[Federal Register Volume 59, Number 214 (Monday, November 7, 1994)]
[Unknown Section]
[Page 0]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 94-27472]
[[Page Unknown]]
[Federal Register: November 7, 1994]
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Part V
Department of Health and Human Services
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Centers for Disease Control and Prevention
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Draft Guideline for Isolation Precautions in Hospitals; Notice
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Disease Control and Prevention
Draft Guideline for Isolation Precautions in Hospitals: Part I.
``Evolution of Isolation Practices'' and Part II. ``Recommendations for
Isolation Precautions in Hospitals''; Notice of Comment Period
AGENCY: Centers for Disease Control and Prevention (CDC), Public Health
Service (PHS), Department of Health and Human Services (DHHS).
ACTION: Notice.
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SUMMARY: This notice is a request for review and comment of the draft
Guideline for Isolation Precautions in Hospitals. The Guideline
consists of two parts, ``Evolution of Isolation Practices'' and
``Recommendations for Isolation Precautions in Hospitals,'' and was
prepared by the Hospital Infection Control Practices Advisory Committee
(HICPAC) and the National Center for Infectious Diseases (NCID), CDC.
DATES: Written comments on the draft document must be received on or
before January 6, 1995.
ADDRESSES: Comments on this document should be submitted in writing to
the CDC, Attention: Isolation Guideline Information Center, Mailstop
A07, 1600 Clifton Road, NE, Atlanta, Georgia 30333.
FOR FURTHER INFORMATION CONTACT: The Isolation Guideline Information
Center, telephone (404) 332-2569.
SUPPLEMENTARY INFORMATION: This document updates and replaces the
previously published CDC Guideline for Isolation Precautions in
Hospitals (Infect Control 1983;4:245-325, Am J Infect Control
1984;12:103-163, and HHS Publ. No. [CDC] 83-8314). Part I, ``Evolution
of Isolation Practices,'' reviews the evolution of isolation practices
in U.S. 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.''
HICPAC was established in 1991 to provide advice and guidance to
the Secretary, DHHS; the Assistant Secretary for Health, DHHS; the
Director, CDC; and the Director, NCID, regarding the practice of
hospital infection control and strategies for surveillance, prevention,
and control of nosocomial infections in U.S. hospitals. The committee
also advises the CDC on periodic updating of guidelines and other
policy statements regarding prevention of nosocomial infections.
The Guideline for Isolation Precautions in Hospitals is the second
of a series of CDC guidelines being revised by HICPAC and NCID, CDC.
Dated: November 1, 1994.
Claire V. Broome,
Deputy Director, Centers for Disease Control and Prevention (CDC).
Guideline for Isolation Precautions in Hospitals
Executive Summary
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 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 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 together 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.
A working draft of this guideline was reviewed by experts in
infection control. However, all recommendations in the guideline may
not reflect the opinions of all reviewers.
Introduction
To assist hospitals in maintaining up-to-date isolation practices,
HICPAC\1\ has updated the CDC recommendations for isolation precautions
for use in hospitals. The recommendations are based on the latest
epidemiologic information on transmission of infection in hospitals;
they supersede previous CDC recommendations for isolation precautions
for use in hospitals.2-4
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 extended-care
facilities. The recommendations are not intended for use in day care,
well care, or domiciliary care programs. Because (1) there have been
few studies to test the efficacy of isolation precautions, and (2) gaps
still exist in the knowledge of the epidemiology and modes of
transmission of some diseases, disagreement with some of the
recommendations is expected.
HICPAC recognizes that the goal of preventing transmission of
infections in hospitals can be accomplished 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.
Part I. Evolution of Isolation Practices
Early Isolation Practices
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 U.S. 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, U.S. 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.
CDC Isolation Systems
CDC Isolation Manual
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 (i.e., 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, and/or charts of patients on
isolation precautions.
By the mid-1970s, 93% of U.S. 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 were increasingly 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 1981-1983, 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.
CDC Isolation Guideline
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 hospital's circumstances
and environment. 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 expanded to include (1) patients with AIDS and (2) 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 originally been
described.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 in-service
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, especially if the disease was not regularly
seen 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\
Since 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 was also disagreement about the
lack of a recommendation for adult patients with influenza, the need
for a private room 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
reports16-18 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 health care facilities was published in draft for
public comment.\22\ After review of written comments, the guidelines
were modified and published.\23\
Universal Precautions
In 1985, largely because of the HIV epidemic, isolation practices
in the United States were dramatically altered 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 placed
emphasis for the first time 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 health care 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 health care settings must focus on preventing
exposures to blood as well as on delivery of HBV immunization. The
report stated that UP applied to blood, body fluids that had been
implicated in the transmission of bloodborne infections (semen and
vaginal secretions), 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 health care and community setting 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.
