To
assist hospitals in maintaining up-to-date isolation practices, the Centers for
Disease Control and Prevention (CDC) and the Hospital Infection Control
Practices Advisory Committee (1) (HICPAC) have revised the "CDC Guideline
for Isolation Precautions in Hospitals." HICPAC was established in 1991 to
provide advice and guidance to the Secretary, Department of Health and Human
Services (DHHS); the Assistant Secretary for Health, DHHS; the Director, CDC;
and the Director, National Center for Infectious Diseases, regarding the
practice of hospital infection control and strategies for surveillance,
prevention, and control of nosocomial infections in US hospitals. HICPAC also
advises the CDC on periodic updating of guidelines and other policy statements
regarding prevention of nosocomial infections.
The
revised guideline contains two parts. Part I, "Evolution of Isolation
Practices," reviews the evolution of isolation practices in US hospitals,
including their advantages, disadvantages, and controversial aspects, and
provides the background for the HICPAC-consensus recommendations contained in
Part II, "Recommendations for Isolation Precautions in Hospitals." The
guideline supersedes previous CDC recommendations for isolation precautions in
hospitals.(2-4)
The
guideline recommendations are based on the latest epidemiologic information on
transmission of infection in hospitals. The recommendations are intended
primarily for use in the care of patients in acute-care hospitals, although
some of the recommendations may be applicable for some patients receiving care
in subacute-care or extended-care facilities. The recommendations are not
intended for use in daycare, well care, or domiciliary care programs. Because
there have been few studies to test the efficacy of isolation precautions and
gaps still exist in the knowledge of the epidemiology and modes of transmission
of some diseases, disagreement with some of the recommendations is expected. A
working draft of the guideline was reviewed by experts in infection control and
published in the Federal Register for public comment. However, all
recommendations in the guideline may not reflect the opinions of all reviewers.
HICPAC
recognizes that the goal of preventing transmission of infections in hospitals
can be ccomplished by multiple means and that hospitals will modify the
recommendations according to their needs and circumstances and as directed by
federal, state, or local regulations. Modification of the recommendations is
encouraged if 1) the principles of epidemiology and disease transmission are
maintained, and 2) precautions are included to interrupt spread of infection by
all routes that are likely to be encountered in the hospital.
The
"Guideline for Isolation Precautions in Hospitals" was revised to
meet the following objectives: 1) to be epidemiologically sound; 2) to
recognize the importance of all body fluids, secretions, and excretions in the
transmission of nosocomial pathogens; 3) to contain adequate precautions for
infections transmitted by the airborne, droplet, and contact routes of
transmission; 4) to be as simple and user friendly as possible; and 5) to use
new terms to avoid confusion with existing infection control and isolation
systems.
The
revised guideline contains two tiers of precautions. In the first, and most
important, tier are those precautions designed for the care of all patients in
hospitals regardless of their diagnosis or presumed infection status. Implementation
of these "Standard Precautions" is the primary strategy for
successful nosocomial infection control. In the second tier are precautions
designed only for the care of specified patients. These additional
"Transmission-Based Precautions" are used for patients known or
suspected to be infected or colonized with epidemiologically important
pathogens that can be transmitted by airborne or droplet transmission or by
contact with dry skin or contaminated surfaces.
Standard
Precautions synthesize the major features of Universal (Blood and Body Fluid)
Precautions (designed to reduce the risk of transmission of bloodborne
pathogens) and Body Substance Isolation (designed to reduce the risk of
transmission of pathogens from moist body substances). Standard Precautions
apply to 1) blood; 2) all body fluids, secretions, and excretions, except
sweat, regardless of whether or not they contain visible blood; 3)
nonintact skin; and 4) mucous membranes. Standard ecautions are designed to
reduce the risk of transmission of microorganisms from both recognized and
unrecognized sources of infection in hospitals.
Transmission-Based
Precautions are designed for patients documented or suspected to be infected or
colonized with highly transmissible or epidemiologically important pathogens
for which additional precautions beyond Standard Precautions are needed to
interrupt transmission in hospitals. There are three types of
Transmission-Based Precautions: Airborne Precautions, Droplet Precautions, and
Contact Precautions. They may be combined for diseases that have multiple
routes of transmission. When used either singularly or in combination, they are
to be used in addition to Standard Precautions.
The
revised guideline also lists specific clinical syndromes or conditions in both
adult and pediatric patients that are highly suspicious for infection and
identifies appropriate Transmission-Based Precautions to use on an empiric,
temporary basis until a diagnosis can be made; these empiric, temporary
precautions are also to be used in addition to Standard Precautions.
The
first published recommendations for isolation precautions in the United States
appeared as early as 1877, when a hospital handbook recommended placing
patients with infectious diseases in separate facilities,(5) which ultimately
became known as infectious disease hospitals. Although this practice segregated
infected patients from noninfected patients, nosocomial transmission continued
to occur because infected patients were not separated from each other according
to their disease, and few, if any, aseptic procedures were practiced. Personnel
in infectious disease hospitals began to combat problems of nosocomial
transmission by setting aside a floor or ward for patients with similar
diseases (6) and by practicing aseptic procedures recommended in nursing
textbooks published from 1890 to 1900.(5)
In
1910, isolation practices in US hospitals were altered by the introduction of
the cubicle system of isolation, which placed patients in multiple-bed
wards.(6) With the cubicle system, hospital personnel used separate gowns,
washed their hands with antiseptic solutions after patient contact, and
disinfected objects contaminated by the patient. These nursing procedures,
designed to prevent transmission of pathogenic organisms to other patients and
personnel, became known as "barrier nursing." Use of the cubicle
system of isolation and barrier nursing procedures provided general hospitals
with an alternative to placing some patients in infectious disease hospitals.
During
the 1950s, US infectious disease hospitals, except those designated exclusively
for tuberculosis, began to close. In the mid-1960s, tuberculosis hospitals also
began to close, partly because general hospital or outpatient treatment became
preferred for patients with tuberculosis. Thus, by the late 1960s, patients
with infectious diseases were housed in wards in general hospitals, either in
specially designed, single-patient isolation rooms or in regular single or
multiple-patient rooms.
In 1970, CDC published a detailed manual
entitled Isolation Techniques for Use in Hospitals to assist general
hospitals with isolation precautions.(2) A revised edition appeared in 1975.(3)
The manual could be applied in small community hospitals with limited
resources, as well as in large, metropolitan, university-associated medical
centers.
The
manual introduced the category system of isolation precautions. It recommended
that hospitals use one of seven isolation categories (Strict Isolation,
Respiratory Isolation, Protective Isolation, Enteric Precautions, Wound and
Skin Precautions, Discharge Precautions, and Blood Precautions). The
precautions recommended for each category were determined almost entirely by the
epidemiologic features of the diseases grouped in the category, primarily their
routes of transmission. Certain isolation techniques, believed to be the
minimum necessary to prevent transmission of all diseases in the category, were
indicated for each isolation category. Because all diseases in a category did
not have the same epidemiology (ie, were not spread by exactly the same
combination of modes of transmission), with some requiring fewer precautions
than others, more precautions were suggested for some diseases than were
necessary. This disadvantage of "over-isolation" for some diseases
was offset by the convenience of having a small number of categories. More
importantly, the simple system required personnel to learn only a few
established routines for applying isolation precautions. To make the system
even more user friendly, instructions for each category were printed on
color-coded cards and placed on the doors, beds, or charts of patients on
isolation precautions.
By
the mid-1970s, 93% of US hospitals had adopted the isolation system recommended
in the manual.(7) However, neither the efficacy of the category approach in
preventing spread of infections nor the costs of using the system were
evaluated by empirical studies.
By
1980, hospitals were experiencing new endemic and epidemic nosocomial infection
problems, some caused by multidrug-resistant microorganisms and others caused
by newly recognized pathogens, which required different isolation precautions
from those specified by any existing isolation category. There was increasing
need for isolation precautions to be directed more specifically at nosocomial
transmission in special-care units, rather than at the intrahospital spread of
infectious diseases acquired in the community.(8) Infection control
professionals and nursing directors in hospitals with particularly
sophisticated nursing staffs increasingly were calling for new isolation
systems that would tailor precautions to the modes of transmission for each
infection and avoid the over-isolation inherent in the category-specific
approach. Further, new facts about the epidemiology and modes of transmission
of some diseases made it necessary for CDC to revise the isolation manual. Toward
that end, during 1981 to 1983, CDC Hospital Infections Program personnel
consulted with infectious disease specialists in medicine, pediatrics, and
surgery; hospital epidemiologists; and infection control practitioners about
revising the manual.
In 1983, the CDC Guideline for Isolation Precautions
in Hospitals (4) (hereafter referred to as the isolation guideline) was
published to take the place of the 1975 isolation manual; it contained many
important changes. One of the most important was the increased emphasis on
decision making on the part of users. Unlike the 1975 manual, which encouraged
few decisions on the part of users, the isolation guideline encouraged decision
making at several levels.(9,10) First, hospital infection control committees
were given a choice of selecting between category-specific or disease-specific
isolation precautions or using the guideline to develop a unique isolation
system appropriate to their hospitals' circumstances and environments. Second,
personnel who placed a patient on isolation precautions were encouraged to make
decisions about the individual precautions to be taken (e.g., whether the
patient's age, mental status, or condition indicated that a private room was
needed to prevent sharing of contaminated articles). Third, personnel taking
care of patients on isolation precautions were encouraged to decide whether
they needed to wear a mask, gown, or gloves based on the likelihood of exposure
to infective material. Such decisions were deemed necessary to isolate the
infection, but not the patient, and to reduce the costs associated with
unnecessary isolation precautions.
In
the category-specific section of the guideline, existing categories were
modified, new categories were added, and many infections were reassigned to
different categories. The old category of Blood Precautions, primarily directed
toward patients with chronic carriage of hepatitis B virus (HBV), was renamed
Blood and Body Fluid Precautions and was expanded to include patients with AIDS
and body fluids other than blood. The old category of Protective Isolation was
deleted because of studies demonstrating its lack of efficacy in general
clinical practice in preventing the acquisition of infection by the
immunocompromised patient for whom it had been described originally.(11,12) The
1983 guideline contained the following categories of isolation: Strict
Isolation, Contact Isolation, Respiratory Isolation, Tuberculosis (acid-fast
bacilli [AFB]) Isolation, Enteric Precautions, Drainage/Secretion Precautions,
and Blood and Body Fluid Precautions. As with the category approach in the
former CDC isolation manuals, these categories tended to over-isolate some
patients.
