Draft Guideline for Isolation Precautions in Hospitals: Part I. ``Evolution of Isolation Practices'' and Part II. ``Recommendations for Isolation Precautions in Hospitals''; Notice of Comment Period

SUMMARY: This notice is a request for review and comment of the draft

Guideline for Isolation Precautions in Hospitals. The Guideline

consists of two parts, ``Evolution of Isolation Practices'' and

``Recommendations for Isolation Precautions in Hospitals,'' and was

prepared by the Hospital Infection Control Practices Advisory Committee

(HICPAC) and the National Center for Infectious Diseases (NCID), CDC.

DATES: Written comments on the draft document must be received on or

before January 6, 1995.

ADDRESSES: Comments on this document should be submitted in writing to

the CDC, Attention: Isolation Guideline Information Center, Mailstop

A07, 1600 Clifton Road, NE, Atlanta, Georgia 30333.

FOR FURTHER INFORMATION CONTACT: The Isolation Guideline Information

Center, telephone (404) 332-2569.

SUPPLEMENTARY INFORMATION: This document updates and replaces the

previously published CDC Guideline for Isolation Precautions in

Hospitals (Infect Control 1983;4:245-325, Am J Infect Control

1984;12:103-163, and HHS Publ. No. [CDC] 83-8314). Part I, ``Evolution

of Isolation Practices,'' reviews the evolution of isolation practices

in U.S. hospitals including their advantages, disadvantages, and

controversial aspects and provides the background for the HICPAC-

consensus recommendations contained in Part II, ``Recommendations for

Isolation Precautions in Hospitals.''

HICPAC was established in 1991 to provide advice and guidance to

the Secretary, DHHS; the Assistant Secretary for Health, DHHS; the

Director, CDC; and the Director, NCID, regarding the practice of

hospital infection control and strategies for surveillance, prevention,

and control of nosocomial infections in U.S. hospitals. The committee

also advises the CDC on periodic updating of guidelines and other

policy statements regarding prevention of nosocomial infections.

The Guideline for Isolation Precautions in Hospitals is the second

of a series of CDC guidelines being revised by HICPAC and NCID, CDC.

Dated: November 1, 1994.

Claire V. Broome,

Deputy Director, Centers for Disease Control and Prevention (CDC).

Guideline for Isolation Precautions in Hospitals

Executive Summary

The Guideline for Isolation Precautions in Hospitals was revised to

meet the following objectives: (1) to be epidemiologically sound, (2)

to recognize the importance of all body fluids, secretions, and

excretions in the transmission of nosocomial pathogens, (3) to contain

adequate precautions for infections transmitted by the airborne,

droplet, and contact routes of transmission, (4) to be as simple and

user friendly as possible, and (5) to use new terms to avoid confusion

with existing infection control and isolation systems.

The revised guideline contains two tiers of precautions. In the

first, and most important, tier are those precautions designed for the

care of all patients in hospitals regardless of their diagnosis or

presumed infection status. Implementation of these ``Standard

Precautions'' is the primary strategy for successful nosocomial

infection control. In the second tier are precautions designed only for

the care of specified patients. These additional ``Transmission-based

Precautions'' are used for patients known or suspected to be infected

or colonized with epidemiologically important pathogens that can be

transmitted by airborne or droplet transmission or by contact with dry

skin or contaminated surfaces.

Standard Precautions synthesize the major features of Universal

(Blood and Body Fluid) Precautions (designed to reduce the risk of

transmission of bloodborne pathogens) and Body Substance Isolation

(designed to reduce the risk of transmission of pathogens from moist

body substances). Standard Precautions apply to (1) blood, (2) all body

fluids, secretions, and excretions regardless of whether or not they

contain visible blood, (3) nonintact skin, and (4) mucous membranes.

Standard Precautions are designed to reduce the risk of transmission of

microorganisms from both recognized and unrecognized sources of

infection in hospitals.

Transmission-based Precautions are designed for patients documented

or suspected to be infected or colonized with highly transmissible or

epidemiologically important pathogens for which additional precautions

beyond Standard Precautions are needed to interrupt transmission in

hospitals. There are three types of Transmission-based Precautions:

Airborne Precautions, Droplet Precautions, and Contact Precautions.

They may be combined together for diseases that have multiple routes of

transmission. When used either singularly or in combination, they are

to be used in addition to Standard Precautions.

The revised guideline also lists specific clinical syndromes or

conditions in both adult and pediatric patients that are highly

suspicious for infection and identifies appropriate Transmission-based

Precautions to use on an empiric, temporary basis until a diagnosis can

be made; these empiric, temporary precautions are also to be used in

addition to Standard Precautions.

A working draft of this guideline was reviewed by experts in

infection control. However, all recommendations in the guideline may

not reflect the opinions of all reviewers.

Introduction

To assist hospitals in maintaining up-to-date isolation practices,

HICPAC\1\ has updated the CDC recommendations for isolation precautions

for use in hospitals. The recommendations are based on the latest

epidemiologic information on transmission of infection in hospitals;

they supersede previous CDC recommendations for isolation precautions

for use in hospitals.2-4

The recommendations are intended primarily for use in the care of

patients in acute-care hospitals, although some of the recommendations

may be applicable for some patients receiving care in extended-care

facilities. The recommendations are not intended for use in day care,

well care, or domiciliary care programs. Because (1) there have been

few studies to test the efficacy of isolation precautions, and (2) gaps

still exist in the knowledge of the epidemiology and modes of

transmission of some diseases, disagreement with some of the

recommendations is expected.

HICPAC recognizes that the goal of preventing transmission of

infections in hospitals can be accomplished by multiple means, and that

hospitals will modify the recommendations according to their needs and

circumstances and as directed by federal, state, or local regulations.

Modification of the recommendations is encouraged if (1) the principles

of epidemiology and disease transmission are maintained, and (2)

precautions are included to interrupt spread of infection by all routes

that are likely to be encountered in the hospital.

Part I. Evolution of Isolation Practices

Early Isolation Practices

The first published recommendations for isolation precautions in

the United States appeared as early as 1877, when a hospital handbook

recommended placing patients with infectious diseases in separate

facilities,\5\ which ultimately became known as infectious disease

hospitals. Although this practice segregated infected patients from

noninfected patients, nosocomial transmission continued to occur

because infected patients were not separated from each other according

to their disease, and few, if any, aseptic procedures were practiced.

Personnel in infectious disease hospitals began to combat problems of

nosocomial transmission by setting aside a floor or ward for patients

with similar diseases\6\ and by practicing aseptic procedures

recommended in nursing textbooks published from 1890 to 1900.\5\

In 1910, isolation practices in U.S. hospitals were altered by the

introduction of the cubicle system of isolation which placed patients

in multiple-bed wards.\6\ With the cubicle system, hospital personnel

used separate gowns, washed their hands with antiseptic solutions after

patient contact, and disinfected objects contaminated by the patient.

These nursing procedures, designed to prevent transmission of

pathogenic organisms to other patients and personnel, became known as

``barrier nursing.'' Use of the cubicle system of isolation and barrier

nursing procedures provided general hospitals with an alternative to

placing some patients in infectious disease hospitals.

During the 1950s, U.S. infectious disease hospitals, except those

designated exclusively for tuberculosis, began to close. In the mid-

1960s, tuberculosis hospitals also began to close, partly because

general hospital or outpatient treatment became preferred for patients

with tuberculosis. Thus, by the late 1960s patients with infectious

diseases were housed in wards in general hospitals, either in specially

designed, single-patient isolation rooms or in regular single or

multiple-patient rooms.

CDC Isolation Systems

CDC Isolation Manual

In 1970, CDC published a detailed manual entitled Isolation

Techniques for Use in Hospitals to assist general hospitals with

isolation precautions;\2\ a revised edition appeared in 1975.\3\ The

manual could be applied in small community hospitals with limited

resources as well as in large metropolitan university-associated

medical centers.

The manual introduced the category system of isolation precautions.

It recommended that hospitals use one of seven isolation categories

(Strict Isolation, Respiratory Isolation, Protective Isolation, Enteric

Precautions, Wound and Skin Precautions, Discharge Precautions, and

Blood Precautions). The precautions recommended for each category were

determined almost entirely by the epidemiologic features of the

diseases grouped in the category, primarily their routes of

transmission. Certain isolation techniques, believed to be the minimum

necessary to prevent transmission of all diseases in the category, were

indicated for each isolation category. Because all diseases in a

category did not have the same epidemiology (i.e., were not spread by

exactly the same combination of modes of transmission), with some

requiring fewer precautions than others, more precautions were

suggested for some diseases than were necessary. This disadvantage of

``over-isolation'' for some diseases was offset by the convenience of

having a small number of categories. More importantly, the simple

system required personnel to learn only a few established routines for

applying isolation precautions. To make the system even more user

friendly, instructions for each category were printed on color-coded

cards and placed on the doors, beds, and/or charts of patients on

isolation precautions.

By the mid-1970s, 93% of U.S. hospitals had adopted the isolation

system recommended in the manual.\7\ However, neither the efficacy of

the category approach in preventing spread of infections nor the costs

of using the system were evaluated by empirical studies.

