Practice Guidelines

CDC and HICPAC Release Updated Guidelines on the Prevention of Health-Care–Associated Pneumonia



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Am Fam Physician. 2004 Aug 1;70(3):596-598.

The Centers for Disease Control and Prevention (CDC) and the Healthcare Infection Control Practices Advisory Committee (HICPAC) has issued recommendations on reducing the incidence of pneumonia and other severe, acute lower respiratory tract infections in acute-care hospitals and in other health care settings. This report updates, expands, and replaces the 1994 “Guideline for Prevention of Nosocomial Pneumonia.”

The report contains the consensus HICPAC recommendations for the prevention of the following infections: bacterial pneumonia, legionnaires’ disease, pertussis, invasive pulmonary aspergillosis, lower respiratory tract infections caused by respiratory syncytial virus, parainfluenza and adenoviruses, and influenza. These recommendations address issues such as educating 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 infection, prevention of person-to-person transmission of each disease, and reduction of host risk for infection. The guideline authors were unable to make recommendations for a number of interventions where evidence is lacking. For more details on these items, see the full guideline. The recommendations appear in the March 26, 2004 recommendations and reports series of Morbidity and Mortality Weekly Report, and are available online at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm.

Prevention of Health-Care–Associated Bacterial Pneumonia

STAFF EDUCATION AND INVOLVEMENT IN INFECTION PREVENTION

The authors recommend educating health care workers about the epidemiology of, and infection-control procedures for, preventing health-care–associated bacterial pneumonia to ensure worker competency according to their level of responsibility in the health care setting. Workers should be involved in the implementation of interventions to prevent health-care–associated pneumonia by using performance-improvement techniques and tools.

INFECTION AND MICROBIOLOGIC SURVEILLANCE

Surveillance should be conducted for bacterial pneumonia in intensive care unit patients who are at high risk for health-care–related bacterial pneumonia (e.g., patients with mechanically assisted ventilation, selected postoperative patients) to help identify outbreaks and other potential infection-control problems. The authors recommend the use of the National Nosocomial Infection Surveillance system’s surveillance definition of pneumonia. Monitored rates (e.g., number of infected patients) should be linked with prevention efforts, and data should be returned to appropriate health care personnel.

In the absence of specific clinical, epidemiologic, or infection-control objectives, surveillance cultures of patients or of equipment or devices used for respiratory therapy, pulmonary-function testing, or delivery of inhalation anesthesia should not be routinely performed.

PREVENTION OF TRANSMISSION OF MICROORGANISMS

Sterilization or disinfection and maintenance of equipment and devices:

  • Thoroughly clean all equipment and devices to be sterilized or disinfected.

  • Whenever possible, use steam sterilization (by autoclaving) or high-level disinfection by wet heat pasteurization at > 70°C (>158°F) for 30 minutes for reprocessing semicritical equipment or devices (i.e., items that come in direct contact with mucous membranes of the lower respiratory tract) that are not sensitive to heat and moisture. For equipment or devices that are sensitive to heat and moisture, low-temperature sterilization methods should be used. After disinfection, proceed with appropriate rinsing, drying, and packaging, being careful not to contaminate the disinfected items.

  • Preferentially use sterile water for rinsing reusable semicritical respiratory equipment and devices when rinsing is needed after they have been chemically treated. If this is not possible, rinse the device with filtered water or tap water, and then rinse with isopropyl alcohol and dry with forced air or in a drying cabinet.

  • Adhere to provisions in the U.S. Food and Drug Administration’s (FDA) enforcement document for single-use devices that are reprocessed by third parties.

  • Do not routinely sterilize or disinfect the internal machinery of mechanical ventilators.

  • Do not change routinely, on the basis of duration of use, the breathing circuit (i.e., ventilator tubing and exhalation valve and the attached humidifier) that is in use on an individual patient. Change the circuit when it is visibly soiled or mechanically malfunctioning.

