contained >6 ng/mL endotoxin and >10 4 CFU/mL bacteria. 820 In addition to the variability in endotoxin assays, host factors also are involved in determining whether a patient will mount a response to endotoxin. 803 Outbreak investigations of pyrogenic reactions and bacteremias associated with hemodialyzer reuse have demonstrated that pyrogenic reactions are prevented once the endotoxin level in the water used to reprocess the dialyzers is returned to below the AAMI standard level. 821 Reuse of dialyzers and use of bicarbonate dialysate, high-flux dialyzer membranes, or high-flux dialysis may increase the potential for pyrogenic reactions if the water in the dialysis setting does not meet standards.  Although investigators have been unable to demonstrate endotoxin transfer across dialyzer membranes, 803,822,823 the preponderance of reports now supports the ability of endotoxin to transfer across at least some high-flux membranes under some operating conditions. In addition to the acute risk of pyrogenic reactions, indirect evidence in increasingly demonstrating that chronic exposure to low amounts of endotoxin may play a role in some of the long-term complications of hemodialysis therapy. Patients treated with ultrafiltered dialysate for 5-6 months have demonstrated a decrease in serum 2 microglobulin concentrations and a decrease in markers of an inflammatory response.  In studies of longer duration, use of microbiologically ultrapure dialysate has been associated with a decreased incidence of 2 microglobulin-associated amyloidosis. 827,828 Although patient benefit likely is associated with the use of ultrapure dialysate, no consensus has been reached regarding the potential adoption of this as standard in the United States. Debate continues regarding the bacterial and endotoxin limits for dialysate. As advances in water treatment and hemodialysis processes occur, efforts are underway to move improved technology from the manufacturer out into the user community. Cost-benefit studies, however, have not been done, and substantially increased costs to implement newer water treatment modalities are anticipated.
To reconcile AAMI documents with current International Organization for Standardization (ISO) format, AAMI has determined that its hemodialysis standards will be discussed in the following four installments: RD 5 for hemodialysis equipment, RD 62 for product water quality, RD 47 for dialyzer reprocessing, and RD 52 for dialysate quality. The Renal Diseases and Dialysis Committee of AAMI is expected to finalize and promulgated the dialysate standard pertinent to the user community (RD 52), adopting by reference the bacterial and endotoxin limits in product water as currently outlined in the AAMI standard that applies to systems manufacturers (RD 62). At present, the user community should continue to observe water quality and dialysate standards as outlined in AAMI RD 5 (Hemodialysis Systems, 1992) and AAMI RD 47 (Reuse of Hemodialyzers, 1993) until the new RD 52 standard becomes available (Table 18). 789, 791   RD 47-1993).
The current AAMI standard directed at systems manufacturers (RD 62 ) now specifies that all product water used to prepare dialysate or to reprocess dialyzers for multiple use should contain <2 endotoxin units per milliliter (EU/mL). 792 A level of 2 EU/mL was chosen as the upper limit for endotoxin because this level is easily achieved with contemporary water treatment systems using RO and/or ultrafiltration. CDC has advocated monthly endotoxin testing along with microbiologic assays of water, because endotoxin activity may not correspond to the total heterotrophic plate counts. 829 Additionally, the current AAMI standard RD 62 for manufacturers includes action levels for product water. Because 48 hours can elapse between the time of sampling water for microbial contamination and the time when results are received, and because bacterial proliferation can be rapid, action levels for microbial counts and endotoxin concentrations are reported as 50 CFU/mL and 1 EU/mL, respectively, in this revision of the standard. 792 These recommendations will allow users to initiate corrective action before levels exceed the maximum levels established by the standard.
In hemodialysis, the net movement of water is from the blood to the dialysate, although within the dialyzer, local movement of water from the dialysate to the blood through the phenomenon of backfiltration may occur, particularly in dialyzers with highly permeable membranes. 830 In contrast, hemofiltration and hemodiaflltration feature infusion of large volumes of electrolyte solution (20-70 L) into the blood. Increasingly, this electrolyte solution is being prepared on-line from water and concentrate. Because of the large volumes of fluid infused, AAMI considered the necessity of setting more stringent requirements for water to be used in this application, but this organization has not yet established these because of lack of expert consensus and insufficient experience with on-line therapies in the United States. On-line hemofiltration and hemodiafiltration systems use sequential ultrafiltration as the final step in the preparation of infusion fluid. Several experts from AAMI concur that these point-ofuse ultrafiltration systems should be capable of further reducing the bacteria and endotoxin burden of solutions prepared from water meeting the requirements of the AAMI standard to a safe level for infusion.

# b. Microbial Control Strategies
The strategy for controlling massive accumulations of gram-negative water bacteria and NTM in dialysis systems primarily involves preventing their growth through proper disinfection of water-treatment systems and hemodialysis machines. Gram-negative water bacteria, their associated lipopolysaccharides (bacterial endotoxins), and NTM ultimately come from the community water supply, and levels of these bacteria can be amplified depending on the water treatment system, dialysate distribution system, type of dialysis machine, and method of disinfection (Table 19). 634,794,831 Control strategies are designed to reduce levels of microbial contamination in water and dialysis fluid to relatively low levels but not to completely eradicate it.

# Format Change :
The format of this section was changed to improve readability and accessibility. The content is unchanged. - Size Oversized diameter and length decrease fluid flow and increase bacterial reservoir for both treated water and centrally-prepared dialysate.

# Construction
Rough joints, dead ends, unused branches, and polyvinyl chloride (PVC) piping can act as bacterial reservoirs.

# Elevation
Outlet taps should be located at the highest elevation to prevent loss of disinfectant; keep a recirculation loop in the system; flush unused ports routinely.

# Storage tanks
Tanks are undesirable because they act as a reservoir for water bacteria; if tanks are present, they must be routinely scrubbed and disinfected.

# Dialysis machines
- Single-pass Disinfectant should have contact with all parts of the machine that are exposed to water or dialysis fluid.

# Recirculating single-pass or recirculating (batch)
Recirculating pumps and machine design allow for massive contamination levels if not properly disinfected; overnight chemical germicide treatment is recommended.
Two components of hemodialysis water distribution systems -pipes (particularly those made of polyvinyl chloride ) and storage tanks -can serve as reservoirs of microbial contamination. Hemodialysis systems frequently use pipes that are wider and longer than are needed to handle the required flow, which slows the fluid velocity and increases both the total fluid volume and the wetted surface area of the system. Gram-negative bacteria in fluids remaining in pipes overnight multiply rapidly and colonize the wet surfaces, producing bacterial populations and endotoxin quantities in proportion to the volume and surface area. Such colonization results in formation of protective biofilm that is difficult to remove and protects the bacteria from disinfection. 832 Routine (i.e., monthly), low-level disinfection of the pipes can help to control bacterial contamination of the distribution system. Additional measures to protect pipes from contaminations include a. situating all outlet taps at equal elevation and at the highest point of the system so that the disinfectant cannot drain from pipes by gravity before adequate contact time has elapsed and b. eliminating rough joints, dead-end pipes, and unused branches and taps that can trap fluid and serve as reservoirs of bacteria capable of continuously inoculating the entire volume of the system. 800
Maintain a flow velocity of 3-5 ft/sec.
A storage tank in the distribution system greatly increases the volume of fluid and surface area available and can serve as a niche for water bacteria. Storage tanks are therefore not recommended for use in dialysis systems unless they are frequently drained and adequately disinfected, including scrubbing the sides of the tank to remove bacterial biofilm. An ultrafilter should be used distal to the storage tank. 808,833 Microbiologic sampling of dialysis fluids is recommended because gram-negative bacteria can proliferate rapidly in water and dialysate in hemodialysis systems; high levels of these organisms place patients at risk for pyrogenic reactions or health-care associated infection. 667,668,808 Health-care facilities are advised to sample dialysis fluids at least monthly using standard microbiologic assay methods for waterborne microorganisms. 788,793,799, Product water used to prepare dialysate and to reprocess hemodialyzers for reuse on the same patient should also be tested for bacterial endotoxin on a monthly basis. 792,829,837 (See Appendix C for information about water sampling methods for dialysis.)
Cross-contamination of dialysis machines and inadequate disinfection measures can facilitate the spread of waterborne organisms to patients. Steps should be taken to ensure that dialysis equipment is performing correctly and that all connectors, lines, and other components are specific for the equipment, in good repair, and properly in place. A recent outbreak of gram-negative bacteremias among dialysis patients was attributed to faulty valves in a drain port of the machine that allowed backflow of saline used to flush the dialyzer before patient use. 838,839 This backflow contaminated the drain priming connectors, which contaminated the blood lines and exposed the patients to high concentrations of gram-negative bacteria. Environmental infection control in dialysis settings also includes low-level disinfection of housekeeping surfaces and spot decontamination of spills of blood (see Environmental Services in Part I of this guideline for further information).

# c. Infection-Control Issues in Peritoneal Dialysis
Peritoneal dialysis (PD), most commonly administered as continuous ambulatory peritoneal dialysis (CAPD) and continual cycling peritoneal dialysis (CCPD), is the third most common treatment for end-stage renal disease (ESRD) in the United States, accounting for 12% of all dialysis patients. 840 Peritonitis is the primary complication of CAPD, with coagulase-negative staphylococci the most clinically significant causative organisms. 841 Other organisms that have been found to produce peritonitis include Staphylococcus aureus, Mycobacterium fortuitum, M. mucogenicum, Stenotrophomonas maltophilia, Burkholderia cepacia, Corynebacterium jeikeium, Candida spp., and other fungi.  Substantial morbidity is associated with peritoneal dialysis infections. Removal of peritoneal dialysis catheters usually is required for treatment of peritonitis caused by fungi, NTM, or other bacteria that are not cleared within the first several days of effective antimicrobial treatment. Furthermore, recurrent episodes of peritonitis may lead to fibrosis and loss of the dialysis membrane.
Many reported episodes of peritonitis are associated with exit-site or tunneled catheter infections. Risk factors for the development of peritonitis in PD patients include 1. under dialysis, 2. immune suppression, 3. prolonged antimicrobial treatment, 4. patient age , 5. length of hospital stay, and 6. hypoalbuminemia. 844,851,852 Concern has been raised about infection risk associated with the use of automated cyclers in both inpatient and outpatient settings; however, studies suggest that PD patients who use automated cyclers have much lower infection rates. 853 One study noted that a closed-drainage system reduced the incidence of systemrelated peritonitis among intermittent peritoneal dialysis (IPD) patients from 3.6 to 1.5 cases/100 patient days. 854 The association of peritonitis with management of spent dialysate fluids requires additional study. Therefore, ensuring that the tip of the waste line is not submerged beneath the water level in a toilet or in a drain is prudent.

# Ice Machines and Ice
Microorganisms may be present in ice, ice-storage chests, and ice-making machines. The two main sources of microorganisms in ice are the potable water from which it is made and a transferral of organisms from hands (Table 20). Ice from contaminated ice machines has been associated with patient colonization, blood stream infections, pulmonary and gastrointestinal illnesses, and pseudoinfections. 602,603,683,684,854,855 Microorganisms in ice can secondarily contaminate clinical specimens and medical solutions that require cold temperatures for either transport or holding. 601,620 An outbreak of surgical-site infections was interrupted when sterile ice was used in place of tap water ice to cool cardioplegia solutions. 601 Format Change : The format of this section was changed to improve readability and accessibility. The content is unchanged.

# Table 20. Microorganisms and their sources in ice and ice machines
From potable water - Legionella spp. 684,685,857,858 - Nontuberculous mycobacteria (NTM) 602,603,859 - Pseudomonas aeruginosa 859 - Burkholderia cepacia 859,860 - Stenotrophomonas maltophilia 860 - Flavobacterium spp. 860 From fecally-contaminated water - Norwalk virus  - Giardia lamblia 864 - Cryptosporidium parvum 685 From hand-transfer of organisms - Acinetobacter spp. 859 - Coagulase-negative staphylococci 859 - Salmonella enteriditis 865 - Cryptosporidium parvum 685 In a study comparing the microbial populations of hospital ice machines with organisms recovered from ice samples gathered from the community, samples from 27 hospital ice machines yielded low numbers (<10 CFU/mL) of several potentially opportunistic microorganisms, mainly gram-negative bacilli. 859 During the survey period, no health-care associated infections were attributed to the use of ice. Ice from community sources had higher levels of microbial contamination (75%-95% of 194 samples had total heterotrophic plate counts <500 CFU/mL, with the proportion of positive cultures dependent on the incubation temperature) and showed evidence of fecal contamination from the source water. 859 Thus, ice machines in health-care settings are no more heavily contaminated compared with ice machines in the community. If the source water for ice in a health-care facility is not fecally contaminated, then ice from clean ice machines and chests should pose no increased hazard for immunocompetent patients. Some waterborne bacteria found in ice could potentially be a risk to immunocompromised patients if they consume ice or drink beverages with ice. For example, Burkholderia cepacia in ice could present an infection risk for cystic fibrosis patients. 859,860 Therefore, protecting immunosuppressed and otherwise medically at-risk patients from exposure to tap water and ice potentially contaminated with opportunistic pathogens is prudent. 9 No microbiologic standards for ice, ice-making machines, or ice storage equipment have been established, although several investigators have suggested the need for such standards. 859,866 Culturing of ice machines is not routinely recommended, but it may be useful as part of an epidemiologic investigation.  Sampling might also help determine the best schedule for cleaning open ice-storage chests. Recommendations for a regular program of maintenance and disinfection have been published.  Health-care facilities are advised to clean ice-storage chests on a regular basis. Open ice chests may require a more frequent cleaning schedule compared with chests that have covers. Portable ice chests and containers require cleaning and low-level disinfection before the addition of ice intended for consumption. Ice-making machines may require less frequent cleaning, but their maintenance is important to proper performance. The manufacturer's instructions for both the proper method of cleaning and/or maintenance should be followed. These instructions may also recommend an EPA-registered disinfectant to ensure chemical potency, materials compatibility, and safety. In the event that instructions and suitable EPA-registered disinfectants are not available for this process, then a generic approach to cleaning, disinfecting, and maintaining ice machines and dispensers can be used (Box 12).
Ice and ice-making machines also may be contaminated via improper storage or handling of ice by patients and/or staff. 684-686, 855-858, 870 Suggested steps to avoid this means of contamination include a. minimizing or avoiding direct hand contact with ice intended for consumption, b. using a hard-surface scoop to dispense ice, and c. installing machines that dispense ice directly into portable containers at the touch of a control. 687,869 Box 12. General steps for cleaning and maintaining ice machines, dispensers, and storage chests*+ 1. Disconnect unit from power supply. 2. Remove and discard ice from bin or storage chest. 3. Allow unit to warm to room temperature. 4. Disassemble removable parts of machine that make contact with water to make ice. 5. Thoroughly clean machine and parts with water and detergent. 6. Dry external surfaces of removable parts before reassembling. 7. Check for any needed repair. 8. Replace feeder lines, as appropriate (e.g., when damaged, old, or difficult to clean). 9. Ensure presence of an air space in tubing leading from water inlet into water distribution system of machine. 10. Inspect for rodent or insect infestations under the unit and treat, as needed. 11. Check door gaskets (open compartment models) for evidence of leakage or dripping into the storage chest. 12. Clean the ice-storage chest or bin with fresh water and detergent; rinse with fresh tap water. 13. Sanitize machine by circulating a 50-100 parts per million (ppm) solution of sodium hypochlorite (i.e., 4-8 mL sodium hypochlorite/gallon of water) through the ice-making and storage systems for 2 hours (100 ppm solution), or 4 hours (50 ppm solution). 14. Drain sodium hypochlorite solutions and flush with fresh tap water. 15. Allow all surfaces of equipment to dry before returning to service. - Material in this box is adapted from reference 869. + These general guidelines should be used only where manufacturer-recommended methods and EPA-registered disinfectants are not available.

# Hydrotherapy Tanks and Pools

# a. General Information
Hydrotherapy equipment (e.g., pools, whirlpools, whirlpool spas, hot tubs, and physiotherapy tanks) traditionally has been used to treat patients with certain medical conditions (e.g., burns, 871,872 septic ulcers, lesions, amputations, 873 orthopedic impairments and injuries, arthritis, 874 and kidney lithotripsy). 654 Wound-care medicine is increasingly moving away from hydrotherapy, however, in favor of bedside pulsed-lavage therapy using sterile solutions for cleaning and irrigation. 492, Several episodes of health-care associated infections have been linked to use of hydrotherapy equipment ( Infection control for hydrotherapy tanks, pools, or birthing tanks presents unique challenges because indigenous microorganisms are always present in the water during treatments. In addition, some studies have found free living amoebae (i.e., Naegleria lovaniensis), which are commonly found in association with Naegleria fowleri, in hospital hydrotherapy pools. 890 Although hydrotherapy is at times appropriate for patients with wounds, burns, or other types of non-intact skin conditions (determined on a case-bycase basis), this equipment should not be considered "semi-critical" in accordance with the Spaulding classification. 891 Microbial data to evaluate the risk of infection to patients using hydrotherapy pools and birthing tanks are insufficient. Nevertheless, health-care facilities should maintain stringent cleaning and disinfection practices in accordance with the manufacturer's instructions and with relevant scientific literature until data supporting more rigorous infection-control measures become available. Factors that should be considered in therapy decisions in this situation would include a. availability of alternative aseptic techniques for wound management and b. a risk-benefit analysis of using traditional hydrotherapy.

# b. Hydrotherapy Tanks
Hydrotherapy tanks (e.g., whirlpools, Hubbard tanks and whirlpool bath tubs) are shallow tanks constructed of stainless steel, plexiglass, or tile. They are closed-cycle water systems with hydrojets to circulate, aerate, and agitate the water. The maximum water temperature range is 50F-104F (10C-40C). The warm water temperature, constant agitation and aeration, and design of the hydrotherapy tanks provide ideal conditions for bacterial proliferation if the equipment is not properly maintained, cleaned, and disinfected. The design of the hydrotherapy equipment should be evaluated for potential infection-control problems that can be associated with inaccessible surfaces that can be difficult to clean and/or remain wet in between uses (i.e., recessed drain plates with fixed grill plates). 887 Associated equipment (e.g., parallel bars, plinths, Hoyer lifts, and wheelchairs) can also be potential reservoirs of microorganisms, depending on the materials used in these items (i.e., porous vs. non-porous materials) and the surfaces that may become wet during use. Patients with active skin colonizations and wound infections can serve as sources of contamination for the equipment and the water. Contamination from spilled tub water can extend to drains, floors, and walls.  Health-care associated colonization or infection can result from exposure to endogenous sources of microorganisms (autoinoculation) or exogenous sources (via cross-contamination from other patients previously receiving treatment in the unit).
Although some facilities have used tub liners to minimize environmental contamination of the tanks, the use of a tub liner does not eliminate the need for cleaning and disinfection. Draining these small pools and tanks after each patient use, thoroughly cleaning with a detergent, and disinfecting according to manufacturers' instructions have reduced bacterial contamination levels in the water from 10 4 CFU/mL to <10 CFU/mL. 892 A chlorine residual of 15 ppm in the water should be obtained prior to the patient's therapy session (e.g., by adding 15 grams of calcium hypochlorite 70%  per 100 gallons of water). 892 A study of commercial and residential whirlpools found that superchlorination or draining, cleaning, disinfection, and refilling of whirlpools markedly reduced densities of Pseudomonas aeruginosa in whirlpool water. 893 The bacterial populations were rapidly replenished, however, when disinfectant concentrations dropped below recommended levels for recreational use (i.e., chlorine at 3.0 ppm or bromine at 6.0 ppm). When using chlorine, however, knowing whether the community drinking-water system is disinfected with chloramine is important, because municipal utilities adjust the pH of the water to the basic side to enhance chloramine formation. Because chlorine is not very effective at pH levels above 8, it may be necessary to re-adjust the pH of the water to a more acidic level. 894 A few reports describe the addition of antiseptic chemicals to hydrotherapy tank water, especially for burn patient therapy.  One study involving a minimal number of participants demonstrated a reduction in the number of Pseudomonas spp. and other gram-negative bacteria from both patients and equipment surfaces when chloramine-T ("chlorazene") was added to the water. 898 Chloramine-T has not, however, been approved for water treatment in the United States.

# c. Hydrotherapy Pools
Hydrotherapy pools typically serve large numbers of patients and are usually heated to 91.4F-98.6F (31C-37C). The temperature range is more narrow (94F-96.8F ) for pediatric and geriatric patient use. 899 Because the size of hydrotherapy pools precludes draining after patient use, proper management is required to maintain the proper balance of water conditioning (i.e., alkalinity, hardness, and temperature) and disinfection. The most widely used chemicals for disinfection of pools are chlorine and chlorine compounds -calcium hypochlorite, sodium hypochlorite, lithium hypochlorite, chloroisocyanurates, and chlorine gas. Solid and liquid formulations of chlorine chemicals are the easiest and safest to use. 900 Other halogenated compounds have also been used for pool-water disinfection, albeit on a limited scale. Bromine, which forms bactericidal bromamines in the presence of ammonia, has limited use because of its association with contact dermatitis. 901 Iodine does not bleach hair, swim suits, or cause eye irritation, but when introduced at proper concentrations, it gives water a greenish-yellowish cast. 892 In practical terms, maintenance of large hydrotherapy pools (e.g., those used for exercise) is similar to that for indoor public pools (i.e., continuous filtration, chlorine residuals no less than 0.4 ppm, and pH of 7.2-7.6). 902,903 Supply pipes and pumps also need to be maintained to eliminate the possibility of this equipment serving as a reservoir for waterborne organisms. 904 Specific standards for chlorine residual and pH of the water are addressed in local and state regulations. Patients who are fecally incontinent or who have draining wounds should refrain from using these pools until their condition improves.

# d. Birthing Tanks and Other Equipment
The use of birthing tanks, whirlpool spas, and whirlpools is a recent addition to obstetrical practice. 905 Few studies on the potential risks associated with these pieces of equipment have been conducted. In one study of 32 women, a newborn contracted a Pseudomonas infection after being birthed in such a tank, the strain of which was identical to the organism isolated from the tank water. 906 Another report documented identical strains of P. aeruginosa isolates from a newborn with sepsis and on the environmental surfaces of a tub that the mother used for relaxation while in labor. 907 Other studies have shown no significant increases in the rates of post-immersion infections among mothers and infants. 908,909 Because the water and the tub surfaces routinely become contaminated with the mother's skin flora and blood during labor and delivery, birthing tanks and other tub equipment must be drained after each patient use and the surfaces thoroughly cleaned and disinfected. Health-care facilities are advised to follow the manufacturer's instructions for selection of disinfection method and chemical germicide. The range of chlorine residuals for public whirlpools and whirlpool spas is 2-5 ppm. 910 Use of an inflatable tub is an alternative solution, but this item must be cleaned and disinfected between patients if it is not considered a single-use unit.
Recreational tanks and whirlpool spas are increasingly being used as hydrotherapy equipment. Although such home equipment appears to be suitable for hydrotherapy, they are neither designed nor constructed to function in this capacity. Additionally, manufacturers generally are not obligated to provide the healthcare facility with cleaning and disinfecting instructions appropriate for medical equipment use, and the U.S. Food and Drug Administration (FDA) does not evaluate recreational equipment. Health-care facilities should therefore carefully evaluate this "off-label" use of home equipment before proceeding with a purchase.

# Miscellaneous Medical/Dental Equipment Connected to Main Water Systems a. Automated Endoscope Reprocessors
The automated endoscopic reprocessor (AER) is classified by the FDA as an accessory for the flexible endoscope. 654 A properly operating AER can provide a more consistent, reliable method of decontaminating and terminal reprocessing for endoscopes between patient procedures than manual reprocessing methods alone. 911 An endoscope is generally subjected to high-level disinfection using a liquid chemical sterilant or a high-level disinfectant. Because the instrument is a semi-critical device, the optimal rinse fluid for a disinfected endoscope would be sterile water. 3 Sterile water, however, is expensive and difficult to produce in sufficient quantities and with adequate quality assurance for instrument rinsing in an AER. 912,913 Therefore, one option to be used for AERs is rinse water that has been passed through filters with a pore size of 0.1-0.2 m to render the water "bacteria-free." These filters usually are located in the water line at or near the port where the mains water enters the equipment. The product water (i.e., tap water passing through these filters) in these applications is not considered equivalent in microbial quality to that for membrane-filtered water as produced by pharmaceutical firms. Membrane filtration in pharmaceutical applications is intended to ensure the microbial quality of polished product water.
Water has been linked to the contamination of flexible fiberoptic endoscopes in the following two scenarios: a. rinsing a disinfected endoscope with unfiltered tap water, followed by storage of the instrument without drying out the internal channels and b. contamination of AERs from tap water inadvertently introduced into the equipment.
In the latter instance, the machine's water reservoirs and fluid circuitry become contaminated with waterborne, heterotrophic bacteria (e.g., Pseudomonas aeruginosa and NTM), which can survive and persist in biofilms attached to these components.  Colonization of the reservoirs and water lines of the AER becomes problematic if the required cleaning, disinfection, and maintenance are not performed on the equipment as recommended by the manufacturer. 669,916,917 Use of the 0.1-0.2-m filter in the water line helps to keep bacterial contamination to a minimum, 670,911,917 but filters may fail and allow bacteria to pass through to the equipment and then to the instrument undergoing reprocessing. 671-674, 913, 918 Filters also require maintenance for proper performance. 670,911,912,918,919 Heightened awareness of the proper disinfection of the connectors that hook the instrument to the AER may help to further reduce the potential for contaminating endoscopes during reprocessing. 920 An emerging issue in the field of endoscopy is that of the possible role of rinse water monitoring and its potential to help reduce endoscopy/bronchoscopyassociated infections. 918 Studies have linked deficiencies in endoscope cleaning and/or disinfecting processes to the incidence of post-endoscopic adverse outcomes.  Several clusters have been traced to AERs of older designs and these were associated with water quality. 675, Regardless of whether manual or automated terminal reprocessing is used for endoscopes, the internal channels of the instrument should be dried before storage. 925 The presence of residual moisture in the internal channels encourages the proliferation of waterborne microorganisms, some of which may be pathogenic. One of the most frequently used methods employs 70% isopropyl alcohol to flush the internal channels, followed by forced air drying of these channels and hanging the endoscope vertically in a protected cabinet; this method ensures internal drying of the endoscope, lessens the potential for proliferation of waterborne microorganisms, 669,913,917,922,926,927 and is consistent with professional organization guidance for endoscope reprocessing. 928 An additional problem with waterborne microbial contamination of AERs centers on increased microbial resistance to alkaline glutaraldehyde, a widely used liquid chemical sterilant/high-level disinfectant. 669,929 Opportunistic waterborne microorganisms (e.g., Mycobacterium chelonae, Methylobacterium spp.) have been associated with pseudo-outbreaks and colonization; infection caused by these organisms has been associated with procedures conducted in clinical settings (e.g., bronchoscopy). 669,913, Increasing microbial resistance to glutaraldehyde has been attributed to improper use of the disinfectant in the equipment, allowing the dilution of glutaraldehyde to fall below the manufacturer's recommended minimal use concentration. 929

# b. Dental Unit Water Lines
Dental unit water lines (DUWLs) consist of small-bore plastic tubing that delivers water used for general, non-surgical irrigation and as a coolant to dental handpieces, sonic and ultrasonic scalers, and air-water syringes; municipal tap water is the source water for these lines. The presence of biofilms of waterborne bacteria and fungi (e.g., Legionella spp., Pseudomonas aeruginosa, and NTM) in DUWLs has been established. 636,637,694,695, Biofilms continually release planktonic microorganisms into the water, the titers of which can exceed 1H10 6 CFU/mL. 694 However, scientific evidence indicates that immunocompetent persons are only at minimal risk for substantial adverse health effects after contact with water from a dental unit. Nonetheless, exposing patients or dental personnel to water of uncertain microbiological quality is not consistent with universally accepted infection-control principles. 935 In 1993, CDC issued guidelines relative to water quality in a dental setting. These guidelines recommend that all dental instruments that use water (including high-speed handpieces) should be run to discharge water for 20-30 seconds after each patient and for several minutes before the start of each clinic day. 936 This practice can help to flush out any patient materials that many have entered the turbine, air, or waterlines. 937,938 The 1993 guidance also indicated that waterlines be flushed at the beginning of the clinic day. Although these guidelines are designed to help reduce the number of microorganisms present in treatment water, they do not address the issue of reducing or preventing biofilm formation in the waterlines. Research published subsequent to the 1993 dental infection control guideline suggests that flushing the lines at the beginning of the day has only minimal effect on the status of the biofilm in the lines and does not reliably improve the quality of water during dental treatment.  Updated recommendations on infection-control practices for water line use in dentistry will be available in late 2003. 942 The numbers of microorganisms in water used as coolant or irrigant for non-surgical dental treatment should be as low as reasonably achievable and, at a minimum, should meet nationally recognized standards for safe drinking water. 935,943 Only minimal evidence suggests that water meeting drinking water standards poses a health hazard for immunocompetent persons. The EPA, the American Public Health Association (APHA), and the American Water Works Association (AWWA) have set a maximum limit of 500 CFU/mL for aerobic, heterotrophic, mesophilic bacteria in drinking water in municipal distribution systems. 944,945 This standard is achievable, given improvements in water-line technology. Dentists should consult with the manufacturer of their dental unit to determine the best equipment and method for maintaining and monitoring good water quality. 935,946

