Infection Control and Barrier Precautions

The purpose of this course is to prepare healthcare professionals to adhere to scientifically accepted principles and practices of infection control, understand modes and mechanisms of transmission, understand the use of engineering and work practice controls, select and use appropriate barrier protections, create and maintain a safe environment, and prevent and manage infectious and communicable diseases.

After completing this course, the learner will be able to:

1. Discuss the responsibility to adhere to scientifically accepted infection control standards and to monitor subordinates,
2. Identify disease transmission mechanisms and strategies for prevention,
3. Discuss the use of engineering and work practice controls to minimize exposure to potentially infectious blood borne pathogens,
4. Discuss the selection and use of personal protective equipment (PPE) and other preventive barriers,
5. Identify cleaning, disinfection and sterilization standards for creating and maintaining a safe environment, and
6. Discuss prevention and management of infectious or communicable diseases in healthcare professionals.

Healthcare professionals have an obligation to adhere to scientifically accepted standards for infection control to prevent disease transmission amongst patients or between patients and healthcare professionals. The healthcare professional also has a responsibility to monitor the infection control practices of subordinates. The state of New York takes this very seriously. In fact New York rules and regulations require healthcare professionals to participate in infection control and barrier precautions education at least every four years. Evidence of completion of this training must be submitted to the State Department of Health or the Education Department. Physicians with hospital privileges will present the training documentation to the hospital in lieu of the Department of Health during the process of renewal of hospital privileges (NY, 2008).

New York professions required to obtain this education are dental hygienists, dentists, licensed practical nurses, optometrists, physicians, physician assistants, podiatrists, registered professional nurses and specialist assistants, medical students, medical residents, and physician assistant students Exemptions may be granted because the professional has completed equivalent course work or because the nature of his or her practice does not require the use of infection control techniques or barrier precautions (NY, 2008). A written application for exemption from completion of this course work must be presented to the Department of Health for approval.

In New York, state rules and regulations define responsibility for compliance and consequences for non-compliance with infection control practices. All licensed healthcare facilities are responsible for monitoring and enforcing proper use of infections control practices and standard precaution. Failure to comply can result in a citation, potential fines, and other disciplinary action against the facility. Licensed healthcare professionals who fail to use appropriate infection control techniques may be charged with professional misconduct and disciplinary action. Patient or employee complaints about lax infection control practices in private offices will cause an investigation by the Department of Health and/or Education. Substantiated lapses may result in charges of professional misconduct against licensed healthcare professionals who were directly involved, who were aware of the violations, or who were responsible for ensuring staff education and compliance (NY, 2008). Scientifically accepted infection control techniques include but are not limited to (NY, 1992, p D):

• wearing appropriate protective gloves at all times when touching blood, saliva, other body fluids or secretions, mucous membranes, non-intact skin, blood-soiled items or bodily fluid-soiled items, contaminated surfaces, sterile body areas, and during instrument cleaning and decontamination procedures;
• discarding gloves used following treatment of a patient and changing to new gloves if torn or damaged during treatment of a patient; washing hands and donning new gloves prior to performing services for another patient; and washing hands and other skin surfaces immediately if contaminated with blood or other body fluids;
• wearing of appropriate masks, gowns or aprons, and protective eyewear or chin length plastic face shields whenever splashing or spattering of blood or other body fluids is likely to occur;
• sterilizing equipment and devices that enter the patient’s vascular system or other normally sterile areas of the body;
• sterilizing equipment and devices that touch intact mucous membranes but do not penetrate the patient’s body or using high-level disinfection for equipment and devices which cannot be sterilized prior to use for a patient;
• using appropriate agents including but not limited to detergents for cleaning all equipment and devices prior to sterilization or disinfection;
• cleaning, by use of appropriate agents including but not limited to detergents, equipment and devices which do not touch the patient or that only touch the intact skin of the patient;
• maintaining equipment and devices used for sterilization according to the manufacturer’s instructions;
• adequately monitoring the performance of all personnel, licensed or unlicensed, for whom the licensee is responsible regarding infection control techniques;
• placing disposable used syringes, needles, scalpel blades, and other sharp instruments in appropriate puncture-resistant containers for disposal; and placing reusable needles, scalpel blades, and other sharp instruments in appropriate puncture resistant containers until appropriately cleaned and sterilized;
• maintaining appropriate ventilation devices to minimize the need for emergency mouth-to-mouth resuscitation;
• refraining from all direct patient care and handling of patient care equipment when the healthcare professional has exudative lesions or weeping dermatitis and the condition had not been medically evaluated and determined to be safe or capable of being safely protected against in providing direct patient care or in handling patient care equipment; and
• placing all specimens of blood and body fluids in well-constructed containers with secure lids to prevent leaking; and cleaning any spill of blood or other body fluid with an appropriate detergent and appropriate chemical germicide.

Controls are incorporated into the healthcare work setting to avoid or reduce exposure to potentially infectious materials. Healthcare associated transmission is the transmission of microorganisms that is likely to occur in a healthcare setting that can be reduced by using engineered controls, safe injection practices, and safe work practices. Engineering controls are equipment, devices, or instruments that remove or isolate a hazard. Safe injection practices are equipment and practices that allow the performance of injections in an optimally safe manner for patients, healthcare providers, and others that reduce exposure (CDC, 2008). Work practice controls change practices and procedures to reduce or eliminate risks.

Standard precautions are strategies for protecting healthcare professionals from occupational transmission of organisms. The premise is that all pre-existing patient infections cannot be identified; therefore, barrier precautions should be used routinely to protect from all sources of potential infection. Standard precautions apply to nonintact skin and mucous membranes, blood, all body fluids, secretions, and excretions, except sweat, regardless of whether or not they contain visible blood. Additional precautions are based on highly transmissible or epidemiologically important pathogens. Transmission Based Precautions (isolation) are airborne, droplet, and contact.

New elements of standard precautions have been added to focus on patient protection. These elements are respiratory hygiene/cough etiquette, safe injection practices, and the use of masks for insertion of catheters or injections into spinal or epidural spaces via lumbar puncture CDC, 2007).

Respiratory hygiene/cough etiquette is a strategy to reduce transmission of respiratory infections at the first point of entry into a healthcare setting. Signs educating patients and families should be posted at entry areas. The instructions are that persons with cough, congestion, rhinorrhea, or increased respiratory secretions should (CDC, 2007):

• Cover the mouth and nose when coughing or sneezing
• Dispose of used tissues promptly
• Use a surgical mask if coughing and if tolerated
• Wash hands after contact with respiratory secretions
• Separate at least three feet from persons with respiratory infections in common areas when possible.

Healthcare personnel should observe Droplet Precautions when caring for patients with signs and symptoms of a respiratory infection. Healthcare personnel who have a respiratory infection are advised to avoid direct patient contact, especially with high risk patients. If this is not possible, then a mask should be worn while providing patient care (CDC, 2007).

Needlestick and sharps injuries are major occupational hazards for nurses (Cho, et al, 2012). Nurses sustain a large proportion of the needlestick and sharps injuries sustained by healthcare professionals, but laboratory staff, physicians, housekeepers, and other healthcare professionals are also injured (Himmelreich, et al, 2012). Some of these injuries expose professionals to bloodborne pathogens that can cause infection. The most important of these pathogens are hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV). Infections with each of these pathogens are potentially life threatening and preventable.

One serious bloodborne infection can cost more than a million dollars for medications, follow up laboratory testing, clinical evaluation, lost wages, and disability payments. The human costs after an exposure are immeasurable. Employees may experience anger, depression, fear, anxiety, difficulty with sexual relations, difficulty sleeping, problems concentrating, and doubts regarding their career choice. The emotional effect can be long lasting, even in a low risk exposure that does not result in infection (Zhang, et al, 2013).

Percutaneous injuries can be avoided by eliminating the unnecessary use of needles, using devices with safety features, and promoting education and safe work practices for handling needles and related systems. Since 1993, the use of safety-engineered sharps devices has increased while the use of conventional sharps devices has decreased. Vigorous efforts to prevent needlestick and sharps injuries (e.g., the Needlestick Prevention and Safety Act of 2000) and increased awareness have helped to decrease the number of these injuries: several authors noted that needlestick injuries have decreased 38% in recent years (Phillips, et al, 2012; Trossman, 2012). A number of sources have identified the desirable characteristics of safety devices. These characteristics include the following (NIOSH, 1999):

• The device is needleless.
• The safety feature is an integral part of the device.
• The device preferably works passively (i.e., it requires no activation by the user). If user activation is necessary, the safety feature can be engaged with a single-handed technique and allows the professional's hands to remain behind the exposed sharp.
• The user can easily tell whether the safety feature is activated.
• The safety feature cannot be deactivated and remains protective through disposal.
• The device performs reliably.
• The device is easy to use and practical.
• The device is safe and effective for patient care.

Although each of these characteristics is desirable, some are not feasible, applicable, or available for certain healthcare situations. For example, needles will always be necessary where alternatives for skin penetration are not available. Also, a safety feature that requires activation by the user might be preferable to one that is passive in some cases. Each device must be considered on its own merit and ultimately on its ability to reduce workplace injuries. The desirable characteristics listed here should serve only as a guideline for device design and selection.

Needles should NEVER be recapped, bent, broken, or removed from contaminated syringes. Recapping by hand is prohibited under the OSHA bloodborne pathogens standard [29 CFR 1910.1030] unless no alternative exists. Sharps should be disposed into a puncture-proof container.

