Cdc Guidelines for Envoirment Infeksi

7/25/2019 Cdc Guidelines for Envoirment Infeksi

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Guidelines for Environmental Infection

Control in Health-Care Facilities

Recommendations of CDC and the Healthcare Infection Control

Practices Advisory Committee (HICPAC)

Prepared by

&ynne 'ehulster, Ph.(.)

*aymond +.. hinn, .(./

1Division of Healthcare Qualit Promotion

!ational "enter for #nfectious Diseases$H#"PA" member

%harp &emorial Hospital

%an Dieo, "alifornia

he material in this report originated in the 0ational enter for 1nfectious (iseases, James . 2ughes,.(., (irector3 and the (ivision of 2ealthcare 4uality Promotion, 'teven &. 'olomon, .(., $cting(irector.

Sommaire

(he health)care facilit environment is rarel implicated in disease transmission,

e*cept amon patients +ho are immunocompromised. !onetheless, inadvertent

e*posures to environmental pathoens e.., $spergillusspp. and &egionellaspp.- or

airborne pathoens e.., ycobacterium tuberculosisand varicella)zoster virus- canresult in adverse patient outcomes and cause illness amon health)care +orers.

/nvironmental infection)control strateies and enineerin controls can effectivel

prevent these infections. (he incidence of health)care))associated infections and

pseudo)outbreas can be minimized b 1- appropriate use of cleaners and

disinfectants0 $- appropriate maintenance of medical equipment e.., automated

endoscope reprocessors or hdrotherap equipment-0 - adherence to +ater)qualit

standards for hemodialsis, and to ventilation standards for specialized care

environments e.., airborne infection isolation rooms, protective environments, or

operatin rooms-0 and 2- prompt manaement of +ater intrusion into the facilit.

3outine environmental samplin is not usuall advised, e*cept for +ater qualit

determinations in hemodialsis settins and other situations +here samplin isdirected b epidemioloic principles, and results can be applied directl to infection)
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control decisions.

(his report revie+s previous uidelines and strateies for preventin environment)

associated infections in health)care facilities and offers recommendations. (hese

include 1- evidence)based recommendations supported b studies0 $- requirements offederal aencies e.., 4ood and Dru Administration, 5.%. /nvironmental Protection

Aenc, 5.%. Department of 6abor, 7ccupational %afet and Health Administration,

and 5.%. Department of 8ustice-0 - uidelines and standards from buildin and

equipment professional oranizations e.., American #nstitute of Architects,

Association for the Advancement of &edical #nstrumentation, and American %ociet of

Heatin, 3efrieration, and Air)"onditionin /nineers-0 2- recommendations derived

from scientific theor or rationale0 and 9- e*perienced opinions based upon infection)

control and enineerin practices. (he report also suests a series of performance

measurements as a means to evaluate infection)control efforts.

Introduction

Parameters of the Reort

his report, which contains the complete list of recommendations with pertinent

references, is Part 11 of uidelines for /nvironmental #nfection "ontrol in Health)"are

4acilities. he full four-part guidelines will be available on (5s (ivision of

2ealthcare 4uality Promotion 6(24P7 website. *elative to previous ( guidelines,

this report

revises multiple sections 6e.g., cleaning and disinfection of environmentalsurfaces, environmental sampling, laundry and bedding, and regulated medical

waste7 from previous editions of (5s uideline for Hand+ashin and

Hospital /nvironmental "ontrol3

incorporates discussions of air and water environmental concerns from (5s

uideline for Prevention of !osocomial Pneumonia3

consolidates relevant environmental infection-control measures from other

( guidelines3 and

includes two topics not addressed in previous ( guidelines --- infection-

control concerns related to animals in health-care facilities and water quality in

hemodialysis settings.

1n the full guidelines, Part 1, 8ac9ground 1nformation: nvironmental 1nfection

ontrol in 2ealth-are Facilities, provides a comprehensive review of the relevant

scientific literature. $ttention is given to engineering and infection-control concerns

during construction, demolition, renovation, and repair of health-care facilities. ;se of

an infection-control ris9 assessment is strongly supported before the start of these or

any other activities e


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limited effects of environmental surfaces, laundry, plants, animals, medical wastes,

cloth furnishings, and carpeting on disease transmission in health-care facilities. Part

111 and Part 1= of the full guidelines provide references 6for the complete guideline7

and appendices, respectively.

Part 11 6this report7 contains recommendations for environmental infection control in

health-care facilities, describing control measures for preventing infections associated

with air, water, or other elements of the environment. hese recommendations

represent the views of different divisions within (5s 0ational enter for 1nfectious

(iseases and the 2ealthcare 1nfection ontrol Practices $dvisory ommittee

621P$7, a )/-member group that advises ( on concerns related to the

surveillance, prevention, and control of health-care--associated infections, primarily in

;.'. health-care facilities. 1n )>>>, 21P$5s infection-control focus was e


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unit water lines, and automated endoscope reprocessors73

environmental surface cleaning and disinfection strategies with respect to

antibiotic-resistant microorganisms3

infection-control procedures for health-care laundry3

use of animals in health care for activities and therapy3

managing the presence of service animals in health-care facilities3

infection-control strategies for when animals receive treatment in human

health-care facilities3 and

a call to reinstate the practice of inactivating amplified cultures and stoc9s ofmicroorganisms onsite during medical waste treatment.

opics outside the scope of this report include )7 noninfectious adverse events 6e.g.,

sic9 building syndrome7, /7 environmental concerns in the home, 7 home health care,

A7 terrorism, and !7 health-care--associated foodborne illness.

herever possible, the recommendations in this report are based on data from well-

designed scientific studies. 2owever, certain of these studies were conducted by using

narrowly defined patient populations or specific health-care settings 6e.g., hospitals

versus long-term care facilities7, ma9ing generaliBation of findings potentially

problematic. onstruction standards for hospitals or other health-care facilities may not

apply to residential home-care units. 'imilarly, infection-control measures indicated

for immunosuppressed patient care are usually not necessary in those facilities where

such patients are not present.

Cther recommendations were derived from 9nowledge gained during infectious

disease investigations in health-care facilities, where successful termination of the

outbrea9 was often the result of multiple interventions, the ma%ority of which cannot be

independently and rigorously evaluated. his is especially true for construction

situations involving air or water.

Cther recommendations were derived from empiric engineering concepts and may

reflect industry standards rather than evidence-based conclusions. here

recommendations refer to guidance from the $merican 1nstitute of $rchitects 6$1$7,

the statements reflect standards intended for new construction or renovation.