# E. Environmental Services 1. Principles of Cleaning and Disinfecting Environmental Surfaces
Although microbiologically contaminated surfaces can serve as reservoirs of potential pathogens, these surfaces generally are not directly associated with transmission of infections to either staff or patients. The transferral of microorganisms from environmental surfaces to patients is largely via hand contact with the surface. 947,948 Although hand hygiene is important to minimize the impact of this transfer, cleaning and disinfecting environmental surfaces as appropriate is fundamental in reducing their potential contribution to the incidence of healthcare-associated infections.
The principles of cleaning and disinfecting environmental surfaces take into account the intended use of the surface or item in patient care. CDC retains the Spaulding classification for medical and surgical instruments, which outlines three categories based on the potential for the instrument to transmit infection if the instrument is microbiologically contaminated before use. 949,950 These categories are "critical," "semicritical," and "noncritical." In 1991, CDC proposed an additional category designated "environmental surfaces" to Spaulding's original classification 951 to represent surfaces that generally do not come into direct contact with patients during care. Environmental surfaces carry the least risk of disease transmission and can be safely decontaminated using less rigorous methods than those used on medical instruments and devices. Environmental surfaces can be further divided into medical equipment surfaces (e.g., knobs or handles on hemodialysis machines, x-ray machines, instrument carts, and dental units) and housekeeping surfaces (e.g., floors, walls, and tabletops). 951 The following factors influence the choice of disinfection procedure for environmental surfaces: a. the nature of the item to be disinfected, b. the number of microorganisms present, c. the innate resistance of those microorganisms to the inactivating effects of the germicide, d. the amount of organic soil present, e. the type and concentration of germicide used, f. duration and temperature of germicide contact, and g. if using a proprietary product, other specific indications and directions for use. 952,953 Cleaning is the necessary first step of any sterilization or disinfection process. Cleaning is a form of decontamination that renders the environmental surface safe to handle or use by removing organic matter, salts, and visible soils, all of which interfere with microbial inactivation.  The physical action of scrubbing with detergents and surfactants and rinsing with water removes large numbers of microorganisms from surfaces. 957 If the surface is not cleaned before the terminal reprocessing procedures are started, the success of the sterilization or disinfection process is compromised.
Spaulding proposed three levels of disinfection for the treatment of devices and surfaces that do not require sterility for safe use. These disinfection levels are "high-level," "intermediate-level," and "low level." 949,950 The basis for these levels is that microorganisms can usually be grouped according to their innate resistance to a spectrum of physical or chemical germicidal agents (Table 22). This information, coupled with the instrument/surface classification, determines the appropriate level of terminal disinfection for an instrument or surface. The process of high-level disinfection, an appropriate standard of treatment for heat-sensitive, semicritical medical instruments (e.g., flexible, fiberoptic endoscopes), inactivates all vegetative bacteria, mycobacteria, viruses, fungi, and some bacterial spores. High-level disinfection is accomplished with powerful, sporicidal chemicals (e.g., glutaraldehyde, peracetic acid, and hydrogen peroxide) that are not appropriate for use on housekeeping surfaces. These liquid chemical sterilants/high-level disinfectants are highly toxic.  Use of these chemicals for applications other than those indicated in their label instructions (i.e., as immersion chemicals for treating heat-sensitive medical instruments) is not appropriate. 964 Intermediate-level disinfection does not necessarily kill bacterial spores, but it does inactivate Mycobacterium tuberculosis var. bovis, which is substantially more resistant to chemical germicides than ordinary vegetative bacteria, fungi, and medium to small viruses (with or without lipid envelopes). Chemical germicides with sufficient potency to achieve intermediate-level disinfection include chlorine-containing compounds (e.g., sodium hypochlorite), alcohols, some phenolics, and some iodophors. Low-level disinfection inactivates vegetative bacteria, fungi, enveloped viruses (e.g., human immunodeficiency virus , and influenza viruses), and some non-enveloped viruses (e.g., adenoviruses). Low-level disinfectants include quaternary ammonium compounds, some phenolics, and some iodophors. Sanitizers are agents that reduce the numbers of bacterial contaminants to safe levels as judged by public health requirements, and are used in cleaning operations, particularly in food service and dairy applications. Germicidal chemicals that have been approved by FDA as skin antiseptics are not appropriate for use as environmental surface disinfectants. 951 The selection and use of chemical germicides are largely matters of judgment, guided by product label instructions, information, and regulations. Liquid sterilant chemicals and high-level disinfectants intended for use on critical and semi-critical medical/dental devices and instruments are regulated exclusively by the FDA as a result of recent memoranda of understanding between FDA and the EPA that delineates agency authority for chemical germicide regulation. 965,966  A common misconception in the use of surface disinfectants in health-care settings relates to the underlying purpose for use of proprietary products labeled as a "tuberculocidal" germicide. Such products will not interrupt and prevent the transmission of TB in health-care settings because TB is not acquired from environmental surfaces. The tuberculocidal claim is used as a benchmark by which to measure germicidal potency. Because mycobacteria have the highest intrinsic level of resistance among the vegetative bacteria, viruses, and fungi, any germicide with a tuberculocidal claim on the label (i.e., an intermediate-level disinfectant) is considered capable of inactivating a broad spectrum of pathogens, including much less resistant organisms such the bloodborne pathogens (e.g., hepatitis B virus , hepatitis C virus , and HIV). It is this broad spectrum capability, rather than the product's specific potency against mycobacteria, that is the basis for protocols and OSHA regulations indicating the appropriateness of using tuberculocidal chemicals for surface disinfection. 967

# General Cleaning Strategies for Patient-Care Areas
The number and types of microorganisms present on environmental surfaces are influenced by the following factors: a. number of people in the environment, b. amount of activity, c. amount of moisture, d. presence of material capable of supporting microbial growth, e. rate at which organisms suspended in the air are removed, and f. type of surface and orientation . 968 Strategies for cleaning and disinfecting surfaces in patient-care areas take into account a. potential for direct patient contact, b. degree and frequency of hand contact, and c. potential contamination of the surface with body substances or environmental sources of microorganisms (e.g., soil, dust, and water).

# a. Cleaning of Medical Equipment
Manufacturers of medical equipment should provide care and maintenance instructions specific to their equipment. These instructions should include information about a. the equipments' compatibility with chemical germicides, b. whether the equipment is water-resistant or can be safely immersed for cleaning, and c. how the equipment should be decontaminated if servicing is required. 967 In the absence of manufacturers' instructions, non-critical medical equipment (e.g., stethoscopes, blood pressure cuffs, dialysis machines, and equipment knobs and controls) usually only require cleansing followed by low-to intermediate-level disinfection, depending on the nature and degree of contamination.
Ethyl alcohol or isopropyl alcohol in concentrations of 60%-90% (v/v) is often used to disinfect small surfaces (e.g., rubber stoppers of multiple-dose medication vials, and thermometers) 952, 969 and occasionally external surfaces of equipment (e.g., stethoscopes and ventilators). However, alcohol evaporates rapidly, which makes extended contact times difficult to achieve unless items are immersed, a factor that precludes its practical use as a large-surface disinfectant. 951 Alcohol may cause discoloration, swelling, hardening, and cracking of rubber and certain plastics after prolonged and repeated use and may damage the shellac mounting of lenses in medical equipment. 970 Barrier protection of surfaces and equipment is useful, especially if these surfaces are a. touched frequently by gloved hands during the delivery of patient care, b. likely to become contaminated with body substances, or c. difficult to clean. Impervious-backed paper, aluminum foil, and plastic or fluid-resistant covers are suitable for use as barrier protection.
An example of this approach is the use of plastic wrapping to cover the handle of the operatory light in dental-care settings. 936,942 Coverings should be removed and discarded while the health-care worker is still gloved. 936,942 The health-care worker, after ungloving and performing hand hygiene, must cover these surfaces with clean materials before the next patient encounter.

# b. Cleaning Housekeeping Surfaces
Housekeeping surfaces require regular cleaning and removal of soil and dust. Dry conditions favor the persistence of gram-positive cocci (e.g., coagulase-negative Staphylococcus spp.) in dust and on surfaces, whereas moist, soiled environments favor the growth and persistence of gram-negative bacilli. 948,971,972 Fungi are also present on dust and proliferate in moist, fibrous material.
Most, if not all, housekeeping surfaces need to be cleaned only with soap and water or a detergent/disinfectant, depending on the nature of the surface and the type and degree of contamination.
Cleaning and disinfection schedules and methods vary according to the area of the health-care facility, type of surface to be cleaned, and the amount and type of soil present. Disinfectant/detergent formulations registered by EPA are used for environmental surface cleaning, but the actual physical removal of microorganisms and soil by wiping or scrubbing is probably as important, if not more so, than any antimicrobial effect of the cleaning agent used. 973 Therefore, cost, safety, product-surface compatibility, and acceptability by housekeepers can be the main criteria for selecting a registered agent. If using a proprietary detergent/disinfectant, the manufacturers' instructions for appropriate use of the product should be followed. 974 Consult the products' material safety data sheets (MSDS) to determine appropriate precautions to prevent hazardous conditions during product application. Personal protective equipment (PPE) used during cleaning and housekeeping procedures should be appropriate to the task.
Housekeeping surfaces can be divided into two groups -those with minimal hand-contact (e.g., floors, and ceilings) and those with frequent hand-contact ("high touch surfaces"). The methods, thoroughness, and frequency of cleaning and the products used are determined by health-care facility policy. 6 However, high-touch housekeeping surfaces in patient-care areas (e.g., doorknobs, bedrails, light switches, wall areas around the toilet in the patient's room, and the edges of privacy curtains) should be cleaned and/or disinfected more frequently than surfaces with minimal hand contact. Infection-control practitioners typically use a risk-assessment approach to identify high-touch surfaces and then coordinate an appropriate cleaning and disinfecting strategy and schedule with the housekeeping staff.
Horizontal surfaces with infrequent hand contact (e.g., window sills and hard-surface flooring) in routine patient-care areas require cleaning on a regular basis, when soiling or spills occur, and when a patient is discharged from the facility. 6 Regular cleaning of surfaces and decontamination, as needed, is also advocated to protect potentially exposed workers. 967 Cleaning of walls, blinds, and window curtains is recommended when they are visibly soiled. 972,973,975 Disinfectant fogging is not recommended for general infection control in routine patient-care areas. 2,976 Further, paraformaldehyde, which was once used in this application, is no longer registered by EPA for this purpose. Use of paraformaldehyde in these circumstances requires either registration or an exemption issued by EPA under the Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA). Infection control, industrial hygienists, and environmental services supervisors should assess the cleaning procedures, chemicals used, and the safety issues to determine if a temporary relocation of the patient is needed when cleaning in the room.
Extraordinary cleaning and decontamination of floors in health-care settings is unwarranted. Studies have demonstrated that disinfection of floors offers no advantage over regular detergent/water cleaning and has minimal or no impact on the occurrence of health-care associated infections. 947,948, Additionally, newly cleaned floors become rapidly recontaminated from airborne microorganisms and those transferred from shoes, equipment wheels, and body substances. 971,975,981 Nevertheless, healthcare institutions or contracted cleaning companies may choose to use an EPA-registered detergent/disinfectant for cleaning low-touch surfaces (e.g., floors) in patient-care areas because of the difficulty that personnel may have in determining if a spill contains blood or body fluids (requiring a detergent/disinfectant for clean-up) or when a multi-drug resistant organism is likely to be in the environment. Methods for cleaning non-porous floors include wet mopping and wet vacuuming, dry dusting with electrostatic materials, and spray buffing. 973, Methods that produce minimal mists and aerosols or dispersion of dust in patient-care areas are preferred. 9,20,109,272 Part of the cleaning strategy is to minimize contamination of cleaning solutions and cleaning tools. Bucket solutions become contaminated almost immediately during cleaning, and continued use of the solution transfers increasing numbers of microorganisms to each subsequent surface to be cleaned. 971,981,985 Cleaning solutions should be replaced frequently. A variety of "bucket" methods have been devised to address the frequency with which cleaning solutions are replaced. 986,987 Another source of contamination in the cleaning process is the cleaning cloth or mop head, especially if left soaking in dirty cleaning solutions. 971, Laundering of cloths and mop heads after use and allowing them to dry before re-use can help to minimize the degree of contamination. 990 A simplified approach to cleaning involves replacing soiled cloths and mop heads with clean items each time a bucket of detergent/disinfectant is emptied and replaced with fresh, clean solution (B. Stover, Kosair Children's Hospital, 2000). Disposable cleaning cloths and mop heads are an alternative option, if costs permit.
Another reservoir for microorganisms in the cleaning process may be dilute solutions of the detergents or disinfectants, especially if the working solution is prepared in a dirty container, stored for long periods of time, or prepared incorrectly. 547 Gram-negative bacilli (e.g., Pseudomonas spp. and Serratia marcescens) have been detected in solutions of some disinfectants (e.g., phenolics and quaternary ammonium compounds). 547,991 Contemporary EPA registration regulations have helped to minimize this problem by asking manufacturers to provide potency data to support label claims for detergent/disinfectant properties under real-use conditions (e.g., diluting the product with tap water instead of distilled water). Application of contaminated cleaning solutions, particularly from small-quantity aerosol spray bottles or with equipment that might generate aerosols during operation, should be avoided, especially in high-risk patient areas. 992,993 Making sufficient fresh cleaning solution for daily cleaning, discarding any remaining solution, and drying out the container will help to minimize the degree of bacterial contamination. Containers that dispense liquid as opposed to spray-nozzle dispensers (e.g., quart-sized dishwashing liquid bottles) can be used to apply detergent/disinfectants to surfaces and then to cleaning cloths with minimal aerosol generation. A pre-mixed, "ready-to-use" detergent/disinfectant solution may be used if available.

# c. Cleaning Special Care Areas
Guidelines have been published regarding cleaning strategies for isolation areas and operating rooms. 6,7 The basic strategies for areas housing immunosuppressed patients include a. wet dusting horizontal surfaces daily with cleaning cloths pre-moistened with detergent or an EPAregistered hospital disinfectant or disinfectant wipes; 94, 98463 b. using care when wet dusting equipment and surfaces above the patient to avoid patient contact with the detergent/disinfectant; c. avoiding the use of cleaning equipment that produces mists or aerosols; d. equipping vacuums with HEPA filters, especially for the exhaust, when used in any patient-care area housing immunosuppressed patients; 9, 94, 986 and e. regular cleaning and maintenance of equipment to ensure efficient particle removal.
When preparing the cleaning cloths for wet-dusting, freshly prepared solutions of detergents or disinfectants should be used rather than cloths that have soaked in such solutions for long periods of time. Dispersal of microorganisms in the air from dust or aerosols is more problematic in these settings than elsewhere in health-care facilities. Vacuum cleaners can serve as dust disseminators if they are not operating properly. 994 Doors to immunosuppressed patients' rooms should be closed when nearby areas are being vacuumed. 9 Bacterial and fungal contamination of filters in cleaning equipment is inevitable, and these filters should be cleaned regularly or replaced as per equipment manufacturer instructions.
Mats with tacky surfaces placed in operating rooms and other patient-care areas only slightly minimize the overall degree of contamination of floors and have little impact on the incidence rate of health-careassociated infection in general. 351,971,983 An exception, however, is the use of tacky mats inside the entry ways of cordoned-off construction areas inside the health-care facility; these mats help to minimize the intrusion of dust into patient-care areas.
Special precautions for cleaning incubators, mattresses, and other nursery surfaces have been recommended to address reports of hyperbilirubinemia in newborns linked to inadequately diluted solutions of phenolics and poor ventilation.  These medical conditions have not, however, been associated with the use of properly prepared solutions of phenolics. Non-porous housekeeping surfaces in neonatal units can be disinfected with properly diluted or pre-mixed phenolics, followed by rinsing with clean water. 997 However, phenolics are not recommended for cleaning infant bassinets and incubators during the stay of the infant. Infants who remain in the nursery for an extended period should be moved periodically to freshly cleaned and disinfected bassinets and incubators. 997 If phenolics are used for cleaning bassinets and incubators after they have been vacated, the surfaces should be rinsed thoroughly with water and dried before either piece of equipment is reused. Cleaning and disinfecting protocols should allow for the full contact time specified for the product used. Bassinet mattresses should be replaced, however, if the mattress cover surface is broken. 997

# Cleaning Strategies for Spills of Blood and Body Substances
Neither HBV, HCV, nor HIV has ever been transmitted from a housekeeping surface (i.e., floors, walls, or countertops). Nonetheless, prompt removal and surface disinfection of an area contaminated by either blood or body substances are sound infection-control practices and OSHA requirements. 967 Studies have demonstrated that HIV is inactivated rapidly after being exposed to commonly used chemical germicides at concentrations that are much lower than those used in practice.  HBV is readily inactivated with a variety of germicides, including quaternary ammonium compounds. 1004 Embalming fluids (e.g., formaldehyde) are also capable of completely inactivating HIV and HBV. 1005,1006 OSHA has revised its regulation for disinfecting spills of blood or other potentially infectious material to include proprietary products whose label includes inactivation claims for HBV and HIV, provided that such surfaces have not become contaminated with agent(s) or volumes of or concentrations of agent(s) for which a higher level of disinfection is recommended. 1007 These registered products are listed in EPA's List D -Registered Antimicrobials Effective Against Hepatitis B Virus and Human HIV-1, which may include products tested against duck hepatitis B virus (DHBV) as a surrogate for HBV. 1008,1009 Additional lists of interest include EPA's List C -Registered Antimicrobials Effective Against Human HIV-1 and EPA's List E -Registered Antimicrobials Effective Against Mycobacterium spp., Hepatitis B Virus, and Human HIV-1.
Sodium hypochlorite solutions are inexpensive and effective broad-spectrum germicidal solutions. 1010,1011 Generic sources of sodium hypochlorite include household chlorine bleach or reagent grade chemical. Concentrations of sodium hypochlorite solutions with a range of 5,000-6,150 ppm (1:10 v/v dilution of household bleaches marketed in the United States) to 500-615 ppm (1:100 v/v dilution) free chlorine are effective depending on the amount of organic material (e.g., blood, mucus, and urine) present on the surface to be cleaned and disinfected. 1010, 1011 EPA-registered chemical germicides may be more compatible with certain materials that could be corroded by repeated exposure to sodium hypochlorite, especially the 1:10 dilution. Appropriate personal protective equipment (e.g., gloves and goggles) should be worn when preparing and using hypochlorite solutions or other chemical germicides. 967 Despite laboratory evidence demonstrating adequate potency against bloodborne pathogens (e.g., HIV and HBV), many chlorine bleach products available in grocery and chemical-supply stores are not registered by the EPA for use as surface disinfectants. Use of these chlorine products as surface disinfectants is considered by the EPA to be an "unregistered use." EPA encourages the use of registered products because the agency reviews them for safety and performance when the product is used according to label instructions. When unregistered products are used for surface disinfection, users do so at their own risk.
Strategies for decontaminating spills of blood and other body fluids differ based on the setting in which they occur and the volume of the spill. 1010 In patient-care areas, workers can manage small spills with cleaning and then disinfecting using an intermediate-level germicide or an EPA-registered germicide from the EPA List D or E. 967,1007 For spills containing large amounts of blood or other body substances, workers should first remove visible organic matter with absorbent material (e.g., disposable paper towels discarded into leak-proof, properly labeled containment) and then clean and decontaminate the area. 1002, 1003, 1012 If the surface is nonporous and a generic form of a sodium hypochlorite solution is used (e.g., household bleach), a 1:100 dilution is appropriate for decontamination assuming that a. the worker assigned to clean the spill is wearing gloves and other personal protective equipment appropriate to the task, b. most of the organic matter of the spill has been removed with absorbent material, and c. the surface has been cleaned to remove residual organic matter.
A recent study demonstrated that even strong chlorine solutions (i.e., 1:10 dilution of chlorine bleach) may fail to totally inactivate high titers of virus in large quantities of blood, but in the absence of blood these disinfectants can achieve complete viral inactivation. 1011 This evidence supports the need to remove most organic matter from a large spill before final disinfection of the surface. Additionally, EPAregistered proprietary disinfectant label claims are based on use on a pre-cleaned surface. 951,954 Managing spills of blood, body fluids, or other infectious materials in clinical, public health, and research laboratories requires more stringent measures because of a. the higher potential risk of disease transmission associated with large volumes of blood and body fluids and b. high numbers of microorganisms associated with diagnostic cultures.
The use of an intermediate-level germicide for routine decontamination in the laboratory is prudent. 954 Recommended practices for managing large spills of concentrated infectious agents in the laboratory include a. confining the contaminated area, b. flooding the area with a liquid chemical germicide before cleaning, and c. decontaminating with fresh germicidal chemical of at least intermediate-level disinfectant potency. 1010 A suggested technique when flooding the spill with germicide is to lay absorbent material down on the spill and apply sufficient germicide to thoroughly wet both the spill and the absorbent material. 1013 If using a solution of household chlorine bleach, a 1:10 dilution is recommended for this purpose. EPAregistered germicides should be used according to the manufacturers' instructions for use dilution and contact time. Gloves should be worn during the cleaning and decontamination procedures in both clinical and laboratory settings. PPE in such a situation may include the use of respiratory protection (e.g., an N95 respirator) if clean-up procedures are expected to generate infectious aerosols. Protocols for cleaning spills should be developed and made available on record as part of good laboratory practice. 1013 Workers in laboratories and in patient-care areas of the facility should receive periodic training in environmentalsurface infection-control strategies and procedures as part of an overall infection-control and safety curriculum.

# Carpeting and Cloth Furnishings a. Carpeting
Carpeting has been used for more than 30 years in both public and patient-care areas of health-care facilities. Advantages of carpeting in patient-care areas include a. its noise-limiting characteristics b. the "humanizing" effect on health care; and c. its contribution to reductions in falls and resultant injuries, particularly for the elderly.  Compared to hard-surface flooring, however, carpeting is harder to keep clean, especially after spills of blood and body substances. It is also harder to push equipment with wheels (e.g., wheelchairs, carts, and gurneys) on carpeting.
Several studies have documented the presence of diverse microbial populations, primarily bacteria and fungi, in carpeting; 111, 1017-1024 the variety and number of microorganisms tend to stabilize over time. New carpeting quickly becomes colonized, with bacterial growth plateauing after about 4 weeks. 1019 Vacuuming and cleaning the carpeting can temporarily reduce the numbers of bacteria, but these populations soon rebound and return to pre-cleaning levels. 1019,1020,1023 Bacterial contamination tends to increase with higher levels of activity. 1025 Soiled carpeting that is or remains damp or wet provides an ideal setting for the proliferation and persistence of gram-negative bacteria and fungi. 1026 Carpeting that remains damp should be removed, ideally within 72 hours.
Despite the evidence of bacterial growth and persistence in carpeting, only limited epidemiologic evidence demonstrates that carpets influence health-care associated infection rates in areas housing immunocompetent patients. 1023,1025,1027 This guideline, therefore, includes no recommendations against the use of carpeting in these areas. Nonetheless, avoiding the use of carpeting is prudent in areas where spills are likely to occur (e.g., laboratories, areas around sinks, and janitor closets) and where patients may be at greater risk of infection from airborne environmental pathogens (e.g., HSCT units, burn units, ICUs, and ORs). 111,1028 An outbreak of aspergillosis in an HSCT unit was recently attributed to carpet contamination and a particular method of carpet cleaning. 111 A window in the unit had been opened repeatedly during the time of a nearby building fire, which allowed fungal spore intrusion into the unit. After the window was sealed, the carpeting was cleaned using a "bonnet buffing" machine, which dispersed Aspergillus spores into the air. 111 Wet vacuuming was instituted, replacing the dry cleaning method used previously; no additional cases of invasive aspergillosis were identified.
The care setting and the method of carpet cleaning are important factors to consider when attempting to minimize or prevent production of aerosols and dispersal of carpet microorganisms into the air. 94,111 Both vacuuming and shampooing or wet cleaning with equipment can disperse microorganisms to the air. 111,994 Vacuum cleaners should be maintained to minimize dust dispersal in general, and be equipped with HEPA filters, especially for use in high-risk patient-care areas. 9, 94, 986 Some formulations of carpetcleaning chemicals, if applied or used improperly, can be dispersed into the air as a fine dust capable of causing respiratory irritation in patients and staff. 1029 Cleaning equipment, especially those that engage in wet cleaning and extraction, can become contaminated with waterborne organisms (e.g., Pseudomonas aeruginosa) and serve as a reservoir for these organisms if this equipment is not properly maintained. Substantial numbers of bacteria can then be transferred to carpeting during the cleaning process. 1030 Therefore, keeping the carpet cleaning equipment in good repair and allowing such equipment to dry between uses is prudent.
Carpet cleaning should be performed on a regular basis determined by internal policy. Although spills of blood and body substances on non-porous surfaces require prompt spot cleaning using standard cleaning procedures and application of chemical germicides, 967 similar decontamination approaches to blood and body substance spills on carpeting can be problematic from a regulatory perspective. 1031 Most, if not all, modern carpet brands suitable for public facilities can tolerate the activity of a variety of liquid chemical germicides. However, according to OSHA, carpeting contaminated with blood or other potentially infectious materials cannot be fully decontaminated. 1032 Therefore, facilities electing to use carpeting for high-activity patient-care areas may choose carpet tiles in areas at high risk for spills. 967,1032 In the event of contamination with blood or other body substances, carpet tiles can be removed, discarded, and replaced. OSHA also acknowledges that only minimal direct skin contact occurs with carpeting, and therefore, employers are expected to make reasonable efforts to clean and sanitize carpeting using carpet detergent/cleaner products. 1032 Over the last few years, some carpet manufacturers have treated their products with fungicidal and/or bactericidal chemicals. Although these chemicals may help to reduce the overall numbers of bacteria or fungi present in carpet, their use does not preclude the routine care and maintenance of the carpeting. Limited evidence suggests that chemically treated carpet may have helped to keep health-care-associated aspergillosis rates low in one HSCT unit, 111 but overall, treated carpeting has not been shown to prevent the incidence of health-care associated infections in care areas for immunocompetent patients.

