• Hand hygiene recommendations
• Standard precautions in hospitals
• Contact precautions in hospitals
• Environmental measures for the prevention and management of multi-drug resistant organisms
• Prevention of surgical site infections
• Prevention of bloodstream infections
• Prevention of catheter-associated urinary tract infections

Level of evidence ranking (I – V) and strength of recommendation ranking (A – D, Unresolved issue [UI], No recommendation) definitions are presented at the end of "Major Recommendations" field.

General Prophylaxis

1. Effective infection control measures: staff education, compliance with alcohol-based hand disinfection, and isolation to reduce cross-infection with multi-drug resistant pathogens should be used routinely. A-I*
2. Surveillance of intensive care unit (ICU) infections and preparation of timely data for infection control and to guide appropriate antimicrobial therapy in patients with suspected ventilator-associated pneumonia (VAP) or other nosocomial infections are recommended. A-II*

Intubation and Mechanical Ventilation

3. Intubation and reintubation should be avoided, if possible, as it increases the risk of VAP. A-II (Elward, Warren, & Fraser, 2002)
4. Noninvasive ventilation should be used whenever possible in selected patients with respiratory failure. A-I (Burns, Adhikari, & Meade, 2003; Esteban et al., 2004)
   • 4-P**. Noninvasive ventilation should be considered whenever possible in pediatric patients with respiratory failure. A-IV***

5. Orotracheal intubation and orogastric tubes are preferred over nasotracheal intubation and nasogastric tubes to prevent nosocomial sinusitis and to reduce the risk of VAP, although direct causality has not been proved. B-II (Holzapfel, 2003)
   • 5-P**. Orotracheal intubation and orogastric tubes are preferred, particularly for emergency situations. Depending on particular circumstances related to age and indication, nasotracheal intubation can be considered as well. When inserting endotracheal tubes, "clean" technique should be followed (i.e., hand hygiene, gloves, face shield, with equipment placed on sterile drape). B-IV***

6. Oral and subglottic secretions are important contributors to the development of VAP, and hospitals should develop policies and procedures for the management of these secretions. These policies and procedures should include scheduled oral care and intermittent (i.e., at regular intervals and when repositioning the patient or tube) or continuous suctioning of subglottic secretions. A-I (Dezfulian et al., 2005; Girou et al., 2004; Bercault et al., 2005; Kollef et al., 1997)
   • 6-P**. Oral and subglottic secretions are important contributors to the development of VAP, and hospitals should develop policies and procedures for the management of these secretions. These policies and procedures should include scheduled oral care and intermittent suctioning in pediatric patients (i.e., at regular intervals and when repositioning the patient or tube). A-II (Curley et al., "Tailoring the Institute for Health," 2006)

7. The endotracheal tube should be of proper size and cuff pressure should be maintained at the minimal occluding volume to prevent leakage of bacterial pathogens around the cuff into the lower respiratory tract without inducing tracheal injury. B-II (Young et al., 2006; Macchiarini et al., 2000)
   • 7-P**. Data in pediatrics about the role of cuffed endotracheal tubes (ETT) in the prevention of VAP is limited. However, the use of cuffed ETTs outside the neonatal intensive care units is recommended. The ETT should be of proper size and cuff pressure should be monitored and maintained to achieve minimal occluding volume. B-III (Newth et al., 2004; Weiss, Gerber, & Dullenkopf, 2005)

8. Contaminated condensate should be carefully emptied from ventilator circuits and condensate should be prevented from entering either the endotracheal tube or inline medication nebulizers. A-II (Hess et al., 2003; Boots et al., 2006; Pediatric Affinity Group 2007).
9. Passive humidifiers or heat–moisture exchangers decrease ventilator circuit colonization, but have not consistently reduced the incidence of VAP, and thus they cannot be regarded as a pneumonia prevention tool. B-I (Kola, Eckmanns, & Gastmeier, 2005; Lacherade et al., 2005; Lorente et al., 2006)
10. Reduced duration of intubation and mechanical ventilation may prevent VAP and can be achieved by protocols to improve the use of sedation and to accelerate weaning. A-II (Kollef, 2004; Dries et al., 2004; Schweickert et al., 2004; Randolph et al., 2002)