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Performance !easurements

1nfections 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. herefore, the following steps to measure performance aresuggested to evaluate these recommendations:

). (ocument whether infection-control personnel are actively involved in all

phases of a health-care facility5s demolition, construction, and renovation.

$ctivities should include performing a ris9 assessment of the necessary types

of construction barriers, and daily monitoring and documenting of the presence

of negative airflow within the construction Bone or renovation area.

/. onitor and document daily the negative airflow in $11 rooms and positive

airflow in P rooms, especially when patients are in these rooms.

. Perform assays at least once a month by using standard quantitative methods

for endoto


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of &egionella spp.

(. Euidelines for preventing the transmission of mcobacterium tuberculosis in

health-care facilities. * )>>A3A60o. **)7. Provides supplemental information

on engineering controls.

(. *ecommendations for preventing the spread of vancomycin resistance:

recommendations of the 2ospital 1nfection ontrol Practices $dvisory ommittee

621P$7. * )>>!3AA60o. **)/7. 'upplements environmental infection-

control information from the section, 2ospitals with ndemic =* or ontinued =*

ransmission.

Earner J', 2ospital 1nfection ontrol Practices $dvisory ommittee. Euideline for

isolation precautions in hospitals. 1nfect ontrol 2osp pidemiol )>>3)D:!--#".

'upplements and updates topics in Part 11 --- *ecommendations for 1solation

Precautions in 2ospitals 6linen and laundry, routine and terminal cleaning, airborneprecautions7.

angram $J, 2oran , Pearson &, 'ilver &, Jarvis *, 2ospital 1nfection

ontrol Practices $dvisory ommittee. Euideline for prevention of surgical site

infection. 1nfect ontrol 2osp pidemiol )>>>3A:/!"--D#. ;pdates operating room

ventilation and surface cleaningGdisinfection recommendations from the section,

1ntraoperative 1ssues: Cperating *oom nvironment.

;.'. Public 2ealth 'ervice, 1nfectious (iseases 'ociety of $merica, Prevention of

Cpportunistic 1nfections or9ing Eroup. ;'P2'G1('$ guidelines for the preventionof opportunistic infections in persons infected with human immunodeficiency virus.

1nfect (is Cbstet Eynecol /""/3 )":--A. 'upplements information regarding patient

interaction with pets and animals in the home.

(, 1nfectious (iseases 'ociety of $merica, $merican 'ociety of 8lood and arrow

ransplantation. Euidelines for preventing opportunistic infections among

hematopoietic stem cell transplant recipients. ytotherapy /"")3:A)--!A. 'upplements

and updates the section, 2ospital 1nfection ontrol.

#ey $erms

Air%orne infection isolation (AII) refers to the isolation of patients infected with

organisms spread via airborne droplet nuclei H! Im in diameter. his isolation area

receives numerous air changes per hour 6$27 6)/ $2 for new construction as of

/"")3 $2 for construction before /"")7, and is under negative pressure, such that

the direction of the air flow is from the outside ad%acent space 6e.g., the corridor7 into

the room. he air in an $11 room is preferably e


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Protective environment (PE)is a specialiBed patient-care area, usually in a hospital,

with a positive air flow relative to the corridor 6i.e., air flows from the room to the

outside ad%acent space7. he combination of 2P$ filtration, high numbers of air

changes per hour 6)/ $27, and minimal lea9age of air into the room creates an

environment that can safely accommodate patients who have undergone allogeneichematopoietic stem cell transplant 62'7.

Immunocomromised atients are those patients whose immune mechanisms are

deficient because of immunologic disorders 6e.g., human immunodeficiency virus

K21=M infection or congenital immune deficiency syndrome7, chronic diseases 6e.g.,

diabetes, cancer, emphysema, or cardiac failure7, or immunosuppressive therapy 6e.g.,

radiation, cytoto


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(22' ;.'. (epartment of 2ealth and 2uman 'ervices

(C ;.'. (epartment of ransportation

environment of care

P$ ;. '. nvironmental Protection $gency

F($ ;.'. Food and (rug $dministration

28= hepatitis 8 virus

2P$ high efficiency particulate air

21= human immunodeficiency virus

2' hematopoietic stem cell transplant

2=$ heating, ventilation, air conditioning

1*$ infection-control ris9 assessment

J$2C Joint ommission on $ccreditation of 2ealthcare CrganiBations

0aC2 sodium hydro


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=*'$ vancomycin-resistant %taphlococcus aureus

=L= varicella Boster virus

Recommendations for Environmental Infection Control in Health-CareFacilities

Rationale for Recommendations

$s in previous ( guidelines, each recommendation is categoriBed on the basis of

e


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"nresolved issue 0o recommendation is offered. 0o consensus or insufficient

evidence e


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construction of new facilities and renovation of e7.

ategory 1 6$1$: D.).(,#.).(,>.).(,)".).(,)).).(7

a. &ocate e


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(. Follow appropriate procedures for use of areas with through-the-wall

ventilation units 617. ategory 1 6$1$: #.).(), #.).(#, >.).(/,

)".).()#, )).).()!7

). (o not use such areas as P rooms 617. ategory 1 6$1$: D./.(7

/. (o not use a room with a through-the-wall ventilation unit as an $11 room

unless it can be demonstrated that all required $11 engineering controls are met

61,27. ategory16$1$.D./.7

. onduct an infection-control ris9 assessment 61*$7 and provide an adequate

number of $11 and P rooms 6if required7 or other areas to meet the needs of

the patient population 61,$,>,;,1>,1=, $?,2,


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systems to maintain filtration, constant $2, and pressure differentials in