In
the disease-specific section of the guideline, the epidemiology of each
infectious disease was considered individually by advocating only those
precautions (e.g., private room, mask, gown, and gloves) needed to interrupt
transmission of the infection. In place of the categories and signs of the
category-specific approach, a chart listed all diseases posing the threat of
in-hospital transmission, with checks in columns indicating which precautions
were required for each. Because precautions were individualized for each
disease, hospitals using the system were encouraged to provide more initial
training and inservice education and to encourage a much higher level of
attention from patient-care personnel. Although disease-specific isolation
precautions eliminated over-isolation, personnel might be prone to mistakes in
applying the precautions, particularly if the disease was not seen regularly in
the hospital,(9,10) if there was a delay in diagnosis, or if there was a
misdiagnosis. Placing disease-specific isolation precautions in a hospital
computerized information system resulted in more accurate use of the
system.(13)
Because
gaps existed in the knowledge of the epidemiology of some diseases,
disagreement was expected, and occurred, regarding the placement of individual
diseases within given categories, especially diseases with a respiratory
component of transmission.(14) Placing measles in Respiratory Isolation
(designed to prevent transmission of large-particle droplets) rather than in a
category that had provisions for preventing transmission by airborne droplet
nuclei and placing rubella and respiratory syncytial virus (RSV) infection in
Contact Isolation were controversial.(15) There also was disagreement about the
lack of a recommendation for adult patients with influenza, the need for
private rooms for pediatric patients with RSV infections, and the length of
time that precautions should be maintained.(15) The lack of empiric studies on
the efficacy and costs of implementing the recommendations contributed to the
disagreements.
As
new epidemiologic data became available, several subsequent CDC reports (16-18)
updated portions of the isolation guideline. Updated recommendations for
management of patients with suspected hemorrhagic fever were published in
1988.(16) The recommendation for Respiratory Isolation for acute erythema
infectiosum was superseded by a 1989 report that recommended Respiratory
Isolation for human parvovirus B19 (the causative agent for erythema
infectiosum) only when infected patients were in transient aplastic crisis or
had immunodeficiency and chronic human parvovirus B19 infection.(17)
Recommendations
for Tuberculosis (AFB) Isolation were updated in 1990 (18) because of
heightened concern about nosocomial transmission of multidrug-resistant
tuberculosis,(19,20) particularly in settings where persons with human
immunodeficiency virus (HIV) infection were receiving care. The 1990
tuberculosis guidelines emphasized 1) placing a hospital patient with confirmed
or suspected tuberculosis in a private room that has lower, or negative, air
pressure compared with surrounding areas; 2) reducing mycobacterial contamination
of air by dilution and removal of airborne contaminants; and 3) wearing
particulate respirators, rather than standard surgical masks, when hospital
personnel shared air space with an infectious tuberculosis patient. Subsequent
recommendations reemphasized the importance of early diagnosis and treatment of
tuberculosis.(21) In 1993, a second edition of the guidelines for preventing
the transmission of tuberculosis in healthcare facilities was published in
draft for public comment.(22) After review of written comments, the guidelines
were modified and published.(23)
In
1985, largely because of the HIV epidemic, isolation practices in the United
States were altered dramatically by the introduction of a new strategy for
isolation precautions, which became known as Universal Precautions (UP). Following
the initial reports of hospital personnel becoming infected with HIV through
needlesticks and skin contamination with patients' blood, a widespread outcry
created the urgent need for new isolation strategies to protect hospital
personnel from bloodborne infections. The subsequent modification of isolation
precautions in some hospitals produced several major strategic changes and
sacrificed some measures of protection against patient-to-patient transmission
in the process of adding protection against patient-to-personnel transmission. In
acknowledgment of the fact that many patients with bloodborne infections are
not recognized, the new UP approach for the first time placed emphasis to
applying Blood and Body Fluid Precautions universally to all persons regardless
of their presumed infection status.(24) Until this time, most patients placed
on isolation precautions were those for whom a diagnosis of an infectious
disease had been made or was suspected. This provision led to the new name of
Universal Precautions.
In
addition to emphasizing prevention of needlestick injuries and the use of
traditional barriers such as gloves and gowns, UP expanded Blood and Body Fluid
Precautions to include use of masks and eye coverings to prevent mucous
membrane exposures during certain procedures and the use of individual
ventilation devices when the need for resuscitation was predictable. This
approach, and particularly the techniques for preventing mucous membrane
exposures, was reemphasized in subsequent CDC reports that contained
recommendations for prevention of HIV transmission in healthcare
settings.(25-28)
In
1987, one of these reports (27) stated that implementation of UP for all
patients eliminated the need for the isolation category of Blood and Body Fluid
Precautions for patients known or suspected to be infected with bloodborne
pathogens; however, the report stated that other category- or disease-specific
isolation precautions recommended in the CDC isolation guideline (4) should be
used as necessary if infections other than bloodborne infections were diagnosed
or suspected.
The
1987 report was updated by a 1988 report (28) that emphasized two important
points: 1) blood was the single most important source of HIV, HBV, and other
bloodborne pathogens in the occupational setting, and 2) infection control
efforts for preventing transmission of bloodborne pathogens in healthcare
settings must focus on preventing exposures to blood, as well as on delivery of
HBV immunization. The report stated that UP applied to blood, to body fluids
that had been implicated in the transmission of bloodborne infections (semen
and vaginal secretions), to body fluids from which the risk of transmission was
unknown (amniotic, cerebrospinal, pericardial, peritoneal, pleural, and
synovial fluids), and to any other body fluid visibly contaminated with blood,
but not to feces, nasal secretions, sputum, sweat, tears, urine, or vomitus
unless they contained visible blood. Although HIV and HBV surface antigen
(HBsAg) had been found in some of the fluids, secretions, or excretions to
which UP did not apply, epidemiologic studies in the healthcare and community
settings had not implicated these substances in the transmission of HIV and HBV
infections. However, the report noted that some of the fluids, secretions, and
excretions not covered under UP represented a potential source for nosocomial
and community-acquired infections with other pathogens and referred readers to
the CDC isolation guideline.
In
1987, a new system of isolation, called Body Substance Isolation (BSI), was
proposed after 3 years of study by infection control personnel at the
Harborview Medical Center in Seattle, Washington, and the University of
California at San Diego, California, as an alternative to diagnosis-driven
isolation systems.(29) BSI focused on the isolation of all moist and
potentially infectious body substances (blood, feces, urine, sputum, saliva,
wound drainage, and other body fluids) from all patients, regardless of their
presumed infection status, primarily through the use of gloves. Personnel were
instructed to put on clean gloves just before contact with mucous membranes and
nonintact skin, and to wear gloves for anticipated contact with moist body
substances. In addition, a "Stop Sign Alert" was used to instruct
persons wishing to enter the room of some patients with infections transmitted
exclusively, or in part, by the airborne route to check with the floor nurse,
who would determine whether a mask should be worn. Personnel were to be immune
to or immunized against selected infectious diseases transmitted by airborne or
droplet routes (measles, mumps, rubella, and varicella), or they were not to
enter the rooms housing patients with these diseases. Other issues related to
implementing BSI in a university teaching hospital were described.(30)
Among
the advantages cited for BSI were that it was a simple, easy to learn and
administer system, that it avoided the assumption that individuals without
known or suspected diagnoses of transmissible infectious diseases were free of
risk to patients and personnel, and that only certain body fluids were
associated with transmission of infections. The disadvantages of BSI included
the added cost of increased use of barrier equipment, particularly gloves (31);
the difficulty in maintaining routine application of the protocol for all
patients; the uncertainty about the precautions to be taken when entering a
room with a "Stop Sign Alert"; and the potential for misapplication
of the protocol to overprotect personnel at the expense of the patient.(32)
In
a prospective study,(33) a combination use of gown and glove protocols similar
to BSI led to lower infection rates in a pediatric intensive care unit (ICU),
and, in other studies, similar combinations of barriers were associated with
lower rates of nosocomial RSV infection in a pediatric ICU (34) and of
resistant gram-negative organisms in an acute-care hospital.(35) However, in
none of these studies, initiated before publication of BSI, were the authors
attempting to evaluate BSI, nor were they able to separate the effect of gloves
from that of gowns or from gloves and gowns used in combination.
Controversial
aspects of BSI have been summarized.(15,36) BSI appeared to replace some, but
not all, of the isolation precautions necessary to prevent transmission of
infection. BSI did not contain adequate provisions to prevent 1) droplet
transmission of serious infections in pediatric populations (e.g., invasive Haemophilus
influenza, Neisseria meningitides meningitis and pneumonia, and pertussis);
2) direct or indirect contact transmission of epidemiologically important
microorganisms from dry skin or environmental sources (e.g., Clostridium
difficile and vancomycin-resistant enterococci); or, 3) true airborne
transmission of infections transmitted over long distances by floating droplet
nuclei. Although BSI emphasized that a private room was indicated for some
patients with some diseases transmitted exclusively, or in part, by the true
airborne route, it did not emphasize the need for special ventilation for
patients known or suspected of having pulmonary tuberculosis or other diseases
transmitted by airborne droplet nuclei. The lack of emphasis on special
ventilation was of particular concern to CDC in the early 1990s because of
multidrug-resistant tuberculosis.(18,19)
BSI
and UP shared many similar features designed to prevent the transmission of
bloodborne pathogens in hospitals. However, there was an important difference
in the recommendation for glove use and handwashing. Under UP, gloves were
recommended for anticipated contact with blood and specified body fluids, and
hands were to be washed immediately after gloves were removed.(27,28) Under
BSI, gloves were recommended for anticipated contact with any moist body
substance, but handwashing after glove removal was not required unless the
hands visibly were soiled.(29) The lack of emphasis on handwashing after glove
removal was cited as one of the theoretical disadvantages of BSI.(15,37,38)
Using gloves as a protective substitute for handwashing may have provided a
false sense of security, resulted in less handwashing, increased the risk of
nosocomial transmission of pathogens, because hands can become contaminated
even when gloves are used (39) and are contaminated easily in the process of
removing gloves, and contributed to skin problems and allergies associated with
the use of gloves.(40,41) On the other hand, proponents of BSI have noted that
studies of handwashing have indicated that there is relatively low compliance
by hospital personnel,(42,43) that glove use may have been easier to manage
than handwashing, and that frequent handwashing may have led to eczema, skin
cracking, or, in some persons, clinical damage to the skin of the hands.(44)
Although use of gloves may have been better than no handwashing, the efficacy
of using gloves as a substitute for handwashing has not been demonstrated.
