Chapter 42. Targeting Health Care–Associated 

Infections: Evidence-Based Strategies 

Ruth M. Kleinpell, Cindy L. Munro, Karen K. Giuliano 

Background 

Hospitalization for an acute illness, trauma, chronic care, or other health care conditions is a 

common occurrence. There were 39.2 million hospital discharges in 2005, with an average 

length of stay of 4.6 days.1

 Hospitalization brings associated risks, including risk of infection. 

Nosocomial infections, or hospital-associated infections, are estimated to occur in 5 percent of 

all acute care hospitalizations, or 2 million cases per year.2 Hospital-associated infections have 

been identified as one of the most serious patient safety issues in health care.3 

Infections that become clinically evident after 48 hours of hospitalization are considered 

hospital-associated.2

 Risks factors for hospital-associated infections are generally categorized 

into three areas: iatrogenic, organizational, or patient-related. Iatrogenic risk factors include 

invasive procedures (e.g., intubation, indwelling vascular lines, urine catheterization) and 

antibiotic use and prophylaxis. Organizational risk factors include such things as contaminated 

air-conditioning systems, contaminated water systems, staffing (e.g., nurse-to-patient ratio), and 

physical layout of the facility (e.g., open beds close together). Examples of patient-related risk 

factors include severity of illness, immunosuppression, and length of stay.2 

Nosocomial infections more than double the mortality and morbidity risk for hospitalized 

patients, resulting in an estimated 20,000 deaths a year.2 Nosocomial infections increase the costs 

of hospitalization in addition to increasing morbidity and mortality risk. A meta-analysis of 55 

studies examining nosocomial infections and infection control interventions determined that 

attributable costs are significant; costs associated with bloodstream infections (mean = $38,703) 

and methicillin-resistant Staphylococcus aureus infections (mean = $35,367) are the largest.3

 

Most infections in hospitalized patients are endogenous, meaning they are caused by bacteria 

that have already colonized the patient’s digestive tract prior to infection.4

 The majority (60 

percent) of infections in patients hospitalized in an intensive care unit (ICU) setting are caused 

by bacteria already colonizing the patient on admission (primary endogenous). A lesser amount 

(23 percent) of infections result from bacteria acquired during the ICU stay, leading to 

colonization before infection (secondary endogenous). A total of seventeen percent of infections 

are caused by bacteria introduced from the ICU environment that lead to infection without prior 

colonization (exogenous). Targeting hospital-associated infections is, therefore, a very important 

aspect of providing quality health care.

This chapter reviews the evidence-based knowledge on health care–associated infections, 

highlighting important information for nurses caring for hospitalized patients. The review 

focuses on hospital-associated pneumonia, urinary tract infection, catheter-related bloodstream 

infection, sepsis, and antibiotic-resistant infection. An evaluation of the literature, including 

recent research, and evidence-based practices are presented. 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Hospital-Associated Pneumonia 

Pneumonia is the second most common hospital-associated infection (after urinary tract 

infection).5

 In critically ill patients, ventilator-associated pneumonia (VAP) is the most common 

nosocomial infection. VAP doubles the risk of death, significantly increases ICU length of stay, 

and adds more than $10,000 to each affected patient’s hospital costs.6 

The current evidence-based recommendations by the Centers for Disease Control and 

Prevention (CDC) for prevention of nosocomial pneumonia were published in 2004.5 Although 

some of the interventions to reduce nosocomial pneumonia are the responsibility of physicians or 

other health care workers, many of the interventions are the direct responsibility of nurses or can 

be influenced by nurses. Nursing care can directly contribute to prevention of hospital-associated 

pneumonia, particularly in patients who are most at risk due to advanced age, postoperative 

status, or mechanical ventilation. The evidence shows that the most important contributions of 

nursing care to prevention of hospital-associated pneumonia are in four areas: hand hygiene, 

respiratory care, patient positioning, and education of staff. 

Hand Hygiene 

Hand hygiene is an essential component of hospital-associated pneumonia reduction. 

Evidence-based guidelines have been published for general hand hygiene7, 8 as well as specific 

hand hygiene measures related to respiratory care.6 

Excellent evidence exists that alcohol hand rubs effectively reduce the transmission of 

potential pathogens from health care workers’ hands to patients. For hands that are not visibly 

soiled, alcohol hand rubs are more effective than hand washing with plain or antimicrobial 

soap.8, 9 In the health care setting, the preferred method for cleaning visibly soiled hands is 

washing with water and antimicrobial soap. Gloves should be worn for handling respiratory 

secretions or any objects contaminated with respiratory secretions.5 If soiling from respiratory 

secretions is anticipated, a gown should also be worn. Hand decontamination and glove changes 

are required between contacts with different patients, as well as in an encounter with a single 

patient between contacts with a contaminated body site and the respiratory tract or respiratory 

equipment. 

Respiratory Care 

Encouraging patients to do deep-breathing exercises is a common component of nursing care 

to reduce respiratory complications, particularly in postoperative patients. Most research 

supports this practice, although some controversy remains regarding the effectiveness of deepbreathing exercises versus incentive spirometry in particular patient populations. Thomas and 

McIntosh10 conducted a meta-analysis of literature from 1966 through 1992 that focused on the 

effects of deep-breathing exercises, incentive spirometry, and intermittent positive pressure 

breathing on pulmonary complications after upper abdominal surgery. They concluded that both 

deep-breathing and incentive spirometry were more effective than no treatment, but there was no 

significant difference between any of the three treatments. More recently, a systematic review of 

postoperative incentive spirometry studies from 1966 through 2000 concluded that there was not 

enough evidence to support the use of incentive spirometry to reduce postoperative respiratory 

complications.11 

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Targeting Health Care–Associated Infections

Chumillas and colleagues12 randomized subjects who had upper abdominal surgery to a 

breathing exercise program or to no breathing exercise. Postoperative pulmonary complications 

were reduced in the deep-breathing group (7.5 percent versus 19.5 percent in the control group), 

and the deep-breathing group had fewer postoperative chest radiograph abnormalities (P = 0.01). 

In a study of 456 abdominal surgery patients, Hall and colleagues13 found that deep-breathing 

exercises for low-risk patients, and incentive spirometry plus physiotherapy for high-risk 

patients, was as effective for prevention of postoperative pulmonary complications as incentive 

spirometry. 

Deep breathing also appears to be effective after coronary artery bypass graft (CABG) 

surgery. Westerdahl and colleagues14 randomly assigned subjects for the first 4 postoperative 

days to hourly deep-breathing exercises during the daytime (n = 48) or to no breathing exercises 

(n = 42). Compared to the control group, the deep-breathing group had smaller atelectasis on 

spiral CT scan (P = 0.045 at the basal level and P = 0.01 at the apical level) and significantly 

smaller postoperative reduction in lung function (forced vital capacity [FVC], P = 0.01; forced 

expiratory volume [FEV1], P = 0.01). In contrast, a randomized study of 56 abdominal surgery 

patients at high risk for postoperative pulmonary complications demonstrated beneficial results 

of early postoperative mobilization; however, the study produced no statistically significant 

difference in outcomes when deep breathing and coughing interventions were added to the early 

mobilization.15 Based on current evidence, CDC guidelines encourage deep breathing for all 

postoperative patients and use of incentive spirometry on postoperative patients who are at high 

risk for pneumonia.5

The earliest CDC guidelines addressing nosocomial pneumonia, published in 1981, placed 

great emphasis on standardization of practices related to care of respiratory equipment, and this 

area has been a continued focus in subsequent reports. Recommendations related to procedures 

for cleaning, sterilizing or disinfecting, and maintaining respiratory equipment now have a strong 

evidence base, and those recommended procedures are presented in detail in the current CDC 

report.5 Compliance with those procedures is primarily the responsibility of respiratory therapy, 

but it requires the cooperation and support of nurses. Many unresolved issues remain regarding 

optimal procedures for respiratory tract secretion suctioning, including whether sterile or clean 

gloves should be used when performing endotracheal suctioning, and whether multiuse closedsystem suction catheters or single-use open-system suction catheters are more effective in 

prevention of pneumonia. 

Patient Positioning 

Elevation of the head of the bed is believed to reduce the risk of gastroesophageal reflux and 

aspiration of gastric secretions, and thus to reduce risk of hospital-associated pneumonia. Supine 

position is an independent risk factor for mortality in mechanically ventilated patients16, 17 and in 

all ICU patients.18 Torres and coworkers19 conducted a randomized crossover study of the effect 

of semirecumbent versus supine position in 19 critically ill mechanically ventilated adults. After 

radiolabeling gastric contents, the researchers found higher radioactive counts in endobronchial 

aspirates when subjects were in a supine position than when in a semirecumbent position (P = 

0.036). In a similar design, Orozco-Levi and coworkers20 introduced radio label through 

nasogastric tubes in 15 mechanically ventilated subjects and obtained radioactive counts in 

pharyngeal and endobronchial secretions over a 5-hour period in supine and semirecumbent 

positions. Bronchial radioactive counts were higher at 5 hours in a supine position compared 

with baseline (P < 0.05) and semirecumbency (P < 0.01); importantly, significant reflux 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

occurred by 5 hours even with semirecumbent positioning. These studies support a relationship 

between head-of-bed position and aspiration of gastric secretions. 