P rooms, $11 rooms, operating rooms, and other critical-care areas

61,>,2>7. ategory 1 6$1$: !.), !,/7

. For areas not served by installed emergency ventilation and bac9up systems,use portable units and monitor ventilation parameters and patients in those

areas 67. ategory 11

A. oordinate system startups with infection-control staff to protect patients in

P rooms from bursts of fungal spores 61,,>,2>7. ategory 1 6$1$: !.),

!,/7

!. $llow sufficient time for $2 to clean the air once the system is operational

6able )7 61,7. ategory 1 6$1$: !.), !,/7

?. 2=$ systems serving offices and administrative areas may be shut down forenergy conservation purposes, but the shutdown must not alter or adversely

affect pressure differentials maintained in laboratories or critical-care areas

with specific ventilation requirements 6i.e., P rooms, $11 rooms, operating

rooms7. ategory 11

&. henever possible, avoid inactivating or shutting down the entire 2=$

system, especially in acute-care facilities. ategory 11

. henever feasible, design and install fi


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demolition activities to ensure the health and safety of immunocompromised

patients 6$>,9>))9=7. ategory 18

).;sing active surveillance, monitor for airborne infections in

immunocompromised patients 6$>,>,9>,9;7. ategory 18

/. Periodically review the facility5s microbiologic, histopathologic, and

postmortem data to identify additional cases 6$>,>,9>,9;7. ategory 18

. 1f cases of aspergillosis or other health-care--associated airborne fungal

infections occur, aggressively pursue the diagnosis with tissue biopsies and

cultures as feasible 611,1))1,9?,9>))9=7. ategory 18

. 1mplement infection-control measures relevant to construction, renovation,

maintenance, demolition, and repair 61,1


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codes 61,29,2;,2=,99,


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1


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differentials as needed 61,2?,>;7. ategory 18, 1 6$1$: !,)7

. onduct a prospective search for additional cases and intensify retrospective

epidemiologic review of the hospital5s medical and laboratory records

6$>,2;,>=,;?7. ategory 18

A. 1f no epidemiologic evidence of ongoing transmission e,>97. ategory 18

1. 1f no epidemiologic evidence e


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. Provide respiratory protection for severely immunocompromised patients when

they must leave P for diagnostic procedures and other activities3 consult the

most recent revision of (5s uideline for Prevention of Health)"are))

Associated Pneumonia for information regarding the appropriate type of

respiratory protection. 6$>,>7. ategory 11

(. 1ncorporate ventilation engineering specifications and dust-controlling

processes into the planning and construction of new P units 6Figure )7.

ategory 18, 1

). 1nstall central or point-of-use 2P$ filters for supply 6incoming7 air

61,$,$>,2;,9?, ;?,;$,;9,=9))1?$7. ategory 18, 1 6$1$: !.), !./, D./.(7

/. nsure that rooms are well-sealed by )7 properly constructing windows,

doors, and inta9e and e,22 1?? 1?17.

ategory 18, 1 6$1$: D./.(7

. =entilate the room to maintain )/ $2 61,$>,>,1?? 1?1 1?7. ategory 1

6$1$: D./.(7

A. &ocate air supply and e,1?? 1?17. ategory 18, 1 6$1$: able D,/7

. aintain airflow patterns and monitor these on a daily basis by using

permanently installed visual means of detecting airflow in new or renovated

construction, or by using other visual

methods 6e.g., flutter strips or smo9e tubes7 in e


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industrial-grade 2P$ filters to enhance filtration of spores in the room 67.

ategory 11

E. aintain bac9up ventilation equipment 6e.g., portable units for fans or filters7for emergency provision of required ventilation for P areas and ta9e

immediate steps to restore the fi,2>7. ategory 1

6$1$: !,)7

I, Infection-Control and ,entilation Reuirements for AII Rooms

$. 1ncorporate certain specifications into the planning and construction or

renovation of $11 units 61,2,1?? 1?1 1?27 6Figure 7. ategory 18, 1

). aintain continuous negative air pressure 6/,! Pa K",") inch water gaugeM7 in

Orelation to the air pressure in the corridor3 monitor air pressure periodically,preferably daily, with

audible manometers or smo9e tubes at the door 6for e


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surrounding spaces with an e


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. ?eep operating room doors closed e 1$;7.

ategory 18

8. Follow precautionary procedures for infectious 8 patients who also require

emergency surgery 62,1$= 1?7. ategory 18, 1

). ;se an 0>! respirator approved by the 0ational 1nstitute for Cccupational

'afety and 2ealth without e ode of Federal *egulations

KF*M )>)".)A,)>7

/. 1ntubate the patient in either the $11 room or the operating room3 if

intubating the patient in the operating room, do not allow the doors to open

until >> of the airborne contaminantsare removed 6able )7 62,11>7. ategory 18

. hen anesthetiBing a patient with confirmed or suspected 8, place a

bacterial filter between the anesthesia circuit and patient5s airway to prevent

contamination of anesthesia

equipment or discharge of tubercle bacilli into the ambient air 6 1? 1$7.

ategory 18

A. 7. ategory

18

!. 1f the patient has to be e> of airborne particles from the air 6able )7, because

e7. ategory 18

. ;se portable, industrial-grade 2P$ filters temporarily for supplemental air

cleaning during intubation and e7. ategory 11

). Position the units appropriately so that all room air passes through the filter3

obtain engineering consultation to determine the appropriate placements 627.

ategory 11/. 'witch the portable unit off during the surgical procedure. ategory 11

. Provide fresh air as per ventilation standards for operating rooms3 portable

units do not meet the requirements for the number of fresh $2 6 1,,17.

ategory 11

(. 1f possible, schedule 8 patients as the last surgical cases of the day to

ma


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F. aintain bac9up ventilation equipment 6e.g., portable units for fans or filters7

for emergency ventilation of operating rooms, and ta9e immediate steps to

restore the fi,11,127. ategory 18, 1 6$1$: !,)7

,I .ther Potential Infectious Aerosol Ha/ards in Health-Care Facilities

$. 1n settings where surgical lasers are used, wear appropriate personal protective

equipment 6PP7, including 0>! or 0)"" respirators, to minimiBe e


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6'tates3 $'2*$: )/:/"""7

8. 1f the hot water temperature can be maintained at )/AQF 6!)Q7, e


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disruption in service or a cross-connection with sewer lines has occurred.

). (econtaminate the system when the fewest occupants are present in the

building 6e.g., nights or wee9ends7 6$>,197. ategory 1 6$'2*$: )/:/"""7

/. 1f using high-temperature decontamination, raise the hot-water temperature

to )"QF--)D"QF 6D)Q--DDQ7 and maintain that level while progressively

flushing each outlet around the system for ! minutes 6$>,197. ategory 1

6$'2*$: )/:/"""7

. 1f using chlorination, add enough chlorine, preferably overnight, to achieve a

free chlorine residual of / mgG& 6/ ppm7 throughout the system 6197.

ategory 1 6$'2*$:/"""7

a. Flush each outlet until chlorine odor is detected.

b. aintain the elevated chlorine concentration in the system for / 6but H/A

hrs7.