In
1989, the Occupational Safety and Health Administration (OSHA) published a
proposed rule regarding occupational exposure to bloodborne pathogens in
hospitals and other healthcare settings.(45) The proposed rule, based on the
concept of UP, raised concerns in the infection control community. Among them
were concerns about the use of "visibly bloody" as a marker for the
infectious risk of certain body fluids and substances, the imbalance toward
precautions to protect personnel and away from protection for patients, the
lack of proven efficacy of UP, and the costs for implementing the proposed
regulations.(46-50) After a series of OSHA public hearings and the review of
written comments, the proposed rule was modified, and the final rule on
occupational exposure to bloodborne pathogens was published in 1991.(51) Although
the final rule was expected to improve occupational safety in the care of
patients infected with bloodborne pathogens, its impact on the cost of patient
care and on nosocomial infection control has remained undefined. Information on
complying with the OSHA final rule has been made available by the American
Hospital Association (52) and others.(53)
By
the early 1990s, isolation had become an infection control conundrum.(54)
Although many hospitals had incorporated all or portions of UP into their
category- or disease-specific isolation system and others had adopted all or
portions of BSI,(55,56) there was much local variation in the interpretation
and use of UP and BSI, and a variety of combinations was common. Further, there
was considerable confusion about which body fluids or substances required
precautions under UP and BSI. Many hospitals espousing UP really were using BSI
and vice versa. Moreover, there was continued lack of agreement about the
importance of handwashing when gloves were used (14,15,27-29,37,38,57,58) and
the need for additional precautions beyond BSI to prevent airborne, droplet,
and contact transmission.(14,15,27-29,31,36,59,60) Some hospitals had not
implemented appropriate guidelines for preventing transmission of tuberculosis,
including multidrug-resistant tuberculosis.(61) As other multidrug-resistant
microorganisms (62,63) were emerging, some hospitals failed to recognize them
as new problems and to add appropriate precautions that would contain them.
In
view of these problems and concerns, no simple adjustment to any of the
existing approaches-UP, BSI, the CDC isolation guideline, or other isolation
systems-appeared likely to solve the conundrum. Clearly what was needed was a
new synthesis of the various systems that would provide a guideline with
logistically feasible recommendations for preventing the many infections that
occur in hospitals through diverse modes of transmission. To achieve this, the
new guideline would 1) have to be epidemiologically sound; 2) have to recognize
the importance of all body fluids, secretions, and excretions in the
transmission of nosocomial pathogens; 3) have to contain adequate precautions
for infections transmitted by the airborne, droplet, and contact routes of
transmission; 4) have to be as simple and user friendly as possible; and 5)
have to use new terms to avoid confusion with existing systems.
Based
on these considerations, this guideline subsequently was developed. It contains
three important changes from previous recommendations. First, it synthesizes
the major features of UP (27,28) and BSI (29,30) into a single set of
precautions to be used for the care of all patients in hospitals regardless of
their presumed infection status. These precautions, called Standard
Precautions, are designed to reduce the risk of transmission of bloodborne and
other pathogens in hospitals. As a result of this synthesis, a large number of
patients with diseases or conditions that previously required category- or disease-specific
precautions in the 1983 CDC isolation guideline (4) now are covered under
Standard Precautions and do not require additional precautions. Second, it
collapses the old categories of isolation precautions (Strict Isolation,
Contact Isolation, Respiratory Isolation, Tuberculosis Isolation, Enteric
Precautions, and Drainage/Secretion Precautions) and the old disease-specific
precautions into three sets of precautions based on routes of transmission for
a smaller number of specified patients known or suspected to be infected or
colonized with highly transmissible or epidemiologically important pathogens. These
Transmission-Based Precautions, designed to reduce the risk of airborne,
droplet, and contact transmission in hospitals, are to be used in addition to
Standard Precautions. Third, it lists specific syndromes in both adult and
pediatric patients that are highly suspicious for infection and identifies
appropriate Transmission-Based Precautions to use on an empiric, temporary
basis until a diagnosis can be made. These empiric, temporary precautions also
are designed to be used in addition to Standard Precautions. The details of the
guideline recommendations are presented in Part II, "Recommendations for
Isolation Precautions in Hospitals."
In
summary, this new guideline is another step in the evolution of isolation
practices in US hospitals. It now is recommended for review and use by
hospitals with the following provision. No guideline can address all of the
needs of the more than 6,000 US hospitals, which range in size from five beds
to more than 1,500 beds and serve very different patient populations. Hospitals
are encouraged to review the recommendations and to modify them according to
what is possible, practical, and prudent.
Transmission
of infection within a hospital requires three elements: a source of infecting
microorganisms, a susceptible host, and a means of transmission for the
microorganism.
Human sources of the infecting microorganisms
in hospitals may be patients, personnel, or, on occasion, visitors, and may
include persons with acute disease, persons in the incubation period of a
disease, persons who are colonized by an infectious agent but have no apparent disease,
or persons who are chronic carriers of an infectious agent. Other sources of
infecting microorganisms can be the patient's own endogenous flora, which may
be difficult to control, and inanimate environmental objects that have become
contaminated, including equipment and medications.
Resistance among persons to pathogenic microorganisms varies greatly. Some persons may be immune to infection or may be able to resist colonization by an infectious agent; others exposed to the same agent may establish a commensal relationship with the infecting microorganism and become asymptomatic carriers; still others may develop clinical disease. Host factors such as age; underlying diseases; certain treatments with antimicrobials, corticosteroids, or other immunosuppressive agents; irradiation; and breaks in the first line of defense mechanisms caused by such factors as surgical operations, anesthesia, and indwelling catheters may render patients more susceptible to infection.
Microorganisms are transmitted in hospitals by
several routes, and the same microorganism may be transmitted by more than one
route. There are five main routes of transmission: contact, droplet, airborne,
common vehicle, and vectorborne. For the purpose of this guideline, common
vehicle and vectorborne transmission will be discussed only briefly, because
neither play a significant role in typical nosocomial infections.
(1) |
Contact transmission, the most important and frequent
mode of transmission of nosocomial infections, is divided into two subgroups:
direct-contact transmission and indirect-contact transmission. |
|
|
(a) |
Direct-contact transmission involves a direct
body surface-to-body surface contact and physical ransfer of microorganisms
between a susceptible host and an infected or colonized person, such as
occurs when a person turns a patient, gives a patient a bath, or performs
other patient-care activities that require direct personal contact. Direct-contact
transmission also can occur between two patients, with one serving as the
source of the infectious microorganisms and the other as a susceptible host. |
|
(b) |
Indirect-contact transmission involves
contact of a susceptible host with a contaminated intermediate object,
usually inanimate, such as contaminated instruments, needles, or dressings,
or contaminated hands that are not washed and gloves that are not changed
between patients. |
(2) |
Droplet transmission, theoretically, is a form of
contact transmission. However, the mechanism of transfer of the pathogen to
the host is quite distinct from either direct- or indirect-contact
transmission. Therefore, droplet transmission will be considered a separate
route of transmission in this guideline. Droplets are generated from the
source person primarily during coughing, sneezing, and talking, and during
the performance of certain procedures such as suctioning and bronchoscopy. Transmission
occurs when droplets containing microorganisms generated from the infected
person are propelled a short distance through the air and deposited on the
host's conjunctivae, nasal mucosa, or mouth. Because droplets do not remain
suspended in the air, special air handling and ventilation are not required
to prevent droplet transmission; that is, droplet transmission must not
be confused with airborne transmission. |
|
(3) |
Airborne transmission occurs by dissemination of either
airborne droplet nuclei (small-particle residue [5 µm or smaller in size] of
evaporated droplets containing microorganisms that remain suspended in the
air for long periods of time) or dust particles containing the infectious
agent. Microorganisms carried in this manner can be dispersed widely by air
currents and may become inhaled by a susceptible host within the same room or
over a longer distance from the source patient, depending on environmental
factors; therefore, special air handling and ventilation are required to
prevent airborne transmission. Microorganisms transmitted by airborne
transmission include Mycobacterium tuberculosis and the rubeola and varicella
viruses. |
|
(4) |
Common vehicle transmission applies to microorganisms
transmitted by contaminated items such as food, water, medications, devices,
and equipment. |
|
(5) |
Vectorborne transmission occurs when vectors such as
mosquitoes, flies, rats, and other vermin transmit microorganisms; this route
of transmission is of less significance in hospitals in the United States
than in other regions of the world. |
Isolation precautions are designed to prevent transmission of microorganisms by
these routes in hospitals. Because agent and host factors are more difficult to
control, interruption of transfer of microorganisms is directed primarily at
transmission. The recommendations presented in this guideline are based on this
concept.
Placing
a patient on isolation precautions, however, often presents certain
disadvantages to the hospital, patients, personnel, and visitors. Isolation
precautions may require specialized equipment and environmental modifications
that add to the cost of hospitalization. Isolation precautions may make
frequent visits by nurses, physicians, and other personnel inconvenient, and
they may make it more difficult for personnel to give the prompt and frequent
care that sometimes is required. The use of a multi-patient room for one
patient uses valuable space that otherwise might accommodate several patients. Moreover,
forced solitude deprives the patient of normal social relationships and may be
psychologically harmful, especially to children. These disadvantages, however,
must be weighed against the hospital's mission to prevent the spread of serious
and epidemiologically important microorganisms in the hospital.
A variety
of infection control measures are used for decreasing the risk of transmission
of microorganisms in hospitals. These measures make up the fundamentals of
isolation precautions.
Handwashing frequently is called the single
most important measure to reduce the risks of transmitting organisms from one
person to another or from one site to another on the same patient. The
scientific rationale, indications, methods, and products for handwashing have
been delineated in other publications.(64-72)
Washing
hands as promptly and thoroughly as possible between patient contacts and after
contact with blood, body fluids, secretions, excretions, and equipment or
articles contaminated by them is an important component of infection control
and isolation precautions. In addition to handwashing, gloves play an important
role in reducing the risks of transmission of microorganisms.