Two clinical trials have examined the effect of head-of-bed position on VAP. Prior to the 

publication of the 2004 CDC guidelines, Drakulovic and coworkers21 conducted a randomized 

clinical trial assigning 86 mechanically ventilated ICU subjects to semirecumbent (45 degree) or 

supine (0 degrees) positions, with position documented once daily. The trial was stopped early 

because significant findings at an interim analysis showed that the semirecumbent group had 

lower frequency of clinically suspected pneumonia (P = 0.003) and microbiologically confirmed 

pneumonia (P = 0.018) than the supine group. Both supine body position (P = 0.006) and enteral 

nutrition (P = 0.013) were identified as independent risk factors for nosocomial pneumonia. A 

second, larger multicenter trial by van Nieuwenhoven and colleagues22 was published in 2006. 

Mechanically ventilated ICU patients were prospectively randomly assigned to a semirecumbent 

position (45 degrees, n = 109) or standard care (10 degrees, n = 112). Because backrest elevation 

was continuously electronically monitored during the first week of mechanical ventilation, the 

researchers were able to document that subjects assigned to 45-degree elevation achieved the 

target position only 15 percent of the study time, despite intensive efforts to ensure provider 

compliance. Average elevations (28 degrees in the group assigned to 45-degree elevation, and 10 

degrees in the standard-care group) were significantly different between groups (P < 0.001), but 

differences in VAP were not demonstrated. 

These two clinical trials of the effect of head-of-bed elevation on VAP differed in several 

ways that may have affected study outcomes. Important differences existed in the comparison 

groups, with Draculovic and colleagues assigning subjects to 0 degree elevation, while the 

subjects assigned to usual care in the van Nieuwenhoven study had an average elevation of 10 

degrees. The nosocomial pneumonia rate in the van Nieuwenhoven standard-care group was 6.5 

percent, much lower than the 23 percent reported for the Draculovic control group (23 percent).

While current evidence and practice guidelines support the elevation of the head of bed to reduce 

pneumonia risk, additional research is needed to further determine the optimal level for head-ofbed elevation.

Grap and colleagues23 examined the relationship of backrest elevation to VAP in a 

descriptive study of 66 subjects over a total of 276 patient days. Backrest elevation was 

continuously monitored. Mean backrest elevation for the entire study period was 21.7 degrees, 

but backrest elevations were less than 30 degrees 72 percent of the time, and less than 10 degrees 

39 percent of the time. In a statistical model predicting pneumonia risk on study day 4, 81 

percent of the variability (F = 7.31, P = 0.003) was accounted for by the pneumonia score on 

study day 1, severity of illness, and percentage of time spent at less than 30 degrees in the first 

24 hours. Thus, early initiation of elevated backrest may influence outcomes in patients who are 

at highest risk. 

Elevation of the head of the bed for patients at risk is a simple and inexpensive intervention 

that has the potential to decrease nosocomial pneumonia. Adverse effects of elevating the head 

of the bed have not been demonstrated in patients who do not have a medical contraindication. 

However, most evidence suggests that this intervention is not widely used. The effectiveness of 

turning or lateral rotation remains an unresolved issue. Additional research is needed to identify 

optimal or sufficient head-of-bed elevation to prevent nosocomial pneumonia, to determine the 

effects of turning, and to address barriers to implementation of optimal patient positioning.

The Institute for Healthcare Improvement (IHI) outlines a ventilator bundle, or care 

strategies, to target VAP. A “bundle” is a group of interventions that when implemented 

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Targeting Health Care–Associated Infections

together, produce better outcomes than when implemented individually.24 The ventilator bundle 

incorporates evidence-based interventions aimed at reducing VAP incidence, including head-ofbed elevation greater than 20 degrees, assessment of the need for continued mechanical 

ventilation, and prophylaxis for stress ulcer disease and deep vein thrombosis.25

Additional VAP Prevention Measures 

Additional measures for VAP prevention include preventing orophyarngeal colonization 

through oral care and effective endotracheal tube maintenance. Guidelines for VAP prevention 

recommend maintaining endotracheal tube cuff pressures above 20 cm H20 to ensure minimal 

leakage.26 Continuous aspiration of subglottic secretions has also been advocated for preventing 

microaspiration. A meta-analysis assessing the impact of continuous aspiration of subglottic 

secretions in five randomized clinical trials found a 50-percent reduction in VAP and a delayed 

onset in the development of VAP by 6.8 days,27 yet further research on the use and costeffectiveness is needed. 

Implementation of oral care protocols can be an effective mechanism to target removal of 

dental plaque and minimize colonization and aspiration of biofilm. Several studies have 

demonstrated benefits of tooth brushing and oral suctioning.28–31 Research assessing the impact 

of chlorhexidine gluconate (CHG) for oral care hygiene has demonstrated beneficial impact with 

tooth brushing,31, 32 however additional research is indicated.33

Staff Education and Compliance 

The CDC urges education of staff and involvement of health care workers at all levels in 

implementing interventions to prevent hospital-associated pneumonia, and nurses are an essential 

component of these preventive efforts. The potential for compliance programs to positively 

affect nosocomial infections was demonstrated by Won and colleagues34 in their study of hand 

hygiene. Following an intensive hand hygiene compliance program in a neonatal ICU, which 

increased hand hygiene compliance from 43 percent to 80 percent, a significant decrease in all 

nosocomial infections (P = 0.003) was documented. The effect was even more apparent for 

nosocomial respiratory infection (P = 0.002), with a significant correlation between hand 

washing compliance and nosocomial respiratory infections (r = –0.385; P = 0.014). 

Education aimed at reducing the occurrence of VAP using a self-study module on risk factors 

and practice modifications demonstrated beneficial results in another study.35 The education 

program, directed toward respiratory care practitioners and ICU nurses, was developed by a 

multidisciplinary task force. Fact sheets and posters reinforcing the study module information 

were distributed in an urban teaching hospital. Following implementation of the education 

intervention, the rate of VAP decreased from 12.6 per 1,000 ventilator days to 5.7 per 1,000 

ventilator days, a decrease of 57.6 percent (P < 0.001). 

In addition to promoting best practices for the care of ventilator patients, nurses should 

advocate for physician practices that reduce the risk of hospital-associated pneumonia. The use 

of noninvasive modalities whenever possible (for example, positive pressure ventilation by face 

mask to reduce endotracheal intubation) and removal of invasive devises when they are no 

longer necessary are important considerations. The IHI bundle focuses on daily assessment of the 

need for mechanical ventilation as one mechanism for removing invasive devices when 

indicated. Nurses can also help to educate all hospital personnel about procedures to prevent 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

pneumonia that are appropriate to the worker’s level of responsibility. Table 1 outlines evidencebased guidelines for hospital-associated pneumonia prevention and management, including 

nursing-based care. 

Urinary Tract Infections 

The use of indwelling urinary catheters is common in the hospital setting. Urinary tract 

infection (UTI) is the most common hospital-associated infection, and a major associated cause 

is indwelling urinary catheters.36 UTIs account for about 40 percent of hospital-associated 

infections, and an estimated 80 percent are associated with urinary catheters.37 Almost 1 million 

episodes of nosocomial UTI occur each year in the United States,38 and the most important risk 

factor is the presence of an indwelling urinary catheter.39 Biofilm formation by uropathogens on 

the urinary catheter have been implicated as the underlying cause of catheter-associated UTI.40

Adverse consequences of a catheter-associated UTI include local and systemic morbidity, 

secondary bloodstream infection, increased costs, and mortality.41 In the hospital setting, the ICU 

has the highest prevalence of nosocomial UTIs with an estimated rate of 8–21 percent.39

Guidelines for the prevention of catheter-associated UTIs issued by the CDC outline several 

recommendations, including appropriate use of indwelling catheters, education of personnel on 

proper catheter insertion using aseptic technique and sterile equipment, and maintenance to 

ensure closed sterile drainage (see Table 2).42 

Due to increased risk of infection associated with urinary catheters, a number of practices 

have been evaluated in an attempt to reduce the incidence of urinary catheter-related infections.38

These include alternative approaches to use of urinary catheters and antimicrobial urinary 

catheters. 

