DRAFT Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings

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DRAFT
Guideline for Isolation Precautions:
Preventing Transmission of Infectious Agents in
Healthcare Settings
Recommendations of the Healthcare Infection Control Practices
Advisory Committee
Disclaimer: This draft document is intended for public comment only.
Healthcare personnel should not modify practices or policies based on
these preliminary recommendations.
Prepared by:
Jane Siegel, MD 1
Larry Strausbaugh, MD 2
Marguerite Jackson, PhD, RN, FAAN 3
Emily Rhinehart, RN, MPH 4
Linda A. Chiarello, RN, MS 5
1
University of Texas Southwest Medical Center, Dallas, TX
Portland VA Medical Center, Portland, OR
3
Jackson Consulting, Escondido, CA
4
AIG Consultants, Inc., Atlanta, GA
5
Division of Healthcare Quality Promotion, National Center for Infectious Diseases, CDC
2
HEALTHCARE INFECTION CONTROL PRACTICES ADVISORY COMMITTEE *
Chair: Robert A. Weinstein, M.D., Cook County Hospital, Chicago, Illinois
Co-Chair: Jane D. Siegel, M.D., University of Texas Southwestern Medical Center, Dallas,
Texas
Executive Secretary: Michele L. Pearson, M.D., CDC, Atlanta, Georgia
Members: Raymond Y.W. Chinn, M.D., Sharp Memorial Hospital, San Diego, California; Alfred
DeMaria, Jr., M.D., Massachusetts Department of Public Health, Jamaica Plains, Massachusetts;
Elaine L. Larson, R.N., Ph.D., Columbia University School of Nursing, New York, New York;
James T. Lee, M.D.,Ph.D., Veterans Affairs Medical Center, University of Minnesota, St. Paul,
Minnesota; Ramon E. Moncada, M.D.,Coronado Physician’s Medical Center Coronado,
California; William A. Rutala, Ph.D.; University of North Carolina School of Medicine, Chapel Hill,
North Carolina; William E. Scheckler, M.D.; University of Wisconsin Medical School,
Madison,Wisconsin; Beth H. Stover, Kosair Children’s Hospital, Louisville, Kentucky; Marjorie
Underwood, Three Rivers Community Hospital, Grants Pass, Oregon.
Liaison Representatives: Loretta L. Fauerbach, M.S., CIC, Association for Professionals of
Infection Control and Epidemiology, Inc., Shands Hospital at University of Florida, Gainesville,
Florida; Sandra L. Fitzler, R.N., American Healthcare Association, Washington, D.C.; Dorothy M.
Fogg, R.N., B.S.N., M.A., Association of periOperative Registered Nurses, Denver, Colorado;
Stephen F. Jencks, M.D., M.P.H., Center for Medicare and Medicaid Services, Baltimore,
Maryland; Chiu S. Lin, Ph.D., Food and Drug Administration, Rockville, Maryland; James P.
Steinberg, Society for Healthcare Epidemiology of America, Inc., Crawford Long Hospital, Atlanta,
Georgia; Michael L. Tapper, M.D., Advisory Committee for the Elimination of Tuberculosis, Lenox
Hill Hospital, New York, New York.
*
Committee members and liaisons at the time the draft guideline was finalized
TABLE OF CONTENTS
Executive Summary ………………………………………………….….…………………...........…5
Part I: Review of the Scientific Data Regarding Transmission of Infectious Agents in
Healthcare Settings.................................................................................................................. 9
I.A. Evolution of the 2004 document .......................................................................................... 9
I.B. Rationale for Standard and Expanded Precautions in healthcare settings ........................ 11
I.B.1. Source of infectious agents....................................................................................... 11
I.B.2. Susceptible hosts...................................................................................................... 11
I.B.3. Modes of transmission ............................................................................................. 12
I.B.3.a. Contact.......................................................................................................... 12
I.B.3.a.i. Direct .............................................................................................. 12
I.B.3.a.ii. Indirect........................................................................................... 13
I.B.3.b. Droplet ........................................................................................................ 13
I.B.3.c. Airborne........................................................................................................ 14
I.B.3.d. Other sources of infection ............... ……………………………………………16
I.C. Emerging pathogens of special concern to healthcare settings......................................... 16
I.C.1. Multidrug-resistant organisms (MDROs)................................................................... 16
I.C.2. Agents of bioterrorism............................................................................................... 17
I.C.3. Prions ...................................................................................................................... 19
I.C.4. Severe acute respiratory syndrome (SARS) ............................................................. 20
I.C.5. Monkeypox ............................................................................................................... 22
I.C.6. Avian influenza A ...................................................................................................... 22
I.D.Transmission risks associated with specific types of healthcare settings ........................... 23
I.D.1. Hospitals .................................................................................................................. 24
I.D.1.a. Intensive care units ...................................................................................... 24
I.D.1.b. Burn units..................................................................................................... 24
I.D.1.c. Pediatrics ..................................................................................................... 25
I.D.2. Non-acute care settings…………............................................................................. 26
I.D.2.a. Long term care ............................................................................................ 27
I.D.2.b. Ambulatory care settings ............................................................................. 28
I.D.2.c. Home care ................................................................................................... 29
I.D.2.d. Other sites of healthcare delivery ............................................................... 30
I.E. Transmission risks associated with special patient populations....................................... 31
I.E.1. Immunocompromised patients ................................................................................. 31
I.E.2. Cystic fibrosis patients ............................................................................................. 32
I.F. New therapies with potential transmissible infectious agents........................................... 33
I.F.1. Gene therapy ........................................................................................................... 33
I.F.2. Xenotransplantation and tissue allografts ................................................................ 33
I.G. Healthcare system components that influence the effectiveness of
precautions to prevent transmission................................................................................ 34
I.G.1. Safety culture and organizational characteristics.................................................... 34
I.G.2. Nurse staffing ......................................................................................................... 34
I.G.3. Adherence of healthcare personnel to recommended guidelines ........................... 35
I.G.4. Clinical microbiology laboratory support ................................................................. 36
2
Part II. Fundamental Elements to Prevent Transmission of Infectious Agents in
Healthcare Settings................................................................................................................ 37
II.A. Administrative measures................................................................................................. 37
II.B. Education of healthcare workers, patients, and families ................................................. 38
II.C. Hand hygiene.................................................................................................................. 39
II.D. Personal protective equipment ....................................................................................... 40
II.D.1. Gloves................................................................................................................... 40
II.D.2. Isolation gowns and other protective apparel........................................................ 41
II.D.3. Mouth, nose, eye, and face protection .................................................................. 42
II.D.4. Respiratory protection........................................................................................... 43
II.E. Safe work practices to prevent HCW exposure to bloodborne pathogens ..................... 45
II.E.1. Prevention of needlesticks and other sharps-related injuries ................................ 45
II.E.2. Prevention of mucous membrane contact............................................................. 45
II.F. Patient placement .......................................................................................................... 45
II.F.1. Hospitals and long-term care settings ................................................................... 45
II.F.2. Ambulatory care settings....................................................................................... 47
II.F.3. Home care............................................................................................................. 48
II.G.Transport of patients....................................................................................................... 48
II.H. Environmental measures ............................................................................................... 49
II.I. Patient care equipment ................................................................................................. 50
II.J. Textiles and laundry ....................................................................................................... 51
II.K. Dishware and eating utensils ......................................................................................... 51
II.L. Adjunctive measures ...................................................................................................... 52
II.L.1. Chemoprophylaxis................................................................................................. 52
II.L.2. Immunization ......................................................................................................... 52
Part III. HICPAC Precautions to Prevent Transmission of Infectious Agents ................... 53
III.A. Standard Precautions ................................................................................................... 54
III.A.1.New Standard Precautions for patients: Respiratory
Hygiene/Cough Etiquette ............................................................................................. 55
III.B. Expanded Precautions.................................................................................................. 56
III.B.1. Contact Precautions............................................................................................. 57
III.B.2. Droplet Precautions ............................................................................................. 57
III.B.3. Airborne Infection Isolation (AII) Precautions ....................................................... 57
III.B.4. Protective environment (PE) ................................................................................ 58
III.C. Syndromic or empiric application of Expanded Precautions ......................................... 59
III.D. Discontinuation of precautions...................................................................................... 60
III.E. Application of Expanded Precautions in ambulatory and home care settings ............... 60
Part IV: Recommendations.................................................................................................... 62
Part V: Performance Indicators............................................................................................. 95
Tables...................................................................................................................................... 96
Table 1. Recent history of guidelines for prevention of healthcare-associated infections.... 96
3
Table 2. Definition of terms.................................................................................................. 98
Table 3. Infection control considerations for high-priority (CDC Category A) diseases that
may result from bioterrorist attacks or are considered to be bioterrorist threats .. 105
Table 4. Recommendations for application of Standard Precautions for the care of all
patients in all healthcare settings......................................................................... 109
Table 5. Components of a Protective Environment ........................................................... 110
Table 6. Clinical syndromes or conditions warranting additional empiric precautions to
prevent transmission of epidemiologically important pathogens pending
confirmation of diagnosis..................................................................................... 111
Figure Sequence for donning and removing PPE ................................................................ 113
Appendix A.Type and duration of precautions needed for selected infections and
conditions .......................................................................................................... 115
Appendix B. Management of multidrug-resistant organisms
(MDROs) in healthcare settings....................................................................... …131
Table B-1 Categorization of reports about control of MDROs in healthcare settings,
1982-2003 .......................................................................................... 149
Table B-2 Control measures for MDROs employed in studies performed in healthcare settings,
1982-2003 .......................................................................................... 150
Table B-3 Summary of recommended MDRO prevention and control measures:
routine and intensified .........................................................................151
Table B-4 Summary of recommended MDRO prevention and control measures for all
long-term care facilities........................................................................152
Table B-5 Summary of recommended MDRO prevention and control measures for all
ambulatory care settings .....................................................................153
Table B-6 Summary of recommended MDRO prevention and control measures for
home care ...........................................................................................154
References.............................................................................................................................155
4
EXECUTIVE SUMMARY
The Guideline for Isolation Precautions: Preventing Transmission of Infectious
Agents in Healthcare Settings 2004 updates and expands the 1996 Guideline for Isolation
Precautions in Hospitals (1). The following developments led to revision of the 1996
guideline:
1. The transition of healthcare delivery from primarily acute care hospitals to other
healthcare settings (e.g., home care, ambulatory care, free-standing specialty
care sites, long-term care) created a need for recommendations that can be
applied to all healthcare settings while adhering to common principles of infection
control practice. Accordingly, the revised guideline addresses the spectrum of
healthcare delivery and the term “nosocomial infections“ is replaced by
“healthcare-associated infections” (HAIs) to reflect changing patterns in
healthcare delivery.
2. The emergence of new pathogens (e.g., severe acute respiratory syndrome
[SARS], Avian influenza) and new therapies (e.g., gene therapy) and increasing
concern for the threat of bioweapons attacks established a need to address a
broader scope of issues than in previous isolation guidelines.
3. Experience with Standard Precautions since it was recommended in the 1996
guideline, has led to a reaffirmation of this approach as the foundation for
preventing transmission of infectious agents in all healthcare settings. A new
addition to the recommendations for Standard Precautions is Respiratory
Hygiene/Cough Etiquette. The need for this recommendation grew out of
observations during the SARS epidemic where failure to implement simple source
control measures with patients, visitors, and healthcare personnel with respiratory
symptoms may have contributed to SARS coronavirus (SARS-CoV) transmission.
4. Accumulated evidence that environmental controls decrease the risk of lifethreatening fungal infections in the most severely immunocompromised patients
(allogeneic hematopoietic stem cell transplant patients) led to the addition of a
new category of isolation precautions, the Protective Environment (PE).
5
5. Evidence that organizational characteristics (e.g., nurse staffing levels and
composition, establishment of a safety culture) and levels of adherence of
healthcare workers to recommended infection control practices are important
factors in preventing transmission of infectious agents has led to a new emphasis
on the importance of administrative involvement in development and support of
infection control programs.
6. Continued increase in the incidence of HAIs caused by multidrug-resistant
organisms (MDROs) in all healthcare settings and the expanded body of
knowledge concerning prevention of transmission of MDROs created a need for
more specific recommendations for surveillance and control of these pathogens
that would be practical and effective in various types of healthcare settings.
7. There has been an increase in the number of published studies of various
practices used to prevent transmission of infectious agents.
This document is intended for use by infection control staff, healthcare epidemiologists,
healthcare administrators, and other persons responsible for developing, implementing, and
evaluating infection control programs for healthcare settings across the continuum of care.
The reader is referred to other guidelines and websites for more detailed information and for
recommendations concerning specialized infection control problems.
Part I: Review of the Scientific Data Regarding Transmission of Infectious Agents in
Healthcare Settings
This section reviews the relevant scientific literature that supports the recommended
prevention and control practices. This section also updates the fundamental elements
needed to prevent transmission of infectious agents in healthcare settings. The categories
of precautions developed by the Healthcare Infection Control Practices Advisory Committee
(HICPAC) and the Centers for Disease Control and Prevention (CDC) are described and
guidance for application of these precautions in various healthcare settings is provided. A
new category, Protective Environment (PE), has been added.
Additionally, there are several tables that include 1) a summary of the evolution of
this document; 2) definitions; 3) a summary of infection control recommendations for
6
category A agents of bioterrorism; 4) components of Standard Precautions and
recommendations for their application; 5) components of the Protective Environment; and 6)
guidance on using empiric precautions according to clinical syndrome. New in this guideline
is a figure that shows the recommended sequence for donning and removing personal
protective equipment used for isolation precautions.
Part II: Recommendations for Preventing Transmission of Infectious Agents in
Healthcare Settings
This section provides evidence-based recommendations for specific prevention and
control practices using the CDC/HICPAC system for ranking the strength of
recommendations. Those practices for which there is no recommendation and which are
considered unresolved issues are topics in need of further research.
New to this guideline are the detailed recommendations for prevention of
transmission of MDROs. Seven categories of interventions to control MDROs are described:
administrative measures, education of healthcare personnel, judicious antimicrobial use ,
surveillance, infection control precautions, environmental measures, and decolonization.
Recommendations for each category apply to and are adapted for the various healthcare
settings. With the increasing incidence and prevalence of MDROs, all healthcare facilities
must identify the prevalent MDROs, implement control measures, and assess the
effectiveness of the control program. A set of intensified MDRO prevention interventions is
presented to be added for situations where there is evidence of continuing transmission or
the prevalence of target MDRO has exceeded institutional goals despite implementation of
basic MDRO infection control measures, and when the first case(s) of an epidemiologically
important MDRO is identified within a healthcare facility. Recommendations for MDRO
prevention and control with modifications suggested for settings outside of acute care are
summarized in 4 tables that are included in Appendix B.
Part III: Performance Measures
Five practices for the general prevention of transmission of infectious agents in
healthcare settings and two practices specifically for prevention of transmission of (MDROs)
7
are presented as a means for healthcare facilities to monitor implementation of some of the
key recommendations in this guideline.
Appendix A: Type and Duration of Precautions Recommended for Selected Infections
and Conditions
Appendix A consists of an updated alphabetical list of most infections and clinical
conditions for which isolation precautions are recommended. The type and duration of
recommended precautions are presented with additional comments concerning the use of
adjunctive measures or other relevant considerations to prevent transmission of the specific
agent.
Appendix B: Management of MDROs in Healthcare Settings
Appendix B provides a detailed review of the complex and controversial topic of
MDRO control in healthcare settings that will allow the reader to place into perspective the
MDRO conditions present within a specific healthcare setting. A rationale and institutional
requirements for developing an effective MDRO control program are summarized. Although
the focus of this guideline is on measures to prevent transmission of MDROs in healthcare
settings, information concerning the judicious use of antimicrobial agents is presented since
such practices are intricately related to the size of the reservoir of MDROs which in turn
influences transmission (e.g. colonization pressure). This section elaborates on the
principles introduced in earlier HICPAC guidelines and expands their application to address
control of current and future MDROs across the spectrum of healthcare settings. Appendix
B includes two tables that summarize the characteristics of selected MDRO studies
published in the literature and four tables that summarize recommended prevention and
control practices.
Summary
This updated guideline responds to changes in healthcare delivery and addresses
new concerns about transmission of infectious agents to patients and healthcare workers in
the United States and infection control. The primary objective of the guideline is to improve
the safety of the nation’s healthcare delivery system by reducing the rates of HAIs.
8
Part I: Review of Scientific Data Regarding Transmission of Infectious
Agents in Healthcare Settings
I.A. Evolution of the 2004 Document
The Guideline for Isolation Precautions: Preventing Transmission of Infectious
Agents in Healthcare Settings 2004 builds upon a series of isolation and infection
prevention documents promulgated since 1970. These previous documents are summarized
and referenced in Table 1 and in Part I of the 1996 Guideline for Isolation Precautions in
Hospitals (1).
Objectives and methods. The objectives of this guideline are to 1) provide infection
control recommendations for all components of the healthcare delivery system, including
hospitals, long-term care facilities, ambulatory care, and home health; 2) reaffirm Standard
Precautions as the foundation for preventing transmission during patient care in all
healthcare settings; 3) provide epidemiologically sound and, whenever possible, evidencebased recommendations; and 4) provide a unified infection control approach to MDROs,
thus replacing prior pathogen-specific recommendations such as those issued for
vancomycin-resistant enterococci (VRE) (2) and Staphylococcus aureus with reduced
susceptibility to vancomycin (VISA) (3).
The guideline is designed for individuals who are charged with administering infection
control programs and healthcare personnel in hospitals and other healthcare settings. All
healthcare personnel who need general information about infection control measures to
prevent transmission will also find this guideline useful. Terms used in the guideline are
defined in the glossary in Table 2. Med-line and Pub Med were used to search for relevant
English language studies published primarily since 1996.
Standard Precautions is reaffirmed as the foundation for preventing transmission of
infectious agents during healthcare personnel-patient interactions. Consistent observance of
Standard Precautions by healthcare personnel offers the greatest potential for preventing
transmission of infectious agents in healthcare settings. A new addition to the
recommendations for Standard Precautions is Respiratory Hygiene/Cough Etiquette, The
need for this recommendation grew out of observations during the SARS epidemic where
failure to implement basic source control measures with patients, visitors, and healthcare
personnel with signs and symptoms of respiratory tract infection may have contributed to
9
SARS coronavirus (SARS-CoV) transmission. This concept has been incorporated into
CDC planning documents for SARS and pandemic influenza.
Changes or clarifications in terminology. This guideline contains 3 changes in
terminology from the 1996 guideline:
ƒ
The term “Transmission-based Precautions” has been replaced by “Expanded
Precautions” to eliminate a contradiction – Standard Precautions is a “transmissionbased” approach. The term “Expanded Precautions” was adopted to reflect the need
for additional measures to prevent transmission when the route of transmission (e.g.,
contact, droplet, airborne) is not interrupted completely by Standard Precautions, or
when a Protective Environment (PE) is required (e.g., for allogeneic hematopoietic
stem cell transplant (HSCT) patients) to prevent acquisition of fungi from the
environment.
ƒ
“Airborne Precautions” has been replaced with “Airborne Infection Isolation (AII)” to
be consistent with the revised Guidelines for Preventing the Transmission of
Mycobacterium tuberculosis in Healthcare Settings 2004 (MMWR in preparation),
the Guidelines for Environmental Infection Control in Healthcare Facilities (4), and the
American Institute of Architects (AIA) guidelines for design and construction of
hospitals(5).
ƒ
The term “nosocomial infection,” which refers only to infection acquired in hospitals,
has been replaced by “healthcare-associated infection”(HAI) which refers to
infections associated with healthcare delivery in any setting.
Scope. This guideline, like its predecessors, focuses primarily on interactions
between patients and healthcare providers. Several other HICPAC guidelines to prevent
transmission of infectious agents associated with healthcare delivery are cited, e.g.,
Guideline for Hand Hygiene (6), Guideline for Disinfection and Sterilization (in preparation)
(7), Guideline for Environmental Infection Control (4), Guideline for Prevention of
Healthcare-Associated Pneumonia (8), and Guideline for Infection Control in Healthcare
Personnel (9). In combination, these provide comprehensive guidance on the primary
infection control measures for ensuring a safe environment for patients and healthcare
personnel.
10
This guideline also does not discuss in detail specialized infection control issues in
defined populations that are addressed elsewhere (e.g., Recommendations for Preventing
Transmission of Infections among Chronic Hemodialysis Patients (10), Guidelines for
Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Facilities, 1994
(11), Guidelines for Infection Control in Dental Health-Care Settings (12)) . An exception has
been made by including abbreviated guidance for a Protective Environment (PE) used for
allogeneic HSCT recipients since components of the PE have been more completely
defined since publication of the Guidelines for Preventing Opportunistic Infections Among
HSCT Recipients in 2000 (13).
I.B. Rationale for Standard and Expanded Precautions in healthcare
settings
Transmission of infection within a healthcare setting requires three elements: a
source (or reservoir) of infecting microorganisms, a susceptible host, and a mode of
transmission for the microorganism. This section describes the interrelationship of these
elements in the epidemiology of healthcare-associated infections.
I.B.1. Sources of infectious agents
Infectious agents transmitted during healthcare derive primarily from human sources
but inanimate environmental sources also are implicated in transmission. Human reservoirs
include patients, healthcare personnel, household members, and visitors (e.g., family,
friends). Such individuals may have active infections, may be in the asymptomatic and/or
incubation period of an infectious disease, or may be transiently or chronically colonized
with pathogenic microorganisms, particularly in the respiratory and gastrointestinal tracts. In
many situations the endogenous flora of patients (e.g., bacteria residing in the respiratory or
gastrointestinal tract) are the source of healthcare-associated infections (14).
I.B.2. Susceptible hosts
Individual susceptibility to infection varies. Some persons exposed to pathogenic
microorganisms never develop symptomatic disease because of their resistance to
colonization or immunity to specific virulence properties of the pathogen. Others may
become transiently or permanently colonized but remain asymptomatic. Still others progress
from colonization to symptomatic disease either immediately following exposure, or after a
period of asymptomatic colonization. Host factors such as extremes of age and underlying
11
disease (e.g., diabetes, HIV/AIDS) enhance susceptibility to infection as do a variety of
medications that alter the normal flora (e.g., antimicrobial agents, gastric acid suppressants,
corticosteroids, antirejection drugs, antineoplastic agents, immunosuppressive drugs, and
others). Surgical procedures and radiation therapy impair defenses of the skin and other
involved organ systems. Indwelling devices such as urinary catheters, endotracheal tubes,
central venous and arterial catheters, and synthetic implants facilitate development of
healthcare-associated infections by allowing potential pathogens to bypass local defenses
that would ordinarily impede their invasion and by providing surfaces for development of
bioflms that may facilitate adherence of microorganisms. Some infections associated with
invasive procedures are a result of transmission within the healthcare facility; others are
acquired from endogenous organisms on the patient’s body. High-risk patient populations
with noteworthy risk factors for infection are discussed further in subsequent sections of this
document.
I.B.3. Modes of transmission
Persons are exposed to human sources of microorganisms in healthcare settings via
three primary routes: contact (direct and indirect), respiratory droplets, and airborne droplet
nuclei (i.e., respirable particles of <5 µm).
I.B.3.a. Contact transmission, the most common mode of transmission, is divided into two
subgroups: direct contact and indirect contact.
I.B.3.a.i. Direct contact transmission occurs when microorganisms are transferred directly
from one person to another person. Examples of direct contact transmission in healthcare
settings include:
•
blood from a patient directly enters a caregiver’s body through a cut in the skin;
•
scabies mites from a patient are transferred to the skin of a caregiver while he/she
is lifting the patient;
•
a healthcare provider develops herpetic whitlow on a finger after contact with
Herpes simplex virus when providing oral care to a patient without using gloves or
HSV is transmitted to a patient from a herpetic whitlow on an ungloved hand of a
HCW (9).
Direct contact transmission is more efficient than indirect contact transmission but occurs
less frequently in healthcare settings than does indirect contact transmission. Transmission
12
by direct contact occurs more frequently between patients and healthcare personnel than
between patients. Disease is more likely to develop following direct contact transmission
when the pathogen is highly virulent or has a low infectious dose or the patient or HCW is
immunocompromised.
I.B.3.a.ii. Indirect contact transmission, the most frequent mode of transmission, involves
the transfer of an infectious agent through a contaminated intermediate object or person.
Hands of personnel are usually cited as the most important contributors to indirect contact
transmission (6). Examples of indirect contact transmission are as follows:
•
Hands of healthcare personnel touch an infected or colonized body site on one
patient or a contaminated inanimate object, and then subsequently touch another
patient without healthcare personnel performing hand hygiene between patient
contacts.
•
Patient-care devices (e.g., electronic thermometers (15), glucose monitoring
devices (16, 17)) contaminated with blood or body fluids are shared between
patients without cleaning and disinfecting between patients.
•
Shared toys become a vehicle for transmitting respiratory viruses (e.g., respiratory
syncytial virus (18) or pathogenic bacteria (e.g., Pseudomonas aeruginosa (19))
to pediatric patients.
•
Instruments that are inadequately cleaned between patients before disinfection or
sterilization (e.g., endoscopes or surgical instruments) (20-24) or that have
manufacturing defects that interfere with the effectiveness of reprocessing (25,
26) may transmit bacterial and viral pathogens.
I.B.3.b. Droplet transmission, technically, is a form of contact transmission. However, the
mechanism of transfer of the pathogen to the host is distinct and additional prevention
measures are required. Respiratory droplets are generated when an infected person
coughs, sneezes, or talks or during procedures such as suctioning, bronchoscopy, and
cough induction by chest physiotherapy. Transmission occurs when droplets propelled short
distances (traditionally, <3 feet through the air) are deposited on the conjunctivae, nasal
mucosa, or mouth (27-30).
The defntition of droplet transmission is of current interest and under discussion.
Historically, the area of defined risk has been a distance of <3 feet around the patient and is
13
based on epidemiologic and simulated studies of selected infections. Using this distance for
donning masks has been effective in preventing transmission of infectious agents via the
droplet route. However, experimental studies with smallpox (31) and investigations of the
global SARS outbreak of 2003 (www.cdc.gov/ncidod/sars) suggest that droplets from
patients with these two infections rarely could reach persons 6 feet or more away from their
source. It is possible that the distance droplets travel depends on a number of factors,
including the velocity and mechanism by which they are propelled from the source,
environmental factors such as temperature and humidity, and the density of respiratory
secretions (32). Thus, a distance of <3 feet around the patient is best viewed as an example
of what is meant by “a short distance from a patient” and not used as a criterion for deciding
when a mask should be donned to protect from exposure. Based on these considerations, it
may be prudent to don a mask when within 6 to 10 feet of the patient or upon entry into the
patient’s room; more information is needed.
Droplet size is another subject under discussion. Droplets traditionally have been
defined as being >5 µm in size and droplet nuclei, which are associated with airborne
transmission, <5 µm in size. The behavior of droplets and droplet nuclei affect
recommendations for preventing transmission. Because droplets are relatively heavy and
do not remain suspended in the air, special air handling and ventilation are not required to
prevent droplet transmission. Examples of infectious agents that can be transmitted via the
droplet route include Bordetella pertussis (33), influenza virus (32), adenovirus (29),
rhinovirus (34), Mycoplasma pneumoniae (35), SARS-associated coronavirus (SARS-CoV)
(30, 36, 37) , group A streptococcus (38), and Neisseria meningitidis (27, 39, 40). As the
subjects of droplets and droplet nuclei and the droplet and airborne routes of transmission
are studied and discussed, there may be changes in future recommendations for preventing
droplet transmission.
I.B.3.c. Airborne transmission occurs by dissemination of airborne droplet nuclei (smallparticle residue [5 µm or smaller in size] of evaporated droplets, sometimes referred to as
“small droplets,” that contain infectious microorganisms that remain suspended in the air for
long periods of time) or dust particles containing the infectious agent. Microorganisms
carried in this manner can be dispersed widely by air currents and may be inhaled by
susceptible hosts within the same room or over a longer distance from the source patient
14
when the air supply is shared (41-43). Special air handling and ventilation as well as
respiratory protection with NIOSH approved N-95 or higher respirators are required to
prevent airborne transmission. There are only a few microorganisms known to be
transmitted by the airborne route: Mycobacterium tuberculosis (11, 41, 44), rubeola virus
(measles) (43), and varicella-zoster virus (chickenpox) (42). Airborne transmission of
smallpox (31, 45) has been documented, but is less frequent than transmission via contact
and droplet routes. Airborne transmission of SARS (46) (www.cdc.gov/ncidod/sars),
monkeypox (www.cdc.gove/ncidod/monkeypox) and the viral hemorrhagic fever viruses (47)
has been reported, though not proven conclusively. Although airborne transmission has
been considered in some outbreaks of influenza, droplet spread is the most frequent mode
of transmission for influenza in healthcare settings (32).
A new classification of aerosol transmission was proposed when evaluating routes of
SARS transmission (48): 1) obligate: under natural conditions, disease occurs following
transmission of the agent only through small particle aerosols (e.g., tuberculosis); 2)
preferential: natural infection results from transmission through multiple routes, but small
particle aerosols are the predominant route (e.g. measles, varicella); and 3) opportunistic:
agents that naturally cause disease through other routes, but under certain environmental
conditions may be transmitted via fine particle aerosol (e.g., SARS transmission via an
aerosol plume that originated from sewage in the Amoy Gardens housing complex in 2003
(46).
Some airborne infectious agents are derived from the environment and do not usually
involve person-to-person transmission. For example, anthrax spores present in a finely
milled powdered preparation can be aerosolized and re-aerosolized from contaminated
environmental surfaces and inhaled into the respiratory tract (49, 50). Currently,
reaerosolization is not known to occur with agents that are transmitted from the respiratory
tract. Spores of environmental fungi (e.g., Aspergillus spp.) are ubiquitous and may be
aerosolized via construction dust, and inhaled by immunosuppressed neutropenic oncology
patients. A Protective Envrionment (PE) decreases the risk of environmental fungal
infections in allogeneic HSCT patients (13). Person-to-person transmission of Aspergillus
sp. generally does not occur, but has been documented in a multibed intensive care unit
(ICU) via the airborne route from a source patient who developed an extensive abdominal
15
wound complicating liver transplant and required deep debridement and frequent dressing
changes (51).
I.B.3.d. Other sources of infection that do not involve person-to-person transmission
include those associated with common source vehicles, e.g. contaminated food, water, or
medications (e.g. intravenous fluids). Vectorborne transmission of infectious agents from
mosquitoes, flies, rats, and other vermin also can occur in healthcare settings. However,
these route of transmission is of less significance in U.S. healthcare facilities than in other
regions of the world and will not be addressed in this document.
I.C. Emerging pathogens of special concern to healthcare settings
Several classes of microorganisms can cause infection, including bacteria, viruses,
fungi, parasites, and prions. The routes of transmission vary by type of organism; some are
transmitted primarily by the contact route (e.g., Herpes simplex, multidrug-resistant
bacteria), others by the droplet (e.g., influenza virus, B. pertussis) or airborne routes (e.g.,
M. tuberculosis), while others, such as bloodborne viruses (e.g., hepatitis B and C viruses
[HBV, HCV] and human immunodeficiency virus [HIV]) are transmitted under limited
circumstances via percutaneous or mucous membrane exposure. With some infections,
there is a constellation of symptoms that categorize the infection as an “infectious disease.”
Importantly, not all infections or infectious diseases are transmitted from person to person.
These are distinguished in Appendix A.
Some groups of microorganisms have become established endemically in healthcare
settings or have new and/or epidemiologically important implications. Six groups or types of
organisms with important infection control implications at the time of publication of this
guideline are MDROs, agents of bioterrorism, prions, SARS-CoV, monkeypox and Avian
influenza A (H5N1) viruses. Each is discussed in the following section.
I.C.1. Multidrug-Resistant Organisms (MDROs)
All healthcare settings constitute important environments for the emergence and
transmission of antimicrobial resistant microbes, although transmission of MDROs is
especially well documented in acute care facilities. MDROs are defined as microorganisms
– predominantly bacteria – that are resistant to one or more classes of antimicrobial agents
(52). Although the names of certain MDROs suggest resistance to only one agent (e.g.,
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methicillin-resistant Staphylococcus aureus [MRSA] r vancomycin resistant enterococcus
[VRE]), these pathogens are usually resistant to all but one or two commercially available
antimicrobial agents (53). This latter feature defines MDROs that deserve special attention
in healthcare facilities (53). Other MDROs of current concern include nonsusceptible
Streptococcus pneumoniae (NSSP) which is resistant to penicillin and other broad-spectrum
agents such as macrolides and fluoquinolones, multidrug-resistant gram-negative bacilli
(MDR- GNB), especially those producing extended spectrum beta-lactamases (ESBLs); and
strains of S. aureus that are intermediate or resistant to vancomycin (i.e., vancomycin
intermediate S. aureus [VISA], vancomycin resistant S. aureus [VRSA]) (3, 54-69). The
terminology for M. tuberculosis is a special case, where multidrug-resistant strains are
defined as those resistant to at least isoniazid and rifampin (the two most important and
potent of the first line drugs) with or without resistance to other drugs (11).
MDROs cause concern primarily because they limit treatment options. Until recently,
only vancomycin provided effective therapy for life-threatening MRSA infections. During the
1990’s, there were virtually no antimicrobial agents to treat infections caused by VRE.
Although quinupristin-dalfopristin (Synercid™), linezolid, and daptomycin are now available
for treatment of MRSA and VRE infections, their utility may be limited since resistance to
quinupristin-dalfopristin and linezolid has emerged in clinical isolates (70-74). Similarly,
therapeutic options are limited for ESBL-producing isolates of gram-negative bacilli, strains
of Acinetobacter baumannii resistant to all antimicrobial agents except imipenem (75-80)
and intrinsically resistant Stenotrophomonas sp. (81-84). These limitations may drive
antibiotic usage patterns in ways that suppress normal flora and create a favorable
environment for further transmission of MDROs among patients exposed to other patients
colonized or infected with MDROs (i.e., selective advantage) as demonstrated by VRE (85).
Patient-to-patient transmission in healthcare settings, usually via hands of HCWs,
has been a major factor accounting for the increase in MDRO incidence and prevalence,
especially for MRSA and VRE in acute care facilities (86-88). A detailed discussion of this
complex and controversial topic is provided in Appendix B.
I.C.2. Agents of bioterrorism
CDC has designated anthrax, smallpox, plague, tularemia, viral hemorrhagic fevers,
and botulism as Category A (high priority) because these agents can be easily disseminated
17
environmentally and/or transmitted from person to person; can cause high mortality and
have the potential for major public health impact; might cause public panic and social
disruption; and require special action for public health preparedness. Information relevant to
infection control for Category A agents of bioterrorism is summarized in Table 3. Consult
www.bt.cdc.gov for additional, updated Category A agent information as well as information
concerning Category B and C agents of bioterrorism and updates.
Healthcare facilities confront a different set of issues when dealing with a suspected
bioterrorism event as compared with other communicable diseases. An understanding of the
epidemiology, modes of transmission, and clinical course of each disease and carefully
drafted plans that provide disease-specific guidance to healthcare, administrative, and
support personnel are essential for responding to and managing a bioterrorism event.
Among the infection control issues that may need to be addressed are: preventing
transmission among patients, healthcare personnel, and visitors; identifying persons who
may be infected and exposed; providing treatment or prophylaxis to large numbers of
people; protecting the environment; and logistical issues associated with securing sufficient
AII environments, providing barrier protection, and providing appropriate staffing (e.g.,
vaccinated healthcare personnel for care of patients with smallpox). The response is likely
to differ based on whether exposure is a result of a biological release or person-to-person
transmission.
A variety of sources offer guidance for the management of persons exposed to the
most likely agents of bioterrorism. Federal agency websites (e.g.,
www.usamriid.army.mil/publications/index.html; www.bt.cdc.gov) and state and county
health department web sites should be consulted for the most up-to-date information.
Sources of information on specific agents include: anthrax:(89); smallpox:(90);
www.bt.cdc.gov/DocumentsApp/Smallpox/RPG/index.asp; Smallpox and its Eradication
(www.who.int/emc/diseases/smallpox/Smallpoxeradication.html); plague:(91); botulinum
toxin:(92); tularemia: (93); and viral hemorrhagic fevers:(47).
In addition to the agents of bioterrorism, pre-event administration of smallpox
(vaccinia) vaccine to healthcare personnel has important infection control implications (9496). These include the need for meticulous screening for vaccine contraindications in
persons who are at increased risk for adverse vaccinia events; containment and monitoring
18
of the vaccination site to prevent transmission in the healthcare setting and at home; and
the management of patients with vaccinia-related adverse events (97, 98). The pre-event
U.S. smallpox vaccination program of 2003 is an excellent example of how close monitoring
of vaccination sites is an effective measure to prevent vaccinia transmission (99).
Recommendations for pre-event smallpox vaccination of healthcare personnel and vacciniarelated infection control recommendations are published in the MMWR (97, 100) with
updates posted on the web site (www.bt.cdc.gov/smallpox).