# b. Cloth Furnishings
Upholstered furniture and furnishings are becoming increasingly common in patient-care areas. These furnishings range from simple cloth chairs in patients' rooms to a complete decorating scheme that gives the interior of the facility more the look of an elegant hotel. 1033 Even though pathogenic microorganisms have been isolated from the surfaces of cloth chairs, no epidemiologic evidence suggests that general patient-care areas with cloth furniture pose increased risks of health-care associated infection compared with areas that contain hard-surfaced furniture. 1034,1035 Allergens (e.g., dog and cat dander) have been detected in or on cloth furniture in clinics and elsewhere in hospitals in concentrations higher than those found on bed linens. 1034,1035 These allergens presumably are transferred from the clothing of visitors. Researchers have therefore suggested that cloth chairs should be vacuumed regularly to keep the dust and allergen levels to a minimum. This recommendation, however, has generated concerns that aerosols created from vacuuming could place immunocompromised patients or patients with preexisting lung disease (e.g., asthma) at risk for development of health-care associated, environmental airborne disease. 9, 20, 109, 988 Recovering worn, upholstered furniture (especially the seat cushion) with covers that are easily cleaned (e.g., vinyl), or replacing the item is prudent; minimizing the use of upholstered furniture and furnishings in any patient-care areas where immunosuppressed patients are located (e.g., HSCT units) reduces the likelihood of disease. 9

# Flowers and Plants in Patient-Care Areas
Fresh flowers, dried flowers, and potted plants are common items in health-care facilities. In 1974, clinicians isolated an Erwinia sp. post mortem from a neonate diagnosed with fulminant septicemia, meningitis, and respiratory distress syndrome. 1038 Because Erwinia spp. are plant pathogens, plants brought into the delivery room were suspected to be the source of the bacteria, although the case report did not definitively establish a direct link. Several subsequent studies evaluated the numbers and diversity of microorganisms in the vase water of cut flowers. These studies revealed that high concentrations of bacteria, ranging from 10 4 -10 10 CFU/mL, were often present, especially if the water was changed infrequently. 515,702,1039 The major group of microorganisms in flower vase water was gram-negative bacteria, with Pseudomonas aeruginosa the most frequently isolated organism. 515, 702, 1039, 1040 P. aeruginosa was also the primary organism directly isolated from chrysanthemums and other potted plants. 1041,1042 However, flowers in hospitals were not significantly more contaminated with bacteria compared with flowers in restaurants or in the home. 702 Additionally, no differences in the diversity and degree of antibiotic resistance of bacteria have been observed in samples isolated from hospital flowers versus those obtained from flowers elsewhere. 702 Despite the diversity and large numbers of bacteria associated with flower-vase water and potted plants, minimal or no evidence indicates that the presence of plants in immunocompetent patient-care areas poses an increased risk of health-care associated infection. 515 In one study involving a limited number of surgical patients, no correlation was observed between bacterial isolates from flowers in the area and the incidence and etiology of postoperative infections among the patients. 1040 Similar conclusions were reached in a study that examined the bacteria found in potted plants. 1042 Nonetheless, some precautions for general patient-care settings should be implemented, including a. limiting flower and plant care to staff with no direct patient contact, b. advising health-care staff to wear gloves when handling plants, c. washing hands after handling plants, d. changing vase water every 2 days and discharging the water into a sink outside the immediate patient environment, and e. cleaning and disinfecting vases after use. 702 Some researchers have examined the possibility of adding a chemical germicide to vase water to control bacterial populations. Certain chemicals (e.g., hydrogen peroxide and chlorhexidine) are well tolerated by plants. 1040,1043,1044 Use of these chemicals, however, was not evaluated in studies to assess impact on health-care associated infection rates. Modern florists now have a variety of products available to add to vase water to extend the life of cut flowers and to minimize bacterial clouding of the water.
Flowers (fresh and dried) and ornamental plants, however, may serve as a reservoir of Aspergillus spp., and dispersal of conidiospores into the air from this source can occur. 109 Health-care associated outbreaks of invasive aspergillosis reinforce the importance of maintaining an environment as free of Aspergillus spp. spores as possible for patients with severe, prolonged neutropenia. Potted plants, fresh-cut flowers, and dried flower arrangements may provide a reservoir for these fungi as well as other fungal species (e.g., Fusarium spp.). 109,1045,1046 Researchers in one study of bacteria and flowers suggested that flowers and vase water should be avoided in areas providing care to medically at-risk patients (e.g., oncology patients and transplant patients), although this study did not attempt to correlate the observations of bacterial populations in the vase water with the incidence of health-care associated infections. 515 Another study using molecular epidemiology techniques demonstrated identical Aspergillus terreus types among environmental and clinical specimens isolated from infected patients with hematological malignancies. 1046 Therefore, attempts should be made to exclude flowers and plants from areas where immunosuppressed patients are be located (e.g., HSCT units). 9, 1046

# Pest Control
Cockroaches, flies and maggots, ants, mosquitoes, spiders, mites, midges, and mice are among the typical arthropod and vertebrate pest populations found in health-care facilities. Insects can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by serving as a vector.  Arthropods recovered from health-care facilities have been shown to carry a wide variety of pathogenic microorganisms.  Studies have suggested that the diversity of microorganisms associated with insects reflects the microbial populations present in the indoor health-care environment; some pathogens encountered in insects from hospitals were either absent from or present to a lesser degree in insects trapped from residential settings.  Some of the microbial populations associated with insects in hospitals have demonstrated resistance to antibiotics. 1048,1059, Insect habitats are characterized by warmth, moisture, and availability of food. 1064 Insects forage in and feed on substrates, including but not limited to food scraps from kitchens/cafeteria, foods in vending machines, discharges on dressings either in use or discarded, other forms of human detritis, medical wastes, human wastes, and routine solid waste.  Cockroaches, in particular, have been known to feed on fixed sputum smears in laboratories. 1065,1066 Both cockroaches and ants are frequently found in the laundry, central sterile supply departments, and anywhere in the facility where water or moisture is present (e.g., sink traps, drains and janitor closets). Ants will often find their way into sterile packs of items as they forage in a warm, moist environment. 1057 Cockroaches and other insects frequent loading docks and other areas with direct access to the outdoors.
Although insects carry a wide variety of pathogenic microorganisms on their surfaces and in their gut, the direct association of insects with disease transmission (apart from vector transmission) is limited, especially in health-care settings; the presence of insects in itself likely does not contribute substantially to health-care associated disease transmission in developed countries. However, outbreaks of infection attributed to microorganisms carried by insects may occur because of infestation coupled with breaks in standard infection-control practices. 1063 Studies have been conducted to examine the role of houseflies as possible vectors for shigellosis and other forms of diarrheal disease in non-health-care settings. 1046, 1067 When control measures aimed at reducing the fly population density were implemented, a concomitant reduction in the incidence of diarrheal infections, carriage of Shigella organisms, and mortality caused by diarrhea among infants and young children was observed.
Myiasis is defined as a parasitosis in which the larvae of any of a variety of flies use living or necrotic tissue or body substances of the host as a nutritional source. 1068 Larvae from health-care acquired myiasis have been observed in nares, wounds, eyes, ears, sinuses, and the external urogenital structures.  Patients with this rare condition are typically older adults with underlying medical conditions (e.g., diabetes, chronic wounds, and alcoholism) who have a decreased capacity to ward off the flies. Persons with underlying conditions who live or travel to tropical regions of the world are especially at risk. 1070,1071 Cases occur in the summer and early fall months in temperate climates when flies are most active. 1071 An environmental assessment and review of the patient's history are necessary to verify that the source of the myiasis is health-care acquired and to identify corrective measures. 1069,1072 Simple prevention measures (e.g., installing screens on windows) are important in reducing the incidence of myiasis. 1072 From a public health and hygiene perspective, arthropod and vertebrate pests should be eradicated from all indoor environments, including health-care facilities. 1073,1074 Modern approaches to institutional pest management usually focus on a. eliminating food sources, indoor habitats, and other conditions that attract pests b. excluding pests from the indoor environments; and c. applying pesticides as needed. 1075 Sealing windows in modern health-care facilities helps to minimize insect intrusion. When windows need to be opened for ventilation, ensuring that screens are in good repair and closing doors to the outside can help with pest control. Insects should be kept out of all areas of the health-care facility, especially ORs and any area where immunosuppressed patients are located. A pest-control specialist with appropriate credentials can provide a regular insect-control program that is tailored to the needs of the facility and uses approved chemicals and/or physical methods. Industrial hygienists can provide information on possible adverse reactions of patients and staff to pesticides and suggest alternative methods for pest control, as needed. ) represent crucial and growing concerns for infection control. Although the term GISA is technically a more accurate description of the strains isolated to date (most of which are classified as having intermediate resistance to both vancomycin and teicoplanin), the term "glycopeptide" may not be recognized by many clinicians. Thus, the label of VISA, which emphasizes a change in minimum inhibitory concentration (MICs) to vancomycin, is similar to that of VRE and is more meaningful to clinicians. 1076 According to National Nosocomial Infection Surveillance (NNIS) statistics for infections acquired among ICU patients in the United States in 1999, 52.3% of infections resulting from S. aureus were identified as MRSA infections, and 25.2% of enterococcal infections were attributed to VRE. These figures reflect a 37% and a 43% increase, respectively, since 1994-1998. 1077 People represent the primary reservoir of S. aureus. 1078 Although S. aureus has been isolated from a variety of environmental surfaces (e.g., stethoscopes, floors, charts, furniture, dry mops, and hydrotherapy tanks), the role of environmental contamination in transmission of this organism in health care appears to be minimal.  S. aureus contamination of surfaces and tanks within burn therapy units, however, may be a major factor in the transmission of infection among burn patients. 1083 Colonized patients are the principal reservoir of VRE, and patients who are immunosuppressed (e.g., transplant patients) or otherwise medically at-risk (e.g., ICU patients, cardio-thoracic surgical patients, patients previously hospitalized for extended periods, and those having received multi-antimicrobial or vancomycin therapy) are at greatest risk for VRE colonization.  The mechanisms by which crosscolonization take place are not well defined, although recent studies have indicated that both MRSA and VRE may be transmitted either a. directly from patient to patient, b. indirectly by transient carriage on the hands of health-care workers, 1088-1091 or c. by hand transfer of these gram-positive organisms from contaminated environmental surfaces and patient-care equipment. 1084,1087, In one survey, hand carriage of VRE in workers in a long-term care facility ranged from 13%-41%. 1098 Many of the environmental surfaces found to be contaminated with VRE in outbreak investigations have been those that are touched frequently by the patient or the health-care worker. 1099 Such high-touch surfaces include bedrails, doorknobs, bed linens, gowns, overbed tables, blood pressure cuffs, computer table, bedside tables, and various medical equipment. 22,1087,1094,1095, Contamination of environmental surfaces with VRE generally occurs in clinical laboratories and areas where colonized patients are present, 1087, 1092, 1094, 1095, 1103 but the potential for contamination increases when such patients have diarrhea 1087 or have multiple body-site colonization. 1104 Additional factors that can be important in the dispersion of these pathogens to environmental surfaces are misuse of glove techniques by healthcare workers (especially when cleaning fecal contamination from surfaces) and patient, family, and visitor hygiene.

# Special Pathogen Concerns a. Antibiotic-Resistant Gram-Positive Cocci
Interest in the importance of environmental reservoirs of VRE increased when laboratory studies demonstrated that enterococci can persist in a viable state on dry environmental surfaces for extended periods of time (7 days to 4 months) 1099,1105 and multiple strains can be identified during extensive periods of surveillance. 1104 VRE can be recovered from inoculated hands of health-care workers (with or without gloves) for up to 60 minutes. 22 The presence of either MRSA, VISA, or VRE on environmental surfaces, however, does not mean that patients in the contaminated areas will become colonized. Strict adherence to hand hygiene/handwashing and the proper use of barrier precautions help to minimize the potential for spread of these pathogens. Published recommendations for preventing the spread of vancomycin resistance address isolation measures, including patient cohorting and management of patient-care items. 5 Direct patient-care items (e.g., blood pressure cuffs) should be disposable whenever possible when used in contact isolation settings for patients with multiply resistant microorganisms. 1102  1114,1115 These represented isolated cases, and neither the family members nor the health-care providers of these case-patients had evidence of colonization or infection with VRSA. Conventional environmental infection-control measures (i.e., cleaning and then disinfecting surfaces using EPA-registered disinfectants with label claims for S. aureus) were used during the environmental investigation of these two cases; 1110-1112 however, studies have yet to evaluate the potential intrinsic resistance of these VRSA strains to surface disinfectants.
Standard procedures during terminal cleaning and disinfection of surfaces, if performed incorrectly, may be inadequate for the elimination of VRE from patient rooms. 1113, Given the sensitivity of VRE to hospital disinfectants, current disinfecting protocols should be effective if they are diligently carried out and properly performed. Health-care facilities should be sure that housekeeping staff use correct procedures for cleaning and disinfecting surfaces in VRE-contaminated areas, which include using sufficient amounts of germicide at proper use dilution and allowing adequate contact time. 1118

# b. Clostridium difficile
Clostridium difficile is the most frequent etiologic agent for health-care associated diarrhea. 1119,1120 In one hospital, 30% of adults who developed health-care associated diarrhea were positive for C. difficile. 1121 One recent study employing PCR-ribotyping techniques demonstrated that cases of C. difiicile-acquired diarrhea occurring in the hospital included patients whose infections were attributed to endogenous C. difficile strains and patients whose illnesses were considered to be health-care-associated infections. 1122 Most patients remain asymptomatic after infection, but the organism continues to be shed in their stools. Risk factors for acquiring C. difficile-associated infection include a. exposure to antibiotic therapy, particularly with beta-lactam agents; 1123 b. gastrointestinal procedures and surgery; 1124 c. advanced age; and d. indiscriminate use of antibiotics.  Of all the measures that have been used to prevent the spread of C. difficile-associated diarrhea, the most successful has been the restriction of the use of antimicrobial agents. 1129,1130 C. difficile is an anaerobic, gram-positive bacterium. Normally fastidious in its vegetative state, it is capable of sporulating when environmental conditions no longer support its continued growth. The capacity to form spores enables the organism to persist in the environment (e.g., in soil and on dry surfaces) for extended periods of time. Environmental contamination by this microorganism is well known, especially in places where fecal contamination may occur. 1131 The environment (especially housekeeping surfaces) rarely serves as a direct source of infection for patients. 1024, However, direct exposure to contaminated patient-care items (e.g., rectal thermometers) and high-touch surfaces in patients' bathrooms (e.g., light switches) have been implicated as sources of infection. 1130,1135,1136,1138 Transfer of the pathogen to the patient via the hands of health-care workers is thought to be the most likely mechanism of exposure. 24,1133,1139 Standard isolation techniques intended to minimize enteric contamination of patients, health-care-workers' hands, patient-care items, and environmental surfaces have been published. 1140 Handwashing remains the most effective means of reducing hand contamination. Proper use of gloves is an ancillary measure that helps to further minimize transfer of these pathogens from one surface to another.
The degree to which the environment becomes contaminated with C. difficile spores is proportional to the number of patients with C. difficile-associated diarrhea, 24,1132,1135 although asymptomatic, colonized patients may also serve as a source of contamination. Few studies have examined the use of specific chemical germicides for the inactivation of C. difficile spores, and no well-controlled trials have been conducted to determine efficacy of surface disinfection and its impact on health-care associated diarrhea. Some investigators have evaluated the use of chlorine-containing chemicals (e.g., 1,000 ppm hypochlorite at recommended use-dilution, 5,000 ppm sodium hypochlorite , 1:100 v/v dilutions of unbuffered hypochlorite, and phosphate-buffered hypochlorite ). One of the studies demonstrated that the number of contaminated environmental sites was reduced by half, 1135 whereas another two studies demonstrated declines in health-care associated C. difficile infections in a HSCT unit 1141 and in two geriatric medical units 1142 during a period of hypochlorite use. The presence of confounding factors, however, was acknowledged in one of these studies. 1142 The recommended approach to environmental infection control with respect to C. difficile is meticulous cleaning followed by disinfection using hypochlorite-based germicides as appropriate. 952,1130,1143 However, because no EPAregistered surface disinfectants with label claims for inactivation of C. difficile spores are available, the recommendation is based on the best available evidence from the scientific literature.

# c. Respiratory and Enteric Viruses in Pediatric-Care Settings
Although the viruses mentioned in this guideline are not unique to the pediatric-care setting in healthcare facilities, their prevalence in these areas, especially during the winter months, is substantial. Children (particularly neonates) are more likely to develop infection and substantial clinical disease from these agents compared with adults and therefore are more likely to require supportive care during their illness.
Common respiratory viruses in pediatric-care areas include rhinoviruses, respiratory syncytial virus (RSV), adenoviruses, influenza viruses, and parainfluenza viruses. Transmission of these viruses occurs primarily via direct contact with small-particle aerosols or via hand contamination with respiratory secretions that are then transferred to the nose or eyes. Because transmission primarily requires close personal contact, contact precautions are appropriate to interrupt transmission. 6 Hand contamination can occur from direct contact with secretions or indirectly from touching high-touch environmental surfaces that have become contaminated with virus from large droplets. The indirect transfer of virus from one persion to other via hand contact with frequently-touched fomites was demonstrated in a study using a bacteriophage whose environmental stability approximated that of human viral pathogens (e.g., poliovirus and parvovirus). 1144 The impact of this mode of transmission with respect to human respiratory-and enteric viruses is dependent on the ability of these agents to survive on environmental surfaces. Infectious RSV has been recovered from skin, porous surfaces, and non-porous surfaces after 30 minutes, 1 hour, and 7 hours, respectively. 1145 Parainfluenza viruses are known to persist for up to 4 hours on porous surfaces and up to 10 hours on non-porous surfaces. 1146 Rhinoviruses can persist on porous surfaces and non-porous surfaces for approximately 1 and 3 hours respectively; study participants in a controlled environment became infected with rhinoviruses after first touching a surface with dried secretions and then touching their nasal or conjunctival mucosa. 1147 Although the efficiency of direct transmission of these viruses from surfaces in uncontrolled settings remains to be defined, these data underscore the basis for maintaining regular protocols for cleaning and disinfecting of high-touch surfaces.
The clinically important enteric viruses encountered in pediatric care settings include enteric adenovirus, astroviruses, caliciviruses, and rotavirus. Group A rotavirus is the most common cause of infectious diarrhea in infants and children. Transmission of this virus is primarily fecal-oral, however, the role of fecally contaminated surfaces and fomites in rotavirus transmission is unclear. During one epidemiologic investigation of enteric disease among children attending day care, rotavirus contamination was detected on 19% of inanimate objects in the center. 1148,1149 In an outbreak in a pediatric unit, secondary cases of rotavirus infection clustered in areas where children with rotaviral diarrhea were located. 1150 Astroviruses cause gastroenteritis and diarrhea in newborns and young children and can persist on fecally contaminated surfaces for several months during periods of relatively low humidity. 1151,1152 Outbreaks of small roundstructured viruses (i.e., caliciviruses ) can affect both patients and staff, with attack rates of 50%. 1153 Routes of person-to-person transmission include fecal-oral spread and aerosols generated from vomiting.  Fecal contamination of surfaces in care settings can spread large amounts of virus to the environment. Studies that have attempted to use low-and intermediate-level disinfectants to inactivate rotavirus suspended in feces have demonstrated a protective effect of high concentrations of organic matter. 1157,1158 Intermediate-level disinfectants (e.g., alcoholic quaternary ammonium compounds, and chlorine solutions) can be effective in inactivating enteric viruses provided that a cleaning step to remove most of the organic matter precedes terminal disinfection. 1158 These findings underscore the need for proper cleaning and disinfecting procedures where contamination of environmental surfaces with body substances is likely. EPA-registered surface disinfectants with label claims for these viral agents should be used in these settings. Using disposable, protective barrier coverings may help to minimize the degree of surface contamination. 936

# d. Severe Acute Respiratory Syndrome (SARS) Virus
In November 2002 an atypical pneumonia of unknown etiology emerged in Asia and subsequently developed into an international outbreak of respiratory illness among persons in 29 countries during the first six months of 2003. "Severe acute respiratory syndrome" (SARS) is a viral upper respiratory infection associated with a newly described coronavirus (SARS-associated Co-V ). SARS-CoV is an enveloped RNA virus. It is present in high titers in respiratory secretions, stool, and blood of infected persons. The modes of transmission determined from epidemiologic investigations were primarily forms of direct contact (i.e., large droplet aerosolization and person-to-person contact). Respiratory secretions were presumed to be the major source of virus in these situations; airborne transmission of virus has not been completely ruled out. Little is known about the impact of fecal-oral transmission and SARS.
The epidemiology of SARS-CoV infection is not completely understood, and therefore recommended infection control and prevention measures to contain the spread of SARS will evolve as new information becomes available. 1159 At present there is no indication that established strategies for cleaning (i.e., to remove the majority of bioburden) and disinfecting equipment and environmental surfaces need to be changed for the environmental infection control of SARS. In-patient rooms housing SARS patients should be cleaned and disinfected at least daily and at the time of patient transfer or discharge. More frequent cleaning and disinfection may be indicated for high-touch surfaces and following aerosolproducing procedures (e.g., intubation, bronchoscopy, and sputum production). While there are presently no disinfectant products registered by EPA specifically for inactivation of SARS-CoV, EPA-registered hospital disinfectants that are equivalent to low-and intermediate-level germicides may be used on precleaned, hard, non-porous surfaces in accordance with manufacturer's instructions for environmental surface disinfection. Monitoring adherence to guidelines established for cleaning and disinfection is an important component of environmental infection control to contain the spread of SARS.

# e. Creutzfeldt-Jakob Disease (CJD) in Patient-Care Areas
Creutzfeldt-Jakob disease (CJD) is a rare, invariably fatal, transmissible spongiform encephalopathy (TSE) that occurs worldwide with an average annual incidence of 1 case per million population.  CJD is one of several TSEs affecting humans; other diseases in this group include kuru, fatal familial insomnia, and Gerstmann-Straussler-Scheinker syndrome. A TSE that affects a younger population (compared to the age range of CJD cases) has been described primarily in the United Kingdom since 1996. 1163 This variant form of CJD (vCJD) is clinically and neuropathologically distinguishable from classic CJD; epidemiologic and laboratory evidence suggests a causal association for bovine spongiform encephalopathy (BSE ) and vCJD.  The agent associated with CJD is a prion, which is an abnormal isoform of a normal protein constituent of the central nervous system.  The mechanism by which the normal form of the protein is converted to the abnormal, disease-causing prion is unknown. The tertiary conformation of the abnormal prion protein appears to confer a heightened degree of resistance to conventional methods of sterilization and disinfection. 1170,1171 Although about 90% of CJD cases occur sporadically, a limited number of cases are the result of a direct exposure to prion-containing material (usually central nervous system tissue or pituitary hormones) acquired as a result of health care (iatrogenic cases). These cases have been linked to a. pituitary hormone therapy , 1170-1174 b. transplants of either dura mater or corneas,  and c. neurosurgical instruments and depth electrodes.  In the cases involving instruments and depth electrodes, conventional cleaning and terminal reprocessing methods of the day failed to fully inactivate the contaminating prions and are considered inadequate by today's standards.
Prion inactivation studies involving whole tissues and tissue homogenates have been conducted to determine the parameters of physical and chemical methods of sterilization or disinfection necessary for complete inactivation; 1170, 1186-1191 however, the application of these findings to environmental infection control in health-care settings is problematic. No studies have evaluated the effectiveness of medical instrument reprocessing in inactivating prions. Despite a consensus that abnormal prions display some extreme measure of resistance to inactivation by either physical or chemical methods, scientists disagree about the exact conditions needed for sterilization. Inactivation studies utilizing whole tissues present extraordinary challenges to any sterilizing method. 1192 Additionally, the experimental designs of these studies preclude the evaluation of surface cleaning as a part of the total approach to pathogen inactivation. 951,1192 Some researchers have recommended the use of either a 1:2 v/v dilution of sodium hypochorite (approximately 20,000 ppm), full-strength sodium hypochlorite (50,000-60,000 ppm), or 1-2 N sodium hydroxide (NaOH) for the inactivation of prions on certain surfaces (e.g., those found in the pathology laboratory). 1170,1188 Although these chemicals may be appropriate for the decontamination of laboratory, operating-room, or autopsy-room surfaces that come into contact with central nervous system tissue from a known or suspected patient, this approach is not indicated for routine or terminal cleaning of a room previously occupied by a CJD patient. Both chemicals pose hazards for the healthcare worker doing the decontamination. NaOH is caustic and should not make contact with the skin. Sodium hypochlorite solutions (i.e., chlorine bleach) can corrode metals (e.g., aluminum). MSDS information should be consulted when attempting to work with concentrated solutions of either chemical. Currently, no EPAregistered products have label claims for prion inactivation; therefore, this guidance is based on the best available evidence from the scientific literature.
Environmental infection-control strategies must based on the principles of the "chain of infection," regardless of the disease of concern. 13 Although CJD is transmissible, it is not highly contagious. All iatrogenic cases of CJD have been linked to a direct exposure to prion-contaminated central nervous system tissue or pituitary hormones. The six documented iatrogenic cases associated with instruments and devices involved neurosurgical instruments and devices that introduced residual contamination directly to the recipient's brain. No evidence suggests that vCJD has been transmitted iatrogenically or that either CJD or vCJD has been transmitted from environmental surfaces (e.g., housekeeping surfaces). Therefore, routine procedures are adequate for terminal cleaning and disinfection of a CJD patient's room. Additionally, in epidemiologic studies involving highly transfused patients, blood was not identified as a source for prion transmission.  Routine procedures for containing, decontaminating, and disinfecting surfaces with blood spills should be adequate for proper infection control in these situations. 951,1199 Guidance for environmental infection control in ORs and autopsy areas has been published. 1197,1199 Hospitals should develop risk-assessment procedures to identify patients with known or suspected CJD in efforts to implement prion-specific infection-control measures for the OR and for instrument reprocessing. 1200 This assessment also should be conducted for older patients undergoing non-lesionous neurosurgery when such procedures are being done for diagnosis. Disposable, impermeable coverings should be used during these autopsies and neurosurgeries to minimize surface contamination. Surfaces that have become contaminated with central nervous system tissue or cerebral spinal fluid should be cleaned and decontaminated by a. removing most of the tissue or body substance with absorbent materials, b. wetting the surface with a sodium hypochlorite solution containing 5,000 ppm or a 1 N NaOH solution, and c. rinsing thoroughly. 951,1201 The optimum duration of contact exposure in these instances is unclear. Some researchers recommend a 1-hour contact time on the basis of tissue-inactivation studies, 1197,1198,1201 whereas other reviewers of the subject draw no conclusions from this research. 1199 Factors to consider before cleaning a potentially contaminated surface are a. the degree to which gross tissue/body substance contamination can be effectively removed and b. the ease with which the surface can be cleaned.

# F. Environmental Sampling
This portion of Part I addresses the basic principles and methods of sampling environmental surfaces and other environmental sources for microorganisms. The applied strategies of sampling with respect to environmental infection control have been discussed in the appropriate preceding subsections.

# General Principles: Microbiologic Sampling of the Environment
Before 1970, U.S. hospitals conducted regularly scheduled culturing of the air and environmental surfaces (e.g., floors, walls, and table tops). 1202 By 1970, CDC and the American Hospital Association (AHA) were advocating the discontinuation of routine environmental culturing because rates of healthcare-associated infection had not been associated with levels of general microbial contamination of air or environmental surfaces, and because meaningful standards for permissible levels of microbial contamination of environmental surfaces or air did not exist. 1203-1205During 1970, 25% of U.S. hospitals reduced the extent of such routine environmental culturing -a trend that has continued. 1206,1207 Random, undirected sampling (referred to as "routine" in previous guidelines) differs from the current practice of targeted sampling for defined purposes. 2,1204 Previous recommendations against routine sampling were not intended to discourage the use of sampling in which sample collection, culture, and interpretation are conducted in accordance with defined protocols. 2 In this guideline, targeted microbiologic sampling connotes a monitoring process that includes a. a written, defined, multidisciplinary protocol for sample collection and culturing b. analysis and interpretation of results using scientifically determined or anticipatory baseline values for comparison; and c. expected actions based on the results obtained.
Infection control, in conjunction with laboratorians, should assess the health-care facility's capability to conduct sampling and determine when expert consultation and/or services are needed.
Microbiologic sampling of air, water, and inanimate surfaces (i.e., environmental sampling) is an expensive and time-consuming process that is complicated by many variables in protocol, analysis, and interpretation. It is therefore indicated for only four situations. 1208 The first is to support an investigation of an outbreak of disease or infections when environmental reservoirs or fomites are implicated epidemiologically in disease transmission. 161,1209,1210 It is important that such culturing be supported by epidemiologic data. Environmental sampling, as with all laboratory testing, should not be conducted if there is no plan for interpreting and acting on the results obtained. 11,1211,1212 Linking microorganisms from environmental samples with clinical isolates by molecular epidemiology is crucial whenever it is possible to do so.
The second situation for which environmental sampling may be warranted is in research. Well-designed and controlled experimental methods and approaches can provide new information about the spread of health-care associated diseases. 126, 129 A classic example is the study of environmental microbial contamination that compared health-care associated infection rates in an old hospital and a new facility before and shortly after occupancy. 947 The third indication for sampling is to monitor a potentially hazardous environmental condition, confirm the presence of a hazardous chemical or biological agent, and validate the successful abatement of the hazard. This type of sampling can be used to: a. detect bioaerosols released from the operation of health-care equipment (e.g., an ultrasonic cleaner)
and determine the success of repairs in containing the hazard, 1213 b. detect the release of an agent of bioterrorism in an indoor environmental setting and determine its successful removal or inactivation, and c. sample for industrial hygiene or safety purposes (e.g., monitoring a "sick building").
The fourth indication is for quality assurance to evaluate the effects of a change in infection-control practice or to ensure that equipment or systems perform according to specifications and expected outcomes. Any sampling for quality-assurance purposes must follow sound sampling protocols and address confounding factors through the use of properly selected controls. Results from a single environmental sample are difficult to interpret in the absence of a frame of reference or perspective. Evaluations of a change in infection-control practice are based on the assumption that the effect will be measured over a finite period, usually of short duration. Conducting quality-assurance sampling on an extended basis, especially in the absence of an adverse outcome, is usually unjustified. A possible exception might be the use of air sampling during major construction periods to qualitatively detect breaks in environmental infection-control measures. In one study, which began as part of an investigation of an outbreak of health-care associated aspergillosis, airborne concentrations of Aspergillus spores were measured in efforts to evaluate the effectiveness of sealing hospital doors and windows during a period of construction of a nearby building. 50 Other examples of sampling for quality-assurance purposes may include commissioning newly constructed space in special care areas (i.e., ORs and units for immunosuppressed patients) or assessing a change in housekeeping practice. However, the only types of routine environmental microbiologic sampling recommended as part of a quality-assurance program are a. the biological monitoring of sterilization processes by using bacterial spores 1214 and b. the monthly culturing of water used in hemodialysis applications and for the final dialysate use dilution. Some experts also advocate periodic environmental sampling to evaluate the microbial/particulate quality for regular maintenance of the air handling system (e.g., filters) and to verify that the components of the system meet manufacturer's specifications (A. Streifel, University of Minnesota, 2000). Certain equipment in health-care settings (e.g., biological safety cabinets) may also be monitored with air flow and particulate sampling to determine performance or as part of adherence to a certification program; results can then be compared with a predetermined standard of performance. These measurements, however, usually do not require microbiologic testing.