A. ;se a thorough flushing of the water system instead of chlorination if a

highly chlorine-resistant microorganism 6e.g., "rptosporidium spp.7 is

suspected as the water contaminant. ategory 11

F. Flush and restart equipment and fi


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ategory 11

/. 1f hands are not visibly soiled or contaminated with proteinaceous material,

include an alcohol-based hand rub in the hand hygiene process )7 before

performing invasive procedures3

/7 before and after each patient contact3 and 7 whenever hand hygiene is

indicated 612


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for Controllin' 0ater%orne+ Health-Care--Associated 1e'ionnaires Disease

$. hen using a pulse or one-time decontamination method, superheat the water

by flushing each outlet for ! minutes with water at )" QF--)D"QF 6D)Q--DDQ7

or hyperchlorinate the system by flushing all outlets for ! minutes with watercontaining / mgG& 6/ ppm7 free residual chlorine using a chlorine-based

product registered by the P$ for water treatment 6e.g., sodium hypochlorite

Kchlorine bleachM7 619,199,1


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disease, and perform laboratory diagnostic tests for legionellosis on suspected

cases, especially in patients at ris9 who do not require a P for care 6e.g.,

patients receiving systemic steroids3 patients aged ! years3 or patients with

chronic underlying disease 6e.g., diabetes mellitus, congestive heart failure, or

chronic obstructive lung disease7 6$>,1


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superheating and hyperchlorination 6$>,$1?,$117.atNgorie 18

E. 1f an environmental source is not identified during a &egionnaires disease

outbrea9, continue surveillance for new cases for / months. ither defer

decontamination pending identification of the source of 6eionella spp. orproceed with decontamination of the hospital5s water distribution system, with

special attention to areas involved in the outbrea9. ategory 11

2. 0o recommendation is offered regarding routine culturing of water systems in

health-care facilities that do not have patient-care areas 6i.e., P or transplant

units7 for persons at high ris9 for 6eionella spp. infection 6see $ppendi


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solid-organ transplant units can be performed as part of a comprehensive

strategy to prevent &egionnaires disease in these units 6>,192 1;= $1;7.

ategory 11

. 0o recommendation is offered regarding the optimal methodology 6i.e.,frequency or number of sites7 for environmental surveillance cultures in 2'

or solid-organ transplant units. ;nresolved issue

A. 1n areas with patients at ris9, when6eionellaspp. are not detectable in unit

water, remove, clean, and disinfect shower heads and tap aerators monthly by

using a chlorine-based, P$-registered product. 1f an P$-registered chlorine

disinfectant is not available, use a chlorine bleach solution 6!""--)! ppm

K):)"" vGv dilutionM7 619 1;>7. ategory 11

. 1f6eionellaspp. are determined to be present in the water of a transplant unit,

implement certain measures until 6eionellaspp. are no longer detected byculture.

). (econtaminate the water supply as outlined previously 6ater: 1=7

6$>,>,19 1,$1=7. ategory 18

. *estrict severely immunocompromised patients from ta9ing showers

6>,$1=7. ategory 18

A. ;se water that is not contaminated with6eionellaspp. for 2' patients5

sponge baths 6>,$1=7. ategory 18

!. Provide patients with sterile water for tooth brushing, drin9ing, and for

flushing nasogastric tubing during legionellosis outbrea9s 6>,$1=7. ategory

18

(. (o not use large-volume room air humidifiers that create aerosols 6e.g., by

=enturi principle, ultrasound, or spinning dis97 unless they are sub%ected tohigh-level disinfection and filled only with sterile water 6$>,>,$?1 $$?7.

ategory 18

,II Coolin' $o2ers and Evaorative Condensers

$. hen planning construction of new health-care facilities, locate cooling towers

so that the drift is directed away from the air-inta9e system, and design the

towers to minimiBe the volume of aerosol drift 619 $? $$17. ategory 1

6$'2*$ )/-/"""7

8. 1mplement infection-control procedures for operational cooling towers 619
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$? $$$7. ategory 1 6$'2*$ )/-/"""7

). 1nstall drift eliminators 619 $? $$$7. ategory 1 6$'2*$ )/-/"""7

/. ;se an effective P$-registered biocide on a regular basis 6197. ategory1 6$'2*$ )/-/"""7

. aintain towers according to manufacturers5 recommendations, and 9eep

detailed maintenance and infection-control records, including environmental

test results from legionellosis outbrea9 investigations 6197. ategory 1

6$'2*$ )/-/"""7

. 1f cooling towers or evaporative condensers are implicated in health-care--

associated legionellosis, decontaminate the cooling-tower system 61== $? $$1

$$7. ategory 18

,III Dialysis 0ater 3uality and Dialysate

$. $dhere to current $$1 standards for quality-assurance performance of

devices and equipment used to treat, store, and distribute water in hemodialysis

centers 6both acute and maintenance KchronicM settings7 and for the preparation

of concentrates and dialysate 6$$2))$97. ategory 1$, 1 6$$1: $merican

0ational 'tandards 1nstitute K$0'1MG$$1 *(!:)>>/, $0'1G$$1

*(AD:)>>7

8. 0o recommendation is offered regarding whether more stringent requirements

for water quality should be imposed in hemofiltration and hemodiafiltration.

;nresolved issue

. onduct microbiologic testing specific to water in dialysis settings

6$$=,$?,$>, *(/:/"")7

). Perform bacteriologic assays of water and dialysis fluids at least once a

month and during outbrea9s by using standard quantitative methods 6$>/, $0'1G$$1 *(AD:)>>7

. nsure that water does not e>7
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(. (isinfect water distribution systems in dialysis settings at least wee9ly 6$$


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disconnected before anticipated lengthy water disruptions. ategory 11

E. 1nstall proper air gaps where the condensate lines meet the waste lines.

ategory 11.