Gloves
are worn for three important reasons in hospitals. First, gloves are worn to
provide a protective barrier and to prevent gross contamination of the hands
when touching blood, body fluids, secretions, excretions, mucous membranes, and
nonintact skin (27-29); the wearing of gloves in specified circumstances to
reduce the risk of exposures to bloodborne pathogens is mandated by the OSHA
bloodborne pathogens final rule.(51) Second, gloves are worn to reduce the
likelihood that microorganisms present on the hands of personnel will be
transmitted to patients during invasive or other patient-care procedures that
involve touching a patient's mucous membranes and nonintact skin. Third, gloves
are worn to reduce the likelihood that hands of personnel contaminated with
microorganisms from a patient or a fomite can transmit these microorganisms to
another patient. In this situation, gloves must be changed between patient
contacts and hands washed after gloves are removed.
Wearing
gloves does not replace the need for handwashing, because gloves may have
small, inapparent defects or may be torn during use, and hands can become
contaminated during removal of gloves.(14,15,39,72-76) Failure to change gloves
between patient contacts is an infection control hazard.(32)
Appropriate patient placement is a significant
component of isolation precautions. A private room is important to prevent
direct- or indirect-contact transmission when the source patient has poor
hygienic habits, contaminates the environment, or cannot be expected to assist
in maintaining infection control precautions to limit transmission of
microorganisms (i.e., infants, children, and patients with altered mental
status). When possible, a patient with highly transmissible or
epidemiologically important microorganisms is placed in a private room with
handwashing and toilet facilities, to reduce opportunities for transmission of
microorganisms.
When
a private room is not available, an infected patient is placed with an
appropriate roommate. Patients infected by the same microorganism usually can
share a room, provided they are not infected with other potentially
transmissible microorganisms and the likelihood of reinfection with the same
organism is minimal. Such sharing of rooms, also referred to as cohorting
patients, is useful especially during outbreaks or when there is a shortage of
private rooms. When a private room is not available and cohorting is not
achievable or recommended,(23) it is very important to consider the
epidemiology and mode of transmission of the infecting pathogen and the patient
population being served in determining patient placement. Under these
circumstances, consultation with infection control professionals is advised
before patient placement. Moreover, when an infected patient shares a room with
a noninfected patient, it also is important that patients, personnel, and
visitors take precautions to prevent the spread of infection and that roommates
are selected carefully.
Guidelines
for construction, equipment, air handling, and ventilation for isolation rooms
have been delineated in other publications.(77-79) A private room with
appropriate air handling and ventilation is particularly important for reducing
the risk of transmission of microorganisms from a source patient to susceptible
patients and other persons in hospitals when the microorganism is spread by
airborne transmission. Some hospitals use an isolation room with an anteroom as
an extra measure of precaution to prevent airborne transmission. Adequate data
regarding the need for an anteroom, however, is not available. Ventilation
recommendations for isolation rooms housing patients with pulmonary
tuberculosis have been delineated in other CDC guidelines.(23)
Limiting the movement and transport of patients infected with virulent or epidemiologically important microorganisms and ensuring that such patients leave their rooms only for essential purposes reduces opportunities for transmission of microorganisms in hospitals. When patient transport is necessary, it is important that 1) appropriate barriers (e.g., masks, impervious dressings) are worn or used by the patient to reduce the opportunity for transmission of pertinent microorganisms to other patients, personnel, and visitors and to reduce contamination of the environment; 2) personnel in the area to which the patient is to be taken are notified of the impending arrival of the patient and of the precautions to be used to reduce the risk of transmission of infectious microorganisms; and 3) patients are informed of ways by which they can assist in preventing the transmission of their infectious microorganisms to others.
Various types of masks, goggles, and face
shields are worn alone or in combination to provide barrier protection. A mask
that covers both the nose and the mouth, and goggles or a face shield are worn
by hospital personnel during procedures and patient-care activities that are
likely to generate splashes or sprays of blood, body fluids, secretions, or
excretions to provide protection of the mucous membranes of the eyes, nose, and
mouth from contact transmission of pathogens. The wearing of masks, eye
protection, and face shields in specified circumstances to reduce the risk of
exposures to bloodborne pathogens is mandated by the OSHA bloodborne pathogens
final rule.(51) A surgical mask generally is worn by hospital personnel to
provide protection against spread of infectious large-particle droplets that
are transmitted by close contact and generally travel only short distances (up
to 3 ft) from infected patients who are coughing or sneezing.
An
area of major concern and controversy over the last several years has been the
role and selection of respiratory protection equipment and the implications of
a respiratory protection program for prevention of transmission of tuberculosis
in hospitals. Traditionally, although the efficacy was not proven, a surgical
mask was worn for isolation precautions in hospitals when patients were known
or suspected to be infected with pathogens spread by the airborne route of
transmission. In 1990, however, the CDC tuberculosis guidelines (18) stated
that surgical masks may not be effective in preventing the inhalation of
droplet nuclei and recommended the use of disposable particulate respirators,
despite the fact that the efficacy of particulate respirators in protecting
persons from the inhalation of M tuberculosis had not been demonstrated.
By definition, particulate respirators included dust-mist (DM), dust-fume-mist
(DFM), or high-efficiency particulate air (HEPA) filter respirators certified
by the CDC National Institute for Occupational Safety and Health (NIOSH);
because the generic term "particulate respirator" was used in the
1990 guidelines, the implication was that any of these respirators provided
sufficient protection.(80)
In
1993, a draft revision of the CDC tuberculosis guidelines (22) outlined
performance criteria for respirators and stated that some DM or DFM respirators
might not meet these criteria. After review of public comments, the guidelines
were finalized in October 1994,(23) with the draft respirator criteria
unchanged. At that time, the only class of respirators that were known to
consistently meet or exceed the performance criteria outlined in the 1994
tuberculosis guidelines and that were certified by NIOSH (as required by OSHA)
were HEPA filter respirators. Subsequently, NIOSH revised the testing and
certification requirements for all types of air-purifying respirators,
including those used for tuberculosis control.(81) The new rule, effective in
July 1995, provides a broader range of certified respirators that meet the
performance criteria recommended by CDC in the 1994 tuberculosis guidelines. NIOSH
has indicated that the N95 (N category at 95% efficiency) meets the CDC performance
criteria for a tuberculosis respirator. The new respirators are likely to be
available in late 1995. Additional information on the evolution of respirator
recommendations, regulations to protect hospital personnel, and the role of
various federal agencies in respiratory protection for hospital personnel has
been published.(80)
Various types of gowns and protective apparel
are worn to provide barrier protection and to reduce opportunities for
transmission of microorganisms in hospitals. Gowns are worn to prevent
contamination of clothing and to protect the skin of personnel from blood and
body fluid exposures. Gowns especially treated to make them impermeable to
liquids, leg coverings, boots, or shoe covers provide greater protection to the
skin when splashes or large quantities of infective material are present or
anticipated. The wearing of gowns and protective apparel under specified
circumstances to reduce the risk of exposures to bloodborne pathogens is
mandated by the OSHA bloodborne pathogens final rule.(51)
Gowns
are also worn by personnel during the care of patients infected with
epidemiologically important microorganisms to reduce the opportunity for
transmission of pathogens from patients or items in their environment to other
patients or environments; when gowns are worn for this purpose, they are
removed before leaving the patient's environment and hands are washed. Adequate
data regarding the efficacy of gowns for this purpose, however, is not
available.
Many factors determine whether special handling
and disposal of used patient-care equipment and articles are prudent or
required, including the likelihood of contamination with infective material;
the ability to cut, stick, or otherwise cause injury (needles, scalpels, and
other sharp instruments [sharps]); the severity of the associated disease; and
the environmental stability of the pathogens involved.(27,51,82-84) Some used
articles are enclosed in containers or bags to prevent inadvertent exposures to
patients, personnel, and visitors and to prevent contamination of the
environment. Used sharps are placed in puncture-resistant containers; other
articles are placed in a bag. One bag is adequate if the bag is sturdy and the
article can be placed in the bag without contaminating the outside of the bag
(85); otherwise, two bags are used.
The
scientific rationale, indications, methods, products, and equipment for
reprocessing patient-care equipment have been delineated in other publications.(68,84,86-91)
Contaminated, reusable critical medical devices or patient-care equipment
(i.e., equipment that enters normally sterile tissue or through which blood
flows) or semicritical medical devices or patient-care equipment (i.e.,
equipment that touches mucous membranes) are sterilized or disinfected
(reprocessed) after use to reduce the risk of transmission of microorganisms to
other patients; the type of reprocessing is determined by the article and its
intended use, the manufacturer's recommendations, hospital policy, and any
applicable guidelines and regulations.
Noncritical
equipment (i.e., equipment that touches intact skin) contaminated with blood,
body fluids, secretions, or excretions is cleaned and disinfected after use,
according to hospital policy. Contaminated disposable (single-use) patient-care
equipment is handled and transported in a manner that reduces the risk of
transmission of microorganisms and decreases environmental contamination in the
hospital; the equipment is disposed of according to hospital policy and
applicable regulations.
Although soiled linen may be contaminated with pathogenic microorganisms, the risk of disease transmission is negligible if it is handled, transported, and laundered in a manner that avoids transfer of microorganisms to patients, personnel, and environments. Rather than rigid rules and regulations, hygienic and common sense storage and processing of clean and soiled linen are recommended.(27,83,92,93) The methods for handling, transporting, and laundering of soiled linen are determined by hospital policy and any applicable regulations.
No special precautions are needed for dishes, glasses, cups, or eating utensils. Either disposable or reusable dishes and utensils can be used for patients on isolation precautions. The combination of hot water and detergents used in hospital dishwashers is sufficient to decontaminate dishes, glasses, cups, and eating utensils.
The room, or cubicle, and bedside equipment of patients on Transmission-Based Precautions are cleaned using the same procedures used for patients on Standard Precautions, unless the infecting microorganism(s) and the amount of environmental contamination indicates special cleaning. In addition to thorough cleaning, adequate disinfection of bedside equipment and environmental surfaces (e.g., bedrails, bedside tables, carts, commodes, doorknobs, faucet handles) is indicated for certain pathogens, especially enterococci, which can survive in the inanimate environment for prolonged periods of time.(94) Patients admitted to hospital rooms that previously were occupied by patients infected or colonized with such pathogens are at increased risk of infection from contaminated environmental surfaces and bedside equipment if they have not been cleaned and disinfected adequately. The methods, thoroughness, and frequency of cleaning and the products used are determined by hospital policy.