By 1980, hospitals were experiencing new endemic and epidemic

nosocomial infection problems, some caused by multidrug-resistant

microorganisms and others caused by newly recognized pathogens, which

required different isolation precautions from those specified by any

existing isolation category. There was increasing need for isolation

precautions to be directed more specifically at nosocomial transmission

in special-care units, rather than at the intrahospital spread of

infectious diseases acquired in the community.\8\ Infection control

professionals and nursing directors in hospitals with particularly

sophisticated nursing staffs were increasingly calling for new

isolation systems that would tailor precautions to the modes of

transmission for each infection and avoid the over-isolation inherent

in the category-specific approach. Further, new facts about the

epidemiology and modes of transmission of some diseases made it

necessary for CDC to revise the isolation manual. Toward that end,

during 1981-1983, CDC Hospital Infections Program personnel consulted

with infectious disease specialists in medicine, pediatrics, and

surgery; hospital epidemiologists; and infection control practitioners

about revising the manual.

CDC Isolation Guideline

In 1983, the CDC Guideline for Isolation Precautions in

Hospitals\4\ (hereafter referred to as the isolation guideline) was

published to take the place of the 1975 isolation manual; it contained

many important changes. One of the most important was the increased

emphasis on decision-making on the part of users. Unlike the 1975

manual, which encouraged few decisions on the part of users, the

isolation guideline encouraged decision-making at several

levels.9-10 First, hospital infection control committees were

given a choice of selecting between category-specific or disease-

specific isolation precautions or using the guideline to develop a

unique isolation system appropriate to their hospital's circumstances

and environment. Second, personnel who placed a patient on isolation

precautions were encouraged to make decisions about the individual

precautions to be taken, (e.g., whether the patient's age, mental

status, or condition indicated that a private room was needed to

prevent sharing of contaminated articles). Third, personnel taking care

of patients on isolation precautions were encouraged to decide whether

they needed to wear a mask, gown, or gloves based on the likelihood of

exposure to infective material. Such decisions were deemed necessary to

isolate the infection but not the patient and to reduce the costs

associated with unnecessary isolation precautions.

In the category-specific section of the guideline, existing

categories were modified, new categories were added, and many

infections were reassigned to different categories. The old category of

Blood Precautions, primarily directed toward patients with chronic

carriage of hepatitis B virus (HBV), was renamed Blood and Body Fluid

Precautions and expanded to include (1) patients with AIDS and (2) body

fluids other than blood. The old category of Protective Isolation was

deleted because of studies demonstrating its lack of efficacy in

general clinical practice in preventing the acquisition of infection by

the immunocompromised patient for whom it had originally been

described.11-12 The 1983 guideline contained the following

categories of isolation: Strict Isolation, Contact Isolation,

Respiratory Isolation, Tuberculosis (acid-fast bacilli [AFB])

Isolation, Enteric Precautions, Drainage/Secretion Precautions, and

Blood and Body Fluid Precautions. As with the category approach in the

former CDC isolation manuals, these categories tended to over-isolate

some patients.

In the disease-specific section of the guideline, the epidemiology

of each infectious disease was considered individually by advocating

only those precautions (e.g., private room, mask, gown, and gloves)

needed to interrupt transmission of the infection. In place of the

categories and signs of the category-specific approach, a chart listed

all diseases posing the threat of in-hospital transmission with checks

in columns indicating which precautions were required for each. Because

precautions were individualized for each disease, hospitals using the

system were encouraged to provide more initial training and in-service

education and to encourage a much higher level of attention from

patient-care personnel. Although disease-specific isolation precautions

eliminated ``over-isolation,'' personnel might be prone to mistakes in

applying the precautions, especially if the disease was not regularly

seen in the hospital,9-10 if there was a delay in diagnosis, or if

there was a misdiagnosis. Placing disease-specific isolation

precautions in a hospital computerized information system resulted in

more accurate use of the system.\13\

Since gaps existed in the knowledge of the epidemiology of some

diseases, disagreement was expected, and occurred, regarding the

placement of individual diseases within given categories, especially

diseases with a respiratory component of transmission.\14\ Placing

measles in Respiratory Isolation (designed to prevent transmission of

large-particle droplets) rather than in a category that had provisions

for preventing transmission by airborne droplet nuclei and placing

rubella and respiratory syncytial virus (RSV) infection in Contact

Isolation were controversial.\15\ There was also disagreement about the

lack of a recommendation for adult patients with influenza, the need

for a private room for pediatric patients with RSV infections, and the

length of time that precautions should be maintained.\15\ The lack of

empiric studies on the efficacy and costs of implementing the

recommendations contributed to the disagreements.

As new epidemiologic data became available, several subsequent CDC

reports16-18 updated portions of the isolation guideline. Updated

recommendations for management of patients with suspected hemorrhagic

fever were published in 1988.\16\ The recommendation for Respiratory

Isolation for acute erythema infectiosum was superseded by a 1989

report that recommended Respiratory Isolation for human parvovirus B19

(the causative agent for erythema infectiosum) only when infected

patients were in transient aplastic crisis or had immunodeficiency and

chronic human parvovirus B19 infection.\17\

Recommendations for Tuberculosis (AFB) Isolation were updated in

1990\18\ because of heightened concern about nosocomial transmission of

multidrug-resistant tuberculosis,19-20 particularly in settings

where persons with human immunodeficiency virus (HIV) infection were

receiving care. The 1990 tuberculosis guidelines emphasized (1) placing

a hospital patient with confirmed or suspected tuberculosis in a

private room that has lower, or negative, air pressure compared with

surrounding areas, (2) reducing mycobacterial contamination of air by

dilution and removal of airborne contaminants, and (3) wearing

particulate respirators, rather than standard surgical masks, when

hospital personnel shared air space with an infectious tuberculosis

patient. Subsequent recommendations reemphasized the importance of

early diagnosis and treatment of tuberculosis.\21\ In 1993, a second

edition of the guidelines for preventing the transmission of

tuberculosis in health care facilities was published in draft for

public comment.\22\ After review of written comments, the guidelines

were modified and published.\23\

Universal Precautions

In 1985, largely because of the HIV epidemic, isolation practices

in the United States were dramatically altered by the introduction of a

new strategy for isolation precautions, which became known as Universal

Precautions (UP). Following the initial reports of hospital personnel

becoming infected with HIV through needlesticks and skin contamination

with patients' blood, a widespread outcry created the urgent need for

new isolation strategies to protect hospital personnel from bloodborne

infections. The subsequent modification of isolation precautions in

some hospitals produced several major strategic changes and sacrificed

some measures of protection against patient-to-patient transmission in

the process of adding protection against patient-to-personnel

transmission. In acknowledgment of the fact that many patients with

bloodborne infections are not recognized, the new UP approach placed

emphasis for the first time to applying Blood and Body Fluid

Precautions universally to all persons regardless of their presumed

infection status.\24\ Until this time, most patients placed on

isolation precautions were those for whom a diagnosis of an infectious

disease had been made or was suspected. This provision led to the new

name of Universal Precautions.

In addition to emphasizing prevention of needlestick injuries and

the use of traditional barriers such as gloves and gowns, UP expanded

Blood and Body Fluid Precautions to include use of masks and eye-

coverings to prevent mucous membrane exposures during certain

procedures and the use of individual ventilation devices when the need

for resuscitation was predictable. This approach, and particularly the

techniques for preventing mucous membrane exposures, was reemphasized

in subsequent CDC reports that contained recommendations for prevention

of HIV transmission in health care settings.25-28

In 1987, one of these reports\27\ stated that implementation of UP

for all patients eliminated the need for the isolation category of

Blood and Body Fluid Precautions for patients known or suspected to be

infected with bloodborne pathogens; however, the report stated that

other category- or disease-specific isolation precautions recommended

in the CDC isolation guideline\4\ should be used as necessary if

infections other than bloodborne infections were diagnosed or

suspected.

The 1987 report was updated by a 1988 report\28\ that emphasized

two important points: (1) blood was the single most important source of

HIV, HBV, and other bloodborne pathogens in the occupational setting,

and (2) infection control efforts for preventing transmission of

bloodborne pathogens in health care settings must focus on preventing

exposures to blood as well as on delivery of HBV immunization. The

report stated that UP applied to blood, body fluids that had been

implicated in the transmission of bloodborne infections (semen and

vaginal secretions), body fluids from which the risk of transmission

was unknown (amniotic, cerebrospinal, pericardial, peritoneal, pleural,

and synovial fluids), and to any other body fluid visibly contaminated

with blood, but not to feces, nasal secretions, sputum, sweat, tears,

urine, or vomitus unless they contained visible blood. Although HIV and

HBV surface antigen (HBsAg) had been found in some of the fluids,

secretions, or excretions to which UP did not apply, epidemiologic

studies in the health care and community setting had not implicated

these substances in the transmission of HIV and HBV infections.

However, the report noted that some of the fluids, secretions, and

excretions not covered under UP represented a potential source for

nosocomial and community-acquired infections with other pathogens and

referred readers to the CDC isolation guideline.

Body Substance Isolation

In 1987, a new system of isolation, called Body Substance Isolation

(BSI), was proposed, after 3 years of study by infection control

personnel at the Harborview Medical Center in Seattle and the

University of California at San Diego, as an alternative to diagnosis-

driven isolation systems.29 BSI focused on the isolation of all

moist and potentially infectious body substances (blood, feces, urine,

sputum, saliva, wound drainage, and other body fluids) from all

patients, regardless of their presumed infection status, primarily

through the use of gloves. Personnel were instructed to put on clean

gloves just before contact with mucous membranes and nonintact skin,

and to wear gloves for anticipated contact with moist body substances.