There is exposure to percutaneous injuries during procedures where there is opportunity for percutaneous exposure, especially where there is poor visualization, blind suturing, non-dominant hand opposing or next to a sharp, and exposure to bone spicules and metal fragments. Sharp equipment should be disassembled using forceps or other devices. Suturing should always be done with a needle holder, forceps, or other tool. Do not use fingers to hold tissue when suturing or cutting. Never leave sharps on a work field. If used needles or other sharps are left in the work area or are discarded in a sharps container that is not puncture resistant, a needlestick injury may result. Injury may occur when a healthcare professional attempts to transfer blood or other body fluids from a syringe to a specimen container (such as a vacuum tube) and misses the target.

Safe injection practice in hospitals is well established. However, outbreaks of HBV and HCV amongst patients were traced back to ambulatory care facilities, which identified the need to define and reinforce safe injection practices in outpatient care setting. The reuse of needles, multidose vials, and work areas containing both sterile and contaminated injection supplies contributed to the problem. There was a lack of understanding of aseptic technique, a lack of oversight, and failure to follow up on infection control breeches (Kuehn, 2012).. The following are safe injection practices recommended by CDC (CDC, April 1, 2011) that apply to the use of needles, cannulas that replace needles and, where applicable, intravenous delivery systems.

• Use aseptic technique to avoid contamination of sterile injection equipment.
  • Do not administer medications from a syringe to multiple patients, even if the needle or cannula on the syringe is changed.
  • Needles, cannula and syringes are sterile, single-use items; they should not be reused for another patient nor to access a medication or solution that might be used for a subsequent patient. 
• Use fluid infusion and administration sets (i.e., intravenous bags, tubing and connectors) for one patient only and dispose appropriately after use.
  • Consider a syringe or needle/cannula contaminated once it has been used to enter or connect to a patient's intravenous infusion bag or administration set. 
• Use single-dose vials for parenteral medications whenever possible.
  • Do not administer medications from single-dose vials or ampules to multiple patients or combine leftover contents for later use. 
• If multidose vials must be used, both the needle or cannula and syringe used to access the multidose vial must be sterile.
  • Do not keep multidose vials in the immediate patient treatment area and store in accordance with the manufacturer's recommendations; discard if sterility is compromised or questionable. 
• Do not use bags or bottles of intravenous solution as a common source of supply for multiple patients.
• Infection control practices for special lumbar puncture procedures
  • Wear a surgical mask when placing a catheter or injecting material into the spinal canal or subdural space (i.e., during myelograms, lumbar puncture and spinal or epidural anesthesia. 
• Employee safety
  • Adhere to federal and state requirements for protection of healthcare personnel from exposure to bloodborne pathogens. 

Handwashing is the most important measure to reduce the transmission of microorganisms. Hands should be washed or alcohol-based rubs should be used between patient contacts and after gloves are removed. Hands should be washed after contact with blood, body fluids, secretions, excretions, and contaminated equipment. It may be necessary to wash hands between tasks on the same patient to prevent cross-contamination of different body sites. CDC and Prevention Guideline for Hand Hygiene in Healthcare Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force (Morbidity and Mortality Weekly Report, October 25, 2002; WHO, 2009)

• Improved adherence to hand hygiene (i.e. hand washing or use of alcohol-based hand rubs) has been shown to terminate outbreaks in healthcare facilities, to reduce transmission of antimicrobial resistant organisms (e.g. methicillin resistant staphylococcus aureus) and reduce overall infection rates (Marra, et al, 2013).
• CDC is releasing guidelines to improve adherence to hand hygiene in healthcare settings. In addition to traditional handwashing with soap and water, CDC is recommending the use of alcohol-based hand cleansers by healthcare personnel for patient care because they address some of the obstacles that healthcare professionals face when taking care of patients and frequently washing their hands.
• Handwashing with soap and water remains a sensible strategy for hand hygiene in non-healthcare settings and is recommended by CDC and other experts.
• When healthcare personnel's hands are visibly soiled, they should wash with soap and water.
• The use of gloves does not eliminate the need for hand hygiene. Likewise, the use of hand hygiene does not eliminate the need for gloves. Gloves reduce hand contamination by 70% to 80 %, prevent cross contamination and protect patients and healthcare personnel from infection. Alcohol-based hand rubs should be used before and after caring for each patient just as gloves should be changed before and after each patient.
• When using an alcohol-based hand rub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers until hands are dry. Note that the volume needed to reduce the number of bacteria on hands varies by product.
• Alcohol-based hand rubs significantly reduce the number of microorganisms on skin, are fast acting, and cause less skin irritation than soap and water.
• Healthcare personnel should avoid wearing artificial nails and keep natural nails less than one quarter of an inch long if they care for patients at high risk of acquiring infections (e.g. Patients in intensive care units or in transplant units).
• When evaluating hand hygiene products for potential use in healthcare facilities, administrators or product selection committees should consider the relative efficacy of antiseptic agents against various pathogens and the acceptability of hand hygiene products by personnel. Characteristics of a product that can affect acceptance and therefore usage include its smell, consistency, color and the effect of dryness on hands.
• As part of these recommendations, CDC is asking healthcare facilities to develop and implement a system for measuring improvements in adherence to these hand hygiene recommendations. Some of the suggested performance indicators include periodic monitoring of hand hygiene adherence and providing feedback to personnel regarding their performance, monitoring the volume of alcohol-based hand rub used/1000 patient days, monitoring adherence to policies dealing with wearing artificial nails, and focused assessment of the adequacy of healthcare personnel hand hygiene when outbreaks of infection occur.
• Allergic contact dermatitis due to alcohol hand rubs is very uncommon. However, with increasing use of such products by healthcare personnel, it is likely that true allergic reactions to such products will occasionally be encountered.
• Alcohol-based hand rubs take less time to use than traditional hand washing. In an eight-hour shift, an estimated one hour of an ICU nurse's time will be saved by using an alcohol-based hand rub.

The appropriate use of personal protective equipment (PPE) is an important element of standard precautions. Gloves provide a protective barrier between the patient and the healthcare professional and prevent gross contamination of the hands. Gloves do not replace the need for handwashing because the gloves may have small defects, may be torn during use, and hands may become contaminated during glove removal.

Masks, goggles, or face shields should be used to protect the mucous membranes of the eyes, nose, and mouth during situations where there is a likelihood of splashes or sprays. A surgical mask is worn by healthcare professionals to provide protection against large-particle droplets during close patient contact. When tuberculosis is known or suspected, healthcare professionals should wear an N95 respirator, a high-efficiency particulate air (HEPA) filter respirator or a powered air-purifying respirator (PAPR).

Gowns are worn to prevent contamination of clothing and protect the healthcare professional’s skin from blood and body fluid exposure. Impermeable gowns, leg coverings, boots, or shoe covers provide more protection when large quantities of blood or body fluids may be splashed. Gowns are also worn as a part of some transmission based precautions. Mouthpieces, resuscitation bags, or other ventilation devices should be used instead of mouth-to-mouth resuscitation.

Transmission based precautions and protective environment (PE) are terms used to describe protective measures that need to be employed for specific groups of patients. An older term for this was isolation. Patients requiring transmission based precautions require a private room. A negative pressure air handling system that exhausts to the outside is required for airborne precautions. Movement of these patients should be limited. When transport is necessary, appropriate barriers should be used. Masks should be used for patients who are on airborne precautions. Patients infected with the same organism can share a room. This is called cohorting.

Airborne Precautions are implemented for diseases that are transmitted by microorganisms in airborne droplet nuclei. Droplet nuclei are tiny particle residues left when droplets evaporate. Droplet nuclei remain suspended in the air and can be widely dispersed by air currents. Early identification and triage of suspected cases of airborne transmitted diseases should be done and possibly infectious patients should be separated from others and asked to wear a surgical mask.

Airborne precautions require a specially ventilated room with at least 6 air changes per hour; negative air pressure relative to the hallway; and outside exhaust or HEPA-filtered recirculation. The door to the room must be kept closed. The negative air pressure should be monitored. An N-95 mask or a PAPR is used in airborne precautions.

• These masks and respirators should be labeled and stored in a paper bag between uses.
• These mask and respirators should be discarded if soiled or if it no longer maintains its structural or functional integrity.
• The N-95 mask should also be discarded at the end of each work shift.
• The disposable respirator should be discarded at the end of 2 weeks.

When the patient in airborne precautions has to be moved or transported, the patient should wear a surgical mask from the time he leaves the isolation room, until he returns.

Droplet precautions are used for patients known or suspected to be infected with microorganisms transmitted by droplets generated during coughing, sneezing, talking, or performance of procedures.

Droplet precautions require a private room, but no special ventilation is necessary and the door may remain open. Masks should be worn if working within three feet of the patient. The patient should be masked if transported.

Contact precautions are used for patients with known or suspected infections or colonized with epidemiologically important microorganisms that can be transmitted by direct or indirect contact.

The patient should be in a private room. Standard precautions should be used, and a gown should be worn if there is likely to be contact with the patient or environmental surfaces.

Some facilities may be implementing special isolation for VRE. This is an exaggerated form of contact precautions requiring the use of gowns and gloves anytime the room is entered, even if you do not anticipate patient contact. The rational is that VRE survives in the environment for a long time and contact with any surface may lead to transmission. This isolation is not recommended by CDC.

Neutropenic precautions (reverse isolation) are implemented to protect immunocompromised patients.