  • Periodically drain and discard any condensate that collects in the tubing of a mechanical ventilator, taking precautions not to allow condensate to drain toward the patient. Gloves should be worn when performing this procedure or handling the fluid. After performing the procedure or handling the fluid, decontaminate your hands with soap and water or an alcohol-based hand rub.

  • Use sterile (not distilled, nonsterile) water to fill bubbling humidifiers.

  • A heat-moisture exchanger (HME) should be changed when it malfunctions mechanically or becomes visibly soiled. An HME that is in use on a patient should not be routinely changed more often than every 48 hours.

  • The breathing circuit attached to an HME while it is in use on a patient should not be changed routinely (in the absence of gross contamination or malfunction).

  • The manufacturers’ instructions for the use of oxygen humidifiers should be followed. The humidifier tubing (including any nasal prongs or mask) should be changed when it malfunctions or becomes visibly contaminated.

  • Between treatments on the same patient, small-volume medication nebulizers (in-line and hand-held) should be cleaned, disinfected, rinsed with sterile water (if rinsing is needed), and dried. Use only sterile fluid for nebulization, and dispense the fluid into the nebulizer aseptically. Whenever possible, use aerosolized medications in single-dose vials. If multidose medication vials are used, follow the manufacturers’ instructions for handling, storing, and dispensing the medications.

  • Between uses on different patients, replace mist tents and their nebulizers, reservoirs, and tubings with those that have been subjected to sterilization or high-level disinfection.

  • Mist-tent nebulizers, reservoirs, and tubings that are used on the same patient should be subjected to daily low-level disinfection (e.g., with 2% acetic acid) or pasteurization followed by air-drying.

  • Between uses on different patients, portable respirometers and ventilator thermometers should be sterilized or subjected to high-level disinfection.

  • Between uses on different patients, reusable hand-powered resuscitation bags should be sterilized or subjected to high-level disinfection.

  • Do not routinely sterilize or disinfect the internal machinery of anesthesia equipment.

  • Between uses on different patients, clean reusable components of the breathing system or patient circuit inspiratory and expiratory breathing tubing, y-piece, reservoir bag, humidifier, and tubing, and then sterilize or subject them to high-level liquid chemical disinfection or pasteurization in accordance with the device manufacturers’ instructions.

  • Follow published guidelines or manufacturers’ instructions about in-use maintenance, cleaning, and disinfection or sterilization of other components or attachments of the breathing system or patient circuit of anesthesia equipment.

  • Do not routinely sterilize or disinfect the internal machinery of pulmonary-function testing machine between uses on different patients.

  • The mouthpiece of a peak flow meter or the mouth-piece and filter of a spirometer should be changed between uses on different patients.

  • Do not use large-volume room-air humidifiers that create aerosols unless they can be sterilized or subjected to high-level disinfection at least daily and filled with only sterile water.

  • If Legionella spp. are detected in the water of a transplant unit and until Legionella spp. are no longer detected by culture, remove faucet aerators in the unit.

Prevention of person-to-person transmission of bacteria:

  • Decontaminate hands by washing them with anti-microbial soap and water or with nonantimicrobial soap and water (if hands are visibly dirty or contaminated with proteinaceous material or are soiled with blood or body fluids) or by using an alcohol-based waterless antiseptic agent if hands are not visibly soiled after contact with mucous membranes, respiratory secretions, or objects contaminated with respiratory secretions, whether or not gloves are worn.

  • Decontaminate hands as described previously before and after contact with a patient who has an endotracheal or tracheostomy tube in place, and before and after contact with any respiratory device that is used on the patient, whether or not gloves are worn.

  • Wear gloves for handling respiratory secretions or objects contaminated with respiratory secretions of any patient.

  • Change gloves and decontaminate hands as described previously between contacts with different patients; after handling respiratory secretions or objects contaminated with secretions from one patient and before contact with another patient, object, or environmental surface; and between contacts with a contaminated body site and the respiratory tracts of, or respiratory device on, the same patient.

  • When soiling with respiratory secretions from a patient is expected, wear a gown and change it after soiling occurs and before providing care to another patient.

