For more information, see November 2018 HICPAC Meeting Minutes [PDF – 126 Inadequately-sterilized medical instruments, jet injectors 617, 618.
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1 of 241 Accessable version : https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html Guidelines for Environmental Infection Control in Health -Care Facilities Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC) U.S. Dep artment of Health and Human Services Centers for Disease Control and Prevention (CDC) Atlanta, GA 303 29 2003 Updated: July 2019 Ebola Virus Disease Update [August 2014]: The recommendations in this guideline for Ebola has been superseded by these CDC documents: Infection Prevention and Control Recommendations for Hospitalized Patients with Known or Suspected Ebola Virus Disease in U.S. Hospitals (https://www.cdc.gov/vhf/ebola/healthcare -us/hospitals/infection -control.html ) Interim Guidance for Environmental Infection Control in Hospitals for Ebola Virus (https://www.cdc.gov/vhf/ebola/healthcare -us/cleaning/hospitals.html ) See CDC™s Ebola Virus Disease website (https://www.cdc.gov/vhf/ebol a/index.html ) for current information on how Ebola virus is transmitted. New Categorization Scheme for Recommendations [November 2018] In November 2018, HICPAC voted to approve an updated recommendation scheme. The category Recommendation means that we are confident that the benefits of the recommended approach clearly exceed the harms (or, in the case of a negative recommendation, that the harms clearly exceed the benefits). In general, Recommendations should be supported by high – to mode rate -quality evidence. In some circumstances, however, Recommendations may be made based on lesser evidence or even expert opinion when high -quality evidence is impossible to obtain and the anticipated benefits strongly outweigh the harms or when then Reco mmendation is required by federal law. For more information, see November 2018 HICPAC Meeting Minutes [PDF – 126 pages] (http://www.cdc.gov/hicpac/pdf/2018 -Nov -HICPAC -Meeting -508.pdf). C. difficile Update [April 2019]: Recommendations E.VI.G. and E.VI.H. and the supporting text were updated to reflect changes in Federal regulatory approvals: LIST K: EPA™s Registered Antimicrobial Products Effective against Clostridium difficile Spores (https://www.epa.gov/pesticide -registration/list -k-epas -registered -antimicrobial -products -effective -against -clostridium ). Interim Measles Infection Control [July 2019] See Interim Infection Prevention and Control Recommendations for Measles in Healthcare Settings (https://www.cdc.gov/infectioncontrol/guidelines/measles)
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Guidelines for Environmental Infection Control in Health -Care Facilities (2003) Last update: July 2019 2 of 241 Suggested Citations: Available from the CDC Internet Site: The full -text version of the guidelines appears as a web -based document at the CDC™s Division of Healthcare Quality Promotion ™s Infection Control website (https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html ). The full -text version of the guidelines should be cited when reference is made primarily to material in Parts I and IV. The print version of the guidelines appears as: Sehulster LM, Chinn RYW, Arduino MJ, Carpenter J, Donlan R, Ashford D, Besser R, Fields B, McNeil MM, Whitney C, Wong S, Juranek D, Cleveland J. Guidelines for environmental infection control in health -care facilities. Recommendations from CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). Chicago IL; American So ciety for Healthcare Engineering/American Hospital Association; 2004. Part II of these guidelines appeared in the CDC™s fiMorbidity and Mortality Weekly Report:fl Centers for Disease Control and Prevention. Guidelines for environmental infection control in health -care facilities: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). MMWR 2003; 52 (No. RR -10): 1 Œ48. Updates to the Part II recommendations also appeared in the MMWR in 2003 as fiErrata: Vol. 52 (No. RR-10)fl (MMWR Vol. 52 [42]: 1025 Œ6) on October 24, 2003 and as a fiNotice to Readersfl scheduled to appea r in February 2004. The full -text version of these guidelines (this document) incorporates these updates.
