The health-care facility environment is rarely implicated in disease transmission, except among patients who are immunocompromised. Nonetheless, inadvertent exposures to environmental pathogens (e.g., Aspergillus spp. and Legionella spp.) or airborne pathogens (e.g., Mycobacterium tuberculosis and varicella-zoster virus) can result in adverse patient outcomes and cause illness among health-care workers. Environmental infection-control strategies and engineering controls can effectively prevent these infections. The incidence of health-care--associated infections and pseudo-outbreaks can be minimized by 1) appropriate use of cleaners and disinfectants; 2) appropriate maintenance of medical equipment (e.g., automated endoscope reprocessors or hydrotherapy equipment); 3) adherence to water-quality standards for hemodialysis, and to ventilation standards for specialized care environments (e.g., airborne infection isolation rooms, protective environments, or operating rooms); and 4) prompt management of water intrusion into the facility. Routine environmental sampling is not usually advised, except for water quality determinations in hemodialysis settings and other situations where sampling is directed by epidemiologic principles, and results can be applied directly to infection-control decisions. This report reviews previous guidelines and strategies for preventing environment-associated infections in health-care facilities and offers recommendations. These include 1) evidence-based recommendations supported by studies; 2) requirements of federal agencies (e.g., Food and Drug Administration, U.S. Environmental Protection Agency, U.S. Department of Labor, Occupational Safety and Health Administration, and U.S. Department of Justice); 3) guidelines and standards from building and equipment professional organizations (e.g., American Institute of Architects, Association for the Advancement of Medical Instrumentation, and American Society of Heating, Refrigeration, and Air-Conditioning Engineers); 4) recommendations derived from scientific theory or rationale; and 5) experienced opinions based upon infection-control and engineering practices. The report also suggests a series of performance measurements as a means to evaluate infection-control efforts.

Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC)

This report updates, expands, and replaces the previously published CDC "Guideline for Prevention of Nosocomial Pneumonia". The new guidelines are designed to reduce the incidence of pneumonia and other severe, acute lower respiratory tract infections in acute-care hospitals and in other health-care settings (e.g., ambulatory and long-term care institutions) and other facilities where health care is provided. 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.

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Guidelines for Preventing Health-Care-- Associated Pneumonia, 2003 Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee

Colloid mobilization and transport in groundwater

Publisher Summary This chapter discusses antimicrobial activity and action of silver. Silver and its compounds have long been used, in one form or another, as antimicrobial agents. The silver compound of major therapeutic interest at the present time is silver sulphadiazine. Many in healthcare know that other silver compounds are still in use. It is worth stating that the treatment of ophthalmia neonatorum was revolutionized by the instillation of silver derivatives into the eyes of new-born sufferers. Several factors influence the antimicrobial activity of silver salts. Silver has a marked tendency to adsorb to surfaces and bactericidal activity is reduced in the presence of phosphates, chlorides, sulphides and hard water. Activity is increased as the temperature is raised and is pH-dependent, increasing with increasing pH. Sodium thioglycollate has been recommended as a suitable neutralizing agent for use in bactericidal testing although other SH compounds also fulfil this role. Silver, one of the native metals and second only to gold in its stability amongst the metals of antiquity, has provided several therapeutic agents which have been employed since the beginning of recorded history. These agents range from the metal itself, its salts and complexes with proteins and other macromolecules to the latest, silver sulphadiazine (AgSD).

Antimicrobial activity and action of silver

Guidelines for environmental infection control in health-care facilities. Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC).

In a series of pH 7 continuous-flow column experiments, removal of the bacteriophage MS-2 by attachment to silica beads had a strong, systematic dependence on the amount of hydrophobic surface present on the beads. With no hydrophobic surface, removal of phage at pH 5 was much greater than at pH 7. Release of attached phage at both pH values did occur, but was slow; breakthrough curves exhibited tailing. Poliovirus attached to silica beads at pH 5.5 much more than at pH 7.0, and attachment was also slowly reversible. Time scales for phage and poliovinis attachment were of the order of hours. The sticking efficiency factor (α), reflecting microscaie physicochemical influences on virus attachment, was in the range of 0.0007–0.02. Phage release was small but measurable under steady state conditions. Release was enhanced by lowering ionic strength and by introducing beef extract, a high-ionic-strength protein solution. Results show that viruses experience reversible attachment/detachment (sometimes termed sorption), that large chemical perturbations are needed to induce rapid virus detachment, and that viruses should be quite mobile in sandy porous media. Even small amounts of hydrophobic organic material in the porous media (≥0.001%) can retard virus transport.

