1、DAEN-ECE-B Engineer Technical Letter 1110-3-374 3535789 0023699 TT3 m DEPARTMENT OF THE ARMY U. S. Army Corps of Engineers Washington, D.C. 20314-1000 6- 5 3-30 ETL 1110-3-374 16 March 1987 Engineering and Design Prevention of Nosocomial Infections During Hospital Rehabilitation/Construction 1. This
2、 letter provides criteria for renovation and construction of new or existing medical treatment facilities (MTF). This letter is applicable to all ffQUSACE/OCE elements 2. APDlicabilitv. and field operating activities (FOA) having military construction design responsibility. 3. BackarQund. The constr
3、uction methods employed to renovate medical facilities lead to the generation of dust, debris, and the disturbance of settled microorganisms that may be present in the construction area. of the microorganisms that may be present in the work area may also have the potential of producing severe or fat
4、al disease in non-healthy individuals, such as patients with impaired immune systems. These persons are especially susceptible to opportunistic infections from the inhalation of organisms that normally do not effect healthy individuals. When contaminants generated during construction activities are
5、not effectively treated or controlled, they may be conveyed into patient treatment or care areas by normal air currents through construc tion openings, doors, windows, plenums, etc; and may be entrained in airhandling systems and carried throughout the building. immuno-suppressed individuals may be
6、disasterous. the case at the recently completed renovation of the Fitzsimons Army Medical Center (FAMC) in which eleven patients died as a result of infection with a common fungus (Aspergillosis). The enclosed report of that outbreak discusses the incident and the steps taken to prevent further occu
7、rrence during the remainder of the project. standards uniformly acceptable to the medical profession for use during the se situations. Some The results of exposure to these contaminants by This may well have been There are no known 4. Commander during predesign planning and with engineering and cons
8、truction personnel and the MTJ? Commander for projects currently at the post-design to be Taken. The enclosed report will be discussed with the MTF Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-m 3515789 0023700 545 m FIZ 1110-3-374 16 I%r 87 stage
9、 as of the date of this ETL. The applicability of the procedures discussed will be agreed upon. During design, all procedures agreed upon as necessary for the prevention of construction related nosocomial infection will be incorporated into the plans and specifications. 5. ImDlementatiQn, This lette
10、r will have immediate application as defined in paragraph 6c, ER 1110-345-100, including those projects currently under construction. FOR THE COMMANDER: Encl WILLIAM N. NcCORMICK, JR. Chief, Engineering Division Directorate of Engineering and Construction 2 Provided by IHSNot for ResaleNo reproducti
11、on or networking permitted without license from IHS-,-,-EXL 1110-3-374 16 %r 87 Efficaq of Infection Cntrol Measures During 8 Kosocomial Oulbreah oi Disseminated Aspergillosis Associaicd with Hospital Construclion Disseminated aspergillosis is a devastating opportunistic infection with an exceedingl
12、y high death rate Aspergilli are among the most common fungi in the world. Their ubiquitous distribut ion coupled with their potential to pro- ducc severe disease in the immunocompromised host pose a serious health hazard i). targc numbers of Aspergillus spores may be generated during environmental
13、manipu- lations such as hospital construction projects. Suspcnded fungal spores vy be convcytd by air currents to distant rites and then concentrated by air-handling systems that lack adequate filtration. Construction in and around hospi- tals housing large numbers of susceptible patients has ben as
14、sociated with sevcral limited epidemics i-51. These out- breaks have prompted a search for methods that prevent fungal dissemination during construction projects. MC have recently experienced such an epidemic of asper- gillosis associated with hospital renovation in a large mili- tary medical center
15、. During the period July 1981 through July 1963. li sewrely compromised patients dewloped dis- seminated aspergillosis.lThe epidemic coincided with ex- tensivc renovation of the Medical Intensive Care Unit and several hospital wards. All infections ultimately proved fa- tal. despite intervention wit
16、h appropriate antifungal ther- ap! in men paricnrs. Several control measures were in- stituted in an attempt to further reduce morbidity and mortality during ongoing renovations. There measures in- cluded ihr Construction of airtight plastic and dry wall barriers about the consrruaion sites, usc of
17、nepative- pressure vcntilaiion in the work area, arca decontamina- tion u iih copper-8-quinolinolaie. and the installation of high-cfficienq particularc air (HEP.4) filters in rooms housing compromised patients. Since the institution of these measures. cons:ruction has continued ar an acceler- ated