Neutropenic precautions require a private room with positive air pressure. Other precautions may range from standard precautions and limitation of traffic to extensive precautions using gloves, gowns, and masks. This varies depending on the reason for the precautions and the degree of the patient’s immunosuppression.

Although the environment is a reservoir for a variety of microorganisms, it is rarely implicated in disease transmission except in the immunocompromised population. Consistently applied infection-control strategies and engineering controls are effective in preventing opportunistic, environmentally-related infections in immunocompromised populations (CDC, June 6, 2003).

Medical equipment should come with manufacturer instructions on how to provide care and maintenance. The instructions should include 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 (CDC, 2008). If manufacturers’ instructions are not available for non-critical medical equipment, like stethoscopes and blood pressure cuffs, they usually only require cleansing followed by low- to intermediate-level disinfection, depending on the nature and degree of contamination (CDC, 2008).

Cleaning disinfecting and sterilizing patient care items should be done in a central location to control the quality. If disinfecting and sterilizing is done in outside the central processing location, the same level of efficiency and safety should be maintained (CDC, 2008).

The following principles about sterilization or disinfection of patient-care equipment are put forth by CDC (CDC, 2008).

General Principles

• In general, reusable medical devices or patient-care equipment that enters normally sterile tissue or the vascular system or through which blood flows should be sterilized before each use. Sterilization means the use of a physical or chemical procedure to destroy all microbial life, including highly resistant bacterial endospores. The major sterilizing agents used in hospitals are a) moist heat by steam autoclaving, b) ethylene oxide gas, and c) dry heat. However, there are a variety of chemical germicides (sterilants) that have been used for purposes of reprocessing reusable heat-sensitive medical devices and appear to be effective when used appropriately, i.e., according to manufacturer's instructions. These chemicals are rarely used for sterilization, but appear to be effective for high-level disinfection of medical devices that come into contact with mucous membranes during use (e.g., flexible fiberoptic endoscopes).
• Heat stable reusable medical devices that enter the blood stream or enter normally sterile tissue should always be reprocessed using heat-based methods of sterilization (e.g., steam autoclave or dry heat oven).
• Laparoscopic or arthroscopic telescopes (optic portions of the endoscopic set) should be subjected to a sterilization procedure before each use; if this is not feasible, they should receive high-level disinfection. Heat stable accessories to the endoscopic set (e.g., trocars, operative instruments) should be sterilized by heat-based methods (e.g., steam autoclave or dry heat oven).
• Reusable devices or items that touch mucous membranes should, at a minimum, receive high-level disinfection between patients. These devices include reusable flexible endoscopes, endotracheal tubes, anesthesia breathing circuits, and respiratory therapy equipment.
• Medical devices that require sterilization or disinfection must be thoroughly cleaned to reduce organic material or bioburden before being exposed to the germicide and the germicide and the device manufacturer's instructions should be closely followed.
• Except on rare and special instances (as mentioned below), items that do not ordinarily touch the patient or touch only intact skin are not involved in disease transmission, and generally do not necessitate disinfection between uses on different patients. These items include crutches, bedboards, blood pressure cuffs, and a variety of other medical accessories. Consequently, depending on the particular piece of equipment or item, washing with a detergent or using a low-level disinfectant may be sufficient when decontamination is needed. If noncritical items are grossly soiled with blood or other body fluids, a higher level of disinfections is required.

Exceptional circumstances that require noncritical items to be either dedicated to one patient or patient cohort or subjected to low-level disinfection between patient uses are those involving:

• Patients infected or colonized with vancomycin-resistant enterococci or other drug-resistant microorganisms judged by the infection control program, based on current state, regional, or national recommendations, to be of special or clinical or epidemiologic significance

or

• Patients infected with highly virulent microorganisms, e.g., viruses causing hemorrhagic fever (such as Ebola or Lassa).

The manufacturer should be contacted for questions about disinfectants. A source of information about low level or intermediate level disinfectants is the Antimicrobial Program Branch, Environmental Protection Agency (EPA) hotline (703) 308-0127 or email: info_antimicrobial@epa.gov. A source of information about high level disinfectants if the Food and Drug Administration (FDA) regional office or the FDA Center for Devices and Radiological Health at (301) 443-4690 (CDC, December 21, 2012).

Construction activities in or near healthcare facilities cause increase disease risks for airborne and waterborne disease Berger, et al, 2011). The increasing age of healthcare facilities is generating ongoing need for repair and remediation work that can introduce or increase contamination of the air and water in patient-care environments (CDC, June 6, 2003). The CDC has further recommendations for constructions that should be reviewed if applicable (CDC, June 6, 2003).

The purpose of heating, ventilation, and air conditioning (HVAC) systems in healthcare facilities is to a) maintain the indoor air temperature and humidity at comfortable levels; b) control odors; c) remove contaminated air; d) facilitate air-handling requirements to provide protection from airborne healthcare–related pathogens; and e) minimize the risk for transmission of airborne pathogens (CDC, June 6, 2003). Decreased performance of healthcare facility HVAC systems, filter inefficiencies, improper installation, and poor maintenance can contribute to the spread of healthcare–related airborne infections. The CDC has further recommendations for HVAC systems that should be reviewed if applicable (CDC, June 6, 2003).

The following are risk factors for healthcare-associated bacterial pneumonia (Kollef, 2011).

Recommendations for the prevention of healthcare associated pneumonia typically focus on: 1) educating staff of the risks; 2) preventing cross-infection; 3) increasing the host’s defenses; 4) optimizing nutrition while reducing the risk of aspiration; 5) reducing colonization, and; 6) correcting/minimizing co-morbid conditions (Morrow, 2009). The following are the CDC and the American Thoracic Society recommendations for the prevention of healthcare associated pneumonia (CDC, 2003; American Thoracic Society, 2005). Recommendations from the Institute for Health Improvement are included, as well (Institute for Health Improvement, 2012).

• Staff Education
• Conduct Surveillance in ICU Patients
  • Do not routinely perform surveillance cultures of patient, equipment or devices 
• Prevention of Transmission in a Healthcare Setting
  • Sterilization or disinfection: 
    • Thoroughly clean all equipment. When possible use steam sterilization or high level disinfection by wet heat pasteurization
    • Use sterile water for rinsing reusable semicritical respiratory equipment after chemical disinfection. If this not feasible, rinse with filtered water.
    • Adhere to provisions in the FDA/s enforcement document for single use devices that are reprocess by third parties.  
  • Do not routinely sterilize or disinfect the internal machinery of the mechanical ventilator 
  • Do not routinely change the breathing circuits with humidifiers based on duration of use. Clean only when visibly soiled or malfunctioning.
  • Breathing-circuit- tubing condensate 
    • Periodically drain and discard any condensate, making sure the condensate does not drain toward the patient.
    • Wear gloves during procedure or handling of condensate
    • Decontaminate hands with soap and water if visible soiled or with alcohol-based hand rub after procedure.
    • No recommendation can be made for placing a filter or trap at the distal end of the expiratory-phase tubing to collect condensate.  
  • Use sterile water to fill bubbling humidifiers
  • No recommendation can be made for the preferential use of a close, continuous-feed humidification system.
  • Ventilator breathing circuits with heat moisture exchange (HME): 
    • No recommendation can be made for the preferential use of either HMEs or heated humidifiers to prevent pneumonia in patients receiving mechanically assisted ventilation
    • Change an HME that is in use on a patient when it malfunctions mechanically or becomes visibly soiled.
    • Do not routinely change an HME that is in use on a patient more frequently than every 48 hours.
    • Do not routinely change the breathing circuit attached to an HME while it is in use on a patient  
  • Oxygen humidifiers 
    • Follow manufacturers' instructions for use of oxygen humidifiers
    • Change the humidifier-tubing (including any nasal prongs or mask) that is in use on one patient when it malfunctions or becomes visibly contaminated.  
  • Small-volume medication nebulizers: in-line and hand-held nebulizers 
    • Between treatments on the same patient: clean, disinfect; rinse with sterile water (if rinsing is needed), and dry small-volume in-line or hand-held medication nebulizers
    • Use only sterile fluid for nebulization, and dispense the fluid into the nebulizer aseptically
    • Whenever possible, use aerosolized medications in single-dose vials. If multidose medication vials are used, follow manufacturers’ instructions for handling, storing, and dispensing the medications  
  • Mist-tents 
    • Between uses on different patients, replace mist tents and their nebulizers, reservoirs, and tubings with those that have been subjected to sterilization or high-level disinfection
    • No recommendation can be made about the frequency of routinely changing mist-tent nebulizers, reservoirs, and tubings while in use on one patient.
    • Subject mist-tent nebulizers, reservoirs and tubings that are used on the same patient to daily low-level disinfection (e.g., with 2% acetic acid) or pasteurization followed by air-drying  
  • Other devices 
    • Between uses on different patients, sterilize or subject to high level disinfection:  
      • Portable respirometers and ventilator thermometers
      • Reusable hand-powered resuscitation bags   
    • No recommendation can be made about the frequency of changing hydrophobic filters placed on the connection port of resuscitation bags.  
  • Anesthesia machines and breathing systems or patient circuits: 
    • Do not routinely sterilize or disinfect the internal machinery of anesthesia equipment
    • Between uses on different patients, clean reusable components of the breathing system or patient circuit and then sterilize or subject them to high-level liquid chemical disinfection or pasteurization in accordance with the device manufacturers’ instructions for their reprocessing
    • No recommendation can be made about the frequency of routinely cleaning and disinfecting unidirectional valves and carbon dioxide absorber chambers
    • Follow published guidelines and manufacturers' instructions about in use maintenance, cleaning, and disinfection or sterilization of other components or attachments of the breathing system or patient circuit of anesthesia equipment
    • No recommendation can be made for placing a bacterial filter in the breathing system or patient circuit of anesthesia equipment  
  • Pulmonary-function testing equipment 
    • Do not routinely sterilize or disinfect the internal machinery of pulmonary-function testing machines between uses on different patients
    • Change the mouthpiece of a peak flow meter or the mouthpiece and filter of a spirometer between uses on different patients  
  • Room-air “humidifiers” and faucet aerators 
    • Do not use large-volume room-air humidifiers that create aerosols (e.g., by venturi principle, ultrasound, or spinning disk, and thus actually are nebulizers) unless they can be sterilized or subjected to high-level disinfection at least daily and filled only with sterile water
    • No recommendation can be made about the removal of faucet aerators from areas for immunocompetent patients
    • If Legionella spp. are detected in the water of a transplant unit and until Legionella spp. are no longer detected by culture, remove faucet aerators in the unit  