# Air Sampling
Biological contaminants occur in the air as aerosols and may include bacteria, fungi, viruses, and pollens. 1215,1216 Aerosols are characterized as solid or liquid particles suspended in air. Talking for 5 minutes and coughing each can produce 3,000 droplet nuclei; sneezing can generate approximately 40,000 droplets which then evaporate to particles in the size range of 0.5-12 m. 137,1217 Particles in a biological aerosol usually vary in size from <1 m to 50 m. These particles may consist of a single, unattached organism or may occur in the form of clumps composed of a number of bacteria. Clumps can also include dust and dried organic or inorganic material. Vegetative forms of bacterial cells and viruses may be present in the air in a lesser number than bacterial spores or fungal spores. Factors that determine the survival of microorganisms within a bioaerosol include a. the suspending medium, b. temperature, c. relative humidity, d. oxygen sensitivity, and e. exposure to UV or electromagnetic radiation. 1215 Many vegetative cells will not survive for lengthy periods of time in the air unless the protective cover (e.g., dried organic or inorganic matter). 1216 Pathogens that resist drying (e.g., Staphylococcus spp., Streptococcus spp., and fungal spores) can survive for long periods and can be carried considerable distances via air and still remain viable. They may also settle on surfaces and become airborne again as secondary aerosols during certain activities (e.g., sweeping and bed making). 1216,1218 Microbiologic air sampling is used as needed to determine the numbers and types of microorganisms, or particulates, in indoor air. 289 Air sampling for quality control is, however, problematic because of lack of uniform air-quality standards. Although airborne spores of Aspergillus spp. can pose a risk for neutropenic patients, the critical number (i.e., action level) of these spores above which outbreaks of aspergillosis would be expected to occur has not been defined. Health-care professionals considering the use of air sampling should keep in mind that the results represent indoor air quality at singular points in time, and these may be affected by a variety of factors, including a. indoor traffic, b. visitors entering the facility, c. temperature, d. time of day or year, e. relative humidity, f. relative concentration of particles or organisms, and g) the performance of the air-handling system components.
To be meaningful, air-sampling results must be compared with those obtained from other defined areas, conditions, or time periods.
Several preliminary concerns must be addressed when designing a microbiologic air sampling strategy (Box 13). Because the amount of particulate material and bacteria retained in the respiratory system is largely dependent on the size of the inhaled particles, particle size should be determined when studying airborne microorganisms and their relation to respiratory infections. Particles >5 m are efficiently trapped in the upper respiratory tract and are removed primarily by ciliary action. 1219 Particles 5 m in diameter reach the lung, but the greatest retention in the alveoli is of particles 1-2 m in diameter. 

# Box 13. Preliminary concerns for conducting air sampling
- Consider the possible characteristics and conditions of the aerosol, including size range of particles, relative amount of inert material, concentration of microorganisms, and environmental factors.
- Determine the type of sampling instruments, sampling time, and duration of the sampling program.
- Determine the number of samples to be taken.
- Ensure that adequate equipment and supplies are available.
- Determine the method of assay that will ensure optimal recovery of microorganisms.
- Select a laboratory that will provide proper microbiologic support.
- Ensure that samples can be refrigerated if they cannot be assayed in the laboratory promptly.
Bacteria, fungi, and particulates in air can be identified and quantified with the same methods and equipment (Table 23). The basic methods include a. impingement in liquids, b. impaction on solid surfaces, c. sedimentation, d. filtration, e. centrifugation, f. electrostatic precipitation, and g. thermal precipitation. 1218 Of these, impingement in liquids, impaction on solid surfaces, and sedimentation (on settle plates) have been used for various air-sampling purposes in health-care settings. 289 Several instruments are available for sampling airborne bacteria and fungi (Box 14). Some of the samplers are self-contained units requiring only a power supply and the appropriate collecting medium, but most require additional auxiliary equipment (e.g., a vacuum pump and an airflow measuring device ). Sedimentation or depositional methods use settle plates and therefore need no special instruments or equipment. Selection of an instrument for air sampling requires a clear understanding of the type of information desired and the particular determinations that must be made (Box 14). Information may be needed regarding a. one particular organism or all organisms that may be present in the air, b. the concentration of viable particles or of viable organisms, c. the change in concentration with time, and d. the size distribution of the collected particles.
Before sampling begins, decisions should be made regarding whether the results are to be qualitative or quantitative. Comparing quantities of airborne microorganisms to those of outdoor air is also standard operating procedure. Infection-control professionals, hospital epidemiologists, industrial hygienists, and laboratory supervisors, as part of a multidisciplinary team, should discuss the potential need for microbial air sampling to determine if the capacity and expertise to conduct such sampling exists within the facility and when it is appropriate to enlist the services of an environmental microbiologist consultant.

# Box 14. Selecting an air sampling device*
The following factors must be considered when choosing an air sampling instrument:
- Viability and type of the organism to be sampled
- Compatibility with the selected method of analysis
- Sensitivity of particles to sampling - Assumed concentrations and particle size
- Whether airborne clumps must be broken (i.e., total viable organism count vs. particle count)
- Volume of air to be sampled and length of time sampler is to be continuously operated Liquid impinger and solid impactor samplers are the most practical for sampling bacteria, particles, and fungal spores, because they can sample large volumes of air in relatively short periods of time. 289 Solid impactor units are available as either "slit" or "sieve" designs. Slit impactors use a rotating disc as support for the collecting surface, which allows determinations of concentration over time. Sieve impactors commonly use stages with calibrated holes of different diameters. Some impactor-type samplers use centrifugal force to impact particles onto agar surfaces. The interior of either device must be made sterile to avoid inadvertent contamination from the sampler. Results obtained from either sampling device can be expressed as organisms or particles per unit volume of air (CFU/m 3 ).
Sampling for bacteria requires special attention, because bacteria may be present as individual organisms, as clumps, or mixed with or adhering to dust or covered with a protective coating of dried organic or inorganic substances. Reports of bacterial concentrations determined by air sampling therefore must indicate whether the results represent individual organisms or particles bearing multiple cells. Certain types of samplers (e.g., liquid impingers) will completely or partially disintegrate clumps and large particles; the sampling result will therefore reflect the total number of individual organisms present in the air.
The task of sizing a bioaerosol is simplified through the use of sieves or slit impactors because these samplers will separate the particles and microorganisms into size ranges as the sample is collected. These samplers must, however, be calibrated first by sampling aerosols under similar use conditions. 1225 The use of settle plates (i.e., the sedimentation or depositional method) is not recommended when sampling air for fungal spores, because single spores can remain suspended in air indefinitely. 289 Settle plates have been used mainly to sample for particulates and bacteria either in research studies or during epidemiologic investigations. 161, Results of sedimentation sampling are typically expressed as numbers of viable particles or viable bacteria per unit area per the duration of sampling time (i.e., CFU/area/time); this method can not quantify the volume of air sampled. Because the survival of microorganisms during air sampling is inversely proportional to the velocity at which the air is taken into the sampler, 1215 one advantage of using a settle plate is its reliance on gravity to bring organisms and particles into contact with its surface, thus enhancing the potential for optimal survival of collected organisms. This process, however, takes several hours to complete and may be impractical for some situations.
Air samplers are designed to meet differing measurement requirements. Some samplers are better suited for one form of measurement than others. No one type of sampler and assay procedure can be used to collect and enumerate 100% of airborne organisms. The sampler and/or sampling method chosen should, however, have an adequate sampling rate to collect a sufficient number of particles in a reasonable time period so that a representative sample of air is obtained for biological analysis. Newer analytical techniques for assaying air samples include PCR methods and enzyme-linked immunosorbent assays (ELISAs).

# Water Sampling
A detailed discussion of the principles and practices of water sampling has been published. 945 Water sampling in health-care settings is used detect waterborne pathogens of clinical significance or to determine the quality of finished water in a facility's distribution system. Routine testing of the water in a health-care facility is usually not indicated, but sampling in support of outbreak investigations can help determine appropriate infection-control measures. Water-quality assessments in dialysis settings have been discussed in this guideline (see Water, Dialysis Water Quality and Dialysate, and Appendix C).
Health-care facilities that conduct water sampling should have their samples assayed in a laboratory that uses established methods and quality-assurance protocols. Water specimens are not "static specimens" at ambient temperature; potential changes in both numbers and types of microbial populations can occur during transport. Consequently, water samples should be sent to the testing laboratory cold (i.e., at approximately 39.2F ) and testing should be done as soon as practical after collection (preferably within 24 hours).
Because most water sampling in health-care facilities involves the testing of finished water from the facility's distribution system, a reducing agent (i.e., sodium thiosulfate ) needs to be added to neutralize residual chlorine or other halogen in the collected sample. If the water contains elevated levels of heavy metals, then a chelating agent should be added to the specimen. The minimum volume of water to be collected should be sufficient to complete any and all assays indicated; 100 mL is considered a suitable minimum volume. Sterile collection equipment should always be used.
Sampling from a tap requires flushing of the water line before sample collection. If the tap is a mixing faucet, attachments (e.g., screens and aerators) must be removed, and hot and then cold water must be run through the tap before collecting the sample. 945 If the cleanliness of the tap is questionable, disinfection with 500-600 ppm sodium hypochlorite (1:100 v/v dilution of chlorine bleach) and flushing the tap should precede sample collection.
Microorganisms in finished or treated water often are physically damaged ("stressed") to the point that growth is limited when assayed under standard conditions. Such situations lead to false-negative readings and misleading assessments of water quality. Appropriate neutralization of halogens and chelation of heavy metals are crucial to the recovery of these organisms. The choice of recovery media and incubation conditions will also affect the assay. Incubation temperatures should be closer to the ambient temperature of the water rather than at 98.6F (37C), and recovery media should be formulated to provide appropriate concentrations of nutrients to support organisms exhibiting less than rigorous growth. 945 High-nutrient content media (e.g., blood agar and tryptic soy agar ) may actually inhibit the growth of these damaged organisms. Reduced nutrient media (e.g., diluted peptone and R2A) are preferable for recovery of these organisms. 945 Use of aerobic, heterotrophic plate counts allows both a qualitative and quantitative measurement for water quality. If bacterial counts in water are expected to be high in number (e.g., during waterborne outbreak investigations), assaying small quantities using pour plates or spread plates is appropriate. 945 Membrane filtration is used when low-count specimens are expected and larger sampling volumes are required (100 mL). The sample is filtered through the membrane, and the filter is applied directly faceup onto the surface of the agar plate and incubated.
Unlike the testing of potable water supplies for coliforms (which uses standardized test and specimen collection parameters and conditions), water sampling to support epidemiologic investigations of disease outbreaks may be subjected to modifications dictated by the circumstances present in the facility. Assay methods for waterborne pathogens may also not be standardized. Therefore, control or comparison samples should be included in the experimental design. Any departure from a standard method should be fully documented and should be considered when interpreting results and developing strategies. Assay methods specific for clinically significant waterborne pathogens (e.g., Legionella spp., Aeromonas spp., Pseudomonas spp., and Acinetobacter spp.) are more complicated and costly compared with both methods used to detect coliforms and other standard indicators of water quality.

# Environmental Surface Sampling
Routine environmental-surface sampling (e.g., surveillance cultures) in health-care settings is neither cost-effective nor warranted. 951, 1225 When indicated, surface sampling should be conducted with multidisciplinary approval in adherence to carefully considered plans of action and policy (Box 15).

# Box 15. Undertaking environmental-surface sampling*
The following factors should be considered before engaging in environmental-surface sampling:
- Background information from the literature and present activities (i.e., preliminary results from an epidemiologic investigation)
- Location of surfaces to be sampled Surface sampling is used currently for research, as part of an epidemiologic investigation, or as part of a comprehensive approach for specific quality assurance purposes. As a research tool, surface sampling has been used to determine a. potential environmental reservoirs of pathogens, 564, b. survival of microorganisms on surfaces, 1232,1233 and c. the sources of the environmental contamination. 1023 Some or all of these approaches can also be used during outbreak investigations. 1232 Discussion of surface sampling of medical devices and instruments is beyond the scope of this document and is deferred to future guidelines on sterilization and disinfection issues.
Meaningful results depend on the selection of appropriate sampling and assay techniques. 1214 The media, reagents, and equipment required for surface sampling are available from any well-equipped microbiology laboratory and laboratory supplier. For quantitative assessment of surface organisms, nonselective, nutrient-rich agar media and broth (e.g., TSA and brain-heart infusion broth  with or without 5% sheep or rabbit blood supplement) are used for the recovery of aerobic bacteria. Broth media are used with membrane-filtration techniques. Further sample work-up may require the use of selective media for the isolation and enumeration of specific groups of microorganisms. Examples of selective media are MacConkey agar (MAC ), Cetrimide agar (selects for Pseudomonas aeruginosa), or Sabouraud dextrose-and malt extract agars and broths (select for fungi). Qualitative determinations of organisms from surfaces require only the use of selective or non-selective broth media.
Effective sampling of surfaces requires moisture, either already present on the surface to be sampled or via moistened swabs, sponges, wipes, agar surfaces, or membrane filters. 1214, Dilution fluids and rinse fluids include various buffers or general purpose broth media (Table 24). If disinfectant residuals are expected on surfaces being sampled, specific neutralizer chemicals should be used in both the growth media and the dilution or rinse fluids. Lists of the neutralizers, the target disinfectant active ingredients, and the use concentrations have been published. 1214,1237 Alternatively, instead of adding neutralizing chemicals to existing culture media (or if the chemical nature of the disinfectant residuals is unknown), the use of either a. commercially available media including a variety of specific and nonspecific neutralizers or b. double-strength broth media will facilitate optimal recovery of microorganisms.
The inclusion of appropriate control specimens should be included to rule out both residual antimicrobial activity from surface disinfectants and potential toxicity caused by the presence of neutralizer chemicals carried over into the assay system. 1214 Several methods can be used for collecting environmental surface samples (Table 25). Specific stepbystep discussions of each of the methods have been published. 1214,1239 For best results, all methods should incorporate aseptic techniques, sterile equipment, and sterile recovery media. Sample/rinse methods are frequently chosen because of their versatility. However, these sampling methods are the most prone to errors caused by manipulation of the swab, gauze pad, or sponge. 1238 Additionally, no microbiocidal or microbiostatic agents should be present in any of these items when used for sampling. 1238 Each of the rinse methods requires effective elution of microorganisms from the item used to sample the surface. Thorough mixing of the rinse fluids after elution (e.g., via manual or mechanical mixing using a vortex mixer, shaking with or without glass beads, and ultrasonic bath) will help to remove and suspend material from the sampling device and break up clumps of organisms for a more accurate count. 1238 In some instances, the item used to sample the surface (e.g., gauze pad and sponge) may be immersed in the rinse fluids in a sterile bag and subjected to stomaching. 1238 This technique, however, is suitable only for soft or absorbent items that will not puncture the bag during the elution process.
If sampling is conducted as part of an epidemiologic investigation of a disease outbreak, identification of isolates to species level is mandatory, and characterization beyond the species level is preferred. 1214 When interpreting the results of the sampling, the expected degree of microbial contamination associated with the various categories of surfaces in the Spaulding classification must be considered. Environmental surfaces should be visibly clean; recognized pathogens in numbers sufficient to result in secondary transfer to other animate or inanimate surfaces should be absent from the surface being sampled. 1214 Although the interpretation of a sample with positive microbial growth is self-evident, an environmental surface sample, especially that obtained from housekeeping surfaces, that shows no growth does not represent a "sterile" surface. Sensitivities of the sampling and assay methods (i.e., level of detection) must be taken into account when no-growth samples are encountered. Properly collected control samples will help rule out extraneous contamination of the surface sample.

# G. Laundry and Bedding

# General Information
Laundry in a health-care facility may include bed sheets and blankets, towels, personal clothing, patient apparel, uniforms, scrub suits, gowns, and drapes for surgical procedures. 1245 Although contaminated textiles and fabrics in health-care facilities can be a source of substantial numbers of pathogenic microorganisms, reports of health-care associated diseases linked to contaminated fabrics are so few in number that the overall risk of disease transmission during the laundry process likely is negligible. When the incidence of such events are evaluated in the context of the volume of items laundered in health-care settings (estimated to be 5 billion pounds annually in the United States), 1246 existing control measures (e.g., standard precautions) are effective in reducing the risk of disease transmission to patients and staff. Therefore, use of current control measures should be continued to minimize the contribution of contaminated laundry to the incidence of health-care associated infections. The control measures described in this section of the guideline are based on principles of hygiene, common sense, and consensus guidance; they pertain to laundry services utilized by health-care facilities, either inhouse or contract, rather than to laundry done in the home.

# Epidemiology and General Aspects of Infection Control
Contaminated textiles and fabrics often contain high numbers of microorganisms from body substances, including blood, skin, stool, urine, vomitus, and other body tissues and fluids. When textiles are heavily contaminated with potentially infective body substances, they can contain bacterial loads of 10 6 -10 8 CFU/100 cm 2 of fabric. 1247 Disease transmission attributed to health-care laundry has involved contaminated fabrics that were handled inappropriately (i.e., the shaking of soiled linens). Bacteria (Salmonella spp., Bacillus cereus), viruses (hepatitis B virus ), fungi (Microsporum canis), and ectoparasites (scabies) presumably have been transmitted from contaminated textiles and fabrics to workers via a. direct contact or b. aerosols of contaminated lint generated from sorting and handling contaminated textiles.  In these events, however, investigations could not rule out the possibility that some of these reported infections were acquired from community sources. Through a combination of soil removal, pathogen removal, and pathogen inactivation, contaminated laundry can be rendered hygienically clean. Hygienically clean laundry carries negligible risk to health-care workers and patients, provided that the clean textiles, fabric, and clothing are not inadvertently contaminated before use.
OSHA defines contaminated laundry as "laundry which has been soiled with blood or other potentially infectious materials or may contain sharps." 967 The purpose of the laundry portion of the standard is to protect the worker from exposure to potentially infectious materials during collection, handling, and sorting of contaminated textiles through the use of personal protective equipment, proper work practices, containment, labeling, hazard communication, and ergonomics.
Experts are divided regarding the practice of transporting clothes worn at the workplace to the healthcare worker's home for laundering. Although OSHA regulations prohibit home laundering of items that are considered personal protective apparel or equipment (e.g., laboratory coats), 967 experts disagree about whether this regulation extends to uniforms and scrub suits that are not contaminated with blood or other potentially infectious material. Health-care facility policies on this matter vary and may be inconsistent with recommendations of professional organizations. 1253,1254 Uniforms without blood or body substance contamination presumably do not differ appreciably from street clothes in the degree and microbial nature of soilage. Home laundering would be expected to remove this level of soil adequately. However, if health-care facilities require the use of uniforms, they should either make provisions to launder them or provide information to the employee regarding infection control and cleaning guidelines for the item based on the tasks being performed at the facility. Health-care facilities should address the need to provide this service and should determine the frequency for laundering these items. In a recent study examining the microbial contamination of medical students' white coats, the students perceived the coats as "clean" as long as the garments were not visibly contaminated with body substances, even after wearing the coats for several weeks. 1255 The heaviest bacterial load was found on the sleeves and the pockets of these garments; the organisms most frequently isolated were Staphylococcus aureus, diphtheroids, and Acinetobacter spp. 1255 Presumably, the sleeves of the coat may make contact with a patient and potentially serve to transfer environmentally stable microorganisms among patients. In this study, however, surveillance was not conducted among patients to detect new infections or colonizations. The students did, however, report that they would likely replace their coats more frequently and regularly if clean coats were provided. 1255 Apart from this study, which documents the presence of pathogenic bacteria on health-care facility clothing, reports of infections attributed to either the contact with such apparel or with home laundering have been rare. 1256,1257 Laundry services for health-care facilities are provided either in-house (i.e., on-premise laundry ), co-operatives (i.e., those entities owned and operated by a group of facilities), or by off-site commercial laundries. In the latter, the textiles may be owned by the health-care facility, in which case the processor is paid for laundering only. Alternatively, the textiles may be owned by the processor who is paid for every piece laundered on a "rental" fee. The laundry facility in a health-care setting should be designed for efficiency in providing hygienically clean textiles, fabrics, and apparel for patients and staff. Guidelines for laundry construction and operation for health-care facilities, including nursing facilities, have been published. 120,1258 The design and engineering standards for existing facilities are those cited in the AIA edition in effect during the time of the facility's construction. 120 A laundry facility is usually partitioned into two separate areas -a "dirty" area for receiving and handling the soiled laundry and a "clean" area for processing the washed items. 1259 To minimize the potential for recontaminating cleaned laundry with aerosolized contaminated lint, areas receiving contaminated textiles should be at negative air pressure relative to the clean areas.  Laundry areas should have handwashing facilities readily available to workers. Laundry workers should wear appropriate personal protective equipment (e.g., gloves and protective garments) while sorting soiled fabrics and textiles. 967 Laundry equipment should be used and maintained according to the manufacturer's instructions to prevent microbial contamination of the system. 1250,1263 Damp textiles should not be left in machines overnight. 1250

# Collecting, Transporting, and Sorting Contaminated Textiles and Fabrics
The laundry process starts with the removal of used or contaminated textiles, fabrics, and/or clothing from the areas where such contamination occurred, including but not limited to patients' rooms, surgical/operating areas, and laboratories. Handling contaminated laundry with a minimum of agitation can help prevent the generation of potentially contaminated lint aerosols in patient-care areas. 967,1259 Sorting or rinsing contaminated laundry at the location where contamination occurred is prohibited by OSHA. 967 Contaminated textiles and fabrics are placed into bags or other appropriate containment in this location; these bags are then securely tied or otherwise closed to prevent leakage. 967 Single bags of sufficient tensile strength are adequate for containing laundry, but leak-resistant containment is needed if the laundry is wet and capable of soaking through a cloth bag. 1264 Bags containing contaminated laundry must be clearly identified with labels, color-coding, or other methods so that health-care workers handle these items safely, regardless of whether the laundry is transported within the facility or destined for transport to an off-site laundry service. 967 Typically, contaminated laundry originating in isolation areas of the hospital is segregated and handled with special practices; however, few, if any, cases of health-care associated infection have been linked to this source. 1265 Single-blinded studies have demonstrated that laundry from isolation areas is no more heavily contaminated with microorganisms than laundry from elsewhere in the hospital. 1266 Therefore, adherence to standard precautions when handling contaminated laundry in isolation areas and minimizing agitation of the contaminated items are considered sufficient to prevent the dispersal of potentially infectious aerosols. 6 Contaminated textiles and fabrics in bags can be transported by cart or chute. 1258,1262 Laundry chutes require proper design, maintenance, and use, because the piston-like action of a laundry bag traveling in the chute can propel airborne microbial contaminants throughout the facility.  Laundry chutes should be maintained under negative air pressure to prevent the spread of microorganisms from floor to floor. Loose, contaminated pieces of laundry should not be tossed into chutes, and laundry bags should be closed or otherwise secured to prevent the contents from falling out into the chute. 1270 Health-care facilities should determine the point in the laundry process at which textiles and fabrics should be sorted. Sorting after washing minimizes the exposure of laundry workers to infective material in soiled fabrics, reduces airborne microbial contamination in the laundry area, and helps to prevent potential percutaneous injuries to personnel. 1271 Sorting laundry before washing protects both the machinery and fabrics from hard objects (e.g., needles, syringes, and patients' property) and reduces the potential for recontamination of clean textiles. 1272 Sorting laundry before washing also allows for customization of laundry formulas based on the mix of products in the system and types of soils encountered. Additionally, if work flow allows, increasing the amount of segregation by specific product types will usually yield the greatest amount of work efficiency during inspection, folding, and pack-making operations. 1253 Protective apparel for the workers and appropriate ventilation can minimize these exposures. 967, Gloves used for the task of sorting laundry should be of sufficient thickness to minimize sharps injuries. 967 Employee safety personnel and industrial hygienists can help to determine the appropriate glove choice.

# Parameters of the Laundry Process
Fabrics, textiles, and clothing used in health-care settings are disinfected during laundering and generally rendered free of vegetative pathogens (i.e., hygienically clean), but they are not sterile. 1273 Laundering cycles consist of flush, main wash, bleaching, rinsing, and souring. 1274 Cleaned wet textiles, fabrics, and clothing are then dried, pressed as needed, and prepared (e.g., folded and packaged) for distribution back to the facility. Clean linens provided by an off-site laundry must be packaged prior to transport to prevent inadvertent contamination from dust and dirt during loading, delivery, and unloading. Functional packaging of laundry can be achieved in several ways, including a. placing clean linen in a hamper lined with a previously unused liner, which is then closed or covered b. placing clean linen in a properly cleaned cart and covering the cart with disposable material or a properly cleaned reusable textile material that can be secured to the cart; and c. wrapping individual bundles of clean textiles in plastic or other suitable material and sealing or taping the bundles.
The antimicrobial action of the laundering process results from a combination of mechanical, thermal, and chemical factors. 1271,1275,1276 Dilution and agitation in water remove substantial quantities of microorganisms. Soaps and detergents function to suspend soils and also exhibit some microbiocidal properties. Hot water provides an effective means of destroying microorganisms. 1277 A temperature of at least 160F (71C) for a minimum of 25 minutes is commonly recommended for hot-water washing. 2 Water of this temperature can be provided by steam jet or separate booster heater. 120 The use of chlorine bleach assures an extra margin of safety. 1278, 1279 A total available chlorine residual of 50-150 ppm is usually achieved during the bleach cycle. 1277 Chlorine bleach becomes activated at water temperatures of 135F-145F (57.2C-62.7C). The last of the series of rinse cycles is the addition of a mild acid (i.e., sour) to neutralize any alkalinity in the water supply, soap, or detergent. The rapid shift in pH from approximately 12 to 5 is an effective means to inactivate some microorganisms. 1247 Effective removal of residual alkali from fabrics is an important measure in reducing the risk for skin reactions among patients.
Chlorine bleach is an economical, broad-spectrum chemical germicide that enhances the effectiveness of the laundering process. Chlorine bleach is not, however, an appropriate laundry additive for all fabrics. Traditionally, bleach was not recommended for laundering flame-retardant fabrics, linens, and clothing because its use diminished the flame-retardant properties of the treated fabric. 1273 However, some modernday flame retardant fabrics can now tolerate chlorine bleach. Flame-retardant fabrics, whether topically treated or inherently flame retardant, should be thoroughly rinsed during the rinse cycles, because detergent residues are capable of supporting combustion. Chlorine alternatives (e.g., activated oxygenbased laundry detergents) provide added benefits for fabric and color safety in addition to antimicrobial activity. Studies comparing the antimicrobial potencies of chlorine bleach and oxygen-based bleach are needed. Oxygen-based bleach and detergents used in health-care settings should be registered by EPA to ensure adequate disinfection of laundry. Health-care workers should note the cleaning instructions of textiles, fabrics, drapes, and clothing to identify special laundering requirements and appropriate hygienic cleaning options. 1278 Although hot-water washing is an effective laundry disinfection method, the cost can be substantial. Laundries are typically the largest users of hot water in hospitals. They consume 50%-75% of the total hot water, 1280 representing an average of 10%-15% of the energy used by a hospital. Several studies have demonstrated that lower water temperatures of 71F-77F (22C-25C) can reduce microbial contamination when the cycling of the washer, the wash detergent, and the amount of laundry additive are carefully monitored and controlled. 1247, Low-temperature laundry cycles rely heavily on the presence of chlorine-or oxygen-activated bleach to reduce the levels of microbial contamination. The selection of hot-or cold-water laundry cycles may be dictated by state health-care facility licensing standards or by other regulation. Regardless of whether hot or cold water is used for washing, the temperatures reached in drying and especially during ironing provide additional significant microbiocidal action. 1247 Dryer temperatures and cycle times are dictated by the materials in the fabrics. Man-made fibers (i.e., polyester and polyester blends) require shorter times and lower temperatures.
After washing, cleaned and dried textiles, fabrics, and clothing are pressed, folded, and packaged for transport, distribution, and storage by methods that ensure their cleanliness until use. 2 State regulations and/or accrediting standards may dictate the procedures for this activity. Clean/sterile and contaminated textiles should be transported from the laundry to the health-care facility in vehicles (e.g., trucks, vans, and carts) that allow for separation of clean/sterile and contaminated items. Clean/sterile textiles and contaminated textiles may be transported in the same vehicle, provided that the use of physical barriers and/or space separation can be verified to be effective in protecting the clean/sterile items from contamination. Clean, uncovered/unwrapped textiles stored in a clean location for short periods of time (e.g., uncovered and used within a few hours) have not been demonstrated to contribute to increased levels of health-care acquired infection. Such textiles can be stored in convenient places for use during the provision of care, provided that the textiles can be maintained dry and free from soil and body-substance contamination.
In the absence of microbiologic standards for laundered textiles, no rationale exists for routine microbiologic sampling of cleaned health-care textiles and fabrics. 1286 Sampling may be used as part of an outbreak investigation if epidemiologic evidence suggests that textiles, fabrics, or clothing are a suspected vehicle for disease transmission. Sampling techniques include aseptically macerating the fabric into pieces and adding these to broth media or using contact plates (RODAC plates) for direct surface sampling. 1271,1286 When evaluating the disinfecting properties of the laundering process specifically, placing pieces of fabric between two membrane filters may help to minimize the contribution of the physical removal of microorganisms. 1287 Washing machines and dryers in residential-care settings are more likely to be consumer items rather than the commercial, heavy-duty, large volume units typically found in hospitals and other institutional healthcare settings. Although all washing machines and dryers in health-care settings must be properly maintained for performance according to the manufacturer's instructions, questions have been raised
about the need to disinfect washers and dryers in residential-care settings. Disinfection of the tubs and tumblers of these machines is unnecessary when proper laundry procedures are followed; these procedures involve a. the physical removal of bulk solids (e.g., feces) before the wash/dry cycle and b. proper use of temperature, detergent, and laundry additives.
Infection has not been linked to laundry procedures in residential-care facilities, even when consumer versions of detergents and laundry additives are used.

