Environmental Infection Control Guidelines

Guidelines for Environmental Infection Control in Health-Care Facilities (2003)
HICPAC Recommendation Categories
Description of HICPAC recommendation categories.
Rank Description
Category IA Strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies.
Category IB Strongly recommended for implementation and supported by certain experimental, clinical, or epidemiologic studies and a strong theoretical rationale.
Category IC Required by state or federal regulation, or representing an established association standard. (Note: Abbreviations for governing agencies and regulatory citations are listed, where appropriate. Recommendations from regulations adopted at state levels are also noted. Recommendations from AIA guidelines cite the appropriate sections of the standard).
Category II Suggested for implementation and supported by suggestive clinical or epidemiologic studies, or a theoretical rationale.
Unresolved Issue No recommendation is offered. No consensus or insufficient evidence exists regarding efficacy.

See updates to this guideline.

  • Interim Measles Infection Control Recommendations
  • C. difficile Update
  • New Categorization Scheme for Recommendations
  • Environmental Fogging
  • Edits and Changes
  • Ebola Virus Disease
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Summary of Recommendations

C. Air

C.I. Air-Handling Systems in Health-Care Facilities
Edit [February 2017]

Edit: An indicates recommendations that were renumbered for clarity. The renumbering does not constitute change to the intent of the recommendations.

Recommendations for air-handling systems by ID number and category.
# Recommendation Category
C.I.A. Use AIA guidelines as minimum standards where state or local regulations are not in place for design and construction of ventilation systems in new or renovated health-care facilities. Ensure that existing structures continue to meet the specifications in effect at the time of construction. (AIA: 1.1.A, 5.4) IC
C.I.B. Monitor ventilation systems in accordance with engineers’ and manufacturers’ recommendations to ensure preventive engineering, optimal performance for removal of particulates, and elimination of excess moisture. (AIA: 7.2, 7.31.D, 8.31.D, 9.31.D, 10.31.D, 11.31.D, EPA guidance) IB, IC
C.I.B.1. Ensure that heating, ventilation, air conditioning (HVAC) filters are properly installed and maintained to prevent air leakages and dust overloads. IB
C.I.B.2. Monitor areas with special ventilation requirements (e.g., AII or PE) for ACH, filtration, and pressure differentials. (AIA: 7.2.C7, 7.2.D6)
  • * Develop and implement a maintenance schedule for ACH, pressure differentials, and filtration efficiencies using facility-specific data as part of the multidisciplinary risk assessment. Take into account the age and reliability of the system.
  • * Document these parameters, especially the pressure differentials.
C.I.B.3. Engineer humidity controls into the HVAC system and monitor the controls to ensure proper moisture removal. (AIA: 7.31.D9)
  • * Locate duct humidifiers upstream from the final filters.
  • * Incorporate a water-removal mechanism into the system.
  • * Locate all duct takeoffs sufficiently down-stream from the humidifier so that moisture is completely absorbed.
C.I.B.4. Incorporate steam humidifiers, if possible, to reduce potential for microbial proliferation within the system, and avoid use of cool mist humidifiers. II
C.I.B.5. Ensure that air intakes and exhaust outlets are located properly in construction of new facilities and renovation of existing facilities. (AIA: 7.31.D3, 8.31.D3, 9.31.D3, 10.31.D3, 11.31.D3)
  • * Locate exhaust outlets >25 ft. from air-intake systems.
  • * Locate outdoor air intakes ≥6 ft. above ground or ≥3 ft. above roof level.
  • * Locate exhaust outlets from contaminated areas above roof level to minimize recirculation of exhausted air.
C.I.B.6. Maintain air intakes and inspect filters periodically to ensure proper operation. (AIA: 7.31.D8) IC
C.I.B.7. Bag dust-filled filters immediately upon removal to prevent dispersion of dust and fungal spores during transport within the facility.
  • * Seal or close the bag containing the discarded filter.
  • * Discard spent filters as regular solid waste, regardless of the area from which they were removed.
C.I.B.8. Remove bird roosts and nests near air intakes to prevent mites and fungal spores from entering the ventilation system. IB
C.I.B.9. Prevent dust accumulation by cleaning air-duct grilles in accordance with facility- specific procedures and schedules when rooms are not occupied by patients. (AIA: 7.31.D10) IC, II
C.I.B.10. Periodically measure output to monitor system function; clean ventilation ducts as part of routine HVAC maintenance to ensure optimum performance. (AIA: 7.31.D10) II
C.I.C. Use portable, industrial-grade HEPA filter units capable of filtration rates in the range of 300–800 ft3/min. to augment removal of respirable particles as needed. II
C.I.C.1. Select portable HEPA filters that can recirculate all or nearly all of the room air and provide the equivalent of ≥12 ACH. II
C.I.C.2. Portable HEPA filter units previously placed in construction zones can be used later in patient-care areas, provided all internal and external surfaces are cleaned, and the filter’s performance verified by appropriate particle testing. II
C.I.C.3. Situate portable HEPA units with the advice of facility engineers to ensure that all room air is filtered. II
C.I.C.4. Ensure that fresh-air requirements for the area are met. II
C.I.D. Follow appropriate procedures for use of areas with through-the-wall ventilation units. (AIA: 8.31.D1, 8.31.D8, 9.31.D23, 10.31.D18, 11.31.D15) IC
C.I.D.1. Do not use such areas as PE rooms. (AIA: 7.2.D3) IC
C.I.D.2. Do not use a room with a through-the-wall ventilation unit as an AII room unless it can be demonstrated that all required AII engineering controls required are met. (AIA: 7.2.C3) IC
C.I.E. Conduct an infection-control risk assessment (ICRA) and provide an adequate number of AII and PE rooms (if required) or other areas to meet the needs of the patient population. (AIA: 7.2.C, 7.2.D) IA, IC
C.I.F. When UVGI is used as a supplemental engineering control, install fixtures
  • * on the wall near the ceiling or suspended from the ceiling as an upper air unit;
  • * in the air-return duct of an AII room; or
  • * in designated enclosed areas or booths for sputum induction.
C.I.G. Seal windows in buildings with centralized HVAC systems and especially with PE areas. (AIA: 7.2.D3) IB, IC
C.I.H. Keep emergency doors and exits from PE rooms closed except during an emergency; equip emergency doors and exits with alarms. II
C.I.I. Develop a contingency plan for backup capacity in the event of a general power failure. (Joint Commission on Accreditation of Healthcare Organizations [JCAHO]: Environment of Care [EC] 1.4) IC
C.I.I.1. Emphasize restoration of proper air quality and ventilation conditions in AII rooms, PE rooms, operating rooms, emergency departments, and intensive care units. (AIA: 1.5.A1; JCAHO: EC 1.4) IC
C.I.I.2. Deploy infection-control procedures to protect occupants until power and systems functions are restored. (AIA: 5.1, 5.2; JCAHO: EC 1.4) IC
C.I.J. Do not shut down HVAC systems in patient-care areas except for maintenance, repair, testing of emergency backup capacity, or new construction. (AIA: 5.1, 5.2.B, C) IB, IC
C.I.J.1. Coordinate HVAC system maintenance with infection-control staff to allow for relocation of immunocompromised patients if necessary. (AIA: 5.1, 5.2) IC
C.I.J.2. Provide backup emergency power and air-handling and pressurization systems to maintain filtration, constant ACH, and pressure differentials in PE rooms, AII rooms, operating rooms, and other critical-care areas. (AIA: 1.5, 5.1, 5.2) IC
C.I.J.3. For areas not served by installed emergency ventilation and backup systems, use portable units and monitor ventilation parameters and patients in those areas. II
C.I.J.4. Coordinate system startups with infection-control staff to protect patients in PE rooms from bursts of fungal spores. (AIA: 5.1, 5.2) IC
C.I.J.5. Allow sufficient time for ACH to clean the air once the system is operational (Appendix B, Table B.1). (AIA: 5.1, 5.2) IC
C.I.K. HVAC systems serving offices and administration areas may be shut down for energy conservation purposes, but the shutdown must not alter or adversely affect pressure differentials maintained in laboratories or critical-care areas with specific ventilation requirements (i.e., PE rooms, AII rooms, operating rooms). II
C.I.L. Whenever possible, avoid inactivating or shutting down the entire HVAC system at one time, especially in acute-care facilities. II
C.I.M. Whenever feasible, design and install fixed backup ventilation systems for new or renovated construction for PE rooms, AII rooms, operating rooms, and other critical care areas identified by ICRA. (AIA: 1.5.A1) IC
C.II. Construction, Renovation, Remediation, Repair, and Demolition
Edit [February 2017]

Edit: These recommendations contain minor edits in order to clarify the meaning. The edits do not constitute any change to the intent of the recommendations.
Indicates a change to the numbering system.
~ Indicates a text change.