I.C.3. Prions
Creutzfeldt-Jakob Disease (CJD) is a rapidly progressive, degenerative, neurologic
disorder of humans with an incidence in the United States of approximately 1 person/million
population/year (101, 102). CJD is caused by a transmissible proteinaceous infectious
agent, or prion protein (PrP). The incubation period varies and symptoms may not present
for decades after the exposure. However, death typically occurs within 1 year of the onset of
symptoms. Approximately 90% of cases are sporadic and 10% are familial. Iatrogenic
transmission has occurred. Most iatrogenic cases have resulted from treatment with human
cadaveric pituitary-derived hormone (>130 cases) or gonadotropin (4 cases) or from
implantation of contaminated dura mater grafts from humans (>110 cases) or corneal
transplants (3 cases). Only 6 (<1%) reported cases have been linked to contaminated
neurosurgical instruments or stereotactic electroencephalogram electrodes (103).
Six prion diseases in animals have been described, including scrapie in sheep and
goats, bovine spongiform encephalopathy (BSE, or “mad cow disease”) in cattle, and
chronic wasting disease in deer and elk. BSE, first recognized in the United Kingdom (UK)
in 1986, was associated with a major epidemic among cattle that had consumed meat and
bone meal prepared from sheep and beef with scrapie.
The first animal-to-human cases of a neurologic prion disease, BSE, termed variant
CJD (vCJD) were announced in 1996 and subsequently found to be associated with
consumption of beef from infected cattle outside the United States. Less than 300 cases
have been reported worldwide at the time of publication of this guideline. Although most
cases of vCJD were reported from the UK, a few cases were also reported from France,
Italy, and Ireland. The first case of BSE in U.S. cattle was recognized in December 2003, in
a single adult cow in Mabton, Washington (104). This animal was part of the same herd as
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the first positive cow from Canada in the province of Alberta (105). Although there has been
no transmissionof vCJD to humans in the United States, these cases have heightened
awareness of the possibility that such infections could occur and have led to increased
surveillance activities. Updated information may be found on the following website:
www.cdc.gov/ncidod/diseases/cjd/bse_washington.htm.
vCJD differs from sporadic CJD in the following aspects: 1) younger mean age at
onset: 28 (range 16-48) vs. 65 years; 2) longer duration of illness: mean 13 months vs. 4.5
months; 3) shorter incubation period: 5-10 years vs. decades; 4) increased frequency of
sensory and psychiatric symptoms; and 5) detection of PrP tonsillar tissue from vCJD
patients prior to the onset of symptoms, but not from sporadic CJD patients (106). Similar to
sporadic CJD, there have been no reported cases of direct human-to-human transmission of
vCJD by contact, droplet, or airborne routes. Although there is strong evidence that vCJD
can be transmitted by blood transfusion, there is no such evidence to date that sporadic
CJD or vCJD is transmissible from environmental surfaces (107, 108), but surveillance is
ongoing. Potential for transmission of vCJD through blood transfusion is of increasing
concern based on animal studies (109) and one case report of highly probable transmission
to a British patient (110). Since there is no direct patient-to-patient transmission, Standard
Precautions is used when caring for patients with suspected or confirmed CJD or vCJD.
Upon the death of a patient with CJD, special precautions are recommended only for
conducting an autopsy, embalming, and for contact with a body that has undergone
autopsy. Recommendations for reprocessing surgical instruments to prevent transmission of
CJD or vCJD in healthcare settings have been published elsewhere (7, 103);
www.who.int/emc-documents/tse/docs/whocdscsraph2003.pdf).
1.C.4. Severe Acute Respiratory Syndrome (SARS)
SARS is a newly discovered respiratory disease that emerged in China late in 2002
and spread globally (111, 112). Mainland China, Hong Kong, Hanoi, Singapore, and
Toronto, Canada, were affected significantly by SARS. SARS is caused by SARS CoV, a
previously unrecognized member of the coronavirus family (113, 114). The incubation
period from exposure to the onset of symptoms is generally between 2 to 7 days but can be
as long as 10 days. The illness is initially difficult to distinguish from other common
respiratory infections. Signs and symptoms usually include fever >38.0oC and chills and
20
rigors, sometimes accompanied by headache, myalgia, and mild to severe respiratory
symptoms. Radiographic finding of atypical pneumonia is an important clinical indicator of
possible SARS. Children have been affected only rarely and there are only two reported
cases of transmission from children to adults and no reports of child-to-child transmission
(112, 115). The case fatality rate is approximately 6.0%; underlying disease and advanced
age increase the risk of mortality. Local health departments should be consulted to
determine where to perform diagnostic studies (e.g. culture, nucleic acid detection by
polymerase chain reaction [PCR], acute and convalescent serology).
Outbreaks in healthcare settings, with transmission to large numbers of healthcare
personnel and patients, have been a particularly striking feature of this disease; unidentified
infected patients and visitors were an important source of these infections (37, 116). The
exact mode(s) of transmission is unknown. However, there is ample evidence for droplet
and contact transmission (30, 36), and airborne dissemination and transmission through
contaminated fomites cannot be excluded (112, 117, 118). SARS CoV may be considered
an opportunistic airborne pathogen that is transmitted through the airborne route only under
unusal circumstances (46, 48). Exposure to “super-shedders” during cough-inducing
procedures has been associated with transmission of infection to large numbers of
healthcare personnel outside of the United States (36). In addition, subtle breaches in
recommended laboratory practices have led to SARS-CoV transmission in laboratories
where the SARS-CoV was under investigation. The research laboratory was the source of
most cases reported after the first series of outbreaks in the winter and spring of 2003 (119)
(www.cdc.gov/ncidod/sars/situation.htm). Studies of the SARS outbreaks of 2003 and
transmissions that occurred in the laboratory re-affirm the effectiveness of recommended
infection control precautions and highlight the importance of consistent adherence to these
measures.
Screening for travel to areas experiencing community transmission or contact with
SARS patients, followed by prompt placement of a surgical mask over the nose and mouth
at the initial point of encounter and segregation of suspected SARS patients from others is
essential to prevent transmission in ambulatory settings and the emergency department.
When Standard Precautions, including use of hand hygiene and eye protection, Contact
Precautions, and AII Precautions, including fit-tested NIOSH-approved N95 or higher
21
respirators, are used, transmission in healthcare settings has been controlled. Updated
guidance for infection control precautions in various settings is available at
www.cdc.gov/ncidod/sars.
I.C.5. Monkeypox
Monkeypox is a rare viral disease found mostly in the rain forest countries of central
and West Africa. The disease, which was first discovered in laboratory monkeys, hence the
name “monkeypox,” is caused by an orthopoxvirus and is similar in appearance, though not
in severity, to smallpox. Monkeypox was first reported in the United States in June 2003
after several people became ill following contact with sick pet prairie dogs. Infection in the
prairie dogs was subsequently traced back to contact with a shipment of animals from
Africa, including Giant Gambian Rats. This outbreak illustrated the potential for epizoonotic
disease in the United States with transmission to humans and the need to improve controls
on the importation of animals.
Limited data on transmission of monkeypox are available. Transmission from infected
animals and humans is believed to occur primarily through direct contact with lesions and
respiratory droplets; the possibility of airborne transmission cannot be excluded.
Transmission of monkeypox within hospitals has been reported in Africa, albeit rarely. To
date in the United States, there has been no evidence of person-to-person transmission of
monkeypox, and no new cases of monkeypox have been identified since the initial outbreak
in June 2003. Smallpox vaccine is protective (120) and may be administered to individuals
who have been exposed to patients or animals with monkeypox since there is an associated
case fatality rate of <10% (121). For the most current information on monkeypox, see
www.cdc.gov/ncidod/monkeypox/clinicians.htm.
I.C.6. Avian influenza A
In 2003-2004, transmission of avian influenza A (H5N1) among domestic poultry
resulted in highly contagious, rapidly fatal disease, and severe epidemics in >9 countries in
Asia (www.cdc.gov/flu/avian/index.htm; www.who.int/csr/disease/avian_influenza/en). Avian
influenza A (H7N2) was also identified in 2004 among poultry in the states of Delaware,
New Jersey, and Texas. This strain is known to circulate in live bird markets in the New
York City area and has been associated with only one possible case of disease in humans.
This virus is distinct from the Asian H5N1 strain. In humans, laboratory-confirmed cases of
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avian influenza A (H5N1) with high mortality have occurred (122). During the 2003-2004
outbreak in Asia, at least 34 cases with 23 deaths (68% case fatality rate) (as of March 31,
2004) in two countries, Viet Nam and Thailand, were reported by the World Health
Organization (WHO). Viruses from these patients contained only avian genes with no
human influenza virus genes. Most patients were children and all but two are reported to
have had direct contact with infected birds or surfaces or materials contaminated with
excretions from infected birds in areas experiencing severe influenza outbreaks among
poultry and birds. Thus, to date, human-to-human transmission of H5N1 is inefficient and
rare. Preliminary testing of some of the recent H5N1 viruses found resistance to
amantidine/rimantadine, but susceptibility to oseltamivir (123).
Instances of various avian influenza strains and subtypes affecting humans (e.g.,
H7N7, H9N2, and H5N1) have been reported sporadically since 1997. Of these subtypes,
only H5N1 infection was associated with high mortality and none were associated with
efficient transmisison from person-to-person (124-126). The influenza A virus subtype H5N1
is of particular concern because of its high virulence and its ability to directly infect humans.
The avian viruses that can infect humans may change over time, either through point
mutations or reassortment with a human influenza virus, and acquire the ability to transmit
readily form human- to- human, with high morbidity and mortality and rapid global spread.
Thus, prompt detection and control of H5N1 are critical. Control among birds has focused
on 1) culling of flocks of birds; 2) use of avian vaccines; 3) surveillance; and 4) biosecurity
measures such as quarantine and isolation of farms. Measures recommended for the care
of humans with suspected or confirmed H5N1 disease include vaccination of healthcare
personnel with the appropriate seasonal human influenza vaccine and the combined use of
Standard Precautions, AII, Contact Precautions, and eye protection
(www.cdc.gov/flu/han020302.htm). Although human influenza viruses are transmitted most
frequently by the droplet route, because of the potential for emergence of a pandemic
influenza strain, additional precautions are recommended for avian influenza infections until
the human epidemiology of infection with avian strains is defined.
I.D. Transmission risks associated with specific types of healthcare settings
Numerous factors influence differences in transmission risks among the various
healthcare settings. These include the population characteristics (e.g., increased
23
susceptibility to infections, type and prevalence of indwelling devices), intensity of care,
exposure to environmental sources, length of stay, and frequency and intensity of
interaction between patients/residents with each other and with HCWs. These factors, as
well as organizational priorities, goals, and resources, influence how the different healthcare
settings adapt transmission prevention guidelines to meet their specific needs. Infection
control management decisions should be informed by information and data regarding
institutional experience/epidemiology, trends in community and institutional HAIs, local and
regional epidemiology as well as national trends and emerging risks.
I.D.1. Hospitals
Infection transmission risks are present throughout all hospital settings. However, certain
hospital populations have unique conditions that predispose to infection and that merit
special mention. These populations are often sentinel sites for emergence of new
transmission risks that may be unique to that setting or present opportunities for
transmission to other settings in the hospital. More rigorous infection control measures to
prevent transmission are often required in these settings.
I.D.1.a. Intensive Care Units. Intensive care units (ICUs) serve patients who are
immunocompromised by disease state and/or by treatment modalities, as well as patients
with major trauma, respiratory failure and other life-threatening conditions (e.g., myocardial
infarction, congestive heart failure, overdoses, strokes, gastrointestinal bleeding, renal
failure, hepatic failure, multi-organ system failure, and the extremes of age). Although ICUs
account for a relatively small proportion of hospitalized patients, infections acquired in these
units account for >20% of all healthcare-associated infections (127).This patient population
exhibits high infection rates and susceptibility to colonization and infection, especially with
MDROs, because of their underlying diseases and conditions, the invasive medical devices
and technology used in their care, the frequency of their contact with healthcare personnel,
and the prolonged duration of exposure to antimicrobial agents (128-130). Furthermore,
adverse patient outcomes in this setting are more severe and are associated with a higher
mortality. Outbreaks associated with a variety of bacterial, fungal and viral pathogens due to
common-source and person-to-person transmissions are frequent in adult and pediatric
ICUs.
24
I.D.1.b. Burn Units. Exposed burn tissues provide optimal conditions for colonization,
infection, and transmission; therefore, infection acquired by burn patients is a frequent
cause of morbidity and mortality. The risk of invasive burn wound infections is particularly
high for patients with a burn injury involving >30% of the total body surface area
(TBSA)(131, 132). Infections that occur in patients with <30% TBSA are usually associated
with the use of invasive devices. In recent years, there has been a shift in the predominant
organisms causing infections in burn unit patients from gram-negative to gram-positive
bacteria and fungi. Methicillin-susceptible Staphylococcus aureus and enterococci, including
VRE (133), are prevalent and outbreaks of MRSA are reported frequently in burn units (134,
135). Gram-negative bacteremia is associated with a 50% increase in predicted mortality.
Hydrotherapy equipment is an important environmental reservoir of gram-negative
organisms and its use is discouraged based on investigations that used molecular typing
techniques to demonstrate an association between hydrotherapy and wound infection or
colonization with multidrug-resistant P. aeruginosa (136) and A. baumannii BSI (137);
excision of burn wounds in operating rooms is preferred.
Advances in burn care, specifically early excision and grafting of the burn wound, use
of topical antimicrobial agents, and institution of early enteral feeds, have led to decreased
infectious complications. Others have included prophylactic antibiotic usage, selective
digestive decontamination (SDD), and use of antimicrobial-coated catheters (ACC), but few
epidemiologic studies and no efficacy studies have been performed to show the relative
benefit of these measures (138).
There is no consensus on the most effective infection control practices (e.g., singlebed rooms (139), laminar flow and high efficiency particulate air filtration [HEPA]) to prevent
transmission of infections to and from patients with serious burns. There also is controversy
regarding the need for and type of barrier precautions for care of burn patients. One
retrospective study (140) demonstrated the efficacy and cost effectiveness of a simplified
barrier isolation protocol on wound colonization. This protocol emphasized handwashing
and use of gloves, caps, masks and plastic impermeable aprons (rather than isolation
gowns) for direct patient contact. However, none of the studies have determined definitively
the most effective combination of infection control precautions for use in burn settings.
Prospective studies in this area are needed.
25
I.D.1.c. Pediatrics. Studies of the epidemiology of HAIs in children have identified unique
infection control issues in this population (141). Pediatric and neonatal intensive care units
(PICU and NICU) monitored in the National Nosocomial Infection Surveillance (NNIS)
system have higher rates of central venous catheter-associated bloodstream infections than
adult ICUs (142-144). Additionally, there is a high prevalence of community-acquired
infections among hospitalized infants and young children who have not yet become immune
either by vaccination or by natural infection. The result is more patients and their sibling
visitors with transmissible infections in pediatric healthcare settings, especially during
seasonal epidemics (e.g., pertussis; respiratory infections including those caused by
respiratory syncytial, influenza, parainfluenza, and adeno viruses; rubeola [measles],
varicella [chickenpox], and rotavirus infection) (18, 33, 145, 146).
Close physical contact between healthcare personnel and infants and young children
including cuddling, feeding, playing, changing soiled diapers, and cleaning copious
uncontrolled respiratory secretions, provides abundant opportunities for transmission of
infectious agents. The congregation of children in play areas where toys and bodily
secretions may be shared, and family rooming-in further enhance the risk of transmission.
There is one report, for example, of contaminated bath toys that were implicated in an
outbreak of multidrug-resistant P. aeruginosa on a pediatric oncology unit (19). The
innovative practices of co-bedding (147) and kangaroo care (148) in the NICU for the
purpose of improving developmental outcomes increase the potential for skin-to-skin
exposure of multiple gestation infants to each other and to their mothers. In addition,
several patient factors increase the likelihood that infection will result from these close
contacts (e.g., immaturity of the neonatal immune system, lack of previous natural infection
and resulting immunity, use of life saving invasive devices in the NICU and PICU, and
prevalence of patients with congenital or acquired immune deficiencies and congenital
anatomic anomalies).
I.D.2. Nonacute healthcare settings
Healthcare is provided in various settings outside of hospitals including residential
facilities, such as long-term care facilities (e.g. nursing homes), homes for the
developmentally disabled, settings where behavioral health services are provided,
rehabilitation centers, hospices, and others. In addition, healthcare may be provided in
26
nonhealthcare settings such as factories with occupational health clinics, adult day care
centers, assisted living facilities, homeless shelters, and school clinics and infirmaries. Each
of these settings has unique circumstances and population risks to consider when designing
and implementing an infection control program. Several of the most common settings and
their particular challenges are discussed below. While this Guideline does not discuss each
specific type of setting, the principles and strategies provided should be reviewed, adapted,
and applied as appropriate to the setting and its population.
I.D.2.a. Long-term care. The term “long-term care facility” (LTCF) applies to a diverse
group of residential settings, ranging from institutions for the developmentally disabled to
nursing homes for the elderly and pediatric chronic-care facilities (149, 150). Nursing homes
for the elderly predominate numerically and frequently represent the group. Approximately
1.8 million Americans reside in the nation’s 16,500 nursing homes (151). HAI rates of 1.8 to
13.5 per 1000 resident-care days have been reported with estimates in the range of 3 to 7
per 1000 resident-care days in the more rigorous studies (149, 152-154).
LCTFs are different from other healthcare settings in that elderly patients at
increased risk for infection are brought together in one setting and remain in the facility for
extended periods of time; for most “residents,” it is their home. An atmosphere of
“community” is fostered and residents share common eating and living areas and participate
in various facility-sponsored activities. Able residents interact freely with each other.
Controlling transmission in this setting is challenging. Residents who are colonized or
infected with certain microorganisms may, in some cases, be restricted to their room
environment. Such actions, if not fully justified, may be perceived as infringing on patient
rights and quality of care.
Risk factors for infection abound in LTCF residents (149). Age-related declines in
immunity may affect responses to immunizations for influenza and other infectious agents or
increase susceptibility to tuberculosis. Immobility, incontinence, dysphagia and age-related
skin changes increase susceptibility to urinary, respiratory and cutaneous and soft tissue
infections while malnutrition impairs wound healing. Medications that affect level of
consciousness, immune function, and gastric acid secretions, and normal flora heighten
susceptibility to infection. Antibiotic therapy, invasive devices, and feeding tubes also
contribute to infection risks in LTCF residents. Finally, total dependence on healthcare
27
personnel for activities of daily living has been identified as an independent risk factor for
colonization with MRSA (155-157) and ESBL-producing K. pneumoniae (158). Several
position papers have been published that provide guidance on various aspects of infection
control and antimicrobial resistance in LTCFs (159-165).
Because residents of LTCFs are hospitalized frequently, they can serve as conduits
for transmission of infectious agents between the healthcare facilities in which they receive
care (166-168). Pediatric chronic care facilities also were the source of imported
colonization with extended -spectrum cephalosporin-resistant Gram-negative bacilli in one
PICU (169, 170). Children from child care centers (171, 172) and pediatric rehabilitation
units (173) may also contribute to the reservoir of community-onset MRSA infections in
pediatrics (174-178).
I.D.2.b. Ambulatory Care. In the past decade, healthcare delivery in the United States has
shifted from the acute, inpatient hospital to a variety of ambulatory and community-based
settings, including the home. Ambulatory care is provided in hospital-based outpatient
clinics, nonhospital-based clinics and physician offices, public health clinics, free-standing
dialysis centers, ambulatory surgical centers, urgent care centers, and many others. In
2000, there were 83 million visits to hospital outpatient clinics (179) and more than 823
million visits to physician offices (180). A characteristic of these settings that presents
unique challenges for adapting transmission prevention guidelines is that care is often
episodic, patients remain in common areas for prolonged periods of time waiting to be seen
by a healthcare provider or awaiting admission to the hospital, examination or treatment
rooms are turned around quickly with minimal cleaning, and infectious patients may not be
recognized immediately. Furthermore, immunocompromised patients often receive
chemotherapy in infusion rooms where they are maintained for extended periods of time
among other patients receiving similar treatment.
There are few data on the risk of HAIs in ambulatory care settings, with the exception
of hemodialysis centers (10, 181, 182). However, infections are transmitted in these settings
and one review noted 53 outbreaks or clusters of infections (183). Twenty-nine of the
episodes were related to a common source exposure, usually a contaminated medical
device, multi-dose vial, or solution. Fourteen reports involved person-to-person
transmission, and 10 were due to airborne or droplet transmission. Several reports have
28
involved transmission of bloodborne pathogens, primarily hepatitis B and C viruses from
healthcare personnel to patients. Others have reported similar findings (184, 185).
Transmission of hepatitis B and C viruses among patients continues to occur in these
settings due to failure to adhere to recommended practices (186).
M.tuberculosis is the most frequently reported airborne infection transmitted in
ambulatory settings (183, 185); measles virus also has been transmitted in physician offices
and outpatient settings in an era when immunization rates were low and measles outbreaks
were occurring regularly (43, 185, 187). Of interest, there are no published reports of
outbreaks of varicella in the outpatient setting. Droplet transmission of rubella and Herpes
simplex viruses from HCWs has caused outbreaks in ambulatory settings, and adenovirus
type 8 epidemic keratoconjunctivitis has been reported as a result of HCW-to-patient
transmission or via incompletely disinfected medical equipment used by ophthalmologists
(9, 183, 185).
Screening for potentially infectious symptomatic and asymptomatic individuals,
especially those who may be at risk for transmitting airborne infectious agents, e.g. M.
tuberculosis, varicella virus, rubeola (measles), is critical during the initial patient encounter.
When identified, prompt separation of potentially infectious patients and implementation of
respiratory hygiene/cough etiquette precautions and appropriate isolation precautions based
on the suspected infection decreases transmission risks (11).
I.D.2.c. Home Care. Home care in the United States is delivered by over 20,000 provider
agencies that include home health agencies, home care aide organizations, hospices, home
health pharmacies and providers of medical equipment for use in the home. Home care is
provided to patients of all ages with both acute and chronic conditions. The scope of
services ranges from assistance with activities of daily living and physical and occupational
therapy to the care of postoperative wounds, infusion therapy, and chronic ambulatory
peritoneal dialysis (CAPD).
The incidence of infection in home care patients, other than those associated with
infusion therapy (188-193), is not well studied. Data collection and calculation of infection
rates have been accomplished for central venous catheter-associated bloodstream
infections in patients receiving home infusion therapy (192) and for the risk of blood contact
through percutaneous or mucosal exposures (194), suggesting that, while difficult,
29
surveillance can be performed in this setting. However, transmission risks during home care
are presumed to be minimal. The main transmission risks to home care patients are from an
infectious healthcare provider or contaminated equipment; providers also can become
exposed to an infectious patient during home visits. Since home care interactions usually
involve a limited number of home care staff who are not concurrently interacting with other
patients, the potential reservoir of pathogens from other patients in the same setting is
eliminated.
Infection risks to home care providers that could pose a risk to other home care
patients if the provider becomes infected include infections transmitted by the airborne or
droplet routes (e.g., chickenpox, tuberculosis, influenza) and skin infestations (e.g., scabies,
lice, impetigo) occurring in home care patients or family members. There are no published
data on indirect transmission of MDROs from one home care patient to another, although
this is theoretically possible if equipment is used by and transported from an infected or
colonized patient to a non-colonized or infected patient. Investigation of the first case of
VISA in homecare (61) and the first 2 reported cases of VRSA (63, 64, 66) found no
evidence of transmission of VISA or VRSA to contacts in the home setting.
Although most home care agencies have implemented policies and procedures to
prevent transmission of organisms, the current approach is based on the adaptation of the
1996 Guideline for Isolation Precautions in Hospitals (1) as well as other recommendations
to prevent transmission of MDROs (195). This issue has been very challenging in the home
care industry and practice has been inconsistent and frequently not evidence-based. For
example, many home health agencies continue to observe “nursing bag technique,” a
practice that prescribes the use of barriers between the nursing bag and environmental
surfaces in the home (196). While the home environment may not always appear clean, the
use of barriers between two non-critical surfaces is not supported scientifically.
I.D.2.d. Other sites of healthcare delivery. Facilities that are not primarily healthcare
settings, but in which healthcare is delivered, include correctional facilities and shelters.
Both of these settings are often crowded and poorly ventilated. Many economically
disadvantaged individuals with healthcare problems related to alcoholism, injection drug
use, poor nutrition, and inadequate shelter are housed under these suboptimal conditions
and receive their primary healthcare at these sites. Also, there is a conspicuous absence of
30
hand hygiene materials. A high index of suspicion for tuberculosis and MRSA in these
populations is needed, as outbreaks in these settings have been reported (197-200).
Residence in these types of facilities provides an opportunity to deliver recommended
immunizations and screen for M. tuberculosis infection in addition to diagnosing and treating
acute illnesses. Infection control measures in areas designated for healthcare are the same
as for other ambulatory care settings and these areas must be equipped to observe
Standard and Expanded Precautions as recommended for ambulatory clinics (201).
I.E. Transmission risks associated with special patient populations
As new treatments emerge for complicated diseases, unique infection control
challenges associated with special patient populations receiving these treatments are
identified. Important lessons may be learned from studying the epidemiology and prevention
of infection in these populations.
I.E.1. Immunocompromised patients. Patients who have congenital primary immune
deficiencies or acquired disease- or treatment-induced immune deficiencies are at
increased risk for numerous types of infections while receiving healthcare. The specific
defects of the immune system determine the types of infections that are most likely to be
acquired (e.g., viral infections are associated with T-cell defects and fungal and bacterial
infections occur in patients who are neutropenic). As a general group, immunocompromised
patients can be cared for in the same environment as other patients; however, it is always
advisable to minimize exposure to other patients with highly transmissible infections such as
influenza and other respiratory viruses or easily transmitted bacteria. Application of
transmission prevention guidelines to this population needs to address two aspects of
patient placement: 1) determining when to avoid placing other patients in the same room
with an immunocompromised patient and 2) when to place immunocompromised patients in
a PE to minimize the patient’s risk of acquiring environmental fungal infections. Other
patients with active infections, especially viral respiratory tract infections (202), or patients
colonized with MDROs pose a risk to immunocompromised patients if they are in the same
room. Published data provide evidence to support environmental protection for allogeneic
HSCT patients (13, 203). Three other published guidelines address the special
requirements of immunocompromised patients, including use of antimicrobial prophylaxis
and engineering controls to create a PE for the prevention of infections caused by
31
Aspergillus spp. and other environmental fungi (4, 8, 13). As more intense chemotherapy
regimens associated with prolonged periods of graft versus host disease are implemented,
the period of risk and duration of environmental protection may need to be prolonged
beyond the traditional 100 days.
I.E.2. Cystic fibrosis patients. Patients with cystic fibrosis (CF) require special
consideration when developing infection control guidelines. In addition to the usual
pathogens that are a threat to all patients and healthcare personnel (e.g., MRSA and
respiratory viruses), CF patients require additional protection to prevent transmission from
contaminated respiratory therapy equipment (204-208) as well as patient-to-patient
transmission of infectious agents that have unique clinical and prognostic significance for
CF patients (e.g., Burkholderia cepacia complex and P. aeruginosa (209)). B. cepacia
infection has been associated with increased morbidity and mortality in CF patients (210,
211) while delayed acquisition of chronic P.aeruginosa infection may be associated with an
improved long-term clinical outcome in CF patients (212). B. cepacia complex and P.
aeruginosa may be transmitted by direct contact with patients and their secretions, by
contact with a contaminated environment, and by the droplet route; the natural environment
(e.g. soil or water) is an unlikely source of B. cepacia for CF patients.
Person-to-person transmission of B. cepacia complex has been demonstrated among
children (211) and adults (213) with CF in healthcare settings and during various social
contacts (214), most notably attendance at camps for patients with CF (215), and among
siblings with CF (216). Successful infection control measures used to prevent transmission
of these infections include containment of respiratory secretions (e.g., by observing
respiratory hygiene/cough etiquette), segregation of CF patients from each other in
ambulatory and hospital settings (including use of private rooms with separate showers),
environmental decontamination of surfaces and equipment contaminated with respiratory
secretions, elimination of group chest physiotherapy sessions, and disbanding of CF camps
(217-220). The Cystic Fibrosis Foundation published a consensus document with evidencebased recommendations for infection control practices for CF patients (221). It is important
to note that B. cepacia has also been implicated in many outbreaks and pseudo-outbreaks
of HAI associated with contamination of antiseptics, distilled water, and respiratory therapy
equipment that are unrelated to cystic fibrosis patients (221, 222).
32
I.F. New therapies associated with potentially transmissible infectious agents
I.F.1. Gene therapy. Gene therapy has progressed at a brisk rate within the last several
years. As of May 2000, 425 gene therapy protocols had enrolled 3,476 patients worldwide
(223). These trials use a number of different viral vectors, including nonreplicating
retroviruses, adenoviruses, adeno-associated viruses, and replication-competent strains of
poxviruses. Monitoring for unexpected adverse events has been incorporated into all gene
therapy protocols.
The infectious hazards of gene therapy are theoretical at this time, but require
meticulous surveillance due to the possibile occurrence of in vivo recombination and the
subsequent emergence of a transmissible genetically altered “superbug.” Greatest concern
attends the use of replication-competent viruses, especially vaccinia. As of the time of
publication of this guideline, no reports have described transmission of a vector virus from
the recipient to another individual, but surveillance is ongoing. Rigorous protocols and
recommendations to monitor infection control issues throughout the course of gene therapy
trials have been published (223-225).
I.F.2. Xenotransplantation and tissue allografts. The potential hazards of
xenotransplantation and human tissue allografts have become an infection control concern
within the last decade. Reported infections arising from transplanted allografts of human
origin include cytomegalovirus infection, Creutzfeldt-Jacob disease, hepatitis C virus,
Clostridium spp., group A streptococcus (226, 227). The transplantation of nonhuman cells,
tissues, and organs into man potentially expose patients to infectious agents of animal
origin. Transmission of known zoonotic infections, (e.g., trichinosis from porcine tissue),
constitutes one concern, but of greater concern is the possibility that transplantation of
nonhuman cells, tissues, and organs may transmit previously unknown zoonotic infections
(xenozoonoses) to immunosuppressed human recipients. Potential infections that might
accompany transplantation of porcine organs have been described (228). Recently
published guidelines from the U.S. Public Health Service address the many infectious
diseases and infection control issues that surround the developing field of
xenotransplantation (229); work in this area is ongoing.
33
I.G. Healthcare system components that influence the effectiveness of precautions to
prevent transmission
Three interdependent factors, institutional climate, individual worker behavior, and
the work environment may affect the transmission of infectious agents during patient care.
Improvements in nurse staffing levels and monitoring of healthcare personnel adherence to
recommended infection control practices can be incorporated into the organization’s patient
safety goals (230-233)
I.G.1. Safety Culture and Organizational Characteristics. Safety culture (or “safety
climate”) refers to a work environment where a shared commitment to safety on the part of
management and the workforce is understood and followed (234, 235)
(www.patientsafety/vision.html). The authors of the recent Institute of Medicine Report, To
Err is Human (230), acknowledge that causes of medical error are multifaceted but
emphasize repeatedly the pivotal roles of system failures and a safety culture. A safety
culture is created through 1) the actions management takes to improve patient and worker
safety; 2) worker participation in safety planning; 3) the availability of appropriate protective
equipment; 4) influence of group norms regarding acceptable safety practices; and 5) the
organization’s socialization process for new personnel. Safety and patient outcomes can be
enhanced by improving organizational characteristics within patient care units as
demonstrated by studies of surgical ICUs (236, 237). Each of these perception factors has a
direct bearing on the application of and adherence to transmission prevention
recommendations. Measurements of an institutional culture of safety is useful for designing
improvements in healthcare (238). One hospital-based study linked measures of safety
culture with both employee adherence to safe practices and reduced exposures to blood
and body fluids (239) and another study of hand hygiene practices concluded that improved
adherence requires integration of infection control into the organization’s safety culture
(240).
I.G.2. Nurse staffing. There is increasing evidence that levels of nurse staffing influence
the quality of patient care (241, 242). If there is adequate nursing staff, it is more likely that
infection control practices, including hand hygiene and Standard and Expanded
Precautions, will be given appropriate attention and be applied correctly and consistently
(243). A national multicenter study reported recently strong and consistent inverse
34
relationships between nurse staffing variables and five outcomes in medical patients, two of
which were HAIs: urinary tract infections and pneumonia (241). The association of nursing
staff shortages with increased rates of HAIs also has been demonstrated in several
outbreaks in hospitals and long term care settings (244-258). In two studies (254, 258), the
composition of the nursing staff (“pool” or “float” vs. regular staff nurses) influenced the rate
of primary bloodstream infections with an increased infection rate occurring when the
proportion of pool nurses increased. In most cases, when staffing improved as part of a
comprehensive control intervention, the outbreak ended or the HAI rate declined.
1.G.3. Adherence of healthcare personnel to recommended guidelines. Adherence to
recommended infection control practices decreases disease transmission (259, 260).
Several observational studies of healthcare personnel adherence to recommended
practices have been published (6, 260-277). Observed adherence to universal precautions
ranged from 43% to 89% (261, 262, 269, 271, 272). However, the degree of adherence
depended frequently on the barrier that was assessed and, for gloves, the circumstance in
which they were used. Appropriate glove use overall has ranged from a low of 15% (265) to
a high of 82% (270) while 92% and 98% adherence has been reported during arterial blood
gas collection and resuscitation, respectively, procedures where there may be considerable
blood contact (263, 276). Differences in observed adherence have been reported among
occupational groups in the same healthcare facility (261) and between experienced and
nonexperienced professionals (265). In surveys of healthcare personnel, self-reported
adherence was generally higher than that reported in observational studies. Furthermore,
where an observational component was included with a self-reported survey, self-perceived
adherence was often greater than observed adherence (277). Among nurses and
physicians, years of experience is a negative predictor of adherence (265, 271). Education
to improve adherence is the primary intervention that has been studied. While positive
changes in knowledge and attitude have been demonstrated, (260, 278) there often has
been limited or no accompanying change in behavior (262, 264). Self-reported adherence is
higher in groups that have received an educational intervention (279, 280). Educational
interventions that incorporated videotaping and performance feedback were successful in
improving adherence (274). The use of videotape also served to identify system problems
35
(e.g., communication, access to personal protective equipment) that otherwise may not
have been understood.
Improving adherence to infection control practices requires a multifaceted approach
that incorporates continuous assessment of both the individual and the work environment
(6, 240). Using several behavioral theories, Kretzer and Larson (281) concluded that a
single intervention (e.g., a handwashing campaign or putting up new posters about
transmission precautions) would likely be ineffective in improving healthcare personnel
adherence; improvement requires that the organizational leadership make prevention an
institutional priority and integrate infection control practices into the organization’s safety
culture (240).
I.G.4. Clinical microbiology laboratory support. The critical role of the microbiology
laboratory in infection control and healthcare epidemiology has been well described (282284) and is supported by the Infectious Disease Society of America policy statement on
consolidation of clinical microbiology laboratories published in 2001(284). The clinical
laboratory contributes to preventing the transmission of infectious agents in healthcare
settings by promptly detecting and reporting epidemiologically important organisms,
identifying emerging patterns of antimicrobial resistance, and assessing the effectiveness of
recommended precautions in limiting transmission during outbreaks. Healthcare facilities
need to ensure that the recommended scope and quality of laboratory services are available
and that systems to rapidly communicate epidemiologically important results are in place.
As concerns about emerging pathogens and bioterrorism grow, the role of the clinical
laboratory takes on even greater importance. For healthcare organizations that outsource
microbiology laboratory services (e.g., ambulatory care, home care, LTCFs, smaller acute
care hospitals), it is important to specify by contract the types of services, (e.g. periodic
institution-specific aggregate susceptibility reports) needed for infection control purposes.
Several key functions of the clinical laboratory apply to this guideline:
•
Adherence to current guidelines for antimicrobial susceptibility testing and interpretive
criteria developed by the National Committee for Clinical Laboratory Standards
(NCCLS) for the detection of emerging resistance patterns(285, 286).
•
Support for performing surveillance cultures as needed to assess healthcare facility
transmission risks.
36
•
Capacity to perform on site or to outsource molecular typing to investigate and
control healthcare-associated outbreaks (287).
•
Capacity to employ rapid diagnostic testing techniques in situations where there is an
immediate need for clinical information for decisions regarding patient treatment,
room placement, and implementation of control measures including barrier
precautions and use of vaccine or chemoprophylaxis agents (e.g., influenza (8, 288,
289), B. pertussis (290), respiratory syncytial virus (RSV) (291, 292), and enterovirus
(293)). At the same time, the microbiologist provides guidance in limiting rapid testing
to those clinical situations in which test results influence early patient management
decisions and oversight of point-of-care testing performed by non-laboratory
healthcare workers (294).
•
A quality control program that ensures appropriate testing services for the population
served and stringent evaluation of new products for sensitivity, specificity,
applicability, and feasibility. With an understanding of testing availability, limitations,
and proper specimen collection, the clinical team can utilize the microbiology
laboratory resources more efficiently.
•
A collaborative effort by microbiology, pharmacy, infection control, and infectious
diseases representatives to develop and maintain an effective institutional program
for the judicious use of antimicrobial agents.