Body Substance Isolation
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 and the
University of California at San Diego, 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, and that it avoided the assumption that
(1) individuals without known or suspected diagnoses of transmissible
infectious diseases were free of risk to patients and personnel, and
(2) that only certain body fluids were associated with transmission of
infection. 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 ICU34 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.15,16 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 were
visibly 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
used39 and are easily contaminated 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 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.
OSHA Bloodborne Pathogens Regulations
In 1989, the Occupational Safety and Health Administration (OSHA)
published a proposed rule regarding occupational exposure to bloodborne
pathogens in hospitals and other health care 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
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 Association52 and others.53
The Need for a New Isolation Guideline
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 were really
using BSI and vice-versa. Moreover, there was continued lack of
agreement about the importance of handwashing when gloves were
used14-15,27-29,37-38,57-58 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 microorganisms62-63 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
have to be (1) epidemiologically sound, (2) recognize the importance of
all body fluids, secretions, and excretions in the transmission of
nosocomial pathogens, (3) contain adequate precautions for infections
transmitted by the airborne, droplet, and contact routes of
transmission, (4) be as simple and user friendly as possible, and (5)
use new terms to avoid confusion with existing systems.
Based on these considerations, a new guideline was subsequently
developed. It contains three important changes from previous
recommendations. First, it synthesizes the major features of UP27-
28 and BSI29-30 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
guideline4 are now 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 are also 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, the new guideline is another step in the evolution of
isolation practices in U.S. hospitals. It is now 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 U.S. hospitals, which
range in size from 5 beds to more than 1,500 beds and serve very
different patient populations. Hospitals are encouraged to review the
guideline and to modify it according to what is possible, practical,
and prudent.
Part II. Recommendations for Isolation Precautions in Hospitals
Rationale for Isolation Precautions in Hospitals
Spread of infection within a hospital requires three elements: a
source of infecting microorganisms, a susceptible host, and a means of
transmission for the microorganism.
Source
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.
Host
Resistance among persons to pathogenic microorganisms varies
greatly. Some persons may be immune to infection or 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.
Transmission
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 since 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 transfer 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 can also 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 or dressings, or contaminated 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. Transmission of this nature must
not be confused with airborne transmission.
3. Airborne Transmission occurs by dissemination of either airborne
droplet nuclei (small-particle residue [5 microns 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 widely
dispersed 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.
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. Since agent and host
factors are more difficult to control, interruption of spread of
infection 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 is sometimes
required. The use of a multi-patient room for one patient uses valuable
space that might otherwise 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.
Fundamentals of Isolation Precautions
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 and Gloving
Handwashing is frequently called the single most important measure
for preventing spread of infection. The scientific rationale,
indications, methods, and products for handwashing have been delineated
in other publications.64-71
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 the
prevention of the spread of infection.
Gloves are worn for three important reasons in hospitals. First,
gloves are worn to provide a protective barrier and 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
(1) gloves may have small inapparent defects or be torn during use, and
(2) hands can become contaminated during removal of gloves.14-
15,39,72-75 Failure to change gloves between patient contacts is an
infection control hazard.32
Patient Placement
Appropriate patient placement is an important component of
isolation precautions. When possible, patients with highly
transmissible or epidemiologically important microorganisms are placed
in a private room with handwashing and toilet facilities to reduce
opportunities for transmission of microorganisms. A private room is
also 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 a private room is not available, infected patients are placed
with appropriate roommates. Patients infected by the same microorganism
can usually share a room provided (1) they are not infected with other
potentially transmissible microorganisms, and (2) the likelihood of
reinfection with the same organism is minimal. Such sharing of rooms,
also referred to as cohorting patients, is especially useful 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 is also important that
patients, personnel, and visitors take precautions to prevent the
spread of infection and that roommates are carefully selected.
Guidelines for construction, equipment, air handling, and
ventilation for isolation rooms have been delineated in other
publications.76-78 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 anterooms, however,
is not available. Ventilation recommendations for isolation rooms
housing patients with pulmonary tuberculosis have been delineated in
other CDC guidelines.23
Transport of Infected Patients
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 reduce
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.