# Special Laundry Situations
Some textile items (e.g., surgical drapes and reusable gowns) must be sterilized before use and therefore require steam autoclaving after laundering. 7 Although the American Academy of Pediatrics in previous guidelines recommended autoclaving for linens in neonatal intensive care units (NICUs), studies on the microbial quality of routinely cleaned NICU linen have not identified any increased risk for infection among the neonates receiving care. 1288 Consequently, hygienically clean linens are suitable for use in this setting. 997 The use of sterile linens in burn therapy units remains unresolved.
Coated or laminated fabrics are often used in the manufacture of PPE. When these items become contaminated with blood or other body substances, the manufacturer's instructions for decontamination and cleaning take into account the compatibility of the rubber backing with the chemical germicides or detergents used in the process. The directions for decontaminating these items should be followed as indicated; the item should be discarded when the backing develops surface cracks.
Dry cleaning, a cleaning process that utilizes organic solvents (e.g., perchloroethylene) for soil removal, is an alternative means of cleaning fabrics that might be damaged in conventional laundering and detergent washing. Several studies, however, have shown that dry cleaning alone is relatively ineffective in reducing the numbers of bacteria and viruses on contaminated linens; 1289, 1290 microbial populations are significantly reduced only when dry-cleaned articles are heat pressed. Dry cleaning should therefore not be considered a routine option for health-care facility laundry and should be reserved for those circumstances in which fabrics can not be safely cleaned with water and detergent. 1291

# Surgical Gowns, Drapes, and Disposable Fabrics
An issue of recent concern involves the use of disposable (i.e., single use) versus reusable (i.e., multiple use) surgical attire and fabrics in health-care settings. 1292 Regardless of the material used to manufacture gowns and drapes, these items must be resistant to liquid and microbial penetration. 7, Surgical gowns and drapes must be registered with FDA to demonstrate their safety and effectiveness. Repellency and pore size of the fabric contribute to gown performance, but performance capability can be influenced by the item's design and construction. 1298,1299 Reinforced gowns (i.e., gowns with double-layered fabric) generally are more resistant to liquid strike-through. 1300,1301 Reinforced gowns may, however, be less comfortable. Guidelines for selection and use of barrier materials for surgical gowns and drapes have been published. 1302 When selecting a barrier product, repellency level and type of barrier should be compatible for the exposure expected. 967 However, data are limited regarding the association between gown or drape characteristics and risk for surgical site infections. 7,1303 Health-care facilities must ensure optimal protection of patients and health-care workers. Not all fabric items in health care lend themselves to single-use. Facilities exploring options for gowns and drapes should consider the expense of disposable items and the impact on the facility's waste-management costs once these items are discarded. Costs associated with the use of durable goods involve the fabric or textile items; staff expenses to collect, sort, clean, and package the laundry; and energy costs to operate the laundry if on-site or the costs to contract with an outside service. 1304,1305

# Antimicrobial-Impregnated Articles and Consumer Items Bearing Antimicrobial Labeling
Manufacturers are increasingly incorporating antibacterial or antimicrobial chemicals into consumer and health-care items. Some consumer products bearing labels that indicate treatment with antimicrobial chemicals have included pens, cutting boards, toys, household cleaners, hand lotions, cat litter, soaps, cotton swabs, toothbrushes, and cosmetics. The "antibacterial" label on household cleaning products, in particular, gives consumers the impression that the products perform "better" than comparable products without this labeling, when in fact all household cleaners have antibacterial properties.
In the health-care setting, treated items may include children's pajamas, mattresses, and bed linens with label claims of antimicrobial properties. These claims require careful evaluation to determine whether they pertain to the use of antimicrobial chemicals as preservatives for the fabric or other components or whether they imply a health claim. 1306,1307 No evidence is available to suggest that use of these products will make consumers and patients healthier or prevent disease. No data support the use of these items as part of a sound infection-control strategy, and therefore, the additional expense of replacing a facility's bedding and sheets with these treated products is unwarranted.
EPA has reaffirmed its position that manufacturers who make public health claims for articles containing antimicrobial chemicals must provide evidence to support those claims as part of the registration process. 1308 Current EPA regulations outlined in the Treated Articles Exemption of the Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA) require manufacturers to register both the antimicrobial chemical used in or on the product and the finished product itself if a public health claim is maintained for the item. The exemption applies to the use of antimicrobial chemicals for the purpose of preserving the integrity of the product's raw material(s). The U.S. Federal Trade Commission (FTC) is evaluating manufacturer advertising of products with antimicrobial claims. 1309

# Standard Mattresses, Pillows, and Air-Fluidized Beds
Standard mattresses and pillows can become contaminated with body substances during patient care if the integrity of the covers of these items is compromised. The practice of sticking needles into the mattress should be avoided. A mattress cover is generally a fitted, protective material, the purpose of which is to prevent the mattress from becoming contaminated with body fluids and substances. A linen sheet placed on the mattress is not considered a mattress cover. Patches for tears and holes in mattress covers do not provide an impermeable surface over the mattress. Mattress covers should be replaced when torn; the mattress should be replaced if it is visibly stained. Wet mattresses, in particular, can be a substantial environmental source of microorganisms. Infections and colonizations caused by Acinetobacter spp., MRSA, and Pseudomonas aeruginosa have been described, especially among burn patients.  In these reports, the removal of wet mattresses was an effective infection-control measure. Efforts were made to ensure that pads and covers were cleaned and disinfected between patients using disinfectant products compatible with mattress-cover materials to ensure that these covers remained impermeable to fluids.  Pillows and their covers should be easily cleanable, preferably in a hot water laundry cycle. 1315 These should be laundered between patients or if contaminated with body substances.
Air-fluidized beds are used for the care of patients immobilized for extended periods of time because of therapy or injury (e.g., pain, decubitus ulcers, and burns). 1316 These specialized beds consist of a base unit filled with microsphere beads fluidized by warm, dry air flowing upward from a diffuser located at the bottom of the unit. A porous, polyester filter sheet separates the patient from direct contact with the beads but allows body fluids to pass through to the beads. Moist beads aggregate into clumps which settle to the bottom where they are removed as part of routine bed maintenance.
Because the beads become contaminated with the patient's body substances, concerns have been raised about the potential for these beds to serve as an environmental source of pathogens. Certain pathogens (e.g., Enterococcus spp., Serratia marcescens, Staphylococcus aureus, and Streptococcus fecalis) have been recovered either from the microsphere beads or the polyester sheet after cleaning. 1317,1318 Reports of crosscontamination of patients, however, are few. 1318 Nevertheless, routine maintenance and between-patient decontamination procedures can minimize potential risks to patients. Regular removal of bead clumps, coupled with the warm, dry air of the bed, can help to minimize bacterial growth in the unit.  Beads are decontaminated between patients by high heat (113F-194F , depending on the manufacturer's specifications) for at least 1 hour; this procedure is particularly important for the inactivation of Enterococcus spp. which are relatively resistant to heat. 1322,1323 The polyester filter sheet requires regular changing and thorough cleaning and disinfection, especially between patients. 1317,1318,1322,1323 Microbial contamination of the air space in the immediate vicinity of a properly maintained air-fluidized bed is similar to that found in air around conventional bedding, despite the air flow out of the base unit and around the patient. 1320,1324,1325 An operational air-fluidized bed can, however, interfere with proper pressure differentials, especially in negative-pressure rooms; 1326 the effect varies with the location of the bed relative to the room's configuration and supply and exhaust vent locations. Use of an air-fluidized bed in a negative-pressure room requires consultation with a facility engineer to determine appropriate placement of the bed.
H. Animals in Health-Care Facilities

# General Information
Animals in health-care facilities traditionally have been limited to laboratories and research areas. However, their presence in patient-care areas is now more frequent, both in acute-care and long-term care settings, prompting consideration for the potential transmission of zoonotic pathogens from animals to humans in these settings.
Although dogs and cats may be commonly encountered in health-care settings, other animals (e.g., fish, birds, non-human primates, rabbits, rodents, and reptiles) also can be present as research, resident, or service animals. These animals can serve as sources of zoonotic pathogens that could potentially infect patients and health-care workers (Table 26).  Animals potentially can serve as reservoirs for antibiotic-resistant microorganisms, which can be introduced to the health-care setting while the animal is present. VRE have been isolated from both farm animals and pets, 1341 and a cat in a geriatric care center was found to be colonized with MRSA. 1342 + Indicates that the pathogen associated with the infection has been isolated from animals and is considered to pose potential risk to humans.
Zoonoses can be transmitted from animals to humans either directly or indirectly via bites, scratches, aerosols, ectoparasites, accidental ingestion, or contact with contaminated soil, food, water, or unpasteurized milk. 1331,1332, Colonization and hand transferral of pathogens acquired from pets in health-care workers' homes represent potential sources and modes of transmission of zoonotic pathogens in health-care settings. An outbreak of infections caused by a yeast (Malassezia pachydermatis) among newborns was traced to transfer of the yeast from the hands of health-care workers with pet dogs at home. 1346 In addition, an outbreak of ringworm in a NICU caused by Microsporum canis was associated with a nurse and her cat, 1347 and an outbreak of Rhodococcus (Gordona) bronchialis sternal SSIs after coronary-artery bypass surgery was traced to a colonized nurse whose dogs were culture-positive for the organism. 1348 In the latter outbreak, whether the dogs were the sole source of the organism and whether other environmental reservoirs contributed to the outbreak are unknown. Nonetheless, limited data indicate that outbreaks of infectious disease have occurred as a result of contact with animals in areas housing immunocompetent patients. However, the low frequency of outbreaks may result from a. the relatively limited presence of the animals in health-care facilities and b. the immunocompetency of the patients involved in the encounters.
Formal scientific studies to evaluate potential risks of transmission of zoonoses in health-care settings outside of the laboratory are lacking.

# Animal-Assisted Activities, Animal-Assisted Therapy, and Resident Animals
Animal-Assisted Activities (AAA) are those programs that enhance the patients' quality of life. These programs allow patients to visit animals in either a common, central location in the facility or in individual patient rooms. A group session with the animals enhances opportunities for ambulatory patients and facility residents to interact with caregivers, family members, and volunteers.  Alternatively, allowing the animals access to individual rooms provides the same opportunity to nonambulatory patients and patients for whom privacy or dignity issues are a consideration. The decision to allow this access to patients' rooms should be made on a case-by-case basis, with the consultation and consent of the attending physician and nursing staff.
Animal-Assisted Therapy (AAT) is a goal-directed intervention that incorporates an animal into the treatment process provided by a credentialed therapist. 1330,1331 The concept for AAT arose from the observation that some patients with pets at home recover from surgical and medical procedures more rapidly than patients without pets. 1352,1353 Contact with animals is considered beneficial for enhancing wellness in certain patient populations (e.g., children, the elderly, and extended-care hospitalized patients). 1349, However, evidence supporting this benefit is largely derived from anecdotal reports and observations of patient/animal interactions.  Guidelines for establishing AAT programs are available for facilities considering this option. 1360 The incorporation of non-human primates into an AAA or AAT program is not encouraged because of concerns regarding potential disease transmission from and unpredictable behavior of these animals. 1361,1362 Animals participating in either AAA or AAT sessions should be in good health and up-to-date with recommended immunizations and prophylactic medications (e.g., heartworm prevention) as determined by a licensed veterinarian based on local needs and recommendations. Regular re-evaluation of the animal's health and behavior status is essential. 1360 Animals should be routinely screened for enteric parasites and/or have evidence of a recently completed antihelminthic regimen. 1363 They should also be free of ectoparasites (e.g., fleas and ticks) and should have no sutures, open wounds, or obvious dermatologic lesions that could be associated with bacterial, fungal, or viral infections or parasitic infestations. Incorporating young animals (i.e., those aged <1 year) into these programs is not encouraged because of issues regarding unpredictable behavior and elimination control. Additionally, health of these animals at risk. Animals should be clean and well-groomed. The visits must be supervised by persons who know the animals and their behavior. Animal handlers should be trained in these activities and receive site-specific orientation to ensure that they work efficiently with the staff in the specific healthcare environment. 1360 Additionally, animal handlers should be in good health. 1360 The most important infection-control measure to prevent potential disease transmission is strict enforcement of hand-hygiene measures (e.g., using either soap and water or an alcohol-based hand rub) for all patients, staff, and residents after handling the animals. 1355,1364 Care should also be taken to avoid direct contact with animal urine or feces. Clean-up of these substances from environmental surfaces requires gloves and the use of leak-resistant plastic bags to discard absorbent material used in the process. 2 The area must be cleaned after visits according to standard cleaning procedures.
The American Academy of Allergy, Asthma, and Immunology estimates that dog or cat allergies occur in approximately 15% of the population. 1365 Minimizing contact with animal saliva, dander, and/or urine helps to mitigate allergic responses. 1365-1367 Some facilities may not allow animal visitation for patients with a. underlying asthma, b. known allergies to cat or dog hair, c. respiratory allergies of unknown etiology, and d. immunosuppressive disorders.
Hair shedding can be minimized by processes that remove dead hair (e.g., grooming) and that prevent the shedding of dead hair (e.g., therapy capes for dogs). Allergens can be minimized by bathing therapy animals within 24 hours of a visit. 1333,1368 Animal therapists and handlers must take precautions to prevent animal bites. Common pathogens associated with animal bites include Capnocytophaga canimorsus, Pasteurella spp., Staphylococcus spp., and Streptococcus spp. Selecting well-behaved and well-trained animals for these programs greatly decreases the incidence of bites. Rodents, exotic species, wild/domestic animals (i.e., wolf-dog hybrids), and wild animals whose behavior is unpredictable should be excluded from AAA or AAT programs. A well-trained animal handler should be able to recognize stress in the animal and to determine when to terminate a session to minimize risk. When an animal bites a person during AAA or AAT, the animal is to be permanently removed from the program. If a bite does occur, the wound must be cleansed immediately and monitored for subsequent infection. Most infections can be treated with antibiotics, and antibiotics often are prescribed prophylactically in these situations.
The health-care facility's infection-control staff should participate actively in planning for and coordinating AAA and AAT sessions. Many facilities do not offer AAA or AAT programs for severely immunocompromised patients (e.g., HSCT patients and patients on corticosteroid therapy). 1339 The question of whether family pets or companion animals can visit terminally-ill HSCT patients or other severely immunosuppressed patients is best handled on a case-by-case basis, although animals should not be brought into the HSCT unit or any other unit housing severely immunosuppressed patients. An indepth discussion of this issue is presented elsewhere. 1366 Immunocompromised patients who have been discharged from a health-care facility may be at higher risk for acquiring some pet-related zoonoses. Although guidelines have been developed to minimize the risk of disease transmission to HIV-infected patients, 8 these recommendations may be applicable for patients with other immunosuppressive disorders. In addition to handwashing or hand hygiene, these recommendations include avoiding contact with a. animal feces and soiled litter box materials, b. animals with diarrhea, c. very young animals (i.e., dogs <6 months of age and cats <1 year of age), and d. exotic animals and reptiles. 8 Pets or companion animals with diarrhea should receive veterinary care to resolve their condition.
Many health-care facilities are adopting more home-like environments for residential-care or extendedstay patients in acute-care settings, and resident animals are one element of this approach. 1369 One concept, the "Eden Alternative," incorporates children, plants, and animals (e.g., dogs, cats, fish, birds, rabbits, and rodents) into the daily care setting. 1370,1371 The concept of working with resident animals has not been scientifically evaluated. Several issues beyond the benefits of therapy must be considered before embarking on such a program, including a. whether the animals will come into direct contact with patients and/or be allowed to roam freely in the facility b. how the staff will provide care for the animals; c. the management of patients' or residents' allergies, asthma, and phobias; d. precautionary measures to prevent bites and scratches; and e. measures to properly manage the disposal of animal feces and urine, thereby preventing environmental contamination by zoonotic microorganisms (e.g., Toxoplasma spp., Toxocara spp., and Ancylostoma spp.). 1372,1373 Few data document a link between health-care acquired infection rates and frequency of cleaning fish tanks or rodent cages. Skin infections caused by Mycobacterium marinum have been described among persons who have fish aquariums at home. 1374,1375 Nevertheless, immunocompromised patients should avoid direct contact with fish tanks and cages and the aerosols that these items produce. Further, fish tanks should be kept clean on a regular basis as determined by facility policy, and this task should be performed by gloved staff members who are not responsible for patient care. The use of the infectioncontrol risk assessment can help determine whether a fish tank poses a risk for patient or resident safety and health in these situations. No evidence, however, links the incidence of health-care acquired infections among immunocompetent patients or residents with the presence of a properly cleaned and maintained fish tank, even in dining areas. As a general preventive measure, resident animal programs are advised to restrict animals from a. food preparation kitchens, b. laundries, c. central sterile supply and any storage areas for clean supplies, and d. medication preparation areas.
Resident-animal programs in acute-care facilities should not allow the animals into the isolation areas, protective environments, ORs, or any area where immunocompromised patients are housed. Patients and staff routinely should wash their hands or use waterless, alcohol-based hand-hygiene products after contact with animals.

# Service Animals
Although this section provides an overview about service animals in health-care settings, it cannot address every situation or question that may arise (see Appendix E -Information Resources). A service animal is any animal individually trained to do work or perform tasks for the benefit of a person with a disability. 1366, 1376 A service animal is not considered a pet but rather an animal trained to provide assistance to a person because of a disability. Title III of the "Americans with Disabilities Act" (ADA) of 1990 mandates that persons with disabilities accompanied by service animals be allowed access with their service animals into places of public accommodation, including restaurants, public transportation, schools, and health-care facilities. 1366,1376 In health-care facilities, a person with a disability requiring a service animal may be an employee, a visitor, or a patient.
An overview of the subject of service animals and their presence in health-care facilities has been published. 1366 No evidence suggests that animals pose a more significant risk of transmitting infection than people; therefore, service animals should not be excluded from such areas, unless an individual patient's situation or a particular animal poses greater risk that cannot be mitigated through reasonable measures. If health-care personnel, visitors, and patients are permitted to enter care areas (e.g., inpatient rooms, some ICUs, and public areas) without taking additional precautions to prevent transmission of infectious agents (e.g., donning gloves, gowns, or masks), a clean, healthy, well-behaved service animal should be allowed access with its handler. 1366 Similarly, if immunocompromised patients are able to receive visitors without using protective garments or equipment, an exclusion of service animals from this area would not be justified. 1366 Because health-care facilities are covered by the ADA or the Rehabilitation Act, a person with a disability may be accompanied by a service animal within the facility unless the animal's presence or behavior creates a fundamental alteration in the nature of a facility's services in a particular area or a direct threat to other persons in a particular area. 1366 A "direct threat" is defined as a significant risk to the health or safety of others that cannot be mitigated or eliminated by modifying policies, practices, or procedures. 1376 The determination that a service animal poses a direct threat in any particular healthcare setting must be based on an individualized assessment of the service animal, the patient, and the health-care situation.
When evaluating risk in such situations, health-care personnel should consider the nature of the risk (including duration and severity); the probability that injury will occur; and whether reasonable modifications of policies, practices, or procedures will mitigate the risk (J. Wodatch, U.S. Department of Justice, 2000). The person with a disability should contribute to the risk-assessment process as part of a pre-procedure health-care provider/patient conference.
Excluding a service animal from an OR or similar special care areas (e.g., burn units, some ICUs, PE units, and any other area containing equipment critical for life support) is appropriate if these areas are considered to have "restricted access" with regards to the general public. General infection-control measures that dictate such limited access include a. the area is required to meet environmental criteria to minimize the risk of disease transmission, b. strict attention to hand hygiene and absence of dermatologic conditions, and c. barrier protective measures  are indicated for persons in the affected space.
No infection-control measures regarding the use of barrier precautions could be reasonably imposed on the service animal. Excluding a service animal that becomes threatening because of a perceived danger to its handler during treatment also is appropriate; however, exclusion of such an animal must be based on the actual behavior of the particular animal, not on speculation about how the animal might behave.
Another issue regarding service animals is whether to permit persons with disabilities to be accompanied by their service animals during all phases of their stay in the health-care facility. Healthcare personnel should discuss all aspects of anticipatory care with the patient who uses a service animal. Health-care personnel may not exclude a service animal because health-care staff may be able to perform the same services that the service animal does (e.g., retrieving dropped items and guiding an otherwise ambulatory person to the restroom). Similarly, health-care personnel can not exclude service animals because the health-care staff perceive a lack of need for the service animal during the person's stay in the health-care facility. A person with a disability is entitled to independent access (i.e., to be accompanied by a service animal unless the animal poses a direct threat or a fundamental alteration in the nature of services); "need" for the animal is not a valid factor in either analysis. For some forms of care (e.g., ambulation as physical therapy following total hip replacement or knee replacement), the service animal should not be used in place of a credentialed health-care worker who directly provides therapy. However, service animals need not be restricted from being in the presence of its handler during this time; in addition, rehabilitation and discharge planning should incorporate the patient's future use of the animal. The health-care personnel and the patient with a disability should discuss both the possible need for the service animal to be separated from its handler for a period of time during non-emergency care and an alternate plan of care for the service animal in the event the patient is unable or unwilling to provide that care. This plan might include family members taking the animal out of the facility several times a day for exercise and elimination, the animal staying with relatives, or boarding off-site. Care of the service animal, however, remains the obligation of the person with the disability, not the health-care staff.
Although animals potentially carry zoonotic pathogens transmissible to man, the risk is minimal with a healthy, clean, vaccinated, well-behaved, and well-trained service animal, the most common of which are dogs and cats. No reports have been published regarding infectious disease that affects humans originating in service dogs. Standard cleaning procedures are sufficient following occupation of an area by a service animal. 1366 Clean-up of spills of animal urine, feces, or other body substances can be accomplished with blood/body substance procedures outlined in the Environmental Services section of this guideline. No special bathing procedures are required prior to a service animal accompanying its handler into a health-care facility.
Providing access to exotic animals (e.g., reptiles and non-human primates) that are used as service animals is problematic. Concerns about these animals are discussed in two published reviews. 1331,1366 Because some of these animals exhibit high-risk behaviors that may increase the potential for zoonotic disease transmission (e.g., herpes B infection), providing health-care facility access to nonhuman primates used as service animals is discouraged, especially if these animals might come into contact with the general public. 1361,1362 Health-care administrators should consult the Americans with Disabilities Act for guidance when developing policies about service animals in their facilities. 1366,1376 Requiring documentation for access of a service animal to an area generally accessible to the public would impose a burden on a person with a disability. When health-care workers are not certain that an animal is a service animal, they may ask the person who has the animal if it is a service animal required because of a disability; however, no certification or other documentation of service animal status can be required. 1377

# Animals as Patients in Human Health-Care Facilities
The potential for direct and indirect transmission of zoonoses must be considered when rooms and equipment in human health-care facilities are used for the medical or surgical treatment or diagnosis of animals. 1378 Inquiries should be made to veterinary medical professionals to determine an appropriate facility and equipment to care for an animal.
The central issue associated with providing medical or surgical care to animals in human health-care facilities is whether cross-contamination occurs between the animal patient and the human health-care workers and/or human patients. The fundamental principles of infection control and aseptic practice should differ only minimally, if at all, between veterinary medicine and human medicine. Health-careassociated infections can and have occurred in both patients and workers in veterinary medical facilities when lapses in infection-control procedures are evident.  Further, veterinary patients can be at risk for acquiring infection from veterinary health-care workers if proper precautions are not taken. 1385 The issue of providing care to veterinary patients in human health-care facilities can be divided into the following three areas of infection-control concerns: a. whether the room/area used for animal care can be made safe for human patients, b. whether the medical/surgical instruments used on animals can be subsequently used on human patients, and c. which disinfecting or sterilizing procedures need to be done for these purposes.
Studies addressing these concerns are lacking. However, with respect to disinfection or sterilization in veterinary settings, only minimal evidence suggests that zoonotic microbial pathogens are unusually resistant to inactivation by chemical or physical agents (with the exception of prions). Ample evidence supports the contrary observation (i.e., that pathogens from human-and animal sources are similar in their relative instrinsic resistance to inactivation).  Further, no evidence suggests that zoonotic pathogens behave differently from human pathogens with respect to ventilation. Despite this knowledge, an aesthetic and sociologic perception that animal care must remain separate from human care persists. Health-care facilities, however, are increasingly faced with requests from the veterinary medical community for access to human health-care facilities for reasons that are largely economical (e.g., costs of acquiring sophisticated diagnostic technology and complex medical instruments). If hospital guidelines allow treatment of animals, alternate veterinary resources (including veterinary hospitals, clinics, and universities) should be exhausted before using human health-care settings. Additionally, the hospital's public/media relations should be notified of the situation. The goal is to develop policies and procedures to proactively and positively discuss and disclose this activity to the general public.
An infection-control risk assessment (ICRA) must be undertaken to evaluate the circumstances specific to providing care to animals in a human health-care facility. Individual hospital policies and guidelines should be reviewed before any animal treatment is considered in such facilities. Animals treated in human health-care facilities should be under the direct care and supervision of a licensed veterinarian; they also should be free of known infectious diseases, ectoparasites, and other external contaminants (e.g., soil, urine, and feces). Measures should be taken to avoid treating animals with a known or suspected zoonotic disease in a human health-care setting (e.g., lambs being treated for Q fever).
If human health-care facilities must be used for animal treatment or diagnostics, the following general infection-control actions are suggested: a. whenever possible, the use of ORs or other rooms used for invasive procedures should be avoided  b. when all other space options are exhausted and use of the aforementioned rooms is unavoidable, the procedure should be scheduled late in the day as the last procedure for that particular area such that patients are not present in the department/unit/area; c. environmental surfaces should be thoroughly cleaned and disinfected using procedures discussed in the Environmental Services portion of this guideline after the animal is removed from the care area; d. sufficient time should be allowed for ACH to help prevent allergic reactions by human patients ; e. only disposable equipment or equipment that can be thoroughly and easily cleaned, disinfected, or sterilized should be used; f. when medical or surgical instruments, especially those invasive instruments that are difficult to clean , are used on animals, these instruments should be reserved for future use only on animals; and g) standard precautions should be followed.