In addition, a ``Stop Sign Alert'' was used to instruct persons wishing

to enter the room of some patients with infections transmitted

exclusively or in part by the airborne route to check with the floor

nurse, who would determine whether a mask should be worn; personnel

were to be immune to or immunized against selected infectious diseases

transmitted by airborne or droplet routes (measles, mumps, rubella, and

varicella) or they were not to enter the rooms housing patients with

these diseases. Other issues related to implementing BSI in a

university teaching hospital were described.30

Among the advantages cited for BSI were that it was a simple, easy

to learn and administer system, and that it avoided the assumption that

(1) individuals without known or suspected diagnoses of transmissible

infectious diseases were free of risk to patients and personnel, and

(2) that only certain body fluids were associated with transmission of

infection. The disadvantages of BSI included the added cost of

increased use of barrier equipment, particularly gloves;31 the

difficulty in maintaining routine application of the protocol for all

patients; the uncertainty about the precautions to be taken when

entering a room with a ``Stop Sign Alert''; and the potential for

misapplication of the protocol to overprotect personnel at the expense

of the patient.32

In a prospective study,33 a combination use of gown and glove

protocols similar to BSI led to lower infection rates in a pediatric

intensive care unit (ICU), and in other studies similar combinations of

barriers were associated with lower rates of nosocomial RSV infection

in a pediatric ICU34 and of resistant gram-negative organisms in

an acute-care hospital.35 However, in none of these studies,

initiated before publication of BSI, were the authors attempting to

evaluate BSI, nor were they able to separate the effect of gloves from

that of gowns or from gloves and gowns used in combination.

Controversial aspects of BSI have been summarized.15,16 BSI

appeared to replace some, but not all, of the isolation precautions

necessary to prevent transmission of infection. BSI did not contain

adequate provisions to prevent (1) droplet transmission of serious

infections in pediatric populations (e.g., invasive Haemophilus

influenza, Neisseria meningitides meningitis and pneumonia, and

pertussis), (2) direct or indirect contact transmission of

epidemiologically important microorganisms from dry skin or

environmental sources (e.g., Clostridium difficile and vancomycin-

resistant enterococci), or (3) true airborne transmission of infections

transmitted over long distances by floating droplet nuclei. Although

BSI emphasized that a private room was indicated for some patients with

some diseases transmitted exclusively or in part by the true airborne

route, it did not emphasize the need for special ventilation for

patients known or suspected of having pulmonary tuberculosis or other

diseases transmitted by airborne droplet nuclei. The lack of emphasis

on special ventilation was of particular concern to CDC in the early

1990s because of multidrug-resistant tuberculosis.18-19

BSI and UP shared many similar features designed to prevent the

transmission of bloodborne pathogens in hospitals. However, there was

an important difference in the recommendation for glove use and

handwashing. Under UP, gloves were recommended for anticipated contact

with blood and specified body fluids and hands were to be washed

immediately after gloves were removed.27-28 Under BSI, gloves were

recommended for anticipated contact with any moist body substance but

handwashing after glove removal was not required unless the hands were

visibly soiled.29 The lack of emphasis on handwashing after glove

removal was cited as one of the theoretical disadvantages of

BSI.15,37-38 Using gloves as a protective substitute for

handwashing may have provided a false sense of security, resulted in

less handwashing, increased the risk of nosocomial transmission of

pathogens because hands can become contaminated even when gloves are

used39 and are easily contaminated in the process of removing

gloves, and contributed to skin problems and allergies associated with

the use of gloves.40-41 On the other hand, proponents of BSI have

noted that studies of handwashing have indicated relatively low

compliance by hospital personnel,42-43 that glove use may have

been easier to manage than handwashing, and that frequent handwashing

may have led to eczema, skin cracking, or, in some persons, clinical

damage to the skin of the hands.44 Although use of gloves may have

been better than no handwashing, the efficacy of using gloves as a

substitute for handwashing has not been demonstrated.

OSHA Bloodborne Pathogens Regulations

In 1989, the Occupational Safety and Health Administration (OSHA)

published a proposed rule regarding occupational exposure to bloodborne

pathogens in hospitals and other health care settings.45 The

proposed rule, based on the concept of UP, raised concerns in the

infection control community. Among them were concerns about the use of

``visibly bloody'' as a marker for the infectious risk of certain body

fluids and substances, the imbalance toward precautions to protect

personnel and away from protection for patients, the lack of proven

efficacy of UP, and the costs for implementing the proposed

regulations.46-50 After a series of OSHA public hearings and

review of written comments, the proposed rule was modified and the

final rule on occupational exposure to bloodborne pathogens was

published in 1991.51 Although the final rule was expected to

improve occupational safety in the care of patients infected with

bloodborne pathogens, its impact on the cost of patient care and on

nosocomial infection control has remained undefined. Information on

complying with the OSHA final rule has been made available by the

American Hospital Association52 and others.53

The Need for a New Isolation Guideline

By the early 1990s, isolation had become an infection control

conundrum.54 Although many hospitals had incorporated all or

portions of UP into their category- or disease-specific isolation

system and others had adopted all or portions of BSI,55-56 there

was much local variation in the interpretation and use of UP and BSI

and a variety of combinations was common. Further, there was

considerable confusion about which body fluids or substances required

precautions under UP and BSI. Many hospitals espousing UP were really

using BSI and vice-versa. Moreover, there was continued lack of

agreement about the importance of handwashing when gloves were

used14-15,27-29,37-38,57-58 and the need for additional

precautions beyond BSI to prevent airborne, droplet, and contact

transmission.14-15,27-29,31,36,59-60 Some hospitals had not

implemented appropriate guidelines for preventing transmission of

tuberculosis, including multidrug-resistant tuberculosis.61 As

other multidrug-resistant microorganisms62-63 were emerging, some

hospitals failed to recognize them as new problems and to add

appropriate precautions that would contain them.

In view of these problems and concerns, no simple adjustment to any

of the existing approaches--UP, BSI, the CDC isolation guideline, or

other isolation systems--appeared likely to solve the conundrum.

Clearly what was needed was a new synthesis of the various systems that

would provide a guideline with logistically feasible recommendations

for preventing the many infections that occur in hospitals through

diverse modes of transmission. To achieve this, the new guideline would

have to be (1) epidemiologically sound, (2) recognize the importance of

all body fluids, secretions, and excretions in the transmission of

nosocomial pathogens, (3) contain adequate precautions for infections

transmitted by the airborne, droplet, and contact routes of

transmission, (4) be as simple and user friendly as possible, and (5)

use new terms to avoid confusion with existing systems.

Based on these considerations, a new guideline was subsequently

developed. It contains three important changes from previous

recommendations. First, it synthesizes the major features of UP27-

28 and BSI29-30 into a single set of precautions to be used for

the care of all patients in hospitals regardless of their presumed

infection status. These precautions, called Standard Precautions, are

designed to reduce the risk of transmission of bloodborne and other

pathogens in hospitals. As a result of this synthesis, a large number

of patients with diseases or conditions that previously required

category- or disease-specific precautions in the 1983 CDC isolation

guideline4 are now covered under Standard Precautions and do not

require additional precautions. Second, it collapses the old categories

of isolation precautions (Strict Isolation, Contact Isolation,

Respiratory Isolation, Tuberculosis Isolation, Enteric Precautions, and

Drainage/Secretion Precautions) and the old disease-specific

precautions into three sets of precautions based on routes of

transmission for a smaller number of specified patients known or

suspected to be infected or colonized with highly transmissible or

epidemiologically important pathogens; these Transmission-based

Precautions, designed to reduce the risk of airborne, droplet, and

contact transmission in hospitals, are to be used in addition to

Standard Precautions. Third, it lists specific syndromes in both adult

and pediatric patients that are highly suspicious for infection and

identifies appropriate Transmission-based Precautions to use on an

empiric, temporary basis until a diagnosis can be made; these empiric,

temporary precautions are also designed to be used in addition to

Standard Precautions. The details of the guideline recommendations are

presented in Part II, ``Recommendations for Isolation Precautions in

Hospitals.''

In summary, the new guideline is another step in the evolution of

isolation practices in U.S. hospitals. It is now recommended for review

and use by hospitals with the following provision. No guideline can

address all of the needs of the more than 6,000 U.S. hospitals, which

range in size from 5 beds to more than 1,500 beds and serve very

different patient populations. Hospitals are encouraged to review the

guideline and to modify it according to what is possible, practical,

and prudent.

Part II. Recommendations for Isolation Precautions in Hospitals

Rationale for Isolation Precautions in Hospitals

Spread of infection within a hospital requires three elements: a

source of infecting microorganisms, a susceptible host, and a means of

transmission for the microorganism.

Source

Human sources of the infecting microorganisms in hospitals may be

patients, personnel, or, on occasion, visitors and may include persons

with acute disease, persons in the incubation period of a disease,

persons who are colonized by an infectious agent but have no apparent

disease, or persons who are chronic carriers of an infectious agent.

Other sources of infecting microorganisms can be the patient's own

endogenous flora, which may be difficult to control, and inanimate

environmental objects that have become contaminated, including

equipment and medications.