Part II. Fundamental elements to prevent transmission of infectious agents in
healthcare settings
II.A. Administrative measures.
Healthcare organizations can demonstrate a commitment to preventing transmission
of infectious agents by incorporating infection control into the objectives of the
organization’s patient and occupational safety programs (230-232, 295). An infrastructure to
guide, support, and monitor adherence to Standard and Expanded Precautions (162, 296,
297) will help carry out the organization’s mission. Policies and procedures that explain how
Standard and Expanded Precautions will be applied, including systems used to identify and
37
communicate information about patients with potentially transmissible infectious agents are
essential to ensure the success of these measures.
Key administrative measures include adherence monitoring, assessment and
correction of system failures that contribute to transmission, and providing feedback to
healthcare personnel and senior administrators. The positive influence of institutional
leadership has been demonstrated repeatedly in studies of HCW adherence to
recommended hand hygiene practices (6, 52, 53, 240, 296-301). Thus, healthcare
administrator involvement in infection control processes can improve understanding of the
rationale and resource requirements for following recommended infection control practices.
II.B. Education of HCWs, patients, and families
Education and training of healthcare personnel are a prerequisite for ensuring that
policies and procedures for Standard (e.g., hand hygiene, use of gowns and gloves, etc.)
and Expanded Precautions are understood and practiced. An explanation of the scientific
rationale for the precautions will assist HCWs to apply the procedures as well as inform
necessary judgments to safely modify precautions based on changing requirements,
resources, or adaptation in a different healthcare setting (275, 302-306).
Education on the principles and practices for preventing transmission of infectious
agents during healthcare begins ideally during training in the health professions and is
provided to anyone who has an opportunity for contact with patients or medical equipment
(e.g., nursing and medical staff, therapists, and technicians, including respiratory, physical,
and occupational, radiology and cardiology technicians; phlebotomists; housekeeping and
maintenance staff; and students). In health care facilities, education and training on
Standard and Expanded Precautions are typically provided at the time of orientation and
repeated as necessary to maintain competency; updated education and training are
necessary when policies and procedures are revised or when there is a special
circumstance, such as an outbreak that requires modification of current practice or
publication of new recommendations. Education and training materials appropriate to the
HCW’s level of responsibility and individual learning level and language needs improve
understanding (6, 307-311). Periodic assessment of the HCWs knowledge and adherence
to recommended practices with feedback is another important component of all educational
programs (6, 299, 312-314).
38
Patients and family members can be partners in preventing transmission of infections
in healthcare settings. Information about Standard Precautions, especially hand hygiene
and respiratory hygiene/cough etiquette, and other routine infection prevention strategies
may be incorporated into patient information materials that are provided upon admission to
the healthcare facility. Additional information about Expanded Precautions is best provided
at the time they are initiated. Fact sheets, pamphlets, and other printed material may include
information on the rationale for the additional precautions, risks to family members and
visitors, room assignment for Expanded Precautions purposes, explanation about the use of
personal protective equipment by HCWs and visitors, and directions for use of such attire by
family members and visitors. Such information may be particularly helpful in the home
environment where family members often have primary responsibility for adherence to
recommended infection control practices for preventing transmission. Healthcare personnel
must be available and prepared to explain this material and answer questions as needed.
II.C. Hand hygiene
Hand hygiene is the single most important practice to reduce the transmission of
infectious agents in healthcare settings (6) and is an essential element of Standard
Precautions. The term “hand hygiene” includes both handwashing with either plain or
antiseptic-containing soap and water and use of alcohol-based products (gels, rinses,
foams) containing an emollient that do not require the use of water. In the absence of visible
soiling of hands, approved alcohol-based products for hand disinfection are preferred over
antimicrobial or plain soap and water because of their superior microbiocidal activity,
reduced drying of the skin, and convenience (6). Improved hand hygiene practices have
been associated with a sustained decrease in the incidence of MRSA and VRE infections in
the ICU (240, 299, 315-318). The scientific rationale, indications, methods, and products for
hand hygiene are summarized in other publications (6, 318).
The quality of performing hand hygiene can be affected by the type and length of
fingernails and wearing jewelry. Artificial fingernails and extenders are discouraged for
healthcare personnel who have contact with high-risk patients (e.g., those in the ICU, OR, or
NICU) due to their association with outbreaks of gram-negative bacillus and candidal
infections (319-323). Whether there is a need to restrict the wearing of artificial fingernails
by all healthcare personnel who provide direct patient care or by healthcare personnel who
39
have contact with other high risk groups (e.g., oncology or cystic fibrosis patients) (221), has
not been determined. At this time such decisions are at the discretion of an individual
facility’s infection control department. There is less evidence that jewelry affects the quality
of hand hygiene practices. Although hand contamination with potential healthcareassociated pathogens is increased with ring-wearing (6, 324), no studies have related this
practice to HCW-to-patient or patient-to-patient transmission of pathogens.
II.D Personal protective equipment (PPE)
PPE refers to a variety of barriers and respirators used alone or in combination to
protect mucous membranes, skin, and clothing from contact with infectious agents. The
selection of PPE is based on the nature of the patient interaction and/or the likely mode(s)
of transmission. Guidance on the use of PPE should is discussed in Section III. A suggested
procedure for donning and removing PPE that will prevent skin or clothing contamination is
presented in the Figure. The following sections highlight the primary uses and methods for
selecting this equipment.
II.D.1. Gloves. Gloves prevent contamination of healthcare personnel hands when direct
contact with blood or body fluids, mucous membranes, and nonintact skin is anticipated;
when having direct contact with patients; and when handling or touching visibly or
potentially contaminated patient care equipment and environmental surfaces (6). Gloves
protect both patients and healthcare personnel from exposure to infectious agents that may
be carried on the hands of HCWs (6, 325, 326). Although gloves may reduce the volume of
blood on the external surface of a sharp by 46-86% (327), the residual blood in the lumen of
a hollowbore needle would not be affected; therefore, the effect on transmission risk is
unknown.
Nonsterile disposable gloves made of a variety of materials (e.g., latex, vinyl, nitrile)
may be used for routine patient care (328). A single pair of gloves generally provides
adequate barrier protection. Nonlatex gloves are required for healthcare personnel who are
sensitive to latex and/or who are caring for patients with latex hypersensitivity (9, 329, 330).
Gloves that fit the healthcare personnel hands and are appropriate for the task to be
performed are preferred. For example, gloves that fit loosely around the wrist may be
appropriate for patient care activities that involve limited touching of a contaminated body
site. However, gloves that fit snugly are needed when a large amount of blood or body
40
fluids is present, or the procedure requires greater dexterity or tactile sensitivity. Heavier,
reusable utility gloves are indicated for non-patient care activities, e.g., handling or cleaning
contaminated equipment or surfaces (4, 8, 313).
During patient care, opportunities for spreading contamination, and therefore
increasing opportunities for transmission, can be reduced by adhering to the principles of
working from “clean” to “dirty” and confining or limiting contamination to surfaces that are
directly needed for patient care. It may be necessary to change gloves during the care of a
single patient to prevent cross-contamination of body sites, especially if an MDRO is present
(2, 6). Discarding gloves between patients further reduces opportunities for transmission.
Gloves must not be washed for subsequent reuse because microorganisms cannot be
removed reliably from glove surfaces and continued glove integrity cannot be ensured.
Furthermore, glove reuse has been associated with transmission of MRSA and gramnegative bacilli (331-334).
When gloves are worn in combination with other PPE, they are put on last. Gloves
that fit snugly around the wrist are preferred for use with an isolation gown because they will
cover the gown cuff and provide a more reliable continuous barrier for the arms, wrists, and
hands. Gloves that are removed properly will prevent hand contamination (Figure). Hand
hygiene following glove removal futher ensures that the hands will not carry potentially
infectious agents that could penetrate through micro-tears (6, 326, 331). Procedures for
PPE use specify removal and disposal of gloves before removing other PPE.
II.D.2. Isolation gowns and other protective apparel. Isolation gowns and other protective
apparel (e.g., aprons) are used to protect the HCW’s arms and exposed body areas and
prevent contamination of clothing from blood and body fluid contact and from contamination
with transmissible infectious agents (e.g., RSV, MDROs, C. difficile) (18, 335-338)
(www.cdc.gov/ncidod/sars), as specified by Standard and Expanded Precautions. Selection
of protective apparel is based on the nature of the patient interaction and the anticipated
degree of body contact with infectious material and level of needed protection from fluid
penetration. The wearing of gowns and other protective apparel as PPE to reduce the risk of
exposure to bloodborne pathogens is mandated by the OSHA Bloodborne Pathogens
Standard (313). Clinical and laboratory coats or jackets worn over personal clothing are not
considered PPE.
41
In most instances, gowns are worn only if contact with blood and body fluid is likely.
However, when Contact Precautions are used to prevent transmission of an MDRO,
donning of both gown and gloves prior to room entry, regardless of the anticipated level of
contact, may reduce unanticipated contact with an MDRO in the environment. The practice
of routine gowning upon entrance into an intensive care or other high-risk area does not
prevent colonization or infection of patients (140, 339-342). Therefore, CDC
recommendations for this practice have been rescinded (13).
Isolation gowns are always worn in combination with gloves, and with other PPE
when indicated. Gowns are usually the first piece of PPE to be donned. Full coverage of the
upper and lower torso (mid-thigh to the knees) and arms will ensure clothing and exposed
upper body areas are covered. Most isolation gowns are affixed (e.g., tied, taped) at the
back of the neck and waist. Regardless of gown type, there should be a contiguous barrier
over the front torso and arms. Several gown sizes may be needed in a healthcare facility. If
a single gown does not fit a given individual, two gowns may be needed; the first to cover
the back and the second, worn over the first, to cover the front of the body. Removal of
isolation gowns before leaving the patient care area is advised to prevent opportunities for
possible contamination outside the patient’s room. Isolation gowns can be removed in a
manner that prevents contamination of clothing or skin. When the outer, “contaminated” side
of the gown is turned inward and rolled into a ball, and then discarded into a designated
container for waste or linen, contamination is contained (Figure).
II.D.3. Mouth, nose, eye, and face protection. The mucous membranes of the mouth,
nose, and eyes are particularly vulnerable to infection as is facial skin if skin integrity is
compromised (e.g. by acne, dermatitis). Therefore, face protection is an important
component of Standard Precautions. Masks are used as PPE for healthcare personnel as
part of Standard and Droplet Precautions, and for prevention of transmission of infectious
agents from the HCW to the patient when performing a procedure that requires sterile
technique (309). A mask placed on a coughing patient with a respiratory infection for source
containment decreases the quantity of infectious droplets transmitted from the respiratory
tract to the surrounding environment (343-345). Masks protect mucosal surfaces against
large droplets and splashes or sprays and should not be confused with particulate
42
respirators that are recommended for protection from small particles (< 5 µm)
containing infectious agents transmitted via the airborne route as described below.
Various types of masks, goggles, and face shields are available for use alone or in
combination to provide barrier protection. The selection of PPE for face, nose and/or eye
protection is determined by the nature of the patient interaction and the extent of blood and
body fluid contact from spray and splatter that can be anticipated. Procedures that generate
splashes or sprays of blood, body fluids, secretions, or excretions (e.g., endotracheal
suctioning, bronchoscopy) generally require either a face shield or mask and goggles (30,
36, 39, 40, 313) (www.cdc.gov/ncidod/sars). The wearing of masks, eye protection, and face
shields in specified circumstances when exposures are likely to occur is mandated by the
OSHA Bloodborne Pathogens Standard (313).
Two mask types are available for use in healthcare settings: surgical masks that are
regulated by the FDA and required to have fluid-resistant properties, and procedure or
isolation masks (www.fda.gov/cdrh/ode/guidance/094.html#4). Masks come in various
shapes (e.g., molded and non-molded), sizes, filtration efficiency, and method of attachment
(e.g., ties, elastic, ear loops). Healthcare facilities may find that several different types of
PPE are needed to best meet healthcare personnel needs; fit, comfort, and durability for the
purpose they will be used are important criteria for mask selection. There are no data to
suggest that any one mask provides better protection than another.
Removal of a face shield, goggles, and mask can be performed safely after the
gloves have been removed. The pieces of this equipment that are considered “clean” , and
therefore safe to touch with the bare hands, are the ties, ear pieces, or headband; the front
of a mask, goggles and face shield are considered contaminated (Figure). Designated
containers for disposable and reusable equipment need to be placed in a location
convenient to the site of removal. Hand hygiene is performed as the final step of PPE
removal.
II.D.4. Respiratory protection. PPE for respiratory protection is intended to prevent
inhalation of respirable particles that can cause harm. The term “respiratory protection” has
a regulatory context that includes components of a program required by OSHA to protect
workers in all employment settings from inhalation of toxic materials. OSHA program
components include medical clearance to wear a respirator, provision and use of
43
appropriate NIOSH-approved fit-tested and fit-checked respirators, and education on
respirator use. In selecting respirators, models shown to have inherently good fitting
characteristics (i.e., expected to provide protection factors of 10 or more to 95% of wearers)
are preferred (346). Information on various types of respirators may be found at
www.cdc.gov/niosh/npptl/respirators/respsars.html and in published studies (346-348).
Respiratory protection (i.e., use of a NIOSH-approved N-95 or higher level respirator)
is required to prevent healthcare personnel exposure to M. tuberculosis (11). Although there
is limited information on the efficacy of respirators or masks in preventing transmission,
particulate respirators have been shown to have greater filtration efficiency and better facial
fit qualities than surgical masks (349). Also, the incremental benefit of respirators, in
addition to administrative and engineering controls, for preventing transmission of airborne
infectious agents has not been assessed. Some studies have shown control of tuberculosis
transmission in hospitals that used surgical masks rather than respirators in conjunction with
other administrative and engineering controls (350-352), but respirators now are required by
OSHA for protection of healthcare personnel from tuberculosis (11).
Respiratory protection is recommended for other diseases that could be transmitted
through the airborne route, including SARS (www.cdc.gov/ncidod/sars), smallpox (45), and
hemorrhagic fevers (47). Although AII and PPE for mouth and nose protection are
recommended for protection from measles and chickenpox, there are no data upon which to
base a recommendation for surgical masks or respirators for protection against these two
infections. However, for purposes of consistency and simplicity, some facilities require the
use of respirators for entry into all AII rooms, regardless of the specific infectious agent.
Removal of respirators outside an AII room, in an anteroom, or just outside the door is
advised to limit opportunities for exposure to airborne contaminants. Procedures for safe
removal, touching only the “clean” elastic are provided (Figure). In some healthcare settings,
particulate respirators used to provide care for patients with tuberculosis in AII are reused by
the same HCW. This is an acceptable practice providing the respirator is not damaged or
soiled, and the fit is not compromised by change in shape. Reuse of respirators that are
likely to have been contaminated with blood or respiratory secretions is not advised.
44
II.E. Safe work practices to prevent HCW exposure to bloodborne pathogens
II.E.1. Prevention of needlesticks and other sharps-related injuries. Injuries due to
needles and other sharps have been associated with transmission of HBV, HCV and HIV to
HCWs (353, 354). Therefore, included in Standard Precautions are measures to handle
needles and other sharp devices in a manner that will prevent injury to the user and to
others who may encounter the device during or after a procedure. Additional guidance on a
sharps injury prevention program may be found at www.cdc.gov/sharpssafety/.
II.E.2. Prevention of mucous membrane contact. Use of safe work practices to protect
mucous membranes whether or not PPE is used will help protect from exposure to a variety
of pathogens. Keeping gloved and ungloved hands that are contaminated from touching the
mouth, nose, eyes, and/or face will prevent exposing healthcare personnel to various
pathogens. Careful placement of PPE before patient contact will help avoid the need to
make adjustments during use.
Mouthpieces, pocket resuscitation masks with one-way valves, and other ventilation
devices are an alternative to mouth-to-mouth resuscitation methods in areas where
resuscitation is predictable and will avoid exposing the nose and mouth to oral and
respiratory fluids during such procedures.
II.F. Patient placement
II.F.1. Hospitals and long-term care settings. There are many competing priorities when
determining the appropriate room placement for patients (e.g., reason for admission;
patient characteristics, such as age, gender, mental status; staffing needs; family requests;
psychosocial factors; reimbursement concerns). In the absence of obvious infectious
diseases that require specified isolation rooms (e.g., tuberculosis, SARS, chickenpox), the
risk of transmission of infectious agents is often overlooked. However, appropriate patient
placement is an important Standard and Expanded Precautions infection control strategy.
From an infection control perspective, it would be preferable to have only singlepatient rooms in healthcare facilities. However, this rarely occurs. When there are only a
limited number of single-patient rooms, they will need to be prioritized for those patients who
have conditions that facilitate transmission of infectious agents to other patients (e.g.,
draining wounds, stool incontinence, uncontained secretions) and for those who are at
increased risk of acquisition and adverse outcomes resulting from HAI (e.g.,
45
immunosuppression, open wounds, indwelling catheters, anticipated prolonged length of
stay, total dependence on HCWs for activities of daily living) (13, 18, 146, 158, 355, 356).
Single-patient rooms are always indicated for patients placed in AII and in a
Protective Environment. For patients who require Contact or Droplet Precautions, single
patient rooms are preferred (18, 32, 163, 357, 358). During a suspected or proven outbreak
caused by a pathogen whose reservoir is the gastrointestinal tract, use of single patient
rooms with private bathrooms limits opportunities for transmission, especially when the
colonized or infected patient has poor personal hygiene habits, fecal incontinence, or cannot
be expected to assist in maintaining procedures that prevent transmission of
microorganisms (e.g., infants, children, and patients with altered mental status or
developmental delay). In the absence of continued transmission or when single-patient
rooms are not available, it is not necessary to provide a private bathroom for patients
colonized or infected with enteric pathogens as long as personal hygiene practices and
Standard Precautions are maintained. Results of several studies to determine the benefit of
a single-patient room to prevent transmission of Clostridium difficile are inconclusive (359).
However, for children, the risk of healthcare-associated diarrhea was increased with the
increased number of patients per room (360). Thus, patient factors are important
determinants of infection transmission risks and the need for a single-patient room and/or
private bathroom for any patient is best determined on a case-by-case basis.
Cohorting is the practice of grouping patients with the same infection or colonization
with the same MDRO together to confine their care to one area and prevent contact with
other patients. This is not a primary prevention strategy due to the logistical difficulties
encountered and the frequent lack of microbiologic data to determine infection or
colonization status, especially in LTCFs. Cohorts are created based on clinical diagnosis,
microbiologic confirmation when available, epidemiology, and mode of transmission of the
infectious agent. Criteria for including a patient in a cohort include 1) the patient is not
infected with other potentially transmissible microorganisms; 2) the likelihood of reinfection
with the same organism is minimal; and 3) the patient is not severely immunocompromised.
Assigning or cohorting healthcare personnel to care only for patients infected or colonized
with a single target pathogen limits further transmission of infectious agents to uninfected
46
patients (361) but is difficult to achieve in the face of current staffing shortages in hospitals
(241) and in non-hospital healthcare sites (www.cdc.gov/nciod/hip/Aresist/aresist.htm).
During the seasons when RSV, influenza, other respiratory viruses, and rotavirus are
circulating in the community, cohorting based on the presenting clinical syndrome is often a
priority in facilities that care for infants and young children (362). For example, during the
respiratory virus season, infants may be cohorted based soley on the clinical diagnosis of
bronchiolitis due to the logistical difficulties and costs associated with requiring microbiologic
confirmation prior to room placement, and the predominance of RSV during most of the
season. The inability of infants and children to contain body fluids plus the close physical
contact that occurs during routine care increases infection transmission risks for this
population considerably (18, 356).
II.F.2. Ambulatory settings. Patients actively infected with or incubating transmissible
infectious diseases are seen frequently in ambulatory settings (e.g., outpatient clinics,
physicians’ offices, emergency departments) and potentially expose healthcare personnel
and other patients, family members and visitors (37, 44, 112, 187, 363). In response to the
global SARS outbreak of 2003 and in preparation for pandemic influenza, outpatient
settings are being urged to implement source containment measures to prevent
transmission of agents causing respiratory infections, beginning at the point of initial patient
encounter (www.cdc.gov/ncidod/sars) as described below in section III.A.1. Signs posted at
the entrance to facilities or at the reception or registration desk may request that the
receptionist promptly be informed if the patient or individuals accompanying the patient has
symptoms of a respiratory infection, e.g., cough, flu-like illness, increased production of
respiratory secretions. The presence of diarrhea, skin rash, or known exposure to a
transmissible disease (e.g., measles, pertussis, chickenpox, tuberculosis, SARS) also could
be added. Whenever possible, placement without delay in an examination room limits the
number of exposed individuals in the common waiting area.
In waiting areas, maintaining a distance between symptomatic and non-symptomatic
patients (e.g. >3 feet), in addition to source control measures, should limit most exposures.
However, infections transmitted via the airborne route (e.g., tuberculosis, measles,
chickenpox) will require additional precautions (11, 364, 365). Patients suspected of having
an airborne infection may be asked to wear a surgical mask, if tolerated, for source
47
containment and placed in an AII room as soon as possible. If this is not possible, having
the patient wear a mask and segregate him/herself from other patients in the waiting area
will reduce opportunities to expose others. HCWs should wear NIOSH-approved respirators
(N95 or higher) when entering the AII room (9, 11). The person accompanying the patient
also should be considered potentially infectious and instructed to follow the same infection
control instructions given to the patient. For example, family members accompanying
children admitted for the suspicion of tuberculosis and who have been diagnosed
subsequently with tuberculosis, frequently have been found to have unsuspected pulmonary
tuberculosis with cavitary lesions (366, 367).
Patients with underlying conditions (e.g., those who are immunocompromised (146,
368) or have cystic fibrosis (221)), require special efforts to protect them from exposures to
infected patients in common waiting areas. These patients should inform the receptionist of
their risk for infection upon arrival so that appropriate steps may be taken to further protect
them from infection. In cystic fibrosis clinics, patients have been given beepers upon
registration so that they may leave the area and receive notification to return when an
examination room becomes available in order to avoid exposure to other patients who could
be colonized with B. cepacia (369).
II.F.3. Home care. In home care, the HCW should identify high-risk persons who would
benefit from being removed from the home or who should be prohibited from visiting as long
as the patient is infectious. For example, if a patient with pulmonary tuberculosis is
contagious and being cared for at home, the removal of small children (370) or
immunocompromised persons who have not been infected may be protective. During the
SARS outbreak of 2003, segregation of infected persons during the communicable phase of
the illness was beneficial for prevention of household transmission.
II.G. Transport of patients
In the inpatient setting, the transport of patients on Expanded Precautions should be
limited to essential purposes such as diagnostic and therapeutic procedures that cannot be
performed in the patient’s room. When transport is necessary, the patient should use
appropriate barriers (e.g., mask, gown, wrapping in sheets or use of impervious dressings
when infectious skin lesions or drainage are present), consistent with the route and risk for
transmission. Healthcare personnel in the receiving area should be notified of the impending
48
arrival of the patient and of the precautions necessary to prevent transmission.
II.H. Environmental measures
As part of Standard Precautions, recommended practices for cleaning and
disinfecting non-critical surfaces in patient-care areas should be followed (4). These
procedures remain the same for patients on Expanded Precautions. Cleaning and
disinfection of all patient-care areas should especially focus on frequently touched surfaces
and those most likely to be contaminated with blood and body fluids (e.g., bedrails, bedside
tables, commodes, doorknobs, sinks, surfaces and equipment in close proximity to the
patient). The frequency or intensity of cleaning may need to change based on the patient’s
level of hygiene and the degree of environmental contamination. This may be especially
true in LTCFs where patients with stool and urine incontinence are encountered more
frequently. Also, increased frequency of cleaning may be needed in a PE to minimize dust
accumulation. Special recommendations for cleaning and disinfecting environmental
surfaces in dialysis centers have been published (10). In all healthcare settings, cleaning
and disinfection of surfaces that could be implicated in transmission should take priority in
administrative staffing and scheduling activities. During a suspected or proven outbreak, an
environmental reservoir is a consideration and routine cleaning procedures should be
reviewed and the need for proper technique re-enforced.
Healthcare facilities should select disinfectant agents that best meet their overall
needs. Consistently following the routine recommendations for the amount, dilution, and
contact time of disinfectants, rather than changing agents or procedures, will generally
suffice for cleaning of rooms of patients colonized or infected with microorganisms
associated with environmental contamination and those that are resistant to multiple classes
of antimicrobial agents (e.g., C. difficile, VRE, MRSA, MDR-GNB (4, 18, 163, 337, 338, 357,
371)). Most often, it is the failure to follow recommended procedures rather than the failure
of the procedures that contributes to the role of an environmental reservoir of pathogens
during outbreaks.
Certain infectious agents (e.g., rotavirus, C. difficile, prions) may be resistant to some
routinely used hospital disinfectants (372-375). The role of specific disinfectants in limiting
transmission of rotavirus has been demonstrated experimentally (372). Also, since C.
49
difficile may display increased levels of spore production when exposed to non-chlorinebased cleaning agents and the spores are more resistant than vegetative cells to commonly
used surface disinfectants, some investigators have recommended the use of a 1:10 dilution
of 5.25% sodium hypochlorite (household bleach) and water for routine environmental
disinfection of rooms of patients with C. difficile when there is continued transmission (7,
374). The need to change disinfectants based on the presence of these organisms should
be decided after consultation with infection control (4). For detailed recommendations for
disinfection and sterilization of surfaces and medical equipment that have been in contact
with prion-containing tissue or high risk body fluids, and for cleaning of blood and body
substance spills, consult the Guideline for Disinfection and Sterilization in Healthcare
Settings 2004 (in preparation) (7) and the Guidelines for Environmental Infection Control in
Healthcare Facilities (4).
II.I. Patient care equipment
Medical equipment must be cleaned and maintained according to the manufacturers’
instructions. Noncritical items, such as commodes, intravenous pumps, and ventilators,
must be thoroughly cleaned and disinfected prior to use on another patient. All such
equipment and devices should be handled in a manner that will prevent HCW and
environmental contact with potentially infectious material.
In all healthcare settings, patients known or suspected to be colonized or infected
with multidrug-resistant or epidemiologically important organisms requiring Expanded
Precautions should be provided with dedicated noncritical medical equipment (e.g.,
stethoscope, blood pressure cuff, electronic thermometer) (2, 15, 376). When this is not
possible, cleaning with a low-level disinfectant after use is recommended. Other guidelines
should be consulted for detailed guidance in developing specific protocols for cleaning and
reprocessing medical equipment and patient care items in both routine and special
circumstances (2, 8, 10).
In home care, durable medical equipment that is taken out of the home should be
visibly inspected prior to leaving the home. Visible soiling or contaminated material should
be removed using an appropriate cleaning/disinfectant agent (221, 313). The equipment
then should be placed in a single plastic bag for transport to the reprocessing location.
50
II.J. Textiles and laundry
Soiled textiles, including bedding, towels, and patient or resident clothing may be
contaminated with pathogenic microorganisms. However, the risk of disease transmission is
negligible if it is handled, transported, and laundered in a safe manner (4, 377, 378). Key
principles for handling soiled laundry are 1) not to shake the items or handle in any way that
may aerosolize infectious agents; 2) to avoid contact of the body and personal clothing with
the laundry; and 3) to contain it in a laundry bag or designated bin. When laundry chutes are
used, they must be maintained to minimize dispersion of aerosols from contaminated items.
The methods for handling, transporting, and laundering of soiled textiles are
determined by organizational policy and any applicable regulations; guidance is provided in
the Guidelines for Environmental Infection Control (4). Rather than rigid rules and
regulations, hygienic and common sense storage and processing of clean and soiled
textiles are recommended (4, 313) (www.jcaho.org). When laundering occurs outside of a
healthcare facility, the clean items must be packaged to prevent contamination with outside
air or construction dust that could contain infectious fungal spores that are a risk for
immunocompromised patients (4).
Institutions are required to launder garments used as personal protective equipment
and uniforms visibly soiled with blood or infective material. There are few data to determine
the safety of home laundering of HCW uniforms, but there was no increase in infection rates
in the one published study (4, 379). In the home, textiles and laundry from patients with
potentially transmissible infectious agents do not require special handling or separate
laundering, but should be washed with hot water and soap (4, 379).
II.K. Dishware and eating utensils
No special precautions are needed for dishware (e.g., dishes, glasses, cups) or
eating utensils; reusable dishware and utensils may be used for patients requiring
Expanded Precautions. The combination of hot water and detergents used in dishwashers
is sufficient to decontaminate dishware and eating utensils. In the home and other
communal settings, all individuals should be taught and encouraged not to share eating
utensils and drinking vessels as part of good personal hygiene and for the purpose of
preventing transmission of respiratory viruses, Herpes simplex virus, and agents that infect
51
the gastrointestinal tract and are transmitted by the fecal/oral route (e.g., hepatitis A virus,
noroviruses). If hot water or adequate conditions for cleaning utensils and dishes are not
available, disposable products should be used.
II.L. Adjunctive measures
Important adjunctive measures that are not considered primary components of
programs to prevent transmission of infectious agents, but that improve effectiveness of
such programs, include 1) antimicrobial management programs; 2) postexposure
chemoprophylaxis with antiviral or antibacterial agents; and 3) vaccines used both for pre
and postexposure prevention. Detailed discussion of judicious use of antimicrobial agents is
beyond the scope of this document. However, implementation of effective programs to limit
use of selected antibiotics has been shown to decrease the reservoir of MDROs for which
Contact Precautions is required in high-risk units and is one component of recommended
MDRO control measures discussed in Appendix B of this guideline (128, 380-405).
II.L.1. Chemoprophylaxis. Antimicrobial agents and topical antiseptics may be used to
prevent outbreaks of selected agents. Infectious agents for which post-exposure
chemoprophylaxis is recommended under defined conditions include: B. pertussis (9), N.
meningitidis (406), B. anthracis (407), influenza virus (408), HIV (353), and group A
streptococcus (409).
Another form of chemoprophylaxis is the use of topical antiseptic agents. Triple dye
is one of the agents used routinely on the umbilical cords of term newborns to reduce the
risk of colonization, skin infections, and omphalitis caused by S. aureus, including MRSA,
and group A streptococcus (410, 411). Extension of the use of triple dye to low birth weight
infants in the NICU was one component of a program that finally controlled a longstanding
MRSA outbreak (248). Chemoprophylaxis for decolonization of healthcare personnel or
patients colonized with MRSA using either orally administered antimicrobials or topical
mupirocin is discussed in the section on MDROs in Appendix B.
II.L.2. Immunization. Certain immunizations are recommended for susceptible healthcare
personnel to decrease the risk of infection and the potential for transmission within the
healthcare facility (9, 412). The OSHA mandate that employers offer hepatitis B vaccination
to HCWs played a substantial role in the sharp decline in incidence of healthcare-associated
HBV (353). Similarly, reports of healthcare-associated transmission of rubella in obstetrical
52
clinics (413, 414) and measles in acute care settings (187) demonstrate the importance of
immunization of susceptible healthcare personnel against childhood diseases. The use of
varicella vaccine in healthcare personnel has decreased the need to place susceptible
HCWs on administrative leave following exposure to patients with varicella (415). Many
states have requirements for HCW vaccination in the absence of evidence of immunity.
Transmission of B. pertussis in healthcare facilities has been associated with large
outbreaks that include both healthcare personnel and patients (9, 33, 304, 363, 416). HCWs
are at particularly high risk because of prolonged close contact with infants with pertussis,
waning immunity, and the absence of a vaccine that can be used in adults. Licensure of an
adult acellular pertussis vaccine in the United States is anticipated within the next 2-3 years.
When licensed, it is likely that healthcare personnel in facilities that care for young infants
and children will be amongst the highest priority groups to receive this vaccine (417).
Annual influenza vaccine campaigns targeted to patients and healthcare personnel in
LTCFs and acute-care settings have been instrumental in preventing or limiting institutional
outbreaks and increasing attention is being directed toward improving influenza vaccination
rates in healthcare personnel (408, 418-420). Anthrax (407) and smallpox (100) vaccines
are two additional vaccines that are likely to be used in HCWs if widespread immunization
should become necessary due to the ongoing threat of bioterrorist attacks.
Immunization of children according to the recommended schedule published annually
in a January issue of the Morbidity Mortality Weekly Report (421) and the January issue of
Pediatrics (422) and with interim updates as needed will further decrease the burden of
transmissible viruses that could be introduced into the healthcare environment by both
patients and visitors. Varicella (423), influenza (408), hepatitis B (353), smallpox (100), and
anthrax (407) vaccines are also recommended for post-exposure prophylaxis of susceptible
individuals (9, 412). Finally, administration of a newly developed S. aureus conjugate
vaccine that is still under investigation to selected patients provides a novel method of
preventing healthcare-associated S. aureus, including MRSA, infections in high-risk groups
(e.g., hemodialysis patients and candidates for selected surgical procedures) (425, 426).
53
Part III. HICPAC/CDC Precautions to Prevent Transmission of Infectious Agents
There are two tiers of HICPAC/CDC transmission precautions, Standard Precautions
and Expanded Precautions. Standard Precautions is intended to be applied to the care of all
patients in all healthcare settings, regardless of the suspected or confirmed presence of an
infectious agent. Implementation of Standard Precautions constitutes the primary
strategy for successful prevention of healthcare-associated transmission of
infectious agents among patients and healthcare personnel. Expanded Precautions are
for patients who are known or suspected to be infected with epidemiologically important
pathogens that require additional control measures to prevent transmission. Expanded
Precautions also include recommendations for creating a PE for allogeneic HSCT patients.
III.A. Standard Precautions
Standard Precautions synthesizes the major features of Universal Precautions (427,
428) and Body Substance Isolation (260) and includes infection control practices and use
of PPE recommended for healthcare personnel when having contact with all patients
wherever healthcare is delivered, regardless of patient diagnoses or presumed infection
status. Standard Precautions is designed to protect HCWs and patients from contact with
infectious agents in recognized and unrecognized sources of infection. Standard
Precautions applies to 1) blood; 2) all body fluids, secretions, and excretions except sweat,
regardless of whether they contain visible blood; 3) nonintact skin; and 4) mucous
membranes. The fundamental elements for transmission prevention discussed in Section II
above apply to Standard Precautions. The same PPE for protection against blood exposure
are also used to prevent healthcare personnel from contacting the various infectious agents
and then carrying them to other patients (18, 335-338, 376) (www.cdc.gov/ncidod/sars).
The application of Standard Precautions during patient care is determined by the
nature of the HCW-patient interaction and the extent of anticipated blood, body fluid, or
pathogen contact. For some interactions, only gloves may be needed; in others gloves,
gowns, and face shields may be required. Education and training on the principles and
rationale for recommended practices are critical elements of Standard Precautions because
they facilitate appropriate decisions when HCWs are faced with new circumstances.
54
Recommendations for the application of Standard Precautions are described below in IV
and summarized in Table 4. Guidance on donning and removing gloves, gowns and other
barriers is presented in the Figure.
III.A.1. New Standard Precautions for patients: Respiratory Hygiene/Cough Etiquette.
The global outbreak of SARS in 2003 identified several opportunities to improve infection
control practice in all healthcare settings. One such opportunity is implementing controls to
prevent transmission of respiratory infections at the first point of contact within a healthcare
setting (e.g., reception and triage areas in emergency departments, outpatient clinics, and
physician offices). The strategy proposed has been termed Respiratory Hygiene/Cough
Etiquette and is intended to be incorporated into infection control practices as one
component of Standard Precautions
(www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm). The term cough etiquette
is derived from recommended source control measures for M. tuberculosis (11).
SARS is but one of a number of respiratory agents that can be transmitted via large
respiratory droplets. Others include influenza virus (32), adenovirus (29), B. pertussis (363)
and Mycoplasma pneumoniae (35). During the SARS outbreak, several instances of SARS
transmission in outpatient settings were reported (37, 116, 429). In one case, the infected
wife of a suspect SARS patient transmitted SARS-CoV to 13 individuals in a hospital
emergency department, including five persons sitting with her in the waiting area (37).
These transmissions highlighted the need for vigilance in detecting possible infection in
patients and accompanying family members or friends and implementing infection control
measures promptly in these healthcare settings.
The elements of Respiratory Hygiene/Cough Etiquette include 1) education of
healthcare facility staff, patients, and visitors; 2) posted signs in language appropriate to the
population served with instructions to patients and accompanying family members or
friends; 3) source control measures (e.g., covering the mouth/nose with a tissue when
coughing and disposing of used tissues, using surgical masks on the coughing person when
tolerated and appropriate); 4) hand hygiene after contact with respiratory secretions; and 5)
spatial separation, ideally >3 feet, of persons with respiratory infections in common waiting
55
areas when possible. Covering sneezes and coughs and placing masks on coughing
patients are proven means of source containment that prevent infected persons from
dispersing respiratory droplets into the air (343-345). Physical proximity of <3 feet has been
associated with an increased risk for transmission of infections via the droplet route (e.g., N.
meningitidis (27) and group A streptococcus (38)) and therefore supports the practice of
distancing infected persons from others who are not infected. Finally, the effectiveness of
good hygiene, especially hand hygiene, practices in preventing transmission of viruses and
reducing the incidence of respiratory infections both within and outside (430-432) healthcare
settings is summarized in several reviews (6, 318, 433).