18、pace without additional cases of disseminated asper- Rcccived for publication 7 lune 19s. and in Tcvid form 26 Scptembcr 1965. This work was prcrcnicd in pari ai the 8Sih annual rncciing of ihc American Socicry for hicrobioiop; 3-7 March 1985. The opinions and asrcnionr found in this papcr are exclu
19、sidy those of ihc authors and arc not intended to reflea the official position of the U. S. Army or Department of Defense (pn 4-3. AR 36QS). This warL was supported b! L. S. Army proiocol no. FAMC W. U. 64 IO-. We ihank Terry Oucns and Raymond Sandotal for technical assiriance Dr. John Hcss for suii
20、riiul analysis, Drs. Alan Cmrr (Washingion. D. C.) and J. Aimer (Baliimorc Md) for their hclpful rugpcriions. and Lynciic Si:hois for iyping the manuscripi. Plcarc address rcqucsii for rcprinis IO Di. Sicven hl. Opal ai his prcscni rddrcri: Infcciiou5 Diicarc Di ision. PauiucLri Slcrnoria! )lospiial
21、. Brw n Uniscr5i: .4ffilraicd Hoipiial. Pror- pcci Sirre;. PauiuAci. Rhodc Island 07660. gillosis. The efficacy of each of these infection control- measures is analyzed in this report. Materials and Methods Cbsc definirion. Cases of disseminated upergillosis were defined as dirm tissue inrasion of t
22、wo or more or- gan systems. as determined clinically and by biopsy or necropsy. All cases satisfied the Centers for Disease Con- trol criteria for nosocomial infection as all occurred dur- ing the course of hospitalization, in patients without evi- dence of preexisting or incubating infection upon a
23、dmission. Information concerning each patients clini- cal presentation. hospital course, and pathological find- ings were obtained from hospital summaries, infection con- trol senice reports. and pathology rcponr. All biopsy, autopsy, and mycology materials over the entire fivc-year study period wem
24、 reviewd for evidence of infections with A sprg illus. Sjwmsampling. A SU-stage microbial air sampler (An- dersen modei 2000. Atlanta) was used to determine spore counts. This technique samplts suspended particulate mat- ter with diameters ranging from 1 to 100 pm. in concen- trations of 0-2.600 via
25、ble particles per cubic foot of air 161. Sabouraud agar plates were incubated at 27 C and screened every 46 hr for 10 days to detect fungal growth. Speciation of the fungi uas based on the classifioition used by Fennel1 and Raper 17). Coninil mcusurcs. Physical barriers consisted of ei- ther floor-t
26、o-ceiling plastic or dry wall barriers across all openings betwen the construction arcas and the adjoining patient care areas. These barriers were sealed with plastic iapc or spackling compounds. All traffic between the con- stmaion sites and patient care arcas UIS strictly prohibited. Uorkmen trans
27、ported building materials into the construc- tion areas from external entrance sites without violating clinic or ward space. All refuse was disposed of through metal shutes constructed on the exterior of the building. Extern21 venting of the construction area was maintained by continuously running e
28、xhaust fans; double-lock air- tight doors in barriers were maintained as fire escapes. Coppcr-8-quinolinolaie (hlaag Chemical, Vero Beach, Fla) was used for area decontamination in the airway ple- nums and the air-handling systems in special care units. This agent was used only once Before applicati
29、on. the spe- cial care areas were scaled and traffic prohibited. Work- ers were required to wear nonuented goggles. masks. and rubber gloves while applying the material. The compound was mixed at a 1 :9 concentration and applied with a hand- held sprayer to the walls, vents, air ducts. and above the
30、 false ceilings. The maicrial uas dry uiihin 24 hr. and pa- tients were allowed to reoccupy the area within 36 hr. Enclosure 1 634 Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-= 3535789 0023702 318 ETL 1110-3-374 16 Mar 87 Concur Communicoiions 63
31、5 Portable HEPA filters (Cleanairel; Air Techniques. Bal- timore, hld) were used in the rooms of severely com- promised patients. The staff and patients were instructed to leave doors and windows closed and to leave the filters in operation 24 hr a day. Srorirrical anatysis. nie Mann-Whitney U test
32、was used to test significant differences berween nonparametric func- tions, and the 2 x 2 x2 contingency test was used to deter- mine the significance of changes in incidence Rrsults Clinical characteristics. The incidence of invasive aspergillosis over the five-year study period is seen in fig- ure
33、 1. Eleven patients contracted disseminated aspergil- losis during the construction period. All were severely immunocompmmised as a result of lymphomicular malig- nancy (seven patients) or high-dose corticosteroid ther- apy (three patients) or disseminated carcinoma (one pa- tient). The mcan.age of