• Standard Precautions
• Care of patients with tracheostomy
  • Good tracheostomy care reduces morbidity and it also reduces the amount of time to decannulation (Mitchell, et al, 2013).
  • All supplies to replace a tracheostomy tube should be at the bedside or within easy reach.
  • Humidification should be used if the patient is mechanically ventilated or has thick secretions.
  • Perform tracheostomy under aseptic conditions.
  • When changing a tracheostomy tube, wear a gown, use aseptic technique, and replace the tube with one that has undergone sterilization or high-level disinfection
  • No recommendation can be made for the daily application of topical antimicrobial agent(s) at the tracheostoma 
• Suctioning of respiratory tract secretions
  • No recommendation can be made for the preferential use of either the multiuse closed-system suction catheter or the single-use open system suction catheter for prevention of pneumonia (Morrow, et al, 2012)
  • No recommendation can be made about wearing sterile rather than clean gloves when performing endotracheal suctioning.
  • No recommendation can be made about the frequency of routinely changing the in-line suction catheter of a closed-suction system in use on one patient
  • If the open-system suction is employed, use a sterile single-use catheter.
  • Use only sterile fluid to remove secretions from the suction catheter if the catheter is to be used for re-entry into the patient's lower respiratory tract. 

• Increasing Host Defense Against Infection: Administration of Immune Modulators
  • Pneumococcal vaccination. Vaccinate patients at high risk for severe pneumococcal infections: (Morbidity and Mortality Weekly Report , 2011; Morbidity and Mortality Weekly Report, 2010; )
    • persons aged >65 years;
    • persons aged 5-64 years who have chronic cardiovascular disease, chronic pulmonary disease, diabetes mellitus, alcoholism, chronic liver disease (cirrhosis), or cerebro-spinal fluid (CSF) leaks;
    • persons aged 5-64 years who have functional or anatomic asplenia;
    • persons aged 5-64 years who are living in special environments or social settings;
    • immunocompromised persons aged >5 years with HIV infection, leukemia, lymphoma, Hodgkin’s disease, multiple myeloma, generalized malignancy, chronic renal failure, nephrotic syndrome, or other conditions associated with immunosuppression and persons in long-term care facilities 
  • Administer the vaccine to all children aged <2 years and to children aged 24-59 months who are at increased risk for pneumococcal disease.
  • Consider administering the vaccine to all children aged 24-59 months, with priority given to children aged 24-35 months, children who are American Indians/Alaska Natives or black, and children who attend group child-care centers
  • In long-term care facilities (LTCFs), establish a standard procedure for the administration of vaccine to persons at high risk of acquiring severe pneumococcal infections, including pneumococcal pneumonia
  • No recommendation can be made for the routine administration of preparations of GCSF or intravenous gamma globulin for prophylaxis against healthcare-associated pneumonia
  • No recommendation can be made for the routine administration of glutamine for prevention of healthcare-associated pneumonia 
• Precautions for Prevention of Aspiration
  • As soon as the clinical indications for their use are resolved, remove devices such as endotracheal, tracheostomy, or enteral (i.e., oro- or nasogastric, or jejunal) tubes from patients
  • Prevention of aspiration associated with endotracheal intubation
    • If possible, limit the use of sedating or paralytic agents that depress cough and other host-protective mechanisms.
    • Maintain endotracheal tube cuff pressure at > 20 ccm H2O.
    • Condensation in the ventilator circuit can become contaminated. Care should be taken to prevent condensation from reaching the lower airway or the nebulizer chamber.
    • Use of non-invasive ventilation (NIV) to reduce the need for and duration of endotracheal intubation
    • When feasible and not medically contraindicated, use noninvasive positive-pressure ventilation delivered continuously by face or nose mask, instead of performing endotracheal intubation in patients who are in respiratory failure and are not needing immediate intubation
    • When feasible and not medically contraindicated, use NIV as part of the weaning process in order to shorten the period of endotracheal intubation
    • As much as possible, avoid repeat endotracheal intubation in patients who have received mechanically assisted ventilation
    • Unless contraindicated by the patient’s condition, perform orotracheal rather than nasotracheal intubation on patients
    • If feasible, use an endotracheal tube with a dorsal lumen above the endotracheal cuff to allow drainage (by continuous or frequent intermittent suctioning) of tracheal secretions that accumulate in the patient's subglottic area
    • Before deflating the cuff of an endotracheal tube in preparation for tube removal, or before moving the tube, ensure that secretions are cleared from above the tube cuff.  
• Prevention of aspiration associated with enteral feeding:
  • In the absence of medical contraindication(s), elevate the head of the bed at an angle of 30-45 degrees if the patient is at high risk for aspiration pneumonia (e.g., a person receiving mechanically assisted ventilation or who has an enteral tube in place)
  • Try and limit the use of medications that affect the cough and gag reflexes or impair swallowing.
  • Routinely verify appropriate placement of the feeding tube. There are many methods for doing this (e.g., auscultation, observing the aspirate contents, checking the pH of the aspirate), but they all have limitations and there is no consensus as to the best method for verifying appropriate placement of a feeding tube (Guy, et al, 2009).
  • Maintain head elevation for one hour after the feeding has finished.
  • Check residuals prior to feeding; if the residual is > 200 mL, the rate and volume of the feeding may need to be adjusted.
  • No recommendation can be made for the preferential use of small bore tubes for enteral feeding
  • No recommendation can be made for preferentially administering enteral feedings continuously or intermittently
  • No recommendation can be made for preferentially placing the feeding tubes (e.g., jejunal tubes) distal to the pylorus 
• Prevention or modulation of oropharyngeal colonization
  • Aerobic and facultatively anerobic gram-negative bacilli frequently colonize the oral cavities in patients who are hospitalized and/or immunocompromised. These pathogens are a significant cause of hospital-acquired pneumonia
  • Oropharyngeal cleaning and decontamination with an antiseptic agent can help reduce the number of these pathogens
  • It is not clear which antiseptic agent is the most effective, and the optimal oral hygiene protocol has not been determined (Lam, et al, 2012).
  • Develop and implement a comprehensive oral-hygiene program (that might include the use of an antiseptic agent) for patients in acute-care settings or residents in long-term care facilities who are at high risk of developing healthcare-associated pneumonia
  • Chlorhexidine oral rinse
    • No recommendation can be made for the routine use of an oral chlorhexidine rinse for the prevention of healthcare associated pneumonia in all postoperative or critically ill patients or other patients at high risk for pneumonia (Kusahara, 2012)
    • Use an oral chlorhexidine gluconate (0.12%) rinse during the perioperative period on adult patients who undergo cardiac surgery 
  • No recommendation can be made for the routine use of topical antimicrobial agents for oral decontamination to prevent ventilator associated pneumonia (VAP) 
• Prevention of gastric colonization
  • Patients who are mechanically ventilated are at risk for stress-related gastric ulcers and bleeding
  • No recommendation can be made for the preferential use of sucralfate, H2-antagonists, or antacids for stress-bleeding prophylaxis in patients receiving mechanically assisted ventilation (Huang, et al, 2010)
  • No recommendation can be made for the routine administration of selective digestive decontamination (SDD) to all critically ill, mechanically ventilated, or ICU patients as there is no conclusive evidence for or against its use (Walden, 2012)
  • No recommendation can be made for routine acidification of gastric feeding 

• Instruct preoperative patients, especially those at high risk for contracting pneumonia, about taking deep breaths and ambulating as soon as medically indicated in the postoperative period. Patients at high-risk include:
  • those who will have abdominal aortic aneurysm repair, thoracic surgery, or emergency surgery;
  • those who will receive general anesthesia;
  • those who are aged >60 years;
  • those with totally dependent functional status;
  • those who have had a weight loss >10%;
  • those using steroids for chronic conditions;
  • those with recent history of alcohol use,
  • history of COPD, or smoking during the preceding year;
  • those with impaired sensorium,
  • a history of cerebrovascular accident with residual neurologic deficit, or low (<8mg/dL) or high (>22 mg/dL) blood urea nitrogen level;
  • and those who will have received more than 4 units of blood before surgery 
• Encourage all postoperative patients to take deep breaths, move about the bed, and ambulate unless these are medically contraindicated
• Head of the bed should be elevated at least 30° while eating
• Oral hygiene with chlorhexidine should be considered
• Use coughing exercises and incentive spirometry on postoperative patients who are at high risk for developing pneumonia
• No recommendation can be made about the routine use of chest physiotherapy on all postoperative patients at high risk for pneumonia