Alternative Approaches to Urinary Catheterization 

A Cochrane systematic review has investigated the advantages and disadvantages of 

alternative approaches to indwelling catheters for short-term bladder drainage in adults.37 Of 17 

randomized clinical trials, 14 compared indwelling urethral catheterization with suprapubic 

catheterization, and 3 trials compared indwelling urethral catheterization with intermittent 

catheterization. Patients managed with an indwelling urinary catheter had higher incidences of 

bacteriuria (relative risk [RR] = 2.60, 95% confidence interval [CI] = 2.12–3.18), more frequent 

recatheterizations (RR = 4.12, 95% CI = 2.94–7.56), and more reports of patient discomfort (RR 

= 2.98, 95% CI = 2.31–3.85). Of the trials assessing indwelling urethral catheters with 

intermittent catheterization, fewer cases of bacteriuria were found in patients receiving 

intermittent catheterization (RR = 2.90, 95% CI = 1.44–5.84). The results of the systematic 

review indicate that suprapubic catheters have advantages over indwelling urinary catheters in 

terms of incidence of bacteriuria, recatheterization, and patient reports of discomfort. Intermittent 

catheterization was also associated with a lower risk of bacteriuria compared to indwelling 

urinary catheters, but supported with limited evidence. However, suprapubic catheterization 

typically involves percutaneous placement of a urinary catheter directly into the bladder, a 

technique that is considered minor surgery;38 therefore, the practical application of this 

alternative measure is questionable. A previous review of studies assessing the efficacy of 

suprapubic catheters with standard noncoated catheters also substantiated lower rates of 

bacteriuria for suprapubic catheters, but highlighted that mechanical complications—including 

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Targeting Health Care–Associated Infections

catheter dislodgement, obstruction, and failed introduction—can occur. The review could not 

substantiate the overall benefit of routine suprapubic catheterization.38 

Antimicrobial Catheters 

A variety of specialized urethral catheters have been designed to reduce the risk of catheterassociated UTI. These include antiseptic-impregnated catheters and catheters coated with silver 

alloy or nitrofurazone.36, 41 A Cochrane systematic review has examined 18 clinical trials to 

assess the different types of urethral catheters for the management of short-term catheter use in 

hospitalized patients.36 Silver oxide catheters were not associated with a statistically significant 

reduction in bacteriuria, but the confidence intervals were wide (RR = 0.89, 95 percent CI = 

0.68–1.15). Silver alloy catheters were found to significantly reduce the incidence of bacteriuria 

(RR = 0.36, 95 percent CI = 0.24–0.52). The results of the review indicated advantages from 

silver alloy catheters, including an economic benefit compared to standard catheter use. A 

previous review of four clinical trials studies assessing silver alloy catheters also substantiated a 

significant reduction in the development of catheter-associated bacteriuria.38

Another systematic review of antimicrobial urinary catheters in the prevention of catheterassociated UTI in hospitalized patients analyzed 12 clinical trials of nitrofurazone-coated or 

silver alloy-coated urinary catheters. Both nitrofurazone-coated and silver alloy-coated catheters 

reduced the development of bacteriuria in comparison with latex or silicone control catheters.41

However data on comparative efficacy is lacking as no trial directly compared nitrofurazonecoated and silver alloy-coated catheters. While evidence exists to support the use of 

antimicrobial urinary catheters in preventing bacteriuria in hospitalized patients during shortterm catheterization, estimates on cost-effectiveness have not been established.41 Additional 

strategies for preventing catheter-associated UTI—including hand-held bladder scanners, 

computerized order/entry system prompts, and education on appropriate use of indwelling 

urinary catheter—have also proved beneficial.43

Table 2 outlines evidence-based strategies for UTI prevention. Nursing-related care aspects 

include thorough assessment to determine need for indwelling catheter use, aseptic insertion 

technique, indwelling catheter care to minimize infection risk, and astute monitoring of patients 

with urinary catheters for signs of UTI. All of these are important measures to decrease the risk 

of catheter-associated UTI. 

Catheter-Related Bloodstream Infection 

Central venous catheters (CVCs) are frequently used in hospitalized patients and they carry 

associated risks, the most common being bloodstream infection (BSI). According to the CDC, up 

to 250,000 hospital-associated catheter-related bloodstream infections (CR-BSIs) occur annually 

in U.S. hospitals, with approximately 80,000 of these occurring in ICUs.44 CVCs of all types are 

the most frequent cause of nosocomial BSIs.45

A CR-BSI is defined as the presence of bacteremia in a patient with an intravascular catheter 

with at least one positive blood culture and clinical signs of infections (i.e., fever, chills, and/or 

hypotension), with no apparent source for the BSI except the catheter. Specific criteria for CRBSI include either a positive culture with the same organism isolated from the catheter and 

peripheral blood, simultaneous blood cultures with a > 5:1 ratio of catheter versus peripheral 

culture, or a differential period of catheter culture versus peripheral blood culture positivity of > 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

2 hours.46 A BSI is considered to be associated with a central line if the line was in place during 

the 48-hour period before development of the BSI.46 Although CVSs account for only a small 

percentage of all intravenous lines, they cause most CR-BSIs.47 The most common mechanism 

of CVC-BSI is migration of the organism from the insertion site along the surface of the catheter 

and colonization of its distal part.48 CR-BSIs can also occur from contamination of the catheter 

hub or infusate administered through the device.45 

Several practices have been evaluated in an attempt to reduce the incidence of CVC-BSI. 

These include the use of antimicrobial catheters, antimicrobial-impregnated dressings, and 

interventions related to catheter insertion and maintenance. 

Antimicrobial Catheters and Dressings 

Catheters impregnated or coated with antimicrobials or antiseptics have been shown to 

decrease the risk of CVC-BSI. Multiple randomized controlled trials and several meta-analyses 

have demonstrated that catheters coated on the external surface with chlorhexidine/silver 

sulfadiazine or minocycline/rifampin reduce the risk for CVC-BSI compared with standard 

noncoated catheters.49–52 Chlorhexidine-impregnated dressings have also been found to reduce 

the rate of CVC colonization.48 While evidence for the efficacy of CVC catheters coated with 

antibacterial or antiseptic agents exists, limited information exists related to their costeffectiveness. Current CDC recommendations include use of CVC catheters coated with 

antibacterial or antiseptic agents for high-risk patients or situations in which CR-BSI rates are 

high despite careful attention to guidelines.52

Catheter Insertion and Maintenance Interventions To Reduce CVC-BSI 

CVC-BSIs often result from contamination of the catheter during insertion.52 Maximum 

sterile barrier precautions during insertion are indicated to reduce the incidence of CVC-BSI.

Effective barrier precautions include the use of sterile gloves, long-sleeved gowns, full-size 

drape, masks, and head covers by all personnel involved in the central line insertion procedure.52 

In addition to maximal barrier precautions during insertions, the 2002 CDC guidelines for the 

prevention of CVC infections outline other evidence-based practices, including the following:53 

1. Use of a 2-percent chlorhexidine preparation as the preferred skin antiseptic prior to 

insertion 

2. Education and training of staff who insert and maintain intravenous lines 

3. No routine replacement of central lines at scheduled intervals 

Additional measures advocated for best practices for CVC care include hand hygiene by 

washing hands with conventional antiseptic-containing soap and water or with waterless alcoholbased gels or foam before and after palpating insertion sites; and before and after insertion, 

replacing, accessing, or dressing a CVC.53 Avoidance of antibiotic ointment at insertion sites, 

which can promote fungal infections and antibiotic resistance, and restricted use of stopcocks on 

any tubing other than pressure tubing to minimize contamination are also recommended.53 Either 

sterile gauze or transparent, semipermeable dressings can be used, as research has demonstrated 

similar risks of CVC-BSI.53 Gauze dressings should be replaced every 2 days and transparent 

dressings every 7 days or when the dressing becomes damp, loose, or soiled.53, 54

The IHI has also published a central line bundle to reduce CVC-BSI.55 The components of 

the central line bundle include hand hygiene to prevent contamination of central lines, maximal 

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Targeting Health Care–Associated Infections

barrier precautions and CHG antisepsis for central line insertion, optimal catheter site selection 

with the subclavian vein as the preferred site for nontunneled catheters, and daily review of line 

necessity with removal of unnecessary lines.55

Educational measures related to CVC insertion and maintenance have proven effective in 

several studies.56–58 Focused aspects of education included proper insertion and maintenance, a 

catheter insertion cart, a checklist to ensure adherence to evidence-based guidelines, and 

empowering nurses to stop the catheter insertion procedure if a violation of guidelines is 

observed. Table 3 outlines evidence-based strategies for CVC-BSI prevention. Nursing-related 

care aspects include maximal barrier precaustings during CVC insertion; maintenance of central 

line site to minimize infection risk; prevention of contamination of CVC ports during blood 

sampling, infusion of intravenous fluids, or medication administration; maintenance of sterile 

technique for dressing changes; intravenous tubing changes based on protocol guidelines; and 

astute monitoring of patients with central lines for signs of infection. 

Sepsis 

Sepsis, or clinical manifestation of the systemic response to infection, represents a significant 

condition that results in increased mortality for hospitalized patients. The incidence of sepsis is 

increasing, with more than 750,000 cases occurring in the United States each year.59 Severe 

sepsis, which occurs when sepsis progresses to involve acute organ dysfunction, results in more 

than 200,000 annual fatalities, and the number of cases are projected to increase.59

Epidemiological studies indicate that between 11 percent and 27 percent of ICU admissions have 

severe sepsis, with mortality rates ranging from 20 percent to more than 50 percent.59–62 As 

infections can progress to sepsis, heightened monitoring of hospitalized patients for signs of 

sepsis are indicated for any patient with a suspected or confirmed infection. Focal areas pertinent 

to sepsis include monitoring, treatment, and prevention. 