There are two tiers of HICPAC isolation precautions. In the first, and most important, tier are those precautions designed for the care of all patients in hospitals, regardless of their diagnosis or presumed infection status. Implementation of these "Standard Precautions" is the primary strategy for successful nosocomial infection control. In the second tier are precautions designed only for the care of specified patients. These additional "Transmission-Based Precautions" are for patients known or suspected to be infected by epidemiologically important pathogens spread by airborne or droplet transmission or by contact with dry skin or contaminated surfaces.
Standard Precautions synthesize the major
features of UP (Blood and Body Fluid Precautions) (27,28) (designed to reduce
the risk of transmission of bloodborne pathogens) and BSI (29,30) (designed to
reduce the risk of transmission of pathogens from moist body substances) and
applies them to all patients receiving care in hospitals, regardless of their
diagnosis or presumed infection status. Standard Precautions apply to 1) blood;
2) all body fluids, secretions, and excretions except sweat, regardless
of whether or not they contain visible blood; 3) nonintact skin; and 4) mucous
membranes. Standard Precautions are designed to reduce the risk of transmission
of microorganisms from both recognized and unrecognized sources of infection in
hospitals.
Transmission-Based Precautions are designed for
patients documented or suspected to be infected with highly transmissible or
epidemiologically important pathogens for which additional precautions beyond
Standard Precautions are needed to interrupt transmission in hospitals. There
are three types of Transmission-Based Precautions: Airborne Precautions,
Droplet Precautions, and Contact Precautions. They may be combined for diseases
that have multiple routes of transmission. When used either singularly or in
combination, they are to be used in addition to Standard Precautions.
Airborne Precautions are designed to reduce the risk of airborne transmission of infectious
agents. Airborne transmission occurs by dissemination of either airborne
droplet nuclei (small-particle residue [5 µm or smaller in size] of evaporated
droplets that may remain suspended in the air for long periods of time) or dust
particles containing the infectious agent. Microorganisms carried in this
manner can be dispersed widely by air currents and may become inhaled by or deposited
on a susceptible host within the same room or over a longer distance from the
source patient, depending on environmental factors; therefore, special air
handling and ventilation are required to prevent airborne transmission. Airborne
Precautions apply to patients known or suspected to be infected with
epidemiologically important pathogens that can be transmitted by the airborne
route.
Droplet Precautions are designed to reduce the risk of droplet transmission of infectious
agents. Droplet transmission involves contact of the conjunctivae or the mucous
membranes of the nose or mouth of a susceptible person with large-particle
droplets (larger than 5 µm in size) containing microorganisms generated from a
person who has a clinical disease or who is a carrier of the microorganism. Droplets
are generated from the source person primarily during coughing, sneezing, or
talking and during the performance of certain procedures such as suctioning and
bronchoscopy. Transmission via large-particle droplets requires close contact
between source and recipient persons, because droplets do not remain suspended
in the air and generally travel only short distances, usually 3 ft or less,
through the air. Because droplets do not remain suspended in the air, special
air handling and ventilation are not required to prevent droplet transmission. Droplet
Precautions apply to any patient known or suspected to be infected with
epidemiologically important pathogens that can be transmitted by infectious
droplets.
Contact Precautions are designed to reduce the risk of transmission of epidemiologically
important microorganisms by direct or indirect contact. Direct-contact
transmission involves skin-to-skin contact and physical transfer of
microorganisms to a susceptible host from an infected or colonized person, such
as occurs when personnel turn patients, bathe patients, or perform other
patient-care activities that require physical contact. Direct-contact
transmission also can occur between two patients (e.g., by hand contact), with
one serving as the source of infectious microorganisms and the other as a
susceptible host. Indirect-contact transmission involves contact of a
susceptible host with a contaminated intermediate object, usually inanimate, in
the patient's environment. Contact Precautions apply to specified patients
known or suspected to be infected or colonized (presence of microorganism in or
on patient but without clinical signs and symptoms of infection) with
epidemiologically important microorganisms than can be transmitted by direct or
indirect contact.
A
synopsis of the types of precautions and the patients requiring the precautions
is listed in Table 1.
In many instances, the risk of nosocomial
transmission of infection may be highest before a definitive diagnosis can be
made and before precautions based on that diagnosis can be implemented. The
routine use of Standard Precautions for all patients should reduce greatly this
risk for conditions other than those requiring Airborne, Droplet, or Contact
Precautions. While it is not possible to prospectively identify all patients
needing these enhanced precautions, certain clinical syndromes and conditions
carry a sufficiently high risk to warrant the empiric addition of enhanced
precautions while a more definitive diagnosis is pursued. A listing of such
conditions and the recommended precautions beyond Standard Precautions is
presented in Table 2.
The
organisms listed under the column "Potential Pathogens" are not
intended to represent the complete or even most likely diagnoses, but rather
possible etiologic agents that require additional precautions beyond Standard
Precautions until they can be ruled out. Infection control professionals are
encouraged to modify or adapt this table according to local conditions. To
ensure that appropriate empiric precautions are implemented always, hospitals
must have systems in place to evaluate patients routinely, according to these
criteria as part of their preadmission and admission care.
Immunocompromised patients vary in their
susceptibility to nosocomial infections, depending on the severity and duration
of immunosuppression. They generally are at increased risk for bacterial,
fungal, parasitic, and viral infections from both endogenous and exogenous
sources. The use of Standard Precautions for all patients and
Transmission-Based Precautions for specified patients, as recommended in this
guideline, should reduce the acquisition by these patients of institutionally
acquired bacteria from other patients and environments.
It
is beyond the scope of this guideline to address the various measures that may
be used for immunocompromised patients to delay or prevent acquisition of
potential pathogens during temporary periods of neutropenia. Rather, the
primary objective of this guideline is to prevent transmission of pathogens
from infected or colonized patients in hospitals. Users of this guideline,
however, are referred to the "Guideline for Prevention of Nosocomial
Pneumonia" (95,96) for the HICPAC recommendations for prevention of
nosocomial aspergillosis and Legionnaires' disease in immunocompromised
patients.
The
recommendations presented below are categorized as follows:
Category IA. Strongly recommended for all
hospitals and strongly supported by well-designed experimental or epidemiologic
studies.
Category IB. Strongly recommended for all
hospitals and reviewed as effective by experts in the field and a consensus of
HICPAC based on strong rationale and suggestive evidence, even though
definitive scientific studies have not been done.
Category II. Suggested for implementation in
many hospitals. Recommendations may be supported by suggestive clinical or
epidemiologic studies, a strong theoretical rationale, or definitive studies
applicable to some, but not all, hospitals.
No recommendation;
unresolved issue. Practices
for which insufficient evidence or consensus regarding efficacy exists.
The recommendations are
limited to the topic of isolation precautions. Therefore, they must be
supplemented by hospital policies and procedures for other aspects of infection
and environmental control, occupational health, administrative and legal issues,
and other issues beyond the scope of this guideline.
I.
Administrative Controls |
||
|
A.
Education |
|
|
|
Develop a
system to ensure that hospital patients, personnel, and visitors are educated
about use of precautions and their responsibility for adherence to them. Category
IB |
|
B.
Adherence to Precautions |
|
|
|
Periodically
evaluate adherence to precautions, and use findings to direct improvements. Category
IB |
II.
Standard Precautions |
||
|
Use
Standard Precautions, or the equivalent, for the care of all patients. Category
IB |
|
|
A.
Handwashing |
|
|
|
(1) Wash
hands after touching blood, body fluids, secretions, excretions, and
contaminated items, whether or not gloves are worn. Wash hands immediately
after gloves are removed, between patient contacts, and when otherwise
indicated to avoid transfer of microorganisms to other patients or
environments. It may be necessary to wash hands between tasks and procedures
on the same patient to prevent cross-contamination of different body sites. Category
IB |
|
|
(2) Use a
plain (nonantimicrobial) soap for routine handwashing. Category IB |
|
|
(3) Use
an antimicrobial agent or a waterless antiseptic agent for specific
circumstances (e.g., control of outbreaks or hyperendemic infections), as
defined by the infection control program. Category IB (See Contact
Precautions for additional recommendations on using antimicrobial and
antiseptic agents.) |
|
B. Gloves |
|
|
|
Wear
gloves (clean, nonsterile gloves are adequate) when touching blood, body
fluids, secretions, excretions, and contaminated items. Put on clean gloves
just before touching mucous membranes and nonintact skin. Change gloves
between tasks and procedures on the same patient after contact with material
that may contain a high concentration of microorganisms. Remove gloves
promptly after use, before touching noncontaminated items and environmental
surfaces, and before going to another patient, and wash hands immediately to
avoid transfer of microorganisms to other patients or environments. Category
IB |
|
C. Mask,
Eye Protection, Face Shield |
|
|
|
Wear a
mask and eye protection or a face shield to protect mucous membranes of the
eyes, nose, and mouth during procedures and patient-care activities that are
likely to generate splashes or sprays of blood, body fluids, secretions, and
excretions. Category IB |
|
D. Gown |
|
|
|
Wear a
gown (a clean, nonsterile gown is adequate) to protect skin and to prevent
soiling of clothing during procedures and patient-care activities that are
likely to generate splashes or sprays of blood, body fluids, secretions, or
excretions. Select a gown that is appropriate for the activity and amount of
fluid likely to be encountered. Remove a soiled gown as promptly as possible,
and wash hands to avoid transfer of microorganisms to other patients or
environments. Category IB |
|
E.
Patient-Care Equipment |
|
|
|
Handle
used patient-care equipment soiled with blood, body fluids, secretions, and
excretions in a manner that prevents skin and mucous membrane exposures,
contamination of clothing, and transfer of microorganisms to other patients
and environments. Ensure that reusable equipment is not used for the care of
another patient until it has been cleaned and reprocessed appropriately. Ensure
that single-use items are discarded properly. Category IB |
|
F.