• Administration of antimicrobial agents other than in SDD
  • No recommendation can be made about the routine administration of systemic antimicrobial agent(s) to prevent pneumonia in critically ill patients and/or in those receiving mechanically-assisted ventilation
  • No recommendation can be made for scheduled changes in the class of antimicrobial agents used routinely for empiric treatment of suspected infections in a particular group of patients 
• No recommendation can be made for the routine use of turning or rotational therapy, either by "kinetic" therapy or by continuous lateral rotational therapy (i.e., placing patients on beds that turn on their longitudinal axes intermittently or continuously) for prevention of healthcare-associated pneumonia in critically ill or immobilized patients

• Staff Education
• Infection and Environmental Surveillance (OSHA. Legionnaire’s Disease: Facts and Frequently Asked Questions; OSHA. Legionnaire’s Disease: Water Sampling Guidelines; OSHA Technical Manual: Legionnaire’s Disease)
  • Maintain a high index of suspicion for the diagnosis of healthcare associated Legionnaires disease and perform laboratory diagnostic tests (both culture of appropriate respiratory specimen and the urine antigen test) for legionellosis on suspected cases, especially in patients who are at high risk of acquiring the disease (CDC. February 5, 2013; Sabria, et al, 2012)
    • patients who are immunosuppressed, including hematopoietic stem cell transplantation (HSCT) or solid-organ-transplant recipients;
    • cigarette smoking;
    • alcohol history;
    • CVA history
    • patients receiving systemic steroids;
    • patients aged >65 years;
    • or patients who have chronic underlying disease such as diabetes mellitus, congestive heart failure, and COPD) 
  • Periodically review the availability and clinicians’ use of laboratory diagnostic tests for Legionnaires disease in the facility, and if clinicians do not routinely use the tests on patients with diagnosed or suspected pneumonia, implement measures to enhance clinicians’ use of the tests (e.g., by conducting educational programs)
  • Routine culturing of water systems for Legionella spp.
  • No recommendation can be made about routinely culturing water systems for Legionella spp. in healthcare facilities that do not have patient-care areas (i.e., transplant units) for persons at high risk for Legionella infection
  • In facilities with hematopoietic stem-cell- or solid-organ transplantation programs, periodic culturing for legionellae in water samples from the transplant unit(s) can be performed as part of a comprehensive strategy to prevent Legionnaires disease in transplant recipients
  • No recommendation can be made about the optimal methods (i.e., frequency, number of sites) for environmental surveillance cultures in transplant units.
  • Perform corrective measures aimed at maintaining undetectable levels of Legionella spp. in the unit’s water system.
  • Maintain a high index of suspicion for legionellosis in transplant patients with healthcare-associated pneumonia even when environmental surveillance cultures do not yield legionellae 
• Use and Care of Medical Devices, Equipment, and Environment
  • If Legionella spp. are detected in the water of a transplant unit and until Legionella spp. are no longer detected by culture, remove faucet aerators in areas for severely immunocompromised patients
  • Cooling towers
    • When a new building is constructed, place cooling towers in such a way that the tower drift is directed away from the facility's air intake system and design the cooling towers such that the volume of aerosol drift is minimized
    • For cooling towers, install drift eliminators, regularly use an effective biocide, maintain the tower according to manufacturers' recommendations, and keep adequate maintenance records  
• Water-distribution system
  • Where practical and allowed by state law, maintain potable water at the outlet at >51oC (>124oF) or <20oC (<68oF), especially in facilities housing organ-transplant recipients or other patients at high risk.
  • If water is maintained at >51oC, use thermostatic mixing valves to prevent scalding
  • No recommendation can be made about the treatment of water with chlorine dioxide, heavy-metal ions, ozone, or ultraviolet light. Hospitals served by municipalities with monochloramine-treated water have had success in controlling legionellae
  • Healthcare facilities with hemopoietic stem-cell or solid-organ transplantation programs
    • If legionellae are detected in the potable water supply of a transplant unit, and until Legionellae are no longer detected by culture:
    • Decontaminate the water supply
    • Restrict severely immunocompromised patients from taking showers
    • Use water that is not contaminated with Legionella spp. for HSCT patients’ sponge baths
    • Provide HSCT patients with sterile water for tooth brushing or drinking, or for flushing nasogastric tubes
    • Do not use water from faucets with Legionella-contaminated water in patients rooms to avoid creating infectious aerosols  

• Staff Education
• Case-Reporting, Disease Surveillance, and Case-Contact Notification
  • Report to the local and/or state health department all confirmed and suspected cases of pertussis
  • Conduct active surveillance for cases of pertussis until 42 days after the onset of the last pertussis case
  • Notify persons who have had close contact with a case of pertussis in the healthcare setting so that they can be monitored for symptoms of pertussis or administered appropriate chemoprophylaxis. Close contact includes
    • face-to-face contact with a patient who is symptomatic (e.g., in the catarrhal or paroxysmal period of illness);
    • sharing a confined space in close proximity for a prolonged period of time (e.g., >1 hour) with a symptomatic patient;
    • or direct contact with respiratory, oral, or nasal secretions from a symptomatic patient (e.g., an explosive cough or sneeze on the face, sharing food, sharing eating utensils during a meal, kissing, mouth-to-mouth resuscitation, or performing a full medical examination of the nose and throat)  
• Prevention of Pertussis Transmission (CDC, February 27, 2013)
  • Vaccination for Primary Prevention (MMWR, 2013)
    • No recommendation can be made for routinely vaccinating adults, including healthcare professionals, with the acellular pertussis vaccine at regular intervals (e.g., every 10 years)
    • In LTCFs for children and for children with prolonged stay in acute-care facilities, follow the recommendations of ACIP for vaccinating children according to their chronologic age 
  • Vaccination for Secondary Prevention
    • No recommendation can be made for vaccinating adults, including healthcare professionals, during an institutional outbreak of pertussis
    • For routine use, adolescents 11- 18 years who have completed the DTP/DTaP vaccine series, and adults 19- 64 should receive a single dose of TDAp.
    • Adults 65 years or older who anticipate having close contact with an infant that is < 12 months should receive a single dose of Tdap. (MMWR, 2011)
    • During an institutional outbreak of pertussis, accelerate scheduled vaccinations to infants and children aged <7 years who have not completed their primary vaccinations, as follows: 
      • Infants aged <2 months who are receiving their initial vaccination: Administer the first dose of the DTaP vaccine as early as age 6 weeks and the second and third doses at a minimum of 4-week intervals between doses. Give the fourth dose on or after age 1 year and >6 months after the third dose
      • Other children aged <7 years: Administer DTaP vaccine to all patients who are aged <7 years and are not up-to-date with their pertussis vaccinations, as follows: administer a fourth dose of DtaP vaccine if the child has had 3 doses of DTaP or diphtheria, tetanus and pertussis (DTP) vaccine, is >12   months old, and >6 months have passed since the third dose of DTaP or DTP vaccine; administer a fifth dose of DTaP vaccine if the child has had four doses of DTaP or DTP vaccine, is aged 4-6 years, and received the fourth vaccine dose before the fourth birthday
  • Vaccination of children with a history of well-documented pertussis disease
    • No recommendation can be made for administering additional dose(s) of pertussis vaccine to children who have a history of well-documented pertussis disease (i.e., pertussis illness with either a B. pertussis-positive culture or epidemiologic linkage to a culture-positive case)  
• Patient Placement and Management
  • Patients with confirmed pertussis
    • Place a patient with diagnosed pertussis in a private room, or if known not to have any other respiratory infection, in a room with other patient(s) with pertussis until after the first 5 days of a full course of antimicrobial treatment or 21 days after the onset of cough if unable to take antimicrobial treatment for pertussis 
  • Patients with suspected pertussis
    • Place a patient with suspected pertussis in a private room. After pertussis and no other infection is confirmed, the patient may be placed in a room with other patient(s) who have pertussis until after the first 5 days of a full course of antimicrobial treatment or 21 days after the onset of cough if unable to take antimicrobial treatment for pertussis
    • Perform diagnostic laboratory tests (for confirmation or exclusion of pertussis) on patients who are admitted with or who develop signs and symptoms of pertussis to allow for the earliest possible downgrading of infection-control precautions to the minimum required for each patient’s specific infection(s)  
• Management of Symptomatic Healthcare Personnel
  • Perform diagnostic laboratory tests for pertussis in healthcare personnel with illness suggestive of pertussis (i.e., unexplained cough illness of >1week duration, paroxysmal cough)
  • Treat symptomatic healthcare personnel who are proven to have pertussis or personnel who are highly suspected of having pertussis with the same antimicrobial regimen, as detailed for chemoprophylaxis of case-contacts
  • Restrict symptomatic pertussis-infected healthcare professionals from work during the first 5 days of their receipt of antimicrobial therapy 
• Masking
  • In addition to observing standard precautions, wear a surgical mask when within three feet of a patient with confirmed or suspected pertussis, when performing procedures or patient-care activities that are likely to generate sprays of respiratory secretions, or on entering the room of a patient with confirmed or suspected pertussis 
• Prophylactic Antibiotic Regimen for Contacts of Persons with Pertussis are recommended (CDC, February 19, 2013)
• Work Exclusion of Asymptomatic Healthcare Professionals Exposed to Pertussis
  • Do not exclude from patient care a healthcare professional who remains asymptomatic and is receiving chemoprophylaxis after an exposure to a case of pertussis
  • If mandated by state law or where feasible, exclude an exposed, asymptomatic healthcare professional who is unable to receive chemoprophylaxis, from providing care to a child aged <4 years during the period starting 7 days after the professional’s first possible exposure until 14 days after his last possible exposure to a case of pertussis 
• Other measures
  • Limit the movement and transport of a patient with diagnosed or suspected pertussis from his room to those for essential purposes only. If the patient is transported out of the room, ensure that precautions are maintained to minimize the risk for disease transmission to other patients and contamination of environmental surfaces or equipment
  • Do not allow persons who have symptoms of respiratory infection to visit pediatric, immunosuppressed, or cardiac patients 