Aspiration, Body Position, and Enteral Feeding

11. Patients should be kept in the semirecumbent position (30 to 45 degrees) rather than supine to prevent aspiration, especially when receiving enteral feeding. The degree of elevation should be measured (using validated instruments or bed markings) and documented every 8 hours. Before lowering the patient's head less than to 30% (e.g., when transporting or repositioning), secretions should be suctioned above and below the cuff to prevent microaspiration. A-I (van Nieuwenhoven et al., 2006; Grap et al., 2005)
    • 11-P**. Data in pediatrics is very limited. However, intubated infants and children should have their head elevated 30 to 45 degrees. Ideal positioning of intubated neonates is 15 to 30 degrees head elevation and cribs with adequate positioning features to achieve this should be used. The degree of elevation should be measured (using validated instruments or bed markings) and documented every 8 hours. Before lowering the patient's head (e.g., when transporting or repositioning), secretions should be suctioned above and below the cuff (if used) to prevent microaspiration. A-IV (Curley et al., "Tailoring the Institute for Health," 2006; Pediatric Affinity Group, 2007).

12. Enteral nutrition is preferred over parenteral nutrition to reduce the risk of complications related to central intravenous catheters and to prevent reflux villous atrophy of the intestinal mucosa that may increase the risk of bacterial translocation. A-I (Bowman et al., 2005; Metheny et al, 2006; Artinian, Krayem, & DiGiovine, 2006)
    • 12-P**. Enteral nutrition, either gastric or post-pyloric, is preferred over parenteral nutrition to reduce the risk of healthcare associated infections and to prevent reflux villous atrophy of the intestinal mucosa that may increase the risk of bacterial translocation. A-I***

Modulation of Colonization: Oral Antiseptics and Antibiotics

13. Although in some short-term studies routine prophylaxis of hospital-acquired pneumonia (HAP) with oral antibiotics (selective decontamination of the digestive tract or SDD), with or without systemic antibiotics, reduced the incidence of ICU-acquired VAP and has helped contain outbreaks of multi-drug resistant bacteria, it should be used selectively to control outbreaks and is NOT recommended for routine use. B-II (Kallet & Quinn, 2005; Liberati et al., 2006; Kollef, 2003; Heininger et al., 2006; de Jonge, 2005)
    • 13-P**. Prophylaxis of HAP with oral antibiotics or selective decontamination of the digestive tract is NOT recommended for routine use. B-IV***

14. Prophylactic administration of systemic antibiotics for 24 hours at the time of emergent intubation has been demonstrated to prevent ICU-acquired HAP in comatose and closed head injury patients, but its routine use is not recommended until more data on mortality and antibiotic resistance become available. B-II (Acquarolo et al., 2005)
    • 14-P**. Prophylactic administration of systemic antibiotics for 24 hours at the time of emergent intubation is not recommended for routine use. B-IV***

15. There is consistent evidence that the use of oral care with antiseptic agents (but not oral antibiotics) can decrease the incidence of ventilator-associated pneumonia, although not the overall ICU length of stay or overall mortality. However, the optimal concentration and formulation of antiseptic agents to use for oral care remains unresolved, as does the optimal timing of oral care. Pending further data, at this time the panel recommends that health care facilities incorporate the regular use of an oral antiseptic agent into the routine care of patients receiving mechanical ventilation. B-I (Chlebicki & Safdar, 2007; Mori et al., 2006; Koeman et al., 2006; Segers et al., 2006; Fourrier et al., 2005)
    • 15-P**. Oral hygiene (removal of plaque from teeth and gums) is recommended at least every 12 hours. Oral care (removal of secretions from the oropharynx and moisturizing the mouth and lips) is recommended every 4 hours and before any manipulation of the ETT or position change of the ventilated patient. There are currently no data evaluating the safety or efficacy of oral antiseptic agents in the pediatric population, although their use can be considered. B-IV (Curley et al., "Tailoring the Institute for Health," 2006)

16. Use daily interruption or lightening of sedation to avoid constant heavy sedation and try to avoid paralytic agents, both of which can depress cough and thereby increase the risk of HAP. A-II (Schweickert et al., 2004; Kress et al., 2003; Kress et al., 2007)
    • 16-P**. Use daily interruption of paralytic drugs and lightening of heavy sedation to avoid prolonged suppression of muscle tone and diaphragm function, which contribute to the retention of pulmonary secretions. The patient's capacity for unassisted breathing should be evaluated daily. Extubation readiness testing and the use of sedation protocols may be beneficial in critically ill pediatric patients but must be balanced against the risk of premature and self-extubation. A-III (Curley et al., "Tailoring the Institute for Health," 2006; Pediatric Affinity Group, 2007; Curley et al., "State Behavioral Scale," 2006)