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Guidelines for Environmental Infection Control in Health -Care Facilities (2003) Last update: July 2019 3 of 241 Centers for Disease Control and Prevention Healthcare Infection Control Practices Advisory Committee (HICPAC) Guidelines for Environmental Infecti on Control in Health -Care Facilities Abstract Background: Although the environment serves as a reservoir for a variety of microorganisms, it is rarely implicated in disease transmission except in the immunocompromised population. Inadvertent exposures to environmental opportunistic pathogens (e.g., Aspergillus spp. and Legionella spp.) or airborne pathogens (e.g., Mycobacterium tuberculosis and varicella -zoster virus) may result in infections with significant morbidity and/or mortality. Lack of adherence to established standards and guidance (e.g., water quality in dialysis, proper ventilation for specialized care areas such as operating rooms, and proper use of disinfectants) can result in adverse patient outcomes in health -care facilities. Objective: The objective is to develop an environmental infection -contro l guideline that reviews and reaffirms strategies for the prevention of environmentally -mediated infections, particularly among health -care workers and immunocompromised patients. The recommendations are evidence -based whenever possible. Search Strategies : The contributors to this guideline reviewed predominantly English -language articles identified from MEDLINE literature searches, bibliographies from published articles, and infection -control textbooks. Criteria for Selecting Citations and Studies for T his Review: Articles dealing with outbreaks of infection due to environmental opportunistic microorganisms and epidemiological – or laboratory experimental studies were reviewed. Current editions of guidelines and standards from organizations (i.e., Americ an Institute of Architects [AIA], Association for the Advancement of Medical Instrumentation [AAMI], and American Society of Heating, Refrigeration, and Air -Conditioning Engineers [ASHRAE]) were consulted. Relevant regulations from federal agencies (i.e., U.S. Food and Drug Administration [FDA]; U.S. Department of Labor, Occupational Safety and Health Administration [OSHA]; U.S. Environmental Protection Agency [EPA]; and U.S. Department of Justice) were reviewed. Some topics did not have well -designed, pros pective studies nor reports of outbreak investigations. Expert opinions and experience were consulted in these instances. Types of Studies: Reports of outbreak investigations, epidemiological assessment of outbreak investigations with control strategies, and in vitro environmental studies were assessed. Many of the recommendations are derived from empiric engineering concepts and reflect industry standards. A few of the infection -control measures proposed cannot be rigorously studied for ethical or logist ical reasons.
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Guidelines for Environmental Infection Control in Health -Care Facilities (2003) Last update: July 2019 4 of 241 Outcome Measures: Infections caused by the microorganisms described in this guideline are rare events, and the effect of these recommendations on infection rates in a facility may not be readily measurable. Therefore, the following steps to measure performance are suggested to evaluate these recommendations: 1. Document whether infection -control personnel are actively involved in all phases of a healthcare facility™s demolition, construction, and renovation. Activities should include performing a risk assessment of the necessa ry types of construction barriers, and daily monitoring and documenting of the presence of negative airflow within the construction zone or renovation area. 2. Monitor and document daily the negative airflow in airborne infection isolation rooms (AII) and positive airflow in protective environment rooms (PE), especially when patients are in these rooms. 3. Perform assays at least once a month by using standard quantitative methods for endotoxin in water used to reprocess hemodialyzers, and for heterotrophic, me sophilic bacteria in water used to prepare dialysate and for hemodialyzer reprocessing. 4. Evaluate possible environmental sources (e.g., water, laboratory solutions, or reagents) of specimen contamination when nontuberculous mycobacteria (NTM) of unlikely c linical importance are isolated from clinical cultures. If environmental contamination is found, eliminate the probable mechanisms. 5. Document policies to identify and respond to water damage. Such policies should result in either repair and drying of wet s tructural materials within 72 hours, or removal of the wet material if drying is unlikely within 72 hours. Main Results: Infection -control strategies and engineering controls, when consistently implemented, are effective in preventing opportunistic, env ironmentally -related infections in immunocompromised populations. Adherence to proper use of disinfectants, proper maintenance of medical equipment that uses water (e.g., automated endoscope reprocessors and hydrotherapy equipment), water -quality standards for hemodialysis, and proper ventilation standards for specialized care environments (i.e., airborne infection isolation [AII], protective environment [PE], and operating rooms [ORs]), and prompt management of water intrusion into facility structural elem ents will minimize health -care associated infection risks and reduce the frequency of pseudo -outbreaks. Routine environmental sampling is not advised except in the few situations where sampling is directed by epidemiologic principles and results can be app lied directly to infection control decisions, and for water quality determinations in hemodialysis. Reviewers™ Conclusions: Continued compliance with existing environmental infection control measures will decrease the risk of health -care associated infec tions among patients, especially the immunocompromised, and health -care workers.