Masks, Respiratory Protection, Eye Protection, Face Shields
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 mouth and goggles or a face shield are worn 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 is generally
worn 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 feet) 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 guidelines18
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 for the inhalation of
Mycobacterium tuberculosis had not been demonstrated. By definition,
particulate respirators include 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); since the generic term particulate respirator was used in the
1990 guidelines, the implication was that any of these respirators
provided sufficient protection.79
In 1993, a draft revision of the CDC tuberculosis guidelines22
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 199423
with the draft respirator criteria unchanged. The only class of
respirators that currently are (1) known to consistently meet or exceed
the performance criteria outlined in the 1994 tuberculosis guidelines,
and (2) certified by NIOSH (as required by OSHA) are HEPA filter
respirators. However, recently NIOSH has announced that they will
change their respirator certification process.80 The proposed
changes should enable users to select from a broader range of certified
respirators for use in hospitals for protection against M.
tuberculosis. 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 prepared for publication.79
Gowns and Protective Apparel
Various types of gowns and protective apparel are worn to provide
barrier protection and reduce opportunities for transmission of
microorganisms in hospitals. Gowns are worn to prevent contamination of
clothing and 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.
Patient-Care Equipment and Articles
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.27,51,81-83 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;\84\
otherwise two bags (double bagging) are used.
The scientific rationale, indications, methods, products, and
equipment for reprocessing patient-care equipment have been delineated
in other publications.68,83,85-90 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.
Linen and Laundry
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 commonsense storage and
processing of clean and soiled linen are recommended.27,82,91 The
methods for handling, transporting, and laundering of soiled linen are
determined by hospital policy and any applicable regulations.
Dishes, Glasses and Cups, and Eating Utensils
No special precautions are needed for dishes, glasses and 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 and cups, and eating utensils.
Routine and Terminal Cleaning
The room or cubicle and bedside equipment of patients on isolation
precautions are cleaned using the same procedures used for other
patients unless the infecting microorganism(s) and the amount of
environmental contamination indicates special cleaning. The methods,
thoroughness, and frequency of cleaning and the products used are
determined by hospital policy.
HICPAC Isolation Precautions
There are two tiers of HICPAC isolation precautions. In 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
Standard Precautions synthesize the major features of Universal
(Blood and Body Fluid) Precautions27-28 (designed to reduce the
risk of transmission of bloodborne pathogens) and Body Substance
Isolation29-30 (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 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
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 together 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 microns 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 widely dispersed 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.
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 microns in size) containing microorganisms generated from a person
who has a clinical disease or 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 since droplets do not remain suspended in the air and generally
travel only short distances, usually 3 feet or less, through the air.
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 a
patient, give a patient a bath, or perform other patient-care
activities that require physical contact. Direct-contact transmission
can also 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.
Empiric Use of Airborne, Droplet, or Contact Precautions
In many instances, the risk of nosocomial transmission of infection
may be highest before a definitive diagnosis can be made and
precautions based on that diagnosis implemented. The routine use of
Standard Precautions for all patients should greatly reduce 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 always implemented, hospitals must have systems in
place to routinely evaluate patients according to these criteria as
part of their preadmission and admission care.
Immunocompromised Patients
Immunocompromised patients vary in their susceptibility to
nosocomial infections depending on the severity and duration of
immunosuppression. They are generally at increased risk for bacterial
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 Pneumonia92-93 for the
HICPAC recommendations for prevention of nosocomial aspergillosis and
Legionnaires' disease in immunocompromised patients.
HICPAC Recommendations for Isolation Precautions in Hospitals
The HICPAC recommendations presented below are categorized
according to the scheme outlined in Table 3. 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. 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
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. Category IB
2. Use a plain (nonantimicrobial) soap for handwashing except for
specific circumstances (e.g., control of outbreaks or hyperendemic
infections) as defined by the infection control program. Category II
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. 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 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 or cause soiling of clothing.
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
appropriately cleaned and reprocessed and single use items are properly
discarded. Category IB
F. 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, contamination of clothing, and avoids
transfer of microorganisms to other patients and environments. Category
IB
G. 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 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 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
H. 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 microns or smaller in size] of evaporated droplets
containing microorganisms that remain suspended in the air and can be
widely dispersed 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) a minimum of six
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 when entering the room of a patient
with known or suspected infectious tuberculosis.\23\ Do not enter the
room of patients known or suspected to have measles (rubeola) or
varicella (chickenpox) if susceptible to these infections. 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 microns 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 feet between the
infected patient and other patients and visitors. Category IB
B. Mask
In addition to standard precautions, wear a mask when working
within 3 feet 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. 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. Environmental Control
Ensure that patient-care items, bedside equipment, and frequently
touched surfaces receive daily cleaning. Category IB
F. Patient-Care Equipment
When possible, dedicate the use of noncritical patient-care
equipment and items such as a stethoscope, sphygmomanometer, bedside
commode, or electronic rectal thermometer 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
G. 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\
VI. Adherence to Precautions
Periodically evaluate adherence to precautions, and use findings to
direct improvements. Category IB
Table 1.--Synopsis of Types of Precautions and Patients Requiring the
Precautions*
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:
(1)Measles
(2)Varicella (including disseminated zoster)
(3)TuberculosisSec.