Monitoring for Sepsis Risk 

Many risk factors exist for the development and progression of sepsis, including advanced 

age, compromised immune system response, chronic illness, broad spectrum antibiotic use, and 

exposure to infection risk associated with surgical and invasive procedures.63 The severity of 

sepsis varies widely. Some patients experience a controlled inflammatory response to systemic 

infection.64 However, the majority of patients with sepsis develop organ dysfunction (severe 

sepsis) with hypotension and a resultant state of decreased tissue perfusion. In addition to 

inflammation, severe sepsis is associated with activation of coagulation and impairment of 

fibrinolysis, which further impairs perfusion. The development of organ system failure can occur 

in the initial stages of severe sepsis, but the duration and progression of organ failure are 

influential in predicting survival.65 Septic shock is the most severe form of sepsis: hypotension is 

resistive to fluid resuscitation, a condition which is often associated with high mortality rates.64

Identified risk factors for increased mortality in sepsis include the microbiological etiology of 

sepsis; the site of the infection, with increased mortality associated with intra-abdominal or lower 

respiratory tract infections; presence of underlying disease; presence of shock; need for 

vasopressors; multiple organ failure; and neutropenia.66 Many factors contribute to multiple 

organ dysfunction syndrome in sepsis, including inadequate tissue/organ perfusion, cellular 

injury, ischemia, and diffuse endothelial cell injury.63 The progression of sepsis can be deterred 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

by early recognition and treatment, including early goal-directed therapy focusing on 

establishing adequate perfusion and targeted measures for sepsis treatment.24, 67

Treatment of Sepsis 

The Surviving Sepsis Campaign evidence-based guidelines for the treatment of sepsis were 

released in 2004 and have been promoted to improve outcomes for patients with severe 

sepsis.24, 68 The guidelines outline recommendations for targeting treatment of patients at risk of 

developing severe sepsis and septic shock. The guideline recommendations are aimed at 

providing resuscitation for sepsis-induced hypoperfusion and enhancing perfusion, antibiotic 

administration to combat infection, cultures to identify the source of infection, mechanical 

ventilation to optimize oxygenation, and source control to contain the infection. Additional 

treatment practices include glycemic control, steroid administration for adrenal insufficiency, 

prophylaxis measures for deep vein thrombosis and stress ulcer prevention, renal replacement 

therapies, administration of recombinant human activated protein C (rhAPC), blood product 

administration, sedation and analgesia, and consideration for limitation of support in critically ill 

patients.68 These evidence-based guidelines are outlined in Table 4. 

Bundles are also established for recognition and treatment of severe sepsis. The severe sepsis 

bundles are categorized into 6- and 24-hour bundles. The 6-hour bundle outlines the following 

interventions, which should be implemented immediately and within the first 6 hours of 

identification of severe sepsis: 

1. Measure serum lactate. 

2. Obtain blood cultures prior to antibiotics. 

3. Administer broad-spectrum antibiotics within 3 hours from time of presentation in the 

emergency room and 1 hour for nonemergency room ICU admissions. 

4. For hypotension and/or lactate > 4 mmol/L, 

a. Administer an initial minimum of 20 ml/kg of crystalloid (or colloid equivalent). 

b. Administer vasopressor for hypotension not responding to initial fluid resuscitation to 

maintain mean arterial pressure > 65 mm Hg. 

5. With persistent hypotension despite fluid resuscitation and/or lactate > 4 mmol/L, 

a. Achieve a central venous pressure (CVP) > 8 mm Hg. 

b. Achieve a central venous oxygen saturation (SCVO2) of > 70 percent. 

The 24-hour bundle outlines the following interventions, which should be implemented 

immediately and within the first 24 hours of identification of severe sepsis: 

1. Administer low-dose steroids for septic shock based on a standardized ICU policy. 

2. Administer drotrecogin alfa (activated) based on a standardized ICU policy. 

3. Maintain glucose control > lower limit of normal, but < 150 mg/dL. 

4. Maintain inspiratory plateau pressures < 30 mm H20 for mechanically ventilated patients. 

Implementation of the Surviving Sepsis Campaign guidelines, including the sepsis bundles, 

can favorably influence the course of sepsis. Additional focused approaches to the management 

of sepsis include early rapid-resuscitation shock protocols,69 comprehensive interdisciplinary 

sepsis treatment protocols,70 and algorithm-based or goal-directed care.71 

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Targeting Health Care–Associated Infections

Prevention of Sepsis 

Nursing-related implications for early detection and treatment of sepsis include assessing 

patients for signs of infection, obtaining cultures for suspected infection, providing medical 

treatments for sepsis, and infection-prevention measures.72 Awareness of the risk factors, clinical 

signs and symptoms, pathophysiology, and updates in the management of sepsis can enhance the 

nursing care for patients with severe sepsis and promote best practices for sepsis care in the ICU.

Infection-prevention measures for sepsis include general infection control practices, handwashing principles, and measures to prevent nosocomial infections (oral care and proper 

positioning to prevent nosocomial pneumonia, care of invasive catheters, skin care, wound care, 

identifying patients at risk for infection, prioritizing cultures for patients with suspected 

infection, and providing astute clinical assessment for early detection of sepsis).73 Table 5 

outlines general infection-prevention measures, highlighting nursing care considerations. A 

Cochrane systematic review is currently underway to assess the impact of the use of preoperative 

bathing or showering with skin antiseptics in reducing surgical-site infections.74 Keeping up to 

date with evidence-based and research practices aimed at preventing health care–associated 

infections is an additional essential aspect of nursing care. 

Antibiotic-Resistant Infections 

Both the CDC and the World Health Organization have identified antibiotic resistance as an 

important public health concern.75 The emergence of antimicrobial resistance in hospitals has 

been attributed to antibiotic use patterns as well as the capability of bacterial strains to develop 

resistance mechanisms through genetic alterations.76 It is estimated that up to 50 percent of 

antibiotic use in hospitals is inappropriate.77 According to the CDC, more than 70 percent of the 

bacteria that cause hospital-associated infections are resistant to at least one of the drugs most 

commonly used to treat them.78

When compared to infections caused by susceptible bacteria, infections caused by multidrugresistant bacteria are associated with higher incidences of mortality, morbidity, and increased 

hospital length of stay.77 Hospitalized patients who contract an infection with an antibioticresistant organism also have more costly management and therapies, and encounter more 

medical complications, than patients who do not acquire an infection or become infected with 

sensitive organisms.79–80

Data from many sources, including the CDC, indicate that antibiotic resistance to all the 

commonly used drug classes is increasing.79 For example, between 1998 and 2003, the following 

increases in resistant organisms have occurred in critically ill patients: 11 percent increase in 

methicillin-resistant Staphylococcus aureus (MRSA); 12 percent increase in vancomycinresistant enterococi (VRE); 47 percent increase in 3rd generation cephalosporin-resistant 

Kliebsiella pneumoniae; and a 20 percent increase in 3rd generation cephalosporin-resistant 

Pseudomonas aeruginosa.

81 An additional nosocomial infection that has been linked to antibiotic 

use in the hospital setting is Clostridium difficile (C. difficile). Although C. difficile is not an 

antibiotic-resistant infection, increased incidences in hospitalized settings have heightened 

awarenes.82

 Because of the widespread increases in resistant organisms with the concomitant difficulties 

associated with treatment and complications, addressing the issue of resistant organisms has 

become one of the CDC’s major concerns. Several main areas of focus for the prevention of 

11 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

antibiotic-resistant infections include control of antibiotic use, determining the right antibiotic, 

and control of patient-to-patient spread.

Control of Antibiotic Use 

Antibiotics are effective in treating infections because they kill or inhibit the growth of 

susceptible bacteria; however, they are not effective against viral infections. In an everincreasing number of instances, one of more of the bacteria causing the infection are able to 

survive. Those bacteria are then able to multiply and begin to proliferate a new strain of bacteria 

that have developed the inherent ability to survive in the presence of the antibiotics that are 

designed to eradicate them. The more exposure bacteria have to various antibiotics, the more 

likely it is that resistant organisms develop. 

According to the CDC, the biggest contribution to the development and continuing increase 

in resistant organisms is the overuse of antibiotics. Therefore, decreasing inappropriate antibiotic 

administration is the best way to control resistance. In 1995, the CDC83 launched a national 

campaign to reduce antimicrobial resistance. The two major goals of this campaign are (1) to 

reduce inappropriate antibiotic use, and (2) to reduce the spread of resistance to antibiotics. 

Following are the three major CDC recommendations for supporting and achieving these goals: 

• Prescribe antibiotic therapy only when it is likely to be beneficial. 

• Use an agent that targets the likely pathogens. 

• Order the antibiotic for the appropriate dose and duration. 

Determining the Right Antibiotic 

To effectively reduce antimicrobial resistance, prescribing health care providers must keep 

themselves informed about the most common infectious organisms present in the patient 

populations that they treat. For example, both VAP and hospital-associated pneumonia due to 

MRSA are becoming more common, and treatment strategies have emerged. Data compiled by 

an expert panel of the American Thoracic Society26 support the following recommendations: 

1. Apply early, appropriate, broad-spectrum antibiotic therapy at adequate doses; avoid 

excessive antibiotics through appropriate antibiotic deescalation. 

2. Empiric regimens should include agents from a different antibiotic class than the patient 

has recently received. 

3. Combination therapy should be used judiciously. 

4. Linezolid may be an appropriate alternative to vancomycin. 

5. Shorten antibiotic duration to the minimum effective period, and use short-course therapy 

whenever possible. 