• Staff Education
• Surveillance
  • Maintain a high index of suspicion for healthcare-associated pulmonary aspergillosis in severely immunocompromised patients
  • Maintain surveillance for cases of healthcare-associated pulmonary aspergillosis by establishing a system by which the facility’s infection-control personnel are promptly informed when Aspergillus sp. is isolated from cultures of specimens from patient’s respiratory tract and by periodically reviewing the hospital's microbiologic, histopathologic, and postmortem data.
  • Do not perform routine, periodic cultures of the nasopharynx of asymptomatic patients at high risk
  • Do not perform routine, periodic cultures of equipment or devices used for respiratory therapy, pulmonary function testing, or delivery of inhalation anesthesia in the HSCT unit, nor of dust in rooms of HSCT recipients
  • No recommendation can be made about routine microbiologic air sampling before, during, or after facility construction or renovation, or before or during occupancy of areas housing immunocompromised patients
  • In facilities with PEs, perform surveillance of the ventilation status of these areas either by continuous monitoring or periodic analysis of the following parameters: room air exchanges, pressure relations and filtration efficacy to ensure that appropriate levels are 
• Prevention of Transmission of Aspergillus spp. Spores
  • Planning New Specialized-Care Units for High-Risk Patients
    • When constructing new specialized-care units with PE for HSCT recipients, ensure that patient rooms have adequate capacity to minimize accumulation of fungal spores via 1) HEPA filtration of incoming air, 2) directed room airflow, 3) positive air pressure in patient's room in relation to the corridor, 4) well-sealed room, and 5) high (>12) air changes per hour
    • Do not use laminar air flow (LAF) routinely in PE
    • Units for autologous HSCT and solid-organ transplant recipients
    • No recommendation can be made for constructing PE for recipients of autologous HSCTs or solid-organ-transplants (e.g., heart, liver, lung, kidney) 
  • In Existing Facilities with HSCT Units and No Cases of Healthcare-Associated Aspergillosis
    • No recommendation can be made for routinely placing a recipient of autologous HSCT or solid-organ transplant in PE.
    • Maintain air-handling systems in PE and other high-risk patient-care areas according to published recommendations
    • Maintain air-handling systems in PE and other high-risk patient-care areas according to published recommendations
    • Develop a water-damage response plan for immediate execution when water leaks, spills, and moisture accumulation occur to prevent fungal growth in the involved areas
    • Use proper dusting methods for patient-care areas designated for severely immunocompromised
    • Wet-dust horizontal surfaces daily using cloth that has been moistened with an EPA-registered hospital disinfectant
    • Avoid dusting methods that disperse dust (e.g., feather dusting)
    • Keep vacuums in good repair and equip them with HEPA filters for use in areas with patients at high risk
    • Do not use carpeting in hallways and rooms occupied by severely immunocompromised patients
    • Avoid using upholstered furniture or furnishings in rooms occupied by severely immunocompromised patients.
    • Minimize the length of time that immunocompromised patients in PEs are outside their rooms for diagnostic procedures and other activities.
    • Instruct severely immunocompromised patients to wear a high efficiency respiratory-protection device (e.g., an N95 respirator) when they leave the PE during periods when construction, renovation, and/or other dust-generating activities are ongoing in and around the healthcare facility
    • No recommendation can be made about the specific type of respiratory-protection device (e.g., surgical mask, N95 respirator) for use by a severely immunocompromised patient who leaves the PE during periods when there is no construction, renovation or other dust-generating activity in progress in or around the healthcare facility.
    • Systematically review and coordinate infection-control strategies with personnel in charge of the facility’s engineering, maintenance, central supply and distribution, and catering services
    • When planning construction, demolition, and renovation activities in and around the facility, assess whether patients at high-risk for aspergillosis are likely to be exposed to high ambient-air spore counts of Aspergillus spp. from construction, demolition, and renovation sites, and if so, develop a plan to prevent such exposures
    • During construction, demolition, or renovation activities, construct impermeable barriers between patient-care and construction areas to prevent dust from entering the patient-care areas
    • Direct pedestrian traffic that come from construction areas away from patient-care areas to limit the opening and closing of doors or other barriers that might cause dust dispersion, entry of contaminated air, or tracking of dust into patient-care areas 
    • Do not allow fresh or dried flowers or potted plants in patient-care areas for severely immunocompromised patients 
  • When a Case of Aspergillosis Occurs
    • Assess whether the infection is healthcare-related or community-acquired.
    • Determine, if any ventilation deficiency exists in the PEs
    • If no evidence exists that the patient’s aspergillosis is facility-acquired, continue routine maintenance procedures to prevent healthcare-associated aspergillosis
    • If evidence of possible facility-acquired infection with Aspergillus spp. exists, conduct an epidemiologic investigation and an environmental assessment to determine and eliminate the source of Aspergillus spp.
    • Use an antifungal biocide (e.g., copper-8-quinolinolate) that is registered with the Environmental Protection Agency for decontamination of structural materials  
• Chemoprophylaxis
  • No recommendation can be made for the routine administration of antifungal agents
  • No recommendation can be made for any specific strategy to prevent recurrence of pulmonary aspergillosis in patients undergoing hematopoietic stemcell transplantation who have a history of pulmonary aspergillosis 

• Staff Education
• Surveillance
  • Establish mechanisms by which the appropriate healthcare personnel are promptly alerted to any increase in the activity of RSV, parainfluenza virus, adenovirus, or other respiratory viruses in the local community. Establish mechanisms by which the appropriate healthcare personnel can promptly inform the local and state health departments of any increase in the activity of the above-named viruses or of influenza-like illness in their facility.
  • In acute-care facilities during periods of increased prevalence of symptoms of viral respiratory illness in the community or healthcare facility, and/or during the RSV and influenza season (i.e., December-March), attempt prompt diagnosis of respiratory infections caused by RSV, influenza, parainfluenza, or other respiratory viruses. Use rapid diagnostic techniques as clinically indicated in patients who are admitted to the healthcare facility with respiratory illness and are at high risk for serious complications from viral respiratory infections (e.g., pediatric patients, especially infants, and those with compromised cardiac, pulmonary, or immune function)
  • No recommendation can be made for routinely conducting surveillance cultures for RSV or other respiratory viruses in respiratory secretions of patients
  • In LTCFs, establish mechanism(s) for continuing surveillance to allow rapid identification of a potential outbreak in the facility. 
• Prevention of Transmission of RSV, Parainfluenza Virus, or Adenovirus (CDC. RSV, October 17, 2008; CDC. Human Parainfluenza Viruses (HPIVs), November 5, 2012; CDC. Adenoviruses, December 27, 2011)
  • Prevention of Person-to-Person Transmission
    • Standard and contact precautions for RSV and parainfluenza virus; and standard, contact, and droplet precautions for adenovirus
    • Patient placement in acute-care facilities 
      • Place a patient with diagnosed RSV, parainfluenza, adenovirus, or other viral respiratory tract infection in a private room when possible or in a room with other patients with the same infection and no other infection
      • Place a patient with suspected RSV, parainfluenza, adenovirus, or other viral respiratory tract infection in a private room.
      • Promptly perform rapid diagnostic laboratory tests on patients who are admitted with or who have symptoms of RSV infection after admission to the healthcare facility to facilitate early downgrading of infection-control precautions to the minimum required for each patient’s specific viral infection
      • Promptly perform rapid diagnostic laboratory tests on patients who are admitted with or who have symptoms of parainfluenza or adenovirus infection after admission to the healthcare facility to facilitate early downgrading of infection-control precautions to the minimum required for each patient’s specific viral infection and early initiation of treatment when indicated.  
  • Limiting patient movement or transport in acute-care facilities
    • Limit to essential purposes only the movement or transport of patients from their rooms when they are diagnosed or suspected to be infected with RSV, parainfluenza virus, or
    • If transport or movement from the room is necessary
    • For a patient with diagnosed or suspected RSV or parainfluenza virus infection, ensure that precautions are maintained to minimize the risk for transmission of the virus to other patients and contamination of environmental surfaces or equipment by ensuring that the patient does not touch other persons’ hands or environmental surfaces with hands that have been contaminated with his/her respiratory secretions
    • For a patient with diagnosed or suspected adenovirus infection, minimize patient dispersal of droplets by having the patient wear a surgical mask, and ensure that contact precautions are maintained to minimize the risk of transmission of the virus to other patients and contamination of environmental surfaces or equipment 
  • Other measures in acute-care facilities
    • Staffing
    • Restrict healthcare personnel in the acute stages of an upper respiratory tract infection from caring for infants and other patients at high risk for complications from viral respiratory tract infections
    • When feasible, perform rapid diagnostic testing on healthcare personnel with symptoms of respiratory tract infection, especially those who provide care to patients at high-risk for acquiring and/or developing severe complications from RSV, parainfluenza, or adenovirus infection, so that their work status can be determined promptly.
    • Limiting visitors
    • Do not allow persons who have symptoms of respiratory infection to visit pediatric, immunocompromised, or cardiac patients
    • Follow the recommendations of the American Academy of Pediatrics to consider monthly administration of palivizumab, an RSV monoclonal-antibody preparation  
• Control of outbreaks in acute-care facilities
  • Perform rapid screening diagnostic tests for the particular virus (es) known or suspected to be causing the outbreak on patients who are admitted with symptoms of viral respiratory illness. Promptly cohort the patients (according to their specific infections) as soon as the results of the screening tests are available. In the interim, when possible, admit patients with symptoms of viral respiratory infections to private rooms.
  • Personnel cohorting
  • During an outbreak of healthcare-associated RSV infection, cohort personnel as much as practical (e.g., restrict personnel who give care to infected patients from giving care to uninfected patients)
  • No recommendation can be made for routinely cohorting personnel during an outbreak of healthcare-associated adenovirus or parainfluenza virus infection.
  • No recommendation can be made for the use of RSV immune globulin or monoclonal antibody to control outbreaks of RSV infection in the healthcare setting 