2. onduct microbiologic sampling of ice, ice chests, and ice-ma9ing machines

and dispensers where indicated during an epidemiologic investigation 6$22 $2;

$2=7. ategory 18

4 Hydrotheray $an5s and Pools

$. (rain and clean hydrotherapy equipment 6e.g., 2ubbard tan9s, tubs, whirlpools,

whirlpool spas, or birthing tan9s7 after each patient5s use, and disinfect

equipment surfaces and components by using an P$-registered product in

accordance with the manufacturer5s instructions. ategory 11

8. 1n the absence of an P$-registered product for water treatment, add sodium

hypochlorite to the water:

). aintain a )!-ppm chlorine residual in the water of small hydrotherapy

tan9s, 2ubbard tan9s, and tubs 6$9?7. ategory 11

/. aintain a /--!-ppm chlorine residual in the water of whirlpools and

whirlpool spas 6$917. ategory 11

. 1f the p2 of the municipal water is in the basic range 6e.g., when chloramineis used as the primary drin9ing water disinfectant in the community7, consult

the facility engineer regarding the possible need to ad%ust the p2 of the water

to a more acidic level before disinfection, to enhance the biocidal activity of the

chlorine 6$9$7. ategory 11

. lean and disinfect hydrotherapy equipment after using tub liners. ategory 11

(. lean and disinfect inflatable tubs unless they are single-use equipment.

ategory 11

. 0o recommendation is offered regarding the use of antiseptic chemicals 6e.g.,chloramine-7 in the water during hydrotherapy sessions. ;nresolved issue

F. onduct a ris9 assessment of patients before their use of large hydrotherapy

pools, deferring patients with draining wounds or fecal incontinence from pool

use until their condition resolves. ategory 11

E. For large hydrotherapy pools, use p2 and chlorine residual levels appropriate

for an indoor pool as provided by local and state health agencies. ategory 1

6'tates7

2. 0o recommendation is offered regarding the use in health-care settings ofwhirlpool or spa equipment manufactured for home or recreational use.


33/93

;nresolved issue

4I !iscellaneous !edical Euiment Connected to 0ater *ystems

$. lean, disinfect, and maintain $* equipment according to the manufacturer5sinstructions and relevant scientific literature to prevent inadvertent

contamination of endoscopes and bronchoscopes with waterborne

microorganisms 6$9))$9>7. ategory 18

). o rinse disinfected endoscopes and bronchoscopes, use water of the highest

quality practical for the system5s engineering and design 6e.g., sterile water or

bacteriologically filtered water Kwater filtered through ",)--",/-Im filtersM7

6$92,$9


34/93

8. (o not use high-level disinfectantsGliquid chemical sterilants for disinfection of

either noncritical instruments and devices or any environmental surfaces3 such

use is counter to label instructions for these to))$>;7.

ategory 1 6Food and (rug $dministration KF($M: /) F* #").!, #"D.#D.e7

. Follow manufacturers5 instructions for cleaning and maintaining noncritical

medical equipment. ategory 11

(. 1n the absence of a manufacturer5s cleaning instructions, follow certain

procedures.

). lean noncritical medical equipment surfaces with a detergentGdisinfectant.

his may be followed by an application of an P$-registered hospital

disinfectant with or without a tuberculocidal claim 6depending on the nature of

the surface and the degree of contamination7, in accordance with germicide

label instructions 6$>27. ategory 11

/. (o not use alcohol to disinfect large environmental surfaces 6$>7. ategory

11

. ;se barrier protective coverings as appropriate for noncritical surfaces that

are )7 touched frequently with gloved hands during the delivery of patient care3

/7 li9ely to become contaminated with blood or body substances3 or 7 difficult

to clean 6e.g., computer 9eyboards7 6$=7. ategory 11

). ;se a one-step process and an P$-registered hospital detergentGdisinfectant

designed for general house9eeping purposes in patient-care areas where )7

uncertainty e2 $;? $;17. ategory 11

/. (etergent and water are adequate for cleaning surfaces in nonpatient-careareas 6e.g., administrative offices7. ategory 11

. lean and disinfect high-touch surfaces 6e.g., door9nobs, bed rails, light

switches, and surfaces in and around toilets in patients5 rooms7 on a more

frequent schedule than minimal-touch house9eeping surfaces. ategory 11

A. lean walls, blinds, and window curtains in patient-care areas when they are

visibly dusty or soiled 6$>?,$;$))$;27. ategory 11

F. (o not perform disinfectant fogging in patient-care areas 6$>? $;97. ategory

18
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E. $void large-surface cleaning methods that produce mists or aerosols, or

disperse dust in patient-care areas 6>,2;,91,>7. ategory 18

2. Follow proper procedures for effective uses of mops, cloths, and solutions.

ategory 11

). Prepare cleaning solutions daily or as needed, and replace with fresh solution

frequently according to facility policies and procedures 6$;? $;17. ategory 11

/. hange the mop head at the beginning of each day and also as required by

facility policy, or after cleaning up large spills of blood or other body

substances. ategory 11

. lean mops and cloths after use and allow to dry before reuse3 or use single-

use, disposable mop heads and cloths 6$;$,$;


36/93

or incubators during an infant5s stay 6$>1,$=?))$=$7. ategory 18

/. *inse disinfectant-treated surfaces, especially those treated with phenolics,

with water 6$=?))$=$7. ategory 18

C. hen using phenolic disinfectants in neonatal units, prepare solutions to

correct concentrations in accordance with manufacturers5 instructions, or use

premi1,$=?))$=$7. ategory 18, 1 6P$: D ;' R ) et

seq.7

II Cleanin' *ills of lood and ody *u%stances

$. Promptly clean and decontaminate spills of blood or other potentially infectious

materials 6$=))??7. ategory 18, 1 6C'2$: /> F* ) >)",) R d.A.ii.$7

8. Follow proper procedures for site decontamination of spills of blood or blood-containing body fluids 6$=))??7. ategory 1 6C'2$: /> F* ) >)",) R

d.A.ii.$7

). ;se protective gloves and other PP appropriate for this tas9 6$=7.

ategory 1 6C'2$: /> F* ) >)",) R d..i, ii7

/. 1f the spill contains large amounts of blood or body fluids, clean the visible

matter with disposable absorbent material, and discard the used cleaning

materials in appropriate, labeled containers 6$= $=; $== ?1 ?$7. ategory

1 6C'2$: /> F* ) >)",) R d.A.iii.87

. 'wab the area with a cloth or paper towels moderately wetted with

disinfectant, and allow the surface to dry 6$= ?17. ategory 1 6C'2$: />

F* ) >)",) R d.A.ii.$7

. ;se germicides registered by the P$ for use as hospital disinfectants and

labeled tuberculocidal or registered germicides on the P$ &ists ( and 6i.e.,

products with specific label claims for 21= or hepatitis 8 virus K28=M7 in

accordance with label instructions to decontaminate spills of blood and other

body fluids 6$= ?1 ?7. ategory 1 6C'2$ /> F* ) >)",) R d.A.ii. $memorandum /G/#G>D3 compliance document KP&M /-/,AA( K))G>>M7

(. $n P$-registered sodium hypochlorite product is preferred, but if such

products are not available, generic sodium hypochlorite solutions 6e.g.,

household chlorine bleach7 may be used.