6. Use local microbiologic data to adapt treatment recommendations to the clinical setting. 

Research has demonstrated the benefit of focused interventions aimed at improving antibiotic 

prescribing practices for hospital patients. A Cochrane systematic review of 66 studies revealed 

that interventions to improve antibiotic prescribing, dosing, timing of first dose, and duration of 

treatment are successful in reducing antimicrobial resistance.77 Specific interventions included 

distribution of educational materials; reminders provided verbally, on paper, or by computer; 

formulary restrictions; therapeutic substitutions; automatic stop orders; antibiotic policy change 

strategies, including cycling, rotation, and crossover studies; computerized order entry; and Webbased antimicrobial approval systems.77, 84 Other strategies, such as selective decontamination of 

12 
Targeting Health Care–Associated Infections

the digestive tract and use of CHG for daily bathing of hospitalized patients, have demonstrated 

efficacy in single-site controlled trials, but require further study.4, 85

Control Patient-to-Patient Spread 

Controlling the patient-to-patient spread of bacteria is one of the least expensive, most basic, 

and effective means for controlling the spread of resistant organisms. Both MRSA and VRE, two 

of the most troublesome resistant organisms, are spread primarily from person-to-person contact. 

In hospitalized patients, this includes transmission by the hands of a health care provider caring 

for an infected patient. Diligent hand washing is therefore of the utmost importance, and nurses 

can have a major influence. Both MRSA and VRE can also survive on equipment and surfaces, 

such as floors, sinks, and blood pressure cuffs. 

Specific CDC recommendations to prevent the spread of antimicrobial-resistant infections in 

hospitalized patients are outlined in Table 6. Focused measures include monitoring antimicrobial 

resistance of both community and nosocomial isolates on a regular basis, monitoring use of 

antimicrobials, increasing clinical staff awareness, and use of the CDC’s guidelines for isolation 

precautions in hospitals.76, 78 Preventative nursing care measures are essential in minimizing 

infection risk for hospitalized patients. Table 5 outlines additional essentials of infectionprevention measures for reducing the risk of health care associated infection among hospitalized 

patients. 

Evidence-Based Practice Implications 

Implementation of evidence-based practices, such as those that follow, can have a significant 

impact on lowering the incidence of health care–associated infections: 

• Preventing health care–associated infections is an important component of ensuring a 

safe health care environment for hospitalized patients. 

• Hand hygiene is an essential aspect of hospital-associated infection-reduction 

strategies. 

• Nursing care measures can directly contribute to prevention of central line infections, 

urinary tract infections, sepsis, and antibiotic-resistant infections. 

• Nursing care can directly contribute to prevention of hospital-associated pneumonia, 

particularly in patients who are most at risk related to advanced age, postoperative 

status, or mechanical ventilation. The evidence shows that the most important 

contributions of nursing care to prevention of hospital-associated pneumonia are in four 

areas: hand hygiene, respiratory care, patient positioning, and education of staff. 

• Nursing-related care aimed at preventing urinary tract infections includes thorough 

assessment to determine need for indwelling catheter use, aseptic insertion technique, 

indwelling catheter care to minimize infection risk, and astute monitoring of patients 

with urinary catheters for signs of infection. 

• Nursing-related measures to reduce the incidence of central line-associated infections 

include ensuring maximal barrier precautions during line insertion, maintenance of the 

central line site to minimize infection risk, prevention of contamination of central line 

ports during blood sampling, and maintenance of sterile techniques for dressing 

changes. 

13 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

• Infection-prevention measures for sepsis include general infection control practices, 

hand-washing principles, and measures to prevent nosocomial infections (oral care and 

proper positioning to prevent nosocomial pneumonia, care of invasive catheters, skin 

care, wound care, identifying patients at risk for infection, prioritizing cultures for 

patients with suspected infection, and providing astute clinical assessment for early 

detection of sepsis). 

• The main areas of focus for the prevention of antibiotic-resistant infections include 

control of antibiotic use, determining the right antibiotic, and control of patient-topatient spread. 

• Controlling patient-to-patient spread of infection with hand hygiene and general 

infection control practices are the most effective means for controlling the spread of 

resistant organisms. 

• Keeping up to date with evidence-based and research practices aimed at preventing 

health care–associated infections is an essential aspect of nursing care. 

 

Research Implications 

Given the gaps in the current evidence base, additional research is needed in the following 

areas: 

1. Continuous aspiration of subglottic secretions for VAP prevention 

2. Semirecumbent position for VAP prevention 

3. Silver alloy-coated catheters to prevent hospital-associated UTI 

4. Suprapubic catheters to prevent hospital-associated UTI 

5. Strategies to ensure use of full barrier precautions (gowns and gloves, dedicated 

equipment, dedicated personnel) during central line insertion 

6. Tunneling short-term CVCs to decrease central line infections 

7. Antibiotic limitations on hospital-associated infections due to antibiotic-resistant 

organisms 

8. Strategies to promote appropriate antibiotic administration in hospitals, including the 

use of informatics technology (e.g., computer-assisted decision support) to assist in 

point-of-care prescribing and patient-outcome monitoring 

9. Source control measures such as chlorhexidine gluconate for bathing, oral care 

protocols, and selective decontamination of the digestive tract 

10. Strategies to improve hand-washing compliance (education/behavior change, sink 

technology and placement) to reduce hospital-associated infections 

Conclusion 

A number of factors can lead to the development of health care–associated infections in the 

hospital setting, including increasing patient acuity levels, chronically ill and acutely ill patients 

who harbor antibiotic-resistant bacteria, and frequent use of broad-spectrum antibiotics. Health 

care–associated infections can significantly impact patient outcomes, including morbidity and 

mortality rates, length of hospital stay, and costs of care. Therefore, focusing on health care–

associated infections is an important aspect of providing quality health care.

14 
Targeting Health Care–Associated Infections

A targeted approach to infection in hospitalized settings includes prevention measures, early 

recognition and treatment of infection, appropriate use of antimicrobials, and measures to 

prevent the transmission of infection among hospitalized patients. This chapter has reviewed the 

evidence-based knowledge on health care–associated infections—including hospital-associated 

pneumonia, urinary tract infection, catheter-related bloodstream infection, sepsis, and antibioticresistant infections—highlighting important information for nurses caring for hospitalized 

patients. Nurses can play a key role in the prevention, identification, and management of 

infections in hospitalized patients through the use of evidence-based measures to ensure a safe 

health care environment for hospitalized patients. 

Author Affiliations 

Ruth M. Kleinpell, Ph.D., R.N., F.A.A.N., professor, Rush University College of Nursing, 

Chicago, Illinois. E-mail: Ruth_M_Kleinpell@rush.edu. 

Cindy L. Munro, R.N., A.N.P., Ph.D., F.A.A.N., professor, Virginia Commonwealth 

University School of Nursing. E-mail: cmunro@vcu.edu. 

Karen K. Giuliano, R.N., Ph.D., F.A.A.N., clinical nurse specialist, Philips Medical Systems, 

Andover, Massachusetts. E-mail: Karen.Guiliano@philips.com. 

References 

1. Levit K, Ryan K, Elixhauser A, et al. HCUP facts and 

figures: statistics on hospital-based care in the United 

States in 2005. Rockville, MD: Agency for Healthcare 

Research and Quality, 2007. Available at: www.hcupus.ahrq.gov/reports.jsp. 

2. Nguyen QV. Hospital acquired infections. Emedicine. 

2004. http://www.emedicine.com/PED/topic1619.htm. 

Accessed March 10, 2006. 

3. Stone PW, Larson E, Kawar LN. A systematic audit of 

economic evidence linking nosocomial infections and 

infection control interventions: 1990-2000. Am J 

Infect Control 2002; 30(3):145-52. 

4. de Jonge E. Effects of selective decontamination of 

digestive tract on mortality and antibiotic resistance in 

the intensive-care unit. Curr Opin Crit Care 

2005;11(2):144-9. 

5. Centers for Disease Control and Prevention. 

Guidelines for preventing health-care associated 

pneumonia, 2003: recommendations of CDC and the 

Healthcare Infection Control Practices Advisory 

Committee. MMWR 2004;53(No. RR-3):1-35. 

6. Safdar N, Dezfulian C, Collard HR, et al. Clinical and 

economic consequences of ventilator-associated 

pneumonia: a systematic review. Crit Care Med 

2005;33, 2184-93. 

7. Healthcare Infection Control Practices Advisory 

Committee and Hand-Hygiene Task Force, Society for 

Healthcare Epidemiology of America, Association for 

Professionals in Infection Control, Epidemiology, & 

Infection Diseases Society of America. Guideline for 

hand hygiene in healthcare settings. J.Am.Coll.Surg 

2004;198:121-7. 

8. Boyce, JM, Pittet D. Guideline for hand hygiene in 

health-care settings: recommendations of the 

Healthcare Infection Control Practices Advisory 

Committee and the HICPAC/SHEA/APIC/IDSA Hand 

Hygiene Task Force. Infect.Control Hos.Epidemiol 

2002;23:S3-40. 

9. Kac G, Podglajen I, Gueneret M, et al. 

Microbiological evaluation of two hand hygiene 

procedures achieved by healthcare workers during 

routine patient care: a randomized study. J Hosp Infect 

2005;60:32-9. 