Host

Resistance among persons to pathogenic microorganisms varies

greatly. Some persons may be immune to infection or be able to resist

colonization by an infectious agent; others exposed to the same agent

may establish a commensal relationship with the infecting microorganism

and become asymptomatic carriers; still others may develop clinical

disease. Host factors such as age; underlying diseases; certain

treatments with antimicrobials, corticosteroids or other

immunosuppressive agents; irradiation; and breaks in the first line of

defense mechanisms caused by such factors as surgical operations,

anesthesia, and indwelling catheters may render patients more

susceptible to infection.

Transmission

Microorganisms are transmitted in hospitals by several routes, and

the same microorganism may be transmitted by more than one route. There

are five main routes of transmission--contact, droplet, airborne,

common vehicle, and vectorborne. For the purpose of this guideline,

common vehicle and vectorborne transmission will be discussed only

briefly since neither play a significant role in typical nosocomial

infections.

1. Contact Transmission, the most important and frequent mode of

transmission of nosocomial infections, is divided into two subgroups:

direct-contact transmission and indirect-contact transmission.

a. Direct-contact transmission involves a direct body surface-to-

body surface contact and physical transfer of microorganisms between a

susceptible host and an infected or colonized person, such as occurs

when a person turns a patient, gives a patient a bath, or performs

other patient-care activities that require direct personal contact.

Direct-contact transmission can also occur between two patients with

one serving as the source of the infectious microorganisms and the

other as a susceptible host.

b. Indirect-contact transmission involves contact of a susceptible

host with a contaminated intermediate object, usually inanimate, such

as contaminated instruments or dressings, or contaminated gloves that

are not changed between patients.

2. Droplet transmission, theoretically, is a form of contact

transmission. However, the mechanism of transfer of the pathogen to the

host is quite distinct from either direct- or indirect-contact

transmission. Therefore, droplet transmission will be considered a

separate route of transmission in this guideline. Droplets are

generated from the source person primarily during coughing, sneezing,

and talking, and during the performance of certain procedures such as

suctioning and bronchoscopy. Transmission occurs when droplets

containing microorganisms generated from the infected person are

propelled a short distance through the air and deposited on the host's

conjunctivae, nasal mucosa, or mouth. Transmission of this nature must

not be confused with airborne transmission.

3. Airborne Transmission occurs by dissemination of either airborne

droplet nuclei (small-particle residue [5 microns or smaller in size]

of evaporated droplets containing microorganisms that remain suspended

in the air for long periods of time) or dust particles containing the

infectious agent. Microorganisms carried in this manner can be widely

dispersed by air currents and may become inhaled by a susceptible host

within the same room or over a longer distance from the source patient

depending on environmental factors.

4. Common Vehicle Transmission applies to microorganisms

transmitted by contaminated items such as food, water, medications,

devices, and equipment.

5. Vectorborne Transmission occurs when vectors such as mosquitoes,

flies, rats, and other vermin transmit microorganisms; this route of

transmission is of less significance in hospitals in the United States

than in other regions of the world.

Isolation precautions are designed to prevent transmission of

microorganisms by these routes in hospitals. Since agent and host

factors are more difficult to control, interruption of spread of

infection is directed primarily at transmission. The recommendations

presented in this guideline are based on this concept.

Placing a patient on isolation precautions, however, often presents

certain disadvantages to the hospital, patients, personnel, and

visitors. Isolation precautions may require specialized equipment and

environmental modifications that add to the cost of hospitalization.

Isolation precautions may make frequent visits by nurses, physicians,

and other personnel inconvenient, and they may make it more difficult

for personnel to give the prompt and frequent care that is sometimes

required. The use of a multi-patient room for one patient uses valuable

space that might otherwise accommodate several patients. Moreover,

forced solitude deprives the patient of normal social relationships and

may be psychologically harmful, especially to children. These

disadvantages, however, must be weighed against the hospital's mission

to prevent the spread of serious and epidemiologically important

microorganisms in the hospital.

Fundamentals of Isolation Precautions

A variety of infection control measures are used for decreasing the

risk of transmission of microorganisms in hospitals. These measures

make up the fundamentals of isolation precautions.

Handwashing and Gloving

Handwashing is frequently called the single most important measure

for preventing spread of infection. The scientific rationale,

indications, methods, and products for handwashing have been delineated

in other publications.64-71

Washing hands as promptly and thoroughly as possible between

patient contacts and after contact with blood, body fluids, secretions,

excretions, and equipment or articles contaminated by them is an

important component of infection control and isolation precautions. In

addition to handwashing, gloves play an important role in the

prevention of the spread of infection.

Gloves are worn for three important reasons in hospitals. First,

gloves are worn to provide a protective barrier and prevent gross

contamination of the hands when touching blood, body fluids,

secretions, excretions, mucous membranes, and nonintact skin;27-29

the wearing of gloves in specified circumstances to reduce the risk of

exposures to bloodborne pathogens is mandated by the OSHA bloodborne

pathogens final rule.51 Second, gloves are worn to reduce the

likelihood that microorganisms present on the hands of personnel will

be transmitted to patients during invasive or other patient-care

procedures that involve touching a patient's mucous membranes and

nonintact skin. Third, gloves are worn to reduce the likelihood that

hands of personnel contaminated with microorganisms from a patient or a

fomite can transmit these microorganisms to another patient; in this

situation, gloves must be changed between patient contacts and hands

washed after gloves are removed.

Wearing gloves does not replace the need for handwashing because

(1) gloves may have small inapparent defects or be torn during use, and

(2) hands can become contaminated during removal of gloves.14-

15,39,72-75 Failure to change gloves between patient contacts is an

infection control hazard.32

Patient Placement

Appropriate patient placement is an important component of

isolation precautions. When possible, patients with highly

transmissible or epidemiologically important microorganisms are placed

in a private room with handwashing and toilet facilities to reduce

opportunities for transmission of microorganisms. A private room is

also important to prevent direct- or indirect-contact transmission when

the source patient has poor hygienic habits, contaminates the

environment, or cannot be expected to assist in maintaining infection

control precautions to limit transmission of microorganisms (i.e.,

infants, children, and patients with altered mental status).

When a private room is not available, infected patients are placed

with appropriate roommates. Patients infected by the same microorganism

can usually share a room provided (1) they are not infected with other

potentially transmissible microorganisms, and (2) the likelihood of

reinfection with the same organism is minimal. Such sharing of rooms,

also referred to as cohorting patients, is especially useful during

outbreaks or when there is a shortage of private rooms. When a private

room is not available and cohorting is not achievable or

recommended,23 it is very important to consider the epidemiology

and mode of transmission of the infecting pathogen and the patient

population being served in determining patient placement. Under these

circumstances, consultation with infection control professionals is

advised before patient placement. Moreover, when an infected patient

shares a room with a noninfected patient, it is also important that

patients, personnel, and visitors take precautions to prevent the

spread of infection and that roommates are carefully selected.

Guidelines for construction, equipment, air handling, and

ventilation for isolation rooms have been delineated in other

publications.76-78 A private room with appropriate air handling

and ventilation is particularly important for reducing the risk of

transmission of microorganisms from a source patient to susceptible

patients and other persons in hospitals when the microorganism is

spread by airborne transmission. Some hospitals use an isolation room

with an anteroom as an extra measure of precaution to prevent airborne

transmission. Adequate data regarding the need for anterooms, however,

is not available. Ventilation recommendations for isolation rooms

housing patients with pulmonary tuberculosis have been delineated in

other CDC guidelines.23

Transport of Infected Patients

Limiting the movement and transport of patients infected with

virulent or epidemiologically important microorganisms and ensuring

that such patients leave their rooms only for essential purposes reduce

opportunities for transmission of microorganisms in hospitals. When

patient transport is necessary, it is important that (1) appropriate

barriers (e.g., masks, impervious dressings) are worn or used by the

patient to reduce the opportunity for transmission of pertinent

microorganisms to other patients, personnel, and visitors and to reduce

contamination of the environment, (2) personnel in the area to which

the patient is to be taken are notified of the impending arrival of the

patient and of the precautions to be used to reduce the risk of

transmission of infectious microorganisms, and (3) patients are

informed of ways by which they can assist in preventing the

transmission of their infectious microorganisms to others.

Masks, Respiratory Protection, Eye Protection, Face Shields

Various types of masks, goggles, and face shields are worn alone or

in combination to provide barrier protection. A mask that covers both

the nose and mouth and goggles or a face shield are worn during

procedures and patient-care activities that are likely to generate

splashes or sprays of blood, body fluids, secretions, or excretions to

provide protection of the mucous membranes of the eyes, nose, and mouth

from contact transmission of pathogens. The wearing of masks, eye

protection, and face shields in specified circumstances to reduce the

risk of exposures to bloodborne pathogens is mandated by the OSHA

bloodborne pathogens final rule.51 A surgical mask is generally

worn to provide protection against spread of infectious large-particle

droplets that are transmitted by close contact and generally travel

only short distances (up to 3 feet) from infected patients who are

coughing or sneezing.