Recommendations for construction and demolition by ID number and category.
# Recommendation Category
C.II.A. Establish a multidisciplinary team that includes infection-control staff to coordinate demolition, construction, and renovation projects and consider proactive preventive measures at the inception; produce and maintain summary statements of the team’s activities. (AIA: 5.1) IB, IC
C.II.B. Educate both the construction team and the health-care staff in immunocompromised patient-care areas regarding the airborne infection risks associated with construction projects, dispersal of fungal spores during such activities, and methods to control the dissemination of fungal spores. IB
C.II.C. Incorporate mandatory adherence agreements for infection control into construction contracts, with penalties for noncompliance and mechanisms to ensure timely correction of problems. (AIA: 5.1) IC
C.II.D. Establish and maintain surveillance for airborne environmental disease (e.g., aspergillosis) as appropriate during construction, renovation, repair, and demolition activities to ensure the health and safety of immunocompromised patients. IB
C.II.D.1. Using active surveillance, monitor for airborne fungal infections in immunocompromised patients. IB
C.II.D.2. Periodically review the facility’s microbiologic, histopathologic, and postmortem data to identify additional cases. IB
C.II.D.3. If cases of aspergillosis or other health-care–associated airborne fungal infections occur, aggressively pursue the diagnosis with tissue biopsies and cultures as feasible. IB
C.II.E. Implement infection-control measures relevant to construction, renovation, maintenance, demolition, and repair. (AIA: 5.1, 5.2) IB, IC
C.II.E.1. Before the project gets underway, perform an ICRA to define the scope of the project and the need for barrier measures. (AIA: 5.1)
  • * Determine if immunocompromised patients may be at risk for exposure to fungal spores from dust generated during the project.
  • * Develop a contingency plan to prevent such exposures.
C.II.E.2. Implement infection-control measures for external demolition and construction activities.
  • * Determine if the facility can operate temporarily on recirculated air; if feasible, seal off adjacent air intakes.
  • * If this is not possible or practical, check the low-efficiency (roughing) filter banks frequently and replace as needed to avoid buildup of particulates.
  • * Seal windows and reduce wherever possible other sources of outside air intrusion (e.g., open doors in stairwells and corridors), especially in PE areas.
C.II.E.3. Avoid damaging the underground water distribution system (i.e., buried pipes) to prevent soil and dust contamination of the water. (AIA: 5.1) IB, IC
C.II.E.4. Implement infection-control measures for internal construction activities. (AIA: 5.1, 5.2)
  • * Construct barriers to prevent dust from construction areas from entering patient-care areas; ensure that barriers are impermeable to fungal spores and in compliance with local fire codes.
  • * Block and seal off return air vents if rigid barriers are used for containment.
  • * Implement dust control measures on surfaces and by diverting pedestrian traffic away from work zones.
  • * Relocate patients whose rooms are adjacent to work zones, depending upon their immune status, the scope of the project, the potential for generation of dust or water aerosols, and the methods used to control these aerosols.
C.II.E.5. Perform those engineering and work-site related infection-control measures as needed for internal construction, repairs, and renovations: (AIA: 5.1, 5.2) IB, IC
C.II.E.5.a. Ensure proper operation of the air-handling system in the affected area after erection of barriers and before the room or area is set to negative pressure. IB
C.II.E.5.b. Create and maintain negative air pressure in work zones adjacent to patient-care areas and ensure that required engineering controls are maintained. ~ IB
C.II.E.5.c. Monitor negative air flow inside rigid barriers. ~ IC
C.II.E.5.d. Monitor barriers and ensure the integrity of the construction barriers; repair gaps or breaks in barrier joints. ~ IC
C.II.E.5.e. Seal windows in work zones if practical; use window chutes for disposal of large pieces of debris as needed, but ensure that the negative pressure differential for the area is maintained. ~ IC
C.II.E.5.f. Direct pedestrian traffic from construction zones away from patient-care areas to minimize the dispersion of dust. ~ IB
C.II.E.5.g. Provide construction crews with
  • * designated entrances, corridors, and elevators whenever practical;
  • * essential services [e.g., toilet facilities], and convenience services [e.g., vending machines];
  • * protective clothing [e.g., coveralls, footgear, and headgear] for travel to patient-care areas; and
  • * a space or anteroom for changing clothing and storing equipment.
~ IB
C.II.E.5.h. Clean work zones and their entrances daily by
  • * wet-wiping tools and tool carts before their removal from the work zone;
  • * placing mats with tacky surfaces inside the entrance; and
  • * covering debris and securing this covering before removing debris from the work zone.
~ IB
C.II.E.5.i. In patient-care areas, for major repairs that include removal of ceiling tiles and disruption of the space above the false ceiling, use plastic sheets or prefabricated plastic units to contain dust; use a negative pressure system within this enclosure to remove dust; and either pass air through an industrial grade, portable HEPA filter capable of filtration rates ranging from 300–800 ft3/min., or exhaust air directly to the outside. ~ IB
C.II.E.5.j. Upon completion of the project, clean the work zone according to facility procedures, and install barrier curtains to contain dust and debris before removal of rigid barriers. ~ IB
C.II.E.5.k. Flush the water system to clear sediment from pipes to minimize waterborne microorganism proliferation. ~ IB
C.II.E.5.l. Restore appropriate ACH, humidity, and pressure differential; clean or replace air filters; dispose of spent filters. ~ IC
C.II.F. Use airborne-particle sampling as a tool to evaluate barrier integrity. II
C.II.G. Commission the HVAC system for newly constructed health-care facilities and renovated spaces before occupancy and use, with emphasis on ensuring proper ventilation for operating rooms, AII rooms, and PE areas. (AIA: 5.1; ASHRAE: 1­ 1996) IC
C.II.H. No recommendation is offered on routine microbiologic air sampling before, during, or after construction or before or during occupancy of areas housing immunocompromised patients. Unresolved issue
C.II.I. If a case of health-care–acquired aspergillosis or other opportunistic environmental airborne fungal disease occurs during or immediately after construction, implement appropriate follow-up measures. IB
C.II.I.1. Review pressure differential monitoring documentation to verify that pressure differentials in the construction zone and in PE rooms were appropriate for their settings. (AIA: 5.1) IB, IC
C.II.I.2. Implement corrective engineering measures to restore proper pressure differentials as needed. (AIA: 5.1) IB, IC
C.II.I.3. Conduct a prospective search for additional cases and intensify retrospective epidemiologic review of the hospital’s medical and laboratory records. IB
C.II.I.4. If there is no evidence of ongoing transmission, continue routine maintenance in the area to prevent health-care–acquired fungal disease. IB
C.II.J. If there is epidemiologic evidence of ongoing transmission of fungal disease, conduct an environmental assessment to determine and eliminate the source. IB
C.II.J.1. Collect environmental samples from potential sources of airborne fungal spores, preferably using a high-volume air sampler rather than settle plates. IB
C.II.J.2. If either an environmental source of airborne fungi or an engineering problem with filtration or pressure differentials is identified, promptly perform corrective measures to eliminate the source and route of entry. IB
C.II.J.3. Use an EPA-registered anti-fungal biocide (e.g., copper-8-quinolinolate) for decontaminating structural materials. IB
C.II.J.4. If an environmental source of airborne fungi is not identified, review infection control measures, including engineering controls, to identify potential areas for correction or improvement. IB
C.II.J.5. If possible, perform molecular subtyping of Aspergillus spp. isolated from patients and the environment to establish strain identities. II
C.II.K. If air-supply systems to high-risk areas (e.g., PE rooms) are not optimal, use portable, industrial-grade HEPA filters on a temporary basis until rooms with optimal air-handling systems become available. II
C.III. Infection-Control and Ventilation Requirements for PE Rooms
Edit [February 2017]

Edit: These recommendations contain minor edits in order to clarify the meaning. The edits do not constitute any change to the intent of the recommendations.
Indicates a change to the numbering system.
~ Indicates a text change.

Recommendations for ventilation requirements for PE rooms by ID number and category.
# Recommendation Category
C.III.A. Minimize exposures of severely immunocompromised patients (e.g., solid organ transplant patients or allogeneic neutropenic patients) to activities that might cause aerosolization of fungal spores (e.g., vacuuming or disruption of ceiling tiles). IB
C.III.B. Minimize the length of time that immunocompromised patients in PE are outside their rooms for diagnostic procedures and other activities. IB
C.III.C. Provide respiratory protection for severely immunocompromised patients when they must leave PE for diagnostic studies and other activities; consult the most recent revision of CDC’s Guidelines for Prevention of Health-Care–Associated Pneumonia for information regarding the appropriate type of respiratory protection. II
C.III.D. Incorporate ventilation engineering specifications and dust-controlling processes into the planning and construction of new PE units. IB, IC
C.III.D.1. Install central or point-of-use HEPA filters for supply (incoming) air. (AIA: 5.1, 5.2, 7.2.D) IB, IC
C.III.D.2. Ensure that rooms are well sealed by
  • * properly constructing windows, doors, and intake and exhaust ports;
  • * maintaining ceilings that are smooth and free of fissures, open joints, and crevices;
  • * sealing walls above and below the ceiling, and
  • * monitoring for leakage and making necessary repairs. (AIA: 7.2.D3)
C.III.D.3. Ventilate the room to maintain ≥12 ACH. (AIA: 7.2.D) IC
C.III.D.4. Locate air supply and exhaust grilles so that clean, filtered air enters from one side of the room, flows across the patient’s bed, and exits from the opposite side of the room. (AIA: 7.31.D1) IC
C.III.D.5. Maintain positive room air pressure (≥2.5 Pa [0.01-inch water gauge]) in relation to the corridor. (AIA: Table 7.2) IB, IC
C.III.D.6. Maintain airflow patterns and monitor these on a daily basis by using permanently installed visual means of detecting airflow in new or renovated construction, or using other visual methods (e.g., flutter strips, or smoke tubes) in existing PE units. Document the monitoring results. (AIA: 7.2.D6) IC
C.III.D.7. Install self-closing devices on all room exit doors in protective environments. (AIA: 7.2.D4) IC
C.III.E. Do not use laminar air flow systems in newly constructed PE rooms. II
C.III.F. Take measures to protect immunocompromised patients who would benefit from a PE room and who also have an airborne infectious disease (e.g., acute VZV infection or tuberculosis).
C.III.F.1. Ensure that the patient’s room is designed to maintain positive pressure. ~ IC
C.III.F.2. Use an anteroom to ensure appropriate air balance relationships and provide independent exhaust of contaminated air to the outside, or place a HEPA filter in the exhaust duct if the return air must be recirculated. (AIA: 7.2.D1, A7.2.D) IC
C.III.F.3. If an anteroom is not available, place the patient in AII and use portable, industrial- grade HEPA filters to enhance filtration of spores in the room. II
C.III.G. Maintain backup ventilation equipment (e.g., portable units for fans or filters) for emergency provision of ventilation requirements for PE areas and take immediate steps to restore the fixed ventilation system function. (AIA: 5.1) IC
C.IV. Infection-Control and Ventilation Requirements for AII Rooms
Edit [February 2017]

Edit: An indicates recommendations that were renumbered for clarity. The renumbering does not constitute change to the intent of the recommendations.

Recommendations for ventilation requirements for AII rooms by ID number and category.
# Recommendation Category
C.IV.A. Incorporate certain specifications into the planning, and construction or renovation of AII units. IB, IC
C.IV.A.1. Maintain continuous negative air pressure (2.5 Pa [0.01-inch water gauge]) in relation to the air pressure in the corridor; monitor air pressure periodically, preferably daily, with audible manometers or smoke tubes at the door (for existing AII rooms) or with a permanently installed visual monitoring mechanism. Document the results of monitoring. (AIA: 7.2.C7, Table 7.2) IB, IC
C.IV.A.2. Ensure that rooms are well-sealed by properly constructing windows, doors, and air- intake and exhaust ports; when monitoring indicates air leakage, locate the leak and make necessary repairs. (AIA: 7.2.C3) IB, IC
C.IV.A.3. Install self-closing devices on all AII room exit doors. (AIA: 7.2.C4) IC
C.IV.A.4. Provide ventilation to ensure ≥12 ACH for renovated rooms and new rooms, and ≥6 ACH for existing AII rooms. (AIA: Table 7.2) IC
C.IV.A.5. Direct exhaust air to the outside, away from air-intake and populated areas. If this is not practical, air from the room can be recirculated after passing through a HEPA filter. (AIA: Table 7.2) IC
C.IV.B. Where supplemental engineering controls for air cleaning are indicated from a risk assessment of the AII area, install UVGI units in the exhaust air ducts of the HVAC system to supplement HEPA filtration or install UVGI fixtures on or near the ceiling to irradiate upper room air. II
C.IV.C. Implement environmental infection-control measures for persons with known or suspected airborne infectious diseases.
C.IV.C.1. Use AII rooms for patients with or suspected of having an airborne infection who also require cough-inducing procedures, or use an enclosed booth that is engineered to provide
  • * ≥12 ACH;
  • * air supply and exhaust rate sufficient to maintain a 2.5 Pa [0.01-inch water gauge] negative pressure difference with respect to all surrounding spaces with an exhaust rate of ≥50 ft3/min.; and
  • * air exhausted directly outside away from air intakes and traffic or exhausted after HEPA filtration prior to recirculation. (AIA: 7.15.E, 7.31.D23, 9.10, Table 7.2)
C.IV.C.2. Although airborne spread of viral hemorrhagic fever (VHF) has not been documented in a health-care setting, prudence dictates placing a VHF patient in an AII room, preferably with an anteroom to reduce the risk of occupational exposure to aerosolized infectious material in blood, vomitus, liquid stool, and respiratory secretions present in large amounts during the end stage of a patient’s illness.
  • * If an anteroom is not available, use portable, industrial-grade HEPA filters in the patient’s room to provide additional ACH equivalents for removing airborne particulates.
  • * Ensure that health-care workers wear face shields or goggles with appropriate respirators when entering the rooms of VHF patients with prominent cough, vomiting, diarrhea, or hemorrhage.