These measures are targeted to patients and accompanying family members or
friends but applies to any person (33, 145, 146) with signs of a cold or other respiratory
infection (e.g., cough, congestion, rhinorrhea, increased production of respiratory
secretions) who enters any healthcare facility. Although fever will be present in many
respiratory infections, patients with pertussis and colds are often afebrile. Therefore, the
absence of fever does not always exclude a respiratory infection. Patients who have
asthma, allergic rhinitis, or chronic obstructive lung disease also may be coughing and
sneezing. Although these patients are not infectious, cough etiquette measures also apply.
Healthcare personnel are advised to observe Droplet Precautions (i.e., wear a
surgical mask) and hand hygiene when examining and caring for patients with signs and
symptoms of a respiratory infection. Healthcare personnel who have a respiratory infection
are advised to avoid patient contact when they are actively coughing and producing
respiratory secretions.
III.B. Expanded Precautions
There are four categories of Expanded Precautions: Contact Precautions, Droplet
Precautions, Airborne Infection Isolation (AII), and Protective Environment (PE). More than
one category may be used for diseases that have multiple routes of transmission (e.g.,
SARS). When used either singularly or in combination, they are always to be used in
addition to Standard Precautions. (See Appendix A for recommended precautions for
specific infections.) PE differs from the other categories in that the goal of placing a high-risk
patient in a PE to prevent the patient from acquiring fungal infections from the environment,
56
whereas the goals of the other categories are to protect HCWs, visitors, and other patients
from acquiring infectious agents from infected patients.
III.B.1. Contact Precautions are intended to reduce the risk of transmission of
epidemiologically important microorganisms by direct or indirect contact with the patient or
the patient’s environment as described in I.B.3.a. With Contact Precautions, greater spatial
separation of the infected/colonized patient is preferred (e.g., single-patient room or >3 feet
between beds in multipatient rooms) and healthcare personnel and visitors wear gown and
gloves for all interactions that may involve contact with the patient or the patient’s
environment. Contact Precautions apply where the presence of excessive wound drainage,
fecal incontinence, or other discharges from the body suggest an increased transmission
risk. In addition, Contact Precautions may apply to patients known or suspected to be
infected or colonized (as locally defined) with epidemiologically important microorganisms
that can be transmitted by direct or indirect contact, e.g. MDROs, as described in Appendix
B. For pathogens that are likely to be associated with extensive environmental
contamination (e.g., VRE), PPE should be donned before room entry and discarded before
exiting the patient’s room. When Contact Precautions is indicated, efforts must be made to
counteract the adverse effects on patients that have been reported in the literature in order
to improve acceptance by the patients and adherence by HCWs (233, 434-437).
III.B.2. Droplet Precautions is intended to reduce the risk of droplet transmission of
infectious agents from close respiratory or mucous membrane contact (e.g., <3 feet) with
large-particle droplets (larger than 5 µm in size) as described in I.B.3.b. Because droplets
do not remain suspended in the air, special air handling and ventilation are not required to
prevent droplet transmission. However, masks (respirators are not necessary) are needed
for close contact with the patient. Indirect evidence suggests that masks are effective in
preventing transmission of B. pertussis (33), N. meningitidis (39, 40), SARS (30), and
influenza virus (32). Masks should be changed when they become wet and should be
considered contaminated and therefore disposed after use. Droplet Precautions apply to
patients known or suspected to be infected with epidemiologically important pathogens that
can be transmitted by infectious droplets (e.g., B. pertussis (33), influenza virus (32),
57
adenovirus (29), SARS-CoV (30), rhinovirus (34), N. meningitidis (39), and group A
streptococcus (38) [for the first 24 hours of antimicrobial therapy]).
III.B.3. Airborne Infection Isolation (AII) Precautions is intended to reduce the risk of
airborne transmission of infectious agents (e.g., rubeola virus [measles], varicella virus, M.
tuberculosis) as described in I.B.3.c. and in Table 2. An AII room is a single-patient room
that is equipped with special air handling and ventilation capacity that meet the American
Institute of Architects/Facility Guidelines Institute (AIA/FGI) standards for AII rooms (i.e.,
monitored negative pressure relative to the surrounding area, 2 air exchanges per hour (6
air exchanges per hour for existing facilities), air exhausted directly to the outside or
recirculated through HEPA filtration). Some state regulations require the availability of such
rooms in hospitals, emergency departments, and nursing homes for care of patients with
tuberculosis. In settings where AII cannot be implemented due to limited engineering
resources, physical separation, masking the patient, and providing respiratory protection for
healthcare personnel will reduce the likelihood of airborne transmission until the patient can
be transferred to a facility with AII. Persons who enter an AII room or area must wear
respiratory protection (e.g., NIOSH-approved N-95 or higher respirator), depending on the
disease-specific recommendations (Respiratory Protection II.D.4 and Appendix A). Nonimmune HCWs should not care for patients with vaccine preventable airborne diseases
(e.g., measles, chickenpox, and smallpox), regardless of use of personal protective
equipment. However, immune persons should also wear masks or NIOSH-approved N-95
respirators for complete protection, due to errors in ascertaining immunity, and for
consistency in the practice of AII.
III.B.4. Protective Environment is designed for allogeneic HSCT patients to minimize
fungal spore counts in the air (see Table 6 for specifications) (4, 5, 8, 13). The need for such
controls has been demonstrated in studies of outbreaks of aspergillosis associated with
construction and in molecular typing studies that have found identical strains of Aspergillus
terreus in patients with hematologic malignancies and in potted plants in the vicinity of the
patients (4, 8, 13, 203). Air quality for HSCT patients is improved through a combination of
environmental controls that include 1) HEPA filtration of incoming air, 2) directed room air
flow, 3) positive room air pressure relative to the corridor, 4) well-sealed rooms (including
sealed walls, floors, ceilings, windows, electrical outlets) to prevent infiltration of air from the
58
outside, 5) ventilation to provide >12 air changes per hour, 6) strategies to lower dust (e.g.,
scrubbable surfaces rather than carpet and upholstery) and routinely cleaning crevices and
sprinkler heads, and 7) prohibiting dried and fresh flowers and potted plants and fresh
flowers in the rooms of HSCT patient. The desired quality of air may be achieved without the
inconvenience or expense of laminar airflow (13, 203). To prevent inhalation of respirable
particles and reaerosolization of exhaled particles in the presence of construction,
placement of an N95 respirator on the patient is advised when patients leave the PE for
diagnostic studies or treatments elsewhere in the facility (438). However, the use of
respirators outside of the protective environment for prevention of environmental fungal
infections in the absence of construction has not been evaluated. A PE does not include the
use of barrier precautions beyond those indicated for Standard and Expanded Precautions
when applicable. No published reports support the benefit of placing solid organ transplants
or other immunocompromised patients in a PE.
III.C. Syndromic or empiric application of Expanded Precautions
Diagnosis of many infections requires laboratory confirmation. Since laboratory
confirmation tests, especially those that depend on culture techniques, often require two or
more days for completion, reliance on confirmed diagnoses to implement preventive
measures allows additional exposures while test results are pending. Use of precautions at
the time patients develop symptoms and signs of transmissible infections or present to
medical attention reduce exposure opportunities. In particular, the routine use of Standard
Precautions for all patient interactions reduces greatly the risk of exposure for conditions
other than those requiring Contact or Droplet Precautions or AII. While it is not possible to
prospectively identify all patients needing Expanded Precautions, certain clinical syndromes
and conditions carry a sufficiently high risk to warrant their use on an empirical basis while
confirmatory tests are pending (Table 6).
Table 6 lists some of the most worrisome infectious agents that require Expanded
Precautions in addition to Standard Precautions. The relevant Expanded Precautions
category should be applied until either a definitive etiologic diagnosis is established or a role
for the worrisome pathogen is excluded. Infection control professionals are encouraged to
modify or adapt this table according to local conditions. For example, in acute care facilities
using Contact Precautions to manage all patients harboring MDROs, these precautions
59
would be applied empirically for all new admissions with a history of prior infection or
colonization with MDROs. They would also be applied empirically to all patients who present
with skin, wound, or urinary tract infections and who have a history of recent hospitalization
or residence in facilities where MDROs are prevalent. Contact Precautions could be
discontinued once admission surveillance cultures are reported to be negative for the target
MDRO. Implementation of Expanded Precautions on an empirical basis requires education
and training of front-line HCWs and competency assessment.
III.D. Discontinuation of Expanded Precautions
Standard Precautions apply to all patients, at all times. In general, Expanded
Precautions remain in effect for limited periods, i.e., while the risk for transmission of the
infectious agent persists or for the duration of the illness (Appendix A). For most diseases
this duration reflects known patterns of microbial persistence and shedding associated with
the natural history of the infectious process and its treatment. For some diseases, e.g.,
pharyngeal or cutaneous diphtheria, Expanded Precautions remain in effect until culture
results document eradication of the pathogen. For other diseases, state laws and
regulations may dictate the duration of Expanded Precaution use. See Appendix B for
discussion of criteria to discontinue Contact Precautions for patients colonized or infected
with MDROs.
III.E. Application of Expanded Precautions in ambulatory and home care settings
Although Expanded Precautions generally apply in all healthcare settings, exceptions exist.
For example, in home care, engineered AII rooms are not available. Furthermore, family
members already exposed to diseases such as varicella and tuberculosis would usually not
use masks or respiratory protection, though visiting HCWs would. Similarly, management of
patients colonized or infected with MDROs may necessitate Contact Precautions in acute
care hospitals, but in ambulatory care and home care, consistent use of Standard
Precautions usually suffices (160).
For healthcare settings using Contact Precautions for patients who are colonized or
infected with MDROs, the duration of these precautions remains undefined. Although
guidelines for VRE suggested discontinuation of Contact Precautions after three stool
cultures, obtained at weekly intervals, proved negative (2), subsequent experiences have
indicated that such screening may fail to detect colonization that may persist for >1 year
60
(439-442). Likewise, carriers of MRSA who have negative nasal cultures after a course of
systemic or topical therapy may resume shedding MRSA in the weeks that follow therapy
(443, 444). Available data indicate that colonization with VRE, MRSA (445), and, probably,
MDR-GNB can persist for many months, especially in the presence of severe underlying
disease, invasive devices, and recurrent courses of antimicrobial agents.
It may be prudent to assume that MDRO carriers are colonized permanently and
manage them accordingly. Alternatively, an interval free of hospitalizations, antimicrobial
therapy, and invasive devices (e.g., 6 or 12 months) before reculturing patients to document
clearance of carriage may be used. Selection of the best strategy awaits the results of
additional studies.
61
Part IV: Recommendations
These recommendations are designed to prevent transmission of infectious agents
among patients and healthcare personnel in all settings where healthcare is delivered
unless otherwise stated. As in other CDC/HICPAC guidelines, each recommendation is
categorized on the basis of existing scientific data, theoretical rationale, applicability, and
when possible, economic impact. The CDC/HICPAC system for categorizing
recommendations is as follows:
Category IA. Strongly recommended for implementation and strongly supported by welldesigned experimental, clinical, or epidemiologic studies.
Category IB. Strongly recommended for implementation and supported by some
experimental, clinical, or epidemiologic studies and a strong theoretical rationale.
Category IC. Required for implementation, as mandated by federal and/or state regulation
or standard.
Category II. Suggested for implementation and supported by suggestive clinical or
epidemiologic studies or a theoretical rationale.
No recommendation; unresolved issue. Practices for which insufficient evidence or no
consensus regarding efficacy exists.
I. Administrative Responsibilities
A. Incorporate preventing transmission of infectious agents into the objectives of the
organization’s patient and occupational safety programs (230-232, 234, 295).
Category II
B. Make preventing transmission of infectious agents a priority for the healthcare
organization. Provide administrative support, including fiscal and human
resources for maintaining infection control programs (6, 162, 240, 243, 281, 296, 297,
299, 446). Category IB
1. Assure that individuals with training in infection control are employed by or are
available by contract to all healthcare organizations, with at least 1 infection
control professional per 250 occupied acute care beds (162, 297, 446, 447).
Category IB
a. Add infection control professionals based on the scope of the infection
62
control program, the complexity of the healthcare facility or system, the
characteristics of the patient population and the unique or urgent needs of
the facility and community (447).
Category II
2. Include prevention of healthcare-associated infections (HAI) as one determinant of
bedside nurse staffing levels and composition, especially in high risk units (162,
241, 254, 255, 257, 258, 297, 299). Category IB
3. Involve infection control personnel in decisions on facility construction and design,
determination of Airborne Infection Isolation (AII) and Protective Environment (PE)
capacity needs, and selection of medical equipment and supplies (4, 5, 448-450).
Category IB/IC
4. Ensure availability of clinical laboratory support appropriate to the healthcare
setting for monitoring transmission of microorganisms and conducting
epidemiologic investigations. Include resources for surveillance cultures, rapid
diagnostic testing for viral and other selected pathogens, preparation of
antimicrobial susceptibility reports, trend analysis, and molecular typing of
clustered isolates performed either on site or in a reference laboratory (162, 284,
287-289, 297). Category IB
5. Provide human and fiscal resources to meet occupational health needs related to
infection control, e.g., healthcare worker immunization, post- exposure evaluation
and care, evaluation and management of healthcare personnel with
communicable infections (9, 11, 313, 353, 412, 416, 451)
(www.cdc.gov/ncid/sars). Category IB/IC
6. Provide supplies and equipment required for the consistent observance of
Standard and Expanded Precautions (Contact, Droplet, AII, PE) including hand
hygiene products and protective barriers (e.g., gloves, gowns, face and eye
protection)(6, 313). Category IB/IC.
7. Provide ventilation systems required for a sufficient number of AII rooms and a PE
in facilities that provide care to patients for whom such rooms are indicated
according to published recommendations (4, 11, 13, 313). Category IA/IC
63
8. Develop and implement policies and procedures to ensure that reusable patient
care equipment is cleaned and reprocessed appropriately before use on another
patient (4, 7, 313). Category IA/IC
C. Develop and implement a process to ensure oversight of infection control activities
appropriate to the healthcare setting.
1. Assign responsibility for oversight of infection control activities to an individual or
group within the healthcare organization that is knowledgeable about infection
control (162, 297). Category II
2. Delegate authority to infection control personnel or their designees (e.g., patient
care unit charge nurses) for making infection control decisions concerning patient
placement and the use of Expanded Isolation Precautions (162, 297)
(www.jcaho.org). Category IC
3. Develop and implement systems for early detection and management, (e.g.
intiation of appropriate isolation precautions) of potentially infectious persons at
initial points of patient encounter in outpatient areas (e.g., triage areas,
emergency departments, outpatient clinics, physician offices) and at the time of
admission to hospitals and long term care facilities (37, 43, 363, 452);
www.cdc.gov/ncidod/sars. Category IB
4. Develop and implement policies that limit patient visitation by persons with signs
or symptoms of a communicable infection. Screen visitors to high-risk patient care
areas (e.g., oncology units, hematopoietic stem cell transplant [HSCT] units,
intensive care units [ICU]) for signs and symptoms of communicable infections,
high risk pediatric units (18, 33, 146, 408). Category IB.
5. Develop indicators to monitor the effectiveness of facility-specific measures to
prevent transmission of infectious agents and provide feedback to staff members
(6, 299, 312-314). Category IB
6. Monitor recommended performance indicators for adherence to recommended
practices for hand hygiene and Standard and Expanded Precautions and provide
feedback to staff (6, 259, 299). Category IA.
64
II. Education and Training
A. Provide education and training on preventing transmission of infectious agents
associated with healthcare during orientation to the healthcare facility; update
information periodically during staff development programs. Target all healthcare
personnel for education and training, including but not limited to medical, nursing,
and laboratory staff; property service (housekeeping), laundry, maintenance, and
dietary workers; and students, contract staff, and volunteers. Enhance training by
applying principles of adult learning and using appropriate reading level and
language for target audience (6, 11, 307-311, 453). Category IB.
B. Provide instructional materials for patients and visitors on recommended hand
hygiene practices and application of Expanded Precautions (18, 146). Category II
III. Surveillance
Conduct ongoing monitoring of sentinel populations (e.g., ICU, post-operative,
hematology-oncology, transplant patients), procedures and device use (e.g., central
venous-catheter associated bloodstream infections (BSI), ventilator-associated
pneumonia (VAP), urinary tract infection associated with indwelling catheters, surgical
site infections (SSI)), and highly transmissible infections (e.g. Clostridium difficile/
rotavirus-associated diarrhea; viral respiratory infections, especially influenza, RSV,
and SARS; environmental fungal infections, tuberculosis) for evidence of contamination
of devices or new or ongoing transmission in the healthcare facility (309, 446, 453459). Category IA
A. Use the following principles of infection control surveillance (454, 455) Category IB:
•
Use standardized definitions of infection
•
Use laboratory-based data for surveillance (when available)
•
Specify location and/or clinical service in hospitals and other large multi-unit
facilities
•
Use established risk stratification when available, e.g. surgical wound class,
device days, birthweight (neonatal intensive care unit [NICU])
•
Monitor results and identify trends that may indicate increased rates of
transmission within the facility.
65
•
Provide information on trends in incidence and prevalence of healthcareassociated infections, probable risk factors and prevention strategies and their
impact to the appropriate healthcare providers and institutional administrators
B. Obtain consultation from persons knowledgeable in infection control and healthcare
epidemiology when indicated by presence of continued transmission despite
implementation of basic infection control measures (446). Category IB
C. Periodically review information on local trends in incidence and prevalence of
pathogens acquired in the community (including in other healthcare facilities in the
community) that may impact rates of HAI, e.g. influenza, RSV, multidrug-resistant
organisms [MDRO] (e.g., MRSA, VRE) (459). Category II
III. Standard Precautions
Assume that every person is potentially infected or colonized with an organism that could
be transmitted in the healthcare setting and apply the following infection control practices
during delivery of health care:
A. Indications for handwashing and hand antisepsis:
1. When hands are visibly dirty or contaminated with proteinaceous material or
visibly soiled with blood or other body fluids, wash hands with either a
nonantimicrobial soap and water or an antimicrobial soap and water (6, 460).
Category IA
2. If hands are not visibly soiled, use an alcohol-based handrub for routinely
decontaminating hands in all other clinical situations described below and in the
Guideline for Hand Hygiene in Health-Care Settings (6, 461-463). Category IA.
Alternatively, wash hands with an antimicrobial soap and water (6, 464). Category
IB
3. Decontaminate hands in the following circumstances, whether or not gloves are
worn (6) :
a. Before having direct contact with patients (465, 466). Category IB
b. After contact with blood, body fluids or excretions, mucous membranes,
nonintact skin, or wound dressings(466). Category IA
66
c. After contact with a patient’s intact skin (e.g. when taking a pulse or blood
pressure or lifting a patient) (461, 465, 467, 468). Category IB
d. If hands will be moving from a contaminated-body site to a clean-body
site (461, 465, 467-469). Category II
e. After contact with inanimate objects (including medical equipment) in the
immediate vicinity of the patient (338, 469, 470). Category II
f. After removing gloves (326, 331, 333). Category IB
4. Wash hands with non-antimicrobial soap and water or with antimicrobial soap and
water if contact with spores (e.g, Bacillus spp. or C. difficile) is anticipated. The
physical action of washing and rinsing hands under such circumstances is
recommended because alcohols, chlorhexidine, iodophors, and other antiseptic
agents have poor activity against spores (6, 7, 471). Category II
5. Do not wear artificial fingernails or extenders when having direct contact with
patients at high risk for infection (e.g., those in ICUs or operating rooms) (6, 319323). Category IA
B. Personal Protective Equipment (see Figure 1)
1. Observe the following principles of use:
a. Wear personal protective equipment (PPE) when the nature of the anticipated
patient interaction indicates that contact with blood or body fluids may occur
(313, 427, 428). Category IB/IC
b. During the delivery of healthcare, avoid touching surfaces in close proximity to
the patient (10, 313, 472, 473). Category IB/IC
c. Prevent contamination of clothing and skin during the process of removing
PPE (www.cdc.gov/ncidod/sars). Category II
d. Before leaving the patient’s room or cubicle, remove and discard gowns and
gloves (10, 313). Category IB/IC
2. Gloves
a. Wear gloves when it can be reasonably anticipated that contact with blood or
other potentially infectious materials, mucous membranes, nonintact skin, or
potentially colonized intact skin (e.g., of a patient with diarrhea), could occur
(10, 313, 326, 331, 428, 474). Category IB/IC
67
b. Wear gloves with fit and durability appropriate to the task (6, 313, 328, 329,
475, 476). Category IB
i. Wear disposable medical examination gloves for providing direct patient
care.
ii. Wear disposable medical examination gloves or reusable utility gloves for
cleaning the environment or medical equipment.
c. Remove gloves after contact with a patient and/or the surrounding
environment (including medical equipment), using proper technique to prevent
hand contamination. Do not wear the same pair of gloves for the care of more
than one patient. Do not wash gloves for reuse with different patients (6, 326,
331-334). Category IB
d. Change gloves during patient care if the hands will move from a contaminated
body site (e.g., perineal area) to a clean body site (e.g., face) (6, 325, 326).
Category II
3. Gowns and other PPE attire
a. Wear a gown, apron, or other PPE attire, that is appropriate to the task, to
protect skin and prevent soiling of clothing during procedures and patient-care
activities when contact with blood, body fluids, secretions, or excretions is
anticipated (313). Category IC
i.
Wear a gown for direct patient contact if the patient has uncontained
secretions or excretions (18, 313, 338, 371, 376). Category IB/IC
ii. Remove gown, apron, or other PPE attire and perform hand hygiene
before leaving the patient’s environment (18, 313, 338, 371, 376).
Category IB/IC
b. No recommendation for re-use of gowns for the same patient by the same or
multiple healthcare personnel. Unresolved issue
4. Mouth, nose, eye protection
a. Use PPE to protect the 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. Masks,
68
goggles, face shields, and combinations of each should be selected according
to the task performed (30, 313). Category IB
b. During procedures that generate sprays of respiratory secretions (e.g.,
bronchoscopy, suctioning, and intubation), wear gloves, gown, and either a
face shield that fully covers the front and sides of the face, or a mask and
goggles. Use an N95 or higher respirator instead of a surgical mask if the
patient has a suspected or proven infection that is likely to be transmitted by
the airborne route (11, 30, 36, 39, 313) (www.cdc.gov/ncidod/sars). Category
IB/IC
C. Respiratory Hygiene/Cough Etiquette
1. Educate staff on the importance of source control measures to contain respiratory
secretions and prevent droplet and fomite transmission of respiratory pathogens,
especially during seasonal outbreaks of viral respiratory tract infections (e.g.,
Severe Acute Respiratory Syndrome (SARS), influenza, RSV, adenovirus,
parainfluenza (8, 18, 305, 408) (www.cdc.gov/ncidod/sars). Category IB
2. Implement the following measures to contain the source of respiratory
secretions in patients and accompanying individuals who have signs and
symptoms of respiratory tract infection, beginning at the point of initial
encounter in a healthcare setting (e.g., triage, reception and waiting areas in
emergency departments, ambulatory clinics, healthcare provider offices):
a. Post signs in ambulatory and inpatient settings with instructions to patients
and other persons with symptoms of a respiratory infection entering the
facility to cover their mouths/noses when coughing or sneezing, use and
dispose of tissues, and perform hand hygiene after hands have been in
contact with respiratory secretions. Category II
b. Provide tissues and no-touch receptacles (i.e.,ideally by foot pedaloperated lid or open waste baskets) for disposal of used tissues (18, 28, 221,
345, 431). Category IB
c. Provide resources and instructions for performing hand hygiene in or near
waiting areas in ambulatory and inpatient settings; provide conveniently
located dispensers of alcohol-based hand rubs and, where sinks are
69
available, supplies for handwashing (6, 430, 431, 432). Category IA
d. During periods of increased rates of respiratory infections in the
community (e.g., as indicated by increased school absenteeism), offer
masks to coughing patients and other persons (e.g., symptomatic persons
who accompany ill patients) with suspected respiratory tract infection upon
entry into common waiting areas (11, 343, 344) and encourage them to
maintain spatial separation, ideally a distance of at least 3 feet, from others in
common waiting areas (27, 29, 32, 38, 221) (www.cdc.gov/ncidod/sars).
Category IB
Some facilities may find it logistically easier to institute this
recommendation year-round as a standard practice. Category II
D. Patient placement
1. Include the potential for transmission of infectious agents in patient-placement
decisions. Place patients who pose a risk for transmission to others(e.g.,
uncontained secretions, excretions or wound drainage or infants with suspected
viral respiratory tract or gastrointestinal tract infections) in a single-patient room
when available (18, 158, 163, 357, 358, 478). Category IB
2. Determine patient placement based on the following principles (Category II):
•
Route(s) of transmission of the infectious agent
•
Risk factors for transmission in the infected patient
•
Risk factors for adverse outcomes resulting from healthcare-associated
infection in other patients in the area
•
Availability of single-patient rooms
•
Patient options for room sharing (e.g., cohorting patients with the same
infection)
E. Patient care equipment (7)
1. Establish policies and procedures for containing, transporting, and handling
patient care equipment that may be contaminated with blood or body fluids (10,
313, 472). Category IB/IC
70
2. Wear appropriate PPE when handling patient care equipment that may have been
in contact with or is visibly soiled with blood or body fluids (10, 313, 472).
Category IB/IC
F. Care of the environment (4)
1. Establish policies and procedures for cleaning and maintaining environmental
surfaces as appropriate for the level of patient contact and degree of soiling (4).
Category II
2. Clean and disinfect surfaces that are in close proximity to the patient and those
that may be contaminated with potential pathogens (e.g., doorknobs, bed rails,
surfaces in and surrounding toilets in patients’ rooms) on a more frequent
schedule compared to that for minimal touch surfaces (e.g., horizontal surfaces in
waiting rooms) (2, 4, 337, 479, 480). Category IB
3. Use EPA-approved disinfectants that have microbiocidal (i.e., killing) activity
against the pathogens most likely to contaminate the patient care environment.
Review the efficacy of in-use disinfectants when there is evidence of transmission
of infectious agents that may indicate resistance to the in-use product (e.g.,
rotavirus, C. difficile) and change to a more effective disinfectant as indicated (7,
372-374). Category II
G. Textiles and laundry
1. Handle used textiles and fabrics with minimum agitation to avoid contamination of
air, surfaces, and persons (313, 481-483). Category IB/IC
2. If laundry chutes are used, ensure that they are properly designed, maintained,
and used in a manner to minimize dispersion of aerosols from contaminated
laundry (4, 5, 484, 485). Category IB/ IC
H. Workers’ safety: Adhere to federal and state requirements for protection of healthcare
personnel from exposure to bloodborne pathogens (313). Category IC
IV. Expanded Precautions
A. General principles
In addition to Standard Precautions, use Expanded Precautions for patients with
documented or suspected infection or colonization with highly transmissible or
71
epidemiologically important pathogens for which additional precautions are needed
to prevent transmission (see Appendix A) (4, 8, 11, 18, 478). Category IA
B. Contact Precautions
1. Use Contact Precautions as recommended in Appendix A for patients with known
or suspected infections or evidence of syndromes that represent an increased risk
for contact transmission, including colonization or infection with MDROs according
to recommendations below (V.A.5.c, V.B.6.b.c). Category IB
2. Patient placement
a. In acute care settings, place patients who may require Contact Precautions in
a single patient room (18, 75, 78, 357, 358, 371, 459, 486, 487). Category IB
Apply the following hierarchy of alternatives when single-patient rooms are in
short supply (Category II):
i.
Prioritize patients with conditions that may facilitate transmission (e.g.,
uncontained drainage, stool incontinence) for single-patient room
placement.
ii. Place together (cohort) in the same room patients who are infected or
colonized with the same pathogen and are suitable roommates (e.g., at low
risk for acquiring an infection or for an adverse outcome should
transmission occur).
a) Ensure that patients are physically separated (i.e.,>3 feet) from each
other. Draw the privacy curtain between beds to minimize opportunity
for direct contact.
b) Change protective attire and perform hand hygiene between patients.
iii. Avoid placing patients on Contact Precautions in the same room with
patients who have conditions that may increase the risk of adverse
outcome from infection or that may facilitate transmission (e.g., those who
are immunocompromised, have open wounds, or have anticipated
prolonged lengths of stay).
b. In long term care settings, make decisions regarding patient placement on a
case-by-case basis, balancing infection risks to other patients in the room and
72
the potential adverse psychosocial impact on the infected or colonized patient
(436, 437). Category II
c. In ambulatory settings, place patients who require Contact Precautions in an
examination room or cubicle as soon as possible (221). Category II
3. Hand hygiene and gloves: Observe hand hygiene practices and wear gloves
according to Standard Precautions and whenever touching the patient’s intact
skin (6, 18, 335, 337, 338, 376) (www.cdc.gov/ncidod/sars)
(Category IB) or surfaces and articles in close proximity to the patient (e.g.,
medical equipment or bed rails). Category II
4. Gowns
a. Wear a gown whenever anticipating that clothing will have direct contact with
the patient or potentially contaminated environmental surfaces or items in the
patient's room. Remove the gown and observe hand hygiene before leaving
the patient's environment (18, 335-338);www.cdc.gov/ncidod/sars. Category
IB
b. After gown removal, ensure that clothing and skin do not contact potentially
contaminated environmental surfaces to avoid transfer of microorganisms to
other patients or environmental surfaces. Category II
5. Patient transport
a. Limit transport and movement of patients outside of the room to medically
necessary purposes. When transport is required, ensure that infected or
colonized areas of the patient are contained and covered. Category II
b. Remove contaminated PPE and perform hand hygiene prior to transporting
patient on Contact Precautions. Category II
d. Don clean PPE to handle the patient when the transport destination has been
reached. Category II
6. Patient care equipment
a. Manage patient care equipment according to Standard Precautions (7, 313).
Category IB/IC
b. Use disposable patient care items (e.g. blood pressure cuffs) wherever
possible or implement patient-dedicated use of noncritical equipment to avoid
73
sharing between patients. If use of common equipment or items is
unavoidable, clean and disinfect them before use on another patient (18, 163,
335, 338, 357, 488). Category IB
In home care settings,
a) Limit the amount of patient-care equipment brought into the home of
patients on Contact Precautions. When possible, leave patient-care
equipment in the home until discharge from home care services.
b) If noncritical patient care equipment (e.g. stethoscopes) cannot remain in
the home, clean and disinfect items before taking them from the home,
using a low- to intermediate- level disinfectant, or place reusable items in a
plastic bag for transport and subsequent cleaning and disinfection.
Category II
7. Environmental measures
Ensure that rooms of patients on Contact Precautions are given cleaning priority
with a focus on frequent (e.g., at least daily) cleaning and disinfection of high
touch surfaces (e.g., bed rails, bedside commodes, faucet handles, doorknobs,
carts, charts) and equipment in the immediate vicinity of the patient (4, 18, 163,
337, 338, 357, 371). Category IB
8. Discontinue Contact Precautions after signs and symptoms have resolved or
according to pathogen-specific recommendations in Appendix A. Category IB.
C. Droplet precautions
1. Use Droplet Precautions as recommended in Appendix A for patients known or
suspected to be infected with microorganisms transmitted by respiratory droplets
(large-particle droplets [>5 µm in size] that can be generated by the patient during
coughing, sneezing, talking, or the performance of cough-inducing procedures) (8,
27-29, 32, 33, 35, 39, 363, 489). Category IB
2. Patient placement
a. In acute care settings, place patients who require Droplet Precautions in a
single patient room (8, 28, 29, 32, 490) (www.cdc.gov/ncidod/sars). Category
IB
74
Apply the following hierarchy of alternatives when single patient rooms are in
short supply (Category II):
i.
Prioritize patients with conditions that may facilitate transmission (e.g.,
uncontained drainage, stool incontinence) for single patient room
placement.
ii. Place together (cohort) in the same room patients who are infected or
colonized with the same organism and are suitable roommates (e.g., low
risk for acquiring an infection or at low risk for an adverse outcome should
transmission occur).
a) Ensure that patients are physically separated (i.e., >3 feet) from each
other. Draw the privacy curtain between beds to minimize opportunity
for transmission or sharing of items.
b) Change PPE and perform hand hygiene between patients.
iii. Avoid placing patients on Droplet Precautions in the same room with
patients who are at increased risk for infection (e.g., immunocompromised
or have an anticipated prolonged length of stay).
b. In residential care settings, make decisions regarding patient placement on a
case-by-case basis, balancing infection risks to other patients in the room
(490) and the potential adverse psychosocial impact on the infected or
colonized patient (436, 437). Category II
c. In ambulatory settings, place patients who may require Droplet Precautions in
an examination room or cubicle as soon as possible. Instruct patients and
accompanying individuals to follow recommendations for Respiratory
Hygiene/Cough Etiquette (184, 185)
(www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm). Category II
3. Mask and eye protection for healthcare personnel
a. Wear a surgical mask for close patient contact (e.g., within 3 feet) (8, 27, 29,
30, 32, 33, 40, 363). Category IB
b. No recommendation for wearing eye protection in addition to a surgical mask
for close contact with patients who require droplet precautions for conditions
75
other than SARS or avian influenza and as recommended for Standard
Precautions. Unresolved issue.
c. For patients with suspected SARS (36) (www.cdc.gov/ncidod/sars) (Category
IB) or Avian influenza (www.cdc.gov/flu/han020302.htm) (Category II), wear
both eye protection (e.g., goggles or face shield) and respiratory protection
(e.g., NIOSH-approved N95 or higher).
4. Patient transport
a. Limit movement and transport of the patient outside of the room to medically
necessary purposes. Category II
b. Instruct patient to wear a surgical mask and follow Respiratory
Hygiene/Cough Etiquette during transport (11, 343, 344). Category II
c. No mask is required for person handling transport. Category II
5. Discontinue Droplet Precautions after signs and symptoms have resolved or
according to pathogen-specific recommendations in Appendix A. Category IB
D. Airborne Infection Isolation (AII) Precautions
1. Use AII as recommended in Appendix A for patients known or suspected to be
infected with infectious agents transmitted person-to-person by the airborne route
e.g., tuberculosis (11), measles (43, 187, 492), chickenpox (42), smallpox (45),
viral hemorrhagic fevers (47), and SARS (111, 493) (www.cdc.gov/ncidod/sars).
Category IA/IC
2. Patient placement
a. In acute care hospitals or residential settings, place the patient in an AII that
should be a single patient room equipped with the following (4, 5, 11)
(Category IA/IC):
i. Continuous, monitored negative air pressure (2.5 Pa [0.01 inch water
gauge]) in relation to the air pressure in the corridor. Monitor air pressure
daily with visual indicators (e.g., smoke tubes, flutter strips) placed in the
room with the door closed (494).
ii. At least six (existing facility) or 12 (new construction) air changes per hour.
iii. Direct exhaust of air to the outside. If it is not possible to exhaust the air
from an AII room directly to the outside, the air may be returned through
76
HEPA filters to the air-handling system serving exclusively the isolation
room.
iv. Keep the room door closed when not required for entry and exit.
v. When a private room is not available or in the event of an outbreak or
exposure where large numbers of patients require AII precautions ,
consult infection control professionals before patient placement to
determine the safety of alternative rooms that do not meet engineering
requirements for AII and/or cohorting patients together based on
clinical diagnosis in areas with the lowest risk of airborne transmission.
b. In ambulatory settings:
i.
Develop systems (e.g., triage, signs) to identify and segregate patients with
known or suspected infections that require AII precautions as soon as
possible after entry into a healthcare setting, including emergency
departments (11, 44, 116, 187) (www.cdc.gov/ncidod/sars). Category IA/IC
ii. Place a surgical mask on the patient immediately and maintain until the
patient has been placed in an AII room (11, 343-345). Category IB/IC
iii. Place patients in appropriately ventilated AII rooms when available. If such
rooms are not available, place these patients in an examination room at the
farthest distance from other patient rooms, preferably one that is at the end
of the ventilation circuit and place a portable HEPA filter in the room. Once
the patient leaves, the room should remain vacant for the appropriate time
according to the number of air changes per hour, usually one hour, to allow
for a full exchange of air (4, 11, 43). Category IB/IC
iv. When hospital admission is indicated, place patients with confirmed or
suspected airborne-transmitted infections in AII rooms. If AII rooms are not
available, transfer to another facility that has AII rooms (11, 44, 185, 187).
Category IB/IC
3. Use of personal protective equipment
a. Restrict susceptible health-care personel from entering the rooms of patients
known or suspected to have measles (rubeola), varicella (chickenpox), or
77
smallpox if other immune health-care personnel are available (9, 100, 187,
415). Category IB
b. Wear fit tested NIOSH-approved respiratory protection (N95 respirator or
higher) when entering the room or home of a patient when the following
diseases are suspected or confirmed:
i.