An area of major concern and controversy over the last several

years has been the role and selection of respiratory protection

equipment and the implications of a respiratory protection program for

prevention of transmission of tuberculosis in hospitals. Traditionally,

although the efficacy was not proven, a surgical mask was worn for

isolation precautions in hospitals when patients were known or

suspected to be infected with pathogens spread by the airborne route of

transmission. In 1990, however, the CDC tuberculosis guidelines18

stated that surgical masks may not be effective in preventing the

inhalation of droplet nuclei and recommended the use of disposable

particulate respirators despite the fact that the efficacy of

particulate respirators in protecting persons for the inhalation of

Mycobacterium tuberculosis had not been demonstrated. By definition,

particulate respirators include dust-mist (DM), dust-fume-mist (DFM),

or high-efficiency particulate air (HEPA) filter respirators certified

by the CDC National Institute for Occupational Safety and Health

(NIOSH); since the generic term particulate respirator was used in the

1990 guidelines, the implication was that any of these respirators

provided sufficient protection.79

In 1993, a draft revision of the CDC tuberculosis guidelines22

outlined performance criteria for respirators and stated that some DM

or DFM respirators might not meet these criteria. After review of

public comments, the guidelines were finalized in October 199423

with the draft respirator criteria unchanged. The only class of

respirators that currently are (1) known to consistently meet or exceed

the performance criteria outlined in the 1994 tuberculosis guidelines,

and (2) certified by NIOSH (as required by OSHA) are HEPA filter

respirators. However, recently NIOSH has announced that they will

change their respirator certification process.80 The proposed

changes should enable users to select from a broader range of certified

respirators for use in hospitals for protection against M.

tuberculosis. Additional information on the evolution of respirator

recommendations, regulations to protect hospital personnel, and the

role of various federal agencies in respiratory protection for hospital

personnel has been prepared for publication.79

Gowns and Protective Apparel

Various types of gowns and protective apparel are worn to provide

barrier protection and reduce opportunities for transmission of

microorganisms in hospitals. Gowns are worn to prevent contamination of

clothing and protect the skin of personnel from blood and body fluid

exposures. Gowns especially treated to make them impermeable to

liquids, leg coverings, boots, or shoe covers provide greater

protection to the skin when splashes or large quantities of infective

material are present or anticipated. The wearing of gowns and

protective apparel under specified circumstances to reduce the risk of

exposures to bloodborne pathogens is mandated by the OSHA bloodborne

pathogens final rule.\51\

Gowns are also worn by personnel during the care of patients

infected with epidemiologically important microorganisms to reduce the

opportunity for transmission of pathogens from patients or items in

their environment to other patients or environments; when gowns are

worn for this purpose, they are removed before leaving the patient's

environment and hands are washed. Adequate data regarding the efficacy

of gowns for this purpose, however, is not available.

Patient-Care Equipment and Articles

Many factors determine whether special handling and disposal of

used patient-care equipment and articles are prudent or required,

including the likelihood of contamination with infective material; the

ability to cut, stick, or otherwise cause injury (needles, scalpels,

and other sharp instruments [sharps]); the severity of the associated

disease; and the environmental stability of the pathogens

involved.27,51,81-83 Some used articles are enclosed in containers

or bags to prevent inadvertent exposures to patients, personnel, and

visitors and to prevent contamination of the environment. Used sharps

are placed in puncture-resistant containers; other articles are placed

in a bag. One bag is adequate if the bag is sturdy and the article can

be placed in the bag without contaminating the outside of the bag;\84\

otherwise two bags (double bagging) are used.

The scientific rationale, indications, methods, products, and

equipment for reprocessing patient-care equipment have been delineated

in other publications.68,83,85-90 Contaminated, reusable critical

medical devices or patient-care equipment (i.e., equipment that enters

normally sterile tissue or through which blood flows) or semicritical

medical devices or patient-care equipment (i.e., equipment that touches

mucous membranes) are sterilized or disinfected (reprocessed) after use

to reduce the risk of transmission of microorganisms to other patients;

the type of reprocessing is determined by the article and its intended

use, the manufacturer's recommendations, hospital policy, and any

applicable guidelines and regulations.

Noncritical equipment (i.e., equipment that touches intact skin)

contaminated with blood, body fluids, secretions, or excretions is

cleaned and disinfected after use according to hospital policy.

Contaminated disposable (single-use) patient-care equipment is handled

and transported in a manner that reduces the risk of transmission of

microorganisms and decreases environmental contamination in the

hospital; the equipment is disposed of according to hospital policy and

applicable regulations.

Linen and Laundry

Although soiled linen may be contaminated with pathogenic

microorganisms, the risk of disease transmission is negligible if it is

handled, transported, and laundered in a manner that avoids transfer of

microorganisms to patients, personnel, and environments. Rather than

rigid rules and regulations, hygienic and commonsense storage and

processing of clean and soiled linen are recommended.27,82,91 The

methods for handling, transporting, and laundering of soiled linen are

determined by hospital policy and any applicable regulations.

Dishes, Glasses and Cups, and Eating Utensils

No special precautions are needed for dishes, glasses and cups, or

eating utensils. Either disposable or reusable dishes and utensils can

be used for patients on isolation precautions. The combination of hot

water and detergents used in hospital dishwashers is sufficient to

decontaminate dishes, glasses and cups, and eating utensils.

Routine and Terminal Cleaning

The room or cubicle and bedside equipment of patients on isolation

precautions are cleaned using the same procedures used for other

patients unless the infecting microorganism(s) and the amount of

environmental contamination indicates special cleaning. The methods,

thoroughness, and frequency of cleaning and the products used are

determined by hospital policy.

HICPAC Isolation Precautions

There are two tiers of HICPAC isolation precautions. In first, and

most important, tier are those precautions designed for the care of all

patients in hospitals regardless of their diagnosis or presumed

infection status. Implementation of these ``Standard Precautions'' is

the primary strategy for successful nosocomial infection control. In

the second tier are precautions designed only for the care of specified

patients. These additional ``Transmission-based Precautions'' are for

patients known or suspected to be infected by epidemiologically

important pathogens spread by airborne or droplet transmission or by

contact with dry skin or contaminated surfaces.

Standard Precautions

Standard Precautions synthesize the major features of Universal

(Blood and Body Fluid) Precautions27-28 (designed to reduce the

risk of transmission of bloodborne pathogens) and Body Substance

Isolation29-30 (designed to reduce the risk of transmission of

pathogens from moist body substances) and applies them to all patients

receiving care in hospitals regardless of their diagnosis or presumed

infection status. Standard Precautions apply to (1) blood, (2) all body

fluids, secretions, and excretions regardless of whether or not they

contain visible blood, (3) nonintact skin, and (4) mucous membranes.

Standard Precautions are designed to reduce the risk of transmission of

microorganisms from both recognized and unrecognized sources of

infection in hospitals.

Transmission-Based Precautions

Transmission-based Precautions are designed for patients documented

or suspected to be infected with highly transmissible or

epidemiologically important pathogens for which additional precautions

beyond Standard Precautions are needed to interrupt transmission in

hospitals. There are three types of Transmission-based Precautions:

Airborne Precautions, Droplet Precautions, and Contact Precautions.

They may be combined together for diseases that have multiple routes of

transmission. When used either singularly or in combination, they are

to be used in addition to Standard Precautions.

Airborne Precautions are designed to reduce the risk of airborne

transmission of infectious agents. Airborne transmission occurs by

dissemination of either airborne droplet nuclei (small-particle residue

[5 microns or smaller in size] of evaporated droplets that may remain

suspended in the air for long periods of time) or dust particles

containing the infectious agent. Microorganisms carried in this manner

can be widely dispersed by air currents and may become inhaled by or

deposited on a susceptible host within the same room or over a longer

distance from the source patient, depending on environmental factors.

Airborne Precautions apply to patients known or suspected to be

infected with epidemiologically important pathogens that can be

transmitted by the airborne route.

Droplet Precautions are designed to reduce the risk of droplet

transmission of infectious agents. Droplet transmission involves

contact of the conjunctivae, or the mucous membranes of the nose or

mouth of a susceptible person with large-particle droplets (larger than

5 microns in size) containing microorganisms generated from a person

who has a clinical disease or is a carrier of the microorganism.

Droplets are generated from the source person primarily during

coughing, sneezing, or talking, and during the performance of certain

procedures such as suctioning and bronchoscopy. Transmission via large-

particle droplets requires close contact between source and recipient

persons since droplets do not remain suspended in the air and generally

travel only short distances, usually 3 feet or less, through the air.

Droplet Precautions apply to any patient known or suspected to be

infected with epidemiologically important pathogens that can be

transmitted by infectious droplets.

Contact Precautions are designed to reduce the risk of transmission

of epidemiologically important microorganisms by direct or indirect

contact. Direct-contact transmission involves skin-to-skin contact and

physical transfer of microorganisms to a susceptible host from an

infected or colonized person, such as occurs when personnel turn a

patient, give a patient a bath, or perform other patient-care

activities that require physical contact. Direct-contact transmission

can also occur between two patients (e.g., by hand contact), with one

serving as the source of infectious microorganisms and the other as a

susceptible host. Indirect-contact transmission involves contact of a

susceptible host with a contaminated intermediate object, usually

inanimate, in the patient's environment. Contact Precautions apply to

specified patients known or suspected to be infected or colonized

(presence of microorganism in or on patient but without clinical signs

and symptoms of infection) with epidemiologically important

microorganisms than can be transmitted by direct- or indirect-contact.

A synopsis of the types of precautions and the patients requiring

the precautions is listed in Table 1.