# Research Animals in Health-Care Facilities
The risk of acquiring a zoonotic infection from research animals has decreased in recent years because many small laboratory animals (e.g., mice, rats, and rabbits) come from quality stock and have defined microbiologic profiles. 1392 Larger animals (e.g., nonhuman primates) are still obtained frequently from the wild and may harbor pathogens transmissible to humans. Primates, in particular, benefit from vaccinations to protect their health during the research period provided the vaccination does not interfere with the study of the particular agent. Animals serving as models for human disease studies pose some risk for transmission of infection to laboratory or health-care workers from percutaneous or mucosal exposure. Exposures can occur either through a. direct contact with an infected animal or its body substances and secretions or b. indirect contact with infectious material on equipment, instruments, surfaces, or supplies. 1392 Uncontained aerosols generated during laboratory procedures can also transmit infection.
Infection-control measures to prevent transmission of zoonotic infections from research animals are largely derived from the following basic laboratory safety principles: a. purchasing pathogen-free animals, b. quarantining incoming animals to detect any zoonotic pathogens, c. treating infected animals or removing them from the facility, d. vaccinating animal carriers and high-risk contacts if possible, e. using specialized containment caging or facilities, and f. using protective clothing and equipment . 1392 An excellent resource for detailed discussion of these safety measures has been published. 1013 The animal research unit within a health-care facility should be engineered to provide a. adequate containment of animals and pathogens; b. daily decontamination and transport of equipment and waste; c. proper ventilation and air filtration, which prevents recirculation of the air in the unit to other areas of the facility; and d. negative air pressure in the animal rooms relative to the corridors.
To ensure adequate security and containment, no through traffic to other areas of the health-care facility should flow through this unit; access should be restricted to animal-care staff, researchers, environmental services, maintenance, and security personnel.
Occupational health programs for animal-care staff, researchers, and maintenance staff should take into consideration the animals' natural pathogens and research pathogens. Components of such programs include a. prophylactic vaccines, b. TB skin testing when primates are used, c. baseline serums, and d. hearing and respiratory testing.
Work practices, PPE, and engineering controls specific for each of the four animal biosafety levels have been published. 1013,1393 The facility's occupational or employee health clinic should be aware of the appropriate post-exposure procedures involving zoonoses and have available the appropriate postexposure biologicals and medications.
Animal-research-area staff should also develop standard operating procedures for a. daily animal husbandry  b. pathogen containment and decontamination; c. management, cleaning, disinfecting and/or sterilizing equipment and instruments; and d. employee training for laboratory safety and safety procedures specific to animal research worksites. 1013 The federal Animal Welfare Act of 1966 and its amendments serve as the regulatory basis for ensuring animal welfare in research. 1394,1395 I. Regulated Medical Waste

# Epidemiology
No epidemiologic evidence suggests that most of the solid-or liquid wastes from hospitals, other healthcare facilities, or clinical/research laboratories is any more infective than residential waste. Several studies have compared the microbial load and the diversity of microorganisms in residential wastes and wastes obtained from a variety of health-care settings.  Although hospital wastes had a greater number of different bacterial species compared with residential waste, wastes from residences were more heavily contaminated. 1397,1398 Moreover, no epidemiologic evidence suggests that traditional wastedisposal practices of health-care facilities (whereby clinical and microbiological wastes were decontaminated on site before leaving the facility) have caused disease in either the health-care setting or the general community. 1400,1401 This statement excludes, however, sharps injuries sustained during or immediately after the delivery of patient care before the sharp is "discarded." Therefore, identifying wastes for which handling and disposal precautions are indicated is largely a matter of judgment about the relative risk of disease transmission, because no reasonable standards on which to base these determinations have been developed. Aesthetic and emotional considerations (originating during the early years of the HIV epidemic) have, however, figured into the development of treatment and disposal policies, particularly for pathology and anatomy wastes and sharps.  Public concerns have resulted in the promulgation of federal, state, and local rules and regulations regarding medical waste management and disposal. 

# Categories of Medical Waste
Precisely defining medical waste on the basis of quantity and type of etiologic agents present is virtually impossible. The most practical approach to medical waste management is to identify wastes that represent a sufficient potential risk of causing infection during handling and disposal and for which some precautions likely are prudent. 2 Health-care facility medical wastes targeted for handling and disposal precautions include microbiology laboratory waste (e.g., microbiologic cultures and stocks of microorganisms), pathology and anatomy waste, blood specimens from clinics and laboratories, blood products, and other body-fluid specimens. 2 Moreover, the risk of either injury or infection from certain sharp items (e.g., needles and scalpel blades) contaminated with blood also must be considered. Although any item that has had contact with blood, exudates, or secretions may be potentially infective, treating all such waste as infective is neither practical nor necessary. Federal, state, and local guidelines and regulations specify the categories of medical waste that are subject to regulation and outline the requirements associated with treatment and disposal. The categorization of these wastes has generated the term "regulated medical waste." This term emphasizes the role of regulation in defining the actual material and as an alternative to "infectious waste," given the lack of evidence of this type of waste's infectivity. State regulations also address the degree or amount of contamination (e.g., blood-soaked gauze) that defines the discarded item as a regulated medical waste. The EPA's Manual for Infectious Waste Management identifies and categorizes other specific types of waste generated in health-care facilities with research laboratories that also require handling precautions. 1406

# Management of Regulated Medical Waste in Health-Care Facilities
Medical wastes require careful disposal and containment before collection and consolidation for treatment. OSHA has dictated initial measures for discarding regulated medical-waste items. These measures are designed to protect the workers who generate medical wastes and who manage the wastes from point of generation to disposal. 967 A single, leak-resistant biohazard bag is usually adequate for containment of regulated medical wastes, provided the bag is sturdy and the waste can be discarded without contaminating the bag's exterior. The contamination or puncturing of the bag requires placement into a second biohazard bag. All bags should be securely closed for disposal. Puncture-resistant containers located at the point of use (e.g., sharps containers) are used as containment for discarded slides or tubes with small amounts of blood, scalpel blades, needles and syringes, and unused sterile sharps. 967 To prevent needlestick injuries, needles and other contaminated sharps should not be recapped, purposefully bent, or broken by hand. CDC has published general guidelines for handling sharps. 6,1415 Health-care facilities may need additional precautions to prevent the production of aerosols during the handling of blood-contaminated items for certain rare diseases or conditions (e.g., Lassa fever and Ebola virus infection). 203 Transporting and storing regulated medical wastes within the health-care facility prior to terminal treatment is often necessary. Both federal and state regulations address the safe transport and storage of on-and off-site regulated medical wastes.  Health-care facilities are instructed to dispose medical wastes regularly to avoid accumulation. Medical wastes requiring storage should be kept in labeled, leakproof, puncture-resistant containers under conditions that minimize or prevent foul odors. The storage area should be well ventilated and be inaccessible to pests. Any facility that generates regulated medical wastes should have a regulated medical waste management plan to ensure health and environmental safety as per federal, state, and local regulations.

# Treatment of Regulated Medical Waste
Regulated medical wastes are treated or decontaminated to reduce the microbial load in or on the waste and to render the by-products safe for further handling and disposal. From a microbiologic standpoint, waste need not be rendered "sterile" because the treated waste will not be deposited in a sterile site. In addition, waste need not be subjected to the same reprocessing standards as are surgical instruments. Historically, treatment methods involved steam-sterilization (i.e., autoclaving), incineration, or interment (for anatomy wastes). Alternative treatment methods developed in recent years include chemical disinfection, grinding/shredding/disinfection methods, energy-based technologies (e.g., microwave or radiowave treatments), and disinfection/encapsulation methods. 1409 State medical waste regulations specify appropriate treatment methods for each category of regulated medical waste.
Of all the categories comprising regulated medical waste, microbiologic wastes (e.g., untreated cultures, stocks, and amplified microbial populations) pose the greatest potential for infectious disease transmission, and sharps pose the greatest risk for injuries. Untreated stocks and cultures of microorganisms are subsets of the clinical laboratory or microbiologic waste stream. If the microorganism must be grown and amplified in culture to high concentration to permit work with the specimen, this item should be considered for on-site decontamination, preferably within the laboratory unit. Historically, this was accomplished effectively by either autoclaving (steam sterilization) or incineration. If steam sterilization in the health-care facility is used for waste treatment, exposure of the waste for up to 90 minutes at 250F (121C) in a autoclave (depending on the size of the load and type container) may be necessary to ensure an adequate decontamination cycle.  After steam sterilization, the residue can be safely handled and discarded with all other nonhazardous solid waste in accordance with state solidwaste disposal regulations. On-site incineration is another treatment option for microbiologic, pathologic, and anatomic waste, provided the incinerator is engineered to burn these wastes completely and stay within EPA emissions standards. 1410 Improper incineration of waste with high moisture and low energy content (e.g., pathology waste) can lead to emission problems. State medical-waste regulatory programs identify acceptable methods for inactivating amplified stocks and cultures of microorganisms, some of which may employ technology rather than steam sterilization or incineration.
Concerns have been raised about the ability of modern health-care facilities to inactivate microbiologic wastes on-site, given that many of these institutions have decommissioned their laboratory autoclaves. Current laboratory guidelines for working with infectious microorganisms at biosafety level (BSL) 3 recommend that all laboratory waste be decontaminated before disposal by an approved method, preferably within the laboratory. 1013 These same guidelines recommend that all materials removed from a BSL 4 laboratory (unless they are biological materials that are to remain viable) are to be decontaminated before they leave the laboratory. 1013 Recent federal regulations for laboratories that handle certain biological agents known as "select agents" (i.e., those that have the potential to pose a severe threat to public health and safety) require these agents (and those obtained from a clinical specimen intended for diagnostic, reference, or verification purposes) to be destroyed on-site before disposal. 1412 Although recommendations for laboratory waste disposal from BSL 1 or 2 laboratories (e.g., most health-care clinical and diagnostic laboratories) allow for these materials to be decontaminated off-site before disposal, on-site decontamination by a known effective method is preferred to reduce the potential of exposure during the handling of infectious material.
A recent outbreak of TB among workers in a regional medical-waste treatment facility in the United States demonstrated the hazards associated with aerosolized microbiologic wastes. 1419,1420 The facility received diagnostic cultures of Mycobacterium tuberculosis from several different health-care facilities before these cultures were chemically disinfected; this facility treated this waste with a grinding/shredding process that generated aerosols from the material. 1419,1420 Several operational deficiencies facilitated the release of aerosols and exposed workers to airborne M. tuberculosis. Among the suggested control measures was that health-care facilities perform on-site decontamination of laboratory waste containing live cultures of microorganisms before release of the waste to a waste management company. 1419,1420 This measure is supported by recommendations found in the CDC/NIH guideline for laboratory workers. 1013 This outbreak demonstrates the need to avoid the use of any medical-waste treatment method or technology that can aerosolize pathogens from live cultures and stocks (especially those of airborne microorganisms) unless aerosols can be effectively contained and workers can be equipped with proper PPE.  Safe laboratory practices, including those addressing waste management, have been published. 1013,1422 In an era when local, state, and federal health-care facilities and laboratories are developing bioterrorism response strategies and capabilities, the need to reinstate in-laboratory capacity to destroy cultures and stocks of microorganisms becomes a relevant issue. 1423 Recent federal regulations require health-care facility laboratories to maintain the capability of destroying discarded cultures and stocks on-site if these laboratories isolate from a clinical specimen any microorganism or toxin identified as a "select agent" from a clinical specimen (Table 27). 1412,1413 As an alternative, isolated cultures of select agents can be transferred to a facility registered to accept these agents in accordance with federal regulations. 1412 State medical waste regulations can, however, complicate or completely prevent this transfer if these cultures are determined to be medical waste, because most states regulate the inter-facility transfer of untreated medical wastes.

# Discharging Blood, Fluids to Sanitary Sewers or Septic Tanks
The contents of all vessels that contain more than a few milliliters of blood remaining after laboratory procedures, suction fluids, or bulk blood can either be inactivated in accordance with state-approved treatment technologies or carefully poured down a utility sink drain or toilet. 1414 State regulations may dictate the maximum volume allowable for discharge of blood/body fluids to the sanitary sewer. No evidence indicates that bloodborne diseases have been transmitted from contact with raw or treated sewage. Many bloodborne pathogens, particularly bloodborne viruses, are not stable in the environment for long periods of time; 1425,1426 therefore, the discharge of small quantities of blood and other body fluids to the sanitary sewer is considered a safe method of disposing of these waste materials. 1414 The following factors increase the likelihood that bloodborne pathogens will be inactivated in the disposal process: a. dilution of the discharged materials with water b. inactivation of pathogens resulting from exposure to cleaning chemicals, disinfectants, and other chemicals in raw sewage; and c. effectiveness of sewage treatment in inactivating any residual bloodborne pathogens that reach the treatment facility.
Small amounts of blood and other body fluids should not affect the functioning of a municipal sewer system. However, large quantities of these fluids, with their high protein content, might interfere with the biological oxygen demand (BOD) of the system. Local municipal sewage treatment restrictions may dictate that an alternative method of bulk fluid disposal be selected. State regulations may dictate what quantity constitutes a small amount of blood or body fluids.
Although concerns have been raised about the discharge of blood and other body fluids to a septic tank system, no evidence suggests that septic tanks have transmitted bloodborne infections. A properly functioning septic system is adequate for inactivating bloodborne pathogens. System manufacturers' instructions specify what materials may be discharged to the septic tank without jeopardizing its proper operation.

# Medical Waste and CJD
Concerns also have been raised about the need for special handling and treatment procedures for wastes generated during the care of patients with CJD or other transmissible spongiform encephalopathies (TSEs). Prions, the agents that cause TSEs, have significant resistance to inactivation by a variety of physical, chemical, or gaseous methods. 1427 No epidemiologic evidence, however, links acquisition of CJD with medical-waste disposal practices. Although handling neurologic tissue for pathologic examination and autopsy materials with care, using barrier precautions, and following specific procedures for the autopsy are prudent measures, 1197 employing extraordinary measures once the materials are discarded is unnecessary. Regulated medical wastes generated during the care of the CJD patient can be managed using the same strategies as wastes generated during the care of other patients. After decontamination, these wastes may then be disposed in a sanitary landfill or discharged to the sanitary sewer, as appropriate.

# Part II. Recommendations for Environmental Infection Control in Health-Care Facilities

# A. Rationale for Recommendations
As in previous CDC guidelines, each recommendation is categorized on the basis of existing scientific data, theoretic rationale, applicability, and possible economic benefit. The recommendations are evidence-based wherever possible. However, certain recommendations are derived from empiric infection-control or engineering principles, theoretic rationale, or from experience gained from events that cannot be readily studied (e.g., floods).
The HICPAC system for categorizing recommendations has been modified to include a category for engineering standards and actions required by state or federal regulations. Guidelines and standards published by the American Institute of Architects (AIA), American Society of Heating, Refrigeration, and Air-Conditioning Engineers (ASHRAE), and the Association for the Advancement in Medical Instrumentation (AAMI) form the basis of certain recommendations. These standards reflect a consensus of expert opinions and extensive consultation with agencies of the U.S. Department of Health and Human Services. Compliance with these standards is usually voluntary. However, state and federal governments often adopt these standards as regulations. For example, the standards from AIA regarding construction and design of new or renovated health-care facilities, have been adopted by reference by >40 states. Certain recommendations have two category ratings (e.g., Categories IA and IC or Categories IB and IC), indicating the recommendation is evidence-based as well as a standard or regulation.

# B. Rating Categories
Recommendations are rated according to the following categories: - - Develop and implement a maintenance schedule for ACH, pressure differentials, and filtration efficiencies using facility-specific data as part of the multidisciplinary risk assessment. Take into account the age and reliability of the system. - - Document these parameters, especially the pressure differentials. 3. Engineer humidity controls into the HVAC system and monitor the controls to ensure proper moisture removal. 120 Category IC (AIA: 7.31.D9)
- - Locate duct humidifiers upstream from the final filters.
- - Incorporate a water-removal mechanism into the system.
- - Locate all duct takeoffs sufficiently down-stream from the humidifier so that moisture is completely absorbed. 4. Incorporate steam humidifiers, if possible, to reduce potential for microbial proliferation within the system, and avoid use of cool mist humidifiers. Category II 5. Ensure that air intakes and exhaust outlets are located properly in construction of new facilities and renovation of existing facilities. - - Locate exhaust outlets from contaminated areas above roof level to minimize recirculation of exhausted air. 6. Maintain air intakes and inspect filters periodically to ensure proper operation. 3,120,249,250,277 Category IC (AIA: 7.31.D8) 7. Bag dust-filled filters immediately upon removal to prevent dispersion of dust and fungal spores during transport within the facility. 106, 221 Category IB - - Seal or close the bag containing the discarded filter.
- - Discard spent filters as regular solid waste, regardless of the area from which they were removed. 221 8. Remove bird roosts and nests near air intakes to prevent mites and fungal spores from entering the ventilation system. 3,98,119 Category IB 9. Prevent dust accumulation by cleaning air-duct grilles in accordance with facility-specific procedures and schedules when rooms are not occupied by patients. 21,120,249,250,277 Category IC, II (AIA: 7.31.D10) 10. Periodically measure output to monitor system function; clean ventilation ducts as part of routine HVAC maintenance to ensure optimum performance. 120,263,264 Category II (AIA: 7.31.D10) C. Use portable, industrial-grade HEPA filter units capable of filtration rates in the range of 300-800 ft 3 /min. to augment removal of respirable particles as needed. 219 Category II M. Whenever feasible, design and install fixed backup ventilation systems for new or renovated construction for PE rooms, AII rooms, operating rooms, and other critical care areas identified by ICRA. 120  A. Establish a multidisciplinary team that includes infection-control staff to coordinate demolition, construction, and renovation projects and consider proactive preventive measures at the inception; produce and maintain summary statements of the team's activities. 17,19,20,97,109,120,249,250, Category IB, IC (AIA: 5.1) B. Educate both the construction team and the health-care staff in immunocompromised patient-care areas regarding the airborne infection risks associated with construction projects, dispersal of fungal spores during such activities, and methods to control the dissemination of fungal spores. 3, 249, 250, 273-277, 1428-1432 Category IB C. Incorporate mandatory adherence agreements for infection control into construction contracts, with penalties for noncompliance and mechanisms to ensure timely correction of problems. 3,120,249, Category IC (AIA: 5.1) D. Establish and maintain surveillance for airborne environmental disease (e.g., aspergillosis) as appropriate during construction, renovation, repair, and demolition activities to ensure the health and safety of immunocompromised patients. 3,64,65,79 Category IB 1. Using active surveillance, monitor for airborne fungal infections in immunocompromised patients. 3,9,64,65 Category IB 2. Periodically review the facility's microbiologic, histopathologic, and postmortem data to identify additional cases. 3,9,64,65 Category IB 3. If cases of aspergillosis or other health-care associated airborne fungal infections occur, aggressively pursue the diagnosis with tissue biopsies and cultures as feasible. 3,64,65,79,249, Category IB E. Implement infection-control measures relevant to construction, renovation, maintenance, demolition, and repair. 96,97,120,276,277 Category IB, IC (AIA: 5.1, 5.2) 1. Before the project gets underway, perform an ICRA to define the scope of the project and the need for barrier measures. 96,97,120,249, - - Determine if immunocompromised patients may be at risk for exposure to fungal spores from dust generated during the project. 20, 109, 273-275, 277 - - Develop a contingency plan to prevent such exposures. 20,109,277 Category IB, IC (AIA: 5.1) 2. Implement infection-control measures for external demolition and construction activities. 50,249,283 - - Determine if the facility can operate temporarily on recirculated air; if feasible, seal off adjacent air intakes. - - If this is not possible or practical, check the low-efficiency (roughing) filter banks frequently and replace as needed to avoid buildup of particulates. - - Seal windows and reduce wherever possible other sources of outside air intrusion (e.g., open doors in stairwells and corridors), especially in PE areas. Category IB 3. Avoid damaging the underground water distribution system (i.e., buried pipes) to prevent soil and dust contamination of the water. 120,305 Category IB, IC (AIA: 5.1) 121 4. Implement infection-control measures for internal construction activities. 20,49,97,120,249, - - Construct barriers to prevent dust from construction areas from entering patient-care areas; ensure that barriers are impermeable to fungal spores and in compliance with local fire codes. 20,49,97,120,284,312,713,1431 - - Block and seal off return air vents if rigid barriers are used for containment. 120,276,277 - - Implement dust control measures on surfaces and by diverting pedestrian traffic away from work zones. 20, 49, 97, 120 - - Relocate patients whose rooms are adjacent to work zones, depending upon their immune status, the scope of the project, the potential for generation of dust or water aerosols, and the methods used to control these aerosols. 49,120,281 120,249, ~ Category IB h. Clean work zones and their entrances daily by
- wet-wiping tools and tool carts before their removal from the work zone;
- placing mats with tacky surfaces inside the entrance; and
- covering debris and securing this covering before removing debris from the work zone. 120,249, ~ Category IB i. In patient-care areas, for major repairs that include removal of ceiling tiles and disruption of the space above the false ceiling, use plastic sheets or prefabricated plastic units to contain dust; use a negative pressure system within this enclosure to remove dust; and either pass air through an industrial grade, portable HEPA filter capable of filtration rates ranging from 300-800 ft 3 /min., or exhaust air directly to the outside. 49,276,277,281,309  - - properly constructing windows, doors, and intake and exhaust ports;
- - maintaining ceilings that are smooth and free of fissures, open joints, and crevices;
- - sealing walls above and below the ceiling, and
- - monitoring for leakage and making necessary repairs. 3,111,120,317,318 Category IB, IC (AIA: 7.2.D3) 3. Ventilate the room to maintain 12 ACH. 3,9,120,241,317,318 Category IC (AIA: 7.2.D) 4. Locate air supply and exhaust grilles so that clean, filtered air enters from one side of the room, flows across the patient's bed, and exits from the opposite side of the room. 3,120,317,318 Category IC (AIA: 7.31.D1) 5. Maintain positive room air pressure (2.5 Pa ) in relation to the corridor. 3,35,120,317,318 Category IB, IC (AIA: Table 7.2) 6. Maintain airflow patterns and monitor these on a daily basis by using permanently installed visual means of detecting airflow in new or renovated construction, or using other visual methods (e.g., flutter strips, or smoke tubes) in existing PE units. Document the monitoring results. 120,273 Category IC (AIA: 7.2.D6) 7. Install self-closing devices on all room exit doors in protective environments. 120  3. Place smallpox patients in negative pressure rooms at the onset of their illness, preferably using a room with an anteroom if available. 6 Category II D. No recommendation is offered regarding negative pressure or isolation rooms for patients with Pneumocystis carinii pneumonia. 126,131,132 Unresolved issue E. Maintain back-up ventilation equipment (e.g., portable units for fans or filters) for emergency provision of ventilation requirements for AII rooms and take immediate steps to restore the fixed ventilation system function. 4,120,278 Category IC (AIA: 5.1)

# C.V. Infection-Control and Ventilation Requirements for Operating Rooms
A. Implement environmental infection-control and ventilation measures for operating rooms. 1. Maintain positive-pressure ventilation with respect to corridors and adjacent areas. 7,120,356 Category IB, IC (AIA: Table 7.2) 2. Maintain 15 ACH, of which 3 ACH should be fresh air. 120,357,358 Category IC (AIA: Table 7.2) 3. Filter all recirculated and fresh air through the appropriate filters, providing 90% efficiency (dust-spot testing) at a minimum. 120,362 Category IC (AIA: Table 7.3) 4. In rooms not engineered for horizontal laminar airflow, introduce air at the ceiling and exhaust air near the floor. 120,357,359 B.1) because extubation is a coughproducing procedure. 4,358 Category IB C. Use portable, industrial-grade HEPA filters temporarily for supplemental air cleaning during intubation and extubation for infectious TB patients who require surgery. 4,219,358 Category II 1. Position the units appropriately so that all room air passes through the filter; obtain engineering consultation to determine the appropriate placement of the unit. 4 Category II 2. Switch the portable unit off during the surgical procedure. Category II 3. Provide fresh air as per ventilation standards for operating rooms; portable units do not meet the requirements for the number of fresh ACH. 120,215,219 Category II D. If possible, schedule infectious TB patients as the last surgical cases of the day to maximize the time available for removal of airborne contamination. Category II E. No recommendation is offered for performing orthopedic implant operations in rooms supplied with laminar airflow. 362,364 Unresolved issue F. Maintain backup ventilation equipment (e.g., portable units for fans or filters) for emergency provision of ventilation requirements for operating rooms, and take immediate steps to restore the fixed ventilation system function. 68,120,278,372 Category IB, IC (AIA: 5.1)

# C.VI. Other Potential Infectious Aerosol Hazards in Health-Care Facilities
A. In settings where surgical lasers are used, wear appropriate personal protective equipment, including N95 or N100 respirators, to minimize exposure to laser plumes. 347, 378, 389 Category IC (OSHA; 29 CFR 1910.134,139) B. Use central wall suction units with in-line filters to evacuate minimal laser plumes. 378,382,386,389 Category II C. Use a mechanical smoke evacuation system with a high-efficiency filter to manage the generation of large amounts of laser plume, when ablating tissue infected with human papilloma virus (HPV) or performing procedures on a patient with extrapulmonary TB. 4,382, Category II

# D. Recommendations-Water

# D.I. Controlling the Spread of Waterborne Microoganisms
A. Practice hand hygiene to prevent the hand transfer of waterborne pathogens, and use barrier precautions (e.g., gloves) as defined by other guidelines. 6,464,577,586,592,1364  - - Flush each outlet until chlorine odor is detected.
- - Maintain the elevated chlorine concentration in the system for 2 hrs (but 24 hrs). 4. Use a very thorough flushing of the water system instead of chlorination if a highly chlorineresistant microorganism (e.g., Cryptosporidium spp.) is suspected as the water contaminant. Category II F. Flush and restart equipment and fixtures according to manufacturers' instructions. Category II G. Change the pretreatment filter and disinfect the dialysis water system with an EPA-registered product to prevent colonization of the reverse osmosis membrane and downstream microbial contamination. 721 Category II H. Run water softeners through a regeneration cycle to restore their capacity and function. Category II I. If the facility has a water-holding reservoir or water-storage tank, consult the facility engineer or local health department to determine whether this equipment needs to be drained, disinfected with an EPA-registered product, and refilled. Category II J. Implement facility management procedures to manage a sewage system failure or flooding (e.g., arranging with other health-care facilities for temporary transfer of patients or provision of services), and establish communications with the local municipal water utility and the local health department to ensure that advisories are received in a timely manner upon release. 713 These recommendations refer to the spraying or fogging of chemicals (e.g., formaldehyde, phenolbased agents, or quaternary ammonium compounds) as a way to decontaminate environmental surfaces or disinfect the air in patient rooms. The recommendation against fogging was based on studies in the 1970's that reported a lack of microbicidal efficacy (e.g., use of quaternary ammonium compounds in mist applications) but also adverse effects on healthcare workers and others in facilities where these methods were utilized. Furthermore, some of these chemicals are not EPA-registered for use in fogging-type applications. The 2003 recommendations still apply; however, CDC does not yet make a recommendation regarding these newer technologies. This issue will be revisited as additional evidence becomes available.
G. Avoid large-surface cleaning methods that produce mists or aerosols or disperse dust in patient-care areas. 9,20,109,272

# H.II. Animal-Assisted Activities, Animal-Assisted Therapy, and Resident Animal Programs
A. Avoid selection of nonhuman primates and reptiles in animal-assisted activities, animal-assisted therapy, or resident animal programs. 1360-1362 Category IB B. Enroll animals that are fully vaccinated for zoonotic diseases and that are healthy, clean, wellgroomed, and negative for enteric parasites or otherwise have completed recent antihelminthic treatment under the regular care of a veterinarian. 1349, 1360 Category II C. Enroll animals that are trained with the assistance or under the direction of individuals who are experienced in this field. 1360 Category II D. Ensure that animals are handled by persons trained in providing activities or therapies safely, and who know the animals' health status and behavior traits. 1349,1360 Category II E. Take prompt action when an incident of biting or scratching by an animal occurs during an animalassisted activity or therapy. 1. Remove the animal permanently from these programs. 1360 Category II 2. Report the incident promptly to appropriate authorities (e.g., infection-control staff, animal program coordinator, or local animal control). 1360 Category II 3. Promptly clean and treat scratches, bites, or other accidental breaks in the skin. Category II F. Perform an ICRA and work actively with the animal handler prior to conducting an animal-assisted activity or therapy to determine if the session should be held in a public area of the facility or in individual patient rooms. 1349,1360 Category II G. Take precautions to mitigate allergic responses to animals. Category II 1. Minimize shedding of animal dander by bathing animals <24 hours before a visit. 1360 Category II 2. Groom animals to remove loose hair before a visit, or using a therapy animal cape. 1358 Category II H. Use routine cleaning protocols for housekeeping surfaces after therapy sessions. Category II I. Restrict resident animals, including fish in fish tanks, from access to or placement in patient-care areas, food preparation areas, dining areas, laundry, central sterile supply areas, sterile and clean supply storage areas, medication preparation areas, operating rooms, isolation areas, and PE areas. Category II J. Establish a facility policy for regular cleaning of fish tanks, rodent cages, bird cages, and any other animal dwellings and assign this cleaning task to a nonpatient-care staff member; avoid splashing tank water or contaminating environmental surfaces with animal bedding. Category II

# H.III. Protective Measures for Immunocompromised Patients
A. Advise patients to avoid contact with animal feces and body fluids such as saliva, urine, or solid litter box material. 8 Category II B. Promptly clean and treat scratches, bites, or other wounds that break the skin. 8 Category II C. Advise patients to avoid direct or indirect contact with reptiles. 1340 Category IB D. Conduct a case-by-case assessment to determine if animal-assisted activities or animal-assisted therapy programs are appropriate for immunocompromised patients. 1349 Category II E. No recommendation is offered regarding permitting pet visits to terminally ill immunosuppressed patients outside their PE units. Unresolved issue

# H.IV. Service Animals
Edit : An - indicates recommendations that were renumbered for clarity. The renumbering does not constitute change to the intent of the recommendations.
A. Avoid providing access to nonhuman primates and reptiles as service animals. 1340, 1362 Category IB B. Allow service animals access to the facility in accordance with the Americans with Disabilities Act of 1990, unless the presence of the animal creates a direct threat to other persons or a fundamental alteration in the nature of services. 1366,1376 Category IC (U.S. Department of Justice: 28 CFR  36.302) C. When a decision must be made regarding a service animal's access to any particular area of the health-care facility, evaluate the service animal, the patient, and the health-care situation on a caseby-case basis to determine whether significant risk of harm exists and whether reasonable modifications in policies and procedures will mitigate this risk. 1376 Category IC (Justice: 28 CFR  36.208 and App.B) D. If a patient must be separated from his or her service animal while in the health-care facility
- - ascertain from the person what arrangements have been made for supervision or care of the animal during this period of separation; and - - make appropriate arrangements to address the patient's needs in the absence of the service animal. Category II