Infectious pulmonary or laryngeal tuberculosis or draining tuberculous skin
lesions (11, 495, 496). Category IB/IC
ii. Smallpox (vaccinated and unvaccinated) (45), viral hemorrhagic fevers
(47), SARS (www.cdc.gov/ncidod/sars). Category II
a) Respiratory protection is recommended even for all health-care
personnel, even with a documented “take” after smallpox vaccination
due to the risk of a genetically engineered virus against which the
vaccine may not provide protection, or of exposure to a very large viral
load (e.g., from high-risk aerosol-generating procedures,
immunocompromised patients, hemorrhagic or flat smallpox) (31).
Category II
c. Wear nose/mouth protection upon entering the room or home of a patient
known or suspected of having measles (rubeola), varicella, or disseminated
zoster (immune and susceptible) for consistency and because of the
difficulties in establishing definite immunity in all health-care personnel.
Category II
i.
No recommendation for the type of protection to use (e.g., N95 respirator
or surgical mask) for exposure to measles and varicella viruses.
Unresolved Issue
d. Immunize susceptible persons as soon as possible following contact with a
patient with smallpox, measles, or varicella as follows: Category IA
i. Administer smallpox vaccine to exposed susceptible persons within 4 days
after exposure (31, 100, 497).
ii. Administer measles vaccine to exposed susceptible persons within 72
hours or administer immunoglobulin within 6 days after exposure (9, 412).
78
iii. Administer varicella vaccine to exposed susceptible persons within 120
hours after exposure or administer varicella immune globulin (VZIG) within
96 hours for high risk persons in whom vaccine is contraindicated (e.g.,
immunocompromised patients, pregnant women, newborns whose
mother’s varicella onset was <5 days before delivery or within 48 h after
delivery. (370, 423).
4. Patient transport
a. Limit the movement and transport of patients who require AII precautions to
medically necessary purposes. Category II
b. If transport or movement outside an AII room is necessary, place a surgical
mask on the patient. For patients with skin lesions associated with varicella or
smallpox or draining skin lesions caused by M. tuberculosis, cover the patient
to prevent aerosolization or contact with the infectious agent present in skin
lesions. Category II
c. Wear respiratory protection when transporting patients who require AII
precautions.
5. Discontinue AII precautions after signs and symptoms have resolved or according
to pathogen-specific recommendations in Appendix A. Category IB
6. For additional precautions for preventing transmission of tuberculosis in healthcare settings, consult CDC’s "Guidelines for Preventing the Transmission of
Tuberculosis in Health-Care Facilities” (11) and the most recent update (in
preparation), and the “Guideline for Environmental Infection Control in HealthCare Facilities” (4).
E. Protective Environment (PE) (Table 5)
1. Place allogeneic hematopoietic stem cell transplant (HSCT) patients in a PE as
defined in the “Guideline to Prevent Opportunistic Infections in HSCT
Patients"(13), the “Guideline for Environmental Infection Control in Health-Care
Facilities”(4), and the “Guidelines for Preventing Health-Care-Associated
Pneumonia, 2003” (8) to reduce exposure to environmental fungi, (e.g.
Aspergillus sp) (203, 498). Category IB
2. No recommendation for placing other patients identified in a facility as being
79
at increased risk for environmental fungal infections, (e.g., aspergillosis) in a
PE (4, 221). Unresolved issue
3. For patients who require a PE, implement the following components (Table 5): (4,
8, 13)
a. Filtered incoming air using central or point-of-use high efficiency particulate air
(HEPA) filters capable of removing 99.7% of particles 0.3 µm in diameter (the
most penetrating particle size) (5). Category IB/IC
b. Directed room airflow with supply on one side of the room across the patient
and out through exhaust on the other side of the room (5). Category IBIC
c. Positive air pressure in room relative to the corridor (pressure differential of
>2.5 Pa [0.01-inch water gauge]) (5). Category IB/IC
d. Well-sealed rooms to prevent infiltration of air from the outside (5). Category
IB/IC
e. At least 12 air changes per hour (5). Category IC
f. Lowered dust levels by using smooth surfaces and finishes that can be
scrubbed rather than textured materials, (i.e. carpet (499) [Category IB],
upholstery, cloth), wet dusting of horizontal surfaces, and routinely cleaning
crevices and sprinkler heads (500). Category II
g. Avoidance of carpeting in hallways and patient rooms in areas housing
immunocompromised patients (499). Category IB
h. Use of vacuum cleaner equipped with HEPA filters (501, 502). Category IB
i. Prohibition of dried and fresh flowers and potted plants (503-505). Category II
4. Minimize the length of time that patients who require a PE are outside their rooms
for diagnostic procedures and other activities (4, 438, 498). Category IB
a. During periods of construction, to prevent inhalation of respirable particles that
could contain infectious spores, provide respiratory protection (e.g., N95
respirator) to patients who are medically fit to tolerate a respirator when they
are required to leave the PE (438). Ensure that patients are instructed on
respirator use. Category II
b. No recommendation on fit testing of patients who are using respirators.
Unresolved issue
80
c. In the absence of construction, no recommendation for use of particulate
respirators when leaving the PE. Unresolved issue
4. Take measures to protect patients who require a PE room and who also have an
airborne infectious disease (e.g. tuberculosis, acute varicella-zoster).
a. Ensure that the patient’s room is designed to maintain positive pressure (5).
Category IC
b. Use an anteroom to ensure appropriate air-balance relationships and provide
independent exhaust of contaminated air to the outside or place a HEPA filter
in the exhaust duct if the return air must be recirculated (5, 506). Category IC
c. If an anteroom is not available, place the patient in an AII room and use
portable, industrial-grade HEPA filters to enhance filtration of spores in the
room (507). Category II
5. Use PPE (e.g., gloves, gown, and mask) according to Standard Precautions. Use
Expanded Precautions only if the patient has a suspected or proven infection for
which Expanded Precautions is indicated. Category II
V. Prevention of transmission of MDROs (Tables B.3-6, Appendix B)
A. General recommendations for all healthcare settings independent of the
frequency of MDRO transmission or the population served.
1. Administrative measures
a. Designate MDRO prevention and control an organizational patient safety
priority (53, 196, 240, 296-301). Category IB
b. Provide administrative support and fiscal and human resources for MDRO
prevention activities (53, 162, 240, 296-301). Category IB
c. Implement systems to communicate information about reportable MDROs
(e.g., VRSA) to administrative personnel and state and/or local health
authorities according to individual state regulations (64). Category II/IC
d. Implement a multidisciplinary program designed to monitor and improve as
necessary adherence of healthcare personnel to recommended practices for
Standard and Expanded Precautions (6, 240, 299, 301). Category IB
81
e. Implement communication systems that will ensure that receiving HCWs are
notifed prior to inter- and intra-facility transfer of patients who have been
identified recently or previously known to be colonized or infected with MDROs
so that recommended infection control precautions may be initiated promptly
(300, 358, 398, 401, 508-513). Category IB
2. Education and training of healthcare personnel
a. Include MDRO education (e.g., clinical impact, epidemiology, and prevention
strategies) in the required curriculum of all healthcare professional training
programs (e.g., medical and nursing schools) (78, 382, 512, 514-521).
Category II
b. Provide education and training on risks and prevention of MDRO transmission
during orientation and periodic educational updates for healthcare personnel
who have patient care responsibilities and who are responsible for care of
equipment and supplies. Include information on organizational experience,
priorities, and goals (248, 312, 392, 508, 521-524). Category IB
3. Judicious use of antimicrobial agents
a. In all healthcare organizations, implement a system to prompt prescribers to
verify that antimicrobial agents used for treatment of infection are active
against the patient’s clinical isolate(s) (53, 160, 283, 380-387, 389-394, 397,
398, 400, 404, 525, 526). Category IB
b. Avoid use of antimicrobials to treat colonization (e.g., for isolates from tracheal
aspirates without evidence of clinical disease) (527-530)
(www.cdc.gov/drugresistance/healthcare/default.htm). Category II
c. In all healthcare organizations, ensure that a multidisciplinary process is in
place to review antimicrobial utilization, local susceptibility patterns, and
antimicrobial agents included in the formulary to foster appropriate
antimicrobial use (53, 151, 300, 358, 380-387, 390, 392, 395, 401-403, 531533). Category IB/IC
4. Surveillance
a. Establish systems between the healthcare organization and its laboratories
(on-site or commercial laboratories that receive outsourced work) for detecting
82
and communicating to designated personnel (e.g., infection control) evidence
of MDRO emergence in clinical isolates (284, 317, 371, 394, 395, 400, 512,
518, 521, 531, 534-540). Category IB
b. In all healthcare organizations, promptly notify infection control staff or a
medical director designee when a novel resistance pattern for that facility (e.g.,
VISA, VRSA, ESBL-producing GNB) is detected. Notify health departments
according to state and local regulations (11, 64). Category IB/IC
c. Prepare facility-specific summary antimicrobial susceptibility reports as
recommended by the National Committee on Clinical Laboratory Standards
(NCCLS). Monitor for evidence of changing resistance patterns (160, 161,
285, 358, 382, 384, 385, 390, 531, 535, 536, 541-548). Category IA
i. In hospitals and LTCFs with specialized units to for the care of high-risk
patients (e.g., ventilator-dependent, ICU, oncology patients), develop unitspecific antimicrobial susceptibility reports and monitor for changes in
susceptibility that may predict emergence and transmission of an MDRO
(53, 454, 455, 549). Category IB
ii. Determine frequency (e.g., quarterly, semi-annually, annually) of summary
reports based on volume of clinical isolates. Category II
iii. Consult with hospital and/or commercial laboratories on methods for
developing and interpreting aggregate susceptibility data (283, 284, 550).
Category IB
iv. Provide clinicians responsible for care of affected patient populations with
summary susceptibility reports and analysis of trends to guide antimicrobial
prescribing practices (52, 53)
(www.cdc.gov/drugresistance/healthcare/default.htm). Category IB
d. In healthcare organizations that outsource microbiology laboratory services
(e.g., ambulatory care, home care, LTCFs, smaller acute care hospitals),
specify by contract that the laboratory provide either facility-specific
susceptibility data or local or regional aggregate susceptibility data in order to
identify prevalent MDROs and trends in the geographic area served (550).
Category II
83
e. Develop local or regional coalitions to share information on changing patterns
of resistance; collaborate with local and state health departments and area
health facilities (459, 486, 551-554). Category II
f. Identify specific MDROs (e.g., MRSA, VISA, VRSA, VRE, MDR-GNB, ESBLs,
nonsusceptible S. pneumoniae) for ongoing systematic monitoring of
susceptibility trends to detect changes in susceptibility due to antibiotic
pressure, emergence of an environmentally significant organism, and/or
transmission within the healthcare setting (23, 56, 61, 63, 64, 75, 76, 78, 129,
155, 166, 168, 169, 173, 317, 358, 380-382, 385, 394, 395, 404, 450, 486,
510, 518, 522, 537, 538, 541, 543, 545, 555-569). Category IB
i. Specify location and clinical service in MDRO monitoring protocols in
hospitals and other large multi-unit facilities with high-risk patients
(53, 75, 78, 248, 300, 395, 454, 455, 518, 539). Category IB
g. Determine the baseline prevalence of targeted MDRO infection/colonization by
reviewing results of clinical cultures and performing baseline point prevalence
studies of colonization in high risk units; when possible, distinguish
colonization from infection (248, 358, 384, 387, 454, 510, 520, 537, 539, 548,
570-574). Category IB
h. Define an incidence or frequency of targeted MDROs that would trigger
implementation of additional control interventions. Base decisions on
frequency of isolation of targeted MDROs, institutional priorities, whether the
patient population has conditions that would facilitate transmission or is at
increased risk of adverse outcomes following acquisition of infection, and
whether there is suspected or proven transmission within the facility, as
described under V.B. (160, 335, 387, 440, 521, 546, 547, 562, 574-577).
Category IB
5. Infection control precautions to prevent transmission of MDROs
a. Observe Standard Precautions during all patient encounters in all settings
where healthcare is delivered under the assumption that any patient could be
colonized or infected with an MDRO (169, 315, 382, 385, 441, 548, 578, 579).
Category IB
84
b. Patient placement in hospitals and LTCFs
i. When single-patient rooms are available, prioritize patients with known or
suspected MDROs for single-patient room placement. Give additional
priority to those patients who have conditions that may facilitate
transmission (e.g., uncontained drainage, stool incontinence,
infants/toddlers) or those who are at increased risk of adverse outcomes
following acquisition of infection (e.g., severely immunocompromised) (75,
78, 335, 459, 486, 487).Category IB
ii. When single-patient rooms are not available, cohort patients with the same
MDRO in the same room, bay, or patient care unit (75, 78, 248, 335, 459,
486, 487). Category IB
iii. When cohorting patients with the same MDRO is not possible, place
MDRO patients in rooms with patients who are at low risk for acquisition of
MDROs and associated adverse outcomes and are likely to have short
lengths of stay. Category II
iv. In the absence of draining wounds or diarrhea, determine degree of
permitted ambulation, socialization, and use of common areas for patients
with known or suspected MDROs based on the risk to other patients and
on the ability of the MDRO-infected patient to observe proper hand hygiene
and other recommended precautions to contain secretions (221, 459, 555,
580). Category II
c. Contact Precautions
i.
In acute care settings, implement Contact Precautions for all patients
known to be infected or colonized with target MDROs (75, 78, 79, 335,
387, 395, 459, 486, 487, 510, 518, 520, 546). Category IB
ii. In LTCFs, implement on a case-by-case basis Contact Precautions for
patients known to be infected or colonized with target MDROs when the
nature of the HCW-patient interaction and/or the risk to other patients
within the facility indicates a need to intensify use of barriers to prevent
transmission (e.g., MDRO patient has uncontrolled secretions, draining
85
wounds, stool incontinence, ostomy tubes/bags, total dependence on
HCWs for all activities of daily living) (160, 555, 559, 560). Category IB
iii. In ambulatory settings, implement on a case-by-case basis Contact
Precautions for patients known to be infected or colonized with target
MDROs when the nature of the HCW-patient interaction or the risk of
acquisition and associated adverse outcomes to other patients in the area
indicates a need to intensify use of barriers to prevent transmission (e.g.,
MDRO patient has uncontrolled secretions, stool incontinence, ostomy
tubes/bags) or immunocompromised patients are in the same clinic area.
Category II
iv. In home care settings,
a) Implement Contact Precautions on a case-by-case basis for patients
known to be infected or colonized with target MDROs when the nature
of the patient HCW-interaction or the risk of transmission to others
indicates a need to intensify use of barriers to prevent transmission
(e.g., MDRO patients has uncontrolled secretions, stool incontinence,
ostomy tubes/bags) (196). Category II
b) Limit the amount of patient care equipment brought into the home of
patients infected or colonized with MDROs. When possible, leave
patient care equipment in the home until discharge from home care
services (196). Category II
c) If noncritical patient care equipment (e.g., stethoscopes) cannot remain
in the home, clean and disinfect items before removing them from the
home, using a low to intermediate level disinfectant, or place reusable
items in a plastic bag for transport and subsequent cleaning and
disinfection (7, 196). Category II
v. No recommendation for routine use of gloves and/or gowns to prevent
MDRO transmission in ambulatory or home care settings. Unresolved
issue
86
vi. In hemodialysis units, follow the “Recommendations to Prevent
Transmission of Infections in Chronic Hemodialysis Patients” (10).
Category IA
d. Discontinuation of Contact Precautions.
i. In acute care settings, no recommendation for criteria to discontinue
Contact Precautions for patients who are no longer infected but may
remain colonized with an MDRO in acute care settings due to the
intermittent and prolonged duration of colonization (442, 445, 511, 581,
582). Unresolved issue
ii. Outside of acute care settings, discontinuation of Contact Precautions for a
patient colonized or infected with MDROs may be considered on a caseby-case basis if the following criteria are met:
a) Surveillance cultures for the target MDRO are repeatedly negative in a
patient who has not received antimicrobial therapy for several weeks.
b) Absence of an active infection or draining wound.
c) No evidence that the patient has been implicated in patient-to-patient
transmission of the target MDRO within the facility.
d) Patient remains colonized but risk factors for transmission are no longer
present. Category II
6. Environmental measures
Follow recommended routine cleaning, sterilization and disinfection
procedures for maintaining patient care areas and critical and noncritical devices and
equipment (4, 7). Category IB
B. Intensified interventions to prevent MDRO transmission
The interventions presented below have been evaluated as part of many
multicomponent quasi-experimental design studies reported in the literature. Therefore, the
effectiveness of a single or specific combination of interventions in preventing transmission
cannot be assessed (722, 723). However, combinations of interventions have successfully
controlled outbreaks of MDROs in healthcare facilities.
87
1. Indications for intensified MDRO prevention and control strategies:
a. Evidence of continued transmission despite implementation of routine control
measures (248, 335, 358, 520, 573, 574).
b. The incidence and prevalence of the target MDRO have increased beyond the
accepted institutional level despite implementation of routine infection control
measures (134, 387, 539, 583).
c. When the first case of an epidemiologically important MDRO (e.g., VRE, VISA,
VRSA) is identified within a healthcare facility (63, 64, 66, 160, 300, 387, 440,
521, 546, 547, 562, 574-577). Category IB
2. Administrative measures
a. Obtain expert consultation. Identify persons with experience in infection control
and the epidemiology of MDROs either in-house or through outside
consultation for assessment of the local MDRO problem and for the design,
implementation, and evaluation of appropriate control measures (162, 163,
240, 248, 297, 300, 358, 371, 387, 446, 459, 518, 537, 539, 546, 573, 574).
Category IB
b. Evaluate the following healthcare system factors for their role in creating or
perpetuating an environment conducive to transmission of MDROs: staffing
levels, education and training, availability of consumable and durable
resources, communication processes, policies and procedures, barriers to
adherence to recommended infection control measures (e.g., hand hygiene
and Standard or Contact Precautions). Develop, implement, and monitor
action plans to correct system failures (6, 75, 78, 230, 236, 237, 239, 240,
246, 248, 249, 252-255, 257, 394, 395, 486, 518, 519, 577, 584-588).
Category IB
c. Provide feedback to health-care providers and administrators on facility and
patient- care unit trends in MDRO infections. Include information on changes
in prevalence and rates of infection and colonization, results of assessments
for system failures, and action plans to improve adherence to recommended
infection control practices to prevent MDRO transmission (53, 248, 300, 387,
455, 508, 512, 518, 540, 548, 574, 589). Category IB
88
3. Educational interventions
Implement MDRO educational programs for healthcare personnel who have patient
care responsibilities facility-wide and/or in high-risk units targeted for intensified
interventions. Include relevant information on clinical risks for acquisition and transmission,
MDRO trends, results of adherence monitoring observations, identified system failures (e.g.,
inadequate staffing, communication, adherence to recommended practices, availability of
PPE), and action plans for reducing transmission of a targeted MDRO. Provide individual or
unit-specific feedback when available (78, 240, 248, 299, 312, 358, 382, 384, 393, 508,
510-512, 518, 520, 521, 537, 548, 562, 589). Category IB
4. Judicious use of antimicrobial agents
Review antimicrobial use and impose limitations on the use of antimicrobial
agents associated with increased prevalence of target MDROs e.g., vancomycin, thirdgeneration cephalosporins, and anti-anaerobic agents for VRE 128, 388, 395, 396, 399);
third generation cepahlosporins for ESBLs (380, 384, 385); and quinolones and
carbapenems (381-383, 386, 387, 389-394, 397, 398, 400-404).
a. Utilize strategies of proven effectiveness in influencing patterns of
antimicrobial use (e.g., formulary restriction, drug approval programs,
computer assisted management programs) (403, 590-594). Category IB
b. No recommendation for the use of antimicrobial cycling (595). Unresolved issue
5. Surveillance
a. Calculate and analyze prevalence and incidence rates of targeted MDRO
infection/colonization in at-risk populations; when possible, distinguish
colonization from infection (248, 358, 384, 387, 454, 510, 520, 537, 539, 548,
570-574).Category IB
i. Use single isolates from each patient (542). Category IB
ii. Increase frequency of compiling and monitoring antimicrobial susceptibility
summary reports, as indicated by rate of increase in incidence of target
MDROs. Category II
b. Implement laboratory protocols for storing isolates of selected MDROs for
molecular typing when there is a need to confirm transmission or a desire to
89
monitor for epidemiologic purposes in a healthcare setting (75, 78, 287, 336,
395, 518, 537, 539, 547, 588, 596, 597). Category IB
c. Develop and implement protocols to obtain surveillance cultures for target
MDROs from patients in at-risk populations (e.g., patients in intensive care,
burn, HSCT and oncology units; transfers from LTCFs and hemodialysis
centers), as defined within the local institution (75, 78, 248, 336, 358, 371,
387, 395, 459, 486, 510, 518, 520, 537, 539, 546, 560, 568, 574, 598-601).
Category IB
i.
Obtain surveillance cultures from areas of skin breakdown and draining
wounds. In addition, include the following sites according to target MDROs.
Category IB:
a) For MRSA: anterior nares; throat and perirectal or perineal may be
added to increase the yield (172, 600, 602-604).
b) For VRE, MDR-GNB: stool, rectal, or perirectal (441, 599, 605, 606).
ii. Obtain surveillance cultures at the time of admission to a high-risk area
(e.g., ICU); especially culture patients previously known to be infected or
colonized with the target MDRO or patients arriving from units or facilities
with high endemic rates of the target MDRO (75, 384, 387, 459, 508, 511,
518, 574, 588, 589, 607). Category IB
d. Conduct culture surveys to assess the efficacy of the enhanced MDRO
control interventions.
i. Conduct unit-specific point prevalence culture surveys of the target
MDRO to determine if transmission has decreased or ceased (87, 371, 393,
394, 401, 486, 560, 574). Category IB
ii. Repeat point-prevalence culture surveys at routine intervals (e.g., weekly,
biweekly, or monthly) and at time of patient discharge or transfer until
transmission has ceased (75, 87, 248, 384, 387, 393, 518, 537, 539, 543,
598, 608). Category IB
iii. Ensure that culture data provide colonization status of roommates and
other patients with substantial exposure to patients with known MDRO
infection/colonization (358, 388, 395, 546, 560, 609). Category IB
90
e. Obtain cultures of healthcare personnel for target MDROs only when there
is epidemiologic evidence implicating the healthcare staff member as a
source of ongoing transmission(78, 248, 371, 390, 518, 539, 573, 575).
Category IB
f. Implement systems to monitor changes in MDRO incidence and prevalence
after reducing the intensity of MDRO control efforts.
Category II
6. Enhanced infection control precautions
a. Patient placement: Implement interim policies for patient admissions,
placement and staffing as needed to prevent transmission of a problem MDRO
(358, 371, 387, 401, 510, 520, 574, 610). Category IB
i.
Place MDRO patients in single-patient rooms when available (336, 371,
397, 459, 513, 522, 533, 544, 547, 562, 588, 611-614).
ii. Cohort patients with the same MDRO in segregated areas (e.g., rooms,
bays, patient care areas (75, 248, 385, 387, 395, 400, 401, 486, 513, 520,
524, 525, 561, 574, 587-589).
iii. When transmission continues despite cohorting patients, assign dedicated
nursing staff (and other staff where possible) to the care of MDRO patients
only (361,387,395,574).
iv. Close unit or facility to new admissions if transmission continues despite
the implementation of the intensified infection control measures described
above (76, 78, 394, 401, 525, 540, 548, 587, 589, 598, 615-617).
b. Implement Contact Precautions routinely for all patients colonized or infected
with target MDROs. Don gowns and gloves before or upon entry to the
patient’s room or cubicle due to possible contamination of environmental
surfaces and medical equipment, especially those in close proximity to the
patient (78, 248, 336, 338, 358, 371, 387, 395, 401, 459, 510, 518, 520, 539,
540, 546, 574, 589, 618). Category IA
c. When active surveillance cultures are obtained as part of an MDRO control
program, implement Contact Precautions until the surveillance culture
91
obtained on admission is reported negative for the target MDRO (87, 341, 486,
511, 512, 539, 546, 619, 620). Category IB
d. No recommendation for universal glove and/or gown use in high-risk units in
acute care hospitals(341, 512, 539, 619, 620, 621). Unresolved issue
e. Masks are not recommended for routine use upon room entry by HCWs to
prevent transmission of MDROs from patient to healthcare worker and
resulting nasal colonization. Use masks to prevent transmission of MRSA,
VISA, and VRSA when aerosol-generating procedures (e.g., wound irrigation,
oral suctioning, intubation, nebulizer respiratory therapy treatments,
bronchoscopy) are performed and in circumstances where there is evidence of
transmission from aerosolization from heavily colonized sources (e.g., burn
wounds) (1,10, 64, 522, 539, 546, 622, 623). Category IB
f. Discontinuation of Contact Precautions
i.
No recommendation for criteria to discontinue Contact Precautions for a
patient who is no longer infected but may remain colonized with an MDRO
and is part of a unit-specific or facility-wide application of Contact
Precautions due to the intermittent and prolonged duration of colonization
(442, 445, 581, 582, 624). Unresolved issue.
ii. Consult experts in infection control and healthcare epidemiology to
determine whether an intensified MDRO control program has been
successful in decreasing transmission of MDROs, for criteria for
discontinuing Contact Precautions for patients previously identified as
colonized or infected with the target MDRO, and for criteria to discontinue
active surveillance cultures (446). Category II
7. Enhanced environmental measures
a. Implement patient-dedicated use of noncritical equipment (e.g., blood pressure
cuff, stethoscope) (15, 78, 317, 383, 391, 395, 459, 523, 544, 545, 555, 559,
561, 589). Category IB
b. Assign dedicated staff who have been trained in the role of the environment in
transmission of MDROs to targeted patient care areas to enhance consistency
of proper environmental cleaning and disinfection services (78, 358, 394, 395,
92
401, 518, 543, 548, 561, 564, 577, 586, 588, 589, 609, 615, 625-627).
Category II
c. Implement procedures that ensure consistent cleaning and disinfection of
surfaces in close proximity to the patient and likely to be touched by the
patient and HCWs (e.g., bedrails, carts, bedside commodes, doorknobs,
faucet handles) (2, 4, 7, 479, 480, 628). Category IB
d. Obtain cultures from environmental sources (e.g., surfaces, shared medical
equipment) only when there is epidemiologic evidence suggesting an
environmental source associated with ongoing transmission of the targeted
MDRO (4, 15, 23, 25, 26, 78, 222, 401, 518, 588, 629). Category IB
e. Vacate units for environmental assessment and intensive cleaning when
previous efforts to eliminate environmental reservoirs have failed (394, 401,
540, 548, 615). Category II
8. Decolonization
a. Consult with physicians with expertise in infectious diseases/healthcare
epidemiology on a case-by-case basis regarding the appropriate use of
decolonization therapy for a limited period of time as a component of an
MRSA control program (487, 630-632). Category II
b. When decolonization is used, perform susceptibility testing of the decolonizing
agent against the target organism in the individual being treated and/or the
MDRO strain epidemiologically implicated in transmission. Monitor
susceptibility to detect emergence of resistance to the decolonizing agent (87,
630, 633, 637). Category IB
c. Do not use topical mupiricin routinely for MRSA decolonization of patients as a
component of MRSA control programs in any healthcare setting due to risk of
emergence of mupiricin-resistant strains and difficulty in eradicating MRSA
when multiple body sites are colonized (444, 630, 631, 633-637). Category IB
d. No recommendation for decolonizing patients with VRE or MDR-GNB.
Regimens and efficacy of decolonization protocols for VRE and MDR-GNB
have not been established (442, 445, 581, 582, 624). Unresolved issue
93
e. Decolonize HCWs found to be colonized with MRSA only when implicated
epidemiologically in transmission to patients (486, 520, 539, 598, 630).
Category IA
94
Part IV. Performance indicators
A. General
1. Monitor appropriateness of Expanded Precautions initiated at the time of
admission based on clinical diagnosis (e.g., bronchiolitis, pertussis, influenza) and
appropriateness of time of discontinuation.
2. Periodically audit the use of PPE by HCWs when caring for patients on Expanded
Precautions.
3. Periodically assess the appropriate use of single-patient rooms to meet infection
control needs. Use this information for future facility planning.
4. Include assessment of staffing levels when ongoing transmission of
epidemiologically important pathogens is evaluated.
5. Assess adequacy of supplies of PPE for adherence to recommended Standard
and Expanded Precautions.
B. Prevention of MDRO transmission
1. Develop and implement a plan for periodically monitoring adherence to selected
performance indicators (e.g., hand hygiene, proper use of barrier precautions) for
MDRO prevention. Provide feedback to personnel regarding their performance
(387, 540, 574, 638).
2. When increased incidence of a target MDRO is observed, monitor selected
indicators to identify contributing factors. Implement corrective actions based on
findings and monitor results (387, 540, 574, 638).
95
TABLE 1. HISTORY OF GUIDELINES FOR ISOLATION PRECAUTIONS IN HOSPITALS*
YEAR
(Ref)
1970
(639)
Isolation Techniques for Use in
Hospitals, 1st ed.
1975
(640)
1983
(641)
Isolation Techniques for Use in
Hospitals, 2nd ed.
CDC Guideline for Isolation Precautions
in Hospitals
1985-88
(427, 428)
DOCUMENT ISSUED
Universal Precautions
COMMENT
- Introduced seven isolation precaution categories with color-coded
cards: Strict, Respiratory, Protective, Enteric, Wound and Skin,
Discharge, and Blood
- No user decision-making required
- Simplicity a strength; overisolation prescribed for some infections
- Same conceptual framework as 1st edition
- Provided two systems for isolation: category-specific and diseasespecific
- Protective Isolation eliminated; Blood Precautions expanded to include
Body Fluids
- Categories included Strict, Contact, Respiratory, AFB, Enteric,
Drainage/Secretion, Blood and Body Fluids
- Emphasized decision-making by users
- Developed in response to HIV/AIDS epidemic
- Dictated application of Blood and Body Fluid precautions to all patients,
regardless of infection status
- Did not apply to feces, nasal secretions, sputum, sweat, tears, urine, or
vomitus unless contaminated by visible blood
- Added personal protective equipment to protect HCWs from mucous
membrane exposures
- Handwashing recommended immediately after glove removal
- Added specific recommendations for handling needles and other sharp
devices; concept became integral to OSHA’s 1991 rule on occupational
exposure to blood-borne pathogens in healthcare settings
96
1987
(642)
Body Substance Isolation
- Emphasized avoiding contact with all moist and potentially infectious
body substances except sweat even if blood not present
- Shared some features with Universal Precautions
- Weak on infections transmitted by large droplets or by contact with dry
surfaces
- Did not emphasize need for special ventilation to contain airborne
infections
- Handwashing after glove removal not specified in the absence of
visible soiling
1996
(1)
Guideline for Isolation Precautions in
Hospitals
- Prepared by the Healthcare Infection Control Practices Advisory
Committee (HICPAC)
- Melded major features of Universal Precautions and Body
Substance Isolation into Standard Precautions to be used with all
patients at all times
- Included three transmission-based precaution categories: airborne,
droplet, and contact
- Listed clinical syndromes that should dictate use of empiric isolation
until an etiological diagnosis is established
* Derived from Garner ICHE 1996
97
TABLE 2. DEFINITIONS
American Institute of Architects (AIA). A professional organization that develops and
updates “Guidelines for Design and Construction of Hospital and Health Care Facilities”.
AIA recommendations for building ventilation are the primary source of guidance for creating
airborne infection isolation and protective environments (www.aia.org/aah).
Ambulatory care settings. Facilities that provide health care to patients who do not
remain overnight e.g., hospital-based outpatient clinics, nonhospital-based clinics and
physician offices, urgent care centers, surgicenters, free-standing dialysis centers, public
health clinics, imaging centers, ambulatory behavioral health and substance abuse clinics,
physical therapy and rehabilitation centers, and dental practices.
Caregivers. Persons who provide care to a patient. This term includes both healthcare
workers (HCWs) (see below) who have technical or professional training and are employed
for the purpose of providing care and persons who are not employees of an organization,
are not paid, and provide or assist in providing healthcare to a patient (e.g., family member,
friend) and acquire technical training as needed based on the tasks that must be performed.
Droplet nuclei. Small particle residue of evaporated droplets that are < 5 µm in size and
are produced when a person coughs, sneezes, shouts, or sings. These particles can remain
suspended in the air for prolonged periods of time and can be carried on normal air currents
within a room or travel long distances outside the room.
Epidemiologically important infectious agents. Infectious agents that have one or more
of the following characteristics: 1) are readily transmissible; 2) have a proclivity toward
causing outbreaks; 3) may be associated with a severe outcome; or 4) are difficult to treat,
such as Acinetobacter, Aspergillus sp., Burkholderia cepacia, Clostridium difficile, Klebsiella
or Enterobacter spP., methicillin-resistant Staphylococcus aureus [MRSA], Pseudomonas
aeruginosa, vancomycin-resistant enterococci [VRE], influenza virus, respiratory syncytial
virus, and rotavirus).
98
Expanded Precautions. A term that has replaced “Transmission-based Precautions” to
reflect infection control measures, in addition to Standard Precautions that are needed to
prevent transmission of highly transmissible or epidemiologically important infectious
agents. The following categories of precautions are included in Expanded Precautions:
Contact Precautions, Droplet Precautions, Airborne Infection Isolation, and Protective
Environment (see text for descriptions).
Hand hygiene. A general term that applies to any one of the following: 1) handwashing
with plain (nonantimicrobial) soap and water); 2) antiseptic handwash (soap containing
antiseptic agents and water); 3) antiseptic handrub (waterless antiseptic product, most often
alcohol-based, rubbed on all surfaces of hands); or 4) surgical hand antisepsis (antiseptic
handwash or antiseptic handrub performed preoperatively by surgical personnel to eliminate
transient and reduce resident hand flora)(6).
Healthcare-associated infection (HAI). An infection that develops in a patient who is
cared for in any setting where healthcare is delivered (e.g., acute care hospital, chronic care
facility, ambulatory clinic, dialysis center, surgicenter, home) and is related to receiving
health care (i.e., was not incubating or present at the time healthcare was provided). In
ambulatory and home settings, HAI would apply to any infection that is associated with a
medical or surgical intervention. Since the geographic location of infection acquisition is
often uncertain, the infection is considered to be healthcare-associated rather than
healthcare-acquired.
Healthcare epidemiologist. A person whose primary training is medical (M.D., D.O.) or
doctorate-level epidemiology who has received advanced training in infectious diseases or
healthcare epidemiology. Typically these professionals direct or provide consultation to an
infection control program in a hospital, long term care facility (LTCF), or healthcare delivery
system (also see infection control professional).
99
Healthcare personnel, healthcare worker (HCW). All paid and unpaid persons who work
in a healthcare setting (e.g. any person who has professional or technical training in a
healthcare-related field and provides patient care in a healthcare setting or any person who
provides services that support the delivery of healthcare such as dietary, housekeeping,
engineering, maintenance personnel).
Hematopoietic stem cell transplantation (HSCT). Any transplantation of blood- or
marrow-derived hematopoietic stem cells, regardless of transplant type (e.g., allogeneic or
autologous) or cell source (e.g., bone marrow, peripheral blood, or placental/umbilical cord
blood); associated with periods of severe immunosuppression that vary with the source of
the cells, the intensity of chemotherapy required, and the presence of graft versus host
disease (13).
High-efficiency particulate air (HEPA) filter. An air filter that removes >99.97% of
particles 0.3µm (the most penetrating particle size) at a specified flow rate of air. HEPA
filters may be integrated into the central air handling systems, installed at the point of use
above the ceiling of a room, or used as portable units (4).
Home health care. A wide-range of medical, nursing, rehabilitation and social services
delivered to patients in their place of residence (e.g., private residence, senior living center,
assisted living facility). Home health-care services include care provided by home health
aides and skilled nurses; provision of durable medical equipment; home infusion therapy;
and physical, speech, and occupational therapy.
Immunocompromised. A condition in which the immune system is not functioning
normally, leaving the patient in a permanent or temporary state of increased susceptibility to
infection. Immunocompromised is the broader term, and immunosuppression refers to
restricted states with iatrogenic causes, including causes that result from therapy for another
condition. Susceptibility to various infections is determined by severity of
immunosuppression and the components of the immune system that are most severely
affected. Conditions associated with immunocompromise may be congenital or acquired
100
(e.g., genetically determined primary immune deficiencies, human immunodeficiency virus
infection, immunosuppressive chemotherapy for a primary disease state such as oncologic
or rheumatologic disorders and HSCT or solid organ transplants). Patients undergoing
allogeneic HSCT and those with chronic graft versus host disease are considered the most
vulnerable to healthcare-associated infections. Immunocompromised states also make it
more difficult to diagnose certain infections (e.g., tuberculosis) and are associated with more
severe clinical disease states than those seen in persons with a normal immune system.
Infection control professional (ICP). A person whose primary training is in either nursing,
medical technology, microbiology, or epidemiology and who has acquired specialized
training in infection control. Responsibilities may include collection and analysis of infection
data; consultation on infection risk assessment, prevention and control strategies;
performance of education and training activities; implementation of evidence-based infection
control practices or those mandated by regulatory and licensing agencies; application of
epidemiologic principles to improve patient outcomes; participation in planning renovation
and construction projects (e.g., to ensure appropriate containment of construction dust);
evaluation of new products or procedures on patient outcomes; and participation in
research. Certification in infection control (CIC) is available through the Certification Board
of Infection Control and Epidemiology.
