Practice Guidelines
CDC and HICPAC Release Updated Guidelines on the Prevention of Health-Care-Associated Pneumonia
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 mouthpiece 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 antimicrobial 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.
Practice Guideline Briefs
Nausea and Vomiting in Pregnancy
The American College of Obstetricians and Gynecologists (ACOG) has released a new guideline on diagnosing and treating nausea and vomiting (morning sickness) in pregnancy. "ACOG Practice Bulletin No. 52: Nausea and Vomiting of Pregnancy," appears in the April 2004 issue of Obstetrics and Gynecology and is available online at http://www.greenjournal.org/cgi/reprint/103/4/803.
The guideline reviews the prevalence, risk factors, and clinical recommendations in treating morning sickness. While the cause of morning sickness remains unknown, there are effective treatments to prevent and treat the problem.
Nausea and vomiting are common in early pregnancy, affecting 70 to 85 percent of pregnant women. Morning sickness typically begins within the first nine weeks of pregnancy, with symptoms ranging from mild to severe. Severe morning sickness (hyperemesis gravidarum) occurs in approximately 0.5 to 2 percent of pregnancies. It is the most common indication for hospitalization during early pregnancy and second only to preterm labor as the most common reason for hospitalization during pregnancy.
According to ACOG, some pregnant women have a higher risk of having hyperemesis gravidarum. They include women carrying multiple fetuses, daughters and sisters of women who had the condition, women carrying a female fetus, and women with a history of hyperemesis gravidarum in a previous pregnancy. Other risk factors include a history of motion sickness or migraines.
Some women do not seek treatment for morning sickness because of concerns about treatment safety. Yet, once symptoms progress, treatment can become more difficult. Mild cases may be resolved with lifestyle and dietary changes, and safe and effective treatments are available for more severe cases.
The following recommendations for the prevention and treatment of nausea and vomiting of pregnancy are based on consistent scientific evidence:
• Taking a multivitamin at the time of conception may decrease the severity of symptoms.
• Taking Vitamin B6 alone or with doxylamine (an antihistamine) is safe and effective and should be considered a first-line treatment.
The following recommendations are based on limited or inconsistent scientific evidence:
• Ginger has shown beneficial effects and can be considered a nonpharmacologic option.
• Antihistamine H1-receptor blockers, phenothiazines, and benzamines have been shown to be safe and effective in treating refractory cases.
• Early treatment of symptoms is recommended to prevent progression to hyperemesis gravidarum.
• Treatment with methylprednisolone (a steroid) may be effective in severe cases, but should be a treatment of last resort because of its potential risk to the fetus.
Use of Transcranial Doppler Ultrasonography
The Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology has released a guideline on transcranial Doppler ultrasonography (TCD) and transcranial color-coded sonography as a diagnostic aid in patients with cerebrovascular disease. "Assessment: Transcranial Doppler Ultrasonography" appears in the May 2004 issue of Neurology and is available online at http://www.aan.com/professionals/practice/guideline/index.cfm#Child.
According to the guideline, TCD provides valuable information in two situations: (1) screening children two to 16 years of age with sickle cell disease for risk of stroke, and (2) detecting and monitoring of vasospasms after subarachnoid hemorrhage.
In other situations, TCD was found to provide important information, but the value of the test, compared with other tests, has not been determined. These include detection of cerebral circulatory arrest and brain death, and monitoring of coronary artery bypass graft operations.
In some situations, TCD does provide important information, but other tests are preferable. These include detection of right-to-left cardiac shunts, and evaluation of extracranial internal carotid artery stenosis.
Increases in Fluoroquinolone-Resistant Neisseria Gonorrhoeae
The Centers for Disease Control and Prevention (CDC) has released revised recommendations for gonorrhea treatment based on an increase in fluoroquinolone-resistant Neisseria gonorrhoeae. "Increases in Fluoroquinolone-Resistant Neisseria gonorrhoeae Among Men Who Have Sex with Men-United States, 2003, and Revised Recommendations for Gonorrhea Treatment, 2004" appears in the April 30, 2004, issue of Morbidity and Mortality Weekly Report and is available online at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5316a1.htm.
