[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.                                                 

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[FR Doc. 94-27472 Filed 11-4-94; 8:45 am]
BILLING CODE 4163-18-P