10. Thomas JA, McIntosh, JM. Are incentive spirometry, 

intermittent positive pressure breathing, and deep 

breathing exercises effective in the prevention of 

postoperative pulmonary complications after upper 

abdominal surgery? A systematic overview and metaanalysis including commentary by Dean E with author 

response. Phys Ther 1994;74(1):3-16. 

15 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

11. Overend TJ, Anderson CM, Lucy SD, et al. The effect 

of incentive spirometry on postoperative pulmonary 

complications: a systematic review. Chest 2001; 

120:971-8. 

12. Chumillas S, Ponce JL, Delgado F, et al. Prevention of 

postoperative pulmonary complications through 

respiratory rehabilitation: a controlled clinical study. 

Arch Phys Med Rehabil 1998;79:5-9. 

13. Hall JC, Tarala RA, Tapper J, et al. Prevention of 

respiratory complications after abdominal surgery: a 

randomised clinical trial. BMJ 1996;312:148-52. 

14. Westerdahl E, Lindmark B, Eriksson T, et al. Deepbreathing exercises reduce atelectasis and improve 

pulmonary function after coronary artery bypass 

surgery. Chest 2005;128:3482-8. 

15. Mackay MR, Ellis E, Johnston C. Randomised clinical 

trial of physiotherapy after open abdominal surgery in 

high risk patients. Aust J Physiother 2005;51:151-9. 

16. Craven DE, Kunches LM, Kilinsky V, et al. Risk 

factors for pneumonia and fatality in patients receiving 

continuous mechanical ventilation. Am Rev Respir 

Dis 1986;133:792-6. 

17. Kollef MH. Ventilator-associated pneumonia. A 

multivariate analysis. JAMA 1993;270:1965-70. 

18. Kollef MH. The identification of ICU-specific 

outcome predictors: a comparison of medical, surgical, 

and cardiothoracic ICUs from a single institution. 

Heart Lung 1995;24:60-6. 

19. Torres A, Serra-Batlles J, Ros E, et al. Pulmonary 

aspiration of gastric contents in patients receiving 

mechanical ventilation: The effect of body position. 

Ann Intern Med 1992;116:540-3. 

20. Orozco-Levi M, Torres A, Ferrer M, et al. 

Semirecumbent position protects from pulmonary 

aspiration but not completely from gastroesophageal 

reflux in mechanically ventilated patients. Am J 

Respir Crit Care Med 1995;152:1387-90. 

21. Drakulovic MB, Torres A, Bauer TT, et al. Supine 

body position as a risk factor for nosocomial 

pneumonia in mechanically ventilated patients: A 

randomised trial. Lancet 1999;354:1851-8. 

22. van Nieuwenhoven CA, Vandenbroucke-Grauls C, 

van Tiel FH, et al. Feasibility and effects of the 

semirecumbent position to prevent ventilatorassociated pneumonia: a randomized study. Critical 

Care Meicine 2006;34:396-402. 

23. Grap MJ, Munro CL, Hummel RS III, et al. Effect of 

backrest elevation on the development of ventilatorassociated pneumonia. Am J Crit Care 2005;14:325-

32. 

24. Townsend S, Dellinger RP, Levy MM, et al. 

Implementing the Surviving Sepsis Campaign. Society 

of Critical Care Medicine, the European Society of 

Intensive Care Medicine, and the International Sepsis 

Forum; 2005. 

25. Institute for Healthcare Improvement. Getting started 

kit: prevent ventilator associated pneumonia. 

http://www.ihi.org/NR/rdonlyres/A448DDB1-E2A4-

4D13-8F02-16417EC52990/0/VAPHowtoGuide 

FINAL.pdf. Accessed March 11, 2006. 

26. American Thoracic Society. Guidelines for the 

management of adults with hospital-acquired, 

ventilator-associated, and healthcare-associated 

pneumonia. Am J Respir Crit Care Med 2005;17:388-

416. 

27. Dezfulian C, Shojania K, Collard HR, et al. Subglottic 

secretion drainage for preventing ventilator-associated 

pneumonia: a meta-analysis. Am J Med 2005;118:11-

8. 

28. Mori H, Hirasawa H, Oda S, et al. Oral care reduces 

incidence of ventilator-associated pneumonia in ICU 

populations. Intensive Care Med 2006;32:230-6. 

29. Cutler CJ, Davis N. Improving oral care in patients 

receiving mechanical ventilation. Am J Crit Care 

2005;14:389-94. 

30. Schleder BJ, Stott K, Lloyd RC. The effect of a 

comprehensive oral care protocol on patients at risk 

for ventilator-associated pneumonia. J Advocate 

Health Care 2002;4:27-30. 

31. Sona CS, Zack JE, Schallom ME, et al. A simple, lowcost oral care protocol reduces ventilator-associated 

pneumonia rates. Crit Care Med 2005;33(12):A13. 

32. Fourrier F, Cau-Pottier E, Boutigny H, et al. Effects of 

dental plaque antiseptic decontamination on bacterial 

colonization and nosocomial infections in critically ill 

patients. Intensive Care Med 2000;26:1239-47. 

33. Munro CL, Grap MJ. Oral health and care in the 

intensive care unit: state of the science. Am J Crit 

Care 2004;13:25-33. 

34. Won SP, Chou HC, Hsieh WS, et al. Handwashing 

program for the prevention of nosocomial infections in 

a neonatal intensive care unit. Infect Control Hosp 

Epidemiol 2004;25:742-6. 

16 
Targeting Health Care–Associated Infections

35. Zack JE, Garrison T, Trovillion E, et al. Effect of an 

education program aimed at reducing the occurence of 

ventilator-associated pneumonia. Crit Care Med 

2002;30:2407-12. 

36. Brosnahan J, Jull A, Tracy C. Types of urethral 

catheters for management of short-term voiding 

problems in hospitalized adults (Cochrane Review). 

The Cochrane Database Syst Rev 2007;1. 

37. Niel-Weise BS, van den Broek PJ. Antibiotic policies 

for short-term catheter bladder drainage in adults. The 

Cochrane Database Syst Rev 2005;3. 

38. Saint S. Prevention of nosocomial urinary tract 

infection. In: Shojania KG, Duncan BW, McDonald 

KM, et al., eds. Making health care safer: a critical 

analysis of patient safety practices. Evidence 

Report/Technology Assessment No. 42. (Prepared by 

the University of California at San Francisco-Stanford 

Evidence-based Practice Center under Contract No. 

290-97-0013), Rockville, MD: Agency for Healthcare 

Research and Quality; 2001. p. 149-61. AHRQ 

Publication No. 01-E058. 

39. Bagshaw SM, Laupland KB. Epidemiology of 

intensive care unit-acquired urinary tract infections. 

Curr Opin Infect Dis 2006;19:67-71. 

40. Trautner BW, Hull RA, Darouiche RO. Prevention of 

catheter-associated urinary tract infection. Current 

Opinion in Infectious Diseases 2005;18;37-41. 

41. Johnson JR, Kuskowski MA, Wilt TJ. Systematic 

review: antimicrobial urinary catheters to prevent 

catheter-associated urinary tract infection in 

hospitalized patients. Ann Intern Med 2006;144:116-

26. 

42. Wong ES. Guideline for prevention of catheterassociated urinary tract infections. 2005. 

http://www.cdc.gov/ncidod/dhqp/gl_catheter_assoc.ht

ml. Accessed March 1, 2006. 

43. Topol J, Conklin S, Camp K, et al. Prevention of 

nosocomial catheter-associated urinary tract infections 

through computerized feedback to physicians and a 

nurse-directed protocol. Am J Med Qual 2005;20:121-

6. 

44. O’Grady NP, Alexander M, Dellinger EP, et al. 

Guidelines for the prevention of intravascular catheterrelated infections. MMWR Recomm Rep 

2002;51(RR-10):1-29. 

45. Safdar N, Fine JP, Maki DG. Meta-analysis: methods 

for diagnosing intravascular device-related 

bloodstream infection. Ann Intern Med 2005;142:451-

66. 

46. Centers for Disease Control. Guidelines for the 

prevention of intravascular catheter-related infections. 

2002. 

http://www.cdc.gov/ncidod/dhqp/gl_intravascular.htm

l. Accessed February 18, 2006. 

47. Todd B. Preventing bloodstream infection. Am J Nurs 

2006;106(1):29-30. 

48. Levy I, Katz J, Solter E, et al. Chlorhexidineimpregnated dressing for prevention of colonization of 

central venous catheters in infants and children: a 

randomized controlled study. Pediatr Infect Dis J 

2005;24:676-9. 

49. Mermel LA. Prevention of intravascular catheterrelated infections. Ann Intern Med 2000;132:391-402. 

50. Rupp ME, Lisco SJ, Lipsett PA, et al. Effect of a 

second-generation venous catheter impregnated with 

chlorhexidine and silver sulfadiazine on central 

catheter-related infections: a randomized, controlled 

trial. Ann Intern Med 2005;143:570-80. 

51. Veenstra DL, Saint S, Saha S, et al. Efficacy of 

antiseptic-impregnated central venous catheters in 

preventing catheter-related bloodstream infection: a 

meta-analysis. JAMA 1999;281:261-7. 

52. Saint S. Prevention of intravascular catheterassociated infections. In: Shojania KG, Duncan BW, 

McDonald KM, et al., eds. Making health care safer: a 

critical analysis of patient safety practices. Evidence 

Report/Technology Assessment No. 42. (Prepared by 

the University of California at San Francisco-Stanford 

Evidence-based Practice Center under Contract No. 