In the United States, an estimated 700,000 to 800,000 persons are infected with N. gonorrhoeae annually. Since 1993, the CDC has recommended use of fluoroquinolones (i.e., ciprofloxacin, ofloxacin, or levofloxacin) for gonorrhea treatment. Fluoroquinolones are used frequently to treat gonorrhea in the United States because they are inexpensive and easy to administer and their continued use might decrease the use of cephalosporins and delay the development of cephalosporin resistance.
However, local and national data suggest that the prevalence of fluoroquinolone-resistant N. gonorrhoeae (QRNG) among men who have sex with men infected with gonorrhea is close to or exceeds 5 percent. While this level of resistance often is used as the level at which a therapeutic regimen should be changed, other factors, including prevalence of gonorrhea, availability of antimicrobial susceptibility data, and cost of various diagnostic and treatment options, might result in higher or lower thresholds for change. In the absence of antimicrobial susceptibility testing or tests of cure, fluoroquinolones should no longer be used to treat proven or suspected gonococcal infections in men who have sex with men.
Fluoroquinolones also should not be used to treat patients whose gonorrhea was acquired in Asia, the Pacific Islands (including Hawaii), California, and other areas, such as England and Wales, with increased QRNG prevalence. For those infections acquired where QRNG is not endemic, before determining treatment, physicians should obtain travel histories from patients and information on the gender of sex partners from male patients with proven or suspected gonorrhea. A list of places that should be included in a relevant travel history is available online at http://www.cdc.gov/std/gisp.
For male patients with gonorrhea who have sex with men or who provide a history suggesting acquisition of infection in an area with high QRNG prevalence, the CDC recommends ceftriaxone, 125 mg intramuscularly, or cefixime, 400 mg orally (which is not available in the United States); spectinomycin, 2 g intramuscularly, is an alternative. Spectinomycin may be used for urogenital and anorectal gonorrhea but is not sufficiently effective to treat pharyngeal gonorrhea. If Chlamydia trachomatis is not ruled out, each regimen should be followed with either azithromycin, 1 g orally (single dose), or doxycycline, 100 mg orally twice daily for seven days, to treat possible co-infection with chlamydia.
The limited availability of a recommended oral treatment regimen for gonorrhea poses practical problems for treating QRNG. Besides the fluoroquinolones, cefixime, whose manufacture was discontinued in 2002, is the only CDC-recommended oral agent for treating gonorrhea. Although Lupin received Food and Drug Administration approval to manufacture and market cefixime in February 2004, the 400-mg tablets to treat gonorrhea are not yet available; the suspension (100 mg/5 mL) is available. The health departments of California and Washington state have suggested alternative oral treatments (e.g., cefpodoxime, 400 mg) that have not yet been evaluated adequately. The CDC will provide additional information about the availability of cefixime and efficacy of other oral agents for treating gonorrhea as it becomes available (http://www.cdc.gov/std/treatment/cefixime.htm).
The CDC advises physicians to be vigilant in identifying treatment failures when fluoroquinolones are used, advise their patients about the importance of follow-up if symptoms persist, and be prepared to evaluate such cases by culture. In cases of persistent gonococcal infection after treatment with fluoroquinolones, antimicrobial susceptibility testing should be performed. Only culture of N. gonorrhoeae can be used to determine antimicrobial susceptibility. The antimicrobial susceptibility testing panel should, at a minimum, include a fluoroquinolone, ceftriaxone, spectinomycin, azithromycin, and any other drugs in local use for gonorrhea treatment. Arrangements for antimicrobial susceptibility testing can be made by contacting state and local health departments.
Given the apparent low prevalence of QRNG among heterosexuals, a national change in treatment in that group is not recommended at this time. However, QRNG prevalence among heterosexuals is likely to increase over time and already might be high enough in some areas to warrant new local treatment recommendations. For example, increased prevalence of QRNG among heterosexuals has been identified in several counties in Michigan, where recommendations have been made to avoid using fluoroquinolones among all persons infected with gonorrhea. Because gonococcal infections, especially in women, frequently are asymptomatic, monitoring for symptomatic treatment failures alone does not provide a reliable indication of emerging antimicrobial resistance. If prevalence increases nationally among heterosexuals, guidance from the CDC will be forthcoming. Local and state treatment recommendations, technical information, surveillance data, references, and other links related to gonococcal resistance are available at http://www.cdc.gov/std/gisp.
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Copyright © 2004 by the American
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