Environmental Control |
|
|
|
Ensure
that the hospital has adequate procedures for the routine care, cleaning, and
disinfection of environmental surfaces, beds, bedrails, bedside equipment,
and other frequently touched surfaces, and ensure that these procedures are
being followed. Category IB |
|
G. Linen |
|
|
|
Handle,
transport, and process used linen soiled with blood, body fluids, secretions,
and excretions in a manner that prevents skin and mucous membrane exposures
and contamination of clothing, and that avoids transfer of microorganisms to
other patients and environments. Category IB |
|
H.
Occupational Health and Bloodborne Pathogens |
|
|
|
(1) Take
care to prevent injuries when using needles, scalpels, and other sharp
instruments or devices; when handling sharp instruments after procedures;
when cleaning used instruments; and when disposing of used needles. Never
recap used needles, or otherwise manipulate them using both hands, or use any
other technique that involves directing the point of a needle toward any part
of the body; rather, use either a one-handed "scoop" technique or a
mechanical device designed for holding the needle sheath. Do not remove used
needles from disposable syringes by hand, and do not bend, break, or
otherwise manipulate used needles by hand. Place used disposable syringes and
needles, scalpel blades, and other sharp items in appropriate
puncture-resistant containers, which are located as close as practical to the
area in which the items were used, and place reusable syringes and needles in
a puncture-resistant container for transport to the reprocessing area. Category
IB |
|
|
(2) Use
mouthpieces, resuscitation bags, or other ventilation devices as an
alternative to mouth-to-mouth resuscitation methods in areas where the need
for resuscitation is predictable. Category IB |
|
I.
Patient Placement |
|
|
|
Place a
patient who contaminates the environment or who does not (or cannot be
expected to) assist in maintaining appropriate hygiene or environmental
control in a private room. If a private room is not available, consult with
infection control professionals regarding patient placement or other
alternatives. Category IB |
III.
Airborne Precautions |
||
|
In
addition to Standard Precautions, use Airborne Precautions, or the
equivalent, for patients known or suspected to be infected with
microorganisms transmitted by airborne droplet nuclei (small-particle residue
[5 µm or smaller in size] of evaporated droplets containing microorganisms
that remain suspended in the air and that can be dispersed widely by air
currents within a room or over a long distance). Category IB |
|
|
A.
Patient Placement |
|
|
|
Place the
patient in a private room that has 1) monitored negative air pressure in
relation to the surrounding areas, 2) 6 to 12 air changes per hour, and 3)
appropriate discharge of air outdoors or monitored high-efficiency filtration
of room air before the air is circulated to other areas in the hospital.(23)
Keep the room door closed and the patient in the room. When a private room is
not available, place the patient in a room with a patient who has active
infection with the same microorganism, unless otherwise recommended,(23) but
with no other infection. When a private room is not available and cohorting
is not desirable, consultation with infection control professionals is
advised before patient placement. Category IB |
|
B.
Respiratory Protection |
|
|
|
Wear respiratory protection (N95 respirator) when entering the room of a patient with known or suspected infectious pulmonary tuberculosis.(23,81) Susceptible persons should not enter the room of patients known or suspected to have measles (rubeola) or varicella (chickenpox) if other immune caregivers are available. If susceptible persons must enter the room of a patient known or suspected to have measles (rubeola) or varicella, they should wear respiratory protection (N95 respirator).(81) Persons immune to measles (rubeola) or varicella need not wear respiratory protection. Category IB |
|
C. Patient
Transport |
|
|
|
Limit the
movement and transport of the patient from the room to essential purposes
only. If transport or movement is necessary, minimize patient dispersal of
droplet nuclei by placing a surgical mask on the patient, if possible. Category
IB |
|
D.
Additional Precautions for Preventing Transmission of Tuberculosis |
|
|
|
Consult
CDC "Guidelines for Preventing the Transmission of Tuberculosis in
Health-Care Facilities"(23) for additional prevention strategies. |
IV.
Droplet Precautions |
||
|
|
In
addition to Standard Precautions, use Droplet Precautions, or the equivalent,
for a patient known or suspected to be infected with microorganisms
transmitted by droplets (large-particle droplets [larger than 5 µm in size]
that can be generated by the patient during coughing, sneezing, talking, or
the performance of procedures). Category IB |
|
A.
Patient Placement |
|
|
|
Place the
patient in a private room. When a private room is not available, place the
patient in a room with a patient(s) who has active infection with the same
microorganism but with no other infection (cohorting). When a private room is
not available and cohorting is not achievable, maintain spatial separation of
at least 3 ft between the infected patient and other patients and visitors. Special
air handling and ventilation are not necessary, and the door may remain open.
Category IB |
|
B. Mask |
|
|
|
In
addition to wearing a mask as outlined under Standard Precautions, wear a
mask when working within 3 ft of the patient. (Logistically, some hospitals
may want to implement the wearing of a mask to enter the room.) Category
IB |
|
C.
Patient Transport |
|
|
|
Limit the
movement and transport of the patient from the room to essential purposes
only. If transport or movement is necessary, minimize patient dispersal of
droplets by masking the patient, if possible. Category IB |
V.
Contact Precautions |
||
|
In
addition to Standard Precautions, use Contact Precautions, or the equivalent,
for specified patients known or suspected to be infected or colonized with
epidemiologically important microorganisms that can be transmitted by direct
contact with the patient (hand or skin-to-skin contact that occurs when
performing patient-care activities that require touching the patient's dry
skin) or indirect contact (touching) with environmental surfaces or
patient-care items in the patient's environment. Category IB |
|
|
A.
Patient Placement |
|
|
|
Place the
patient in a private room. When a private room is not available, place the
patient in a room with a patient(s) who has active infection with the same
microorganism but with no other infection (cohorting). When a private room is
not available and cohorting is not achievable, consider the epidemiology of
the microorganism and the patient population when determining patient
placement. Consultation with infection control professionals is advised
before patient placement. Category IB |
|
B. Gloves
and Handwashing |
|
|
|
In
addition to wearing gloves as outlined under Standard Precautions, wear
gloves (clean, nonsterile gloves are adequate) when entering the room. During
the course of providing care for a patient, change gloves after having contact
with infective material that may contain high concentrations of
microorganisms (fecal material and wound drainage). Remove gloves before
leaving the patient's room and wash hands immediately with an antimicrobial
agent or a waterless antiseptic agent.(72,94) After glove removal and
handwashing, ensure that hands do not touch potentially contaminated
environmental surfaces or items in the patient's room to avoid transfer of
microorganisms to other patients or environments. Category IB |
|
C. Gown |
|
|
|
In
addition to wearing a gown as outlined under Standard Precautions, wear a
gown (a clean, nonsterile gown is adequate) when entering the room if you
anticipate that your clothing will have substantial contact with the patient,
environmental surfaces, or items in the patient's room, or if the patient is
incontinent or has diarrhea, an ileostomy, a colostomy, or wound drainage not
contained by a dressing. Remove the gown before leaving the patient's
environment. After gown removal, ensure that clothing does not contact
potentially contaminated environmental surfaces to avoid transfer of
microorganisms to other patients or environments. Category IB |
|
D.
Patient Transport |
|
|
|
Limit the
movement and transport of the patient from the room to essential purposes
only. If the patient is transported out of the room, ensure that precautions
are maintained to minimize the risk of transmission of microorganisms to
other patients and contamination of environmental surfaces or equipment. Category
IB |
|
E.
Patient-Care Equipment |
|
|
|
When
possible, dedicate the use of noncritical patient-care equipment to a single
patient (or cohort of patients infected or colonized with the pathogen
requiring precautions) to avoid sharing between patients. If use of common
equipment or items is unavoidable, then adequately clean and disinfect them
before use for another patient. Category IB |
|
F.
Additional Precautions for Preventing the Spread of Vancomycin Resistance |
|
|
|
Consult
the HICPAC report on preventing the spread of vancomycin resistance for
additional prevention strategies.(94) |
Standard
Precautions |
||
|
Use
Standard Precautions for the care of all patients |
|
Airborne
Precautions |
||
|
In
addition to Standard Precautions, use Airborne Precautions for patients known
or suspected to have serious illnesses transmitted by airborne droplet nuclei.
Examples of such illnesses include: |
|
|
|
Measles |
|
|
Varicella
(including disseminated zoster)† |
|
|
Tuberculosis‡ |
Droplet
Precautions |
||
|
In
addition to Standard Precautions, use Droplet Precautions for patients known
or suspected to have serious illnesses transmitted by large particle
droplets. Examples of such illnesses include: |
|
|
Invasive Haemophilus
influenzae type b disease, including meningitis, pneumonia, epiglottitis,
and sepsis |
|
|
Invasive Neisseria
meningitidis disease, including meningitis, pneumonia, and sepsis |
|
|
Other
serious bacterial respiratory infections spread by droplet transmission,
including: |
|
|
|
Diphtheria
(pharyngeal) |
|
|
Mycoplasma
pneumonia |
|
|
Pertussis |
|
|
Pneumonic
plague |
|
|
Streptococcal
(group A) pharyngitis, pneumonia, or scarlet fever in infants and young
children |
|
Serious
viral infections spread by droplet transmission, including: |
|
|
|
Adenovirus† |
|
|
Influenza |
|
|
Mumps |
|
|
Parvovirus
B19 |
|
|
Rubella |
Contact
Precautions |
||
|
In
addition to Standard Precautions, use Contact Precautions for patients known
or suspected to have serious illnesses easily transmitted by direct patient
contact or by contact with items in the patient's environment. Examples of
such illnesses include: |
|
|
Gastrointestinal,
respiratory, skin, or wound infections or colonization with
multidrug-resistant bacteria judged by the infection control program, based
on current state, regional, or national recommendations, to be of special
clinical and epidemiologic significance |
|
|
Enteric
infections with a low infectious dose or prolonged environmental survival,
including: |
|
|
|
Clostridium
difficile |
|
|
For
diapered or incontinent patients: enterohemorrhagic Escherichia coli O157:H7,
Shigella, hepatitis A, or rotavirus |
|
Respiratory
syncytial virus, parainfluenza virus, or enteroviral infections in infants
and young children |
|
|
Skin
infections that are highly contagious or that may occur on dry skin, including: |
|
|
|
Diphtheria
(cutaneous) |
|
|
Herpes
simplex virus (neonatal or mucocutaneous) |
|
|
Impetigo |
|
|
Major
(noncontained) abscesses, cellulitis, or decubiti |
|
|
Pediculosis |
|
|
Scabies |
|
|
Staphylococcal
furunculosis in infants and young children |
|
|
Zoster
(disseminated or in the immunocompromised host)† |
|
Viral/hemorrhagic
conjunctivitis |
|
|
Viral
hemorrhagic infections (Ebola, Lassa, or Marburg)* |
* See Appendix A for a complete listing of infections requiring precautions,
including appropriate footnotes.