Ebola Virus Disease [August 2014]

Update: The recommendations in this guideline for Ebola has been superseded by these CDC documents:

See CDC’s Ebola Virus Disease website for current information on how Ebola virus is transmitted.

C.IV.C.3. Place smallpox patients in negative pressure rooms at the onset of their illness, preferably using a room with an anteroom if available. II
C.IV.D. No recommendation is offered regarding negative pressure or isolation rooms for patients with Pneumocystis carinii pneumonia. Unresolved issue
C.IV.E. Maintain back-up ventilation equipment (e.g., portable units for fans or filters) for emergency provision of ventilation requirements for AII rooms and take immediate steps to restore the fixed ventilation system function. (AIA: 5.1) IC
C.V. Infection-Control and Ventilation Requirements for Operating Rooms
Recommendations for ventilation requirements for operating rooms by ID number and category.
# Recommendation Category
C.V.A. Implement environmental infection-control and ventilation measures for operating rooms.
C.V.A.1. Maintain positive-pressure ventilation with respect to corridors and adjacent areas. (AIA: Table 7.2) IB, IC
C.V.A.2. Maintain ≥15 ACH, of which ≥3 ACH should be fresh air. (AIA: Table 7.2) IC
C.V.A.3. Filter all recirculated and fresh air through the appropriate filters, providing 90% efficiency (dust-spot testing) at a minimum. (AIA: Table 7.3) IC
C.V.A.4. In rooms not engineered for horizontal laminar airflow, introduce air at the ceiling and exhaust air near the floor.120, 357, 359 (AIA: 7.31.D4) IC
C.V.A.5. Do not use UV lights to prevent surgical-site infections. IB
C.V.A.6. Keep operating room doors closed except for the passage of equipment, personnel, and patients, and limit entry to essential personnel. IB
C.V.B. Follow precautionary procedures for TB patients who also require emergency surgery. IB, IC
C.V.B.1. Use an N95 respirator approved by the National Institute for Occupational Safety and Health (NIOSH) without exhalation valves in the operating room. (Occupational Safety and Health Administration [OSHA]; 29 Code of Federal Regulations [CFR] 1910.134,139) IC
C.V.B.2. Intubate the patient in either the AII room or the operating room; if intubating the patient in the operating room, do not allow the doors to open until 99% of the airborne contaminants are removed (Appendix B, Table B.1). IB
C.V.B.3. When anesthetizing a patient with confirmed or suspected TB, place a bacterial filter between the anesthesia circuit and patient’s airway to prevent contamination of anesthesia equipment or discharge of tubercle bacilli into the ambient air. IB
C.V.B.4. Extubate and allow the patient to recover in an AII room. IB
C.V.B.5. If the patient has to be extubated in the operating room, allow adequate time for ACH to clean 99% of airborne particles from the air (Appendix B, Table B.1) because extubation is a cough-producing procedure. IB
C.V.C. Use portable, industrial-grade HEPA filters temporarily for supplemental air cleaning during intubation and extubation for infectious TB patients who require surgery. II
C.V.C.1. Position the units appropriately so that all room air passes through the filter; obtain engineering consultation to determine the appropriate placement of the unit. II
C.V.C.2. Switch the portable unit off during the surgical procedure. II
C.V.C.3. Provide fresh air as per ventilation standards for operating rooms; portable units do not meet the requirements for the number of fresh ACH. II
C.V.D. If possible, schedule infectious TB patients as the last surgical cases of the day to maximize the time available for removal of airborne contamination. II
C.V.E. No recommendation is offered for performing orthopedic implant operations in rooms supplied with laminar airflow. Unresolved issue
C.V.F. Maintain backup ventilation equipment (e.g., portable units for fans or filters) for emergency provision of ventilation requirements for operating rooms, and take immediate steps to restore the fixed ventilation system function. (AIA: 5.1) IB, IC
C.VI. Other Potential Infectious Aerosol Hazards in Health-Care Facilities
Recommendations for infectious aerosol hazards by ID number and category.
# Recommendation Category
C.VI.A. In settings where surgical lasers are used, wear appropriate personal protective equipment, including N95 or N100 respirators, to minimize exposure to laser plumes. (OSHA; 29 CFR 1910.134,139) IC
C.VI.B. Use central wall suction units with in-line filters to evacuate minimal laser plumes. II
C.VI.C. Use a mechanical smoke evacuation system with a high-efficiency filter to manage the generation of large amounts of laser plume, when ablating tissue infected with human papilloma virus (HPV) or performing procedures on a patient with extrapulmonary TB. II

D. Water

D.I. Controlling the Spread of Waterborne Microoganisms
Recommendations for controlling waterborne microoganisms by ID number and category.
# Recommendation Category
D.I.A. Practice hand hygiene to prevent the hand transfer of waterborne pathogens, and use barrier precautions (e.g., gloves) as defined by other guidelines. IA
D.I.B. Eliminate contaminated water or fluid environmental reservoirs (e.g., in equipment or solutions) wherever possible. IB
D.I.C. Clean and disinfect sinks and wash basins on a regular basis by using an EPA-registered product as set by facility policies. II
D.I.D. Evaluate for possible environmental sources (e.g., potable water) of specimen contamination when waterborne microorganisms (e.g., NTM) of unlikely clinical importance are isolated from clinical cultures (e.g., specimens collected aseptically from sterile sites or, if post-procedural, colonization occurs after use of tap water in patient care). IB
D.I.E. Avoid placing decorative fountains and fish tanks in patient-care areas; ensure disinfection and fountain maintenance if decorative fountains are used in the public areas of the health­ care facility. IB
D.II. Routine Prevention of Waterborne Microbial Contamination Within the Distribution System
Recommendations for prevention of waterborne microbial contamination by ID number and category.
# Recommendation Category
D.II.A. Maintain hot water temperature at the return at the highest temperature allowable by state regulations or codes, preferably ≥124°F (≥51°C), and maintain cold water temperature at <68°F (<20°C). (States; ASHRAE: 12:2000) IC
D.II.B. If the hot water temperature can be maintained at≥124°F (≥51°C), explore engineering options (e.g., install preset thermostatic valves in point-of-use fixtures) to help minimize the risk of scalding. II
D.II.C. When state regulations or codes do not allow hot water temperatures above the range of 105°F–120°F (40.6°C–49°C) for hospitals or 95°F–110°F (35°C–43.3°C) for nursing care facilities or when buildings cannot be retrofitted for thermostatic mixing valves, follow either of these alternative preventive measures to minimize the growth of Legionella spp. in water systems. II
D.II.C.1. Periodically increase the hot water temperature to ≥150°F (≥66°C) at the point of use. II
D.II.C.2. Alternatively, chlorinate the water and then flush it through the system. II
D.II.D. Maintain constant recirculation in hot-water distribution systems serving patient-care areas. (AIA: 7.31.E.3) IC
D.III. Remediation Strategies for Distribution System Repair or Emergencies
Edit [February 2017]

Edit: An indicates recommendations that were renumbered for clarity. The renumbering does not constitute change to the intent of the recommendations.