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:
(1)Invasive Haemophilus influenzae type b disease, including
meningitis, pneumonia, epiglottitis, and sepsis
(2)Invasive Neisseria meningitidis disease, including meningitis,
pneumonia, and sepsis
(3)Invasive multidrug-resistant Streptococcus pneumoniae disease,
including meningitis, pneumonia, sinusitis, and otitis media
(4)Other serious bacterial respiratory infections spread by droplet
transmission, including:
(a)Diphtheria (pharyngeal)
(b)Mycoplasma pneumonia
(c)Pertussis
(d)Pneumonic plague
(e)Streptococcal pharyngitis, pneumonia, or scarlet fever in infants
and young children
(5) Serious viral infections spread by droplet transmission,
including:
(a)Adenovirus
(b)Influenza
(c)Mumps
(d)Parvovirus B19
(e)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:
(1) 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
(2) Enteric infections with a low infectious dose or prolonged
environmental survival, including:
(a)Clostridium difficile
(b)For diapered or incontinent patients: enterohemorrhagic
Escherichia coli O157:H7, Shigella, hepatitis A, or rotavirus
(3) Respiratory syncytial virus, parainfluenza virus, or enteroviral
infections in infants and young children
(4) Skin infections that are highly contagious or that may occur on
dry skin, including:
(a)Diphtheria (cutaneous)
(b)Herpes simplex virus (neonatal or mucocutaneous)
(c)Impetigo
(d)Major (noncontained) abscesses, cellulitis, or decubiti
(e)Pediculosis
(f)Scabies
(g)Staphylococcal furunculosis in infants and young children
(h)Staphylococcal scaled skin syndrome
(i)Zoster (disseminated or in the immunocompromised host)
(5) Viral/hemorrhagic conjunctivitis
(6) Viral hemorrhagic fevers (Lassa fever or Marburg virus)
*See Appendix A for a complete listing of infections requiring
precautions, including appropriate footnotes.
Certain infections require more than one type of precaution.
Sec. See CDC Guidelines for Preventing the Transmission of Tuberculosis
in Health-Care Facilities.\23\
Table 2.--Clinical Syndromes or Conditions Warranting Additional Empiric
Precautions To Prevent Transmission of Epidemiologically Important
Pathogens Pending Confirmation of Diagnosis*
------------------------------------------------------------------------
Clinical syndrome or Potential Empiric
condition Pathogens Sec. Precautions
------------------------------------------------------------------------
DIARRHEA:
(1) Acute diarrhea with a Enteric pathogens Contact.
likely infectious cause in .
an incontinent or diapered
patient.
(2) Diarrhea in an adult with Clostridium Contact.
a history of broad spectrum difficile.
or long-term antibiotics.
MENINGITIS....................... Neisseria Droplet.
meningitidis.
RASH OR EXANTHEMS, GENERALIZED,
ETIOLOGY UNKNOWN:
(1) Petechial/ecchymotic with Neisseria Droplet.
fever. meningitidis.
(2) Vesicular................ Varicella......... Airborne and
Contact.
(3) Maculopapular with coryza Rubeola (measles). Airborne.
and fever.
RESPIRATORY INFECTIONS:
(1) Cough/fever/upper lobe Mycobacterium Airborne.
pulmonary infiltrate in an tuberculosis.
HIV-negative patient and a
patient at low risk for HIV
infection.
(2) Cough/fever/pulmonary Mycobacterium Airborne.
infiltrate in any lung tuberculosis.
location in a HIV-infected
patient and at high risk for
HIV infection\23\.
(3) Paroxysmal or severe Bordetella Droplet.
persistent cough during pertussis.
periods of pertussis
activity.
(4) Respiratory infections, Respiratory Contact.
particularly broncholitis syncytial or
and croup, in infants and parainfluenza
young children. virus.
RISK OF MULTIDRUG-RESISTANT
MICROORGANISMS:
(1) History of infection or Resistant bacteria Contact.
colonization with multidrug-
resistant organisms**.
(2) Skin, wound, or urinary Resistant bacteria Contact.
tract infection in a patient
with a recent hospital or
nursing home stay in a
facility where multidrug-
resistant organisms are
prevalent.
SKIN OR WOUND INFECTION:
Abscess or draining wound Staphylococcus Contact.
that cannot be covered. aureus, Group A
streptococcus.
------------------------------------------------------------------------
*Infection control professionals are encouraged to modify or adapt this
table according to local conditions. To ensure that appropriate
empiric precautions are always implemented, hospitals must have
systems in place to routinely evaluate patients according to these
criteria as part of their preadmission and admission care.