† Certain infections require more than one type of precaution.
‡ See CDC "Guidelines for Preventing the
Transmission of Tuberculosis in Health-Care Facilities."(23)
Table 2
|
|||
Clinical Syndrome or Condition† |
Potential Pathogens‡ |
Empiric |
|
|
|||
Diarrhea |
|
|
|
|
Acute
diarrhea with a likely infectious cause in an incontinent or diapered patient |
Enteric
pathogens§ |
Contact |
|
Diarrhea
in an adult with a history of recent antibiotic use |
Clostridium
difficile |
Contact |
Meningitis |
Neisseria
meningitidis |
Droplet |
|
Rash or
exanthems, generalized, etiology unknown |
|
|
|
|
Petechial/ecchymotic
with fever |
Neisseria meningitidis |
Droplet |
|
Vesicular
|
Varicella
|
Airborne
and |
|
Maculopapular
with coryza and fever |
Rubeola
(measles) |
Airborne |
Respiratory
infections |
|
|
|
|
Cough/fever/upper
lobe pulmonary infiltrate in an HIV-negative patient or a |
Mycobacterium
tuberculosis |
Airborne |
|
Cough/fever/pulmonary
infiltrate in any lung location in a HIV-infected patient or a |
Mycobacterium
tuberculosis |
Airborne |
|
Paroxysmal
or severe persistent cough during periods of pertussis activity |
Bordetella
pertussis |
Droplet |
|
Respiratory
infections, particularly bronchiolitis |
Respiratory
syncytial or |
Contact |
Risk of
multidrug-resistant microorganisms |
|
|
|
|
History
of infection or colonization with multidrug-resistant organisms|| |
Resistant
bacteria|| |
Contact |
|
Skin,
wound, or urinary tract infection in a patient with a recent hospital or
nursing home stay in a facility where multidrug-resistant organisms are
prevalent |
Resistant
bacteria|| |
Contact |
Skin or
Wound Infection |
|
|
|
|
Abscess
or draining wound that cannot be covered |
Staphylococcus aureus, group A streptococcus |
Contact |
|
APPENDIX A
Type and Duration of
Precautions Needed for Selected Infections and Conditions
|
||
|
Precautions |
|
|
——————— |
|
Infection/Condition |
Type* |
Duration† |
Abscess |
|
|
Draining,
major a |
C |
DI |
Draining,
minor or limited b |
S |
|
Acquired
immunodeficiency syndrome c |
S |
|
Actinomycosis |
S |
|
Adenovirus
infection, in infants and young children |
D,C |
DI |
Amebiasis |
S |
|
Anthrax |
|
|
Cutaneous |
S |
|
Pulmonary |
S |
|
Antibiotic-associated
colitis (see Clostridium difficile) |
|
|
Arthropodborne
viral encephalitides (eastern, western, Venezuelan |
S d |
|
Arthropodborne
viral fevers (dengue, yellow fever, Colorado tick fever) |
S d |
|
Ascariasis |
S |
|
Aspergillosis |
S |
|
Babesiosis |
S |
|
Blastomycosis,
North American, cutaneous or pulmonary |
S |
|
Botulism |
S |
|
Bronchiolitis
(see respiratory infections in infants and young children) |
|
|
Brucellosis
(undulant, Malta, Mediterranean fever) |
S |
|
Campylobacter gastroenteritis (see
gastroenteritis) |
|
|
Candidiasis,
all forms including mucocutaneous |
S |
|
Cat-scratch
fever (benign inoculation lymphoreticulosis) |
S |
|
Cellulitis,
uncontrolled drainage |
C |
DI |
Chancroid
(soft chancre) |
S |
|
Chickenpox (varicella; see F e for varicella exposure) |
A,C |
F e |
Chlamydia
trachomatis |
|
|
Conjunctivitis
|
S |
|
Genital
|
S |
|
Respiratory |
S |
|
Cholera
(see gastroenteritis) |
|
|
Closed-cavity
infection |
|
|
Draining,
limited or minor |
S |
|
Not
draining |
S |
|
Clostridium |
|
|
C
botulinum |
S |
|
C difficile |
C |
DI |
C perfringens |
|
|
Food
poisoning |
S |
|
Gas
gangrene |
S |
|
Coccidioidomycosis
(valley fever) |
|
|
Draining
lesions |
S |
|
Pneumonia
|
S |
|
Colorado
tick fever |
S |
|
Congenital
rubella |
C |
F f |
Conjunctivitis |
|
|
Acute
bacterial |
S |
|
Chlamydia
|
S |
|
Gonococcal
|
S |
|
Acute
viral (acute hemorrhagic) |
C |
DI |
Coxsackievirus
disease (see enteroviral infection) |
|
|
Creutzfeldt-Jakob
disease |
S g |
|
Croup
(see respiratory infections in infants and young children) |
|
|
Cryptococcosis
|
S |
|
Cryptosporidiosis
(see gastroenteritis) |
|
|
Cysticercosis |
S |
|
Cytomegalovirus
infection, neonatal or immunosuppressed |
S |
|
Decubitus
ulcer, infected |
|
|
Major
a |
C |
DI |
Minor
or limited b |
S |
|
Dengue |
S d |
|
Diarrhea,
acute-infective etiology suspected (see gastroenteritis) |
|
|
Diphtheria |
|
|
Cutaneous
|
C |
CN h |
Pharyngeal
|
D |
CN h |
Ebola
viral hemorrhagic fever |
C i |
DI |
Echinococcosis
(hydatidosis) |
S |
|
Echovirus
(see enteroviral infection) |
|
|
Encephalitis
or encephalomyelitis (see specific etiologic agents) |
|
|
Endometritis
|
S |
|
Enterobiasis
(pinworm disease, oxyuriasis) |
S |
|
Enterococcus species (see multidrug-resistant
organisms if epidemiologically |
|
|
Enterocolitis, Clostridium difficile |
C |
DI |
Enteroviral
infections |
|
|
Adults |
S |
|
Infants
and young children |
C |
DI |
Epiglottitis,
due to Haemophilus influenzae |
D |
U(24 hrs) |
Epstein-Barr
virus infection, including infectious mononucleosis |
S |
|
Erythema
infectiosum (also see Parvovirus B19) |
S |
|
Escherichia
coli gastroenteritis
(see gastroenteritis) |
|
|
Food
poisoning |
|
|
Botulism |
S |
|
Clostridium
perfringens or welchii |
S |
|
Staphylococcal
|
S |
|
Furunculosis-staphylococcal |
|
|
Infants
and young children |
C |
DI |
Gangrene (gas
gangrene) |
S |
|
Gastroenteritis |
|
|
Campylobacter
species |
S j |
|
Cholera
|
S j |
|
Clostridium difficile |
C |
DI |
Cryptosporidium species |
S j |
|
Escherichia coli |
|
|
Enterohemorrhagic O157:H7 |
S j |
|
Diapered
or incontinent |
C |
DI |
Other
species |
S j |
|
Giardia lamblia |
S j |
|
Rotavirus |
S j |
|
Diapered
or incontinent |
C |
DI |
Salmonella species (including S typhi) |
S j |
|
Shigella species |
S j |
|
Diapered
or incontinent |
C |
DI |
Vibrio parahaemolyticus |
S j |
|
Viral
(if not covered elsewhere) |
S j |
|
Yersinia enterocolitica |
S j |
|
German
measles (see rubella) |
|
|
Giardiasis
(see gastroenteritis) |
|
|
Gonococcal
ophthalmia neonatorum (gonorrheal ophthalmia, |
S |
|
Gonorrhea
|
S |
|
Granuloma inguinale (donovanosis, granuloma venereum) |
S |
|
Guillain-Barré‚
syndrome |
S |
|
Hand,
foot, and mouth disease (see enteroviral infection) |
|
|
Hantavirus pulmonary syndrome |
S |
|
Helicobacter
pylori |
S |
|
Hemorrhagic
fevers (for example, Lassa and Ebola) |
C i |
DI |
Hepatitis,
viral |
|
|
Type
A |
S |
|
Diapered
or incontinent patients |
C |
F k |
Type
B-HBsAg positive |
S |
|
Type
C and other unspecified non-A, non-B |
S |
|
Type
E |
S |
|
Herpangina
(see enteroviral infection) |
|
|
Herpes simplex
(Herpesvirus hominis) |
|
|
Encephalitis
|
S |
|
C |
DI |
|
Mucocutaneous,
disseminated or primary, severe |
C |
DI |
Mucocutaneous,
recurrent (skin, oral, genital) |
S |
|
Herpes zoster (varicella-zoster) |
|
|
Localized in immunocompromised patient, or disseminated |
A,C |
DI m |
Localized in normal patient |
S m |
|
Histoplasmosis
|
S |
|
HIV (see
human immunodeficiency virus) |
S |
|
Hookworm
disease (ancylostomiasis, uncinariasis) |
S |
|
Human
immunodeficiency virus (HIV) infection c |
S |
|
Impetigo |
C |
U(24 hrs) |
Infectious
mononucleosis |
S |
|
Influenza
|
D n |
DI |
Kawasaki syndrome |
S |
|
Lassa
fever |
C i |
DI |
Legionnaires'
disease |
S |
|
Leprosy |
S |
|
Leptospirosis |
S |
|
Lice
(pediculosis) |
C |
U(24 hrs) |
Listeriosis |
S |
|
Lyme
disease |
S |
|
Lymphocytic
choriomeningitis |
S |
|
Lymphogranuloma
venereum |
S |
|
Malaria |
S d |
|
Marburg
virus disease |
C i |
DI |
Measles
(rubeola), all presentations |
A |
DI |
Melioidosis,
all forms |
S |
|
Meningitis
|
|
|
Aseptic
(nonbacterial or viral meningitis; also see enteroviral infections) |
S |
|
Bacterial, gram-negative enteric, in neonates |
S |
|
Fungal |
S |
|
Haemophilus
influenzae, known or suspected |
D |
U(24 hrs) |
Listeria monocytogenes |
S |
|
Neisseria
meningitidis (meningococcal) known or suspected |
D |
U(24 hrs) |
Pneumococcal |
S |
|
Tuberculosis