Recommendations for remediation strategies for distribution system problems by ID number and category.
# Recommendation Category
D.III.A. Whenever possible, disconnect the ice machine before planned water disruptions. II
D.III.B. Prepare a contingency plan to estimate water demands for the entire facility in advance of significant water disruptions (i.e., those expected to result in extensive and heavy microbial or chemical contamination of the potable water), sewage intrusion, or flooding. (JCAHO: EC 1.4) IC
D.III.C. When a significant water disruption or an emergency occurs, adhere to any advisory to boil water issued by the municipal water utility. (Municipal order) IB, IC
D.III.C.1. Alert patients, families, staff, and visitors not to consume water from drinking fountains, ice, or drinks made from municipal tap water, while the advisory is in effect, unless the water has been disinfected (e.g., by bringing to a rolling boil for ≥1 minute). (Municipal order) IB, IC
D.III.C.2. After the advisory is lifted, run faucets and drinking fountains at full flow for ≥5 minutes, or use high-temperature water flushing or chlorination. (Municipal order; ASHRAE 12:2000) IC, II
D.III.D. Maintain a high level of surveillance for waterborne disease among patients after a boil water advisory is lifted. II
D.III.E. Corrective decontamination of the hot water system might be necessary after a disruption in service or a cross-connection with sewer lines has occurred.
D.III.E.1. Decontaminate the system when the fewest occupants are present in the building (e.g., nights or weekends). (ASHRAE: 12:2000) IC
D.III.E.2. If using high-temperature decontamination, raise the hot-water temperature to 160°F– 170°F (71°C–77°C) and maintain that level while progressively flushing each outlet around the system for ≥5 minutes. (ASHRAE: 12:2000) IC
D.III.E.3. If using chlorination, add enough chlorine, preferably overnight, to achieve a free chlorine residual of ≥2 mg/L (≥2 ppm) throughout the system. (ASHRAE: 12:2000)
  • * Flush each outlet until chlorine odor is detected.
  • * Maintain the elevated chlorine concentration in the system for ≥2 hrs (but ≤24 hrs).
D.III.E.4. Use a very thorough flushing of the water system instead of chlorination if a highly chlorine-resistant microorganism (e.g., Cryptosporidium spp.) is suspected as the water contaminant. II
D.III.F. Flush and restart equipment and fixtures according to manufacturers’ instructions. II
D.III.G. Change the pretreatment filter and disinfect the dialysis water system with an EPA- registered product to prevent colonization of the reverse osmosis membrane and downstream microbial contamination. II
D.III.H. Run water softeners through a regeneration cycle to restore their capacity and function. II
D.III.I. If the facility has a water-holding reservoir or water-storage tank, consult the facility engineer or local health department to determine whether this equipment needs to be drained, disinfected with an EPA-registered product, and refilled. II
D.III.J. Implement facility management procedures to manage a sewage system failure or flooding (e.g., arranging with other health-care facilities for temporary transfer of patients or provision of services), and establish communications with the local municipal water utility and the local health department to ensure that advisories are received in a timely manner upon release. (JCAHO: EC 1.4; Municipal order) IC
D.III.K. Implement infection-control measures during sewage intrusion, flooding, or other water- related emergencies.
D.III.K.1. Relocate patients and clean or sterilize supplies from affected areas. II
D.III.K.2. If hands are not visibly soiled or contaminated with proteinaceous material, include an alcohol-based hand rub in the hand hygiene process
  • * before performing invasive procedures;
  • * before and after each patient contact; and
  • * whenever hand hygiene is indicated.
D.III.K.3. If hands are visibly soiled or contaminated with proteinaceous material, use soap and bottled water for handwashing. II
D.III.K.4. If the potable water system is not affected by flooding or sewage contamination, process surgical instruments for sterilization according to standard procedures. II
D.III.K.5. Contact the manufacturer of the automated endoscope reprocessor (AER) for specific instructions on the use of this equipment during a water advisory. II
D.III.L. Remediate the facility after sewage intrusion, flooding, or other water-related emergencies.
D.III.L.1. Close off affected areas during cleanup procedures. II
D.III.L.2. Ensure that the sewage system is fully functional before beginning remediation so contaminated solids and standing water can be removed. II
D.III.L.3. If hard-surface equipment, floors, and walls remain in good repair, ensure that these are dry within 72 hours; clean with detergent according to standard cleaning procedures. II
D.III.L.4. Clean wood furniture and materials (if still in good repair); allow them to dry thoroughly before restoring varnish or other surface coatings. II
D.III.L.5. Contain dust and debris during remediation and repair as outlined in air recommendations (Air: II G 4, 5). II
D.III.M. Regardless of the original source of water damage (e.g., flooding versus water leaks from point-of-use fixtures or roofs), remove wet, absorbent structural items (e.g., carpeting, wallboard, and wallpaper) and cloth furnishings if they cannot be easily and thoroughly cleaned and dried within 72 hours (e.g., moisture content ≤20% as determined by moisture meter readings); replace with new materials as soon as the underlying structure is declared by the facility engineer to be thoroughly dry. IB
D.IV. Additional Engineering Measures as Indicated by Epidemiologic Investigation for Controlling Waterborne, Health-Care–Associated Legionnaires Disease
Recommendations for engineering measures as indicated by epidemiologic investigation by ID number and category.
# Recommendation Category
D.IV.A. When using a pulse or one-time decontamination method, superheat the water by flushing each outlet for ≥5 minutes with water at 160°F–170°F (71°C–77°C) or hyperchlorinate the system by flushing all outlets for ≥5 minutes with water containing ≥2 mg/L (≥2 ppm) free residual chlorine using a chlorine-based product registered by the EPA for water treatment (e.g., sodium hypochlorite [chlorine bleach]). (ASHRAE: 12:2000) IB
D.IV.B. After a pulse treatment, maintain both the heated water temperature at the return and the cold water temperature as per the recommendation (Water: IIA) wherever practical and permitted by state codes, or chlorinate heated water to achieve 1–2 mg/L (1–2 ppm) free residual chlorine at the tap using a chlorine-based product registered by the EPA for water treatment (e.g., sodium hypochlorite [bleach]). (States; ASHRAE: 12:2000) IC
D.IV.C. Explore engineering or educational options (e.g., install preset thermostatic mixing valves in point-of-use fixtures or post warning signs at each outlet) to minimize the risk of scalding for patients, visitors, and staff. II
D.IV.D. No recommendation is offered for treating water in the facility’s distribution system with chlorine dioxide, heavy-metal ions (e.g., copper or silver), monochloramine, ozone, or UV light. Unresolved issue
D.V. General Infection-Control Strategies for Preventing Legionnaires Disease
Recommendations for strategies for preventing legionnaires disease by ID number and category.
# Recommendation Category
D.V.A. Conduct an infection-control risk assessment of the facility to determine if patients at risk or severely immunocompromised patients are present. IB
D.V.B. Implement general strategies for detecting and preventing Legionnaires disease in facilities that do not provide care for severely immunocompromised patients (i.e., facilities that do not have HSCT or solid organ transplant programs). IB
D.V.B.1. Establish a surveillance process to detect health-care–associated Legionnaires disease. IB
D.V.B.2. Inform health-care personnel (e.g., infection control, physicians, patient-care staff, and engineering) regarding the potential for Legionnaires disease to occur and measures to prevent and control health-care–associated legionellosis. IB
D.V.B.3. Establish mechanisms to provide clinicians with laboratory tests (e.g., culture, urine antigen, direct fluorescence assay [DFA], and serology) for the diagnosis of Legionnaires disease. IB
D.V.C. Maintain a high index of suspicion for health-care–associated Legionnaires disease, and perform laboratory diagnostic tests for legionellosis on suspected cases, especially in patients at risk who do not require a PE for care (e.g., patients receiving systemic steroids; patients aged ≥65 years; or patients with chronic underlying disease [e.g., diabetes mellitus, congestive heart failure, or chronic obstructive lung disease]). IA
D.V.D. Periodically review the availability and clinicians’ use of laboratory diagnostic tests for Legionnaires disease in the facility; if clinicians’ use of the tests on patients with diagnosed or suspected pneumonia is limited, implement measures (e.g., an educational campaign) to enhance clinicians’ use of the test(s). IB
D.V.E. If one case of laboratory-confirmed, health-care–associated Legionnaires disease is identified, or if two or more cases of laboratory-suspected, health-care–associated Legionnaires disease occur during a 6-month period, certain activities should be initiated. IB
D.V.E.1. Report the cases to the state and local health departments where required. (States) IC
D.V.E.2. If the facility does not treat severely immunocompromised patients, conduct an epidemiologic investigation, including retrospective review of microbiologic, serologic, and postmortem data to look for previously unidentified cases of health­ care–associated Legionnaires disease, and begin intensive prospective surveillance for additional cases. IB
D.V.E.3. If no evidence of continued health-care–associated transmission exists, continue intensive prospective surveillance for ≥2 months after the initiation of surveillance. IB
D.V.F. If there is evidence of continued health-care–associated transmission (i.e., an outbreak), conduct an environmental assessment to determine the source of Legionella spp. IB
D.V.F.1. Collect water samples from potential aerosolized water sources (Appendix C). IB
D.V.F.2. Save and subtype isolates of Legionella spp. obtained from patients and the environment. IB
D.V.F.3. If a source is identified, promptly institute water system decontamination measures per recommendations (see Water IV). IB
D.V.F.4. If Legionella spp. are detected in ≥1cultures (e.g., conducted at 2-week intervals during 3 months), reassess the control measures, modify them accordingly, and repeat the decontamination procedures; consider intensive use of techniques used for initial decontamination, or a combination of superheating and hyperchlorination. IB
D.V.G. If an environmental source is not identified during a Legionnaires disease outbreak, continue surveillance for new cases for ≥2 months. Either defer decontamination pending identification of the source of Legionella spp., or proceed with decontamination of the hospital’s water distribution system, with special attention to areas involved in the outbreak. II
D.V.H. No recommendation is offered regarding routine culturing of water systems in health-care facilities that do not have patient-care areas (i.e., PE or transplant units) for persons at high risk for Legionella spp. infection. Unresolved issue
 ID.V. No recommendation is offered regarding the removal of faucet aerators in areas for immunocompetent patients. Unresolved issue
D.V.J. Keep adequate records of all infection-control measures and environmental test results for potable water systems. II
D.VI. Preventing Legionnaires Disease in Protective Environments and Transplant Units
Recommendations for preventing legionnaires disease in special units by ID number and category.
# Recommendation Category
D.VI.A. When implementing strategies for preventing Legionnaires disease among severely immunosuppressed patients housed in facilities with HSCT or solid-organ transplant programs, incorporate these specific surveillance and epidemiologic measures in addition to the steps previously outlined (Water: V and Appendix C).
D.VI.A.1. Maintain a high index of suspicion for legionellosis in transplant patients even when environmental surveillance cultures do not yield legionellae. IB
D.VI.A.2. If a case occurs in a severely immunocompromised patient, or if severely immunocompromised patients are present in high-risk areas of the hospital (e.g., PE or transplant units) and cases are identified elsewhere in the facility, conduct a combined epidemiologic and environmental investigation to determine the source of Legionella spp. IB
D.VI.B. Implement culture strategies and potable water and fixture treatment measures in addition to those previously outlined (Water: V). II
D.VI.B.1. Depending on state regulations on potable water temperature in public buildings, hospitals housing patients at risk for health-care associated legionellosis should either maintain heated water with a minimum return temperature of ≥124°F [≥51°C] and cold water at <68°F [<20°C]), or chlorinate heated water to achieve 1–2 mg/L (1–2 ppm) of free residual chlorine at the tap. II
D.VI.B.2. Periodic culturing for legionellae in potable water samples from HSCT or solid-organ transplant units can be performed as part of a comprehensive strategy to prevent Legionnaires disease in these units. II
D.VI.B.3. No recommendation is offered regarding the optimal methodology (i.e., frequency or number of sites) for environmental surveillance cultures in HSCT or solid organ transplant units. Unresolved issue
D.VI.B.4. In areas with patients at risk, when Legionella spp. are not detectable in unit water, remove, clean, and disinfect shower heads and tap aerators monthly by using a chlorine-based, EPA-registered product. If an EPA-registered chlorine disinfectant is not available, use a chlorine bleach solution (500–615 ppm [1:100 v/v dilution]). II
D.VI.C. If Legionella spp. are determined to be present in the water of a transplant unit, implement certain measures until Legionella spp. are no longer detected by culture.
D.VI.C.1. Decontaminate the water supply as outlined previously (Water: IV). IB
D.VI.C.2. Do not use water from the faucets in patient-care rooms to avoid creating infectious aerosols. IB
D.VI.C.3. Restrict severely immunocompromised patients from taking showers. IB
D.VI.C.4. Use water that is not contaminated with Legionella spp. for HSCT patients’ sponge baths. IB
D.VI.C.5. Provide patients with sterile water for tooth brushing, drinking, and for flushing nasogastric tubing during legionellosis outbreaks. IB
D.VI.D. Do not use large-volume room air humidifiers that create aerosols (e.g., by Venturi principle, ultrasound, or spinning disk) unless they are subjected to high-level disinfection and filled only with sterile water. IB
D.VII. Cooling Towers and Evaporative Condensers
Recommendations for cooling towers and evaporative condensers by ID number and category.
# Recommendation Category
D.VII.A. When planning construction of new health-care facilities, locate cooling towers so that the drift is directed away from the air-intake system, and design the towers to minimize the volume of aerosol drift. (ASHRAE: 12:2000) IC
D.VII.B. Implement infection-control procedures for operational cooling towers. (ASHRAE: 12:2000) IC
D.VII.B.1. Install drift eliminators. (ASHRAE: 12:2000) IC
D.VII.B.2. Use an effective EPA-registered biocide on a regular basis. (ASHRAE: 12:2000) IC
D.VII.B.3. Maintain towers according to manufacturers’ recommendations, and keep detailed maintenance and infection control records, including environmental test results from legionellosis outbreak investigations. (ASHRAE: 12:2000) IC
D.VII.C. If cooling towers or evaporative condensers are implicated in health-care–associated legionellosis, decontaminate the cooling-tower system. IB
D.VIII. Dialysis Water Quality and Dialysate
Edit [February 2017]

Edit: An indicates recommendations that were renumbered for clarity. The renumbering does not constitute change to the intent of the recommendations.