290-97-0013), Rockville, MD: Agency for Healthcare 

Research and Quality; 2001. p. 163-83. 

53. O’Grady NP, Alexander M, Dellinger EP, et al. 

Centers for Disease control and Prevention (CDC) 

Hospital Infection Control Practices Advisory 

Committee. MMWR 2002;vol. 2000;1(RR10):1-26. 

54. Newell-Stokes G, Broughton S, Giuliano K, et al. 

Developing an evidence-based practice procedure: 

maintenance of central venous catheters. Clin Nurse 

Spec 2001;15:199-206. 

55. Institute for Healthcare Improvement. Getting Started 

kit: prevent central line infections. 2006. 

http://www.ihi.org/NR/rdonlyres/BF4CC102-C564-

4436-AC3A-0C57B1202872/0/ 

CentralLinesHowtoGuideFINAL720.pdf. Accessed 

March 11, 2006. 

56. Coopersmith CM, Zack JE, Ward MR, et al. The 

impact of bedside behavior on catheter-related 

bacteremia in the intensive care unit. Arch Surg Feb 

2004;139(2):131-6. 

17 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

57. Coopersmith CM, Rebmann TL, Zack JE, et al. Effect 

of an education program on decreasing catheterrelated bloodstream infections in the surgical intensive 

care unit. Crit Care Med 2002;30:59-64. 

58. Berenholtz S, Pronovost PJ, Lipsett PA, et al. 

Eliminating catheter-related bloodstream infections in 

the intensive care unit. Crit Care Med 2004;32:2014-

20. 

59. Angus DC, Linde-Zwirble WT, Lidicker J, et al. 

Epidemiology of severe sepsis in the United States: 

analysis of incidence, outcome and associated costs of 

care. Crit Care Med 2001;29:1303-10. 

60. Flaatten H. Epidemiology of sepsis in Norway in 

1999. Crit Care 2004;8:R180-4. 

61. Silva E, de Almeida Pedro M, Sogayar AC, et al. 

Brazilian sepsis epidemiological study (BASES 

study). Crit Care 2004;8:R251-R260. 

62. van Gestel A, Bakker J, Veraart CP, van Hout BA. 

Prevalence and incidence of severe sepsis in Dutch 

intensive care units. Crit Care 2004, 8:R153-62. 

63. Balk RA. Pathogenesis and management of multiple 

organ dysfunction or failure in severe sepsis and septic 

shock. Crit Care Clin 2000;16;337-52. 

64. Weycker D, Akhras KS, Edelsberg J, et al. Long-term 

mortality and medical care charges in patients with 

severe sepsis. Crit Care Med 2003;31:2316-23. 

65. Wheeler AP, Bernard GR. Treating patients with 

severe sepsis. N Engl J Med 1999;340:207-14. 

66. Angus DC, Wax RS. Epidemiology of sepsis: an 

update. Crit Care Med 2001;29:S109-16. 

67. Rivers E, Nguyen B, Havstad S, et al. Early goaldirected therapy in the treatment of severe sepsis and 

septic shock. N Engl J Med 2001;345:1368-77. 

68. Dellinger RP, Carlet JM, Masur H, et al. Surviving 

sepsis campaign guidelines for management of severe 

sepsis and septic shock. Crit Care Med 2004;32:858-

72. 

69. Sebat F, Johnson D, Musthafa AA, et al. A 

multidisciplinary community hospital program for 

early and rapid resuscitation of shock in nontrauma 

patients. Chest 2005;127;1729-43. 

70. Shapiro N, Howell MD, Talmor D, et al. 

Implementation and outcomes of the multiple urgent 

sepsis therapies (MUST) protocol. Crit Care Med 

2006;34:1025-32. 

71. Kortgen A. Niederprum P, Maure M. Implementation 

of an evidence-based “standard operating procedure” 

and outcome in septic shock. Crit Care Med 

2006;34:943-9. 

72. Kleinpell RM. The role of the critical care nurse in the 

assessment and management of the patient with severe 

sepsis. Crit Care Nurs Clin North Am 2003;15:27-34. 

73. Kleinpell RM. Advances in treating patients with 

severe sepsis. Crit Care Nurs 2003;23:1-13. 

74. Webster J, Osborne S. Pre-operative bathing or 

showering with skin antiseptics to reduce surgical site 

infection.Cochrane Database Syst Rev 2006 Apr 

19;(2):CD004985. 

75. Centers for Disease Control. Background on antibiotic 

resistance. http://www.cdc.gov/drugresistance/ 

community. Accessed March 8, 2006. 

76. Shales DM, Gerding DN, John JF, et al. Society for 

healthcare epidemiology of the American and 

infectious disease society of American joint committee 

on prevention of antimicrobial resistence: guidelines 

for prevention of antimicrobial resistance in hospitals. 

Infect Control Hosp Epidemiol 1997;18:275-91. 

77. Davey P, Brown E, Fenelon L, et al. Interventions to 

improve antibiotic prescribing practices for hospital 

inpatients. Cochrane Database of Syst Rev 

2005;(4):CD003543. 

78. Centers for Disease Control. Antimicrobial resistence 

in healthcare settings. 2005. 

http://www.cdc.gov/ncidod/dhqp/ar.html. Accessed 

February 20, 2006. 

79. Neiderman MS. Impact of antibiotic resistance on 

clinical outcomes and the cost of care. Crit Care Med 

2001;29, supplement: N114-20. 

80. Farr, BM, Salgado, CD, Karchmer, TB, et al. Can 

antibiotic resistant nocomomial infections be 

controlled? Lancet 2001;1:38-45. 

81. Centers for Disease Control. National Nosocomial 

Infections Surveillance System (NNIS) report, data 

summary from January 1992 through June, 2004, 

issued October, 2004. Am J Infect Control 

2004;32(6):470-85. 

82. Centers for Disease Control. Department of Health 

and Human Services, Center for Disease Control and 

Prevention, National Center for Infectious Diseases 

Hospital Infections Program. 

http://wonder.cdc.gov/wonder/prevguid/p0000107/p00

00107.asp#head002000000000000. Accessed 

February 26, 2006. 

18 
Targeting Health Care–Associated Infections

83. Centers for Disease Control. A public health plan to 

combat antimicrobial resistance. 

http://www.cdc.gov/drugresistance/actionplan/html/int

ro.htm. 2006. Accessed February 10, 2006. 

84. Richards MJ, Robertson MB, Dartnell JG, et al. 

Impact of a web-based antimicrobial approval system 

on broad-spectrum cephalosporin use at a teaching 

hospital. Med J Aust 2003;178(8):386-90. 

85. Vernon MO, Hayden MK, Trick WE, et al 

Chlorhexidine gluconate to cleanse patients in a 

medical intensive care unit. Arch Intern Med 

2006;166:306-12. 

19 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Table 1. Evidence-Based Guidelines for Prevention and Management of Hospital-Associated 

Pneumonia 

• Hand hygiene as an essential component of hospital-associated pneumonia reduction. 

• Respiratory care with encouragement of deep-breathing exercises. 

• Head-of-bed elevation to between 30 and 45 degrees. 

• Daily assessment of readiness for extubation. 

• Control of oral-tracheal secretions and oral care to minimize colonization and aspiration of biofilm. 

• Staff education about the significance of nosocomial pneumonias in patients and how interventions can 

reduce VAP. 

o Consider forming a multidisciplinary team (nurses, physicians, respiratory therapist, clinical 

pharmacist) or a unit group of staff to address VAP practice changes. 

o Develop communication strategies to alert and remind staff of the importance of VAP interventions. 

 

Sources: Adapted from Institute for Healthcare Improvement. Getting Started Kit: Prevent Ventilator Associated Pneumonia,

2006, http://www.ihi.org/NR/rdonlyres/A448DDB1-E2A4-4D13-8F02-16417EC52990/0/VAPHowtoGuideFINAL.pdf (accessed 

March 11, 2006); and the American Association of Critical Care Nurses practice alert: Ventilator-Associated Pneumonia, 

http://www.aacn.org (accessed March 5, 2006). 

Table 2. Evidence-Based Strategies for Urinary Tract Infection Prevention 

• Indwelling urinary catheters should be inserted using aseptic technique and sterile equipment. 

• Only hospital personnel who know the correct technique of aseptic insertion and maintenance of the catheter 

should handle catheters. 

• Hospital personnel should be provided with periodic in-service training stressing the correct techniques and 

potential complications of urinary catheterization. 

• Indwelling urinary catheters should be inserted only when necessary and left in place only for as long as 

necessary. 

• Other methods of urinary drainage such as condom catheter drainage, suprapubic catheterization, and 

intermittent urethral catheterization should be considered as alternatives to indwelling urethral catheterization. 

• Hand washing should be done immediately before and after any manipulation of the indwelling urinary catheter 

site or apparatus. 

• Indwelling catheters should be properly secured after insertion to prevent movement and urethral traction. 

• A sterile, continuously closed drainage system should be maintained.

• The catheter and drainage tube should not be disconnected unless the catheter must be irrigated, and irrigation 

should be used only for suspected obstruction. 