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Guidelines for Environmental Infection Control in Health -Care Facilities (2003) Last update: July 2019 5 of 241 Centers for Disease Control and Prevention Healthcare Infection Control Practices Advisory Committee (HICPAC) Guidelines for Environmental Infection Control in Health -Care Facilities Table of Contents List of Abbreviations Used in This Publication .. 9 Executive Summary 15 Part I. Background Information: Environmental Infection Control in Health -Care Facilities .. 17 A. Introduction . 17 B. Key Terms Used in this Guideline .. 19 C. Air 20 1. Modes of Transmission of Airborne Diseases .. 20 2. Airborne Infectious Diseases in Health -Care Facilities 21 3. Heating, Ventilation, and Air Conditioning Systems in Health -Care Facilities .. 27 4. Construction, Renovation, Remediation, Repair, and Demolition .. 35 5. Environmental Infection -Control Measures for Special Health -Care Settings . 48 6. Other Aerosol Hazards in Health -Care Facilities . 54 D. Water .. 54 1. Modes of Transmission of Waterborne Diseases . 54 2. Waterborne Infectious Diseases in Health -Care Facilities .. 55 3. Water Systems in Health -Care Facilities . 60 4. Strategies for Controlling Waterborne Microbial Contamination 68 5. Cooling Towers and Evaporative Condensers .. 72 6. Dialysis Water Quality and Dialysate 74 7. Ice Machines and Ice .. 80 8. Hydrotherapy Tanks and Pools . 82 9. Miscellaneous Medical/Dental Equipment Connected to Main Water Systems .. 84 E. Environmental Services . 86 1. Principles of Cleaning and Disinfecting Environmental Surfaces .. 86 2. General Cleaning Strategies for Patient -Care Areas .. 88 3. Cleaning Strategies for Spills of Blood and Body Substances . 91 4. Carpeting and Cloth Furnishings . 93 5. Flowers and Plants in Patient -Care Areas 94 6. Pest Control . 95 7. Special Pathogen Concerns . 97 F. Environmental Sampling 103 1. General Principles: Microbiologic Sampling of the Environment 103 2. Air Sampling . 104
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Guidelines for Environmental Infection Control in Health -Care Facilities (2003) Last update: July 2019 6 of 241 3. Water Sampling . 109 4. Environmental Surface Sampling . 110 G. Laundry and Bedding .. 113 1. General Information . 113 2. Epidemiology and General Aspects of Infection Control . 113 3. Collecting, Transporting, and Sorting Contaminated Textiles and Fabrics . 114 4. Parameters of the Laundry Process .. 115 5. Special Laundry Situations .. 117 6. Surgical Gowns, Drapes, and Disposable Fabrics 118 7. Antimicrobial -Impregnated Articles and Consumer Items Bearing Antimicrobial Labeling . 118 8. Standard Mattresses, Pillows, and Air -Fluidized Beds .. 118 H. Animals in Health -Care Facilities . 120 1. General Information . 120 2. Animal -Assisted Activities, Animal -Assisted Therapy, and Resident Animals 121 3. Service Animals . 123 4. Anima ls as Patients in Human Health -Care Facilities 125 5. Research Animals in Health -Care Facilities 126 I. Regulated Medical Waste 127 1. Epidemiology .. 127 2. Categorie s of Medical Waste .. 128 3. Management of Regulated Medical Waste in Health -Care Facilities . 128 4. Treatment of Regulated Medical Waste . 128 5. Discharging Blood, Fluids to Sanitary Sewers or Septic Tanks 131 6. Medical Waste and CJD . 131 Part II. Recommendations for Environmental Infection Control in Health -Care Facilities . 132 A. Rationale for Recommendations 132 B. Rating Categories .. 132 C. Rec ommendations ŠAir . 133 I. Air -Handling Systems in Health -Care Facilities 133 II. Construction, Renovation, Remediation, Repair, and Demolition 135 III. Infection -Control and Ventilation Requirements for PE Rooms .. 