Executive Summary

Overview

The Guidelines for Environmental Infection Control in Health-Care Facilities is a compilation of recommendations for the prevention and control of infectious diseases that are associated with healthcare environments. This document

1. revises multiple sections from previous editions of the Centers for Disease Control and Prevention [CDC] document titled Guideline for Handwashing and Hospital Environmental Control;^{1, 2}
2. incorporates discussions of air and water environmental concerns from CDC's Guideline for the Prevention of Nosocomial Pneumonia;³
3. consolidates relevant environmental infection-control measures from other CDC guidelines;^4–9 and
4. includes two topics not addressed in previous CDC guidelines — infection-control concerns related to animals in health-care facilities and water quality in hemodialysis settings.

Part I

Part I of this report, Background Information: Environmental Infection Control in Health-Care Facilities, provides a comprehensive review of the scientific literature. Attention is given to engineering and infection-control concerns during construction, demolition, renovation, and repairs of health-care facilities. Use of an infection-control risk assessment is strongly supported before the start of these or any other activities expected to generate dust or water aerosols. Also reviewed in Part I are infection-control measures used to recover from catastrophic events (e.g., flooding, sewage spills, loss of electricity and ventilation, and disruption of the water supply) and the limited effects of environmental surfaces, laundry, plants, animals, medical wastes, cloth furnishings, and carpeting on disease transmission in healthcare facilities.

Part II

Part II of this guideline, Recommendations for Environmental Infection Control in Health-Care Facilities, outlines environmental infection control in health-care facilities, describing measures for preventing infections associated with air, water, and other elements of the environment. These recommendations represent the views of different divisions within CDC's National Center for Infectious Diseases (NCID) (e.g., the Division of Healthcare Quality Promotion [DHQP] and the Division of Bacterial and Mycotic Diseases [DBMD]) and the consensus of the Healthcare Infection Control Practices Advisory Committee (HICPAC), a 12-member group that advises CDC on concerns related to the surveillance, prevention, and control of health-care associated infections, primarily in U.S. healthcare facilities.10 In 1999, HICPAC's infection-control focus was expanded from acute-care hospitals to all venues where health care is provided (e.g., outpatient surgical centers, urgent care centers, clinics, outpatient dialysis centers, physicians' offices, and skilled nursing facilities). The topics addressed in this guideline are applicable to the majority of health-care venues in the United States. This document is intended for use primarily by infection-control professionals (ICPs), epidemiologists, employee health and safety personnel, information system specialists, administrators, engineers, facility managers, environmental service professionals, and architects for health-care facilities.

Key recommendations

1. infection-control impact of ventilation system and water system performance;
2. establishment of a multidisciplinary team to conduct infection-control risk assessment;
3. use of dust-control procedures and barriers during construction, repair, renovation, or demolition;
4. environmental infection-control measures for special care areas with patients at high risk;
5. use of airborne particle sampling to monitor the effectiveness of air filtration and dust-control measures;
6. procedures to prevent airborne contamination in operating rooms when infectious tuberculosis [TB] patients require surgery
7. guidance regarding appropriate indications for routine culturing of water as part of a comprehensive control program for legionellae;
8. guidance for recovering from water system disruptions, water leaks, and natural disasters [e.g., flooding];
9. infection-control concepts for equipment that uses water from main lines [e.g., water systems for hemodialysis, ice machines, hydrotherapy equipment, dental unit water lines, and automated endoscope reprocessors]);
10. environmental surface cleaning and disinfection strategies with respect to antibiotic-resistant microorganisms;
11. infection-control procedures for health-care laundry;
12. use of animals in health care for activities and therapy;
13. managing the presence of service animals in health-care facilities;
14. infection-control strategies for when animals receive treatment in human health-care facilities; and
15. a call to reinstate the practice of inactivating amplified cultures and stocks of microorganisms on-site during medical waste treatment.