Recommendations for dialysis water quality and dialysate by ID number and category.
# Recommendation Category
D.VIII.A. Adhere to current AAMI standards for quality assurance performance of devices and equipment used to treat, store, and distribute water in hemodialysis centers (both acute and maintenance [chronic] settings) and for the preparation of concentrates and dialysate. (AAMI: ANSI/AAMI RD5:1992, ANSI/AAMI RD 47:1993) IA, IC
D.VIII.B. No recommendation is offered regarding whether more stringent requirements for water quality should be imposed in hemofiltration and hemodiafiltration. Unresolved issue
D.VIII.C. Conduct microbiological testing specific to water in dialysis settings. (AAMI: ANSI/AAMI RD 5: 1992, ANSI/AAMI RD 47: 1993, ANSI/AAMI RD 62:2001) IA, IC
D.VIII.C.1. Perform bacteriologic assays of water and dialysis fluids at least once a month and during outbreaks using standard quantitative methods. (AAMI: ANSI/AAMI RD 62:2001)
  • * Assay for heterotrophic, mesophilic bacteria (e.g., Pseudomonasspp).
  • * Do not use nutrient-rich media (e.g., blood agar or chocolate agar).
D.VIII.C.2. In conjunction with microbiological testing, perform endotoxin testing on product water used to reprocess dialyzers for multiple use. (AAMI: ANSI/AAMI RD 5:1992, ANSI/AAMI RD 47:1993) IA, IC
D.VIII.C.3. Ensure that water does not exceed the limits for microbial counts and endotoxin concentrations outlined in Table 18. (AAMI: ANSI/AAMI RD 5:1992, ANSI/AAMI RD 47:1993) IA, IC
D.VIII.D. Disinfect water distribution systems in dialysis settings on a regular schedule. Monthly disinfection is recommended. (AAMI: ANSI/AAMI RD62:2001) IA, IC
D.VIII.E. Whenever practical, design and engineer water systems in dialysis settings to avoid incorporating joints, dead-end pipes, and unused branches and taps that can harbor bacteria. (AAMI: ANSI/AAMI RD62:2001) IA, IC
D.VIII.F. When storage tanks are used in dialysis systems, they should be routinely drained, disinfected with an EPA-registered product, and fitted with an ultrafilter or pyrogenic filter (membrane filter with a pore size sufficient to remove small particles and molecules ≥1 kilodalton) installed in the water line distal to the storage tank. (AAMI: ANSI/AAMI RD62:2001) IC
D.IX. Ice Machines and Ice
Recommendations for ice machines and ice by ID number and category.
# Recommendation Category
D.IX.A. Do not handle ice directly by hand, and wash hands before obtaining ice. II
D.IX.B. Use a smooth-surface ice scoop to dispense ice. II
D.IX.B.1. Keep the ice scoop on a chain short enough the scoop cannot touch the floor, or keep the scoop on a clean, hard surface when not in use. II
D.IX.B.2. Do not store the ice scoop in the ice bin. II
D.IX.C. Do not store pharmaceuticals or medical solutions on ice intended for consumption; use sterile ice to keep medical solutions cold, or use equipment specifically manufactured for this purpose. IB
D.IX.D. Machines that dispense ice are preferred to those that require ice to be removed from bins or chests with a scoop. II
D.IX.E. Limit access to ice-storage chests, and keep the container doors closed except when removing ice. II
D.IX.F. Clean, disinfect, and maintain ice-storage chests on a regular basis. II
D.IX.F.1. Follow the manufacturer’s instructions for cleaning. II
D.IX.F.2. Use an EPA-registered disinfectant suitable for use on ice machines, dispensers, or storage chests in accordance with label instructions. II
D.IX.F.3. If instructions and EPA-registered disinfectants suitable for use on ice machines are not available, use a general cleaning/disinfecting regimen as outlined in Box 12. II
D.IX.F.4. Flush and clean the ice machines and dispensers if they have not been disconnected before anticipated lengthy water disruptions. II
D.IX.G. Install proper air gaps where the condensate lines meet the waste lines. II
D.IX.H. Conduct microbiologic sampling of ice, ice chests, and ice-making machines and dispensers where indicated during an epidemiologic investigation. IB
D.X. Hydrotherapy Tanks and Pools
Recommendations for hydrotherapy tanks and pools by ID number and category.
# Recommendation Category
D.X.A. Drain and clean hydrotherapy equipment (e.g., Hubbard tanks, tubs, whirlpools, whirlpool spas, or birthing tanks) after each patient’s use, and disinfect equipment surfaces and components by using an EPA-registered product in accordance with the manufacturer’s instructions. II
D.X.B. In the absence of an EPA-registered product for water treatment, add sodium hypochlorite to the water:
D.X.B.1. Maintain a 15-ppm chlorine residual in the water of small hydrotherapy tanks, Hubbard tanks, and tubs. II
D.X.B.2. Maintain a 2–5 ppm chlorine residual in the water of whirlpools and whirlpool spas. II
D.X.B.3. If the pH of the municipal water is in the basic range (e.g., when chloramine is used as the primary drinking water disinfectant in the community), consult the facility engineer regarding the possible need to adjust the pH of the water to a more acid level before disinfection, to enhance the biocidal activity of chlorine. II
D.X.C. Clean and disinfect hydrotherapy equipment after using tub liners. II
D.X.D. Clean and disinfect inflatable tubs unless they are single-use equipment. II
D.X.E. No recommendation is offered regarding the use of antiseptic chemicals (e.g., chloramine-T) in the water during hydrotherapy sessions. Unresolved issue
D.X.F. Conduct a risk assessment of patients prior to their use of large hydrotherapy pools, deferring patients with draining wounds or fecal incontinence from pool use until their condition resolves. II
D.X.G. For large hydrotherapy pools, use pH and chlorine residual levels appropriate for an indoor pool as provided by local and state health agencies. (States) IC
D.X.H. No recommendation is offered regarding the use in health care of whirlpools or spa equipment manufactured for home or recreational use. Unresolved issue
D.XI. Miscellaneous Medical Equipment Connected to Water Systems
Edit [February 2017]

Edit: An indicates recommendations that were renumbered for clarity. The renumbering does not constitute change to the intent of the recommendations.

Recommendations for miscellaneous medical equipment connected to water systems by ID number and category.
# Recommendation Category
D.XI.A. Clean, disinfect, and maintain AER equipment according to the manufacturer’s instructions and relevant scientific literature to prevent inadvertent contamination of endoscopes and bronchoscopes with waterborne microorganisms. IB
D.XI.A.1. To rinse disinfected endoscopes and bronchoscopes, use water of the highest quality practical for the system’s engineering and design (e.g., sterile water or bacteriologically-filtered water [water filtered through 0.1–0.2-µm filters]). IB
D.XI.A.2. Dry the internal channels of the reprocessed endoscope or bronchoscope using a proven method (e.g., 70% alcohol followed by forced-air treatment) to lessen the potential for the proliferation of waterborne microorganisms and to help prevent biofilm formation. IB
D.XI.B. Use water that meets nationally recognized standards set by the EPA for drinking water (<500 CFU/mL for heterotrophic plate count) for routine dental treatment output water. (EPA: 40 CFR 1 Part 141, Subpart G). IB, IC
D.XI.C. Take precautions to prevent waterborne contamination of dental unit water lines and instruments.
D.XI.C.1. After each patient, discharge water and air for a minimum of 20–30 seconds from any dental device connected to the dental water system that enters the patient’s mouth (e.g., handpieces, ultrasonic scalers, and air/water syringe). II
D.XI.C.2. Consult with dental water-line manufacturers to
  • * determine suitable methods and equipment to obtain the recommended water quality; and
  • * determine appropriate methods for monitoring the water to ensure quality is maintained.
D.XI.C.3. Consult with the dental unit manufacturer on the need for periodic maintenance of anti-retraction mechanisms. IB

E. Environmental Services

E.I. Cleaning and Disinfecting Strategies for Environmental Surfaces in Patient-Care Areas
Edit [February 2017]

Edit: An indicates recommendations that were renumbered for clarity. The renumbering does not constitute change to the intent of the recommendations.

Recommendations for cleaning and disinfecting strategies surfaces by ID number and category.
# Recommendation Category
E.I.A. Select EPA-registered disinfectants, if available, and use them in accordance with the manufacturer’s instructions. (EPA: 7 United States Code [USC] § 136 et seq) IB, IC
E.I.B. Do not use high-level disinfectants/liquid chemical sterilants for disinfection of either noncritical instrument/devices or any environmental surfaces; such use is counter to label instructions for these toxic chemicals. (FDA: 21 CFR 801.5, 807.87.e) IB, IC
E.I.C. Follow manufacturers’ instructions for cleaning and maintaining noncritical medical equipment. II
E.I.D. In the absence of a manufacturer’s cleaning instructions, follow certain procedures.
E.I.D.1. Clean noncritical medical equipment surfaces with a detergent/disinfectant. This may be followed with an application of an EPA-registered hospital disinfectant with or without a tuberculocidal claim (depending on the nature of the surface and the degree of contamination), in accordance with disinfectant label instructions. II
E.I.D.2. Do not use alcohol to disinfect large environmental surfaces. II
E.I.D.3. Use barrier protective coverings as appropriate for noncritical equipment surfaces that are
  • * touched frequently with gloved hands during the delivery of patient care;
  • * likely to become contaminated with blood or body substances; or
  • * difficult to clean (e.g., computer keyboards).
E.I.E. Keep housekeeping surfaces (e.g., floors, walls, and tabletops) visibly clean on a regular basis and clean up spills promptly. II
E.I.E.1. Use a one-step process and an EPA-registered hospital disinfectant/detergent designed for general housekeeping purposes in patient-care areas when
  • * uncertainty exists as to the nature of the soil on these surfaces [e.g., blood or body fluid contamination versus routine dust or dirt]; or
  • * uncertainty exists regarding the presence or absence of multi-drug resistant organisms on such surfaces.
E.I.E.2. Detergent and water are adequate for cleaning surfaces in nonpatient-care areas (e.g., administrative offices). II
E.I.E.3. Clean and disinfect high-touch surfaces (e.g., doorknobs, bed rails, light switches, and surfaces in and around toilets in patients’ rooms) on a more frequent schedule than minimal touch housekeeping surfaces. II
E.I.E.4. Clean walls, blinds, and window curtains in patient-care areas when they are visibly dusty or soiled. II
E.I.F. Do not perform disinfectant fogging in patient-care areas.

Environmental Fogging [December 2009]

Clarification Statement: CDC and HICPAC have recommendations in both 2003 Guidelines for Environmental Infection Control in Health-Care Facilities and the 2008 Guideline for Disinfection and Sterilization in Healthcare Facilities that state that the CDC does not support disinfectant fogging. Specifically, the 2003 and 2008 Guidelines state:

These recommendations refer to the spraying or fogging of chemicals (e.g., formaldehyde, phenol-based agents, or quaternary ammonium compounds) as a way to decontaminate environmental surfaces or disinfect the air in patient rooms. The recommendation against fogging was based on studies in the 1970’s that reported a lack of microbicidal efficacy (e.g., use of quaternary ammonium compounds in mist applications) but also adverse effects on healthcare workers and others in facilities where these methods were utilized. Furthermore, some of these chemicals are not EPA-registered for use in fogging-type applications.

These recommendations do not apply to newer technologies involving fogging for room decontamination (e.g., ozone mists, vaporized hydrogen peroxide) that have become available since the 2003 and 2008 recommendations were made. These newer technologies were assessed by CDC and HICPAC in the 2011 Guideline for the Prevention and Control of Norovirus Gastroenteritis Outbreaks in Healthcare Settings, which makes the recommendation:

“More research is required to clarify the effectiveness and reliability of fogging, UV irradiation, and ozone mists to reduce norovirus environmental contamination. (No recommendation/unresolved issue)”

The 2003 and 2008 recommendations still apply; however, CDC does not yet make a recommendation regarding these newer technologies. This issue will be revisited as additional evidence becomes available.