137 IV. Infection -Control and Ventilation Requirements for All Rooms .. 138 V. Infection -Control and Ventilation Requirements for Operating Rooms 139 VI. Other Potential Infectious Aerosol Hazards in Health -Care Facilities .. 140 D. Recommendations ŠWater .. 140 I. Controlling the Spread of Waterborne Microoganisms . 140 VII. Routine Prevention of Waterborne Microbial Contamination Within the Distribution System 141 VIII. Remediation Strategies for Distribution System Repair or Emergen cies . 141
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Guidelines for Environmental Infection Control in Health -Care Facilities (2003) Last update: July 2019 8 of 241 Appendix B. Air 223 1. Airborne Contaminant Removal 223 2. Air Sampling for Aerosols Containing Legionellae . 224 3. Calculation of Air Sampling Results .. 224 4. Ventilation Specifications for Health -Care Facilities . 225 Appendix C. Water . 233 1. Biofilms .. 233 2. Water and Dialysate Sampling Strategies in Dialysis . 234 3. Water Sampling Strategies and Culture Techniques for Detecting Legionellae 235 4. Procedure for Cleaning Cooling Towers and Related Equipment 237 5. Maintenan ce Procedures Used to Decrease Survival and Multiplications of Legionella spp. in Potable -Water Distribution Systems 238 Appendix D. Insects and Microorganisms .. 239 Appendix E. Information Resources .. 240 Air andWater . 240 Environmental Sampling . 240 Animals in Health -Care Facilities .. 240 Regulated Medical Waste .. 240 Gene ral Resources . 240 Appendix F. Areas of Future Research . 241 Air –.. .. 241 Water –– .. 241 Environmental Servic es .. 241 Laundry and Bedding 241 Animals in Health -Care Facilities .. 241 Regulated Medical Waste .. 241
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Guidelines for Environmental Infection Control in Health -Care Facilities (2003) Last update: July 2019 9 of 241 List of Abbreviations Used in This Publication Abbreviation Meaning AAA animal -assisted activity AAMI Association for the Advancement of Medical Instrumentation AAT animal -assisted therapy ACGIH American Council of Governmental Industrial Hygienists ACH air changes per hour ADA Americans with Disabilities Act AER automated endoscope reprocessor AFB acid -fast bacilli AHA American Hospital Association AHJ authorities having jurisdiction AIA American Institute of Architects AII airborne infection isolation AmB amphotericin B ANC absolute neutrophil count ANSI American National Standards Institute AORN Association of periOperative Registered Nurses ASHE American Society for Healthcare Engineering ASHRAE American Society of Heating, Refirgeration, and Air -Conditioning Engineers BCG Bacille Calmette -Guérin BCYE buffered charcoal yeast extract medium BHI brain -heart infusion BMBL CDC/NIH publication fiBiosafety in Microbiological and Biomedical Laboratoriesfl BOD biological oxygen demand BSE bovine spongiform encephalopathy BSL biosafety level C Centigrade CAPD continuous ambulatory peritoneal dialysis CCPD continual cycling peritoneal dialysis CMAD count median aerodynamic diameter CDC U.S. Centers for Disease Control and Prevention CFR Code of Federal Regulations CFU colony -forming unit CJD Creutzfeldt -Jakob disease cm centimeter CMS U.S. Centers for Medicare and Medicaid Services CPL compliance document (OSHA) CT/EC cooling tower/evaporative condenser DFA direct fluorescence assay; direct fluorescent antibody DHHS U.S. Department of Health and Human Services DHBV duck hepatitis B virus DNA deoxyribonucleic acid DOP dioctylphthalate DOT U.S. Department of Transportation EC environment of care (JCAHO) ELISA enzyme -linked immunosorbent assay EPA U.S. Environmental Protection Agency ESRD end -stage renal disease EU endotoxin unit F Fahrenheit