Whenever possible, the recommendations in Part II are based on data from well-designed scientific studies. However, certain of these studies were conducted by using narrowly defined patient populations or for specific health-care settings (e.g., hospitals versus long-term care facilities), making generalization of findings potentially problematic. Construction standards for hospitals or other healthcare facilities may not apply to residential home-care units. Similarly, infection-control measures indicated for immunosuppressed patient care are usually not necessary in those facilities where such patients are not present. Other recommendations were derived from knowledge gained during infectious disease investigations in health-care facilities, where successful termination of the outbreak was often the result of multiple interventions, the majority of which cannot be independently and rigorously evaluated. This is especially true for construction situations involving air or water.

Other recommendations are derived from empiric engineering concepts and may reflect an industry standard rather than an evidence-based conclusion. Where recommendations refer to guidance from the American Institute of Architects (AIA), (AIA guidance has been superseded by the Facilities Guidelines Institute [FGI]) the statements reflect standards intended for new construction or renovation. Existing structures and engineered systems are expected to be in continued compliance with the standards in effect at the time of construction or renovation. Also, in the absence of scientific confirmation, certain infection-control recommendations that cannot be rigorously evaluated are based on a strong theoretical rationale and suggestive evidence. Finally, certain recommendations are derived from existing federal regulations. The references and the appendices comprise Parts III and IV of this document, respectively.

Infections caused by the microorganisms described in these guidelines are rare events, and the effect of these recommendations on infection rates in a facility may not be readily measurable. Therefore, the following steps to measure performance are suggested to evaluate these recommendations (Box 1).

Box 1. Environmental infection control: performance measures

1. Document whether infection-control personnel are actively involved in all phases of a health-care facility's demolition, construction, and renovation. Activities should include performing a risk assessment of the necessary types of construction barriers, and daily monitoring and documenting of the presence of negative airflow within the construction zone or renovation area.
2. Monitor and document daily the negative airflow in airborne infection isolation (AII) rooms and positive airflow in protective environment (PE) rooms, especially when patients are in these rooms.
3. Perform assays at least once a month by using standard quantitative methods for endotoxin in water used to reprocess hemodialyzers, and for heterotrophic and mesophilic bacteria in water used to prepare dialysate and for hemodialyzer reprocessing.
4. Evaluate possible environmental sources (e.g., water, laboratory solutions, or reagents) of specimen contamination when nontuberculous mycobacteria (NTM) of unlikely clinical importance are isolated from clinical cultures. If environmental contamination is found, eliminate the probable mechanisms.
5. Document policies to identify and respond to water damage. Such policies should result in either repair and drying of wet structural or porous materials within 72 hours, or removal of the wet material if drying is unlikely with 72 hours.

Topics outside the scope of this document include

1. noninfectious adverse events (e.g., sick building syndrome);
2. environmental concerns in the home;
3. home health care;
4. bioterrorism; and
5. healthcare-associated foodborne illness.

This document includes only limited discussion of

1. handwashing/hand hygiene;
2. standard precautions; and
3. infection-control measures used to prevent instrument or equipment contamination during patient care (e.g., preventing waterborne contamination of nebulizers or ventilator humidifiers).

These topics are mentioned only if they are important in minimizing the transfer of pathogens to and from persons or equipment and the environment. Although the document discusses principles of cleaning and disinfection as they are applied to maintenance of environmental surfaces, the full discussion of sterilization and disinfection of medical instruments and direct patient-care devices is deferred for inclusion in the Guideline for Disinfection and Sterilization in Health-Care Facilities, a document currently under development. Similarly, the full discussion of hand hygiene is available as the Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Where applicable, the Guidelines for Environmental Infection Control in Health-Care Facilities are consistent in content to the drafts available as of October 2002 of both the revised Guideline for Prevention of Health-care Associated Pneumonia and Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Facilities.

This guideline was prepared by CDC staff members from NCID and the National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) and the designated HICPAC advisor. Contributors to this document reviewed predominantly English-language manuscripts identified from reference searches using the National Library of Medicine's MEDLINE, bibliographies of published articles, and infection-control textbooks. Working drafts of the guideline were reviewed by CDC scientists, HICPAC committee members, and experts in infection control, engineering, internal medicine, infectious diseases, epidemiology, and microbiology. All recommendations in this guideline may not reflect the opinions of all reviewers.