Stress Bleeding Prophylaxis, Transfusion, and Hyperglycemia

17. Comparative data from randomized trials suggest a trend toward reduced VAP with sucralfate, but there is a slightly higher rate of clinically significant gastric bleeding, compared with H2 antagonists. If needed, stress bleeding prophylaxis with either H2 antagonists or sucralfate is acceptable. There is limited information on the use of proton pump inhibitors for stress ulcer prophylaxis, but evidence suggests that these agents may increase the risk of Clostridium difficile disease. Pending additional data, proton pump inhibitor agents should not be used solely for stress ulcer prophylaxis in the ICU setting. B-II (Bornstain et al., 2004; Metz, 2005)
    • 17-P**. Gastrointestinal bleeding prophylaxis with either H2 antagonists or sucralfate does not appear to alter the risk for VAP. There is limited information on the use of proton pump inhibitors for stress ulcer prophylaxis, but evidence suggests that these agents may increase the risk of Clostridium difficile disease. Pending additional data, proton pump inhibitor agents should not be used solely for stress ulcer prophylaxis in the ICU setting. B-IV (Pediatric Affinity Group, 2007; Lopriore, Markhorst, & Gemke, 2002; Yildizdas, et al., 2002)

18. Transfusion of red blood cell and other allogeneic blood products should follow a restricted transfusion trigger policy; leukocyte-depleted red blood cell transfusions can help to reduce HAP in selected patient populations. A-I (Shorr et al., 2004; Levy et al., 2005; Lacroix et al., 2007)
19. To reduce nosocomial blood stream infections, duration of mechanical ventilation, ICU stay, and morbidity, intensive insulin therapy has been recommended. However, intensive insulin is also associated with an increased risk of hypoglycemia and most trials do not show a mortality benefit. Although data are still accumulating, insulin therapy should probably be used to maintain serum glucose levels between 100 and 150 mg/dL in most critically ill patients. More stringent control (between 80 and 110 mg/dL) can be considered in post-cardiac surgery patients. B-II (Gandhi et al., 2007; Van den Berghe, 2007; Van den Berghe et al., "Intensive insulin therapy in the medical ICU," 2006; Malhotra, 2006; Egi et al., 2006; Van den Berghe et al., "Intensive insulin therapy in mixed medical/surgical intensive care units," 2006; Mitchell et al., 2006)
    • 19-P**. Tight glycemic control may be beneficial in critically ill pediatric patients, but specific target ranges have not been studied. The risk must be balanced against the risk for unrecognized hypoglycemia as a result of insulin therapy. UI***

*Identifies evidence from the Centers for Disease Control and Prevention (CDC)'s updated guidelines without repeating the detailed literature review process.

**Pediatric. The Pediatric Affinity Group was charged with reviewing recommendations of the other Task Groups to identify areas where specific modifications were needed to make the statements applicable to neonates, infants and/or children. After a review of the pediatric literature, the group amended the general/adult statements and determined the strength of recommendations. These revisions are designated with the original number of the statement they relate to, followed by P.

***Identifies pediatric statements in which only the adult evidence cited by the source guideline was used.

Definitions:

Level of Evidence Ranking

Level I: Strong evidence from at least one well-designed randomized controlled trial

Level II: Evidence from well-designed non-randomized trials; cohort or case-controlled analytic studies (preferably from >1 center); multiple time-series studies

Level III: Well-designed descriptive studies from more than one center or research group

Level IV: Opinions of authorities (e.g., guidelines), clinical evidence; reports of expert committees

Level V: No quality studies found and no clear guidance from expert committees, authorities or other sources

Strength of Recommendation Ranking

Category A: Strongly recommended

Category B: Recommended for implementation

Category C: Consider for implementation

Category D: Recommended against implementation

Category UI: Unresolved issue

No recommendation: Unresolved issue. Practices for which insufficient evidence or no consensus regarding efficacy exists.

References open in a new window

Electronic copies: Available in Portable Document Format (PDF) from the Massachusetts Department of Public Health Web site.

• Betsy Lehman Center for Patient Safety and Medical Error Reduction, JSI Research and Training Institute, Inc. Prevention and control of healthcare-associated infections in Massachusetts. Part 2: findings from complementary research activities. Boston (MA): Massachusetts Department of Public Health; 2008 Jan 31. 131 p. Available in Portable Document Format (PDF) from the Massachusetts Department of Public Health Web site.
• Handwashing education materials for health care professionals. Available from the Massachusetts Department of Public Health Web site.

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