Among the changes in the recommendations to prevent bacterial pneumonia, especially
ventilator-associated pneumonia, are the preferential use of oro-tracheal rather than naso-tracheal tubes in patients who receive mechanically assisted ventilation, the use of noninvasive ventilation to reduce the need for and duration of endotracheal intubation, changing the breathing circuits of ventilators when they malfunction or are visibly contaminated, and (when
feasible) the use of an endotracheal tube with a dorsal lumen to allow drainage of respiratory secretions; no
recommendations were made about the use of sucralfate, histamine-2 receptor antagonists, or antacids for stress-bleeding prophylaxis. For prevention of health-care--associated Legionnaires disease, the changes include maintaining potable hot water
at temperatures not suitable for amplification of
Legionella spp., considering routine culturing of water samples from
the potable water system of a facility's organ-transplant unit when it is done as part of the facility's comprehensive
program to prevent and control health-care--associated Legionnaires disease, and initiating an investigation for the source of Legionella spp. when one definite or one possible case of laboratory-confirmed health-care--associated Legionnaires disease is identified in an inpatient hemopoietic stem-cell transplant (HSCT) recipient or in two or more
HSCT recipients who had visited an outpatient HSCT unit during all or part of the 2--10 day period before illness onset. In the section on aspergillosis, the revised recommendations include the use of a room with high-efficiency particulate air filters rather than laminar airflow as the protective environment for allogeneic HSCT recipients and the use of high-efficiency respiratory-protection devices (e.g., N95 respirators) by severely immunocompromised patients when they leave their rooms when dust-generating activities are ongoing in the facility. In the respiratory syncytial virus (RSV) section, the new recommendation is to determine, on a case-by-case basis, whether to administer monoclonal
antibody (palivizumab) to certain infants and children aged <24 months who were born prematurely and are at high risk for RSV infection. In the section on influenza, the new recommendations include the addition of oseltamivir
(to amantadine and rimantadine) for prophylaxis of all patients without influenza illness and oseltamivir and zanamivir (to amantadine and rimantadine) as treatment for patients who are acutely ill with influenza in a unit where an influenza outbreak is recognized.
In addition to the revised recommendations, the guideline contains new sections on pertussis and lower
respiratory tract infections caused by adenovirus and human parainfluenza viruses and refers readers to the source of updated information about prevention and control of
severe acute respiratory syndrome.
Because of the high morbidity and mortality associated with health-care--associated pneumonia, several guidelines for its prevention and control have been published. The first CDC Guideline for Prevention of Nosocomial Pneumonia
was published in 1981 and addressed the main infection-control problems related to hospital-acquired pneumonia at the time: the use of large-volume nebulizers that were attached to mechanical ventilators and improper reprocessing (i.e., cleaning and disinfection or sterilization) of respiratory-care equipment. The document also covered the prevention and control of hospital-acquired influenza and respiratory syncytial virus (RSV) infection.
In 1994, the Healthcare Infection Control Practices Advisory Committee (HICPAC) (then known as the
Hospital Infection Control Practices Advisory Committee) revised and expanded the CDC Guideline for Prevention of Nosocomial Pneumonia to include Legionnaires disease and pulmonary aspergillosis
(1). HICPAC advises the secretary of Health
and Human Services and the directors of CDC about the prevention and control of health-care--associated infections
and related adverse events. The 1994 guideline addressed concerns related to preventing ventilator-associated pneumonia (VAP) (e.g., the role of stress-ulcer prophylaxis in the causation of pneumonia and the contentious roles of selective
gastrointestinal decontamination and periodic changes of ventilator tubings in the prevention of the infection). The report also presented major changes in the recommendations to prevent and control hospital-acquired pneumonia caused by
Legionnella spp. and aspergilli.
In recent years, demand has increased for guidance on preventing and controlling pneumonia and other lower
respiratory tract infections in health-care settings other than the acute-care hospital, probably resulting in part from the progressive shift in the burden and focus of health care in the United States away from inpatient care in the acute-care hospital and
towards outpatient and long-term care in other health-care settings. In response to this demand, HICPAC revised the guideline to cover these other settings. However, infection-control data about the acute-care hospital setting are more abundant and well-analyzed; in comparison, data are limited from long-term care, ambulatory, and psychiatric facilities and other health-care settings.
Part I of the guideline provides the background for the recommendations and includes a discussion of the epidemiology, diagnosis, pathogenesis, modes of transmission, and prevention and control of the infections (3). Part I can be an important resource for educating health-care personnel.
Because education of health-care personnel is the cornerstone of an
effective infection-control program, health-care agencies should give high priority to continuing infection-control education programs for their staff members.
HICPAC recommendations address such issues as education of health-care personnel about the prevention and control
of health-care--associated pneumonia and other lower respiratory tract infections, surveillance and reporting of
diagnosed cases of infections, prevention of person-to-person transmission of each disease, and reduction of host risk for infection.
The document was prepared by CDC; reviewed by experts in infection control, intensive-care medicine,
pulmonology, respiratory therapy, anesthesiology, internal medicine, and pediatrics; and approved by HICPAC. The recommendations are endorsed by the American College of Chest Physicians, American Healthcare Association, Association for Professionals
of Infection Control and Epidemiology, Infectious Diseases Society of America, Society for Healthcare Epidemiology of
America, and Society of Critical Care Medicine.
Protective environment (PE) is a specialized patient-care area, usually in a hospital, with a positive air flow relative to the corridor (i.e., air flows from the room to the outside adjacent space). The combination of high-efficiency particulate
(HEPA) filtration, high numbers (>12) of air changes per hour (ACH), and minimal leakage of air into the room creates an environment that can safely accommodate patients who have received allogeneic hemopoietic stem-cell transplant (HSCT).
Immunocompromised patients are those patients whose immune mechanisms are deficient because of
immunologic disorders (e.g., human immunodeficiency virus [HIV] infection, congenital immune deficiency syndrome, and
chronic diseases [(diabetes mellitus, cancer, emphysema, or cardiac failure]), or immunosuppressive therapy (e.g.,
radiation, cytotoxic chemotherapy, anti-rejection medication, and steroids). Immunocompromised patients who are identified as patients at high risk have the greatest risk for infection and include persons with severe neutropenia (i.e., an absolute neutrophil count [ANC] of <500 cells/mL) for prolonged periods of time, recipients of allogeneic HSCT, and those who receive the
most intensive chemotherapy (e.g., patients with childhood acute myelogenous leukemia).
In this document, each recommendation is categorized on the basis of existing scientific evidence, theoretical
rationale, applicability, and potential economic impact. In addition, a new category accommodates recommendations that are made on the basis of existing national or state health regulations. The following categorization scheme is applied in this guideline:
Educate health-care workers about the epidemiology of, and infection-control procedures for, preventing
health-care--associated bacterial pneumonia to ensure worker competency according to the worker's level of responsibility in the health-care setting, and involve the workers in the implementation of interventions to prevent
health-care--associated pneumonia by using
performance-improvement tools and techniques (IA) (4--11).
Updated information about prevention and control of
severe acute respiratory syndrome in health-care facilities is
available in a separate publication (433).
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