Patients with the syndromes or conditions listed below may
present with atypical signs or symptoms (e.g., pertussis in neonates
and adults may not have paroxysmal or severe cough). The clinician's
index of suspicion should be guided by the prevalence of specific
conditions in the community as well as clinical judgement.
Sec. 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.
These pathogens include enterohemorrhagic Escherichia coli O157:H7,
Shigella, hepatitis A, and rotavirus.
**Resistant bacteria judged by the infection control program, based on
current state, regional or national recommendations, to be of special
clinical or epidemiological significance.
Table 3--Categorization of HICPAC Recommendations
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 viewed 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.
Appendix A.--Type and Duration of Precautions Needed for Selected
Infections and Conditions
------------------------------------------------------------------------
Precautions
--------------------------------
Infection/Condition Duration
Type*
------------------------------------------------------------------------
Abscess:
Draining, major\1\................. C DI
Draining, minor or limited\2\...... S ................
Acquired immunodeficiency syndrome S ................
(AIDS)\3\.
Actinomycosis...................... S ................
Adenovirus infection, in infants D, C DI
and young children.
Amebiasis.......................... S ................
Anthrox:
Cutaneous.......................... S ................
Pulmonary.......................... S ................
Antibiotic-associated colitis (see
Clostridium difficile):
Arthropodborne viral encephalitides s\4\ ................
(eastern, western, Venezuelan
equine encephalomyelitis; St.
Louis, California encephalitis).
Arthropodborne viral fevers S\4\ ................
(dengue, yellow fever, Colorado
tick fever).
Ascariasis......................... S ................
Aspergillosis...................... S ................
Babesiosis......................... S ................
Blastomycosis, North American, S ................
cutaneous or pulmonary.
Botulism........................... S ................
Bronchiolitis (see respiratory
infections in infants and young
children):
Brucellosis (undulant, Malta, S ................
Mediterranean fever).
Campylobacter gastroenteritis (see ............. ................
gastroenteritis)
Candidiasis, all forms including S ................
mucocutaneous.
Cat-scratch fever (benign S ................
inoculation lymphoreticulosis).
Cellulitis, uncontrolled drainage.. C DI
Chancroid (soft chancre)........... S ................
Chickenpox (varicella)............. A, C F\5\
Chlamydia trachomatis:
Conjunctivitis..................... S ................
Genital............................ S ................
Respiratory........................ S ................
Cholera (see gastroenteritis)...... ............. ................
Closed-cavity infection:
Draining, limited or minor......... S ................
Not draining....................... S ................
Clostridium:
C. botulium........................ 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\6\
Conjunctivitis:
Acute bacterial.................... S ................
Chlamydia.......................... S ................
Gonococcal......................... S ................
Acute viral (acute hemorrhagic).... C DI
Coxsackie virus disease (see
enteroviral infection):
Creutzfeldt-Jakob disease.......... S\7\ ................
Croup (see respiratory infections in
infants and young children):
Cryptococcosis..................... S ................
Cryptosporidiosis (see ............. ................
gastroenteritis).
Cysticercosis...................... S ................
Cytomegalovirus infection, neonatal S ................
or immunosuppressed.
Decubitus ulcer, infected:
Major\1\........................... C DI
Minor or limited\2\................ S ................
Dengue................................. S\4\ ................
Diarrhea, acute-infective etiology
suspected (see gastroenteritis):
Diphtheria:
Cutaneous.......................... C CN\8\
Pharyngeal......................... D CN\8\
Echinococcosis (hydatidosis)........... S ................
Echovirus (see enteroviral infection) ............. ................
Encephalitis or encephalomyelitis (see ............. ................
specific etiologic agents)
Endometritis........................... S ................
Enterobiasis (pinworm disease, S ................
oxyuriasis).
Enterococcus species (see multidrug-
resistant organisms if
epidemiologically significant or
vancomycin resistant):
Enterocolitis, Clostridium C DH
difficile.
Enteroviral infections:
Adults............................. S ................
Infants and children............... C DI
Epiglottitis, due to Haemophilus D U24 HRS
influenzae.
Epstein-Barr virus infection, including S ................
infectious mononucleosis.
Erythema infectiosum (also see S ................
Parvovirus B19).
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\9\ ................
Cholera............................ S\9\ ................
Clostridium difficile.............. C DI
Cryptosporidium species............ S\9\ ................
Escherichia coli:
Enterohemorrhagic O157:H7...... S\9\ ................
Diapered or incontinent.... C DI
Other species.................. S\9\ ................
Giardia lamblia.................... S\9\ ................
Rotavirus.......................... S\9\ ................
Diapered or incontinent........ C DI
Salmonella species (including S. S\9\ ................
typhi).
Shigella species................... S\9\ ................
Diapered or incontinent........ C DI
Vibrio parahamolyticus............. S\9\ ................