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Guidelines for Environmental Infection Control in Health -Care Facilities (2003) Last update: July 2019 10 of 241 Abbreviation Meaning FDA U.S. Food and Drug Administration FIFRA Federal Insecticide, Fungicide, and Rodenticide Act FRC free residual chlorine ft foot (feet) FTC U.S. Federal Trade Commission GISA glycopeptide intermediate resistant Staphylococcus aureus HBV hepatitis B virus HCV hepatitis C virus HEPA high efficiency particulate air HICPAC Healthcare Infection Control Practices Advisory Committee HIV human immunodeficiency virus HPV human papilloma virus HSCT hematopoietic stem cell transplant HVAC heating, ventilation, air conditio ning ICRA infection control risk assessment ICU intensive care unit ID 50 50% median infectious dose IPD intermittent peritoneal dialysis JCAHO Joint Commission on Accreditation of Healthcare Organizations kg kilogram L liter MAC Mycobacterium avium complex; also used to denote MacConkey agar MDRO multiple -drug resistant organism MIC minimum inhibitory concentration micrometer; micron mL milliliter min minute mg milligram MMAD mass median aerodynamic diameter MMWR fiMorbidity and Mortality Weekly Reportfl MRSA methicillin -resistant Staphylococcus aureus MSDS material safety data sheet N Normal NaCl sodium chloride NaOH sodium hydroxide NCID National Center for Infectious Diseases NCCDPHP National Center for Chronic Disease Prevention and Health Promotion NCCLS National Committee for Clinical Laboratory Standards ng nanogram NICU neonatal intensive care unit NIH U.S. National Institutes of Health NIOSH National Institute for Occupational Safety and Health nm nanometer NNIS National Nosocomial Infection Surveillance NTM nontuberculous mycobacteria OPL on-premises laundry OSHA U.S. Occupational Safety and Health Administration Pa Pascal PCP Pneumocystis carinii pneumonia PCR polymerase chain reaction PD peritoneal dialysis
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Guidelines for Environmental Infection Control in Health -Care Facilities (2003) Last update: July 2019 11 of 241 Abbreviation Meaning PE protective environment PEL permissible exposure limit PPE personal protective equipment ppm parts per million PVC polyvinylchloride RAPD randomly amplified polymorphic DNA RODAC replicate organism direct agar contact RSV respiratory syncytial virus RO reverse osmosis SARS severe acute respiratory syndrome SARS -CoV SARS coronavirus sec second spp species SSI surgical site infection TB tuberculosis TLV® -TWA threshold limit value -time weighted average TSA tryptic soy agar TSB tryptic soy broth TSE transmissible spongiform encephalopathy U.S. United States USC United States Code USDA U.S. Department of Agriculture USPS U.S. Postal Service UV ultraviolet UVGI ultraviolet germicidal irradiation VAV variable air ventilation vCJD variant Creutzfeldt -Jakob disease VISA vancomycin intermediate resistant Staphylococcus aureus VRE vancomycin -resistant Enterococcus VRSA vancomycin -resistant Staphylococcus aureus v/v volume/volume VZV varicella -zoster virus Note: Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services. References to non -CDC sites on the Internet are provided as a service to the rea der and does not constitute or imply endorsement of these organization s or their programs by CDC or the U.S. Department of Health and Human Services. CDC is not responsible for the content of pages found at these sites.
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