# H.V. Animals as Patients in Human Health-Care Facilities
A. Develop health-care facility policies to address the treatment of animals in human healthcare facilities.
1. Use the multidisciplinary team approach to policy development, including public media relations in order to disclose and discuss these activities. Category II 2. Exhaust all veterinary facility, equipment, and instrument options before undertaking the procedure. Category II 3. Ensure that the care of the animal is supervised by a licensed veterinarian. Category II B. When animals are treated in human health-care facilities, avoid treating animals in operating rooms or other patient-care areas where invasive procedures are performed (e.g., cardiac catheterization laboratories, or invasive nuclear medicine areas). Category II C. Schedule the animal procedure for the last case of the day for the area, at a time when human patients are not scheduled to be in the vicinity. Category II D. Adhere strictly to standard precautions. Category II E. Clean and disinfect environmental surfaces thoroughly using an EPA-registered product in the room after the animal is removed. Category II F. Allow sufficient ACH to clean the air and help remove airborne dander, microorganisms, and allergens [Appendix B,

# Part III. References
Note: The bold item in parentheses indicated the citation number or the location of this reference listed in the MMWR version of this guideline.
microbiological agents they work with. There are four biosafety levels based on the hazards associated with the various microbiological agents. BOD5: the amount of dissolved oxygen consumed in five days by biological processes breaking down organic matter. Bonneting: a floor cleaning method for either carpeted or hard surface floors that uses a circular motion of a large fibrous disc to lift and remove soil and dust from the surface. Capped spur: a pipe leading from the water recirculating system to an outlet that has been closed off ("capped"). A capped spur cannot be flushed, and it might not be noticed unless the surrounding wall is removed. CFU/m 3 : colony forming units per cubic meter (of air). Chlamydospores: thick-walled, typically spherical or ovoid resting spores asexually produced by certain types of fungi from cells of the somatic hyphae. Chloramines: compounds containing nitrogen, hydrogen, and chlorine. These are formed by the reaction between hypochlorous acid (HOCl) and ammonia (NH3) and/or organic amines in water. The formation of chloramines in drinking water treatment extends the disinfecting power of chlorine. The term is also referred to as Combined Available Chlorine.
Cleaning: the removal of visible soil and organic contamination from a device or surface, using either the physical action of scrubbing with a surfactant or detergent and water, or an energy-based process (e.g., ultrasonic cleaners) with appropriate chemical agents. Coagulation-flocculation: coagulation is the clumping of particles that results in the settling of impurities. It may be induced by coagulants (e.g., lime, alum, and iron salts). Flocculation in water and wastewater treatment is the agglomeration or clustering of colloidal and finely-divided suspended matter after coagulation by gentle stirring by either mechanical or hydraulic means, such that they can be separated from water or sewage. Commissioning (a room): testing a system or device to ensure that it meets the pre-use specifications as indicated by the manufacturer or predetermined standard, or air sampling in a room to establish a preoccupancy baseline standard of microbial or particulate contamination. The term is also referred to as benchmarking at 77F (25C).
Completely packaged: functionally packaged, as for laundry.
Conidia: asexual spores of fungi borne externally.
Conidiophores: specialized hyphae that bear conidia in fungi. Conditioned space: that part of a building that is heated or cooled, or both, for the comfort of the occupants. Contaminant: an unwanted airborne constituent that may reduce the acceptibility of air. Convection: the transfer of heat or other atmospheric properties within the atmosphere or in the airspace of an enclosure by the circulation of currents from one region to another, especially by such motion directed upward.
Cooling tower: a structure engineered to receive accumulated heat from ventilation systems and equipment and transfer this heat to water, which then releases the stored heat to the atmosphere through evaporative cooling.
Critical item (medical instrument): a medical instrument or device that contacts normally sterile areas of the body or enters the vascular system. There is a high risk of infection from such devices if they are microbiologically contaminated prior to use. These devices must be sterilized before use. Dead legs: areas in the water system where water stagnates. A dead leg is a pipe or spur, leading from the water recirculating system to an outlet that is used infrequently, resulting in inadequate flow of water from the recirculating system to the outlet. This inadequate flow reduces the perfusion of heat or chlorine into this part of the water distribution system, thereby adversely affecting the disinfection of the water system in that area. Deionization: removal of ions from water by exchange with other ions associated with fixed charges on a resin bed. Cations are usually removed and H + ions are exchanged; OHions are exchanged for anions. Detritis: particulate matter produced by or remaining after the wearing away or disintegration of a substance or tissue. Dew point: the temperature at which a gas or vapor condenses to form a liquid; the point at which moisture begins to condense out of the air. At dew point, air is cooled to the point where it is at 100% relative humidity or saturation.
Dialysate: the aqueous electrolyte solution, usually containing dextrose, used to make a concentration gradient between the solution and blood in the hemodialyzer (dialyzer). Dialyzer: a device that consists of two compartments (blood and dialysate) separated by a semipermeable membrane. A dialyzer is usually referred to as an artificial kidney. Diffuser: the grille plate that disperses the air stream coming into the conditioned air space. Direct transmission: involves direct body surface-to-body surface contact and physical transfer of microorganisms between a susceptible host and an infected/colonized person, or exposure to cloud of infectious particles within 3 feet of the source; the aerosolized particles are >5 m in size. Disability: as defined by the Americans with Disabilities Act, a disability is any physical or mental impairment that substantially limits one or more major life activities, including but not limited to walking, talking, seeing, breathing, hearing, or caring for oneself. Disinfection: a generally less lethal process of microbial inactivation (compared to sterilization) that eliminates virtually all recognized pathogenic microorganisms but not necessarily all microbial forms (e.g., bacterial spores). Drain pans: pans that collect water within the HVAC system and remove it from the system. Condensation results when air and steam come together. Drift: circulating water lost from the cooling tower in the form as liquid droplets entrained in the exhaust air stream (i.e., exhaust aerosols from a cooling tower). Drift eliminators: an assembly of baffles or labyrinth passages through which the air passes prior to its exit from the cooling tower. The purpose of a drift eliminator is to remove entrained water droplets from the exhaust air. Droplets: particles of moisture, such as are generated when a person coughs or sneezes, or when water is converted to a fine mist by a device such as an aerator or shower head. These particles may contain infectious microorganisms. Intermediate in size between drops and droplet nuclei, these particles tend to quickly settle out from the air so that any risk of disease transmission is generally limited to persons in close proximity to the droplet source. Droplet nuclei: sufficiently small particles (1-5 m in diameter) that can remain airborne indefinitely and cause infection when a susceptible person is exposed at or beyond 3 feet of the source of these particles.
Dual duct system: an HVAC system that consists of parallel ducts that produce a cold air stream in one and a hot air stream in the other.
Dust: an air suspension of particles (aerosol) of any solid material, usually with particle sizes 100 m in diameter.
Dust-spot test: a procedure that uses atmospheric air or a defined dust to measure a filter's ability to remove particles. A photometer is used to measure air samples on either side of the filter, and the difference is expressed as a percentage of particles removed. Effective leakage area: the area through which air can enter or leave the room. This does not include supply, return, or exhaust ducts. The smaller the effective leakage area, the better isolated the room. Endotoxin: the lipopolysaccharides of gram-negative bacteria, the toxic character of which resides in the lipid portion. Endotoxins generally produce pyrogenic reactions in persons exposed to these bacterial components.
Enveloped virus: a virus whose outer surface is derived from a membrane of the host cell (either nuclear or the cell's outer membrane) during the budding phase of the maturation process. This membrane-derived material contains lipid, a component that makes these viruses sensitive to the action of chemical germicides. Evaporative condenser: a wet-type, heat-rejection unit that produces large volumes of aerosols during the process of removing heat from conditioned space air. Exhaust air: air removed from a space and not reused therein. Exposure: the condition of being subjected to something (e.g., infectious agents) that could have a harmful effect.
Fastidious: having complex nutritional requirements for growth, as in microorganisms.
Fill: that portion of a cooling tower which makes up its primary heat transfer surface. Fill is alternatively known as "packing." Finished water: treated, or potable water. Fixed room-air HEPA recirculation systems: nonmobile devices or systems that remove airborne contaminants by recirculating air through a HEPA filter. These may be built into the room and permanently

# Air Sampling for Aerosols Containing Legionellae
Air sampling is an insensitive means of detecting Legionella pneumophila, and is of limited practical value in environmental sampling for this pathogen. In certain instances, however, it can be used to a. demonstrate the presence of legionellae in aerosol droplets associated with suspected bacterial reservoirs b. define the role of certain devices  in disease transmission; and c. quantitate and determine the size of the droplets containing legionellae. 1436 Stringent controls and calibration are necessary when sampling is used to determine particle size and numbers of viable bacteria. 1437 Samplers should be placed in locations where human exposure to aerosols is anticipated, and investigators should wear a NIOSH-approved respirator (e.g., N95 respirator) if sampling involves exposure to potentially infectious aerosols.
Methods used to sample air for legionellae include impingement in liquid, impaction on solid medium, and sedimentation using settle plates. 1436 The Chemical Corps.-type all-glass impingers (AGI) with the stem 30 mm from the bottom of the flask have been used successfully to sample for legionellae. 1436 Because of the velocity at which air samples are collected, clumps tend to become fragmented, leading to a more accurate count of bacteria present in the air. The disadvantages of this method are a. the velocity of collection tends to destroy some vegetative cells b. the method does not differentiate particle sizes; and c. AGIs are easily broken in the field.
Yeast extract broth (0.25%) is the recommended liquid medium for AGI sampling of legionellae; 1437 standard methods for water samples can be used to culture these samples.
Andersen samplers are viable particle samplers in which particles pass through jet orifices of decreasing size in cascade fashion until they impact on an agar surface. 1218 The agar plates are then removed and incubated. The stage distribution of the legionellae should indicate the extent to which the bacteria would have penetrated the respiratory system. The advantages of this sampling method are a. the equipment is more durable during use b. the sampler can cetermine the number and size of droplets containing legionellae; c. the agar plates can be placed directly in an incubator with no further manipulations; and d. both selective and nonselective BCYE agar can be used. If the samples must be shipped to a laboratory, they should be packed and shipped without refrigeration as soon as possible.

# Calculation of Air Sampling Results
Assuming that each colony on the agar plate is the growth from a single bacteria-carrying particle, the contamination of the air being sampled is determined from the number of colonies counted. The airborne microorganisms may be reported in terms of the number per cubic foot of air sampled. The following formulas can be applied to convert colony counts to organisms per cubic foot of air sampled. 1218 For solid agar impactor samplers: C / (R H P) = N where N = number of organisms collected per cubic foot of air sampled C = total plate count R = airflow rate in cubic feet per minute P = duration of sampling period in minutes For liquid impingers: (C H V) / (Q H P H R) = N where C = total number of colonies from all aliquots plated V = final volume in mL of collecting media Q = total number of mL plated P, R, and N are defined as above 3. To satisfy exhaust needs, replacement air from outside is necessary. Table B.3 does not attempt to describe specific amounts of outside air to be supplied to individual spaces except for certain areas such as those listed. Distribution of the outside air, added to the system to balance required exhaust, shall be as required by good engineering practice.
4. Number of air changes may be reduced when the room is unoccupied if provisions are made to ensure that the number of air changes indicated is reestablished any time the space is being utilized. Adjustments shall include provisions so that the direction of air movement shall remain the same when the number of air changes is reduced. Areas not indicated as having continuous directional control may have ventilation systems shut down when space is unoccupied and ventilation is not otherwise needed.
5. Air from areas with contamination and/or odor problems shall be exhausted to the outside and not recirculated to other areas. Note that individual circumstances may require special consideration for air exhaust to outside.
6. Because of cleaning difficulty and potential for buildup of contamination, recirculating room units shall not be used in areas marked "No." Isolation rooms may be ventilated by reheat induction units in which only the primary air supplied from a central system passes through the reheat unit. Gravitytype heating or cooling units such as radiators or convectors shall not be used in special care areas.
7. The ranges listed are the minimum and maximum limits where control is specifically needed. See A8.31.D in the AIA guideline (reference 120) for additional information.
8. Where temperature ranges are indicated, the systems shall be capable of maintaining the rooms at any point within the range. A single figure indicates a heating or cooling capacity of at least the indicated temperature. This is usually applicable where residents may be undressed and require a warmer environment. Nothing in these guidelines shall be construed as precluding the use of temperatures lower than those noted when the residents' comfort and medical conditions make lower temperatures desirable. Unoccupied areas such as storage rooms shall have temperatures appropriate for the function intended.
9. See A8.31.D1 in the AIA guideline (reference 120).
10. Food preparation facilities shall have ventilation systems whose air supply mechanisms are interfaced appropriately with exhaust hood controls or relief vents so that exfiltration or infiltration to or from exit corridors does not compromise the exit corridor restrictions of NFPA 90A, the pressure requirements of NFPA 96, or the maximum defined in the table. The number of air changes may be reduced or varied to any extent required for odor control when the space is not in use.    heterotrophic plate count would suggest a greater rate and extent of biofilm formation in a health-care facility water system. The water supplied to the facility should also contain <1 coliform bacteria/100 mL. Coliform bacteria are organisms whose presence in the distribution system could indicate fecal contamination. It has been shown that coliform bacteria can colonize biofilms within drinking water systems. Intermittant contamination of a water system with these organisms could lead to colonization of the system.
Water samples can be collected from throughout the health-care facility system, including both hot and cold water sources; samples should be cultured by standard methods. 945 If heterotrophic plate counts in samples from the facility water system are higher than those from samples collected at the point of water entry to the building, it can be concluded that the facility water quality has diminished. If biofilms are detected in the facility water system and determined by an epidemiologic and environmental investigation to be a reservoir for health-care associated pathogens, the municipal water supplier could be contacted with a request to provide higher chlorine residuals in the distribution system, or the health-care facility could consider installing a supplemental chlorination system.
Sample collection sites for biofilm in health-care facilities include a. hot water tanks b. shower heads; and c. faucet aerators, especially in immunocompromised patient-care areas.
Swabs should be placed into tubes containing phosphate buffered water, pH 7.2 or phosphate buffered saline, shipped to the laboratory under refrigeration and processed within 24 hrs. of collection. Samples are suspended by vortexing with sterile glass beads and plated onto a nonselective medium (e.g., Plate Count Agar or R2A medium) and selective media (e.g., media for Legionella spp. isolation) after serial dilution. If the plate counts are elevated above levels in the water (i.e. comparing the plate count per square centimeter of swabbed surface to the plate count per milliliter of water), then biofilm formation can be suspected. In the case of an outbreak, it would be advisable to isolate organisms from these plates to determine whether the suspect organisms are present in the biofilm or water samples and compare them to the organisms isolated from patient specimens.

# Water and Dialysate Sampling Strategies in Dialysis
In order to detect the low, total viable heterotrophic plate counts outlined by the current AAMI standards for water and dialysate in dialysis settings, it is necessary to use standard quantitative culture techniques with appropriate sensitivity levels. 792,832,833 The membrane filter technique is particularly suited for this application because it permits large volumes of water to be assayed. 792,834 Since the membrane filter technique may not be readily available in clinical laboratories, the spread plate assay can be used as an alternative. 834 If the spread plate assay is used, however, the standard prohibits the use of a calibrated loop when applying sample to the plate. 792 The prohibition is based on the low sensitivity of the calibrated loop. A standard calibrated loop transfers 0.001 mL of sample to the culture medium, so that the minimum sensitivity of the assay is 1,000 CFU/mL. This level of sensitivity is unacceptable when the maximum allowable limit for microorganisms is 200 CFU/mL. Therefore, when the spread plate method is used, a pipette must be used to place 0.1-0.5 mL of water on the culture medium.
The current AAMI standard specifically prohibits the use of nutrient-rich media (e.g., blood agar, and chocolate agar) in dialysis water and dialysate assays because these culture media are too rich for growth of the naturally occurring organisms found in water. 792 Debate continues within AAMI, however, as to the most appropriate culture medium and incubation conditions to be used. The original clinical observations on which the microbiological requirements of this standard were based used Standard Methods Agar (SMA), a medium containing relatively few nutrients. 666 The use of tryptic soy agar (TSA), a general purpose medium for isolating and cultivating microorganisms was recommended in later versions of the standard because it was thought to be more appropriate for culturing bicarbonate-containing dialysate. 788,789,835 Moreover, culturing systems based on TSA are readily available from commercial sources. Several studies, however, have shown that the use of nutrient-poor media, such as R2A, results in an increased recovery of bacteria from water. 1451,1452 The original standard also specified incubation for 48 hours at 95F-98.6F (35C-37C) before enumeration of bacterial colonies. Extending the culturing time up to 168 hours, or 7 days and using incubation temperatures of 73.4F-82.4F (23C-28C) have also been shown to increase the recovery of bacteria. 1451,1452 Other investigators, however, have not found such clear cut differences between culturing techniques. 835,1453 After considerable discussion, the AAMI Committee has not reached a consensus regarding changes in the assay technique, and the use of TSA or its equivalent for 48 hours at 95F-98.6F (35C-37C) remains the recommended method. It should be recognized, however, that these culturing conditions may underestimate the bacterial burden in the water and fail to identify the presence of some organisms. Specifically, the recommended method may not detect the presence of various NTM that have been associated with several outbreaks of infection in dialysis units. 31,32 In these instances, however, the high numbers of mycobacteria in the water were related to the total heterotrophic plate counts, each of which was significantly greater than that allowable by the AAMI standard. Additionally, the recommended method will not detect fungi and yeast, which have been shown to contaminate water used for hemodialysis applications. 1454 Biofilm on the surface of the pipes may hide viable bacterial colonies, even though no viable colonies are detected in the water using sensitive culturing techniques. 1455 Many disinfection processes remove biofilm poorly, and a rapid increase in the level of bacteria in the water following disinfection may indicate significant biofilm formation. Therefore, although the results of microbiological surveillance obtained using the test methods outlined above may be useful in guiding disinfection schedules and in demonstrating compliance with AAMI standards, they should not be taken as an indication of the absolute microbiological purity of the water. 792 Endotoxin can be tested by one of two types of assays a. a kinetic test method  or b. a gel-clot assay.
Endotoxin units are assayed by the Limulus Amebocyte Lysate (LAL) method. Because endotoxins differ in their activity on a mass basis, their activity is referred to a standard Escherichia coli endotoxin. The current standard (EC-6) is prepared from E. coli O113:H10. The relationship between mass of endotoxin and its activity varies with both the lot of LAL and the lot of control standard endotoxin used. Since standards for endotoxin were harmonized in 1983 with the introduction of EC-5, the relationship between mass and activity of endotoxin has been approximately 5-10 EU/ng. Studies to harmonize standards have led to the measurement of endotoxin units (EU) where 5 EU is equivalent to 1 ng E. coli O55:B5 endotoxin. 1456 In summary, water used to prepare dialysate and to reprocess hemodialyzers should not contain a total microbial count >200 CFU/mL as determined by assay on TSA agar for 48 hrs. at 96.8F (36C), and 2 endotoxin units (EU) per mL. The dialysate at the end of a dialysis treatment should not contain >2,000 CFU/mL. 31, 32, 668, 789, 792

# Water Sampling Strategies and Culture Techniques for Detecting Legionellae
Legionella spp. are ubiquitous and can be isolated from 20%-40% of freshwater environments, including man-made water systems. 1457,1458 In health-care facilities, where legionellae in potable water rarely result in disease among immunocompromised patients, courses of remedial action are unclear.
Scheduled microbiologic monitoring for legionellae remains controversial because the presence of legionellae is not necessarily evidence of a potential for causing disease. 1459 CDC recommends aggressive disinfection measures for cleaning and maintaining devices known to transmit legionellae, but does not recommend regularly scheduled microbiologic assays for the bacteria. 396 However, scheduled monitoring of potable water within a hospital might be considered in certain settings where persons are highly susceptible to illness and mortality from Legionella infection (e.g., hematopoietic stem cell transplantation units and solid organ transplant units). 9 Also, after an outbreak of legionellosis, health officials agree monitoring is necessary to identify the source and to evaluate the efficacy of biocides or other prevention measures.
Examination of water samples is the most efficient microbiologic method for identifying sources of legionellae and is an integral part of an epidemiologic investigation into health-care associated Legionnaires disease. Because of the diversity of plumbing and HVAC systems in health-care facilities, the number and types of sites to be tested must be determined before collection of water samples. One environmental sampling protocol that addresses sampling site selection in hospitals might serve as a prototype for sampling in other institutions. 1209 Any water source that might be aerosolized should be considered a potential source for transmission of legionellae. The bacteria are rarely found in municipal water supplies and tend to colonize plumbing systems and point-of-use devices. To colonize, legionellae usually require a temperature range of 77F-108F (25C-42.2C) and are most commonly located in hot water systems. 1460 Legionellae do not survive drying. Therefore, air-conditioning equipment condensate, which frequently evaporates, is not a likely source. 1461 Water samples and swabs from point-of-use devices or system surfaces should be collected when sampling for legionellae (Box C.1). 1437 Swabs of system surfaces allow sampling of biofilms, which frequently contain legionellae. When culturing faucet aerators and shower heads, swabs of surface areas should be collected first; water samples are collected after aerators or shower heads are removed from their pipes. Collection and culture techniques are outlined (Box C.2). Swabs can be streaked directly onto buffered charcoal yeast extract agar (BCYE) plates if the pates are available at the collection site. If the swabs and water samples must be transported back to a laboratory for processing, immersing individual swabs in sample water minimizes drying during transit. Place swabs and water samples in insulated coolers to protect specimens from temperature extremes.
Box C.1. Potential sampling sites for Legionella spp. in health-care facilities*
- Potable water systems incoming water main, water softener unit, holding tanks, cisterns, water heater tanks (at the inflows and outflows)
- Potable water outlets, especially those in or near patient rooms faucets or taps, showers
- Cooling towers and evaporative condensers makeup water (e.g., added to replace water lost because of evaporation, drift, or leakage), basin (i.e., area under the tower for collection of cooled water), sump (i.e., section of basin from which cooled water returns to heat source), heat sources (e.g., chillers)
- Humidfiers (e.g., nebullizers) bubblers for oxygen, water used for respiratory therapy equipment 2. Collect culture swabs of internal surfaces of faucets, aerators, and shower heads in a sterile, screw-top container (e.g., 50 mL plastic centrifuge tube). Submerge each swab in 5-10 mL of sample water taken from the same device from which the sample was obtained. 3. Transport samples and process in a laboratory proficient at culturing water specimens for Legionella spp. as soon as possible after collection. (Samples may be transported at room temperature but must be protected from temperature extremes. Samples not processed within 24 hours of collection should be refrigerated.) 4. Test samples for the presence of Legionella spp. by using semiselective culture media using procedures specific to the cultivation and detection of Legionella spp.
- Detection of Legionella spp. antigen by the direct fluorescent antibody technique is not suitable for environmental samples. o Use of polymerase chain reaction for identification of Legionella spp. is not recommended until more data regading the sensitivity and specificity of this procedure are available.

# Procedure for Cleaning Cooling Towers and Related Equipment I. Perform these steps prior to chemical disinfection and mechanical cleaning.
A. Provide protective equipment to workers who perform the disinfection, to prevent their exposure to chemicals used for disinfection and aerosolized water containing Legionella spp. Protective equipment may include full-length protective clothing, boots, gloves, goggles, and a full-or halfface mask that combines a HEPA filter and chemical cartridges to protect against airborne chlorine levels of up to 10 mg/L. B. Shut off cooling tower.
1. Shut off the heat source, if possible. 2. Shut off fans, if present, on the cooling tower/evaporative condenser (CT/EC).
3. Shut off the system blowdown (i.e., purge) valve. 4. Shut off the automated blowdown controller, if present, and set the system controller to manual. 5. Keep make-up water valves open. 6. Close building air-intake vents within at least 30 meters of the CT/EC until after the cleaning procedure is complete. 7. Continue operating pumps for water circulation through the CT/EC.

# II. Perform these chemical disinfection procedures.
A. Add fast-release, chlorine-containing disinfectant in pellet, granular, or liquid form, and follow safety instructions on the product label. Use EPA-registered products, if available. Examples of disinfectants include sodium hypochlorite (NaOCl) or calcium hypochlorite (Ca2), calculated to achieve initial free residual chlorine (FRC) of 50 mg/L: either a. Monitor the FRC by using an FRC-measuring device with the DPD method (e.g., a swimmingpool test kit), and measure the pH with a pH meter every 15 minutes for 2 hours. Add chlorine as needed to maintain the FRC at 10 mg/L. Because the biocidal effect of chlorine is reduced at a higher pH, adjust the pH to 7.5-8.0. The pH may be lowered by using any acid (e.g., nuriatic acid or sulfuric acid used for maintenance of swimming pools) that is compatible with the treatment chemicals. E. Two hours after adding disinfectant and dispersant or after the FRC level is stable at 10 mg/L, monitor at 2-hour intervals and maintain the FRC at 10 mg/L for 24 hours. F. After the FRC level has been maintained at 10 mg/L for 24 hours, drain the system. CT/EC water may be drained safely into the sanitary sewer. Municipal water and sewerage authorities should be contacted regarding local regulations. If a sanitary sewer is not available, consult local or state authorities (e.g., a department of natural resources or environmental protection) regarding disposal of water. If necessary, the drain-off may be dechlorinated by dissipation or chemical neutralization with sodium bisulfite.
- - sharps . 2 Category II B. Consult federal, state, and local regulations to determine if other waste items are considered regulated medical wastes. 967,1407,1408

# I.II. Disposal Plan for Regulated Medical Wastes
A. Develop a plan for the collection, handling, predisposal treatment, and terminal disposal of regulated medical wastes. 967

# I.III. Handling, Transporting, and Storing Regulated Medical Wastes
A. Inform personnel involved in the handling and disposal of potentially infective waste of the possible health and safety hazards; ensure that they are trained in appropriate handling and disposal methods. 967 Category IC (OSHA: 29 CFR 1910.1030  g.2.i) B. Manage the handling and disposal of regulated medical wastes generated in isolation areas by using the same methods as for regulated medical wastes from other patient-care areas. 2 Category II C. Use proper sharps disposal strategies. 967 Category IC (OSHA: 29 CFR 191029 CFR .1030.iii.A)
1. Use a sharps container capable of maintaining its impermeability after waste treatment to avoid subsequent physical injuries during final disposal. 967 Category IC (OSHA: 29 CFR 191029 CFR .1030.iii.A) 2. Place disposable syringes with needles, including sterile sharps that are being discarded, scalpel blades, and other sharp items into puncture-resistant containers located as close as practical to the point of use. 967 Category IC (OSHA: 29 CFR 191029 CFR .1030.iii.A) 3. Do not bend, recap, or break used syringe needles before discarding them into a container. 6,967,1415 Category IC (OSHA: 29 CFR 1910.1030  d.2.vii and  d.2.vii.A) D. Store regulated medical wastes awaiting treatment in a properly ventilated area that is inaccessible to vertebrate pests; use waste containers that prevent the development of noxious odors. Category IC (States; AHJ) E. If treatment options are not available at the site where the medical waste is generated, transport regulated medical wastes in closed, impervious containers to the on-site treatment location or to another facility for treatment as appropriate. Category IC (States; AHJ)

# I.IV. Treatment and Disposal of Regulated Medical Wastes
A. Treat regulated medical wastes by using a method (e.g., steam sterilization, incineration, interment, or an alternative treatment technology) approved by the appropriate authority having jurisdiction (AHJ) (e.g., states, Indian Health Service , Veterans Affairs ) before disposal in a sanitary landfill. Category IC (States, AHJ) B. Follow precautions for treating microbiological wastes (e.g., amplified cultures and stocks of microorganisms). 1013 Category IC (DHHS: BMBL) 1. Biosafety level 4 laboratories must inactivate microbiological wastes in the laboratory by using an approved inactivation method (e.g., autoclaving) before transport to and disposal in a sanitary landfill. 1013 Category IC (DHHS: BMBL) 2. Biosafety level 3 laboratories must inactivate microbiological wastes in the laboratory by using an approved inactivation method (e.g., autoclaving) or incinerate them at the facility before transport to and disposal in a sanitary landfill. 1013 Category IC (DHHS: BMBL) C. Biosafety levels 1 and 2 laboratories should develop strategies to inactivate amplified microbial cultures and stocks onsite by using an approved inactivation method (e.g., autoclaving) instead of packaging and shipping untreated wastes to an offsite facility for treatment and disposal. 1013, Category II

# Part IV. Appendices Appendix A. Glossary of Terms
Acceptable indoor air quality: air in which there are no known contaminants at harmful concentrations as determined by knowledgeble authorities and with which a substantial majority (80%) of the people exposed do not express dissatisfaction. ACGIH: American Conference of Governmental Industrial Hygienists. Action level: the concentration of a contaminant at which steps should be taken to interrupt the trend toward higher, unacceptable levels. Aerosol: particles of respirable size generated by both humans and environmental sources and that have the capability of remaining viable and airborne for extended periods in the indoor environment. AIA: American Institute of Architects, a professional group responsible for publishing the Guidelines for Design and Construction of Hospitals and Healthcare Facilities, a consensus document for design and construction of health-care facilities endorsed by the U.S. Department of Health and Human Services, healthcare professionals, and professional organizations.