o |
S |
|
Other
diagnosed bacterial |
S |
|
Meningococcal
pneumonia |
D |
U(24 hrs) |
Meningococcemia (meningococcal sepsis) |
D |
U(24 hrs) |
Molluscum contagiosum |
S |
|
Mucormycosis
|
S |
|
Multidrug-resistant
organisms, infection or colonization p |
|
|
Gastrointestinal |
C |
CN |
Respiratory |
C |
CN |
Pneumococcal
|
S |
|
Skin,
wound, or burn |
C |
CN |
Mumps
(infectious parotitis) |
D |
F q |
Mycobacteria,
nontuberculosis (atypical) |
|
|
Pulmonary
|
S |
|
Wound
|
S |
|
Mycoplasma pneumonia |
D |
DI |
Necrotizing enterocolitis |
S |
|
Nocardiosis,
draining lesions or other presentations |
S |
|
Norwalk
agent gastroenteritis (see viral gastroenteritis) |
|
|
Orf |
S |
|
Parainfluenza
virus infection, respiratory in infants and young children |
C |
DI |
Parvovirus B19 |
D |
F r |
Pediculosis
(lice) |
C |
U(24 hrs) |
Pertussis
(whooping cough) |
D |
F s |
Pinworm
infection |
S |
|
Plague |
|
|
Bubonic
|
S |
|
Pneumonic
|
D |
U(72 hrs) |
Pleurodynia (see enteroviral infection) |
|
|
Pneumonia |
|
|
Adenovirus |
D,C |
DI |
Bacterial not listed elsewhere (including gram-negative bacterial) |
S |
|
Burkholderia
cepacia in cystic fibrosis (CF) patients, |
S t |
|
Chlamydia
|
S |
|
Fungal |
S |
|
Haemophilus
influenzae |
|
|
Adults |
S |
|
Infants
and children (any age) |
D |
U(24 hrs) |
Legionella |
S |
|
Meningococcal |
D |
U(24 hrs) |
Multidrug-resistant
bacterial (see multidrug-resistant organisms) |
|
|
Mycoplasma
(primary atypical pneumonia) |
D |
DI |
Pneumococcal |
S |
|
Multidrug-resistant
(see multidrug-resistant organisms) |
|
|
Pneumocystis
carinii |
S u |
|
Pseudomonas
cepacia (see Burkholderia cepacia) |
S t |
|
Staphylococcus
aureus |
S |
|
Streptococcus,
group A |
|
|
Adults |
S |
|
Infants
and young children |
D |
U(24hrs) |
Viral |
|
|
Adults |
S |
|
Infants
and young children (see respiratory infectious disease, acute) |
|
|
Poliomyelitis |
S |
|
Psittacosis
(ornithosis) |
S |
|
Q fever |
S |
|
Rabies |
S |
|
Rat-bite
fever (Streptobacillus moniliformis disease, Spirillum minus
disease) |
S |
|
Relapsing
fever |
S |
|
Resistant
bacterial infection or colonization (see multidrug-resistant organisms) |
|
|
Respiratory
infectious disease, acute (if not covered elsewhere) |
|
|
Adults |
S |
|
Infants
and young children c |
C |
DI |
Respiratory
syncytial virus infection, in infants and |
C |
DI |
Reye's
syndrome |
S |
|
Rheumatic
fever |
S |
|
Rickettsial
fevers, tickborne (Rocky Mountain spotted fever, tickborne typhus fever) |
S |
|
Rickettsialpox
(vesicular rickettsiosis) |
S |
|
Ringworm
(dermatophytosis, dermatomycosis, tinea) |
S |
|
Ritter's
disease (staphylococcal scalded skin syndrome) |
S |
|
Rocky
Mountain spotted fever |
S |
|
Roseola
infantum (exanthem subitum) |
S |
|
Rotavirus
infection (see gastroenteritis) |
|
|
Rubella
(German measles; also see congenital rubella) |
D |
F v |
Salmonellosis
(see gastroenteritis) |
|
|
Scabies |
C |
U(24 hrs) |
Scalded
skin syndrome, staphylococcal (Ritter's disease) |
S |
|
Schistosomiasis
(bilharziasis) |
S |
|
Shigellosis
(see gastroenteritis) |
|
|
Sporotrichosis |
S |
|
Spirillum
minus disease
(rat-bite fever) |
S |
|
Staphylococcal disease (S aureus) |
|
|
Skin,
wound, or burn |
|
|
Major
a |
C |
DI |
Minor
or limited b |
S |
|
Enterocolitis |
S j |
|
Multidrug-resistant
(see multidrug-resistant organisms) |
|
|
Pneumonia
|
S |
|
Scalded
skin syndrome |
S |
|
Toxic
shock syndrome |
S |
|
Streptobacillus
moniliformis disease
(rat-bite fever) |
S |
|
Streptococcal
disease (group A streptococcus) |
|
|
Skin,
wound, or burn |
|
|
Major
a |
C |
U(24 hrs) |
Minor
or limited b |
S |
|
Endometritis
(puerperal sepsis) |
S |
|
Pharyngitis
in infants and young children |
D |
U(24 hrs) |
Pneumonia in infants and young
children |
D |
U(24 hrs) |
Scarlet fever in infants and young
children |
D |
U(24 hrs) |
Streptococcal
disease (group B streptococcus), neonatal |
S |
|
Streptococcal
disease (not group A or B) unless covered elsewhere |
S |
|
Multidrug-resistant
(see multidrug-resistant organisms) |
|
|
Strongyloidiasis |
S |
|
Syphilis |
|
|
Skin
and mucous membrane, including congenital, primary, secondary |
S |
|
Latent
(tertiary) and seropositivity without lesions |
S |
|
Tapeworm
disease |
|
|
Hymenolepis
nana |
S |
|
Taenia solium (pork) |
S |
|
Other
|
S |
|
Tetanus |
S |
|
Tinea
(fungus infection dermatophytosis, dermatomycosis, ringworm) |
S |
|
Toxoplasmosis |
S |
|
Toxic
shock syndrome (staphylococcal disease) |
S |
|
Trachoma,
acute |
S |
|
Trench
mouth (Vincent's angina) |
S |
|
Trichinosis |
S |
|
Trichomoniasis
|
S |
|
Trichuriasis
(whipworm disease) |
S |
|
Tuberculosis |
|
|
Extrapulmonary,
draining lesion (including scrofula) |
S |
|
Extrapulmonary,
meningitis o |
S |
|
Pulmonary,
confirmed or suspected or laryngeal disease |
A |
F w |
Skin-test
positive with no evidence of current pulmonary disease |
S |
|
Tularemia |
|
|
Draining
lesion |
S |
|
Pulmonary
|
S |
|
Typhoid (Salmonella
typhi) fever (see gastroenteritis) |
|
|
Typhus,
endemic and epidemic |
S |
|
Urinary
tract infection (including pyelonephritis), with or without urinary catheter |
S |
|
Varicella (chickenpox) |
A,C |
F e |
Vibrio parahaemolyticus (see
gastroenteritis) |
|
|
Vincent's
angina (trench mouth) |
S |
|
Viral
diseases |
|
|
Respiratory
(if not covered elsewhere) |
|
|
Adults |
S |
|
Infants
and young children (see respiratory infectious disease, acute) |
|
|
Whooping
cough (pertussis) |
D |
F s |
Wound
infections |
|
|
Major
a |
C |
DI |
Minor
or limited b |
S |
|
Yersinia enterocolitica gastroenteritis (see gastroenteritis) |
|
|
Zoster (varicella-zoster) |
|
|
Localized in immunocompromised patient, disseminated |
A,C |
DI m |
Localized in normal patient |
S m |
|
Zygomycosis
(phycomycosis, mucormycosis) |
S |
|
Abbreviations: * Type of Precautions: A,
Airborne; C, Contact; D, Droplet; S, Standard; when A, C, and D are
specified, also use S. |
1. |
Garner
JS. The CDC Hospital Infection Control Practices Advisory Committee. Am J
Infect Control 1993;21:160-162. |
2. |
National
Communicable Disease Center. Isolation Techniques for Use in Hospitals.
1st ed. Washington, DC: US Government Printing Office; 1970. PHS publication
no. 2054. |
3. |
Center
for Disease Control. Isolation Techniques for Use in Hospitals. 2nd
ed. Washington, DC: US Government Printing Office; 1975. HHS publication no. (CDC)
80-8314. |
4. |
Garner
JS, Simmons BP. CDC Guideline for Isolation Precautions in Hospitals. Atlanta,
GA: US Department of Health and Human Services, Public Health Service,
Centers for Disease Control; 1983. HHS publication no. (CDC) 83-8314; Infect
Control 1983;4:245-325, and Am J Infect Control 1984;12:103-163. |
5. |
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Trisha
Barrett, RN, BSN, CIC
Alta Bates Medical Center
Berkeley, California
Gloria
E. Bonnicksen, RN, BS, CIC
Methodist Hospital
Minneapolis, Minnesota
Jeanette
Daniel, RN, CIC
The Retreat Hospital
Richmond, Virginia
Leigh G.
Donowitz, MD
University of Virginia Medical Center
Charlottesville, Virginia
Inge Gurevich, RN, MA
Winthrop-University Hospital
Mineola, New York
Karen
Kroc
American Hospital Association
Chicago, Illinois
Patricia
Lynch, RN, MBA
Seattle, Washington
Sara
McVicker, RN, MN
Veterans Administration Medical Center
Washington, DC
Mary D.
Nettleman, MD, MS
University of Iowa Hospitals and Clinics
Iowa City, Iowa
Gina
Pugliese, RN, MS
American Hospital Association
Chicago, Illinois
William
Schaffner II, MD
Vanderbilt University Hospital
Nashville, Tennessee
Bryan P.
Simmons, MD
Methodist Hospitals
Memphis, Tennessee
Beth H.
Stover, RN, CIC
Kosair Children's Hospital
Louisville, Kentucky
Marjorie
A. Underwood, RN, BSN, CIC
Mt Diablo Medical Center
Concord, California