Empiric Use of Airborne, Droplet, or Contact Precautions

In many instances, the risk of nosocomial transmission of infection

may be highest before a definitive diagnosis can be made and

precautions based on that diagnosis implemented. The routine use of

Standard Precautions for all patients should greatly reduce this risk

for conditions other than those requiring Airborne, Droplet, or Contact

Precautions. While it is not possible to prospectively identify all

patients needing these enhanced precautions, certain clinical syndromes

and conditions carry a sufficiently high risk to warrant the empiric

addition of enhanced precautions while a more definitive diagnosis is

pursued. A listing of such conditions and the recommended precautions

beyond Standard Precautions is presented in Table 2.

The organisms listed under the column ``Potential Pathogens'' are

not intended to represent the complete or even most likely diagnoses,

but rather possible etiologic agents that require additional

precautions beyond Standard Precautions until they can be ruled out.

Infection control professionals are encouraged to modify or adapt this

table according to local conditions. To ensure that appropriate empiric

precautions are always implemented, hospitals must have systems in

place to routinely evaluate patients according to these criteria as

part of their preadmission and admission care.

Immunocompromised Patients

Immunocompromised patients vary in their susceptibility to

nosocomial infections depending on the severity and duration of

immunosuppression. They are generally at increased risk for bacterial

infections from both endogenous and exogenous sources. The use of

Standard Precautions for all patients and Transmission-based

Precautions for specified patients as recommended in this guideline

should reduce the acquisition by these patients of institutionally

acquired bacteria from other patients and environments.

It is beyond the scope of this guideline to address the various

measures that may be used for immunocompromised patients to delay or

prevent acquisition of potential pathogens during temporary periods of

neutropenia. Rather, the primary objective of this guideline is to

prevent transmission of pathogens from infected or colonized patients

in hospitals. Users of this guideline, however, are referred to the

Guideline for Prevention of Nosocomial Pneumonia92-93 for the

HICPAC recommendations for prevention of nosocomial aspergillosis and

Legionnaires' disease in immunocompromised patients.

HICPAC Recommendations for Isolation Precautions in Hospitals

The HICPAC recommendations presented below are categorized

according to the scheme outlined in Table 3. The recommendations are

limited to the topic of isolation precautions. Therefore, they must be

supplemented by hospital policies and procedures for other aspects of

infection and environmental control, occupational health,

administrative and legal issues, and other issues beyond the scope of

this guideline.

I. Education

Develop a system to ensure that hospital patients, personnel, and

visitors are educated about use of precautions and their responsibility

for adherence to them. Category IB

II. Standard Precautions

Use Standard Precautions, or the equivalent, for the care of all

patients. Category IB

A. Handwashing

1. Wash hands after touching blood, body fluids, secretions,

excretions, and contaminated items, whether or not gloves are worn.

Wash hands immediately after gloves are removed, between patient

contacts, and when otherwise indicated to avoid transfer of

microorganisms to other patients or environments. Category IB

2. Use a plain (nonantimicrobial) soap for handwashing except for

specific circumstances (e.g., control of outbreaks or hyperendemic

infections) as defined by the infection control program. Category II

B. Gloves

Wear gloves (clean nonsterile gloves are adequate) when touching

blood, body fluids, secretions, excretions, and contaminated items; put

on clean gloves just before touching mucous membranes and nonintact

skin. Remove gloves promptly after use, before touching noncontaminated

items and environmental surfaces, and before going to another patient,

and wash hands immediately to avoid transfer of microorganisms to other

patients or environments. Category IB

C. Mask, Eye Protection, Face Shield

Wear a mask and eye protection or a face shield to protect mucous

membranes of the eyes, nose, and mouth during procedures and patient-

care activities that are likely to generate splashes or sprays of

blood, body fluids, secretions, and excretions. Category IB

D. Gown

Wear a gown (a clean nonsterile gown is adequate) to protect skin

and prevent soiling of clothing during procedures and patient-care

activities that are likely to generate splashes or sprays of blood,

body fluids, secretions, or excretions or cause soiling of clothing.

Select a gown that is appropriate for the activity and amount of fluid

likely to be encountered. Remove a soiled gown as promptly as possible

and wash hands to avoid transfer of microorganisms to other patients or

environments. Category IB

E. Patient-Care Equipment

Handle used patient-care equipment soiled with blood, body fluids,

secretions, and excretions in a manner that prevents skin and mucous

membrane exposures, contamination of clothing, and transfer of

microorganisms to other patients and environments. Ensure that reusable

equipment is not used for the care of another patient until it has been

appropriately cleaned and reprocessed and single use items are properly

discarded. Category IB

F. Linen

Handle, transport, and process used linen soiled with blood, body

fluids, secretions, and excretions in a manner that prevents skin and

mucous membrane exposures, contamination of clothing, and avoids

transfer of microorganisms to other patients and environments. Category

IB

G. Occupational Health and Bloodborne Pathogens

1. Take care to prevent injuries when using needles, scalpels, and

other sharp instruments or devices; when handling sharp instruments

after procedures; when cleaning used instruments; and when disposing of

used needles. Never recap used needles or otherwise manipulate them

using both hands, or any other technique that involves directing the

point of a needle toward any part of the body; rather, use either a

one-handed ``scoop'' technique or a mechanical device designed for

holding the needle sheath. Do not remove used needles from disposable

syringes by hand, and do not bend, break, or otherwise manipulate used

needles by hand. Place used disposable syringes and needles, scalpel

blades, and other sharp items in appropriate puncture-resistant

containers located as close as practical to the area in which the items

were used, and place reusable syringes and needles in a puncture-

resistant container for transport to the reprocessing area. Category IB

2. Use mouthpieces, resuscitation bags, or other ventilation

devices as an alternative to mouth-to-mouth resuscitation methods in

areas where the need for resuscitation is predictable. Category IB

H. Patient Placement

Place a patient who contaminates the environment or who does not

(or cannot be expected to) assist in maintaining appropriate hygiene or

environmental control in a private room. If a private room is not

available, consult with infection control professionals regarding

patient placement or other alternatives. Category IB

III. Airborne Precautions

In addition to Standard Precautions, use Airborne Precautions, or

the equivalent, for patients known or suspected to be infected with

microorganisms transmitted by airborne droplet nuclei (small-particle

residue [5 microns or smaller in size] of evaporated droplets

containing microorganisms that remain suspended in the air and can be

widely dispersed by air currents within a room or over a long

distance). Category IB

A. Patient Placement

Place the patient in a private room that has (1) monitored negative

air pressure in relation to the surrounding areas, (2) a minimum of six

air changes per hour, and (3) appropriate discharge of air outdoors or

monitored high-efficiency filtration of room air before the air is

circulated to other areas in the hospital.\23\ Keep the room door

closed and the patient in the room. When a private room is not

available, place the patient in a room with a patient who has active

infection with the same microorganism, unless otherwise

recommended,\23\ but with no other infection. When a private room is

not available and cohorting is not desirable, consultation with

infection control professionals is advised before patient placement.

Category IB

B. Respiratory Protection

Wear respiratory protection when entering the room of a patient

with known or suspected infectious tuberculosis.\23\ Do not enter the

room of patients known or suspected to have measles (rubeola) or

varicella (chickenpox) if susceptible to these infections. Category IB

C. Patient Transport

Limit the movement and transport of the patient from the room to

essential purposes only. If transport or movement is necessary,

minimize patient dispersal of droplet nuclei by placing a surgical mask

on the patient, if possible. Category IB

D. Additional Precautions for Preventing Transmission of Tuberculosis

Consult CDC Guidelines for Preventing the Transmission of

Tuberculosis in Health-Care Facilities\23\ for additional prevention

strategies.

IV. Droplet Precautions

In addition to Standard Precautions, use Droplet Precautions, or

the equivalent, for a patient known or suspected to be infected with

microorganisms transmitted by droplets (large-particle droplets [larger

than 5 microns in size] that can be generated by the patient during

coughing, sneezing, talking, or the performance of procedures).

Category IB

A. Patient Placement

Place the patient in a private room. When a private room is not

available, place the patient in a room with a patient(s) who has active

infection with the same microorganism, but with no other infection

(cohorting). When a private room is not available and cohorting is not

achievable, maintain spatial separation of at least 3 feet between the

infected patient and other patients and visitors. Category IB

B. Mask

In addition to standard precautions, wear a mask when working

within 3 feet of the patient. (Logistically, some hospitals may want to

implement the wearing of a mask to enter the room.) Category IB

C. Patient Transport

Limit the movement and transport of the patient from the room to

essential purposes only. If transport or movement is necessary,

minimize patient dispersal of droplets by masking the patient, if

possible. Category IB

V. Contact Precautions

In addition to Standard Precautions, use Contact Precautions, or

the equivalent, for specified patients known or suspected to be

infected or colonized with epidemiologically important microorganisms

that can be transmitted by direct contact with the patient (hand or

skin-to-skin contact that occurs when performing patient-care

activities that require touching the patient's dry skin) or indirect

contact (touching) with environmental surfaces or patient-care items in

the patient's environment. Category IB

A. Patient Placement

Place the patient in a private room. When a private room is not

available, place the patient in a room with a patient(s) who has active

infection with the same microorganism, but with no other infection

(cohorting). When a private room is not available and cohorting is not

achievable, consider the epidemiology of the microorganism and the

patient population when determining patient placement; consultation

with infection control professionals is advised before patient

placement. Category IB

B. Gloves and Handwashing

In addition to wearing gloves as outlined under Standard

Precautions, wear gloves (clean nonsterile gloves are adequate) when

entering the room. During the course of providing care for a patient,

change gloves after having contact with infective material that may

contain high concentrations of microorganisms (fecal material and wound

drainage). Remove gloves before leaving the patient's room and wash

hands immediately with an antimicrobial agent. After glove removal and

handwashing, ensure that hands do not touch potentially contaminated

environmental surfaces or items in the patient's room to avoid transfer

of microorganisms to other patients or environments. Category IB

C. Gown

In addition to wearing a gown as outlined under Standard

Precautions, wear a gown (a clean nonsterile gown is adequate) when

entering the room if you anticipate that your clothing will have

substantial contact with the patient, environmental surfaces, or items

in the patient's room, or if the patient is incontinent, or has

diarrhea, an ileostomy, a colostomy, or wound drainage not contained by

a dressing. Remove the gown before leaving the patient's environment.