# Air changes per hour (ACH):
the ratio of the volume of air flowing through a space in a certain period of time (the airflow rate) to the volume of that space (the room volume). This ratio is expressed as the number of air changes per hour (ACH).
Air mixing: the degree to which air supplied to a room mixes with the air already in the room, usually expressed as a mixing factor. This factor varies from 1 (for perfect mixing) to 10 (for poor mixing). It is used as a multiplier to determine the actual airflow required (i.e., the recommended ACH multiplied by the mixing factor equals the actual ACH required). Airborne transmission: a means of spreading infection when airborne droplet nuclei (small particle residue of evaporated droplets 5 m in size containing microorganisms that remain suspended in air for long periods of time) are inhaled by the susceptible host. Air-cleaning system: a device or combination of devices applied to reduce the concentration of airborne contaminants (e.g., microorganisms, dusts, fumes, aerosols, other particulate matter, and gases).
Air conditioning: the process of treating air to meet the requirements of a conditioned space by controlling its temperature, humidity, cleanliness, and distribution. Allogeneic: non-twin, non-self. The term refers to transplanted tissue from a donor closely matched to a recipient but not related to that person. Ambient air: the air surrounding an object. Anemometer: a flow meter which measures the wind force and velocity of air. An anemometer is often used as a means of determining the volume of air being drawn into an air sampler. Anteroom: a small room leading from a corridor into an isolation room. This room can act as an airlock, preventing the escape of contaminants from the isolation room into the corridor. ASHE: American Society for Healthcare Engineering, an association affiliated with the American Hospital Association. ASHRAE: American Society of Heating, Refrigerating, and Air-Conditioning Engineers Inc.

# Autologous self:
The term refers to transplanted tissue whose source is the same as the recipient, or an identical twin. Automated cycler: a machine used during peritoneal dialysis which pumps fluid into and out of the patient while he/she sleeps. Biochemical oxygen demand (BOD): a measure of the amount of oxygen removed from aquatic environments by aerobic microorganisms for their metabolic requirements. Measurement of BOD is used to determine the level of organic pollution of a stream or lake. The greater the BOD, the greater the degree of water pollution. The term is also referred to as Biological Oxygen Demand (BOD). Biological oxygen demand (BOD): an indirect measure of the concentration of biologically degradable material present in organic wastes (pertaining to water quality). It usually reflects the amount of oxygen consumed in five days by biological processes breaking down organic waste (BOD5). Biosafety level: a combination of microbiological practices, laboratory facilities, and safety equipment determined to be sufficient to reduce or prevent occupational exposures of laboratory personnel to the Intermediate-level disinfection: a disinfection process that inactivates vegetative bacteria, most fungi, mycobacteria, and most viruses (particularly the enveloped viruses), but does not inactivate bacterial spores. Isoform: a possible configuration (tertiary structure) of a protein molecule. With respect to prion proteins, the molecules with large amounts of -conformation are the normal isoform of that particular protein, whereas those prions with large amounts of -sheet conformation are the proteins associated with the development of spongiform encephalopathy (e.g., Creutzfeldt-Jakob disease ). Laminar flow: HEPA-filtered air that is blown into a room at a rate of 90  10 feet/min in a unidirectional pattern with 100 ACH-400 ACH. Large enveloped virus: viruses whose particle diameter is >50 nm and whose outer surface is covered by a lipid-containing structure derived from the membranes of the host cells. Examples of large enveloped viruses include influenza viruses, herpes simplex viruses, and poxviruses. Laser plume: the transfer of electromagnetic energy into tissues which results in a release of particles, gases, and tissue debris. Lipid-containing viruses: viruses whose particle contains lipid components. The term is generally synonymous with enveloped viruses whose outer surface is derived from host cell membranes. Lipidcontaining viruses are sensitive to the inactivating effects of liquid chemical germicides. Lithotriptors: instruments used for crushing caliculi (i.e., calcified stones, and sand) in the bladder or kidneys.
Low efficiency filter: the prefilter with a particle-removal efficiency of approximately 30% through which incoming air first passes. See also Prefilter. Low-level disinfection: a disinfection process that will inactivate most vegetative bacteria, some fungi, and some viruses, but cannot be relied upon to inactivate resistant microorganisms (e.g., mycobacteria or bacterial spores). Makeup air: outdoor air supplied to the ventilation system to replace exhaust air. Makeup water: a cold water supply source for a cooling tower.
Manometer: a device that measures the pressure of liquids and gases. A manometer is used to verify air filter performance by measuring pressure differentials on either side of the filter. Membrane filtration: an assay method suitable for recovery and enumeration of microorganisms from liquid samples. This method is used when sample volume is large and anticipated microbial contamination levels are low. Mesophilic: that which favors a moderate temperature. For mesophilic bacteria, a temperature range of 68F-131F (20C-55C) is favorable for their growth and proliferation.
Mixing box: the site where the cold and hot air streams mix in the HVAC system, usually situated close to the air outlet for the room.
Mixing faucet: a faucet that mixes hot and cold water to produce water at a desired temperature. MMAD: Mass Median Aerodynamic Diameter. This is the unit used by ACGIH to describe the size of particles when particulate air sampling is conducted. Moniliaceous: hyaline or brightly colored. This is a laboratory term for the distinctive characteristics of certain opportunistic fungi in culture (e.g., Aspergillus spp. and Fusarium spp.). Monochloramine: the result of the reaction between chlorine and ammonia that contains only one chlorine atom. Monochloramine is used by municipal water systems as a water treatment. Natural ventilation: the movement of outdoor air into a space through intentionally provided openings (i.e., windows, doors, or nonpowered ventilators). Negative pressure: air pressure differential between two adjacent airspaces such that air flow is directed into the room relative to the corridor ventilation (i.e., room air is prevented from flowing out of the room and into adjacent areas). Neutropenia: a medical condition in which the patient's concentration of neutrophils is substantially less than that in the normal range. Severe neutropenia occurs when the concentration is <1,000 polymorphonuclear cells/L for 2 weeks or <100 polymorphonuclear cells /mL for 1 week, particularly for hematopoietic stem cell transplant (HSCT) recipients. Noncritical devices: medical devices or surfaces that come into contact with only intact skin. The risk of infection from use of these devices is low.
Non-enveloped virus: a virus whose particle is not covered by a structure derived from a membrane of the host cell. Non-enveloped viruses have little or no lipid compounds in their biochemical composition, a characteristic that is significant to their inherent resistance to the action of chemical germicides. Nosocomial: an occurrence, usually an infection, that is acquired in a hospital as a result of medical care. NTM: nontuberculous mycobacteria. These organisms are also known as atypical mycobacteria, or as "Mycobacteria other than tuberculosis" (MOTT). This descriptive term refers to any of the fast-or slowgrowing Mycobacterium spp. found in primarily in natural or man-made waters, but it excludes Mycobacterium tuberculosis and its variants. Nuisance dust: generally innocuous dust, not recognized as the direct cause of serious pathological conditions. Oocysts: a cyst in which sporozoites are formed; a reproductive aspect of the life cycle of a number of parasitic agents (e.g., Cryptosporidium spp., and Cyclospora spp.).
Outdoor air: air taken from the external atmosphere and, therefore, not previously circulated through the ventilation system. Parallel streamlines: a unidirectional airflow pattern achieved in a laminar flow setting, characterized by little or no mixing of air.
Particulate matter (particles): a state of matter in which solid or liquid substances exist in the form of aggregated molecules or particles. Airborne particulate matter is typically in the size range of 0.01-100 m diameter.
Pasteurization: a disinfecting method for liquids during which the liquids are heated to 140F (60C) for a short time (30 mins.) to significantly reduce the numbers of pathogenic or spoilage microorganisms.
Plinth: a treatment table or a piece of equipment used to reposition the patient for treatment.
Portable room-air HEPA recirculation units: free-standing portable devices that remove airborne contaminants by recirculating air through a HEPA filter.
Positive pressure: air pressure differential between two adjacent air spaces such that air flow is directed from the room relative to the corridor ventilation (i.e., air from corridors and adjacent areas is prevented from entering the room). Potable (drinking) water: water that is fit to drink. The microbiological quality of this water as defined by EPA microbiological standards from the Surface Water Treatment Rule: a. Giardia lamblia: 99.9% killed/inactivated b. viruses: 99.9% inactivated; c. Legionella spp.: no limit, but if Giardia and viruses are inactivated, Legionella will also be controlled; d. heterotrophic plate count : 500 CFU/mL; and e. >5% of water samples total coliform-positive in a month. PPE: Personal Protective Equipment. ppm: parts per million. The term is a measure of concentration in solution. Chlorine bleaches (undiluted) that are available in the U.S. (5.25%-6.15% sodium hypochlorite) contain approximately 50,000-61,500 parts per million of free and available chlorine. Prefilter: the first filter for incoming fresh air in a HVAC system. This filter is approximately 30% efficient in removing particles from the air. See also Low-Efficiency Filter. Prion: a class of agent associated with the transmission of diseases knowns as transmissible spongiform encephalopathies (TSEs). Prions are considered to consist of protein only, and the abnormal isoform of this protein is thought to be the agent that causes diseases such as Creutzfeldt-Jakob disease (CJD), kuru, scrapie, bovine spongiform encephalopathy (BSE), and the human version of BSE which is variant CJD (vCJD). Product water: water produced by a water treatment system or individual component of that system. Protective environment: a special care area, usually in a hospital, designed to prevent transmission of opportunistic airborne pathogens to severely immunosuppressed patients. Pseudoepidemic (pseudo-outbreak): a cluster of positive microbiologic cultures in the absence of clinical disease. A pseudoepidemic usually results from contamination of the laboratory apparatus and process used to recover microorganisms. Pyrogenic: an endotoxin burden such that a patient would receive 5 endotoxin units (EU) per kilogram of body weight per hour, thereby causing a febrile response. In dialysis this usually refers to water or dialysate having endotoxin concentrations of 5 EU/mL.
Rank order: a strategy for assessing overall indoor air quality and filter performance by comparing airborne particle counts from lowest to highest (i.e., from the best filtered air spaces to those with the least filtration). RAPD: a method of genotyping microorganisms by randomly amplified polymorphic DNA. This is one version of the polymerase chain reaction method. Recirculated air: air removed from the conditioned space and intended for reuse as supply air.
Relative humidity: the ratio of the amount of water vapor in the atmosphere to the amount necessary for saturation at the same temperature. Relative humidity is expressed in terms of percent and measures the percentage of saturation. At 100% relative humidity, the air is saturated. The relative humidity decreases when the temperature is increased without changing the amount of moisture in the air. Reprocessing (of medical instruments): the procedures or steps taken to make a medical instrument safe for use on the next patient. Reprocessing encompasses both cleaning and the final or terminal step (i.e., sterilization or disinfection) which is determined by the intended use of the instrument according to the Spaulding classification.
Residuals: the presence and concentration of a chemical in media (e.g., water) or on a surface after the chemical has been added.
Reservoir: a nonclinical source of infection.
Respirable particles: those particles that penetrate into and are deposited in the nonciliated portion of the lung. Particles >10 m in diameter are not respirable.
Return air: air removed from a space to be then recirculated.
Reverse osmosis (RO): an advanced method of water or wastewater treatment that relies on a semipermeable membrane to separate waters from pollutants. An external force is used to reverse the normal osmotic process resulting in the solvent moving from a solution of higher concentration to one of lower concentration.
Riser: water piping that connects the circulating water supply line, from the level of the base of the tower or supply header, to the tower's distribution system. RODAC: Replicate Organism Direct Agar Contact. This term refers to a nutrient agar plate whose convex agar surface is directly pressed onto an environmental surface for the purpose of microbiologic sampling of that surface. Room-air HEPA recirculation systems and units: devices (either fixed or portable) that remove airborne contaminants by recirculating air through a HEPA filter. Routine sampling: environmental sampling conducted without a specific, intended purpose and with no action plan dependent on the results obtained.
Sanitizer: an agent that reduces microbial contamination to safe levels as judged by public health standards or requirements. Saprophytic: a naturally-occurring microbial contaminant. Sedimentation: the act or process of depositing sediment from suspension in water. The term also refers to the process whereby solids settle out of wastewater by gravity during treatment. Semicritical devices: medical devices that come into contact with mucous membranes or non-intact skin. Service animal: any animal individually trained to do work or perform tasks for the benefit of a person with a disability. Shedding: the generation and dispersion of particles and spores by sources within the patient area, through activities such as patient movement and airflow over surfaces. Single-pass ventilation: ventilation in which 100% of the air supplied to an area is exhausted to the outside. Small, non-enveloped viruses: viruses whose particle diameter is <50 nm and whose outer surface is the protein of the particle itself and not that of host cell membrane components. Examples of small, nonenveloped viruses are polioviruses and hepatitis A virus. Spaulding Classification: the categorization of inanimate medical device surfaces in the medical environment as proposed in 1972 by Dr. Earle Spaulding. Surfaces are divided into three general categories, based on the theoretical risk of infection if the surfaces are contaminated at time of use. The categories are "critical," "semicritical," and "noncritical." Specific humidity: the mass of water vapor per unit mass of moist air. It is expressed as grains of water per pound of dry air, or pounds of water per pound of dry air. The specific humidity changes as moisture is added or removed. However, temperature changes do not change the specific humidity unless the air is cooled below the dew point.
Splatter: visible drops of liquid or body fluid that are expelled forcibly into the air and settle out quickly, as distinguished from particles of an aerosol which remain airborne indefinitely. Steady state: the usual state of an area. Sterilization: the use of a physical or chemical procedure to destroy all microbial life, including large numbers of highly-resistant bacterial endospores. Stop valve: a valve that regulates the flow of fluid through a pipe. The term may also refer to a faucet. Substitution fluid: fluid that is used for fluid management of patients receiving hemodiafiltration. This fluid can be prepared on-line at the machine through a series of ultrafilters or with the use of sterile peritoneal dialysis fluid. Supply air: air that is delivered to the conditioned space and used for ventilation, heating, cooling, humidification, or dehumidification.
Tensile strength: the resistance of a material to a force tending to tear it apart, measured as the maximum tension the material can withstand without tearing. Ultrafilter: a membrane filter with a pore size in the range of 0.001-0.05 m, the performance of which is usually rated in terms of a nominal molecular weight cut-off (defined as the smallest molecular weight species for which the filter membrance has more than 90% rejection).
Ultrafiltered dialysate: the process by which dialysate is passed through a filter having a molecular weight cut-off of approximately 1 kilodalton for the purpose of removing bacteria and endotoxin from the bath. Ultraviolet germicidal irradiation (UVGI): the use of ultraviolet radiation to kill or inactivate microorganisms.
Ultraviolet germicidal irradiation lamps: lamps that kill or inactivate microorganisms by emitting ultraviolet germicidal radiation, predominantly at a wavelength of 254 nm. UVGI lamps can be used in ceiling or wall fixtures or within air ducts of ventilation systems.
Vapor pressure: the pressure exerted by free molecules at the surface of a solid or liquid. Vapor pressure is a function of temperature, increasing as the temperature rises.
Vegetative bacteria: bacteria that are actively growing and metabolizing, as opposed to a bacterial state of quiescence that is achieved when certain bacteria (gram-positive bacilli) convert to spores when the environment can no longer support active growth. Vehicle: any object, person, surface, fomite, or media that may carry and transfer infectious microorganisms from one site to another.
Ventilation: the process of supplying and removing air by natural or mechanical means to and from any space. Such air may or may not be conditioned. Ventilation air: that portion of the supply air consisting of outdoor air plus any recirculated air that has been treated for the purpose of maintaining acceptable indoor air quality. Ventilation, dilution: an engineering control technique to dilute and remove airborne contaminants by the flow of air into and out of an area. Air that contains droplet nuclei is removed and replaced by contaminantfree air. If the flow is sufficient, droplet nuclei become dispersed, and their concentration in the air is diminished. Ventilation, local exhaust: ventilation used to capture and removed airborne contaminants by enclosing the contaminant source (the patient) or by placing an exhaust hood close to the contaminant source. v/v: volume to volume. This term is an expression of concentration of a percentage solution when the principle component is added as a liquid to the diluent. w/v: weight to volume. This term is an expression of concentration of a percentage solution when the principle component is added as a solid to the diluent.
Weight-arrestance: a measure of filter efficiency, used primarily when describing the performance of lowand medium-efficiency filters. The measurement of weight-arrestance is performed by feeding a standardized synthetic dust to the filter and weighing the fraction of the dust removed.  Q / V = ACH  Values apply to an empty room with no aerosol-generating source. With a person present and generating aerosol, this table would not apply. Other equations are available that include a constant generating source. However, certain diseases (e.g., infectious tuberculosis) are not likely to be aerosolized at a constant rate. The times given assume perfect mixing of the air within the space (i.e., mixing factor = 1). However, perfect mixing usually does not occur. Removal times will be longer in rooms or areas with imperfect mixing or air stagnation. 213 Caution should be exercised in using this table in such situations. For booths or other local ventilation enclosures, manufacturers' instructions should be consulted.

# Appendix B. Air 1. Airborne Contaminant Removal

# Ventilation Specifications for Health-Care Facilities
The following tables from the AIA Guidelines for Design and Construction of Hospitals and Health-Care Facilities, 2001 are reprinted with permission of the American Institute of Architects and the publisher (The Facilities Guidelines Institute). 120 Note: This table is Table 7 20. Food preparation centers shall have ventilation systems whose air supply mechanisms are interfaced appropriately with exhaust hood controls or relief vents so that exfiltration or infiltration to or from exit corridors does not compromise the exit corridor restrictions of NFPA 90A, the pressure requirements of NFPA 96, or the maximum defined in the table. The number of air changes may be reduced or varied to any extent required for odor control when the space is not in use. See Section 7.31.D1.p in the AIA guideline (reference 120).

# Appendix I:
A7. Recirculating devices with HEPA filters may have potential uses in existing facilities as interim, supplemental environmental controls to meet requirements for the control of airborne infectious agents. Limitations in design must be recognized. The design of either portable or fixed systems should prevent stagnation and short circuiting of airflow. The supply and exhaust locations should direct clean air to areas where health-care workers are likely to work, across the infectious source, and then to the exhaust, so that the healthcare worker is not in position between the infectious source and the exhaust location. The design of such systems should also allow for easy access for scheduled preventative maintenance and cleaning.
A11. The verification of airflow direction can include a simple visual method such as smoke trail, ball-in-tube, or flutterstrip. These devices will require a minimum differential air pressure to indicate airflow direction.  Notes:
1. The ventilation rates in this table cover ventilation for comfort, as well as for asepsis and odor control in areas of nursing facilities that directly affect resident care and are determined based on nursing facilities being predominantly "No Smoking" facilities. Where smoking may be allowed, ventilation rates will need adjustment. Areas where specific ventilation rates are not given in the table shall be ventilated in accordance with ASHRAE Standard 62, Ventilation for Acceptable Indoor Air Quality, and ASHRAE Handbook -HVAC Applications. OSHA standards and/or NIOSH criteria require special ventilation requirements for employee health and safety within nursing facilities.
2. Design of the ventilation system shall, insofar as possible, provide that air movement is from clean to less clean areas. However, continuous compliance may be impractical with full utilization of some forms of variable air volume and load shedding systems that may be used for energy conservation.
Areas that do require positive and continuous control are noted with "Out" or "In" to indicate the required direction of air movement in relation to the space named. Rate of air movement may, of course, be varied as needed within the limits required for positive control. Where indication of air movement direction is enclosed in parentheses, continuous directional control is required only when the specialized equipment or device is in use or where room use may otherwise compromise the intent of movement from clean to less clean. Air movement for rooms with dashes and nonpatient areas may vary as necessary to satisfy the requirements of those spaces. Additional adjustments may be needed when space is unused or unoccupied and air systems are deenergized or reduced.

# Appendix C. Water 1. Biofilms
Microorganisms have a tendency to associate with and stick to surfaces. These adherent organisms can initiate and develop biofilms, which are comprised of cells embedded in a matrix of extracellularly produced polymers and associated abiotic particles. 1438 It is inevitable that biofilms will form in most water systems. In the health-care facility environment, biofilms may be found in the potable water supply piping, hot water tanks, air conditioning cooling towers, or in sinks, sink traps, aerators, or shower heads. Biofilms, especially in water systems, are not present as a continuous slime or film, but are more often scanty and heterogeneous in nature. 1439 Biofilms may form under stagnant as well as flowing conditions, so storage tanks, in addition to water system piping, may be vulnerable to the development of biofilm, especially if water temperatures are low enough to allow the growth of thermophilic bacteria (e.g., Legionella spp.). Favorable conditions for biofilm formation are present if these structures and equipment are not cleaned for extended periods of time. 1440 Algae, protozoa, and fungi may be present in biofilms, but the predominant microorganisms of water system biofilms are gram-negative bacteria. Although most of these organisms will not normally pose a problem for healthy individuals, certain biofilm bacteria (e.g., Pseudomonas aeruginosa, Klebsiella spp., Pantoea agglomerans, and Enterobacter cloacae) all may be agents for opportunistic infections for immunocompromised individuals. 1441,1442 These biofilm organisms may easily contaminate indwelling medical devices or intravenous (IV) fluids, and they could be transferred on the hands of health-care workers.  Biofilms may potentially provide an environment for the survival of pathogenic organisms, such as Legionella pneumophila and E. coli O157:H7. Although the association of biofilms and medical devices provides a plausible explanation for a variety of health-care associated infections, it is not clear how the presence of biofilms in the water system may influence the rates of health-care-associated waterborne infection.
Organisms within biofilms behave quite differently than their planktonic (i.e., free floating) counterparts.
Research has shown that biofilm-associated organisms are more resistant to antibiotics and disinfectants than are planktonic organisms, either because the cells are protected by the polymer matrix, or because they are physiologically different.  Nevertheless, municipal water utilities attempt to maintain a chlorine residual in the distribution system to discourage microbiological growth. Though chlorine in its various forms is a proven disinfectant, it has been shown to be less effective against biofilm bacteria. 1448 Higher levels of chlorine for longer contact times are necessary to eliminate biofilms.
Routine sampling of health-care facility water systems for biofilms is not warranted. If an epidemiologic investigation points to the water supply system as a possible source of infection, then water sampling for biofilm organisms should be considered so that prevention and control strategies can be developed. An established biofilm is is difficult to remove totally in existing piping. Strategies to remediate biofilms in a water system would include flushing the system piping, hot water tank, dead legs, and those areas of the facility's water system subject to low or intermittent flow. The benefits of this treatment would include a. elimination of corrosion deposits and sludge from the bottom of hot water tanks, b. removal of biofilms from shower heads and sink aerators, and c. circulation of fresh water containing elevated chlorine residuals into the health-care facility water system.
The general strategy for evaluating water system biofilm depends on a comparision of the bacteriological quality of the incoming municipal water and that of water sampled from within facility's distribution system. Heterotrophic plate counts and coliform counts, both of which are routinely run by the municipal water utility, will at least provide in indication of the potential for biofilm formation. Heterotrophic plate count levels in potable water should be 500 CFU/mL would indicate a general decrease in water quality. A direct correlation between heterotrophic plate count and biofilm levels has been demonstrated. 1450 Therefore, an increase in G. Refill the system with water and repeat the procedure outline in steps 2-7 in I-B above.

# III. Perform mechanical cleaning.
A. After water from the second chemical disinfection has been drained, shut down the CT/EC. B. Inspect all water-contact areas for sediment, sludge, and scale. Using brushes and/or a lowpressure water hose, thoroughly clean all CT/EC water-contact areas, including the basin, sump, fill, spray nozzles, and fittings. Replace components as needed. C. If possible, clean CT/EC water-contact areas within the chillers.

# IV. Perform these procedures after mechanical cleaning.
A. Fill the system with water and add chlorine to achieve an FRC level of 10 mg/L. B. Circulate the water for 1 hour, then open the blowdown valve and flush the entire system until the water is free of turbidity. C. Drain the system. D. Open any air-intake vents that were closed before cleaning. E. Fill the system with water. The CT/EC may be put back into service using an effective watertreatment program.

# Maintenance Procedures Used to Decrease Survival and Multiplications of Legionella spp. in Potable-Water Distribution Systems
Wherever allowable by state code, provide water at 124F (51C) at all points in the heated water system, including the taps. This requires that water in calorifiers (e.g., water heaters) be maintained at 140F (60C). In the United Kingdom, where maintenance of water temperatures at 122F (50C) in hospitals has been mandated, installation of blending or mixing valves at or near taps to reduce the water temperature to 109.4F (63C) has been recommended in certain settings to reduce the risk for scald injury to patients, visitors, and health care workers. 726 However, Legionella spp. can multiply even in short segments of pipe containing water at this temperature. Increasing the flow rate from the hot-watercirculation system may help lessen the likelihood of water stagnation and cooling. 711,1465 Insulation of plumbing to ensure delivery of cold (<68F ) water to water heaters (and to cold-water outlets) may diminish the opportunity for bacterial multiplication. 456 Both dead legs and capped spurs within the plumbing system provide areas of stagnation and cooling to <122F (<50C) regardless of the circulating water temperature; these segments may need to be removed to prevent colonization. 704 Rubber fittings within plumbing systems have been associated with persistent colonization, and replacement of these fittings may be required for Legionella spp. eradication. 1467 Continuous chlorination to maintain concentrations of free residual chlorine at 1-2 mg/L (1-2 ppm) at the tap is an alternative option for treatment. This requires the placement of flow-adjusted, continuous injectors of chlorine throughout the water distribution system. Adverse effects of continuous chlorination can include accelerated corrosion of plumbing (resulting in system leaks) and production of potentially carcinogenic trihalomethanes. However, when levels of free residual chlorine are below 3 mg/L (3 ppm), trihalomethane levels are kept below the maximum safety level recommended by the EPA. 727, 1468, 1469 228

# Appendix D. Insects and Microorganisms
Format Change : The format of this section was changed to improve readability and accessibility. The content is unchanged.

# Appendix E. Information Resources
The following sources of information may be helpful to the reader. Some of these are available at no charge, while others are available for purchase from the publisher.

# Air and Water

# Appendix F. Areas of Future Research Air
- Standardize the methodology and interpretation of microbiologic air sampling (e.g., determine action levels or minimum infectious dose for aspergillosis, and evaluate the significance of airborne bacteria and fungi in the surgical field and the impact on postoperative SSI). - Develop new molecular typing methods to better define the epidemiology of health-care associated outbreaks of aspergillosis and to associate isolates recovered from both clinical and environmental sources. - Develop new methods for the diagnosis of aspergillosis that can lead reliably to early recognition of infection. - Assess the value of laminar flow technology for surgeries other than for joint replacement surgery.
- Determine if particulate sampling can be routinely performed in lieu of microbiologic sampling for purposes such as determining air quality of clean environments (e.g., operating rooms, HSCT units).

# Water
- Evaluate new methods of water treatment, both in the facility and at the water utility (e.g., ozone, chlorine dioxide, copper/silver/monochloramine) and perform cost-benefit analyses of treatment in preventing health-care associated legionellosis. - Evaluate the role of biofilms in overall water quality and determine the impact of water treatments for the control of biofilm in distribution systems. - Determine if the use of ultrapure fluids in dialysis is feasible and warranted, and determine the action level for the final bath. - Develop quality assurance protocols and validated methods for sampling filtered rinse water used with AERs and determine acceptable microbiologic quality of AER rinse water.

# Environmental Services
- Evaluate the innate resistance of microorganisms to the action of chemical germicides, and determine what, if any, linkage there may be between antibiotic resistance and resistance to disinfectants.

# Laundry and Bedding
- Evaluate the microbial inactivation capabilities of new laundry detergents, bleach substitutes, other laundry additives, and new laundry technologies.

# Animals in Health-Care Facilities
- Conduct surveillance to monitor incidence of infections among patients in facilities that use animal programs, and conduct investigations to determine new infection control strategies to prevent these infections. - Evaluate the epidemiologic impact of performing procedures on animals (e.g., surgery or imaging) in human health-care facilities.

# Regulated Medical Waste
- Determine the efficiency of current medical waste treatment technologies to inactivate emerging pathogens that may be present in medical waste (e.g., SARS-coV). - Explore options to enable health-care facilities to reinstate the capacity to inactivate microbiological cultures and stocks on-site.