Infection control program. A multidisciplinary program that includes a group of activities to
ensure that recommended practices for the prevention of healthcare-associated infections
are implemented and followed by HCWs, making the healthcare setting safe from infection
for patients and healthcare personnel. The Joint Commission on Accreditation of Healthcare
Organizations (JCAHO) requires the following five components of an infection control
program for accreditation: 1) surveillance: monitoring patients and healthcare personnel for
acquisition of infection and/or colonization; 2) investigation: identification and analysis of
infection problems or undesirable trends; 3) prevention: implementation of measures to
prevent transmission of infectious agents and to reduce risks for device- and procedurerelated infections; 4) control: evaluation and management of outbreaks; and 5) reporting:
provision of information to external agencies as required by state and federal law and
101
regulation (www.jcaho.org). The infection control program staff has the ultimate authority to
determine infection control policies for a healthcare organization with the approval of the
organization’s governing body.
Long-term care facility (LTCF). An array of residential and outpatient facilities designed to
meet the biopsychosocial needs of persons with sustained self-care deficits. These include
skilled nursing facilities, chronic disease hospitals, nursing homes, foster and group homes,
institutions for the developmentally disabled, residential care facilities, assisted living
facilities, retirement homes, adult day health care facilities, rehabilitation centers, and longterm psychiatric hospitals.
Multidrug-resistant organisms. In general, bacteria (excluding M. tuberculosis) that are
resistant to one or more classes of antimicrobial agents and usually are resistant to all but
one or two commercially available antimicrobial agents (e.g., MRSA, VRE, extended
spectrum beta-lactamase [ESBL]-producing or intrinsically resistant gram-negative bacilli)
(52).
Nosocomial infection. Derived from two Greek words “nosos” (disease) and “komeion” (to
take care of). Refers to any infection that develops during or as a result of an admission to
an acute care facility (hospital) and was not incubating at the time of admission.
Personal protective equipment (PPE). A variety of barriers used alone or in combination
to protect mucous membranes, skin, and clothing from contact with infectious agents. PPE
includes gloves, masks, respirators, goggles, face shields, and gowns/aprons.
Residential care setting. A facility in which people live, minimal medical care is delivered,
and the psychosocial needs of the residents are provided for.
Respirator. A personal protective device worn by healthcare personnel over the nose and
mouth to protect them from acquiring airborne infectious diseases due to inhalation of
infectious airborne particles that are < 5 µm in size. These include infectious droplet nuclei
102
from patients with M. tuberculosis, variola virus [smallpox], SARS-CoV), and dust particles
that contain infectious particles, such as spores of environmental fungi(e.g., Aspergillus sp.).
The CDC’s National Institute for Occupational Safety and Health (NIOSH) certifies
respirators used in healthcare settings (http://www.cdc.gov/niosh/topics/respirators/). The
N-95 disposable particulate, air purifying, respirator is the type used most commonly by
HCWs. Other respirators used include N-99 and N-100 particulate respirators, powered airpurifying respirators (PAPRS) with high efficiency filters; and non-powered full-facepiece
elastomeric negative pressure respirators. A listing of NIOSH- approved respirators can be
found at www.cdc.gov/niosh/npptl/respirators/disp_part/particlist.html. Respirators must be
used in conjunction with a complete Respiratory Protection Program, as required by the
Occupational Safety and Health Administration (OSHA),that includes fit testing, training,
proper selection of respirators, medical clearance and respirator maintenance.
Respiratory Hygiene/ Cough Etiquette. A combination of measures designed to minimize
the transmission of respiratory pathogens via droplet or airborne routes in healthcare
settings. The components of respiratory hygiene/cough etiquette are 1) covering the mouth
and nose during coughing and sneezing, 2) using tissues to contain respiratory secretions
with prompt disposal into a no-touch receptacle, 3) offering a surgical mask to persons who
are coughing to decrease contamination of the surrounding environment, and 4) turning the
head away from others and maintaining spatial separation, ideally >3 feet, when coughing.
These measures are targeted to all patients with symptoms of respiratory infection and their
accompanying family members or friends beginning at the point of initial encounter with a
healthcare setting (e.g., reception/triage in emergency departments, ambulatory clinics,
healthcare provider offices) (11)
(www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm).
Safety culture. Shared perceptions of workers and management regarding the level of
safety in the work environment. A hospital safety climate includes the following six
organizational components: 1) senior management support for safety programs; 2) absence
of workplace barriers to safe work practices; 3) cleanliness and orderliness of the worksite;
4) minimal conflict and good communication among staff members; 5) frequent safety-
103
related feedback/training by supervisors; and 6) availability of PPE and engineering controls
(234).
Standard Precautions. A group of infection prevention practices that apply to all patients,
regardless of diagnosis or presumed infection status. Standard Precautions is a
combination and expansion of Universal Precautions (428) and Body Substance Isolation
(1, 642). Standard Precautions is based on the principle that all blood, body fluids,
secretions, excretions except sweat, nonintact skin, and mucous membranes may contain
transmissible infectious agents. Standard Precautions includes hand hygiene, and
depending on the anticipated exposure, use of gloves, gown, mask, eye protection, or face
shield. Also, equipment or items in the patient environment likely to have been
contaminated with infectious fluids must be handled in a manner to prevent transmission of
infectious agents, e.g. wear gloves for handling, contain heavily soiled equipment, properly
clean and disinfect or sterilize reusable equipment before use on another patient.
Surgical mask. A device worn over the mouth and nose by operating room personnel
during surgical procedures to protect both surgical patients and operating room personnel
from transfer of microorganisms and body fluids. Surgical masks also are used to protect
HCWs from contact with large infectious droplets (>5-10 µm in size). According to draft
guidance issued by the Food and Drug Administration on May 15, 2003, surgical masks are
evaluated using standardized testing procedures for fluid resistance, bacterial filtration
efficiency, differential pressure (air exchange), and flammability in order to mitigate the risks
to health associated with the use of surgical masks. These specifications apply to any
masks that are labeled surgical, laser, isolation, or dental or medical procedure
(www.fda.gov/cdrh/ode/guidance/094.html#4). Surgical masks do not protect against
inhalation of small particles and should not be confused with particulate respirators that are
recommended for protection against airborne infectious particles.
104
TABLE 3. INFECTION CONTROL CONSIDERATIONS FOR HIGH-PRIORITY (CDC CATEGORY A)
DISEASES THAT HAVE RESULTED FROM BIOTERRORIST ATTACKS OR CONSIDERED TO BE
BIOTERRORIST THREATS (www.bt.cdc.gov) a (643)
Agent
Anthrax
Cutaneous and
inhalation
disease have
occurred in past
bioterrorist
incidents.
Smallpox
If used as a
biological
Clinical Features
Diagnosis
Infectivity
Recommended
Precautions
Sites: Skin (contact
with spores), RT
(inhalation of spores),
GIT (ingestion of
spores - rare)
Incubation period:
Usually 1 to 7 days
but up to 60-90 days
possible for RT.
Comment: Spores 12 F or spore clusters
of up to 5 F in size;
infectious dose
estimated to be 8,000
to 15,000 but probably
lower.
Skin: Painless,
reddish papule,
which becomes
edematous in 1-2
days; over next 3-7
days lesion
becomes pustular
and then necrotic
with black eschar.
RT: initial flu-like
illness for 1-3 days
with headache,
fever, malaise,
cough; by day 4
severe dyspnea
and shock;
meningitis in 50%.
Skin: Culture of
swab or punch
biopsy;
RT: CXR
demonstrating wide
mediastinum or chest
CT showing
hypodense hilar and
mediastinal nodes
and mediastinal
edema may suggest
clinical diagnosis;
hemorrhagic pleural
effusion; cultures,
PCR of blood, pleural
fluids and CSF for
etiologic diagnosis.
Skin: Person-toperson
transmission from
contact with
lesion of
untreated patient
possible, but
extremely rare;
RT: Person-toperson
transmission
does not occur.
RT Inhalation of
droplet or, rarely,
aerosols and skin
Fever, malaise,
backache,
headache, and
Electron microscopy
of vesicular fluid or
culture of vesicular
Secondary attack
rates up to 50%
in unvaccinated
Cutaneous: Standard
Precautions; Contact
Precautions if
uncontained copious
drainage.
Inhalation: Standard
Precautions.
Aerosolized powder,
environmental
exposures:
Respirator (N95 mask
or PAPRs), protective
clothing;
decontamination of
persons with powder
on them (644)
Hand hygiene:
Handwashing with
soap and water after
spore contact (alcohol
handrubs inactive
against spores).
Post-exposure
chemoprophylaxis;
Offer post-exposure
vaccine under IND
Combined use of
Standard, Contact,
Precautions and
Site (Means of
Transmission);
Incubation Period
105
Agent
Site (Means of
Transmission);
Incubation Period
Clinical Features
Diagnosis
Infectivity
Recommended
Precautions
weapon, natural
disease, which
has not occurred
since 1977, will
likely result.
lesions (contact with
virus).
Incubation period:
7 to 19 days (mean 12
days)
often vomiting for
2-3 days; then
generalized papular
or maculopapular
rash (more on face
and extremities),
which becomes
vesicular (on day 4
or 5) and then
pustular; lesions all
in same stage.
fluid in eggs or cell
culture, detection by
PCR.
persons; infected
persons may
transmit disease
from time rash
appears until all
lesions have
crusted over
(about 3 weeks);
greatest infectivity
during first 10
days of rash.
Airborne Infection
Isolation (AII)b until all
scabs have separated
(3-4 weeks).
Only immune HCWs
to care for pts; postexposure vaccine
within 4 days.
Vaccinia:
HCWs cover
vaccination site with
gauze and semipermeable dressing
until scab separates
(>21 days). Observe
hand hygiene.
Adverse events with
virus-containing
lesions:c Standard,
Contact Precautions
until all lesions
crusted; AII.
Plague
RT: Inhalation of
respiratory droplets.
Incubation Period: 1
to 6, usually 2 to 3
days.
Pneumonic: fever,
chills, headache,
cough, dyspnea,
hemoptysis, and
rapid progression
Presumptive
diagnosis from Gram
stain or Wayson stain
of sputum, CSF, or
lymph node aspirate;
Person-to-person
transmission
occurs via
respiratory
droplets;
Standard and Droplet
precautions until
patients have received
72 hours of
appropriate therapy.
Pneumonic
plague most
likely to occur if
106
Agent
Site (Means of
Transmission);
Incubation Period
Clinical Features
Diagnosis
Infectivity
Recommended
Precautions
used as a
biological
weapon, but
some cases of
bubonic and 10
septicemia may
also occur.
Comment: infective
dose 100 to 500
bacteria.
of weakness,
circulatory collapse,
and bleeding
diathesis.
definitive diagnosis
from cultures of same
material.
respiratory
secretions
probably remain
infectious for 24
to 48 hours after
initiation of
appropriate
therapy.
Chemoprophylaxis:
Provide antibiotic
prophylaxis for
exposed HCWs.
Botulism
GIT: Ingestion of
items contaminated
with toxin
RT: Inhalation of toxin
containing aerosol
cause disease.
Incubation period: 15 days.
Comment: LD50 for
type A is 0.001
µg/ml/kg.
Ptosis, generalized
weakness,
dizziness, dry
mouth and throat,
blurred vision,
diplopia, dysarthria,
dysphonia, and
dysphagia followed
by symmetrical
descending
paralysis and
respiratory failure.
Clinical diagnosis,
identification of toxin
in stool, serology
unless toxincontaining material
available for toxin
neutralization
bioassays.
Not transmitted
from person to
person. Exposure
to toxin
necessary for
disease.
Standard Precautions.
RT: Inhalation of
aerosolized bacteria.
GIT: Ingestion of food
or drink contaminated
with aerosolized
bacteria.
Incubation period: 2
to 10 days, usually 3
to 5 days.
Comment: infective
dose 10 to 50
Pneumonia: fever,
malaise, cough,
sputum production,
dyspnea;
Typhoidal: fever,
prostration, weight
loss and frequently
an associated
pneumonia.
Diagnosis usually
made with serology
on acute and
convalescent serum
specimens;
bacterium can be
isolated from blood
and other body fluids
on cysteine-enriched
media or mouse
inoculation.
Person-to-person
spread is rare.
Laboratory
workers who
encounter/handle
cultures of this
organism are at
high risk for
disease if
exposed.
Standard Precautions.
BSL-2 laboratory
precautions required.
Toxin ingested or
potentially
delivered by
aerosol in
bioterrorist
incidents.
Tularemia
Pneumonic or
typhoidal
disease likely to
occur after
bioterrorist event
using aerosol
delivery.
107
Agent
Site (Means of
Transmission);
Incubation Period
Clinical Features
Diagnosis
Infectivity
Recommended
Precautions
As a rule infection
develops after
exposure of skin,
mucous membranes,
or RT to viruses
(respiratory droplet or
aerosol, depending
upon the agent, and
contact).
Incubation period: 219 days, usually 5-10
days.
Febrile illnesses
with malaise,
myalgias,
headache, vomiting
and diarrhea that
are rapidly
complicated by
hypotension,
shock, and
hemorrhagic
features.
Etiologic diagnosis
usually requires viral
cultures of blood and
other body fluids or
serologic studies
(role of PCR testing
uncertain).
Person-to-person
transmission
frequent;
transmission in
healthcare
settings common
outbreak reports.
Hemorrhagic fever
specific barrier
precautions: strict
hand hygiene plus
double-gloves,
impermeable gowns,
face shields, eye
protection, and leg
and shoe coverings
plus Airborne Infection
Isolationb
bacteria.
Viral
Hemorrhagic
Fever (VHF),
e.g., Ebola.
Natural disease
would probably
occur after
release of these
agents in any
form.
a
Abbreviations used in this table: RT = respiratory tract; GIT = gastrointestinal tract; CXR = chest x-ray; CT = computerized axial tomography;
CSF = cerebrospinal fluid; and LD50 – lethal dose for 50% of experimental animals; HCWs = healthcare worker; BSL = biosafety level; PAPR =
powered air purifying respirator; PCR = polymerase chain reaction
b
Transmission by the airborne route is a rare event; airborne infection isolation is recommended when possible, but in the event of mass
exposures, barrier precautions and containment within a designated area are most important (47, 90).
c
Vaccinia adverse events with lesions containing infectious virus include inadvertent autoinoculation, ocular lesions (blepharitis, conjunctivitis),
generalized vaccinia, progressive vaccinia, eczema vaccinatum; bacterial superinfection also requires addition of contact precautions if exudates
cannot be contained (97, 98).
108
TABLE 4. RECOMMENDATIONS FOR APPLICATION OF STANDARD
PRECAUTIONS FOR THE CARE OF ALL PATIENTS IN ALL
HEALTHCARE SETTINGS
COMPONENT
Hand hygiene
Personal protective equipment (PPE)
Gloves
Mask, eye protection, face shield
Gown
Soiled patient-care equipment
Environmental control
Textiles and laundry
Needles and other sharps
Patient resuscitation
Patient placement
Respiratory hygiene/cough etiquette
(source containment of infectious respiratory
secretions in symptomatic patients,
beginning at initial point of encounter e.g.,
triage and reception areas in emergency
departments and physician offices)
RECOMMENDATIONS
After touching blood, body fluids, secretions, excretions,
contaminated items; immediately after removing gloves;
between patient contacts
For touching blood, body fluids, secretions, excretions,
contaminated items; for touching mucous membranes and
nonintact skin
During procedures and patient-care activities likely to
generate splashes or sprays of blood, body fluids,
secretions
During procedures and patient-care activities when
contact of clothing/exposed skin with blood/body fluids,
secretions, and excretions is anticipated.
Handle in a manner that prevents transfer of
microorganisms to others and to the environment; wear
gloves if visibly contaminated; perform hand hygiene.
Develop procedures for routine care, cleaning, and
disinfection of environmental surfaces, especially
frequently touched surfaces in patient-care areas.
Handle in a manner that prevents transfer of
microorganisms to others and to the environment
Do not recap, bend, break, or hand-manipulate used
needles; if recapping is required, use a one-handed scoop
technique only; use safety features when available; place
used sharps in puncture-resistant container
Use mouthpiece, resuscitation bag, other ventilation
devices to prevent contact with mouth and oral secretions
Prioritize for single-patient room if patient is at increased
risk of transmission, is likely to contaminate the
environment, does not maintain appropriate hygiene, or is
at increased risk of acquiring infection or developing
adverse outcome following infection.
Instruct symptomatic persons to cover mouth/nose when
sneezing/coughing; use tissues and dispose in no-touch
receptacle; observe hand hygiene after soiling of hands
with respiratory secretions; wear surgical mask if
tolerated or maintain spatial separation, >3 feet if
possible.
109
TABLE 5. COMPONENTS OF A PROTECTIVE ENVIRONMENT (PE)
(Adapted from (4))
I. Patients: allogeneic hematopoeitic stem cell transplant (HSCT) only
• Maintain in PE room except for required diagnostic or therapeutic procedures that cannot be performed in
the room, e.g. radiology, operating room
• Respiratory protection e.g., N95 respirator, for the patient when leaving PE during periods of construction
II. Standard and Expanded Precautions
• Hand hygiene observed before and after patient contact
• Gown, gloves, mask NOT required for HCWs or visitors for routine entry into the room
• Use of gown, gloves, mask by HCWs and visitors according to Standard Precautions and as indicated for
suspected or proven infections for which Expanded Precautions are recommended
III. Engineering
• Central or point-of-use HEPA (99.97% efficiency) filters capable of removing particles 0.3 µm in diameter
for supply (incoming) air
• Well-sealed rooms
o Proper construction of windows, doors, and intake and exhaust ports
o Ceilings: smooth, free of fissures, open joints, crevices
o Walls sealed above and below the ceiling
o If leakage detected, locate source and make necessary repairs
• Ventilation to maintain >12 ACH
• Directed air flow: air supply and exhaust grills located so that clean, filtered air enters from one side of the
room, flows across the patient’s bed, exits on opposite side of the room
• Positive room air pressure in relation to the corridor
o Pressure differential of >2.5 Pa [0.01” water gauge]
• Monitor and document results of air flow patterns daily using visual methods (e.g., flutter strips, smoke
tubes)
• Self-closing door on all room exits
• Maintain back-up ventilation equipment (e.g., portable units for fans or filters) for emergency provision of
ventilation requirements for PE areas and take immediate steps to restore the fixed ventilation system
• For patients who require both a PE and Airborne Infection Isolation, use an anteroom to ensure proper air
balance relationships and provide independent exhaust of contaminated air to the outside or place a
HEPA filter in the exhaust duct. If an anteroom is not available, place patient in an AII room and use
portable ventilation units, industrial-grade HEPA filters to enhance filtration of spores.
IV. Surfaces
• Daily wet-dusting of horizontal surfaces using cloths moistened with EPA-registered hospital
disinfectant/detergent
• Avoid dusting methods that disperse dust
• No carpeting in patient rooms or hallways
• No upholstered furniture and furnishings
V. Other
• No flowers (fresh or dried) or potted plants in PE rooms or areas
• Use vacuum cleaner equipped with HEPA filters when vacuum cleaning is necessary
110
TABLE 6. CLINICAL SYNDROMES OR CONDITIONS WARRANTING ADDITIONAL EMPIRIC PRECAUTIONS
TO PREVENT TRANSMISSION OF EPIDEMIOLOGICALLY IMPORTANT PATHOGENS PENDING
CONFIRMATION OF DIAGNOSIS*
Clinical Syndrome or Condition†
Diarrhea
Potential Pathogens‡
Empiric Precautions
Acute diarrhea with a likely infectious cause in an
incontinent or diapered patient
Meningitis
Enteric pathogens§
Standard plus Contact (pediatrics and adult)
Neisseria meningitidis
Droplet for first 24 hrs of antimicrobial therapy; mask and face
protection for intubation
Enteroviruses
Contact for infants and children
Rash or exanthems, generalized, etiology unknown
Petechial/ecchymotic with fever
Vesicular
Maculopapular with cough, coryza and fever
Neisseria meningitidis
Varicella,smallpox, or
vaccinia virus
Rubeola (measles) virus
Droplet for first 24 hrs of antimicrobial therapy
Airborne Infection Isolation plus Contact;
Contact if vaccinia
Airborne Infection Isolation
Respiratory infections
Airborne Infection Isolation; add Contact plus eye protection if
Cough/fever/upper lobe pulmonary infiltrate in an HIV- M. tuberculosis; severe
negative patient or a patient at low risk for human
acute respiratory syndrome history of SARS exposure, travel
immunodeficiency virus (HIV) infection
virus
(SARS-CoV)
Airborne Infection Isolation
Cough/fever/pulmonary infiltrate in any lung location in M. tuberculosis
an HIV-infected patient or a patient at high risk for HIV
infection
111
Clinical Syndrome or Condition†
Respiratory infections, particularly bronchiolitis
and pneumonia, in infants and young children
Potential Pathogens‡
EmpiricPrecautions
Staphylococcus aureus,
group A streptococcus
Contact
Respiratory syncytial virus, Contact plus Droplet; Droplet may be discontinued when
parainfluenza virus,
adenovirus and influenza have been ruled out
adenovirus, influenza virus
Skin or Wound Infection
Abscess or draining wound that cannot be covered
* Infection control professionals should modify or adapt this table according to local conditions. To ensure that appropriate empiric precautions are implemented
always, hospitals must have systems in place to evaluate patients routinely according to these criteria as part of their preadmission and admission care.
† Patients with the syndromes or conditions listed below may present with atypical signs or symptoms (e.g.neonates and adults with pertussis 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
judgment.
‡ 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 spp, hepatitis A virus, and rotavirus.
112
Figure. Donning and Removing Personal
Protective Equipment (PPE)
DONNING PPE
Type of PPE used will vary based on the level of precautions required, e.g., Standard and
Contact, Droplet or Airborne Isolation Precautions
GOWN
■ Fully
cover torso from neck to
knees, arms to end of wrist, and
wrap around the back
■ Fasten in back at neck and
waist
MASK OR
RESPIRATOR
■ Secure
ties or elastic band at
middle of head and neck
■ Fit flexible band to nose bridge
■ Fit snug to face and below chin
■ Fit-check respirator
GOGGLES/FACE
SHIELD
■ Put
over face and eyes and
adjust to fit
GLOVES
■ Extend
to cover wrist of
isolation gown
SAFE WORK PRACTICES
■ Keep
hands away from face
■ Limit surfaces touched
■ Change when torn or heavily contaminated
■ Perform hand hygiene
113
REMOVING PPE
Remove PPE at doorway before leaving patient room or in anteroom; remove
respirator outside of room
GLOVES
■ Outside
of gloves are contaminated!
outside of glove with
opposite gloved hand; peel off
■ Hold removed glove in gloved hand
■ Slide fingers of ungloved hand
under remaining glove at wrist
■ Grasp
GOGGLES/FACE SHIELD
■ Outside
of goggles or face shield are
contaminated!
■ To remove, handle by “clean” head
band or ear pieces
■ Place in designated receptacle for
reprocessing or in waste container
GOWN
■ Gown
front and sleeves are
contaminated!
■ Unfasten neck, the waist ties
■ Remove gown using a peeling
motion; pull gown from each
shoulder toward the same hand
■ Gown will turn inside out
■ Hold removed gown away from
body, roll into a bundle and discard
into waste or linen receptacle
MASK OR RESPIRATOR
■ Front
of mask/respirator is
contaminated – DO NOT TOUCH!
■ Grasp bottom then top ties/elastics
and remove
■ Discard in waste container
HAND HYGIENE
Perform immediately after removing all PPE!
114
APPENDIX A
TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONS
Infection/Condition
Precautions
Type
*
Duration
†
Abscess
Draining, major
Draining, minor or limited
Acquired human immunodeficiency syndrome (HIV)
Actinomycosis
Adenovirus infection, in infants and young children (also, see
gastroenteritis, adenovirus)
Amebiasis
C
DI
S
S
S
D, C
Pulmonary
Aerosolizable spore-containing powder
Antibiotic-associated colitis (see Clostridium difficile)
S
Postexposure chemoprophylaxis; consider post-exposure
vaccine(407, 644, 645)
Contact Precautions if large amount of drainage that cannot be
contained
S
S
AII,C
Arthropod-borne viral encephalitides (eastern, western, Venezuelan
equine encephalomyelitis; St Louis, California encephalitis; West Nile
Virus)
S
Arthropod-borne viral fevers (dengue, yellow fever, Colorado tick
fever)
S
Ascariasis
S
Aspergillosis
S
Avian influenza
AII, D, C
No dressing or containment of drainage; until drainage stops or can be
contained by dressing
Dressing covers and contains drainage
DI
Anthrax
Cutaneous
Comments
DE
14 days after
onset of
115
Until decontamination of environment complete (644)
Not transmitted from person to person except rarely by transfusion,
and for West Nile virus by organ transplant, by breastmilk or
transplacentally (646);Install screens in windows and doors in endemic
areas
Use DEET-containing mosquito repellants and clothing to cover
extremities
Not transmitted from person to person except by transfusion, rarely
Install screens in windows and doors in endemic areas
Use DEET-containing mosquito repellants and clothing to cover
extremities
Not transmitted from person to person
Contact Precautions and AII if massive soft tissue infection with
copious drainage and repeated irrigations required (51)
AII preferred (D if AII rooms unavailable); N95 respiratory protection
(surgical mask if N95 unavailable); eye protection (goggles, face shield
APPENDIX A
TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONS
Infection/Condition
Precautions
Type
*
Duration
†
symptoms
Comments
Babesiosis
Blastomycosis, North American, cutaneous or pulmonary
Botulism
S
S
S
Bronchiolitis (see respiratory infections in infants and young children)
C
Brucellosis (undulant, Malta, Mediterranean fever)
Campylobacter gastroenteritis (see gastroenteritis)
Candidiasis, all forms including mucocutaneous
Cat-scratch fever (benign inoculation lymphoreticulosis)
S
within 3 feet of patient); 14 days after onset of symptoms or until an
alternative diagnosis is established or until diagnostic test results
indicate that the patient is not infected with influenza A H5N1virus.
Human-to-human transmission inefficient and rare, but risk of
reassortment with human influenza strains and emergence of
pandemic strain serious concern.
Not transmitted from person to person except by transfusion, rarely.
Not transmitted from person to person
Not transmitted from person to person
Use mask according to Standard Precautions and until influenza and
adenovirus have been ruled out as etiologic agents
Not transmitted from person to person
S
S
Not transmitted from person to person
Cellulitis
S
Chancroid (soft chancre)
Chickenpox (see varicella)
Chlamydia trachomatis
Conjunctivitis
Genital
Respiratory
Cholera (see gastroenteritis)
Closed-cavity infection
Open drain in place; limited or minor drainage
No drain or closed drainage system in place
Clostridium
C. botulinum
S
C. difficile (also see gastroenteritis, C. difficile)
DI
S
S
S
S
S
Contact Precautions if there is copious uncontained drainage
S
Not transmitted from person to person
Assess need to discontinue antibiotics
Avoid the use of shared electronic thermometers (519, 647).
C
DI
116
APPENDIX A
TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONS
Infection/Condition
Precautions
Type
*
Duration
†
Comments
Ensure consistent environmental cleaning and disinfection.
C. perfringens
Food poisoning
Gas gangrene
Coccidioidomycosis (valley fever)
Draining lesions
Pneumonia
Colorado tick fever
S
S
S
Congenital rubella
C
Conjunctivitis
Acute bacterial
Chlamydia
Gonococcal
Acute viral (acute hemorrhagic)
Corona virus associated with SARS (SARS-CoV) (see severe acute
respiratory syndrome)
Coxsackie virus disease (see enteroviral infection)
Creutzfeldt-Jakob disease
CJD, vCJD
Croup (see respiratory infections in infants and young children)
Cryptococcosis
Cryptosporidiosis (see gastroenteritis)
Cysticercosis
Cytomegalovirus infection, neonatal or immunosuppressed
Decubitus ulcer (pressure sore) infected
S
S
Not transmitted from person to person
Not transmitted from person to person
Not transmitted from person to person
Not transmitted from person to person
Not transmitted from person to person
Standard Precautions if nasopharyngeal and urine cultures neg. after
Until 1 yr.of age
3 mos. of age
S
S
S
C
DI
S
Use disposable instruments or special sterilization/disinfection for
surfaces, objects contaminated with neural tissue if CJD or vCJD
suspected and has not been R/O; No special burial procedures(4, 7,
103)
S
Not transmitted from person to person
S
S
Not transmitted from person to person
No additional precautions for pregnant HCWs
Major
C
Minor or limited
S
DI
117
If no dressing or containment of drainage; until drainage stops or can
be contained by dressing
If dressing covers and contains drainage
APPENDIX A
TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONS
Infection/Condition
Precautions
Type
Dengue fever
Diarrhea, acute-infective etiology suspected (see gastroenteritis)
Diphtheria
Cutaneous
Pharyngeal
Ebola viral hemorrhagic fever (see viral hemorrhagic fevers)
Echinococcosis (hydatidosis)
Echovirus (see enteroviral infection)
Encephalitis or encephalomyelitis (see specific etiologic agents)
Endometritis
Enterobiasis (pinworm disease, oxyuriasis)
Enterococcus species (see multidrug-resistant organisms if
epidemiologically significant or vancomycin resistant)
Enterocolitis, C. difficile (see C. difficile, gastroenteritis)
Duration
S
†
Comments
Not transmitted from person to person
C
D
CN
CN
S
Until 2 cultures taken 24 hrs. apart neg.
Until 2 cultures taken 24 hrs. apart neg.
Not transmitted from person to person
S
S
Enteroviral infections
S
Epiglottitis, due to Haemophilus influenzae type b
Epstein-Barr virus infection, including infectious mononucleosis
Erythema infectiosum (also see Parvovirus B19)
Escherichia coli gastroenteritis (see gastroenteritis)
Food poisoning
Botulism
C. perfringens or welchii
Staphylococcal
D
S
S
Furunculosis, staphylococcal
*
U 24 hrs
S
S
S
S
Infants and young children
Gangrene (gas gangrene)
C
S
Gastroenteritis
S
Use Contact Precautions for diapered or incontinent children for
duration of illness and to control institutional outbreaks
Not transmitted from person to person
Not transmitted from person to person
Not transmitted from person to person
DI
118
Not transmitted from person to person
Use Contact Precautions for diapered or incontinent persons for the
duration of illness or to control institutional outbreaks for gastroenteritis
caused by all of the agents beloow
APPENDIX A
TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONS
Infection/Condition
Precautions
Type
Adenovirus
S
Campylobacter species
S
Cholera
S
C. difficile
C
Cryptosporidium species
S
E. coli
Enteropathogenic O157:H7 and other shiga toxin-producing
strains
S
Other species
*
Duration
DI
Sj
Giardia lamblia
S
Noroviruses
S
Rotavirus
C
Salmonella species (including S. typhi)
S
Shigella species
S
Vibrio parahaemolyticus
S
DI
119
†
Comments
Use Contact Precautions for diapered or incontinent persons for the
duration of illness or to control institutional outbreaks
Use Contact Precautions for diapered or incontinent persons for the
duration of illness or to control institutional outbreaks
Use Contact Precautions for diapered or incontinent persons for the
duration of illness or to control institutional outbreaks
Assess need to discontinue antibiotics
Avoid the use of shared electronic thermometers (519, 647); ensure
consistent environmental cleaning and disinfection.
Use Contact Precautions for diapered or incontinent persons for the
duration of illness or to control institutional outbreaks
Use Contact Precautions for diapered or incontinent persons for the
duration of illness or to control institutional outbreaks
Use Contact Precautions for diapered or incontinent persons for the
duration of illness or to control institutional outbreaks
Use Contact Precautions for diapered or incontinent persons for the
duration of illness or to control institutional outbreaks
Use Contact Precautions for diapered or incontinent persons for the
duration of illness or to control institutional outbreaks. Persons who
clean areas heavily contaminated with feces or vomitur should wear
masks; ensure consistent environmental cleaning and disinfection.
(648)
Ensure consistent environmental cleaning and disinfection; prolonged
shedding may occur in the immunocompromised
Use Contact Precautions for diapered or incontinent persons for the
duration of illness or to control institutional outbreaks
Use Contact Precautions for diapered or incontinent persons for the
duration of illness or to control institutional outbreaks
Use Contact Precautions for diapered or incontinent persons for the
duration of illness or to control institutional outbreaks
APPENDIX A
TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONS
Infection/Condition
Precautions
Type
Viral (if not covered elsewhere)
S
Yersinia enterocolitica
S
German measles (see rubella; see congenital rubella)
Giardiasis (see gastroenteritis)
Gonococcal ophthalmia neonatorum (gonorrheal ophthalmia,
acute conjunctivitis of newborn)
Gonorrhea
Granuloma inguinale (Donovanosis, granuloma venereum)
Guillain-Barré’ syndrome
Hand, foot, and mouth disease (see enteroviral infection)
Hantavirus pulmonary syndrome
Helicobacter pylori
Hepatitis, viral
Type A
Diapered or incontinent patients
Duration
†
Comments
Use Contact Precautions for diapered or incontinent persons for the
duration of illness or to control institutional outbreaks
Use Contact Precautions for diapered or incontinent persons for the
duration of illness or to control institutional outbreaks
S
S
S
S
Not an infectious condition
S
S
Not transmitted from person to person
S
Provide hepatitis A vaccine postexposure as recommended(649)
Maintain Contact Precautions in infants and children <3 years of age
for duration of hospitalization; for children 3-14 yrs. of age for 2 weeks
after onset of symptoms; >14 yrs. of age for 1 week after onset of
symptoms
See specific recommendations for care of patients in hemodialysis
centers (10)
See specific recommendations for care of patients in hemodialysis
centers (10)
C
Type B-HbsAg positive; acute or chronic
S
Type C and other unspecified non-A, non-B
S
Type D (seen only with hepatitis B)
S
Type E
S
Type G
Herpangina (see enteroviral infection)
Herpes simplex (Herpesvirus hominis)
Encephalitis
*
Use Contact Precautions for diapered or incontinent individuals for the
duration of illness
S
S
120
APPENDIX A
TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONS
Infection/Condition
Precautions
Type
Mucocutaneous, disseminated or primary, severe
C
Mucocutaneous, recurrent (skin, oral, genital)
S
Neonatal
C
Herpes zoster (varicella-zoster)
Disseminated disease in any patient
Localized disease in immunocompromised patient
Duration
S
DI
Influenza
D
U 24 hrs
Susceptible HCWs should not enter room if immune caregivers are
available; if entry is required, susceptibles must wear nose/mouth
protection; once disseminated disease has been ruled out discontinue
AII,C. Provide exposed susceptibles post exposure vaccine within 5
days or place unvaccinated exposed susceptibles on administrative
leave for 10-21days
Susceptible HCWs should not provide direct patient care when other
immune caregivers are available.
Not transmitted from person to person
Post-exposure chemoprophylaxis for high risk blood exposures(353)
5 days except DI Private room when available or cohort; avoid placement with high-risk
in immuno
patients; keep doors closed; mask patient when transported out of
compromised
room; chemoprophylaxis/vaccine to control/prevent outbreaks (408)
persons
S
S
S
S
C
Comments
Also, for asymptomatic,exposed infants delivered vaginally or by CUntil lesions dry section and if mother has active infection and membranes have been
and crusted ruptured for more than 4 to 6 hrss until infant surface cultures obtained
at 24-36 hrs. of age neg after 48 hrs incubation (650, 651)
DI
S
S
C
S
†
Until lesions dry
and crusted
AII,C
Localized in patient with intact immune system with lesions that can
be contained/covered
Histoplasmosis
Human immunodeficiency virus (HIV)
Impetigo
Infectious mononucleosis
Avian influenza (see Avian influenza)
Kawasaki syndrome
Lassa fever (see viral hemorrhagic fevers)
Legionnaires’ disease
Leprosy
Leptospirosis
Lice (head [pediculosis], body, pubic)
*
Not an infectious condition
U 24 hrs
121
APPENDIX A
TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONS
Infection/Condition
Precautions
Type
Listeriosis
Lyme disease
Lymphocytic choriomeningitis
Lymphogranuloma venereum
S
S
S
S
Malaria
S
*
Duration
†
Not transmitted from person to person except through transfusion,
rarely; iInstall screens in windows and doors in endemic areas; use
DEET-containing mosquito repellants and clothing to cover extremities
Marburg virus disease (see hemorrhagic fevers)
Measles (rubeola)
AII
Melioidosis, all forms
Meningitis
Aseptic (nonbacterial or viral; also see enteroviral infections)
Bacterial, gram-negative enteric, in neonates
Fungal
Haemophilus influenzae, type b known or suspected
Listeria monocytogenes
Neisseria meningitidis (meningococcal) known or suspected
Streptococcus pneumoniae
S
S
S
S
D
S
D
S
Tuberculosis
S
Other diagnosed bacterial
S
Meningococcal disease: sepsis, pneumonia, meningitis
D
Molluscum contagiosum
S
Monkeypox
AII,C
Comments
Person-to-person transmission rare (652)
Not transmitted from person to person
Not transmitted from person to person
DI
Susceptible HCWs should not enter room if immune care providers are
available; wear nose/mouth protection regardless of immune status;
no recommendation for type of protection, i.e. surgical mask or
respirator; post-exposure vaccine within 72 hrs. or immune globulin
within 6 days
Not transmitted from person to person
Contact for infants and young children
U 24 hrs
U 24 hrs
Not transmitted from person to person
Concurrent, active pulmonary disease or draining cutaneous lesions
necessitate addition of airborne precautions
U 24 hrs
Until lesions
crusted
122
Postexposure chemoprophylaxis for household contacts, HCWs
exposed to respiratory secretions; pstexposure vaccine only if
outbreak.