After gown removal, ensure that clothing does not contact potentially

contaminated environmental surfaces to avoid transfer of microorganisms

to other patients or environments. Category IB

D. Patient Transport

Limit the movement and transport of the patient from the room to

essential purposes only. If the patient is transported out of the room,

ensure that precautions are maintained to minimize the risk of

transmission of microorganisms to other patients and contamination of

environmental surfaces or equipment. Category IB

E. Environmental Control

Ensure that patient-care items, bedside equipment, and frequently

touched surfaces receive daily cleaning. Category IB

F. Patient-Care Equipment

When possible, dedicate the use of noncritical patient-care

equipment and items such as a stethoscope, sphygmomanometer, bedside

commode, or electronic rectal thermometer to a single patient (or

cohort of patients infected or colonized with the pathogen requiring

precautions) to avoid sharing between patients. If use of common

equipment or items is unavoidable, then adequately clean and disinfect

them before use for another patient. Category IB

G. Additional Precautions for Preventing the Spread of Vancomycin

Resistance

Consult the HICPAC report on preventing the spread of vancomycin

resistance for additional prevention strategies.\94\

VI. Adherence to Precautions

Periodically evaluate adherence to precautions, and use findings to

direct improvements. Category IB

Table 1.--Synopsis of Types of Precautions and Patients Requiring the

Precautions*

Standard Precautions

Use Standard Precautions for the care of all patients

Airborne Precautions

In addition to Standard Precautions, use Airborne Precautions for

patients known or suspected to have serious illnesses transmitted by

airborne droplet nuclei. Examples of such illnesses include:

(1)Measles

(2)Varicella (including disseminated zoster)

(3)TuberculosisSec.

Droplet Precautions

In addition to Standard Precautions, use Droplet Precautions for

patients known or suspected to have serious illnesses transmitted by

large particle droplets. Examples of such illnesses include:

(1)Invasive Haemophilus influenzae type b disease, including

meningitis, pneumonia, epiglottitis, and sepsis

(2)Invasive Neisseria meningitidis disease, including meningitis,

pneumonia, and sepsis

(3)Invasive multidrug-resistant Streptococcus pneumoniae disease,

including meningitis, pneumonia, sinusitis, and otitis media

(4)Other serious bacterial respiratory infections spread by droplet

transmission, including:

(a)Diphtheria (pharyngeal)

(b)Mycoplasma pneumonia

(c)Pertussis

(d)Pneumonic plague

(e)Streptococcal pharyngitis, pneumonia, or scarlet fever in infants

and young children

(5) Serious viral infections spread by droplet transmission,

including:

(a)Adenovirus

(b)Influenza

(c)Mumps

(d)Parvovirus B19

(e)Rubella

Contact Precautions

In addition to Standard Precautions, use Contact Precautions for

patients known or suspected to have serious illnesses easily

transmitted by direct patient contact or by contact with items in the

patient's environment. Examples of such illnesses include:

(1) Gastrointestinal, respiratory, skin, or wound infections or

colonization with multidrug-resistant bacteria judged by the

infection control program, based on current state, regional, or

national recommendations, to be of special clinical and epidemiologic

significance

(2) Enteric infections with a low infectious dose or prolonged

environmental survival, including:

(a)Clostridium difficile

(b)For diapered or incontinent patients: enterohemorrhagic

Escherichia coli O157:H7, Shigella, hepatitis A, or rotavirus

(3) Respiratory syncytial virus, parainfluenza virus, or enteroviral

infections in infants and young children

(4) Skin infections that are highly contagious or that may occur on

dry skin, including:

(a)Diphtheria (cutaneous)

(b)Herpes simplex virus (neonatal or mucocutaneous)

(c)Impetigo

(d)Major (noncontained) abscesses, cellulitis, or decubiti

(e)Pediculosis

(f)Scabies

(g)Staphylococcal furunculosis in infants and young children

(h)Staphylococcal scaled skin syndrome

(i)Zoster (disseminated or in the immunocompromised host)

(5) Viral/hemorrhagic conjunctivitis

(6) Viral hemorrhagic fevers (Lassa fever or Marburg virus)

*See Appendix A for a complete listing of infections requiring

precautions, including appropriate footnotes.

Certain infections require more than one type of precaution.

Sec. See CDC Guidelines for Preventing the Transmission of Tuberculosis

in Health-Care Facilities.\23\

Table 2.--Clinical Syndromes or Conditions Warranting Additional Empiric

Precautions To Prevent Transmission of Epidemiologically Important

Pathogens Pending Confirmation of Diagnosis*

------------------------------------------------------------------------

Clinical syndrome or Potential Empiric

condition Pathogens Sec. Precautions

------------------------------------------------------------------------

DIARRHEA:

(1) Acute diarrhea with a Enteric pathogens Contact.

likely infectious cause in .

an incontinent or diapered

patient.

(2) Diarrhea in an adult with Clostridium Contact.

a history of broad spectrum difficile.

or long-term antibiotics.

MENINGITIS....................... Neisseria Droplet.

meningitidis.

RASH OR EXANTHEMS, GENERALIZED,

ETIOLOGY UNKNOWN:

(1) Petechial/ecchymotic with Neisseria Droplet.

fever. meningitidis.

(2) Vesicular................ Varicella......... Airborne and

Contact.

(3) Maculopapular with coryza Rubeola (measles). Airborne.

and fever.

RESPIRATORY INFECTIONS:

(1) Cough/fever/upper lobe Mycobacterium Airborne.

pulmonary infiltrate in an tuberculosis.

HIV-negative patient and a

patient at low risk for HIV

infection.

(2) Cough/fever/pulmonary Mycobacterium Airborne.

infiltrate in any lung tuberculosis.

location in a HIV-infected

patient and at high risk for

HIV infection\23\.

(3) Paroxysmal or severe Bordetella Droplet.

persistent cough during pertussis.

periods of pertussis

activity.

(4) Respiratory infections, Respiratory Contact.

particularly broncholitis syncytial or

and croup, in infants and parainfluenza

young children. virus.

RISK OF MULTIDRUG-RESISTANT

MICROORGANISMS:

(1) History of infection or Resistant bacteria Contact.

colonization with multidrug-

resistant organisms**.

(2) Skin, wound, or urinary Resistant bacteria Contact.

tract infection in a patient

with a recent hospital or

nursing home stay in a

facility where multidrug-

resistant organisms are

prevalent.

SKIN OR WOUND INFECTION:

Abscess or draining wound Staphylococcus Contact.

that cannot be covered. aureus, Group A

streptococcus.

------------------------------------------------------------------------

*Infection control professionals are encouraged to modify or adapt this

table according to local conditions. To ensure that appropriate

empiric precautions are always implemented, hospitals must have

systems in place to routinely evaluate patients according to these

criteria as part of their preadmission and admission care.

Patients with the syndromes or conditions listed below may

present with atypical signs or symptoms (e.g., pertussis in neonates

and adults may not have paroxysmal or severe cough). The clinician's

index of suspicion should be guided by the prevalence of specific

conditions in the community as well as clinical judgement.

Sec. The organisms listed under the column ``Potential Pathogens'' are

not intended to represent the complete or even most likely diagnoses,

but rather possible etiologic agents that require additional

precautions beyond Standard Precautions until they can be ruled out.

These pathogens include enterohemorrhagic Escherichia coli O157:H7,

Shigella, hepatitis A, and rotavirus.

**Resistant bacteria judged by the infection control program, based on

current state, regional or national recommendations, to be of special

clinical or epidemiological significance.

Table 3--Categorization of HICPAC Recommendations

Category IA. Strongly recommended for all hospitals and strongly

supported by well-designed experimental or epidemiologic studies.

Category IB. Strongly recommended for all hospitals and viewed as

effective by experts in the field and a consensus of HICPAC based on

strong rationale and suggestive evidence, even though definitive

scientific studies have not been done.

Category II. Suggested for implementation in many hospitals.

Recommendations may be supported by suggestive clinical or

epidemiologic studies, a strong theoretical rationale, or definitive

studies applicable to some but not all hospitals.

No recommendation; unresolved issue. Practices for which

insufficient evidence or consensus regarding efficacy exists.

Appendix A.--Type and Duration of Precautions Needed for Selected

Infections and Conditions

------------------------------------------------------------------------

Precautions

--------------------------------

Infection/Condition Duration

Type*

------------------------------------------------------------------------

Abscess:

Draining, major\1\................. C DI

Draining, minor or limited\2\...... S ................

Acquired immunodeficiency syndrome S ................