E.I.G. Avoid large-surface cleaning methods that produce mists or aerosols or disperse dust in patient-care areas. IB
E.I.H. Follow proper procedures for effective use of mops, cloths, and solutions. II
E.I.H.1. Prepare cleaning solutions daily or as needed, and replace with fresh solution frequently according to facility policies and procedures. II
E.I.H.2. Change the mop head at the beginning of the day and also as required by facility policy, or after cleaning up large spills of blood or other body substances. II
E.I.H.3. Clean mops and cloths after use and allow to dry before reuse; or use single-use, disposable mop heads and cloths. II
E.I.I. After the last surgical procedure of the day or night, wet vacuum or mop operating room floors with a single-use mop and an EPA-registered hospital disinfectant. IB
E.I.J. Do not use mats with tacky surfaces at the entrance to operating rooms or infection-control suites. IB
E.I.K. Use appropriate dusting methods for patient-care areas designated for immunocompromised patients (e.g., HSCT patients): IB
E.I.K.1. Wet-dust horizontal surfaces daily by moistening a cloth with a small amount of an EPA-registered hospital detergent/disinfectant. IB
E.I.K.2. Avoid dusting methods that disperse dust (e.g., feather-dusting). IB
E.I.L. Keep vacuums in good repair, and equip vacuums with HEPA filters for use in areas with patients at risk.9, 94, 986, 99 IB
E.I.M. Close the doors of immunocompromised patients’ rooms when vacuuming, waxing, or buffing corridor floors to minimize exposure to airborne dust. IB
E.I.N. When performing low- or intermediate-level disinfection of environmental surfaces in nurseries and neonatal units, avoid unnecessary exposure of neonates to disinfectant residues on environmental surfaces by using EPA-registered disinfectants in accordance with manufacturers’ instructions and safety advisories. (EPA: 7 USC § 136 et seq.) IB, IC
E.I.N.1. Do not use phenolics or any other chemical germicide to disinfect bassinets or incubators during an infant’s stay. IB
E.I.N.2. Rinse disinfectant-treated surfaces, especially those treated with phenolics, with water. IB
E.I.O. When using phenolic disinfectants in neonatal units, prepare solutions to correct concentrations in accordance with manufacturers’ instructions, or use premixed formulations. (EPA: 7 USC § 136 et seq.) IB, IC
E.II. Cleaning Spills of Blood and Body Substances
Recommendations for cleaning blood and body fluids by ID number and category.
# Recommendation Category
E.II.A. Promptly clean and decontaminate spills of blood or other potentially infectious materials. (OSHA: 29 CFR 1910.1030 §d.4.ii.A) IB, IC
E.II.B. Follow proper procedures for site decontamination of spills of blood or blood-containing body fluids. (OSHA: 29 CFR 1910.1030 § d.4.ii.A) IC
E.II.B.1. Use protective gloves and other PPE appropriate for this task. (OSHA: 29 CFR 1910.1030 § d.3.i, ii) IC
E.II.B.2. If the spill contains large amounts of blood or body fluids, clean the visible matter with disposable absorbent material, and discard the contaminated materials in appropriate, labeled containment. (OSHA: 29 CFR 1910.1030 § d.4.iii.B) IC
E.II.B.3. Swab the area with a cloth or paper towels moderately wetted with disinfectant, and allow the surface to dry. (OSHA: 29 CFR 1910.1030 § d.4.ii.A) IC
E.II.C. Use EPA-registered hospital disinfectants labeled tuberculocidal or registered germicides on the EPA Lists D and E (products with specific label claims for HIV or hepatitis B virus [HBV]) in accordance with label instructions to decontaminate spills of blood and other body fluids. (OSHA 29 CFR 1910.1030 § d.4.ii.A memorandum 2/28/97; compliance document CPL 2-2.44D [11/99]) IC
E.II.D. An EPA-registered sodium hypochlorite product is preferred, but if such products are not available, generic versions of sodium hypochlorite solutions (e.g., household chlorine bleach) may be used.
E.II.D.1. Use a 1:100 dilution (500–615 ppm available chlorine) to decontaminate nonporous surfaces after cleaning a spill of either blood or body fluids in patient-care settings. II
E.II.D.2. If a spill involves large amounts of blood or body fluids, or if a blood or culture spill occurs in the laboratory, use a 1:10 dilution (5,000–6,150 ppm available chlorine) for the first application of germicide before cleaning. II
E.III. Carpeting and Cloth Furnishings
Recommendations for carpeting and cloth furnishings by ID number and category.
# Recommendation Category
E.III.A. Vacuum carpeting in public areas of health-care facilities and in general patient-care areas regularly with well-maintained equipment designed to minimize dust dispersion. II
E.III.B. Periodically perform a thorough, deep cleaning of carpeting as determined by facility policy by using a method that minimizes the production of aerosols and leaves little or no residue. II
E.III.C. Avoid use of carpeting in high-traffic zones in patient-care areas or where spills are likely (e.g., burn therapy units, operating rooms, laboratories, and intensive care units). IB
E.III.D. Follow proper procedures for managing spills on carpeting.
E.III.D.1. Spot-clean blood or body substance spills promptly. (OSHA: 29 CFR 1910.1030 § d.4.ii.A, interpretation) IC
E.III.D.2. If a spill occurs on carpet tiles, replace any tiles contaminated by blood and body fluids or body substances. (OSHA 29 CFR 1910.1030 § d.4.ii interpretation) IC
E.III.E. Thoroughly dry wet carpeting to prevent the growth of fungi; replace carpeting that remains wet after 72 hours. IB
E.III.F. No recommendation is offered regarding the routine use of fungicidal or bactericidal treatments for carpeting in public areas of a health-care facility or in general patient-care areas. Unresolved issue
E.III.G. Do not use carpeting in hallways and patient rooms in areas housing immunosuppressed patients (e.g., PE areas). IB
E.III.H. Avoid the use of upholstered furniture and furnishings in high-risk patient-care areas and in areas with increased potential for body substance contamination (e.g., pediatrics units). II
E.III.I. No recommendation is offered regarding whether upholstered furniture and furnishings should be avoided in general patient-care areas. Unresolved issue
E.III.J. Maintain upholstered furniture in good repair. II
E.III.J.1. Maintain the surface integrity of the upholstery by repairing tears and holes. II
E.III.J.2. If upholstered furniture in a patient’s 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 the type of upholstery and the nature of the soil. II
E.IV. Flowers and Plants in Patient-Care Areas
Recommendations for flowers and plants in healthcare by ID number and category.
# Recommendation Category
E.IV.A. Flowers and potted plants need not be restricted from areas for immunocompetent patients. II
E.IV.B. Designate care and maintenance of flowers and potted plants to staff not directly involved with patient care. II
E.IV.C. If plant or flower care by patient-care staff is unavoidable, instruct the staff to wear gloves when handling the plants and flowers and perform hand hygiene after glove removal. II
E.IV.D. Do not allow fresh or dried flowers, or potted plants in patient-care areas for immunosuppressed patients. II
E.V. Pest Control
Recommendations for pest control in healthcare by ID number and category.
# Recommendation Category
E.V.A. Develop pest-control strategies, with emphasis on kitchens, cafeterias, laundries, central sterile supply areas, operating rooms, loading docks, construction activities, and other areas prone to infestations. II
E.V.B. Install screens on all windows that open to the outside; keep screens in good repair.107 IB
E.V.C. Contract for routine pest control service by a credentialed pest-control specialist who will tailor the application to the needs of a health-care facility. II
E.V.D. Place laboratory specimens (e.g., fixed sputum smears) in covered containers for overnight storage. II
E.VI. Special Pathogens
Edit [February 2017]

Edit: An indicates recommendations that were renumbered for clarity. The renumbering does not constitute change to the intent of the recommendations.

Recommendations for special pathogens by ID number and category.
# Recommendation Category
E.VI.A. Use appropriate hand hygiene, PPE (e.g., gloves), and isolation precautions during cleaning and disinfecting procedures. IB
E.VI.B. Use standard cleaning and disinfection protocols to control environmental contamination with antibiotic-resistant gram-positive cocci (e.g., methicillin-resistant Staphylococcus aureus, vancomycin intermediate-resistant Staphylococcus aureus, or vancomycin-resistant Enterococcus [VRE]). IB
E.VI.B.1. Pay close attention to cleaning and disinfection of high-touch surfaces in patient-care areas (e.g., bed rails, carts, bedside commodes, bedrails, doorknobs, or faucet handles). IB
E.VI.B.2. Ensure compliance by housekeeping staff with cleaning and disinfection procedures. IB
E.VI.B.3. Use EPA-registered hospital disinfectants appropriate for the surface to be disinfected (e.g., either low- or intermediate-level disinfection) as specified by the manufacturers’ instructions. (EPA: 7 USC § 136 et seq.) IB, IC
E.VI.B.4. When contact precautions are indicated for patient care, use disposable patient-care items (e.g., blood pressure cuffs) whenever possible to minimize cross-contamination with multiple-resistant microorganisms. IB
E.VI.B.5. Follow these same surface cleaning and disinfecting measures for managing the environment of VRSA patients. II
E.VI.C. Environmental-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 VRE. II
E.VI.C.1. Obtain prior approval from infection-control staff and the clinical laboratory before performing environmental surface culturing. II
E.VI.C.2. Infection-control staff, with clinical laboratory consultation, must supervise all environmental culturing. II
E.VI.D. Thoroughly clean and disinfect environmental and medical equipment surfaces on a regular basis using EPA-registered disinfectants in accordance with manufacturers’ instructions. (EPA: 7 USC § 136 et seq.) IB, IC
E.VI.E. Advise families, visitors, and patients about the importance of hand hygiene to minimize the spread of body substance contamination (e.g., respiratory secretions or fecal matter) to surfaces. II
E.VI.F. Do not use high-level disinfectants (i.e., liquid chemical sterilants) on environmental surfaces; such use is inconsistent with label instructions and because of the toxicity of the chemicals. (FDA: 21 CFR 801.5, 807.87.e) IC
E.VI.G. C. difficile Update [May 2019]


Update or clarification.

Recommendations E.VI.G. and E.VI.H. were updated to reflect changes in Federal regulatory approvals: LIST K: EPA’s Registered Antimicrobial Products Effective against Clostridium difficile Sporesexternal icon

Update: Use an EPA-registered product effective against Clostridium difficile spores for disinfection of environmental surfaces in rooms where C. difficile patients are treated.

New Categorization Scheme: Recommendation
E.VI.H. C. difficile Update [May 2019]


Update or clarification.

Recommendations E.VI.G. and E.VI.H. were updated to reflect changes in Federal regulatory approvals: LIST K: EPA’s Registered Antimicrobial Products Effective against Clostridium difficile Sporesexternal icon

Update: This recommendation has been superseded by recommendation E.VI.G.