Viral (if not covered elsewhere)... S\9\ ................
Yersinia enterocolitica............ S\9\ ................
German measles (rubella)............... D DI
Giardiasis (see gastroenteritis)
Gonococcal ophthalmia neonatorum S ................
(gonorrheal ophthalmia, acute
conjunctivitis of newborn).
Gonorrhea.............................. S ................
Granuloma inguinale (donovaniasis, S ................
granuloma venereum).
Guillain-Barre syndrome................ S ................
Hand, foot, and mouth disease (see ............. ................
enteroviral infection).
Hemorrhagic fevers (for example, Lassa C DI
fever)\10\.
Hepatitis, viral:
Type A............................. S ................
Diapered or incontinent C F\11\
patients.
Type B--HBsAg positive............. S ................
Type C and other unspecified non-A, S ................
non-B.
Type E............................. S ................
Herpangina (see enteroviral infection)
Herpes simplex (Herpesvirus hominis):
Encephalitis....................... S ................
Neonatal\12\....................... C DI
Mucocutaneous, disseminated or C DI
primary, severe.
Mucocutaneous, recurrent (skin, S ................
oral, genital).
Herpes zoster (varicella-zoster):
Localized in immunocompromised A, C DI
patient, or disseminated.
Localized in normal patient........ S ................
Histoplasmosis......................... S ................
Hookworm disease (ancylostomiasis, S ................
uncinariasis).
Human immunodeficiency virus (HIV) S ................
infection\3\.
Impetigo............................... C U24 HRS
Infectious mononucleosis............... S ................
Influenza.............................. D\13\ DI
Kawasaki syndrome...................... S ................
Lassa fever\10\........................ C DI
Legionnaires' disease.................. S ................
Leprosy................................ S ................
Leptospirosis.......................... S ................
Listeriosis............................ S ................
Lyme disease........................... S ................
Lymphocytic choriomeningitis........... S ................
Lymphogranuloma venereum............... S ................
Malaria................................ S ................
Marburg virus disease\10\.............. C DI
Measles (rubeola), all presentations... A DI
Melioidosis, all forms................. S ................
Meningitis:
Aseptic (nonbacterial or viral S ................
meningitis).
Bacterial, gram-negative enteric, S ................
in neonates.
Fungal............................. S ................
Haemophilus influenzae, known or D U24 HRS
suspected.
Listeria monocytogenes............. S ................
Neisseria meningitidis D U24 HRS
(meningococcal) known or suspected.
Pneumococcal....................... S ................
Tuberculosis\14\................... S ................
Other diagnosed bacterial.......... S ................
Meningococcal pneumonia................ D U24 HRS
Meningococcemia (meningococcal sepsis). D U24 HRS
Molluscum contagiosum.................. S ................
Mucormycosis........................... S ................
Multidrug-resistant organisms,
infection or colonization\15\:
Gastrointestinal................... C CN
Respiratory........................ C CN
Pneumococcal................... D CN
Skin, wound, or burn............... C CN
Mumps (infectious parotitis)........... D F\16\
Mycobacteria, nontuberculosis
(atypical):
Pulmonary.......................... S ................
Wound.............................. S ................
Mycoplasma pneumonia................... D DI
Necrotizing enterocolitis.............. S ................
Nacardiosis, draining lesions or other S ................
presentations.
Norwalk agent gastroenteritis (see
viral gastroenteritis)
Orf.................................... S ................
Parinfluenza virus infection, C DI
respiratory in infants and young
children.
Parvovirus B19......................... D F\17\
Pediculois............................. C U\24\HRS
Pertussis (whooping cough)............. D F\18\
Pinworm infection...................... S ................
Plague:
Bubonic............................ S ................
Pneumonic.......................... D U\72\HRS
Pleurodynia (see entervoviral
infection)
Pneumonia:
Adenovirus......................... D, C DI
Bacterial not listed elsewhere S ................
(including gram-negative bacterial).
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 D DI
(pneumonia).
Pneumococcal....................... S ................
Multidrug-resistant (see
multidrug-resistant organisms)
Pneumocytis carinii................ S\19\ ................
Pseudomonas cepacia in cystic C\20\ DH
fibrosis (CF) patients, including
respiratory tract colonization.
Staphylococcus aureus.............. S ................
Streptococuss, Group A:
Adults......................... S ................
Infants and young children..... D U\24\HRS
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 S ................
moniliformis disease, spirillum minus
disease).
Ralapsing 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\3\...... C DI
Respiratory syncytial virus infection, C DI
in infants and young children, and
immunocompromised adults.
Reye syndrome.......................... S ................
Rheumatic fever........................ S ................
Rickettsial fevers, tickborne (Rocky S ................