• Staff Education
• Surveillance
  • Establish mechanisms by which facility personnel are promptly alerted about increased influenza activity in the community.
  • Establish protocols for intensifying efforts to promptly diagnose cases of facility acquired influenza.
  • Arrange for laboratory tests to be available to clinicians for prompt diagnosis of influenza 
• Modifying Host Risk For Infection
  • Vaccination
    • In acute-care settings (including acute-care hospitals, emergency rooms, and walk-in clinics) or ongoing-care facilities (including physicians’ offices, public health clinics, employee health clinics, hemodialysis centers, hospital specialty-care clinics, outpatient rehabilitation programs, or mobile clinics), offer vaccine to inpatients and outpatients at high risk for complications from influenza beginning in September and throughout the influenza season
    • Groups at high risk for influenza-related complications include
      • those aged >65 years;
      • residents of LTCFs that house persons of any age who have chronic medical conditions;
      • adults and children aged >6 months who have chronic disorders of the pulmonary or cardiovascular system, including asthma;
      • adults and children who have required regular medical follow-up or hospitalization during the preceding year because of chronic metabolic diseases (including diabetes mellitus), renal dysfunction, hemoglobinopathies; or immunosuppression (including immunosuppression caused by medications or HIV);
      • children and adolescents (aged 6 months-18 years) who are receiving long-term aspirin therapy; and women who will be in the second or third trimester of pregnancy during the influenza season. 
    • In addition, offer annual influenza vaccination to all persons aged 50-64 years, close contacts of children aged <24 months, and healthy children aged 6-23 months
    • In LCTFs, establish an SOP for timely administration of the inactivated influenza vaccine to high-risk persons
      • Obtain consent for influenza vaccination (if such is required by local or state law) from every resident (or his/her guardian) at the time the resident is admitted to the facility or anytime afterwards, before the next influenza season.
      • Routinely vaccinate all residents, except those with medical contraindication(s) to receipt of influenza vaccine, (under a standing operating procedure (SOP) or with the concurrence of the residents’ respective attending physicians) at one time, annually, before the influenza season. To residents who are admitted during the winter months after completion of the facility’s vaccination program, offer the vaccine at the time of their admission 
    • In other settings where healthcare is given (e.g., in homes visited by personnel from home healthcare agencies), vaccinate patients for whom vaccination is indicated, as listed in section III-A-1, and refer patient’s household members and care givers for vaccination, before the influenza season
    • Personnel
      • Beginning in October each year, provide inactivated influenza vaccine for all personnel including night and weekend staff. Throughout the influenza season, continue to make the vaccine available to newly hired personnel and to those who initially refuse vaccination. If vaccine supply is limited, give highest priority to staff caring for patients at greatest risk for severe complications from influenza infection.
      • Educate healthcare personnel regarding the benefits of vaccination and the potential health consequences of influenza illness for themselves and their patients
      • Take measures to provide all healthcare personnel convenient access to inactivated influenza vaccine at the work site, free of charge, as part of employee health program  
  • Prevention of Person to Person Transmission
    • Droplet Precautions
    • Personnel Restrictions
      • In acute-care facilities, utilize the facility’s employee health service or its equivalent to evaluate personnel with influenza-like illness and determine whether they should be removed from duties that involve direct patient contact. Use more stringent criteria for personnel who work in certain patient-care areas (e.g., ICUs, nurseries, and organ-transplant [especially HSCT] units) where patients who are most susceptible to influenza-related complications are located  
  • Control of Influenza Outbreaks
    • Determine the Outbreak Strain
    • Vaccination of Patients and Personnel
      • Administer current inactivated influenza vaccine to unvaccinated patients and healthcare personnel 
    • Antiviral Agent Administration
      • When a facility outbreak of influenza is suspected or recognized:
      • Administer amantadine, rimantadine, or oseltamivir as prophylaxis to all patients without influenza illness in the involved unit for whom the antiviral agent is not contraindicated (regardless of whether they received influenza vaccinations during the previous fall). Do not delay administration of the antiviral agent(s) for prophylaxis unless the results of diagnostic tests to identify the infecting strain(s) can be obtained within 12-24 hours after specimen collection
      • Administer amantadine, rimantadine, oseltamivir, or zanamivir to patients acutely ill with influenza, within 48 hours of illness onset.
      • Choose the agent appropriate for the type of influenza virus circulating in the community. Offer antiviral agent(s) (amantadine, rimantadine, or oseltamivir) for prophylaxis to unvaccinated personnel for whom the antiviral agent is not contraindicated and who are in the involved unit or taking care of patients at high-risk
      • Consider prophylaxis for all healthcare personnel, regardless of their vaccination status, if the outbreak is caused by a variant of influenza that is not well matched by the vaccine
      • No recommendation can be made about the prophylactic administration of zanamivir to patients or personnel
      • Discontinue the administration of influenza antiviral agents to patients or personnel if laboratory tests confirm or strongly suggest that influenza is not the cause of the facility outbreak
      • If the cause of the outbreak is confirmed or believed to be influenza and vaccine has been administered only recently to susceptible patients and personnel, continue prophylaxis with an antiviral agent until 2 weeks after the vaccination
      • To reduce the potential for transmission of drug-resistant virus, do not allow contact between persons at high risk for complications from influenza and patients or personnel who are taking an antiviral agent for treatment of confirmed or suspected influenza during and for 2 days after the latter discontinue treatment  
  • Other Measures in Acute-Care Facilities:
    • When influenza outbreaks, especially those characterized by high attack rates and severe illness, occur in the community and/or facility:
      • Curtail or eliminate elective medical and surgical admissions
      • Restrict cardiovascular and pulmonary surgery to emergency cases only
      • Restrict persons with influenza or influenza-like illness from visiting patients in the healthcare facility
      • Restrict personnel with influenza or influenza-like illness from patient care   

Special attention in dental facilities is required. Back flow prevention devices are required to prevent cross contamination when using cuspidors, high speed hand piece and air or water syringes. Back-siphonage devices are required to prevent contamination of the public water. This is regulated by the health authority or plumbing code enforcement agencies in the community (CDC, October, 2008).

Employers are required to establish exposure control plans that include post-exposure follow up for their employees and to comply with incident reporting requirements mandated by the 1992 OSHA bloodborne pathogen standard. Access to clinicians who can provide post-exposure care should be available during all working hours, including nights and weekends. HBIG, hepatitis B vaccine, and antiretroviral agents for HIV post-exposure prophylaxis (PEP) should be available for timely administration, either by providing access on site or by creating linkages with other facilities or providers to make them available off-site (OSHA, 2011).

The following are recommendation by the Centers for Disease Control (CDC, July 2003) for immediate activity after exposure.

Provide immediate care to the exposure site.

• Wash wounds and skin with soap and water.
• Flush mucous membranes with water.
• Irrigate eyes with clean water, saline or sterile irrigants.

No scientific evidence shows that using antiseptics or squeezing the wound will reduce the risk of transmission of a bloodborne pathogen. Using a caustic agent such as bleach is not recommended.

Report the exposure to the government agency responsible for managing exposures. Reporting is necessary because PEP treatment may be recommended.

Determine risk associated with exposure by:

• type of fluid (e.g., blood, visibly bloody fluid, other potentially infectious fluid or tissue, and concentrated virus), and
• type of exposure (i.e., percutaneous injury, mucous membrane or non-intact skin exposure, and bites resulting in blood exposure).

Evaluate exposure source.

• Assess the risk of infection using available information.
• Test known sources for HBsAg, anti-HCV, and HIV antibody (consider using rapid testing).
• For unknown sources, assess risk of exposure to HBV, HCV, or HIV infection.
• Do not test discarded needles or syringes for virus contamination.

Evaluate the exposed person.

• Assess immune status for HBV infection (i.e., by history of hepatitis B vaccination and vaccine response).