E.VI.I. Apply standard cleaning and disinfection procedures to control environmental contamination with respiratory and enteric viruses in pediatric-care units and care areas for immunocompromised patients. (EPA: 7 USC § 136 et seq.) IC
E.VI.J. Clean surfaces that have been contaminated with body substances; perform low- to intermediate-level disinfection on cleaned surfaces with an EPA-registered disinfectant in accordance with the manufacturer’s instructions. (OSHA: 29 CFR 1910.1030 § d.4.ii.A; EPA: 7 USC § 136 et seq.) IC
E.VI.K. Use disposable barrier coverings as appropriate to minimize surface contamination. II
E.VI.L. Develop and maintain cleaning and disinfection procedures to control environmental contamination with agents of Creutzfeldt-Jakob disease (CJD), for which no EPA-registered product exists. II
E.VI.L.1. In the absence of contamination with central nervous system tissue, extraordinary measures (e.g., use of 2N sodium hydroxide [NaOH] or applying full-strength sodium hypochlorite) are not needed for routine cleaning or terminal disinfection of a room housing a confirmed or suspected CJD patient. II
E.VI.L.2. After removing gross tissue from the surface, use either 1N NaOH or a sodium hypochlorite solution containing approximately 10,000–20,000 ppm available chlorine (dilutions of 1:5 to 1:3 v/v, respectively, of U.S. household chlorine bleach; contact the manufacturers of commercially available sodium hypochlorite products for advice) to decontaminate operating room or autopsy surfaces with central nervous system or cerebral spinal fluid contamination from a diagnosed or suspected CJD patient.
  • * The contact time for the chemical used during this process should be 30 min–1 hour.
  • * Blot up the chemical with absorbent material and rinse the treated surface thoroughly with water.
  • * Discard the used, absorbent material into appropriate waste containment.
E.VI.L.3. Use disposable, impervious covers to minimize body substance contamination to autopsy tables and surfaces. IB
E.VI.M. Use standard procedures for containment, cleaning, and decontamination of blood spills on surfaces as previously described (Environmental Services: II). (OSHA: 29 CFR 1910.1030 §d.4.ii.A) IC
E.VI.M.1. Wear PPE appropriate for a surface decontamination and cleaning task. (OSHA 29 CFR 1910.1030 §d.3.i, ii) IC
E.VI.M.2. Discard used PPE by using routine disposal procedures or decontaminate reusable PPE as appropriate. (OSHA 29 CFR 1910.1030 §d.3.viii) IC

F. Environmental Sampling

F.I. General Information
Edit [February 2017]

Edit: An indicates recommendations that were renumbered for clarity. The renumbering does not constitute change to the intent of the recommendations.

Recommendations for general Environmental Sampling by ID number and category.
# Recommendation Category
F.I.A. Do not conduct random, undirected microbiologic sampling of air, water, and environmental surfaces in health-care facilities. IB
F.I.B. When indicated, conduct microbiologic sampling as part of an epidemiologic investigation or during assessment of hazardous environmental conditions to detect contamination and verify abatement of a hazard. IB
F.I.C. Limit microbiologic sampling for quality assurance purposes to
  • * biological monitoring of sterilization processes;
  • * monthly cultures of water and dialysate in hemodialysis units; and
  • * short-term evaluation of the impact of infection-control measures or changes in infection- control protocols.
F.II. Air, Water, and Environmental-Surface Sampling
Recommendations for air, water, and environmental-surface sampling by ID number and category.
# Recommendation Category
F.II.A. When conducting any form of environmental sampling, identify existing comparative standards and fully document departures from standard methods. II
F.II.B. Select a high-volume air sampling device if anticipated levels of microbial airborne contamination are expected to be low. II
F.II.C. Do not use settle plates to quantify the concentration of airborne fungal spores. II
F.II.D. When sampling water, choose growth media and incubation conditions that will facilitate the recovery of waterborne organisms. II
F.II.E. When using a sample/rinse method for sampling an environmental surface, develop and document a procedure for manipulating the swab, gauze, or sponge in a reproducible manner so that results are comparable. II
F.II.F. When 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. II

G. Laundry and Bedding

G.I. Employer Responsibilities
Recommendations for employer responsibilities by ID number and category.
# Recommendation Category
G.I.A. Employers must launder workers’ personal protective garments or uniforms that are contaminated with blood or other potentially infectious materials. (OSHA: 29 CFR 1910.1030 § d.3.iv) IC
G.II. Laundry Facilities and Equipment
Recommendations for laundry facilities and equipment by ID number and category.
# Recommendation Category
G.II.A. Maintain the receiving area for contaminated textiles at negative pressure compared with the clean areas of the laundry in accordance with AIA construction standards in effect during the time of facility construction. (AIA: 7.23.B1, B2) IC
G.II.B. Ensure that laundry areas have handwashing facilities and products and appropriate PPE available for workers. (AIA: 7.23.D4; OSHA: 29 CFR 1910.1030 § d.2.iii) IC
G.II.C. Use and maintain laundry equipment according to manufacturers’ instructions. II
G.II.D. Do not leave damp textiles or fabrics in machines overnight. II
G.II.E. Disinfection of washing and drying machines in residential care is not needed as long as gross soil is removed before washing and proper washing and drying procedures are used. II
G.III. Routine Handling of Contaminated Laundry
Recommendations for routine handling of contaminated laundry by ID number and category.
# Recommendation Category
G.III.A. Handle contaminated textiles and fabrics with minimum agitation to avoid contamination of air, surfaces, and persons. (OSHA: 29 CFR 1910.1030 § d.4.iv) IC
G.III.B. Bag or otherwise contain contaminated textiles and fabrics at the point of use. (OSHA: 29 CFR 1910.1030 § d.4.iv) IC
G.III.B.1. Do not sort or prerinse contaminated textiles or fabrics in patient-care areas. (OSHA: 29 CFR 1910.1030 §d.4.iv) IC
G.III.B.2. Use leak-resistant containment for textiles and fabrics contaminated with blood or body substances. (OSHA: 29 CFR 1910.1030 § d.4.iv) IC
G.III.B.3. Identify bags or containers for contaminated textiles with labels, color coding, or other alternative means of communication as appropriate. (OSHA: 29 CFR 1910.1030 § d.4.iv) IC
G.III.C. Covers are not needed on contaminated textile hampers in patient-care areas. II
G.III.D. If laundry chutes are used, ensure that they are properly designed, maintained, and used in a manner to minimize dispersion of aerosols from contaminated laundry. (AAMI: ANSI/AAMI ST65:2000) IC
G.III.D.1. Ensure that laundry bags are closed before tossing the filled bag into the chute. II
G.III.D.2. Do not place loose items in the chute. II
G.III.E. Establish a facility policy to determine when textiles or fabrics should be sorted in the laundry facility (i.e., before or after washing). II
G.IV. Laundry Process
Recommendations for laundry process by ID number and category.
# Recommendation Category
G.IV.A. If hot-water laundry cycles are used, wash with detergent in water ≥160°F (≥71°C) for ≥25 minutes. (AIA: 7.31.E3) IC
G.IV.B. No recommendation is offered regarding a hot-water temperature setting and cycle duration for items laundered in residence-style health-care facilities. Unresolved issue
G.IV.C. Follow fabric-care instructions and special laundering requirements for items used in the facility. II
G.IV.D. Choose chemicals suitable for low-temperature washing at proper use concentration if low- temperature (<160°F [<71°C]) laundry cycles are used. II
G.IV.E. Package, transport, and store clean textiles and fabrics by methods that will ensure their cleanliness and protect them from dust and soil during interfacility loading, transport, and unloading. II
G.V. Microbiologic Sampling of Textiles
Recommendations for microbiologic sampling of textiles by ID number and category.
# Recommendation Category
G.V.A. Do not conduct routine microbiological sampling of clean textiles. IB
G.V.B. Use microbiological sampling during outbreak investigations if epidemiologic evidence suggests a role for health-care textiles and clothing in disease transmission. IB
G.VI. Special Laundry Situations
Recommendations for special laundry situations by ID number and category.
# Recommendation Category
G.VI.A. Use sterilized textiles, surgical drapes, and gowns for situations requiring sterility in patient care. IB
G.VI.B. Use hygienically clean textiles (i.e., laundered, but not sterilized) in neonatal intensive care units. IB
G.VI.C. Follow manufacturers’ recommendations for cleaning fabric products including those with coated or laminated surfaces. II
G.VI.D. Do not use dry cleaning for routine laundering in health-care facilities. II
G.VI.E. Use caution when considering the use of antimicrobial mattresses, textiles, and clothing as replacements for standard bedding and other fabric items; EPA has not approved public health claims asserting protection against human pathogens for treated articles. II
G.VI.F. No recommendation is offered regarding using disposable fabrics and textiles versus durable goods. Unresolved issue
G.VII. Mattresses and Pillows
Recommendations for mattresses and pillows by ID number and category.
# Recommendation Category
G.VII.A. Keep mattresses dry; discard them if they become and remain wet or stained, particularly in burn units. IB
G.VII.B. Clean and disinfect mattress covers using EPA-registered disinfectants, if available, that are compatible with the cover materials to prevent the development of tears, cracks, or holes in the cover. IB
G.VII.C. Maintain the integrity of mattress and pillow covers. II
G.VII.C.1. Replace mattress and pillow covers if they become torn or otherwise in need of repair. II
G.VII.C.2. Do not stick needles into the mattress through the cover. II
G.VII.D. Clean and disinfect moisture-resistant mattress covers between patients using an EPA- registered product, if available. IB
G.VII.E. If using a mattress cover completely made of fabric, change these covers and launder between patients. IB
G.VII.F. Launder pillow covers and washable pillows in the hot-water cycle between patients or when they become contaminated with body substances. IB
G.VIII. Air-Fluidized Beds
Recommendations for air-fluidized beds by ID number and category.
# Recommendation Category
G.VIII.A. Follow manufacturers’ instructions for bed maintenance and decontamination. II
G.VIII.B. Change the polyester filter sheet at least weekly or as indicated by the manufacturer. II
G.VIII.C. Clean and disinfect the polyester filter sheet thoroughly, especially between patients, using an EPA-registered product, if available. IB
G.VIII.D. Consult the facility engineer to determine the proper location of air-fluidized beds in negative-pressure rooms. II

H. Animals in Health-Care Facilities

H.I. General Infection-Control Measures for Animal Encounters
Recommendations for infection-control measures for animal encounters by ID number and category.
# Recommendation Category
H.I.A. Minimize contact with animal saliva, dander, urine, and feces. II
H.I.B. Practice hand hygiene after any animal contact.2, 136 IB
H.I.B.1. Wash hands with soap and water, especially if hands are visibly soiled. IB
H.I.B.2. Use either soap and water or alcohol-based hand rubs when hands are not visibly soiled. IB
H.II. Animal-Assisted Activities, Animal-Assisted Therapy, and Resident Animal Programs
Recommendations for animals in healthcare facilities by ID number and category.
# Recommendation Category
H.II.A. Avoid selection of nonhuman primates and reptiles in animal-assisted activities, animal- assisted therapy, or resident animal programs. IB
H.II.B. Enroll animals that are fully vaccinated for zoonotic diseases and that are healthy, clean, well-groomed, and negative for enteric parasites or otherwise have completed recent antihelminthic treatment under the regular care of a veterinarian. II
H.II.C. Enroll animals that are trained with the assistance or under the direction of individuals who are experienced in this field. II
H.II.D. Ensure that animals are handled by persons trained in providing activities or therapies safely, and who know the animals’ health status and behavior traits. II
H.II.E. Take prompt action when an incident of biting or scratching by an animal occurs during an animal-assisted activity or therapy.
H.II.E.1. Remove the animal permanently from these programs. II
H.II.E.2. Report the incident promptly to appropriate authorities (e.g., infection-control staff, animal program coordinator, or local animal control). II
H.II.E.3. Promptly clean and treat scratches, bites, or other accidental breaks in the skin. II
H.II.F. Perform an ICRA and work actively with the animal handler prior to conducting an animal- assisted activity or therapy to determine if the session should be held in a public area of the facility or in individual patient rooms. II
H.II.G. Take precautions to mitigate allergic responses to animals. II
H.II.G.1. Minimize shedding of animal dander by bathing animals <24 hours before a visit. II
H.II.G.2. Groom animals to remove loose hair before a visit, or using a therapy animal cape. II
H.II.H. Use routine cleaning protocols for housekeeping surfaces after therapy sessions. II
H.II.I. Restrict resident animals, including fish in fish tanks, from access to or placement in 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 PE areas. II
H.II.J. Establish a facility policy for regular cleaning of fish tanks, rodent cages, bird cages, and any other animal dwellings and assign this cleaning task to a nonpatient-care staff member; avoid splashing tank water or contaminating environmental surfaces with animal bedding. II
H.III. Protective Measures for Immunocompromised Patients
Recommendations for protective measures for immunocompromised patients by ID number and category.
# Recommendation Category
H.III.A. Advise patients to avoid contact with animal feces and body fluids such as saliva, urine, or solid litter box material. II
H.III.B. Promptly clean and treat scratches, bites, or other wounds that break the skin. II
H.III.C. Advise patients to avoid direct or indirect contact with reptiles. IB
H.III.D. Conduct a case-by-case assessment to determine if animal-assisted activities or animal- assisted therapy programs are appropriate for immunocompromised patients. II
H.III.E. No recommendation is offered regarding permitting pet visits to terminally ill immunosuppressed patients outside their PE units. Unresolved issue
H.IV. Service Animals
Edit [February 2017]

Edit: An indicates recommendations that were renumbered for clarity. The renumbering does not constitute change to the intent of the recommendations.