). ;se a ):)"" dilution 6!""--)! ppm available chlorine7 to decontaminate

nonporous surfaces after cleaning a spill of either blood or body fluids in

patient-care settings 6?1 ?27. ategory 18

/. 1f a spill involves large amounts of blood or body fluids, or if a blood orculture spill occurs in the laboratory, use a ):)" dilution 6!,"""-- )!" ppm


37/93

available chlorine7 for the first application of germicide before cleaning 6$>=

?17. ategory 18

III Caretin' and Cloth Furnishin's

$. =acuum carpeting in public areas of health-care facilities and in general

patient-care areas regularly with well-maintained equipment designed to

minimiBe dust dispersion 6$;?7. ategory 11

8. Periodically perform a thorough, deep cleaning of carpeting as determined by

facility policy by using a method that minimiBes the production of aerosols and

leaves little or no residue 6227. ategory 11

. $void use of carpeting in high-traffic Bones in patient-care areas or where spills

are li9ely 6e.g., burn therapy units, operating rooms, laboratories, or intensive

care units7 622 ?9 ? F* ) >)",) R d.A.ii.$, interpretation7

/. 1f a spill occurs on carpet tiles, replace any tiles contaminated by blood and

body fluids or body substances 6?>7. ategory 1 6C'2$ /> F* ) >)",) R

d.A.ii interpretation7

. horoughly dry wet carpeting to prevent the growth of fungi3 replace carpeting

that remains wet after D/ hours 6>,1


38/93

ategory 11

. 1f upholstered furniture in a patient5s room requires cleaning to remove

visible soil or body substance contamination, move that item to a maintenance

area where it can be adequately cleaned with a process appropriate for thetype of upholstery and nature of the soil. ategory 11

I, Flo2ers and Plants in Patient-Care Areas

$. Flowers and potted plants need not be restricted from areas for

immunocompetent patients 6?;))117. ategory 11

8. (esignate care and maintenance of flowers and potted plants to staff not

directly involved with patient care 6?=7. ategory 11

. 1f plant or flower care by patient-care staff is unavoidable, instruct the staff towear gloves when handling plants and flowers and perform hand hygiene after

glove removal 6?=7. ategory 11

(. (o not allow fresh or dried flowers, or potted plants, in patient-care areas for

immunosuppressed patients 6>,91 ?; 1$7. ategory 11

, Pest Control

$. (evelop pest-control strategies, with emphasis on 9itchens, cafeterias,

laundries, central sterile supply areas, operating rooms, loading doc9s,construction activities, and other areas prone to infestations 61))197.

ategory 11

8. 1nstall screens on all windows that open to the outside3 9eep screens in good

repair 6127. ategory 18

. ontract for routine pest control service by a credentialed pest-control

specialist who will tailor the application to the needs of a health-care facility

6197. ategory 11

(. Place laboratory specimens 6e.g., fi7. ategory 11

,I *ecial Patho'ens

$. ;se appropriate hand hygiene, PP 6e.g., gloves7, and isolation precautions

during cleaning and disinfecting procedures 6122,1;,1=7. ategory 18

8. ;se standard cleaning and disinfection protocols to control environmental

contamination with antibiotic-resistant, gram-positive cocci 6e.g., methicillin-

resistant %taphlococcus aureus, vancomycin intermediate sensitive

%taphlococcus aureus, or vancomycin-resistant /nterococcus K=*M761;,$?))$$7. ategory 18
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). Pay close attention to cleaning and disinfection of high-touch surfaces in

patient-care areas 6e.g., bed rails, carts, charts, bedside commodes, bed rails,

door9nobs, or faucet handles7 61;,$?))$$7. ategory 18

/. nsure compliance by house9eeping staff with cleaning and disinfection

procedures 61;,$?))$$7. ategory 18

. ;se P$-registered chemical germicides appropriate for the surface to be

disinfected 6e.g., either low- or intermediate-level disinfection7 as specified by

the manufacturer5s instructions 6$>1,$$))$>7. ategory 18, 1 6P$: D

;' R ) et seq.7

A. hen contact precautions are indicated for patient care, use disposable

patient-care items 6e.g., blood pressure cuffs7 wherever possible to minimiBe

cross-contamination with multiple-resistant microorganisms 6$;7. ategory18

!. Follow these same surface-cleaning and disinfecting measures for managing

the environment of =*'$ patients 6$?))$$ $>7. ategory 11

. nvironmental-surface culturing can be used to verify the efficacy of hospital

policies and procedures before and after cleaning and disinfecting rooms that

house patients with =* 61;,$=))7. ategory 11

). Cbtain prior approval from infection-control staff and the clinical laboratorybefore performing environmental-surface culturing. ategory 11

/. 1nfection-control staff, with clinical laboratory staff consultation, must

supervise all environmental culturing. ategory 11

(. horoughly clean and disinfect environmental and medical equipment surfaces

on a regular basis by using P$-registered disinfectants in accordance with

manufacturers5 instructions 6$>1,$>2,1=, 27. ategory 18, 1 6P$: D ;'

R ) et seq.7

. $dvise families, visitors, and patients regarding the importance of handhygiene to minimiBe the spread of body substance contamination 6e.g.,

respiratory secretions or fecal matter7 to surfaces 6$>27. ategory 11

F. (o not use high-level disinfectants 6i.e., liquid chemical sterilants7 on

environmental surfaces3 such use is inconsistent with label instructions because

of the to? $> $>2 $>;7. ategory 1 6F($: /) F*

#").!, #"D.#D.e7

E. 8ecause no P$-registered products are specific for inactivating "lostridium

difficile spores, use hypochlorite-based products for disinfection of

environmental surfaces in accordance with guidance from the scientificliterature in those patient-care areas where surveillance and epidemiology
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40/93

indicate ongoing transmission of ". difficile6$>2 1= 27. ategory 11

2. 0o recommendation is offered regarding the use of specific P$-registered

hospital disinfectants with respect to environmental control of ". difficile.