Mountain spotted fever, tickborne
typhus fever).
Rickettsialpox (vesicular S ................
rickettsiosis).
Ringworm (dermatophytosis, S ................
dermatomycosis, tinea.
Ritter's disease (Staphylococcal C\21\ DI
scalded skin syndrome.
Rocky Mountain spotted fever........... S ................
Roseola infantum (exanthem subitum).... S ................
Rotavirus infection (see
gastroenteritis)
Rubella (German measles) (also D F\22\
congenital rubella).
Salmonellosis (see gastroenteritis)
Scabies................................ C U\24\HRS
Scalded skin syndrome, staphylococcal C\21\ DI
(Ritter's diease).
Schistosomiasis (bilharziasis)......... S ................
Shigellois (see gastroenteritis)
Sporotrichosis......................... S ................
Spirillium minus disease (rat-bite S ................
fever).
Staphylococcal disease (S. aureus):
Skin, wound, or burn:
Major\1\....................... C DI
Minor or limited\2\............ S ................
Enterocolitis...................... S ................
Multidrug-resistant (see multidrug-
reistant organisms)
Pneumonia.......................... S ................
Scalded skin syndrome.............. C DI
Toxic shock syndrome............... S ................
Streptobacillus moniliformis disease S ................
(rat-bite fever).
Streptococcal disease (group A
Streptococcus):
Skin, wound, or burn:
Major\1\....................... C U24HRS
Minor or limited\2\............ S ................
Endometritis (puerperal sepsis).... S ................
Pharyngitis in infants and young D U24HRS
children.
Pneumonia in infants and young D U24HRS
children.
Scarlet fever in infants and young D U24HRS
children.
Streptococcal disease (group B S ................
Streptococcus), neonatal.
Streptococcal disease (not group A or S ................
B) unless covered elsewhere.
Multidrug-resistant (see multidrug-
resistant organisms)
Strongyloidiasis....................... S ................
Syphilis:
Skin and mucous membrane, including S ................
congenital, primary, secondary.
Latent (tertiary) and S ................
seropositivity without lesions.
Tapeworm disease:
Hymenolepis nana................... S ................
Taenia solium (pork)............... S ................
Other.............................. S ................
Tetanus................................ S ................
Tinea (fungus infection S ................
dermatophytosis, dermatomycosis,
ringworm).
Toxoplasmosis.......................... S ................
Toxic shock syndrome (Staphylococcal S ................
disease).
Trachoma, acute........................ S ................
Trench mouth (Vincent's angina)........ S ................
Trichinosis............................ S ................
Trichomoniasis......................... S ................
Trichuriasis (whipworm disease)........ S ................
Tuberculosis:
Extrapulmonary, draining lesion S
(including scrofula).
Extrapulmonary, meningitis\14\..... S
Pulmonary, confirmed or suspected A F\23\
or laryngeal disease.
Skin-test positive with no evidence S
of current pulmonary disease.
Tularemia:
Draining lesion.................... S
Pulmonary.......................... S
Typhoid (Salmonella typhi) fever (see
gastroenteritis)
Typhus, endemic and epidemic........... S
Urinary tract infection (including S
pyelonephritis), with or without
urinary catheter.
Varicella (chickenpox)................. A, C F\5\
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\18\
Wound infections:
Major\1\........................... C DI
Minor or limited\2\................ S
Yersinia enterocolitica gastroenteritis
(see gastroenteritis)
Zoster (varicella-zoster):
Localized in immunocompromised A, C F\5\
patient, disseminated.
Localized in normal patient........ S
Zygomycosis (phycomycosis, S
mucormycosis).
------------------------------------------------------------------------
\1\No dressing or dressing does not adequately contain drainage.
\2\Dressing covers and adequately contains drainage.
\3\Also see syndromes or conditions listed in Table 2.
\4\Install screens in windows and doors in endemic areas.
\5\Maintain precautions until all lesions are crusted. Use varicella
zoster immune globulin (VZIG) when appropriate, and discharge exposed
susceptible patients before the 10th day after exposure, if possible.
Place remaining exposed susceptible patients on precautions beginning
10 days after exposure and continue until 21 days after last exposure
(up to 28 days if VZIG has been given). Susceptible persons should
stay out of room of patients on precautions.
\6\Place infant on precautions during any admission until 1 year of age
unless nasopharyngeal and urine cultures are negative for virus after
age 3 months.
\7\Additional special precautions are necessary for handling and
decontamination of blood, body fluids and tissues, and contaminated
items from patients with confirmed or suspected disease. See latest
College of American Pathologists (Northfield, Illinois) guidelines or
other references.
\8\Until two cultures taken at least 24 hours apart are negative.