34、the patients was 26 z 20.4 years and included seven men and four women. The mean in- terval betwren hospital admission and onset of clinical ill- ness due 10 aspergillosis was 19 day (range, eighi to 28 days). Four of the Il were diagnosed as having dissemi- nated aspergillosis before death. and thr
35、ee additional pa- tients were treated empirically with amphotericin B for suspected fungal infection. All cases ultimately proved fa- tal, regardless of treatment given. Aspergillusjaws was the most commonly recognized species isolated from patients with invasiw disease. This organism was recovered
36、from four patients. u hereas Asper- gillusjumigarirs (one patient). Aspergillus niger (one pa- tient), and a variety of other Aspergillus spp. were iso- lated from the other fite patients. Each paiient had been located on the same floor as or one story below the con- struction area at the onset of i
37、nfection. VEAR inn 1mw IW? 198; I963 1- - A 8 C STUDY PIEC0*;STRJCTOh COhSrR30h CO.STRJCTW CERO3 H lci3d: CDhTRO, Wlw COTROL UEASURES UE4SVSES Figure i. Incidence of ina; period A vs. C. P .4. Table 1. Efficacy of environmental control measures. Method of control samples spornhn 2 SE Ainighi conriru
38、nion barriers rio. of Mun no. of Loution Directly inside barrier 19 4.2 2 0.4 Direeily outride binin 19 1.0 i 0.3 Ponable HEPA filters in patient rooms Loution Inside rooms 38 0.008 2 0.003 Outride rooms 38 1.7 * 0.2 Copper-8quinoiinoIaic in rpcciai Ure mus: Time period etoconazol are not ac- tive a
39、gainsi Aspergilitis spp. In atiemptinp 10 devise control measures to prevent no- socomial arpcrpillosir during hospital construction. pre- viously reported experiences at other institutions were u- imined. Unfortunately, no formal mmmcndations gowming air quality during hospital construction cumtly
40、exist, and control methods used by other institutions are by no means uniform. The National Cancer Institute in Baltimore. Maryland. experienced eight cases of dissemi- nated aspergillosis in the process of relocating to neu. fa- cilities in 1974 and !97S (41. Nearly all the cases were due to A. f7u
41、vus. which had colonized the fireproofing mate- rial used to coat he steel and cement superstructure En- vironmental sampling with settle plater confirmed huge numbers of viable spores. and the epidemic was curuiled after copper-8quinolinolate was applied IS. A renal transplant section of the Indian
42、apolis Veterans Adminis- tration Hospital noted thret cases of aspergillosis during a period of renovation to the floors above their facilities 121. Settle plates confirmed the presenje of large numbers of airborne Aspergillus conidia, and cultures of the dust contained in the space above false ceil
43、ings pinpointed this area as the source of the spores. Patients were evacuated to areas distant from the construction. and airtight plu- tic barriers were erected about the renovation sites. The number of clinical isolates containing Aspcgillus spp. fell markedly, and no further cases of Aspegills i
44、nfmion were reported. The University of North Carolina noted a marked increase in the number of respintory specimens contaminated with A. f7uvus. with one fatal case of noso- comial infection (31. Seitle plates confirmed large num- bers of spores in the rooms housing culture-positive pa- rient; thes
45、e conidia um dispersed by heavy construction contiguous 10 the uards. A reduaion in environmental iso- laies was demonstrated following implemenation of ide- quate air filtration. Owing to the severity of the outbreak at Fituimons Army Medical Center and the lack of comparative effi- cacy of control
46、 measum. ut chox to ux all ihm mahods of infection control; these included the use of copper-8- quinolinolatc. physical barriers, and air filtration. Coppcr- 8quinolinolate was selected as the antifungal agent for area decontamination for several masons. The compound is easily applied in an aeroso!i
47、zcd form, dries to a aon- toxic powder, and has proved to be safe near food stuffs. Upper-airway irritation during application constituta the single recognized risk involved with the use of the chemi- cal. This hazard is easily circumvented y the use of proper protective masks and evacuation of the
48、areas undergoing decontamination. The use of this material proved most effective; residual antifungal activity of copper-8- quinolinolate has been demonstrated 14 months after its application. The combination of plastic and dry wall barriers about the construction aites. combined with traffic restri
49、ction and external venting of air. reduced the dissemination of airborne conidia near the construction am. The barriers 3 Provided by IHSNot for ResaleNo reproduction or networking permitted without license from IHS-,-,-FIZ 1110-3-374 16 Mar 87 Conciw Conimninrions were effective ont when extended from the ceiling to the floor and when efforts were made to se21 all defects. Con- tinuous negatire air prasure in the construction arca, with external venting and airtight barrien, e