Recommendations for service animals by ID number and category.
# Recommendation Category
H.IV.A. Avoid providing access to nonhuman primates and reptiles as service animals. IB
H.IV.B. Allow service animals access to the facility in accordance with the Americans with Disabilities Act of 1990, unless the presence of the animal creates a direct threat to other persons or a fundamental alteration in the nature of services. (U.S. Department of Justice: 28 CFR § 36.302) IC
H.IV.C. When a decision must be made regarding a service animal’s access to any particular area of the health-care facility, evaluate the service animal, the patient, and the health-care situation on a case-by-case basis to determine whether significant risk of harm exists and whether reasonable modifications in policies and procedures will mitigate this risk. (Justice: 28 CFR § 36.208 and App. B) IC
H.IV.D. If a patient must be separated from his or her service animal while in the health-care facility
  • * ascertain from the person what arrangements have been made for supervision or care of the animal during this period of separation; and
  • * make appropriate arrangements to address the patient’s needs in the absence of the service animal.
H.V. Animals as Patients in Human Health-Care Facilities
Recommendations for animals as patients in human healthcare facilities by ID number and category.
# Recommendation Category
H.V.A. Develop health-care facility policies to address the treatment of animals in human healthcare facilities.
H.V.A.1. Use the multidisciplinary team approach to policy development, including public media relations in order to disclose and discuss these activities. II
H.V.A.2. Exhaust all veterinary facility, equipment, and instrument options before undertaking the procedure. II
H.V.A.3. Ensure that the care of the animal is supervised by a licensed veterinarian. II
H.V.B. When animals are treated in human health-care facilities, avoid treating animals in operating rooms or other patient-care areas where invasive procedures are performed (e.g., cardiac catheterization laboratories, or invasive nuclear medicine areas). II
H.V.C. Schedule the animal procedure for the last case of the day for the area, at a time when human patients are not scheduled to be in the vicinity. II
H.V.D. Adhere strictly to standard precautions. II
H.V.E. Clean and disinfect environmental surfaces thoroughly using an EPA-registered product in the room after the animal is removed. II
H.V.F. Allow sufficient ACH to clean the air and help remove airborne dander, microorganisms, and allergens [Appendix B, Table B.1.]). II
H.V.G. Clean and disinfect using EPA-registered products or sterilize equipment that has been in contact with animals, or use disposable equipment. II
H.V.H. If reusable medical or surgical instruments are used in an animal procedure, restrict future use of these instruments to animals only. II
H.VI. Research Animals in Health-Care Facilities
Recommendations for research animals in healthcare facilities by ID number and category.
# Recommendation Category
H.VI.A. Use animals obtained from quality stock, or quarantine incoming animals to detect zoonotic diseases. II
H.VI.B. Treat sick animals or remove them from the facility. II
H.VI.C. Provide prophylactic vaccinations, as available, to animal handlers and contacts at high risk. II
H.VI.D. Ensure proper ventilation through appropriate facility design and location. (U.S. Department of Agriculture [USDA]: 7 USC 2131) IC
H.VI.D.1. Keep animal rooms at negative pressure relative to corridors. (USDA: 7 USC 2131) IC
H.VI.D.2. Prevent air in animal rooms from recirculating elsewhere in the health-care facility. (USDA: 7 USC 2131) IC
H.VI.E. Keep doors to animal research rooms closed. II
H.VI.F. Restrict access to animal facilities to essential personnel. II
H.VI.G. Establish employee occupational health programs specific to the animal research facility, and coordinate management of postexposure procedures specific for zoonoses with occupational health clinics in the health-care facility. (U.S. Department of Health and Human Services [DHHS]: BMBL; OSHA: 29 CFR 1910.1030.132-139) IC
H.VI.H. Document standard operating procedures for the unit. (DHHS: BMBL) IC
H.VI.I. Conduct routine employee training on worker safety issues relevant to the animal research facility (e.g., working safely with animals and animal handling). (DHHS: BMBL; OSHA: 29 CFR 1910.1030.132-139) IC
H.VI.J. Use precautions to prevent the development of animal-induced asthma in animal workers. (DHHS: BMBL) IC

I. Regulated Medical Waste

I.I. Categories of Regulated Medical Waste
Edit [February 2017]

Edit: An indicates recommendations that were renumbered for clarity. The renumbering does not constitute change to the intent of the recommendations.

Recommendations for categories of regulated medical waste by ID number and category.
# Recommendation Category
I.I.A. Designate the following as major categories of medical waste that require special handling and disposal precautions:
  • * microbiology laboratory wastes [e.g., cultures and stocks of microorganisms];
  • * bulk blood, blood products, blood, and bloody body fluid specimens;
  • * pathology and anatomy waste; and
  • * sharps [e.g., needles and scalpels].
I.I.B. Consult federal, state, and local regulations to determine if other waste items are considered regulated medical wastes. (States; Authorities having jurisdiction [AHJ]; OSHA: 29 CFR 1910.1030 §g.2.1; U.S. Department of Transportation [DOT]: 49 CFR 171-180; U.S. Postal Service: CO23.8) IC
I. II. Disposal Plan for Regulated Medical Wastes
Recommendations for disposal for regulated medical wastes by ID number and category.
# Recommendation Category
I.II.A. Develop a plan for the collection, handling, predisposal treatment, and terminal disposal of regulated medical wastes. (States; AHJ; OSHA: 29 CFR 1910.1030 §g.2.i;) IC
I.II.B. Designate a person or persons to be responsible for establishing, monitoring, reviewing, and administering the plan. II
I.III. Handling, Transporting, and Storing Regulated Medical Wastes
Recommendations for handling, transporting, and storing of medical waste by ID number and category.
# Recommendation Category
I.III.A. Inform personnel involved in the handling and disposal of potentially infective waste of the possible health and safety hazards; ensure that they are trained in appropriate handling and disposal methods. (OSHA: 29 CFR 1910.1030 § g.2.i) IC
I.III.B. Manage the handling and disposal of regulated medical wastes generated in isolation areas by using the same methods as for regulated medical wastes from other patient-care areas. II
I.III.C. Use proper sharps disposal strategies. (OSHA: 29 CFR 1910.1030 § d.4.iii.A) IC
I.III.C.1. Use a sharps container capable of maintaining its impermeability after waste treatment to avoid subsequent physical injuries during final disposal. (OSHA: 29 CFR 1910.1030 § d.4.iii.A) IC
I.III.C.2. 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. (OSHA: 29 CFR 1910.1030 § d.4.iii.A) IC
I.III.C.3. Do not bend, recap, or break used syringe needles before discarding them into a container. (OSHA: 29 CFR 1910.1030 § d.2.vii and § d.2.vii.A) IC
I.III.D. Store regulated medical wastes awaiting treatment in a properly ventilated area that is inaccessible to vertebrate pests; use waste containers that prevent the development of noxious odors. (States; AHJ) IC
I.III.E. If treatment options are not available at the site where the medical waste is generated, transport regulated medical wastes in closed, impervious containers to the on-site treatment location or to another facility for treatment as appropriate. (States; AHJ) IC
I.IV. Treatment and Disposal of Regulated Medical Wastes
Recommendations for treatment and disposal of medical wastes by ID number and category.
# Recommendation Category
I.IV.A. Treat regulated medical wastes by using a method (e.g., steam sterilization, incineration, interment, or an alternative treatment technology) approved by the appropriate authority having jurisdiction (AHJ) (e.g., states, Indian Health Service [IHS], Veterans Affairs [VA]) before disposal in a sanitary landfill. (States, AHJ) IC
I.IV.B. Follow precautions for treating microbiological wastes (e.g., amplified cultures and stocks of microorganisms). (DHHS: BMBL) IC
I.IV.B.1. Biosafety level 4 laboratories must inactivate microbiological wastes in the laboratory by using an approved inactivation method (e.g., autoclaving) before transport to and disposal in a sanitary landfill. (DHHS: BMBL) IC
I.IV.B.2. Biosafety level 3 laboratories must inactivate microbiological wastes in the laboratory by using an approved inactivation method (e.g., autoclaving) or incinerate them at the facility before transport to and disposal in a sanitary landfill.101 (DHHS: BMBL) IC
I.IV.C. Biosafety levels 1 and 2 laboratories should develop strategies to inactivate amplified microbial cultures and stocks onsite by using an approved inactivation method (e.g., autoclaving) instead of packaging and shipping untreated wastes to an offsite facility for treatment and disposal. II
I.IV.D. Laboratories that isolate select agents from clinical specimens must comply with federal regulations for the receipt, transfer, management, and appropriate disposal of these agents. (DHHS: 42 CFR 73 § 73.6) IC
I.IV.E. Sanitary sewers may be used for the safe disposal of blood, suctioned fluids, ground tissues, excretions, and secretions, provided that local sewage discharge requirements are met and that the state has declared this to be an acceptable method of disposal. II
I.V. Special Precautions for Wastes Generated During Care of Patients with Rare Diseases
Recommendations for precautions for wastes generated during care of patients with rare diseases by ID number and category.
# Recommendation Category
I.V.A. When discarding items contaminated with blood and body fluids from VHF patients, contain these regulated medical wastes with minimal agitation during handling. II
I.V.B. Manage properly contained wastes from areas providing care to VHF patients in accordance with recommendations for other isolation areas (Regulated Medical Waste: III B). II
I.V.C. Decontaminate bulk blood and body fluids from VHF patients using approved inactivation methods (e.g., autoclaving or chemical treatment) before disposal. (States; AHJ) IC, II
I.V.D. When discarding regulated medical waste generated during the routine (i.e., non-surgical) care of CJD patients, contain these wastes and decontaminate them using approved inactivation methods (e.g., autoclaving or incineration) appropriate for the medical waste category (e.g., blood, sharps, pathological waste). (States; AHJ) IC, II
I.V.E. Incinerate medical wastes (e.g., central nervous system tissues or contaminated disposable materials) from brain autopsy or biopsy procedures of diagnosed or suspected CJD patients. IB