\9\Use contact precautions for diapered or incontinent children <6 years
of age for duration of illness.
\10\Call state health department and CDC for advice about management of
a suspected case.
\11\Maintain precautions in infants and children <3 years of age for
duration of hospitalization; in children 3-14 years of age, until 2
weeks after onset of symptoms; and in others, until 1 week after onset
of symptoms.
\12\For infants delivered vaginally or by C-section and if mother has
active infection and membranes have been ruptured for more than 4-6
hours.
\13\This recommendation is made recognizing the logistic difficulties
and physical plant limitations that may face hospitals admitting
multiple patients with suspected influenza during community outbreaks.
If sufficient private rooms are unavailable, consider cohorting
patients, or at the very least, avoid room-sharing with high risk
patients. See Guideline for Prevention of Nosocomial Pneumonia92-93
For additional prevention and control strategies.
\14\Patient should be examined for evidence of current (active)
pulmonary tuberculosis. If evidence exists, additional precautions are
necessary (see tuberculosis).
\15\Resistant bacteria judged by the infection control program, based on
current state, regional, or national recommendations, to be of special
clinical and epidemiologic significance.
\16\For 9 days after onset of swelling.
\17\Maintain precautions for duration of hospitalization when chronic
disease occurs in an immunodeficient patient. For patients with
transient aplastic crisis or red cell crisis, maintain precautions for
7 days.
\18\Maintain precautions until 5 days after patient is placed on
effective therapy.
\19\Avoid placement in the same room with an immunocompromised patient.
\20\Avoid cohorting or placement in the same room with a CF patient who
is not infected or colonized with P. cepacia.
\21\Blistering is due to the hematogenous dissemination of toxin, not to
presence of organisms in the blisters. However, such patients may be
heavily colonized with staphylococci because of their skin problems;
thus, contact precautions are recommended.
\22\Until 7 days after onset of rash.
\23\Discontinue precautions only when TB patient is on effective
therapy, is improving clinically, and has 3 consecutive negative
sputum smears collected on different days, or TB is ruled out. Also
see CDC Guidelines for Preventing the Transmission of Tuberculosis in
Health-Care Facilities.\23\
*Type of Precautions
A--Airborne.
C--Contact.
D--Droplet.
S--Standard.
When A, C, and D are specified, also use S.
Duration of Precautions
CN--Until off antibiotics and culture negative.
DH--Duration of hospitalization.
DI--Duration of illness (with wound lesions, DI means until they stop
draining).
U--Until time specified in hours (HRS) after initiation of effective
therapy.
F--See footnote number.
References
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Hospitals, 2nd ed. Washington: U.S. Government Printing Office;
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Infect Control 1983;4:245-325, and U.S. Department of Health and
Human Services, Public Health Services, Centers for Disease Control,
Atlanta; 1983. HHS Publ. No. (CDC) 83-8314.
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6. Gage ND, Landon JF, Sider MT. Communicable Disease.
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8. Schaffner W. Infection control: Old myths and new realities.
Infect Control 1980;1:330-334.
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isolation of patients with infectious diseases: alternative systems.
J Hosp Infect 1985;6:128-139.
11. Nauseef WM, Maki DG. A study of the value of simple
protective isolation in patients with granulocytopenia. N Engl J Med
1981;304:448-453.
12. Pizzo PA. The value of protective isolation in preventing
nosocomial infections in high risk patients. Am J Med 1981;70:631-
637.
13. Jacobson JT, Johnson DS, Ross CA, Conti MT, Evans RS, Burke
JP. Adapting disease-specific isolation guidelines to a hospital
information system. Infect Control 1986;7:411-418.
14. Goldmann DA. The role of barrier precautions in infection
control. J Hosp Infect 1991;18:515-523.
15. Goldmann D, Platt R, Hopkins C. Control of hospital-acquired
infections. In: Gorbach SL, Bartlett JG, Blacklow NR, eds.
Infectious Diseases. Philadelphia:WB Saunders, 1992:chap 45:378-390.
16. Centers for Disease Control. Management of patients with
suspected viral hemorrhagic fever. MMWR 1988;37(3S):1-16.
17. Centers for Disease Control. Risks associated with human
parvovirus B19 infection. MMWR 1989;38:81-88,93-97.
18. Centers for Disease Control. Guidelines for preventing the
transmission of tuberculosis in health-care settings, with special
focus on HIV-related issues. MMWR 1990;39(RR-17):1-29.
19. Centers for Disease Control. Nosocomial transmission of
multidrug-resistant tuberculosis to health-care workers and HIV-
infected patients in an urban hospital--Florida. MMWR 1990;39:718-
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[FR Doc. 94-27472 Filed 11-4-94; 8:45 am]
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