Ms-2 and poliovirus transport in porous media : hydrophobic effects and chemical perturbations

Water disinfection systems utilizing electrolytically generated copper and silver ions (200 and 20, 400 and 40, or 800 and 80 micrograms/liter) and low levels of free chlorine (0.1 to 0.4 mg/liter) were evaluated at room (21 to 23 degrees C) and elevated (39 to 40 degrees C) temperatures in filtered well water (pH 7.3) for their efficacy in inactivating Legionella pneumophila (ATCC 33155). At room temperature, a contact time of at least 24 h was necessary for copper and silver (400 and 40 micrograms/liter) to achieve a 3-log10 reduction in bacterial numbers. As the copper and silver concentration increased to 800 and 80 micrograms/liter, the inactivation rate significantly (P less than or equal to 0.05) increased from K = 2.87 x 10(-3) to K = 7.50 x 10(-3) (log10 reduction per minute). In water systems with and without copper and silver (400 and 40 micrograms/liter), the inactivation rates significantly increased as the free chlorine concentration increased from 0.1 mg/liter (K = 0.397 log10 reduction per min) to 0.4 mg/liter (K = 1.047 log10 reduction per min). Compared to room temperature, no significant differences were observed when 0.2 mg of free chlorine per liter with and without 400 and 40 micrograms of copper and silver per liter was tested at 39 to 40 degrees C. All disinfection systems, regardless of temperature or free chlorine concentration, showed increase inactivation rates when 400 and 40 micrograms of copper and silver per liter was added; however, this trend was significant only at 0.4 mg of free chlorine per liter.

Efficacy of copper and silver ions and reduced levels of free chlorine in inactivation of Legionella pneumophila.

Transport of the bacteriophage PRD-1, bacteria, and latex microspheres was studied in a sandy aquifer under natural-gradient conditions. The field injection was carried out at the U.S. Geological Survey's Toxic Substances Hydrology research site on Cape Cod. The three colloids and a salt tracer (Br−) moved along the same path. There was significant attenuation of the phage, with PRD-1 peak concentrations less than 0.001 percent of Br− peaks 6 m from the source; but the low detection limit (one per ml) enabled tracking movement of the PRD-1 plume for 12 m downgradient over the 25-day experiment. Attenuation of phage was apparently due to retention on soil particles (adsorption). Attenuation of bacteria and microspheres was less, with peak concentrations 6 m from the source on the order of 10 and 0.4 percent of Br−, respectively. Injection of a high-pH pulse of water 20 days into the experiment resulted in significant remobilization of retained phage, demonstrating that attached phage remained viable, and that PRD-1 attachment to and detachment from the sandy soil particles was highly pH dependent. Phage behavior in this experiment, i.e. attenuation at pH 5.7 and rapid resuspension at pH 6–8, was consistent with that observed previously in laboratory column studies. Results illustrate that biocolloids travel in a fairly narrow plume in sandy (relatively homogeneous) media, with virus concentrations dropping below detection limit several meters away from the source; bacteria concentrations above detection limits can persist over longer distances.

Virus and Bacteria Transport in a Sandy Aquifer, Cape Cod, MA

Virus transport and removal in wastewater during aquifer recharge

Two bacteriophages, MS-2 and PRD-1, were added to water to an initial concentration of 10 5 -10 6 pfu mL -1 in a trench-to-trench lateral groundwater flow and tracer migration experiment in the upper 55 m of a weathered and fractured clay-rich till Phage were detected in water from seepage collectors set in the wall of a downgradient (gradient=024) trench, located 4 m from the source trench, between 1 and 2 days after the start of the injection Peak phage concentrations in the collectors were typically 10 2 -10 4 pfu mL -1 , and detectable phage (>01 pfu mL -1 ) persisted for up to 5 days In contrast, the travel time for bromide in the same trenches was several months

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Moyasar T. Yahya

Papers

Ms-2 and poliovirus transport in porous media : hydrophobic effects and chemical perturbations

Efficacy of copper and silver ions and reduced levels of free chlorine in inactivation of Legionella pneumophila.

Virus and Bacteria Transport in a Sandy Aquifer, Cape Cod, MA

Virus transport and removal in wastewater during aquifer recharge

A field example of bacteriophage as tracers of fracture flow