;nresolved issue

1. $pply standard cleaning and disinfection procedures to control environmental

contamination with respiratory and enteric viruses in pediatric-care units and

care areas for immunocompromised patients 6$;? 97. ategory 1 6P$: D

;' R ) et seq.7

J. lean surfaces that have been contaminated with body substances3 perform

low- to intermediate-level disinfection on cleaned surfaces with an P$-

registered disinfectant in accordance with the manufacturer5s instructions 6$>1

$= 97. ategory 1 6C'2$: /> F* ) >)",) R d.A.ii.$3 P$: D ;' R )

et seq.7

?. ;se disposable barrier coverings as appropriate to minimiBe surface

contamination. ategory 11

&. (evelop and maintain cleaning and disinfection procedures in patient-care

areas to control environmental contamination with agents of reutBfeldt-Ja9ob

disease 6J(7, for which no P$-registered product e


41/93

contamination to autopsy tables and surfaces 62? 2$7. ategory 11

. ;se standard procedures for containment, cleaning, and decontamination of

blood spills on surfaces as previously described 6nvironmental 'ervices: 117

6$=7. ategory 1 6C'2$: /> F* ) >)",) R d.A.ii.$7

). ear PP appropriate for a surface decontamination and cleaning tas9 6$=

F* ) >)",) R

d..viii7

Recommendations ---Environmental *amlin'

I General Information

$. (o not conduct random, undirected, microbiologic sampling of air, water, and

environmental surfaces in health-care facilities 6$>? 27. ategory 18

8. hen indicated, conduct microbiologic sampling as part of an epidemiologic

investigation or during assessment of haBardous environmental conditions to

detect contamination or verify abatement of a haBard 6$>? 27. ategory 18

. &imit microbiologic sampling for quality assurance purposes to )7 biologic

monitoring of steriliBation processes3 /7 monthly cultures of water anddialysate in hemodialysis units3 and 7 short-term evaluation of the impact of

infection-control measures or changes in infection-control protocols 6$>? 27.

ategory 18

II Air+ 0ater+ and Environmental *urface *amlin'

$. hen conducting any form of environmental sampling, identify e7. ategory 11

8. 'elect a high-volume air sampling device if anticipated levels of microbialairborne contamination are e7. ategory 11


42/93

F. hen environmental samples and patient specimens are available for

comparison, perform the laboratory analysis on the recovered microorganisms

down to the species level at a minimum, and beyond the species level if

possible 627. ategory 11

Recommendations ---1aundry and eddin'

I Emloyer Resonsi%ilities

$. mployers must launder wor9ers5 personal protective garments or uniforms that

are contaminated with blood or other potentially infectious materials 6$=7.

ategory 1 6C'2$: /> F* ) >)",) R d..iv7

II 1aundry Facilities and Euiment

$. aintain the receiving area for contaminated te F* ) >)",) R d.A.iv7

). (o not sort or prerinse contaminated te F* ) >)",) R

d.A.iv7


43/93

. 1dentify bags or containers for contaminated te


44/93

,I *ecial 1aundry *ituations

$. ;se steriliBed te))

>97. ategory 11

. ;se caution when considering use of antimicrobial mattresses, te));$7. ategory 18

8. lean and disinfect mattress covers by using P$-registered disinfectants that

are compatible with the materials to prevent the development of tears, crac9s,

or holes in the covers 6>>));$7. ategory 18

. aintain the integrity of mattress and pillow covers. ategory 11

). *eplace mattress and pillow covers if they become torn or otherwise in need

of repair. ategory 11

/. (o not stic9 needles into a mattress through the cover. ategory 11

(. lean and disinfect moisture-resistant mattress covers between patient use by

using an P$-registered product 6>>));$7. ategory 18

. 1f using a mattress cover completely made of fabric, change these covers and

launder between patient use 6>>));$7. ategory 18

F. &aunder pillow covers and washable pillows in the hot-water cycle between

patients or when they become contaminated with body substances 6;$7.

ategory 18


45/93

,III Air-Fluidi/ed eds

$. Follow manufacturers5 instructions for air-fluidiBed bed maintenance and

decontamination. ategory 11

8. hange the polyester filter sheet at least wee9ly or as indicated by the

manufacturer 6;));?7. ategory 11

). ash hands with soap and water, especially if hands are visibly soiled or

contaminated with proteinaceous material 612


46/93

). *emove the animal permanently from these programs 6=17. ategory 11

/. *eport the incident promptly to appropriate authorities 6e.g., infection-

control staff, animal program coordinator, or local animal control personnel7

6=17. ategory 11

. Promptly clean and treat scratches, bites, or other brea9s in the s9in.

ategory 11

F. Perform an 1*$ and wor9 actively with the animal handler before conducting

an animal-assisted activity or therapy to determine whether the session should

be held in a public area of the facility or in individual patient rooms 6 =1 =27.

ategory 11

E. a9e precautions to mitigate allergic responses to animals. ategory 11

). inimiBe shedding of animal dander by bathing animals H/A hours before a

visit 6=17. ategory 11

/. Eroom animals to remove loose hair before a visit, or use a therapy animal

cape 6=97. ategory 11

2. ;se routine cleaning protocols for house9eeping surfaces after therapy

sessions. ategory 11

1. *estrict resident animals, including fish in tan9s, from access to patient-care

areas, food-preparation areas, dining areas, laundry, central sterile supply areas,

sterile and clean supply storage areas, medication preparation areas, operating

rooms, isolation areas, and P areas. ategory 11

J. stablish a facility policy for regular cleaning of fish tan9s, rodent cages, and

bird cages, and any other animal dwellings and assign this cleaning tas9 to a

nonpatient-care staff member3 avoid splashing tan9 water or contaminating

environmental surfaces with animal bedding. ategory 11

III Protective !easures for Immunocomromised Patients

$. $dvise patients to avoid contact with animal feces, saliva, urine, or solid litter

bo< material 6=


47/93

patients 6=27. ategory 11

. 0o recommendation is offered regarding permitting pet visits to terminally ill

immunocompromised patients outside their P units. ;nresolved issue.