See www.cdc.gov/ncidod/monkeypox for most current
recommendations.
APPENDIX A
TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONS
Infection/Condition
Precautions
Type
Mucormycosis
Multidrug-resistant organisms (MDROs), infection or colonization
(e.g., MRSA, VRE, VISA, ESBLs)
Mumps (infectious parotitis)
Mycobacteria, nontuberculosis (atypical)
Pulmonary
Wound
Mycoplasma pneumonia
Necrotizing enterocolitis
Nocardiosis, draining lesions, or other presentations
Norovirus (see gastroenteritis)
Norwalk agent gastroenteritis (see gastroenteritis)
Orf
Parainfluenza virus infection, respiratory in infants and young children
S
S/C
D
*
Duration
Parvovirus B19
D
Pediculosis (lice)
C
Pertussis (whooping cough)
D
Comments
Pre- and post-exposure smallpox vaccine recommended for exposed
HCWs
MDROs judged by the infection control program, based on local, state, regional, or
national recommendations, to be of clinical and epidemiologic significance. Contact
Precautions required in settings with evidence of ongoing transmission, acute care
settings with increased risk for transmission or wounds that cannot be contained by
dressings; see Recommendations and Appendix B, recommendations for management
options; criteria for discontinuing precautions not established. Contact state health
department for guidance regarding new or emerging MDRO
After onset of swelling; susceptible HCWs should not provide care if
U 9 days
immune caregivers are available.
S
S
D
S
S
S
C
†
DI
Contact Precautions when cases temporally clustered (653-655)
DI
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. Duration of precautions for immunosuppressed patients
with persistently positive PCR not defined (656)
U 24 hrs after
treatment
Private room preferred.
U 5 days
Cohorting an option.
Post-exposure chemoprophylaxis for household contacts and HCWs
123
APPENDIX A
TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONS
Infection/Condition
Precautions
Type
Pinworm infection
Plague (Yersinia pestis)
Bubonic
Pneumonic
Pneumonia
Adenovirus
Bacterial not listed elsewhere (including gram-negative bacterial)
B. cepacia in patients with CF, including
respiratory tract colonization
*
Duration
†
with prolonged exposure to respiratory secretions.
S
S
D
U 72 hrs
D, C
S
DI
C
Unknown
B. cepacia in patients without CF(see
Multidrug-resistant organisms)
Chlamydia
Fungal
Haemophilus influenzae, type b
Adults
Infants and children
Legionella spp.
Meningococcal
Multidrug-resistant bacterial (see multidrug-resistant organisms)
Mycoplasma (primary atypical pneumonia)
Pneumococcal
D
S
Pneumocystis carinii
S
Staphylococcus aureus
Streptococcus, group A
Adults
Infants and young children
Varicella-zoster
Viral
S
Comments
Antimicrobial prophylaxis for exposed HCW.
Avoid exposure to other persons with CF; private room preferred.
Criteria for D/C precautions not established. See CF foundation
guideline (221)
S
S
S
D
S
D
S
D
AII
U 24 hrs
U 24 hrs
DI
Avoid placement in the same room with an immunocompromised
patient.
U 24 hrs
DI
124
Contact Precautions if skin lesions present
APPENDIX A
TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONS
Infection/Condition
Precautions
Type
Adults
Infants and young children (see respiratory infectious disease,
acute)
Poliomyelitis
Prion disease (See Creutzfeld-Jacob Disease)
Psittacosis (ornithosis)
Q fever
C
Rabies
S
Rat-bite fever (Streptobacillus moniliformis disease, Spirillum minus
disease)
Relapsing fever
Resistant bacterial infection or colonization (see multidrug-resistant
organisms)
Respiratory infectious disease, acute (if not covered elsewhere)
Adults
Infants and young children
Respiratory syncytial virus infection, in infants,
young children and immunocompromised adults
Reye's syndrome
Rheumatic fever
Rickettsial fevers, tickborne (Rocky Mountain spotted fever, tickborne
typhus fever)
Rickettsialpox (vesicular rickettsiosis)
Ringworm (dermatophytosis, dermatomycosis, tinea)
Ritter's disease (staphylococcal scalded skin syndrome)
*
Duration
†
Comments
S
S
S
Not transmitted from person to person
DI
If patient has bitten another individual or saliva has contaminated an
open wound or mucous membrane, wash exposed area thoroughly
and administer postexposure prophylaxis
S
C
DI
Also see syndromes or conditions listed in Table 6
C
DI
S
S
S
S
Not an infectious condition
Not an infectious condition
Not transmitted from person to person except through transfusion,
rarely
S
S
S
S
Rocky Mountain spotted fever
S
Roseola infantum (exanthem subitum; caused by HHV-6)
Rotavirus infection (see gastroenteritis)
S
Not transmitted from person to person except through transfusion,
rarely
125
APPENDIX A
TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONS
Infection/Condition
Precautions
Type
Rubella (German measles) ( also see congenital rubella)
Rubeola (see measles)
Severe acute respiratory syndrome (SARS)
Salmonellosis (see gastroenteritis)
Scabies
D
Schistosomiasis (bilharziasis)
Shigellosis (see gastroenteritis)
S
Enterocolitis
U 7 days after
onset of rash
C
S
Sporotrichosis
Spirillum minus disease (rat-bite fever)
Staphylococcal disease (S aureus)
Skin, wound, or burn
Major a
Minor or limited b
Duration
†
Comments
Susceptible HCWs should not enter room if immune caregivers are
available. Wear nose/mouth protection e.g., surgical mask, regardless
of immune status.
DI plus 10 days AII preferred; D if AII rooms unavailable. N95 or higher respiratory
after resolution of protection; surgical mask if N95 unavailable; eye protection (goggles,
fever, provided face shield); aerosol-producing procedures and “supershedders”
AII, D,C
respiratory
highest risk for transmission; vigilant environmental disinfection (see
symptoms are www.cdc.gov/ncidoc/sars)
absent or
improving
Scalded skin syndrome, staphylococcal (Ritter's disease)
Smallpox (variola; see vaccinia for management of vaccinated
persons)
*
U 24
AII,C
DI
S
S
C
S
DI
S
Multidrug-resistant (see multidrug-resistant organisms)
126
Contact Precautions for 24 hours after initiation of effective therapy if
outbreak within a unit
Until all scabs have crusted and separated (3-4 weeks). Nonvaccinated HCWs should not provide care when immune HCWs are
available; N95 or higher respiratory protection required for susceptible
and successfully vaccinated individuals; postexposure vaccine within 4
days of exposure protective.
No dressing or dressing does not contain drainage adequately
Dressing covers and contains drainage adequately
Use Contact Precautions for diapered or incontinent children for
duration of illness
APPENDIX A
TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONS
Infection/Condition
Precautions
Type
Pneumonia
Scalded skin syndrome
Toxic shock syndrome
Streptobacillus moniliformis disease (rat-bite fever)
Streptococcal disease (group A streptococcus)
Skin, wound, or burn
Major
Minor or limited
Endometritis (puerperal sepsis)
Pharyngitis in infants and young children
Pneumonia in infants and young children
Scarlet fever in infants and young children
Serious invasive disease, e.g. necrotizing fasciitis, toxic shock
syndrome
Streptococcal disease (group B streptococcus), neonatal
Streptococcal disease (not group A or B) unless covered elsewhere
Multidrug-resistant (see multidrug-resistant organisms)
Strongyloidiasis
Syphilis
Latent (tertiary) and seropositivity without lesions
Skin and mucous membrane, including congenital, primary,
secondary
Tapeworm disease
Hymenolepis nana
Taenia solium (pork)
Other
Tetanus
Tinea (e.g., fungus infection, dermatophytosis, dermatomycosis,
ringworm)
Toxoplasmosis
*
Duration
S
S
S
S
C
†
Comments
Not transmitted from person to person
U 24 hrs
S
S
D
D
D
U 24 hrs
U 24 hrs
U 24 hrs
D
U24 hrs
S
S
No dressing or dressing does not contain drainage adequately
Dressing covers and contains drainage adequately
Contact Precautions for draining wound as above; follow rec. for
antimicrobial prophylaxis in selected conditions (409)
S
S
S
Not transmitted from person to person
S
S
S
S
Not transmitted from person to person
S
S
127
APPENDIX A
TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONS
Infection/Condition
Precautions
Type
Toxic shock syndrome (staphylococcal disease, streptococcal
disease)
Trachoma, acute
Trench mouth (Vincent's angina)
Trichinosis
Trichomoniasis
Trichuriasis (whipworm disease)
Tuberculosis (M. tuberculosis)
Extrapulmonary, draining lesion including scrofula)
Duration
†
Comments
S
S
S
S
S
S
Discontinue precautions only when patient is improving clinically, and
drainage has ceased or there are three consecutive negative cultures
of continued drainage (495, 496). Examine for evidence of active
pulmonary tuberculosis.
Examine for evidence of pulmonary tuberculosis.
AII,C
Extrapulmonary, no draining lesion, meningitis
S
Pulmonary or laryngeal disease, confirmed
AII
Pulmonary or laryngeal disease, suspected
AII
Skin-test positive with no evidence of current active disease
Tularemia
Draining lesion
Pulmonary
Typhoid (Salmonella typhi) fever (see gastroenteritis)
Typhus, endemic and epidemic
Urinary tract infection (including pyelonephritis), with or without
urinary catheter
Vaccinia (vaccination site, adverse events following vaccination) *
*
Discontinue precautions only when patient on effective therapy is
improving clinically and has three consecutive sputum smears
negative for acid-fast bacilli collected on separate days.
Discontinue precautions only when the likelihood of infectious TB
disease is deemed negligible, and either 1) there is another diagnosis
that explains the clinical syndrome or 2) the results of three sputum
smears for AFB are negative. Each of the three sputum specimens
should be collected 8-24 hours apart, and at least one should be an
early morning specimen
S
S
S
BSL 2 laboratory only for processing cultures
Not transmitted from person to person
Not transmitted from person to person
S
Not transmitted from person to person
S
Only vaccinated HCWs have contact with active vaccination sites and
128
APPENDIX A
TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONS
Infection/Condition
Precautions
Type
Vaccination site care (including autoinoculated areas)
Eczema vaccinatum
Fetal vaccinia
Generalized vaccinia
Progressive vaccinia
Postvaccinia encephalitis
Blepharitis or conjuctivitis
Iritis or keratitis
Vaccinia-associated erythema multiforme (Stevens Johnson
Syndrome)
Secondary bacterial infection (e.g., S. aureus, group A beta
hemolytic streptococcus
Varicella
Variola (see smallpox)
Vibrio parahaemolyticus (see gastroenteritis)
Vincent's angina (trench mouth)
*
Duration
†
S
C
C
C
Until lesions dry
and crusted,
scabs separated
S
S/C
S
AII,C
care for persons with adverse vaccinia events; if unvaccinated, only
HCWs without contraindications to vaccine may provide care.
Vaccination recommended for vaccinators; for newly vaccinated
HCWs: semi-permeable dressing over gauze until scab separates,
with dressing change as fluid accumulates, ~3-5 days; gloves, hand
hygiene for dressing change; vaccinated HCW or HCW without
contraindication to vaccine for dressing changes.
For contact with virus-containing lesions and exudative material
Use Contact Precautions if there is copious drainage
Not an infectious condition
S
S/C
Comments
Follow organism-specific (strep, staph most frequent)
recommendations and consider magnitude of drainage
Susceptible HCWs should not enter room if immune caregivers are
available; wear nose/mouth protection regardless of immune status;
no recommendation for type of protection, i.e. surgical mask or
respirator; in immunocompromised host with varicella pneumonia,
Until lesions dry prolong duration of precautions after lesions crusted; post-exposure
and crusted vaccine within 120 hours; VZIG within 96 hours for post-exposure
prophylaxis for susceptible exposed persons for whom vaccine is
contraindicated, including immunocompromised persons, pregnant
women, newborns whose mother’s varicella onset is <5days before
delivery or within 48 hrs after delivery
S
129
APPENDIX A
TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONS
Infection/Condition
Precautions
Type
Viral hemorrhagic fevers
due to Lassa, Ebola, Marburg, Crimean-Congo fever viruses
Viral respiratory diseases (not covered elsewhere)
Adults
Infants and young children (see respiratory infectious disease,
acute)
Whooping cough (see pertussis)
Wound infections
Major
Minor or limited
Yersinia enterocolitica gastroenteritis (see gastroenteritis)
Zoster (varicella-zoster) (see herpes zoster)
Zygomycosis (phycomycosis, mucormycosis)
*
Duration
AII, C
DI
†
Comments
Add eye protection, double gloves, leg and shoe coverings, and
impermeable gowns, according to hemorrhagic fever specific barrier
precautions. See Table 4. Notify public health officials immediately if
Ebola is suspected (47, 657) (www.bt.cdc.gov)
S
C
S
DI
No dressing or dressing does not contain drainage adequately
Dressing covers and contains drainage adequately
S
Type of Precautions: AII, Airborne Infection Isolation; C, Contact; D, Droplet; S, Standard; when A, C, and D are specified, also use S.
† Duration of precautions: CN, until off antimicrobial treatment and culture-negative; DI, duration of illness (with wound lesions, DI means until
wounds stop draining); DE, until environment completely decontaminated; U, until time specified in hours (hrs) after initiation of effective therapy;
Unknown: criteria for establishing eradication of pathogen has not been determined.
130
Appendix B. Management of MDROs in Healthcare Settings
I. Epidemiology. Multidrug-resistant organisms (MDROs) targeted currently for control in
healthcare facilities include methicillin-resistant S. aureus (MRSA), vancomycin-resistant
enterococci (VRE), and certain gram-negative bacilli (GNB), including those producing
extended spectrum beta lactamases (ESBLs) and others that are resistant to all but one
class of antimicrobial agents (e.g., strains of Acinetobacter baumannii resistant to all
antimicrobial agents except imipenem) (75, 76, 78-80) or that are intrinsically resistant to the
broadest spectrum agents (e.g., Stenotrophomonas maltophilia (81-84) or Burkholderia
cepacia (221, 222, 658). The clinical, logistical, and financial impacts of the emergence and
prevalence of a specific MDRO are important factors that determine healthcare facility
prioritization of MDRO control programs.
Variation in MDRO prevalence. Prevalence of MDROs varies temporally,
geographically, and by healthcare setting. For example, VRE emerged in the eastern
United States in the early 1990s but did not appear in the western United States until
several years later. Recent surveys have indicated that nonsusceptible Streptococcus
pneumoniae (NSSP) are more prevalent in the eastern United States (659). In general,
urban areas report higher frequencies of resistant microbes than do rural areas, presumably
reflecting the influence of tertiary care centers and frequent admissions of colonized or
infected patients to multiple facilities in a city. The type and level of care also influence the
prevalence of MDROs. Intensive care units (ICU), especially those in urban areas and
tertiary care facilities, have a higher prevalence of MDRO infections than do small
community hospitals or long-term care facilitieis (LTCFs) (129, 130). High rates of MRSA,
VRE, and ESBL-producing Klebsiella pneumoniae and Eschericia coli colonization prevail in
some, but not all, LTCFs; however, the frequency of clinical infection with these pathogens
is lower in LTCFs than in acute care hospitals (160, 164, 165, 168, 605, 660).
During the last several decades, the prevalence of MDROs in U.S. hospitals and
medical centers has increased steadily. MRSA was first isolated in the United States in
1968. In the early 1990s, MRSA accounted for 20%-25% of Staphyloccus aureus isolates
from hospitalized patients (575). By 1999, MRSA accounted for >50% of S. aureus isolates
from patients in ICUs in the National Nosocomial Infection Surveillance (NNIS) system (128)
131
and in 2002, 57.1% of S. aureus isolates in NNIS ICUs were MRSA (144). A similar rise in
prevalence has occurred with VRE. From 1990 to 1997, the prevalence of VRE in isolates of
enterococci from hospitalized patients increased from <1% to approximately 15% (62). By
1999, almost 25% of enterococcal isolates obtained from patients in NNIS ICUs were VRE
(128) and in 2002, 28% of enterococcal isolates in NNIS ICUs were VRE (144).
GNB resistant to ESBLs, fluoroquinolones, carbapenems, and aminoglycosides also
have increased in frequency. For example, in 1997, 6.6% of Klebsiella pneumoniae isolates
from U.S. bloodstream infections were resistant to ceftazidime and other third-generation
cephalosporin antibiotics (62). Similarly, in 1999, 23% of Pseudomonas aeruginosa isolates
in ICUs were resistant to fluoroquinolone antibiotics (130). A 3-month survey of 15 Brooklyn
hospitals in 1999 found that 53% of A. baumannii strains exhibited resistance to
carbapenem and 24% of P. aeruginosa strains were resistant to imipenem (77). Finally, in a
national review of 35,790 non-duplicate gram-negative aerobic isolates from ICU patients in
43 states during 1994-2000, the activity of most antimicrobial agents showed a decrease in
susceptibility of 6% or less over the study period. The overall susceptibility to ciprofloxacin
decreased from 86% to 76% and was associated significantly with an increased use of
fluoroquinolones in the United States (68).
An analysis of temporal trends in antimicrobial resistance in 23 U.S. hospitals during
1996-1997 and 1998-1999 (549) found significant increases in the prevalence of resistant
isolates in non-ICU patients but only for MRSA, ciprofloxacin-resistant P. aeruginosa and
ciprofloxacin- or ofloxacin-resistant E. coli. These increases may be a result of selective
pressure exerted by exposure to antimicrobial agents outside of the ICU and/or in the
community, poor adherence to infection control practices, or both.
MDRO-associated morbidity and mortality. In most instances, MDRO infections
have similar clinical manifestations of disease and virulence comparable to infections
caused by susceptible pathogens. Although ensuring adequate matching in comparsons of
patients infected with MDROs and control patients is problematic, several studies have
reported an association between MDRO infections and increased morbidity and mortality,
length of stay, and healthcare costs. This is particularly true of MRSA. Some hospitals have
observed an increase in the overall occurrence of staphylococcal infections following the
introduction of MRSA (248, 546, 661). In addition, when compared with methicillin-
132
susceptible S. aureus (MSSA), higher case fatality rates have been observed for MRSA
bacteremias (662-666), poststernotomy mediastinitis (667), and surgical site infections
(668). Mortality may be further increased by S. aureus with reduced vancomycin
susceptibility (VISA) (MIC >4 µg/ml) (67). MRSA infections also result in increased costs
and lengths of stay (669-673). Therefore, strategies to reduce MRSA transmission may yield
cost savings for individual facilities (508, 546, 600, 673, 674).
Increased lengths of stay also have been associated with other MDROs (551). Two
published studies documented increased mortality, hospital stays, and hospital charges
associated with MDR-GNBs: a neonatal intensive care unti (NICU) outbreak of ESBLproducing K. pneumoniae (675) and emergence of third-generation cephalosporin
resistance in Enterobacter spp. in hospitalized adults (676). Vancomycin resistance has
been reported to be an independent predictor of death from enterococcal bacteremia (677680). Furthermore, VRE was associated with increased mortality, length of hospital stay,
admission to the ICU, surgical procedures, and costs when VRE patients were compared
with a matched hospital population (396). Data are conflicting concerning the potential
association of specific virulence factors (e.g., enterococcal surface protein [esp], gelatinase,
and hemolysin) with mortality due to enterococcal bacteremia in humans (681-683).
However, a strong association has been demonstrated between the presence of the variant
esp-gene and strains from hospital outbreaks and clinical infections among patients with
both vancomycin-resistant Enterococcus faecium and vancomycin-susceptible E. faecium
has been demonstrated (684). The association between the presence of the variant espgene and enhanced adherence capacities to uroepithelial cells and biofilm formation may
explain its role as a virulence factor.
Reservoirs for MDRO transmission. MDROs are introduced most often into
healthcare settings in two ways: 1) via colonized or infected patients and 2) as a result of
antibiotic selective pressure that confers advantages to organisms possessing resistance
mechanisms gained through either mutation or gene transfer (53, 170, 685, 686). The rapid
increase in prevalence of MRSA and VRE is primarily the result of transmission from
colonized or infected patients to other patients who, in some cases, were rendered
susceptible by the suppressive effects of antimicrobial therapy on their normal flora (87).
The emergence of multidrug-resistant gram-negative bacilli (MDR-GNB) is more likely due
133
to the emergence of resistance via genetic changes induced by antimicrobial selective
pressure, but patient-to-patient transmission for these pathogens also is well documented
(382, 384, 687-690).
Once MDROs enter a healthcare setting, the availability of vulnerable patients,
selective pressure exerted by antimicrobial use, “colonization pressure” (i.e., increased
transmission resulting from the presence of larger numbers of colonized or infected patients
(440, 691), and the implementation and success of prevention efforts determine the
likelihood of transmission and persistence of MDROs. Patients vulnerable to colonization
and infection include those with severe disease, especially those with compromised host
defenses from underlying medical conditions; recent surgery; or indwelling medical devices,
e.g., urinary catheters or endotracheal tubes (689). As a rule, risk factors are more
numerous in hospitalized than nonhospitalized patients, especially those in ICUs, where
infection rates tend to be highest. For VRE, the risk of acquisition in an ICU increases
significantly once colonization rates or numbers of VRE-patient days of exposure in an ICU
exceed a defined threshold (e.g., 50% (440) or 15 patient days (621). A similar effect of
colonization pressure has also been demonstrated for MRSA in a medical ICU (691).
Most MDROs are carried from one person to another via the hands of healthcare
workers (HCWs) (6, 86-88, 687, 692) which can be easily contaminated during the process
of care-giving or having contact with environmental surfaces in close proximity to the patient
(338). The latter is especially important when patients have diarrhea and the reservoir of the
MDRO is the gastrointestinal tract (335, 337). Without appropriate hand hygiene and glove
use, contact with colonized or infected patients or the environment of care may result in
transmission of MDROs to other vulnerable patients. Since MDRO transmission occurs by
the same routes as antimicrobial susceptible pathogens, MDRO transmission becomes a
sentinel event for identifying breaches in infection control practice. Occasionally,
HCWs become persistently colonized with MDROs, but such workers have a minimal role in
transmission unless factors that facilitate transmission are present (e.g., chronic sinusitis
(693), upper respiratory infection (623), presence of artificial nails (320-322)).
Implications of community-onset MRSA. The complex relationship between
community-onset and healthcare-associated MRSA further complicates the design of
effective control strategies. Genetic analyses of MRSA strains from hospitals worldwide
134
revealed that a relatively small number of MRSA clones have unique qualities that facilitate
their transmission from patient to patient within healthcare facilities over wide geographic
areas (694). These clones contain the staphylococcal chromosomal cassette (SCC) mec
types I, II, and III, which encode for resistance to all beta-lactam agents and other classes of
antibiotics. A very different mechanism of MRSA resistance occurs in the community. As the
prevalence of community-onset MRSA (CO-MRSA) infections increased within certain
populations (e.g., children (174-178, 695), prisoners (198, 696, 697), and Alaskan natives
(698), the following distinct characteristics challenged the concept that these communityonset strains were merely hospital-acquired strains that had drifted into the community: 1)
lack of traditional risk factors associated with healthcare; 2) lack of multi-drug resistance;
and 3) proclivity for skin infections. Additionally, a unique cytotoxin, Panton-Valentine
leukocidin (PVL), that causes tissue necrosis was more frequently associated with COMRSA strains than with healthcare-associated strains (699). Identification in CO-MRSA
strains from different geographic locations of a unique SCC mec type IV that was small and
highly mobile and did not carry any of the multiple antibiotic resistance genes associated
with types II and III suggests that CO-MRSA infections are emerging de novo outside of
healthcare facilities, possibly in response to antibiotic exposure (696, 700, 701). Thus,
control of MRSA transmission within healthcare facilities may have a limited effect on the
prevalence of CO-MRSA. The extent of transmission of CO-MRSA within healthcare
settings (477) and of healthcare strains within the community remains to be determined.
II. MDRO Prevention and Control. The medical literature provides many examples of
successful MDRO control from countries outside the United States as well as from
healthcare coalitions and individual facilities within the United States. Representative
studies include:
ƒ
Reduced rates of MRSA transmissions in The Netherlands, Belgium, Denmark, and
other Scandinavian countries after implementation of aggressive and sustained
infection control measures (i.e., active surveillance cultures and placement on
Contact Precautions at the time of admission until proven culture negative and, in
some instances, closing units to new admissions) to combat MRSA in many of their
healthcare facilities (616, 702-705).
135
ƒ
Reduced rates of VRE transmission in healthcare facilities in the three-state
Siouxland region (Iowa, Nebraska, South Dakota) following formation of a coalition
and development of an effective community-wide infection control plan (459).
ƒ
Eradication of endemic MRSA infections over a 65 month period from two NICUs: in
the first, with implementation of a combination of strategies, including active
surveillance cultures, Contact Precautions, use of triple dye applied to the umbilical
cord, and systems changes to improve surveillance and adherence to recommended
practices and to reduce over-crowding (248); and in the second, with the use of
active surveillance cultures, and Contact plus Droplet Precautions (539).
ƒ
Eradication of VRE from a burn unit with implementation of multiple control
measures over a 13-month period (518).
ƒ
Eradication of MDR-strains of A. baumannii from a burn unit with implementation of
multiple control measures over a 16-month period (78).
In addition, more than 100 reports published during 1982-2003 support the efficacy of
various control measures and strategies to reduce the burden of MRSA, VRE, and MDRGNBs (Tables B-1, B-2). Reduced case rates or eradication of the pathogen was reported in
a majority of studies for VRE (79%), MRSA (100%), and MDR-GNB (93%). VRE was
eradicated in seven specialized units (391, 404, 518, 522, 544, 589, 613), one hospital
(525), and one LTCF (555); MRSA, in nine special care units (248, 315, 316, 397, 539, 560,
598, 612, 706), one hospital (562), and one LTCF (560), and a MDR-GNB in 12 special
units (75, 76, 78, 389, 394, 524, 538, 540, 543, 564, 626, 627) and two hospitals (79, 561).
Four MRSA reports describe continuing success in sustaining low endemic MDRO
rates in excess of 5 years (397, 546, 577, 586). In each of these reports, strategies for
managing MRSA evolved and changed over time as new challenges to control emerged.
Another report describes ongoing success in maintaining low rates of VRE colonization and
infection over a 5 year period, but the graphic representation of the data in that report does
not support this conlcusion (583).
III. Overview of Control Measures. The various types of practices that have been used to
control or eradicate MDROs may be grouped into the following seven categories and are
136
the basis of the recommendations for control of MDROs in healthcare settings (Tables B36).
Administrative support and intervention measures. Several investigators have
indicated that administrative support was an important factor in the success of their MDRO
control programs (240, 248, 299, 518, 520, 574, 588), and authorities in infection control
strongly recommend such support (6, 53, 87, 196, 297, 300). Use of active surveillance
cultures as an intervention is a strategy requires administrative commitment of fiscal and
human resources (75, 78, 87, 248, 336, 358, 371, 387, 395, 486, 510, 513, 518, 520, 537,
539, 546, 560, 568, 574, 598-601, 707). Other system issues that require administrative
support include 1) prompt and effective communications (e.g., computer alerts to identify
patients previously known to be colonized/infected with MDROs) (358, 510, 511, 574); 2)
provision of appropriate numbers and placement of handwashing sinks and alcoholcontaining handrub dispensers (6); 3) maintenance of staffing levels appropriate to the
intensity of care required (241, 246, 248, 249, 252-255, 257, 584, 585); and 4) enforcement
of adherence to recommended infection control precautions for MDRO control. Direct
observation with feedback to HCWs on adherence to recommended precautions and
feedback on changes in transmission rates have been associated with a positive impact on
prevention efforts (240, 248, 299, 312, 393, 508, 511, 512, 548).
Education. Facility-wide or unit-targeted educational campaigns were included in
several successful intervention studies (240, 248, 358, 382, 395, 510, 513, 520, 588).
Campaigns to enhance adherence to hand hygiene practices have been associated
temporally with sustained decreases in MDRO transmission, in both high- and low-risk
healthcare settings (6, 163, 555, 559).
Judicious use of antimicrobial agents. A temporal association between formulary
changes and decreased occurrence of a target MDRO was found in several studies,
especially in those that focused on MDR-GNBs (128, 380, 382, 384-386, 393, 395, 402,
403, 533). Although some MRSA and VRE control efforts have attempted to limit
antimicrobial use, the relative importance of this measure for controlling these MDROs
remains unclear (358, 395, 399, 520). Failure to control resistance through antimicrobial
restrictions may be the result of a combination of factors, including 1) the role of
antimicrobials in inducing selective pressure initially, rather than perpetuating resistance
137
once it has emerged; 2) inadequate extent of restrictions; or 3) insufficient time to observe
the impact of this intervention.
The CDC Campaign to Prevent Antimicrobial Resistance that was launched in 2002
provides evidence-based principles for judicious use of antimicrobials
(www.cdc.gov/drugresistance/healthcare). Programs have been developed for hospitalized
adults, surgical patients, dialysis patients, hospitalized pediatric patients and for residents in
long term care facilities. This promotional effort targets all healthcare settings and focuses
on effective antimicrobial treatment of infections, use of narrow spectrum agents, treatment
of infections and not contaminants, limiting duration of therapy whenever possible, and
restricting use of broad-spectrum or new, more potent antimicrobials to treatment of serious
infections when no other active agents are available. Achievement of these objectives would
likely diminish the selective pressure that favors proliferation of MDROs. Strategies for
influencing antimicrobial prescribing patterns within the hospital include education; formulary
restriction; prior-approval programs, including pre-approved indications; stop orders;
academic detailing; antimicrobial cycling (595, 708, 709); computer-assisted management
programs (590, 591, 594), and active efforts to reduce use of redundant antimicrobial
combinations (593).
Surveillance. Many MDRO control reports include initiation of active surveillance
cultures when new pathogens emerge in order to define the epidemiology of the particular
agent (63, 64, 87, 557, 710) and when continued transmission of a target MDRO is
apparent, despite implementation of basic infection control measures. This is especially
important for MRSA and VRE because clinical cultures detect only a small proportion of
patients who could potentially transmit these MDROs to other patients (75, 78, 87, 248, 336,
358, 371, 387, 395, 459, 486, 510, 518, 520, 537, 539, 546, 560, 568, 574, 598-601).
Surveillance cultures to detect colonization or transmission were implemented in 67% to
97% of the studies reviewed (Table B-2). This approach requires several types of support
and represents a series of interventions: 1) personnel to obtain the proper culture; 2)
microbiology laboratory personnel to process the culture; 3) communication of results to
caregivers; and 4) concurrent decisions about continuing or implementing additional
isolation measures. The continuous use of active surveillance cultures has been described
138
only in acute care hospitals and only in the context of attempting to control an outbreak or
reduce endemic levels.
Protocols for specimen collection vary. Some hospital programs have obtained
cultures from patients upon admission to the hospital or at the time of transfer to or from
designated units (e.g., ICU) (75), in other studies, cultures were obtained from patients on a
periodic basis (e.g., weekly (589) or at varying intervals (546)) to detect silent transmission.
The authors of several studies concluded that active surveillance, in combination with
Contact Precautions and increased attention to infection control practices contributed
directly to the decline or eradication of the target MDRO (78, 87, 395, 441, 539, 546, 574).
The specific aspects of this series of interventions that were responsible for these
outcomes, e.g.,presence of personnel obtaining surveillance cultures, reporting of results to
clinical staff, use of Contact Precautions, reduced number of personnel entering the rooms,
increased number of staff, has not been studied. In contrast, one report did not find
surveillance cultures for MDR-GNBs to be an effective infection control strategy in the
absence of an outbreak (606).
Sites selected for surveillance cultures in various studies reflect the epidemiology of
the specific MDRO, e.g., skin wounds and nares for MRSA (248, 546) and stool or perirectal
swabs for VRE and MDR-GNBs (395, 518, 606). Some MDRO reports describe surveillance
cultures of healthcare workers during outbreaks, but colonized or infected healthcare
workers are rarely the source of ongoing transmission (78, 248, 371, 486, 518, 539, 573).
Finally, some control efforts have found ongoing population-based calculation and analysis
of incidence and prevalence rates and molecular typing of selected isolates to confirm
clonal transmission useful for monitoring changes in MDRO transmission (78, 248, 320,
358, 371, 477, 537, 546, 547, 687, 690, 706).
Standard and Contact Precautions. No studies have directly compared Standard
Precautions alone and Standard Precautions plus Contact Precautions combined with
active surveillance cultures for control of MDROs. Some reports mention the use of one or
both sets of precautions as part of successful MDRO control efforts; however, the
precautions were not the primary focus of the intervention (169, 315, 382, 385, 537, 548,
578, 579). Standard Precautions has an essential role in preventing MDRO transmission,
even in facilities that use Contact Precautions for patients with an identified MDRO.
139
Colonization with MDROs is frequently undetected, and even surveillance cultures may fail
to identify colonized persons due to lack of sensitivity, laboratory deficiencies, or intermittent
colonization due to antimicrobial therapy (441). Therefore, Standard Precautions must be
relied on to prevent transmission in these patients. Hand hygiene is an important
component of Standard Precautions. In the Guideline for Hand Hygiene in Healthcare
Settings (6), the authors cite nine studies that demonstrated a temporal relationship
between improved adherence to recommended hand hygiene practices and control of
MDROs at the same time that other control measures remained in place.
MDRO control efforts frequently involve changes in isolation practices, especially in
outbreaks. In 66% to 87% of reports reviewed, healthcare facilities adopted Contact
Precautions for MDRO control (see Table B-2). In general, Contact Precautions was
implemented for all patients colonized or infected with the target MDRO. However, some
facilities used Contact Precautions for new admissions until their screening cultures
returned and were negative for the target MDRO (620) or for all patients admitted to a
specific unit (341). The barriers used in Contact Precautions may prevent transmission, but
their use may also draw attention to the need for hand hygiene, a good effect, or reduce
staff contact with patients a poor effect. The frequency of hand hygiene was not improved
with the use of Contact Precautions but was improved when only gloves were worn for
routine contact with MDRO patients (711),
Three studies evaluated the use of gloves with or without gowns for all patient
contacts to prevent VRE acquisition in ICU settings. However, they yielded disparate results
and their differing methodologies made comparisons difficult (341, 620, 621). Specifically,
healthcare worker adherence to the recommended regimen, influence of added precautions
on the number of HCW-patient interactions, and colonization pressure were not assessed
consistently in all studies.
Approaches to control MDRO transmission during outbreaks reflect a hierarchy of
measures that have been implemented stepwise, based on the outcome of initial efforts. In
several reports, cohorting of patients (75, 78, 248, 335, 385, 387, 395, 574) and in some
instances staff (361, 387, 395, 574), use of designated beds or units (520, 574), and even
unit closure (78, 525, 587, 589, 615, 616) as the extreme were necessary to control
transmission. Some studies have presented the latter two strategies as the turning points in
140
their control efforts; however, the measures usually followed in the wake of many other
actions to prevent dissemination, making it difficult to assess their utility.
Environmental measures. Some studies have focused on potential reservoirs for
transmission of VRE and other MDROs in the inanimate environment. In several studies,
environmental cultures were used to document contamination and led to interventions that
included use of dedicated noncritical medical equipment (78, 395), assignment of dedicated
cleaning personnel to the affected patient care unit (75, 358, 395, 401, 518, 588, 589), and
special attention to cleaning and disinfection of high-touch surfaces e.g., bedrails, charts,
bedside commodes, doorknobs) with monitoring of adherence to recommended practices
(2, 4, 479, 480, 628). Rarely, control of the target MDRO was not achieved until patient care
units were vacated for complete environmental cleaning and assessment (394, 512, 615).
The more frequent explanation for environmental contamination and transmission of an
MDRO was a failure to follow routine cleaning and disinfection practices rather than the
failure of the recommended practices. Thus, in settings where the prevalence of MDROs is
stable and low, an increased focus on environmental cultures and cleaning to control
MDROs is not warranted. Adherence to routine cleaning, sterilization, and disinfection
practices, as recommended in the Guideline for Environmental Infection Control in
Healthcare Facilities (4) and the Guideline for Disinfection and Sterilization in Healthcare
Facilities (in preparation) (7), should suffice under such conditions. Monitoring for adherence
is likely to be an important determinant for success in controlling transmission of MDROs
and other pathogens in the environment.