Comprehensive exposure prevention strategies have played a significant role in decreasing the probable risk of infection from bloodborne pathogens. The risks of exposure with appropriate precautions are low, but they are real. Understanding how an exposure occurs and the risks of exposure is imperative for both the occupational health clinician and the healthcare professional. After an occupational exposure to a bloodborne pathogen, the risk of infection depends on a number of factors including:

• type of body substance involved
• route of exposure,
• volume of blood or body fluid involved
• severity of exposure,
• pathogen involved
• degree of viremia
• the immune status of the healthcare professional at the time of the injury
• whether appropriate PEP was used

HBV: The number of occupational infections decreased by 95% after the HBV vaccine became available in 1982 (CDC, July 2003). Healthcare professionals who have received hepatitis B vaccine and have developed immunity to the virus are at virtually no risk for infection. The risk of HBV infection is primarily related to the degree of contact with blood in the workplace and also to the hepatitis B e antigen (HBeAg) status of the source person. Individuals who are both hepatitis B surface antigen (HBsAg) positive and HBeAg positive have more virus in their blood and are more likely to transmit HBV. Amongst healthcare professionals who are susceptible, the risk of infection after one percutaneous exposure is 6%-30% (CDC, July 2003).

Although percutaneous injuries are among the most efficient modes of HBV transmission, these exposures probably account for only a minority of HBV infections among healthcare professionals. In several investigations of nosocomial hepatitis B outbreaks, most infected healthcare professionals could not recall an overt percutaneous injury, although in some studies, up to one third of the infected recalled caring for a patient who was HBsAg-positive. Additionally, HBV has been demonstrated to survive in dried blood at room temperature on environmental surfaces for approximately 4 days (CDC, October 22, 2012).

HBV infections that occur in healthcare professionals with no history of non-occupational exposure or occupational percutaneous injury might have resulted from direct or indirect blood or body fluid exposures that inoculated HBV into cutaneous scratches, abrasions, burns, other lesions, or on mucosal surfaces (CDC, June 29, 2001). HBsAg is also found in several other body fluids, including breast milk, bile, cerebrospinal fluid, feces, nasopharyngeal washings, saliva, semen, sweat, and synovial fluid. However, most body fluids are not efficient vehicles of transmission because they contain low quantities of infectious HBV, despite the presence of HBsAg (CDC, June 29, 2001).

HCV is not transmitted efficiently through occupational exposures to blood. Transmission has been reported rarely, but more than half the reported cases had other risk factors (Pearlman, 2004). The risk for HCV infection after a needlestick or sharps exposure to HCV-positive blood is approximately 1.8% (range: 0%–10%) (CDC, Nov., 2008; Tomkins, et al, 2012). Transmission rarely occurs from mucous membrane exposures to blood, and no transmission in healthcare professionals has been documented from intact or non-intact skin exposures to blood.

HIV: The average risk of HIV transmission after a percutaneous exposure to HIV-infected blood has been estimated to be approximately 0.3% (Gilman, 2012). The risk after a mucous membrane exposure is approximately 0.09% (Gilman, 2012). Although episodes of HIV transmission after non-intact skin exposure have been documented, the average risk for transmission by this route has not been precisely quantified but is estimated to be less than the risk for mucous membrane exposures. The risk for transmission after exposure to fluids or tissues other than HIV-infected blood also has not been quantified but is probably considerably lower than for blood exposures (Gilman, 2012).

By calling 1-888-448-4911 from anywhere in the United States 24 hours a day, clinicians can gain access to the National Clinicians' Post-Exposure Prophylaxis Hotline (PEPline). The PEPline has trained physicians prepared to give clinicians information, counseling and treatment recommendations for professionals who have needlestick injuries and other serious occupational exposures to blood borne microorganisms that lead to such serious infections or diseases as HIV or hepatitis.

HBV: Recommendations for HBV post-exposure management include initiation of the hepatitis B vaccine series to any susceptible, unvaccinated person who sustains an occupational blood or body fluid exposure, regardless of the source person’s hepatitis B status. Postexposure Prophylaxis (PEP) with hepatitis B immune globulin (HBIG) and/or hepatitis B vaccine series should be considered for occupational exposures after evaluation of the hepatitis B surface antigen status of the source and the vaccination and vaccine response status of the exposed person (Mathieu, 2012).

Women who are pregnant or breastfeeding can be vaccinated against HBV infection and/or get HBIG. Pregnant women who are exposed to blood should be vaccinated against HBV infection, because infection during pregnancy can cause severe illness in the mother and a chronic infection in the newborn. The vaccine does not harm the fetus.

Post-exposure treatment should begin as soon as possible after exposure, preferably within 24 hours, and no later than 7 days. Hepatitis B immune globulin (HBIG) is effective in preventing HBV infection after an exposure. The decision to begin treatment is based on several factors, such as (DHHS, 2003):

• _ whether the source individual is positive for hepatitis B surface antigen,
• _ whether the healthcare professional has been vaccinated, and
• _ whether the vaccine provided immunity

HCV: There is no vaccine against hepatitis C and no treatment after an exposure that will prevent infection. Immune globulin and antiviral agents like, Interferon, with or without ribavirin, are not recommended for PEP of hepatitis C.

IG is not effective for postexposure prophylaxis of HCV. Antiviral agents (e.g., interferon) are not recommended to prevent HCV infection. The mechanisms of the effect of interferon in treating HCV are not understood, and an established infection might need to be present for interferon to be effective.

Limited data indicate that antiviral therapy might be beneficial when started early in the course of HCV infection, but no guidelines exist for administration of therapy during the acute phase of infection. When HCV infection is identified early, the individual should be referred for medical management to a specialist in this area.

HIV: There is no vaccine against HIV. PEP is not recommended for all occupational exposures to HIV because most exposures do not lead to HIV infection and because the drugs used to prevent infection may have serious side effects. Based on the level of risk of HIV transmission of the exposure, a two or more drug PEP may be recommended. A three or more drug regimen may be recommended for an exposure of high risk transmission, but potential toxicity many prevent completion of the regimen, making the regimen ineffective (Gilman, 2012; Mathieu, 2012). The PEP regimen should be started immediately. The optimal duration of PEP is not known.

The majority of HIV exposures warrant a two drug regime using two nucleoside reverse transcriptase inhibitors (NRTIs), or one NRTI and one nucleotide reverse transcriptase inhibitors (NtRTIs). Because of the complexity determining PEP, consultation should be sought. The following are resources for consultation (Panlilio, et.al, 2005, pg 10):

• PEPline at UCSF; telephone 888-448-4911;
• HIV Antiretroviral Pregnancy Registry at ; Address: Research Park, 1011 Ashes Drive, Wilmington, NC 28405. Telephone: 800-258-4263; Fax: 800-800-1052; E-mail: registry@nc.crl.com;
• FDA (for reporting unusual or severe toxicity to antiretroviral agents) at ; telephone: 800-332-1088; address: MedWatch, HF-2, Food and Drug Administration, 5600 Fishers Lane, Rockville, MD 20857;
• CDC (for reporting HIV infections in HCP and failures of PEP) at telephone 800-893-0485; and
• HIV/AIDS Treatment Information Service.

All of the antiviral drugs for HIV have been associated with side effects. The most common side effects include nausea, vomiting, diarrhea, tiredness, or headache. The few serious side effects that have been reported in healthcare professionals using combination PEP have included kidney stones, hepatitis, and suppressed blood cell production. Interaction with other medicines can cause serious side effects.

Pregnancy should not rule out the use of post-exposure treatment when it is warranted. However, what is known and not known regarding the potential benefits and risks associated with the use of antiviral drugs in order to make an informed decision about treatment. The effect of antiretroviral drugs on developing fetus may be teratogenic (Gilman, 2012).

If the source individual cannot be identified or tested, decisions regarding follow-up should be based on the exposure risk and whether the source is likely to be a person who is infected with a bloodborne pathogen. Follow-up testing should be available to all professionals who are concerned about possible infection through occupational exposure.

HBV: If the HBV vaccine is given, a follow up test in 1-2 months will determine the response to the vaccine. Other routine follow-up after post-exposure treatment is not recommended, because the prevention is highly effective. Symptoms suggesting hepatitis should be reported (CDC, August 16, 2012).

“CDC's recommendations for prevention and control of HCV infection specify that persons should not be excluded from work, school, play, child care, or other settings on the basis of their HCV infection status. There is no evidence of HCV transmission from food handlers, teachers, or other service providers in the absence of blood-to-blood contact” (CDC, 2008).

HIV: Follow up counseling, postexposure testing, and medical evaluation should be done regardless of whether PEP was used (Gilman, 2012). Perform HIV-antibody testing by enzyme immunoassay should be monitored at baseline, six weeks, 12 weeks, and six months. If the exposed person becomes infected with HCV, HIV testing should be done for 12 months (Gilman, 2012). People on PEP should be monitored closely for toxicity.

HBV: If the exposed healthcare professional receives post-exposure treatment, it is unlikely that infection and exposure to others will occur. No precautions are recommended (DHHS, 2003).

HCV: Because the risk of becoming infected and passing the infection on to others after an exposure to HCV is low, no precautions are recommended.

HIV: During the follow-up period, especially the first 6-12 weeks when most infected persons are expected to show signs of infection, the exposed person should follow recommendations for preventing transmission of HIV. These include not donating blood, semen, or organs and not having sexual intercourse. If the healthcare professional chooses to have sexual intercourse, using a condom consistently and correctly may reduce the risk of HIV transmission. In addition, women should consider not breastfeeding infants during the follow-up period to prevent exposing their infants to HIV in breast milk.

Healthcare professionals have an obligation to adhere to scientifically accepted standards for infection control and responsibility to monitor the infection control practices of subordinates. The correct incorporation of work practice controls and engineering controls help to avoid or reduce exposure to potentially infectious materials and hazards. Compliance with environmental infection control measures will decrease the risk of healthcare related infections among patients, especially the immunocompromised and healthcare professionals (Sehulster et al., 2004).

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