• If breaks in aseptic technique, disconnection, or leakage occur, the collecting system should be replaced using 

aseptic technique after disinfecting the catheter-tubing junction. 

• Specimen collections should be obtained from the distal end of the catheter, preferably from the sampling port 

after cleansing with a disinfectant and then the urine specimen aspirated with a sterile needle and syringe. 

• Consider the use of antimicrobial catheters for indwelling urinary catheters.

Source: Adapted from Wong ES, Guideline for Prevention of Catheter-Associated Urinary Tract Infections.

http://www.cdc.gov/ncidod/dhqp/gl_catheter_assoc.html. 

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Table 3. Evidence-Based Strategies for Central Line Infection Prevention 

• Education and training should be provided for staff who insert and maintain intravenous lines.

• Maximal sterile barriers should be used during catheter insertion (cap, mask, sterile gown and gloves, 

and a large sterile drape). 

• A 2% chlorhexidine preparation is the preferred skin antiseptic, to be applied prior to insertion. 

• Antiseptic- or antibiotic-impregnated catheters should be reserved for very high-risk patients or 

situations in which catheter-related BSI rates are high despite careful attention to these 

recommendations. 

• Replace peripheral intravenous sites in the adult patient population at least every 96 hours but no 

more frequently than every 72 hours. Peripheral venous catheters in children should be left in until the 

intravenous therapy is completed, unless complications such as phlebitis or infiltration occur. 

• Replace intravenous tubing at least every 96 hours but no more frequently than every 72 hours. 

• Replace intravenous catheters as soon as possible when adherence to aseptic technique during 

catheter insertion cannot be ensured (i.e., prehospital, code situation). 

• Central lines should not routinely be replaced at scheduled intervals. 

• Consider use of a central line insertion checklist to ensure all processes related to central line insertion 

are executed for each line placement. 

• Consider use of a central line insertion cart to avoid the difficulty of finding necessary equipment to 

institute maximal barrier precautions. 

• Replace central line dressings whenever damp, loose, or soiled or at a frequency of every 2 days for 

gauze dressings and every 7 days for transparent dressings. 

• Avoid use of antibiotic ointment at insertion sites because it can promote fungal infections and 

antibiotic resistance. 

• Include daily review of line necessity. 

• Assess competency of staff who insert and care for intravascular catheters.

Sources: Adapted from: O’Grady NP, et al., Guidelines for the Prevention of Intravascular Catheter-Related Infections, Centers 

for Disease Control and Prevention, MMWR Recomm Rep 2002;51(RR-10):1–29; Institute for Healthcare Improvement, Getting 

Started Kit: Prevent Central Line Infections, 2006, available at: http://www.ihi.org/NR/rdonlyres/BF4CC102-C564-4436-AC3A0C57B1202872/0/CentralLinesHowtoGuideFINAL720.pdf (accessed March 11, 2006); and American Association of Critical 

Care Nurses practice alert: Preventing Catheter-Related Bloodstream Infections, www.aacn.org (accessed March 5, 2006). 

Table 4. Evidence-Based Guidelines for Sepsis 

The Surviving Sepsis Campaign guidelines outline evidence-based recommendations for targeting 

treatment of patients at risk of developing severe sepsis and septic shock. 

The following grading system was used to classify the treatment recommendations: 

A. Supported by at least two level I investigations (large, randomized trials with confident results) 

B. Supported by one level I investigation 

C. Supported by level II investigations only (small, randomized trials with uncertain results) 

D. Supported by at least one level III investigation (nonrandomized study) 

E. Supported by level IV (nonrandomized, historical controls, and expert opinion) or level V evidence 

(case series, uncontrolled studies, and expert opinion) 

a. Initial resuscitation for sepsis-induced hypoperfusion—grade B 

• Fluid resuscitation to a central venous pressure of 8–12 mmHg 

• Early goal-directed therapy 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

• Transfusion of packed red blood cells to achieve a hematocrit of > 30 percent 

• Administration of inotropic infusion (e.g., dobutamine) 

b. Diagnosis 

• Obtain cultures: at least two blood cultures with one drawn percutaneously and one drawn through 

each vascular access device; cultures of other sites such as urine, wounds, respiratory secretions 

should be obtained before antibiotic therapy is initiated—grade D 

• Diagnostic studies (e.g., ultrasound, imaging studies)—grade E 

c. Antibiotic therapy 

• Empirical antibiotics—grade E 

d. Source control 

• Removal of potentially infected device, drainage of abscess, debridement of infected necrotic 

tissue—grade E 

e. Enhance perfusion 

• Fluid therapy—grade C 

• Vaspressors—grade E 

• Inotropic therapy—grade E 

f. Steroids 

• For patients with relative adrenal insufficiency—grade C 

g. Recombinant human activated protein C (rhAPC)—grade B 

• For patients with sepsis-induced multiple organ failure with no absolute contraindication related to 

bleeding risk 

h. Blood product administration 

• To target hemoglobin of 7.0 to 9.0 g/dL—grade B 

i. Mechanical ventilation 

• Lung protective ventilation for acute lung injury/acute respiratory distress syndrome—grade B 

j. Sedation, analgesia, and neuromuscular blockade 

• To provide comfort yet avoid prolonged sedation—grade B 

k. Glucose control 

• To maintain blood glucose <150 mg/dL—grade D 

l. Renal replacement 

• For acute renal failure—grade B 

m. Prophylaxis measures 

• Deep vein thrombosis—grade A 

• Stress ulcer—grade A 

n. Consideration for limitation of support 

• Discuss end-of-life care for critically ill patients—grade E 

• Promote family communication to discuss use of life-sustaining therapies—grade E 

Source: Adapted from Dellinger et al. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. 

Crit Care Med 2004;32:858-72. 

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Targeting Health Care–Associated Infections

Table 5. General Infection-Prevention Measures 

• Standard precautions apply to the care of all patients. 

• Contact precautions apply to patients with a known or suspected infection with pathogens that 

can be transmitted by direct or indirect contact. 

• Droplet precautions apply to patients with a known or suspected infection with pathogens that can 

be transmitted by infectious droplets. 

• Airborne precautions apply to patients known or suspected to be infected with epidemiologically 

important pathogens that can be transmitted by the airborne route. 

Categories of Infection-Prevention Measures 

• Hand washing: after touching blood, body fluids, secretions, excretions, and contaminated items, 

whether or not gloves are worn; after gloves are removed, between patient contacts, between 

tasks and procedures 

• Gloves: when touching blood, body fluids, secretions, excretions, and contaminated items; before 

touching mucous membranes and nonintact skin; between tasks and procedures; after contact 

with potentially contaminated material 

• Mask, eye protection, face shield: to protect mucous membranes of the eyes, nose, and mouth 

during procedures and patient-care activities with the potential to generate splashes or sprays of 

blood, body fluids, secretions, and excretions 

• Gown: to protect skin and prevent soiling of clothing during procedures and patient-care activities 

with the potential to generate splashes or sprays of blood, body fluids, secretions, or excretions 

• Patient care equipment: appropriate handling of used patient-care equipment soiled with blood, 

body fluids, secretions, and excretions to prevent skin and mucous membrane exposures, 

contamination of clothing, and transfer of microorganisms to other patients and environments; to 

ensure that reusable equipment is not used until it has been cleaned and reprocessed 

appropriately; to ensure that single-use items are discarded properly 

• Environmental control: to ensure adherence with procedures for the routine care, cleaning, and 

disinfection of environmental surfaces, beds, bedrails, bedside equipment, and other frequently 

touched surfaces 

• Linen: procedures for handling, transporting, and processing used linen soiled with blood, body 

fluids, secretions, and excretions to prevent skin and mucous membrane exposures and 

contamination of clothing; to avoid spread of microorganisms to other patients and environments 

• Patient placement: placement of patients with the potential to contaminate the environment in a 

private room 

Source: Adapted from CDC, Standard Precautions. http://www.cdc.gov/ncidod/dhqp/gl_isolation_standard.html. Accessed 

February 21, 2006 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Table 6. Measures To Prevent Antimicrobial Resistance in Hospitalized Patients 

• Establish systems for monitoring bacterial resistance and antibiotic use. 

• Place limitations on antibiotic use. 

• Establish systems for monitoring both process and outcome measures for infected patients, such as appropriate 

use of universal precautions, compliance with hand washing, length of hospital stay, or complication rates. 

• Adopt the recommendations of the CDC’s guidelines for isolation precautions in hospitals to prevent colonization 

and/or spread of resistant microorganisms. 

• Place infected patients in private rooms or only with other infected patients. 

• Hospital staff should wear gloves and gowns whenever they enter the room of an infected patient, even if there 

is no direct patient contact, because these organisms can extensively contaminate the environment. 

• Patient-care items should be single-patient use whenever possible. 

• Use a notification system so that staff are aware of the detection of cases where antimicrobial-resistant 

infections such as MRSA and VRE have been detected. 

• Ensure that clinical staff are knowledgeable about hospital policies regarding antimicrobial-resistant infections 

such as MRSA and VRE colonizing in or infecting patients.

Source: Adapted from Centers for Disease Control, Antimicrobial Resistence in Healthcare Settings, 2005. 

http://www.cdc.gov/ncidod/dhqp/ar.html. Accessed February 20, 2006. 

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