  • Perform tracheostomy under aseptic conditions.

  • When changing a tracheostomy tube, wear a gown, use aseptic technique, and replace the tube with one that has undergone sterilization or high-level disinfection.

  • If the open-system suction is employed, use a sterile, single-use catheter.

  • Use only sterile fluid to remove secretions from the suction catheter if the catheter is to be used for re-entry into the patient’s lower respiratory tract.

MODIFYING HOST RISK FOR INFECTION

Increasing host defense against infection: administration of immune modulators:

  • Patients at high risk for severe pneumococcal infections should be vaccinated.

  • The following groups of people should receive the 23-valent pneumococcal polysaccharide vaccine: persons who are at least 65 years of age; persons aged five to 64 years who have chronic cardiovascular disease, chronic pulmonary disease, diabetes mellitus, alcoholism, chronic liver disease, or cerebrospinal fluid leaks; persons aged five to 64 years who have functional or anatomic asplenia; persons aged five to 64 years who are living in special environments or social settings; immunocompromised persons five years of age or older with human immunodeficiency virus infection, leukemia, lymphoma, Hodgkin’s disease, multiple myeloma, generalized malignancy, chronic renal failure, nephrotic syndrome, or other conditions associated with immunosuppression; and persons in long-term care facilities.

  • The 7-valent pneumococcal polysaccharide protein-conjugate vaccine should be administered to all children at least two years of age and to children aged 24 to 59 months who are at increased risk for pneumococcal disease. Consider administering the vaccine to children aged 24 to 59 months, with priority to children aged 24 to 35 months, children who are Native Americans/Alaska Natives or black, and children who attend group child care centers.

  • In nursing home and other long-term facilities, establish a standing order program for the administration of 23-valent vaccine to persons who are at high-risk for acquiring severe pneumococcal infections, including pneumococcal pneumonia.

Precautions for prevention of aspiration:

  • Devices such as endotracheal, tracheostomy, and/or enteral tubes should be removed from patients as soon as the clinical indicator for their use is resolved.

  • When feasible and not medically contraindicated, use noninvasive positive-pressure ventilation delivered continuously by face or nose mask, instead of performing endotracheal intubation in patients who are in respiratory failure and do not need immediate intubation.

  • When feasible and not medically contraindicated, use noninvasive ventilation as part of the weaning process (from mechanically assisted ventilation) to shorten the period of endotracheal intubation.

  • As much as possible, avoid repeat endotracheal intubation in patients who have received mechanically assisted ventilation.

  • Unless contraindicated by the patient’s condition, perform orotracheal rather than nasotracheal intubation.

  • If feasible, use an endotracheal tube with a dorsal lumen above the endotracheal cuff to allow drainage (by continuous or frequent intermittent suctioning) of tracheal secretions that accumulate in the patient’s subglottic area.

  • Before deflating the cuff of an endotracheal tube in preparation for tube removal, or before moving the tube, ensure that secretions are cleared from above the tube cuff.

  • In the absence of medical contraindications, elevate at an angle of 30 to 45 degrees of the head of the bed of a patient at high risk for aspiration (e.g., a person receiving mechanically assisted ventilation and/or who has an enteral tube in place).

  • Routinely verify appropriate placement of the enteral feeding tube.

  • Oropharyngeal cleaning and decontamination with an antiseptic agent: develop and implement a comprehensive oral-hygiene program for patients in acute-care settings or residents in long-term care facilities who are at high risk for health-care–associated pneumonia.

  • Use an oral chlorhexidine gluconate rinse during the perioperative period on adult patients who undergo cardiac surgery.

Prevention of postoperative pneumonia:

  • Preoperative patients, especially those at high risk for contracting pneumonia, should be instructed about taking deep breaths and ambulating as soon as medically indicated in the postoperative period.

  • All postoperative patients should be encouraged to take deep breaths, move about the bed, and ambulate unless medically contraindicated.

  • Use incentive spirometry on postoperative patients who are at high risk for pneumonia.


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