I, *ervice Animals

$. $void providing facility access to nonhuman primates and reptiles as service

animals 6=,=>7. ategory 18

8. $llow service animals access to the facility in accordance with the $mericans

with (isabilities $ct of )>>", unless the presence of the animal creates a direct

threat to other persons or a fundamental alteration in the nature of services 6 ;=

=;7. ategory 1 6;.'. (epartment of Justice: /# F* R ,7

. hen a decision must be made regarding a service animal5s access to anyparticular area of the health-care facility, evaluate the service animal, patient,

and health-care situation on a case-by-case basis to determine whether

significant ris9 of harm e


48/93

. 'chedule the animal procedure for the last procedure of the day in the area, at a

time when human patients are not scheduled to be in the vicinity. ategory 11

(. $dhere strictly to standard precautions. ategory 11

. lean and disinfect environmental surfaces thoroughly by using an P$-

registered product in the room after the animal has been removed. ategory 11

F. $llow sufficient $2 to clean the air and help remove airborne dander,

microorganisms, and allergens 6able )7. ategory 11

E. lean and disinfect using P$-registered products or steriliBe equipment that

has been in contact with the animal3 or use disposable equipment. ategory 11

2. 1f reusable medical or surgical instruments are used in an animal procedure,

restrict future use of these instruments to animals only. ategory 11

,I Research Animals in Health-Care Facilities

$. ;se animals obtained from quality stoc9, or quarantine incoming animals to

detect Boonotic diseases. ategory 11

8. reat sic9 animals or remove them from the facility. ategory 11

. Provide prophylactic vaccinations, as available, to animal handlers and contacts

at high ris9. ategory 11

(. nsure proper ventilation through appropriate facility design and location

6==7. ategory 1 6;.'. (epartment of $griculture K;'($M: D ;' /))7

). ?eep animal rooms at negative pressure relative to corridors 6==7. ategory

1 6;'($: D ;' /))7

/. Prevent air in animal rooms from recirculating elsewhere in the health-care

facility 6==7. ategory 1 6;'($: D ;' /))7

. ?eep doors to animal research rooms closed. ategory 11

F. *estrict access to animal facilities to essential personnel. ategory 11

E. stablish employee occupational health programs specific to the animal

research facility, and coordinate management of poste F* )>)".)"".)/-)>7

2. (ocument standard operating procedures for the unit 62??7. ategory 1
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49/93

6(22': 88&7

1. onduct routine employee training on wor9er safety concerns relevant to the

animal research facility 6e.g., wor9ing safely with animals, animal handling7

62?? 2?17. ategory 1 6(22': 88&3 C'2$: /> F* )>)".)"".)/--)>7

J. ;se precautions to prevent development of animal-induced asthma in animal

wor9ers 62??7. ategory 1 6(22': 88&7

Recommendations --- Re'ulated !edical 0astes

I Cate'ories of Re'ulated !edical 0aste

$. (esignate the following as ma%or categories of medical waste that require

special handling and disposal precautions: )7 microbiology laboratory wastes

Ke.g., cultures and stoc9s of microorganismsM3 /7 bul9 blood, blood products,

blood, and bloody body fluid specimens3 7 pathology and anatomy waste3 and

A7 sharps Ke.g., needles and scalpelsM 6$>?7. ategory 11

8. onsult federal, state, and local regulations to determine if other waste items

are considered regulated medical wastes 6$= 2?$ 2?7. ategory 1 6'tates3

C'2$: /> F* ) >)",) R g./,)3 (epartment of ransportation K(CM: A> F*

)D)-)#"3 ;.'. Postal 'ervice: C/,#7

II Disosal Plan for Re'ulated !edical 0astes

$. (evelop a plan for the collection, handling, predisposal treatment, and terminal

disposal of regulated medical wastes 6$= 2?27. ategory 1 6'tates3 C'2$:

/> F* ) >)",) R g./.i7

8. (esignate a person or persons as responsible for establishing, monitoring,

reviewing, and administering the plan. ategory 11

III Handlin'+ $ransortin'+ and *torin' Re'ulated !edical 0astes

$. 1nform personnel involved in handling and disposal of potentially infective

waste of possible health and safety haBards3 ensure that they are trained inappropriate handling and disposal methods 6$=7. ategory 1 6C'2$: />

F* ) >)",) R g./.i7

8. anage the handling and disposal of regulated medical wastes generated in

isolation areas by using the same methods used for regulated medical wastes

from other patient-care areas 6$>?7. ategory 11

. ;se proper sharps disposal strategies 6$=7. ategory 1 6C'2$: /> F* )

>)",) R d.A.iii.$7

). ;se a sharps container capable of maintaining its impermeability after wastetreatment to avoid subsequent physical in%uries during final disposal 6$=7.


50/93

ategory 1 6C'2$: /> F* ) >)",) R d.A.iii.$7

/. Place disposable syringes with needles, including sterile sharps that are being

discarded, scalpel blades, and other sharp items into puncture-resistant

containers located as close as practical to the point of use 6$=7. ategory 16C'2$: /> F* ) >)",) R d.A.iii.$7

. (o not bend, recap, or brea9 used syringe needles before discarding them

into a container 6< $= 2?97. ategory 1 6C'2$: /> F* ) >)",) R d./.vii

and R d./.vii.$7

(. 'tore regulated medical wastes awaiting treatment in a properly ventilated area

inaccessible to vertebrate pests3 use waste containers that prevent development

of no


51/93

disposal of these agents 62?=7. ategory 1 6(22': A/ F* D/ R D/..i.).iii7

. 'anitary sewers may be used for safe disposal of blood, suctioned fluids,

ground tissues, e? $> >)3)A:>>#--)""/.

. 'treifel $J. (esign and maintenance of hospital ventilation systems and the

prevention of airborne nosocomial infections Khapter #"M. 1n: ayhall, E,

ed. 2ospital epidemiology and infection control. /nd ed. Philadelphia, P$:

&ippincott illiams and il9ins, )>>>.

A. Pittet (, 2uguenin , (haran ', et al. ;nusual cause of lethal pulmonaryaspergillosis in patients with chronic obstructive pulmonary disease. $m J
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52/93

*espir rit are ed )>>3)!A6/ Pt )7:!A)--A.

!. ;' nvironmental Protection $gency, Cffice of $ir and *adiation, and ;'

(epartment of 2ealth and 2uman 'ervices, 0ational 1nstitute of Cccupational

'afety and 2ealth. 8uilding air quality: a guide for building owners and facilitymanagers. ashington, (: )>>)3 (22' publication 601C'27>)-))A and

P$GA""G)-->)G". $vailable at http:GGwww.cdc.govGnioshGbaqtoc.html.

. *ao +, 8urge 2$, hang J. *eview of quantitative standards and guidelines

for fungi in indoor air. J $ir S aste anage $ssoc )>>3A:#>>-->"#.

D. 8ec9-'aguN , (ooley ', 2utton (, et al. 2ospital outbrea9 of

multidrug-resistant &cobacterium tuberculosis infections: factors in

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