Decolonization. Decolonization entails treatment of colonized persons to eradicate
carriage of MDROs. Although some investigators have attempted to decolonize patients
harboring VRE (399) and MDR-GNB, few have achieved success. However, decolonization
of persons carrying MRSA in their nares has proved possible with several regimens,
including topical mupirocin alone or in combination with orally administered antibiotics (e.g.,
rifampin in combination with trimethoprim- sulfamethoxazole or ciprofloxacin) plus the use of
an antimicrobial soap for bathing (630). In one report daily baths accompanied nasal
therapy with mupirocin for 3 days with povidone-iodine for 3 days (487).
Most healthcare facilities coping with MDROs have limited the use of decolonization
to MRSA outbreaks or other high prevalence situations, especially those affecting special
141
care units. Identification of candidates for decolonization requires surveillance cultures.
Those considering this approach must also choose carefully the recipients and
decolonization regimen(s) and perform follow-up cultures to document eradication.
Recolonization with the same strain, initial colonization with a mupiricin-resistant strain, and
emergence of resistance to mupiricin during treatment limit the utility of this control measure
on a widespread basis (444, 630, 633, 637, 712). HCWs implicated in transmission of
MRSA are prime candidates for decolonization and should be culture negative before
returning to work. This use of mupiricin prophylaxis must be distinguished from the use of
mupiricin prophylaxis in selected groups of patients at high risk for S. aureus infections in
whom clinical and cost effectiveness have been demonstrated (e.g., dialysis patients (632),
but in whom emergence of resistance remains a consideration.
IV. Perspectives on the MDRO control literature. More than 100 reports published during
1982-2003 testify to the importance of dedicated and knowledgeable teams of healthcare
professionals who are willing to persist for years if necessary, to control MDROs.
Eradication and control of MDROs often required periodic reassessment of control
measures and the addition of new and more stringent measures when previous measures
were failing. For example, interventions were added to control measures in a stepwise
fashion during a 3-year effort that eventually eradicated MRSA from a NICU in Dallas (248).
A series of interventions were adopted throughout the course of a year to eradicate VRE
from a burn unit (518). Similarly, eradication of carbapenem-resistant strains of A.
baumannii from a New York City hospital required multiple and progressively more intense
interventions over several years (79). However, it has not been possible to determine the
effectiveness of individual interventions or a specific combination of interventions that would
be appropriate for all healthcare facilities due to the following considerations:
Methods. Despite the volume of published studies on the control of MDROs, an
appropriate set of evidence-based control measures has not been established with certainty
due to methodological variations and limitations. For example, there is an absence of
randomized, controlled trials comparing one MDRO control measure or strategy with
another and a paucity of comparative studies i.e., studies using similar methodologies to
evaluate competing control measures or strategies. The data are largely descriptive,
experiential, and uncontrolled. Factors that challenge the interpretation of results include
142
differences in definitions, study design, endpoints and variables measured, and period of
follow-up. Two-thirds of the reports involved perceived outbreaks, and one-third described
efforts to reduce endemic transmission (Table B-1). None described preemptive efforts or
prospective studies to control MDROs before they had become problematic in a facility.
Nearly all studies reporting successful MDRO control employed a median of 7 to 8
different measures concurrently or sequentially (Table B-1). These figures may
underestimate the actual number of control measures used because authors of these
reports may have considered their earliest efforts routine, e.g., added emphasis on
handwashing, and not included them as interventions and some “single measures” are, in
fact, a complex of several interventions, as noted above. The use of multiple concurrent
control measures in these reports underscores the need for a comprehensive approach for
controlling MDROs, but also makes it difficult to assess the value of any single component
of these control programs. The shortcomings of published studies of MRSA control and their
inadequacy to support national recommendations have been reviewed (722, 723).
Accuracy of detection of patients colonized with target MDROs. Rectal swabs
identify only 60% of individuals harboring VRE (441). Cultures of the nares identify most
patients with MRSA and perirectal and wound cultures can identify additional carriers (603,
604). However, there is a delay of 2-3 days before most MDRO surveillance culture results
are available. Thus, the specific methods used for detection of individuals colonized with a
target MDRO may account for variation in success of control programs.
Impact of interventions on other MDROs. Few studies report on the effect of
colonization or infection with more than a single species of MDRO. Only one of the reports
described control efforts directed at more than one MDRO, i.e., MDR-GNB and MRSA
(512). However, two reports (525, 713) of VRE control efforts demonstrated a rise in MRSA
following the prioritization of VRE patients to private rooms and cohort beds as part of a
VRE control intervention. An outbreak of susceptible Serratia marcescens that was
temporally associated with efforts to control an MRSA outbreak demonstrates the
importance of monitoring for the impact on other pathogens when implementing a program
that targets a single pathogen (158, 714) found that nearly 50% of residents in a skilled care
unit were colonized with a target MDRO and that 26% were co-colonized with >1 MDRO; a
detailed analysis showed that risk factors for colonization varied by pathogen in this study.
143
From a more overarching perspective, Safdar’s review of the literature (715) reported that
the same patient risk factors were associated with colonization with MRSA, VRE, MDRGNB, C. difficile and Candida sp. This review of 74 published studies concluded that control
programs that focus on only one organism or one antimicrobial drug are unlikely to succeed.
Impact of MDRO control interventions on patient care and well-being. Another
concern is the limited data regarding the impact of Contact Precautions on patients.
Although additional work is needed, several studies have demonstrated adverse effects of
Contact Precautions. One study (434) found that HCWs were two times less likely to enter
the rooms of patients on Contact Precautions than those not on Contact Precautions.
Similarly, Saint and colleagues found that attending physicians on a medical unit were
approximately half as likely to examine patients on Contact Precautions compared with
those not on Contact Precautions (35% vs. 73%, p< 0.001); there was no difference for
senior medical residents (84% versus 87%) (435). Two studies reported that use of private
rooms and barrier precautions for MDRO patients increased their scores for anxiety and
depression (436, 437). Another matched study found that patients with MRSA who were on
Contact Precautions had significantly more preventable adverse events, expressed greater
dissatisfaction with their treatment, and had less documented care than control patients who
were not in isolation (233).
Costs. Although several authors have argued for the cost-effectiveness of
approaches that use active surveillance cultures (539, 599, 600, 607, 668, 673, 716), these
arguments invariably rely on assumptions, projections, and estimated attributable costs of
MDRO infections. To date, no studies have directly compared the benefits and costs
associated with different MDRO control strategies.
Feasibility. Smaller hospitals, LTCFs and ambulatory-care facilities may lack the onsite laboratory services needed to obtain active surveillance cultures in a timely manner.
This factor and the need to provide appropriate psychosocial conditions for long-term
residents could limit the applicability of an aggressive program based on obtaining active
surveillance cultures and placing patients on Contact Precautions.
Lack of national and local consensus on the optimal strategy to control
MDROs. There are several controversies and lack of consensus concerning specific MDRO
control strategies. These include the optimal use of active surveillance cultures in
144
management efforts (87, 717, 718) and indications for routine use of both gowns and gloves
for the care of all ICU patients. The latter is largely due to conflicting results from
observations of HCW adherence to recommended practices (341, 620, 621).
This lack of consensus is reflected in differences in recommendations among the
various guidelines currently available that exhibit a spectrum of approaches, which their
authors deem to be evidence-based. The guideline for control of MRSA and VRE approved
by the Board of the Society for Healthcare Epidemiology of America (SHEA) in 2003 (87)
occupies one end of this spectrum. It advocates an aggressive approach, especially in
acute care facilities, with an emphasis on routine use of active surveillance cultures and
Contact Precautions. However, this position paper does not address control of MDR-GNBs.
In contrast, the guideline for LTCFs approved by the SHEA Board in 1996 exemplifies the
other end of the spectrum (160). This guideline emphasizes Standard Precautions, relies on
results of cultures obtained for clinical indications to monitor the problem, and provides for
additional measures when the problem exceeds defined thresholds. Other guidelines for
VRE and MRSA, e.g., those proffered by the Michigan Society for Infection Control
(www.msic-online.org/resource_sections/aro_guidelines), occupy a more intermediate
position on the guideline spectrum, emphasizing consistent practice of Standard
Precautions and tailoring the use of active surveillance cultures and Contact Precautions to
local conditions and the presence of risk factors for transmission.
The magnitude of the MDRO problem, especially the emergence of vancomycinresistant S. aureus (VRSA) that resulted from the transfer of the van A resistance gene from
a VRE strain to an MRSA strain (66), understandably motivates those advocating the most
aggressive approach (87), and in many situations this approach is needed and appropriate.
Notwithstanding, the many factors that influence strategies to control MDROs, discussed
below, argue against adoption of the most comprehensive methods as the sole approach to
this problem. In addition, data are lacking to validate the necessity for an aggressive
approach in LTCFs and outpatient healthcare settings. Therefore, individualized decisions
to implement control programs that rely heavily on active surveillance cultures to define the
MDRO reservoir must be made based on validated principles of MDRO epidemiology and
control.
145
V. Factors that influence selection of MDRO control measures. Although some common
management principles apply, the preceding evaluation of the literature indicates that no
single approach to the control of MDROs is appropriate for all healthcare facilities. Many
factors influence the choice of interventions to be applied within an institution, including:
Differences in the specific MDRO prevalent within the institution. Some facilities
have an MRSA problem while others have ESBL-producing Klebsiella pneumoniae. Some
facilities have no VRE colonization or disease; others have high rates of VRE colonization
without disease; and still others have ongoing VRE outbreaks.
Variability in colonization and infection rates. The experiences of healthcare
facilities with any given MDRO ranges from no prior identification of MDROs to prolonged,
extensive outbreaks. Between these extremes, facilities may have low or high levels of
endemic colonization and variable levels of infection.
Differences in risk factors based on type of facility and/or the patient
population served. Larger, tertiary care hospitals have more patients at high risk for VRE
and/or MRSA infection and the associated complications than do smaller, rural hospitals.
Similarly, nursing home residents appear less likely to develop MDRO infections, despite
high colonization rates, than do patients in acute care facilities (160, 164, 605, 660). Among
the few studies performed in ambulatory healthcare settings, one study of adult outpatients
in a primary care clinic (720) and one study of children attending a pediatric clinic (721)
reported low prevalences of MRSA colonization, 0.2% and 3%, respectively, and it appears
that MDRO transmission seldom occurs in those settings. However, patient-to-patient
transmission of both B. cepacia and P. aeruginosa in cystic fibrosis clinics for both children
and adults has been documented (221). Emergence of VRSA within the ambulatory setting
demonstrates an important role for this setting in detection and prevention of transmission
(63, 64, 66, 69)
Levels of available infection control personnel (e.g., full-time or part-time) and
microbiology laboratory resources (e.g., on- or off-site) and competing priorities for
those resources (243). An administrative decision to allocate necessary resources for
control often requires demonstration of the potential or actual negative impact of MDROs
within the institution.
146
VI. Tiered Approach for Control of MDROs. Details of several categories of interventions
to control MDROs (Table B-3) have been discussed. These reports indicate that facilities
confronting an MDRO problem selected a combination of control measures, implemented
them, and reassessed their impact. In some cases new measures were added serially, to
further enhance control efforts. This evidence indicates that the control of MDROs is a
dynamic process that requires a systematic approach tailored to the problem and healthcare
setting. Furthermore, the absence of evidence-based data and consensus suggests that
flexibility is needed to prevent and control of MDRO transmission.
Detailed recommendations for MDRO control in all healthcare settings are
delineated in Part II. Recommendations (section V) in the body of this guideline and are
summarized in Tables B 3-6 in Appendix B. A multi-intervention, two-tiered approach is
detailed in the table and permits each facilitiy to maximize or minimize the various
components of it’s MDRO control systems as changes in circumstance may dictate. Table
B-3, which applies to all settings where healthcare is provided irecommends a baseline level
of MDRO control activity for all facilities to ensure recognition of MDRO problems, definition
of institutional goals, involvement of healthcare administrators and provision of safeguards
for managing unidentified carriers of MDROs. Tables B-4, B-5, and B-6 elaborate on
modifications of the baseline level of control activities that may be necessary for LCTFs,
ambulatory settings, and home care settings.
Once an MDRO problem emerges in any type of healthcare setting, facilities need to
select additional control measures from the seven major categories of interventions
presented in Table B-3. Decisions to intensify MDRO control activity arise from surveillance
observations and assessments of the risk to patients in various settings. Accordingly, a
number of problematic circumstances may trigger these decisions:
•
Isolation of an MDRO from even one patient in a facility or special unit with a
highly vulnerable patient population (e.g., an ICU, NICU, burn unit) that had
previously not encountered that MDRO.
•
Increased isolations of MDROs in a unit or facility, especially when associated
with infectious morbidity.
In general, the combination of new or frequent MDRO isolation and patients at risk
necessitates escalation of efforts to achieve or re-establish control, i.e., to reduce rates of
147
transmission to the lowest possible level. Ongoing surveillance determines whether selected
control measures are efficacious or not.
VII. Conclusions. Decreasing the prevalence of MDROs and the impact of infection
caused by these pathogens on patient outcomes requires that all healthcare facilities and
agencies assume responsibility for the problem (52, 53);
(www.cdc.gov/drugresistance/healthcare/overview.htm). Only by prioritizing the MDRO
problem and allotting sufficient resources will healthcare facilities eradicate these pathogens
or reduce their transmission to a minimum level. Commitment and support from
organizational leadership are essential for successful control efforts (240, 296, 299, 300).
Leadership must provide authority for targeting specific MDROs and adopting stricter control
measures when needed. In addition, institutional administrators can authorize supplemental
resources for infection control, including expert consultations, laboratory support,
specialized products, adherence monitoring, and data analysis. Further, when
organizational leaders participate in efforts to reduce MDRO transmission, infection control
professionals find healthcare personnel more receptive and adherent to the recommended
control measures (240).
148
Table 1. Categorization of Reports about Control of MDROs in
Healthcare Settings, 1982-2003
MDRO
MDR-GNB
MRSA
VRE
No. of Studies
29
33
38
Reviewed/category
Types of Healthcare Facilities from which Study or Report Arose
29 (100)
28 (85)
32 (84)
No. (%) from
academic
facilitiesα
No. (%) from other
0
3 (10)
3 (8)
hospitals
No. (%) from
0
1 (3)
2 (5)
LTCFs
0
1 (3)
1 (3)
No. (%) from
multiple facilities in
a region
Unit of Study for MDRO Control Efforts
β
19
13
19
Special unit
Hospital
10
18
16
LTCF
0
1
2
Region
0
1
1
χ
Nature of Study or Report on MDRO Control
Outbreak
21
18
27
Non-outbreak
8
15
11
Total Period of Observation after Interventions Introduced
Less than 1 year
16
13
24
1-2 years
6
6
6
2-5 years
5
10
8
Greater than 5
2
4
years
Numbers of Control Measures Employed in Outbreaks/Studies
Range
2-12
0-11
1-12
Median
7
7
8
Mode
8
7
9
α
Variably described as university hospitals, medical school affiliated hospitals, VA teaching
hospitals, and, to a much lesser extent, community teaching hospitals
β
Includes intensive care units, burn units, dialysis units, hematology/oncology units,
neonatal units, neonatal intensive care units, and, in a few instances, individual wards of a
hospital
χ
Based on authors’ description – if they called their experience an outbreak or not; authors
vary in use of term so there is probable overlap between two categories
149
Table 2. Control Measures for MDROs Employed in Studies Performed in
Healthcare Settings, 1982-2003
Focus of MDRO
(No. of Studies)
Education of staff, patients or
visitors
Emphasis on handwashing
Use of antiseptics for
handwashing
Contact Precautions or glove useα
Private Rooms
Segregation of cases
Cohorting of Patients
Cohorting of Staff
Change in Antimicrobial Use
Surveillance cultures of patients
Surveillance cultures of staff
Environmental cultures
Extra cleaning & disinfection
Dedicated Equipment
Decolonization
Ward closure to new admission or
to all patients
Other miscellaneous measures
MDR-GNB
MRSA
VRE
(n=29)
(n=33)
(n=38)
No. (%) of Studies Using Control Measure
18 (62)
9 (27)
20 (53)
15 (52)
8 (30)
20 (61)
12 (36)
8 (21)
15 (39)
19 (66)
4 (15)
4 (15)
10 (34)
2 (7)
12 (41)
18 (67)
9 (31)
14 (48)
10 (34)
5 (17)
3 (10)
6 (21)
25 (76)
9 (27)
3 (9)
11 (33)
5 (15)
1 (3)
32 (97)
7 (21)
14 (42)
7 (21)
0
23 (70)
4 (12)
33 (87)
10 (27)
5 (14)
13 (35)
8 (22)
16 (42)
35 (92)
7 (19)
14 (37)
19 (50)
12 (32)
4 (11)
5 (14)
6 (22) β
9 (27)χ
16 (42)δ
α
Contact Precautions mentioned specifically, use of gloves with gowns or aprons
mentioned, barrier precautions, strict isolation, all included under this heading
β
includes signage, record flagging, unannounced inspections, selective decontamination in
a small number of studies (1 to 4 studies employing any of these measures)
χ
includes requirements for masks, signage, record tracking, alerts, early discharge, and
preventive isolation of new admissions pending results of screening cultures (1 to 3 studies
employing any of these measures)
δ
includes computer flags, signage, requirement for mask, one-to-one nursing, changing
type of thermometer used, and change in rounding sequence (1 to 6 studies employing any
of these measures)
References for Tables B-1 and B-2:
MDR-GNBs (75, 76, 78, 79, 380, 382, 384, 385, 389, 392-394, 400, 510, 512, 524, 531, 537, 538, 540, 543,
561, 564, 606, 608, 614, 626, 627, 658)
MRSA (248, 315, 316, 397, 444, 486, 487, 508, 511, 512, 520, 539, 546-548, 560, 562, 573, 577, 579,
586-588, 598, 609, 610, 612, 615, 625, 706, 724-726)
VRE (240, 317, 335, 336, 341, 358, 381, 383, 386, 387, 391, 395, 398, 401, 404, 459, 518, 519, 522,
523, 525, 533, 544, 545, 555, 559, 574, 583, 589, 601, 613, 617, 620, 621, 727-730)
150
Table B-3. Summary of Recommended Measures for the Prevention and Control of MDROs
Administrative
Measures/Adherence
Monitoring
Designate MDRO prevention/control
an organizational priority with
administrative support and resource
allocation (IB)
Implement/maintain systems to
communicate information about
reportable MDROs to administrative
personnel and state/local health
departments (IC/II)
Implement/maintain a multidisciplinary program to improve
adherence to recommended practices
for hand hygiene, Standard/ Expanded
Precautions, including feedback (IB)
Implement/maintain communication
systems to notify receiving HCWs
when known patients with MDROs are
transferred (IB)
MDRO Education
Include MDRO education
in the required curriculum
of all healthcare worker
professional training
programs (II)
Provide education and
training on transmission
risks and prevention of
MDRO transmission to
patient care personnel
during orientation and
periodic educational
updates, including
information on
organizational
experience, goals (IB)
Judicious
Antimicrobial Use
Implement a system to
prompt prescribers to
verify that prescribed
antibiotics are active
against the patient’s
clinical isolates (IB)
Avoid treating
colonization (II)
In hospitals and
LTCFs, ensure that a
multi-disciplinary
committee reviews
antimicrobial utilization
patterns and compares
them with resistance
patterns for purposes
of minimizing selective
pressure and providing
appropriate
antimicrobial coverage
(IB/IC)
Surveillance
Infection Control Precautions to
Prevent Transmission
Environmental
Measeures
Establish laboratory-based systems to detect
and communicate evidence of MDROs in
clinical isolates (IB)
Observe Standard Precautions during all
patient encounters on assumption any patient
could be colonized with an MDRO (IB/IC)
Prepare and monitor facility-specific and
high- risk unit-specific antimicrobial
susceptibility reports. Provide physicians with
summary reports. If microbiology services
are outsourced, request local or regional
aggregate susceptibility trends (IB)
Prioritize known MDRO patients for single
patient rooms or placement with like MDRO,
or low-risk patient (IB)
Use routine cleaning,
sterilization, and disinfection
procedures for maintaining
patient care areas, critical and
noncritical devices, and
medical equipment
Notify infection control of novel resistance
patterns,e.g., VISA, VRSA (IB/IC)
Develop local, regional coalitions to share
resistance data via health depts (II)
Identify specific MDROs (e.g., MRSA, VRE,
MDR-GNBs) for systematic monitoring
through review of susceptibility trends (IB)
Determine prevalence and define frequency
of MDROs that would trigger intensification of
MDRO control (IB)
Decolonization
Not recommended
routinely
For patients known to be colonized/infected
with MDROs
--- In acute care settings : Implement Contact
Precautions upon room entry (IB)
--- In LTCFs, ambulatory, home care: Use
hand hygiene, gloves. Implement Contact
Precautions on a case-by-case basis
determined by risks for transmission (IB)
---In hemodialysis units: Follow dialysis
specific guidelines (IA)
No recommendation for routine gloving or
gowning in ambulatory or home care settings
Measures above this line should be implements by all healthcare settings. Measures below this line should be implemented if 1) transmission of MDROs is continuing, despite use of routine control measures,
2) if prevalence of MDROs is above institutional thresholds, or 3) if a novel MDRO is emerging within the facility
Intensify MDRO control when ongoing
transmission, prevalence exceeds
institutional goals, or new MDRO (IB)
In the absence of dedicated infection
control staff, consult with experienced
infection control professionals and
healthcare epidemiologists for
assessment, design, implementation,
evaluation of MDRO control measures
(IB)
Evaluate system factors, including
staffing levels and adherence, for role
in MDRO transmission (IB)
Provide feedback to clinicians and
administrators on facility trends in
resistance, adherence monitoring, and
system failures (IB)
When increased incidence of a
targeted MDRO is observed,
implement intensive monitoring of
selected indicators (IB)
Implement educational
programs facility-wide
and/or in high-risk units
targeted for intensified
MDRO control
interventions. Include
relevant information on
MDRO trends, system
failures, action plans and
their outcomes (IB)
Impose limitations on
the use of antimicrobial
agents associated with
increased prevalence
of target MDRO e.g.,
d
vancomycin, thirdgeneration
cephalosporins, antianaerobic agents for
VRE; third generation
cephalosporins for
ESBLs;carbapenems,
quinolones (IB)
Calculate and analyze prevalence and
incidence rates of target MDROs (single
isolates/patient; location-, service-specific)
(IB)
Implement interim policies for patient
placement and staffing as needed to prevent
transmission (e.g., cohorting patients/staff;
unit or facility closure) (IB)
Increase frequency of compiling, monitoring
antimicrobial susceptibility summary reports
(II)
Implement Contact Precautions for all patients
colonized/infected with target MDRO (IA)
Implement laboratory protocols for storing
isolates of selected MDROs for molecular
typing; perform typing if needed (IB)
Develop and implement protocols to obtain
active surveillance cultures in at-risk
populations as defined locally (IB)
---Obtain culture at time of admission
---Conduct unit point prevalence studies
---Repeat cultures at defined intervals and
at discharge until transmission has ceased
---Obtain surveillance cultures from
roommates and other patients with significant
exposure to known MDRO-pos. patients
Obtain cultures from HCWs for target
MDROs only if HCWs epidemiologically
implicated as a source of transmission (IB)
When active surveillance cultures are done,
routinely use Contact Precautions (e.g.
gloves, gowns) for room entry and contact
with patients and their environment pending
negative surveillance culture results (IB)
No recommendation for criteria to discontinue
Contact Precautions; consult experts
No recommendation for universal use of
gloves and/or gowns
Masks are not recommended for routine use
to prevent MDRO transmission. Use mask to
prevent transmission of MRSA/VISA/VRSA
during patient interactions that may result in
droplet aerosols (IB)
Implement patient.-dedicated
use of noncritical equipment
(IB)
Assign dedicated cleaning
personnel who have been
trained in MDRO transmission
to targeted patient care areas
to enhance consistency of
cleaning and disinfection (II)
Implement procedures that
ensure consistent attention is
given to “high touch” surfaces
in patient care areas (IB).
Obtain cultures from
environmental sources (e.g.,
surfaces, shared equipment)
only when epidemiologically
implicated in transmission (IB)
Vacate units for environmental
assessment and intensive
cleaning when previous efforts
to control environmental
transmission have failed (II)
Obtain expert
consultation to
determine if persons
would benefit from
MRSA decolonization
when ongoing
transmission is not
prevented by other
measures (II)
Do not use topical
mupiricin routinely for
MRSA decolonization
as a component of
MRSA control
programs (IB)
No recommendations
for decolonization for
VRE, MDR-GNB
Decolonize HCW s
found to be infected or
colonized with MRSA
only when implicated
epidemiolgically in
ongoing transmission
(IA)
Table B-4. Summary of Recommendations for Management of MDROs in Long-Term Care Facilities (LTCFs)
Administrative Measures
Education of Staff
Designate MDRO prevention/control an
organizational priority in objectives for
patient safety (II)
Provide education and
training on preventing
transmission of MDROs
during HCW orientation
and periodic infection
control updates. Include
information on
organizational
experience with MDROs
(II)
Implement systems for MDRO reporting
as required by local/state health
departments (IC/II)
Implement programs to improve
adherence to recommended practices
for hand hygiene, Standard/ Expanded
Precautions; provide feedback on
performance measures to HCWs and
administrators (IB) (Appropriate
responsibility for Safety or Quality
Committees in the absence of an
infection control committee)
Implement systems to communicate
presence of MDRO’s to HCW’s (IB)
¾ Implement systems to identify
patients with MDROs upon
admission/re-admission to the
facility and during the course of
stay in the facility. (Identification
may rely on patient information
supplied by other providers)
¾ Incorporate information on MDRO
into written patient care plans
Focus education and
training on the following:
¾ risks of MDROs to
patients
¾ how MDROs are
transmitted
¾ importance of
adhering to
Standard
Precautions
¾ procedures for
communicating
information about
patients with
MDROs
¾ policies regarding
patient movement
within the facility
Judicious Antibiotic Use
Implement a system to prompt
prescribers to verify that
prescribed antibiotics are active
against the patient’s clinical
isolates when such information
is available (IB)
Avoid treating colonization in the
absence of clinical disease (II)
Establish a multi-disciplinary
process to ensure adequate
antibiotic coverage and
minimize selective pressure
(IB/IC)
¾ include the Medical
Director, Director of
Nursing, pharmacist and
infection control
coordinator
¾ review information at least
annually, but more
frequently in the presence
of persistent or emerging
resistance
¾ assure appropriate use of
culture and susceptibility
data for adjustment of
treatment regimens
¾ compare the compatibility
of antibiotic utilization
patterns with antimicrobial
susceptibility data
Surveillance
Identify specific MDROs (e.g.,
MRSA, VRE, MDR-GNB) for
systematic monitoring of
susceptibility trends (IB)
¾ Assess whether a newly
identified MDRO is due to
transmission within the facility
¾ Obtain expert consultation when
there is evidence of MDRO
transmission within the facility to
determine appropriate
intensified MDRO measures
Define when the frequency of
MDROs would trigger intensification
of MDRO control (IB)
Establish systems to detect and
communicate evidence of MDROs in
clinical isolates. Require by contract
that laboratories notify an institutional
infection control designate when a
target or novel MDRO is identified
(IB)
Require by contract that the primary
reference laboratory provide an
annual summary antimicrobial
susceptibility report (facility-specific,
local or regional as available).
Provide clinicians with copy of
report(IB)
In facilities with special care units
(e.g., ventilator-dependent), request
unit-specific reports. (IB)
Review local trends in resistance in
referring facilities at least annually,
but more frequently if new patterns
are emerging (II)
Infection Control Precautions
Observe Standard Precautions during all
patient encounters on the assumption that
any patient could be colonized with an
MDRO (IB/IC)
Observe hand hygiene before and after all
contacts with patients and their surrounding
environmental surfaces
---If hands are visibly soiled
--- Before and after contact with the patient
--- Before performance of an aseptic
procedure
--- After removal of gloves (IB)
Environmental
Measures
Use routine cleaning,
sterilization, and disinfection
procedures for maintaining
patient care areas and medical
equipment (IB)
Decolonization
Not recommended
routinely (IB)
Prioritize known MDRO patients for single
patient rooms or placement with like MDRO,
or low risk patient (IB)
¾
Determine the degree of socialization
and use of common areas for patients
with MDROs
Base decisions on the ability to contain
infected/colonized body fluids or body
sites, patient hygiene (e.g.,
handwashing, keeping hands away
from infected/colonized areas) and risk
to other patients.
¾ Implement Contact Precautions on a
case-by-case basis as determined by
risks for transmission including
uncontrolled secretions, stool
incontinence, draining wounds,
diarrhea, total dependence for activities
of daily living (IB)
Discontinue Contact Precautions on a caseby-case basis after considering the following:
¾ Repeatedly negative cultures when
available or
¾ No active infection or draining wounds
¾ Patient not implicated in transmission
¾ Patient remains colonized but risk
factors for transmission are no longer
present (IB)
¾
Recommendations in this table apply to all long-term care facilities. When a facility determines that a more intensified MDRO control program is indicated, refer to Table B-3 and to the recommendations section for guidance in
developing the program. In the absence of dedicated infection control staff, consult with experienced infection control professionals and healthcare epidemiologists for assessment, design, implementation, evaluation of MDRO
control measures
Table B-5. Summary of Recommendations for Management of MDROs in Ambulatory Care Settings
Administrative Measures
Designate MDRO prevention/
control an organizational priority.
Incorporate into administrative
planning/minutes* (II)
Implement systems for MDRO
reporting as required by local/state
health departments. Incorporate
into existing communicable
disease reporting procedures *
(IC/II)
Implement programs to improve
adherence to recommended
practices for hand hygiene,
Standard/ Expanded Precautions
and provide feedback on
performance measures to HCWs
and administrators (IB) Incorporate
into existing quality improvement
and safety processes. If such a
process does not exist, assign
responsibility to nurse managers to
ensure that appropriate infection
control policies and procedures
are developed, maintained and
monitored for adherence* (II)
Implement systems to identify
patients with MDRO’s upon initial
and subsequent encounters.
Utilize patient information or
information supplied by other
organizations or the patient’s
physician* (IB)
Implement systems to
communicate presence of MDRO’s
to HCW’s; incorporate into patient
care records * (IB)
Education of Staff
Provide education and
training on preventing
transmission of MDROs
during HCW orientation
and periodic infection
control updates. Include
information on
organizational
experience with MDROs
(II)
Focus education and
training on the following:
¾ risks of MDROs to
patients
¾ how MDROs are
transmitted
¾ importance of
adhering to
Standard
Precautions
¾ procedures for
communicating
information about
patients with
MDROs
¾ policies regarding
patient movement
within the
ambulatory care
setting
Judicious Antibiotic
Use
Incorporate the following
into existing quality
improvement activities:
Implement a system to
prompt prescribers (e.g.,
physicians, P.A., N.P.) to
verify that prescribed
antibiotics are active
against the patient’s
clinical isolates when such
information is available
(IB)
Avoid treating colonization
in the absence of clinical
disease (II)
Surveillance
Infection Control Precautions
The following are applicable to
ambulatory care sites that
evaluate and treat patient
infections:
Observe Standard Precautions during
all patient encounters on the
assumption that any patient could be
colonized with an MDRO (IB/IC)
Review information on local or
regional trends in resistance
patterns and predominant
MDROs in referring healthcare
facilities within the community at
least annually, but more
frequently if new patterns are
emerging (II)
Observe hand hygiene before and
after all contacts with patients and
their surrounding environmental
surfaces
--- If hands are visibly soiled
--- Before and after contact with the
patient
--- Before performance of an aseptic
procedure
--- After removal of gloves (IB)
Identify specific MDROs (e.g.,
MRSA, VRE, MDR-GNB) for
systematic monitoring of
susceptibility trends (IB)
Establish systems to detect and
communicate evidence of
MDROs in clinical isolates.
Require by contract that
laboratories notify an institutional
infection control designate when
a target or novel MDRO is
identified (IB)
Environmental
Measures
Use routine cleaning,
sterilization, and disinfection
procedures for maintaining
patient care areas and
patient care equipment (IB)
Decolonization
Not recommended
routinely (IB)
In hemodialysis centers,
follow recommendations in
dialysis-specific guidelines
(IA)
Implement Contact Precautions for a
patient with a known MDRO on a
case-by-case basis when the nature
of the patient interaction and/or the
risk of acquisition and associated
adverse outcomes to other patients in
the area indicate a need to intensify
barriers used to prevent transmission,
(e.g. MDRO patient has uncontrolled
secretions, stool incontinence,
ostomy tubes/bags or
immunocompromised patients are
seen in the same clinic area (IB)
Place patients who require Contact
Precautions in an examination room
or cubicle as soon as possible.
Develop procedures for management
of a patient with an MDRO of
particular epidemiologic importance
(e.g., VRSA), throughout the time
spent in the ambulatory care setting
(II)
Recommendations in this table apply to ambulatory settings that provide medical care, except hemodialysis centers and ambulatory settings where cystic fibrosis patients are cared for since specific guidelines have been
developed for these two populations (10, 215). This table does not apply to settings where medical treatment is not provided (e.g., dental, podiatric, chiropractic offices). When a facility determines that a more intensified MDRO
control program is indicated, refer to Table B.3 and to the recommendations section for guidance in developing the program. In the absence of dedicated infection control staff, consult with experienced infection control
professionals and healthcare epidemiologists for assessment, design, implementation, and evaluation of MDRO control measures.
* Italicized statements indicate suggestions for implementing the recommendation
Table B-6. Summary of Recommendations for Management of MDRO’s in Home Care Settings
Administrative Measures
Designate MDRO prevention/
control an organizational priority.
Incorporate into administrative
planning/minutes * (II)
Implement systems for MDRO
reporting as required by
local/state health departments.
Incorporate into existing
communicable disease reporting
procedures * (IC/II)
Implement systems to identify
patients with MDRO’s who
are receiving home care.
Review for MDROs at time
or admission, re-admission
during the course of ongoing
home care services. This
may rely upon patient
information supplied by other
organizations or the patient’s
physician * (IB)
Implement systems to
communicate presence of
MDRO’s to HCW’s. Incorporate
into patient care records *(IB)
Implement programs to improve
adherence to recommended
practices for hand hygiene,
Standard/ Expanded Precautions
and provide feedback to HCWs
and administrators Incorporate
into existing home care quality
improvement and safety
processes * (IB)
Education of
Staff
Provide education
and training on
preventing
transmission of
MDROs during
HCW orientation
and periodic
infection control
updates. Include
information on
organizational
experience with
MDROs (II)
Focus education
and training on the
following:
¾ risks of MDROs
to patients
¾ how MDROs
are transmitted
¾ importance of
adhering to
Standard
Precautions
¾ procedures for
communicating
information
about patients
with MDROs
¾ policies
regarding care
of MDRO
patients in the
home
Judicious Antibiotic
Use
Incorporate the following
into existing quality
improvement activities:
Implement a system to
prompt prescribers (e.g.,
physicians, P.A., N.P.) to
verify that prescribed
antibiotics are active
against the patient’s
clinical isolates when such
information is available
(IB)
Avoid treating colonization
in the absence of clinical
disease (II)
Surveillance
Identify specific MDROs (e.g.,
MRSA, VRE, MDR-GNB) for
systematic monitoring of
susceptibility trends (IB)
Review information on local or
regional trends in resistance
patterns and predominant
MDROs in referring healthcare
facilities within the community
at least annually, but more
frequently if new patterns are
emerging (II)
Establish systems to detect
and communicate evidence of
MDROs in clinical isolates.
Require by contract that
laboratories notify an
institutional infection control
designate when a target or
novel MDRO is identified (IB)
Infection Control
Precautions
Observe Standard Precautions and
hand hygiene during all patient
encounters on the assumption that
any patient could be colonized with
an MDRO (IB/IC)
Dedicate reusable patient care items
to patients known to be colonized or
infected with MDRO’s (e.g., BP cuff,
stethoscope, thermometer) (II)
Observe hand hygiene before and
after all contacts with patients and
their surrounding environmental
surfaces
--- If hands are visibly soiled
--- Before and after contact with the
patient
--- Before performance of an aseptic
procedure
--- After removal of gloves (IB)
Environmental
Measures
Use routine cleaning,
sterilization and
disinfection procedures for
maintaining patient care
areas and patient care
equipment (IB)
Decolonization
Not recommended
routinely (IB)
Limit the amount of patient
care equipment brought
into the home of patients
who require Contact
Precautions(II)
Perform surface
disinfection (i.e., clean
outside surfaces with a
detergent/disinfectant
before transporting used
equipment (II)
Implement Contact Precautions for a
home care patient with a known
MDRO on a case-by-case basis
when the nature of the patient
interaction indicate a need to
intensify barriers used to prevent
transmission (e.g., MDRO patients
has
uncontrolled
secretions, stool incontinence,
ostomy tubes/bags) (IB).
Develop procedures for management
of a patient with an MDRO e.g.,
VRSA, throughout the course of
home care (II)
Recommendations in this table apply to all home care patients except hemodialysis and cystic fibrosis patients since specific guidelines have been developed for these two populations (10, 215). When a home care organization
detects an MDRO problem, consult with experienced infection control professionals and healthcare epidemiologists for assessment, design, implementation, evaluation of MDRO control measures.
* Italicized statements indicate suggestions for implementing the recommendation
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