(AIDS)\3\.

Actinomycosis...................... S ................

Adenovirus infection, in infants D, C DI

and young children.

Amebiasis.......................... S ................

Anthrox:

Cutaneous.......................... S ................

Pulmonary.......................... S ................

Antibiotic-associated colitis (see

Clostridium difficile):

Arthropodborne viral encephalitides s\4\ ................

(eastern, western, Venezuelan

equine encephalomyelitis; St.

Louis, California encephalitis).

Arthropodborne viral fevers S\4\ ................

(dengue, yellow fever, Colorado

tick fever).

Ascariasis......................... S ................

Aspergillosis...................... S ................

Babesiosis......................... S ................

Blastomycosis, North American, S ................

cutaneous or pulmonary.

Botulism........................... S ................

Bronchiolitis (see respiratory

infections in infants and young

children):

Brucellosis (undulant, Malta, S ................

Mediterranean fever).

Campylobacter gastroenteritis (see ............. ................

gastroenteritis)

Candidiasis, all forms including S ................

mucocutaneous.

Cat-scratch fever (benign S ................

inoculation lymphoreticulosis).

Cellulitis, uncontrolled drainage.. C DI

Chancroid (soft chancre)........... S ................

Chickenpox (varicella)............. A, C F\5\

Chlamydia trachomatis:

Conjunctivitis..................... S ................

Genital............................ S ................

Respiratory........................ S ................

Cholera (see gastroenteritis)...... ............. ................

Closed-cavity infection:

Draining, limited or minor......... S ................

Not draining....................... S ................

Clostridium:

C. botulium........................ S ................

C. difficile....................... C DI

C. perfringens ............. ................

Food poisoning................. S ................

Gas gangrene................... S ................

Coccidioidomycosis (valley fever):

Draining lesions................... S ................

Pneumonia.......................... S ................

Colorado tick fever.................... S ................

Congenital rubella..................... C F\6\

Conjunctivitis:

Acute bacterial.................... S ................

Chlamydia.......................... S ................

Gonococcal......................... S ................

Acute viral (acute hemorrhagic).... C DI

Coxsackie virus disease (see

enteroviral infection):

Creutzfeldt-Jakob disease.......... S\7\ ................

Croup (see respiratory infections in

infants and young children):

Cryptococcosis..................... S ................

Cryptosporidiosis (see ............. ................

gastroenteritis).

Cysticercosis...................... S ................

Cytomegalovirus infection, neonatal S ................

or immunosuppressed.

Decubitus ulcer, infected:

Major\1\........................... C DI

Minor or limited\2\................ S ................

Dengue................................. S\4\ ................

Diarrhea, acute-infective etiology

suspected (see gastroenteritis):

Diphtheria:

Cutaneous.......................... C CN\8\

Pharyngeal......................... D CN\8\

Echinococcosis (hydatidosis)........... S ................

Echovirus (see enteroviral infection) ............. ................

Encephalitis or encephalomyelitis (see ............. ................

specific etiologic agents)

Endometritis........................... S ................

Enterobiasis (pinworm disease, S ................

oxyuriasis).

Enterococcus species (see multidrug-

resistant organisms if

epidemiologically significant or

vancomycin resistant):

Enterocolitis, Clostridium C DH

difficile.

Enteroviral infections:

Adults............................. S ................

Infants and children............... C DI

Epiglottitis, due to Haemophilus D U24 HRS

influenzae.

Epstein-Barr virus infection, including S ................

infectious mononucleosis.

Erythema infectiosum (also see S ................

Parvovirus B19).

Escherichia coli gastroenteritis (see

gastroenteritis)

Food poisoning:

Botulism........................... S ................

Clostridium perfringens or welchii. S ................

Staphylococcal..................... S ................

Furunculosis--staphylococcal:

Infants and young children......... C DI

Gangrene (Gas gangrene)................ S ................

Gastroenteritis:

Campylobacter species.............. S\9\ ................

Cholera............................ S\9\ ................

Clostridium difficile.............. C DI

Cryptosporidium species............ S\9\ ................

Escherichia coli:

Enterohemorrhagic O157:H7...... S\9\ ................

Diapered or incontinent.... C DI

Other species.................. S\9\ ................

Giardia lamblia.................... S\9\ ................

Rotavirus.......................... S\9\ ................

Diapered or incontinent........ C DI

Salmonella species (including S. S\9\ ................

typhi).

Shigella species................... S\9\ ................

Diapered or incontinent........ C DI

Vibrio parahamolyticus............. S\9\ ................

Viral (if not covered elsewhere)... S\9\ ................

Yersinia enterocolitica............ S\9\ ................

German measles (rubella)............... D DI

Giardiasis (see gastroenteritis)

Gonococcal ophthalmia neonatorum S ................

(gonorrheal ophthalmia, acute

conjunctivitis of newborn).

Gonorrhea.............................. S ................

Granuloma inguinale (donovaniasis, S ................

granuloma venereum).

Guillain-Barre syndrome................ S ................

Hand, foot, and mouth disease (see ............. ................

enteroviral infection).

Hemorrhagic fevers (for example, Lassa C DI

fever)\10\.

Hepatitis, viral:

Type A............................. S ................

Diapered or incontinent C F\11\

patients.

Type B--HBsAg positive............. S ................

Type C and other unspecified non-A, S ................

non-B.

Type E............................. S ................

Herpangina (see enteroviral infection)

Herpes simplex (Herpesvirus hominis):

Encephalitis....................... S ................

Neonatal\12\....................... C DI

Mucocutaneous, disseminated or C DI

primary, severe.

Mucocutaneous, recurrent (skin, S ................

oral, genital).

Herpes zoster (varicella-zoster):

Localized in immunocompromised A, C DI

patient, or disseminated.

Localized in normal patient........ S ................

Histoplasmosis......................... S ................

Hookworm disease (ancylostomiasis, S ................

uncinariasis).

Human immunodeficiency virus (HIV) S ................

infection\3\.

Impetigo............................... C U24 HRS

Infectious mononucleosis............... S ................

Influenza.............................. D\13\ DI

Kawasaki syndrome...................... S ................

Lassa fever\10\........................ C DI

Legionnaires' disease.................. S ................

Leprosy................................ S ................

Leptospirosis.......................... S ................

Listeriosis............................ S ................

Lyme disease........................... S ................

Lymphocytic choriomeningitis........... S ................

Lymphogranuloma venereum............... S ................

Malaria................................ S ................

Marburg virus disease\10\.............. C DI

Measles (rubeola), all presentations... A DI

Melioidosis, all forms................. S ................

Meningitis:

Aseptic (nonbacterial or viral S ................

meningitis).

Bacterial, gram-negative enteric, S ................

in neonates.

Fungal............................. S ................

Haemophilus influenzae, known or D U24 HRS

suspected.

Listeria monocytogenes............. S ................

Neisseria meningitidis D U24 HRS

(meningococcal) known or suspected.

Pneumococcal....................... S ................

Tuberculosis\14\................... S ................

Other diagnosed bacterial.......... S ................

Meningococcal pneumonia................ D U24 HRS

Meningococcemia (meningococcal sepsis). D U24 HRS

Molluscum contagiosum.................. S ................

Mucormycosis........................... S ................

Multidrug-resistant organisms,

infection or colonization\15\:

Gastrointestinal................... C CN

Respiratory........................ C CN

Pneumococcal................... D CN

Skin, wound, or burn............... C CN

Mumps (infectious parotitis)........... D F\16\

Mycobacteria, nontuberculosis

(atypical):

Pulmonary.......................... S ................

Wound.............................. S ................

Mycoplasma pneumonia................... D DI

Necrotizing enterocolitis.............. S ................

Nacardiosis, draining lesions or other S ................

presentations.

Norwalk agent gastroenteritis (see

viral gastroenteritis)

Orf.................................... S ................

Parinfluenza virus infection, C DI

respiratory in infants and young

children.

Parvovirus B19......................... D F\17\

Pediculois............................. C U\24\HRS

Pertussis (whooping cough)............. D F\18\

Pinworm infection...................... S ................

Plague:

Bubonic............................ S ................

Pneumonic.......................... D U\72\HRS

Pleurodynia (see entervoviral

infection)

Pneumonia:

Adenovirus......................... D, C DI

Bacterial not listed elsewhere S ................

(including gram-negative bacterial).

Chlamydia.......................... S ................

Fungal............................. S ................

Haemophilus influenzae:

Adults......................... S ................

Infants and children (any age). D U\24\HRS

Legionella......................... S ................

Meningococcal...................... D U\24\HRS

Multidrug-resistant bacterial (see

multidrug-resistant organisms)

Mycoplasma (Primary atypical D DI

(pneumonia).

Pneumococcal....................... S ................

Multidrug-resistant (see

multidrug-resistant organisms)

Pneumocytis carinii................ S\19\ ................

Pseudomonas cepacia in cystic C\20\ DH

fibrosis (CF) patients, including

respiratory tract colonization.

Staphylococcus aureus.............. S ................

Streptococuss, Group A:

Adults......................... S ................

Infants and young children..... D U\24\HRS

Viral:

Adults......................... S ................

Infants and young children (see ............. ................

respiratory infectious

disease, acute).

Poliomyelitis.......................... S ................

Psittacosis (ornithosis................ S ................

Q fever................................ S ................

Rabies................................. S ................

Rat-bite fever (Streptobacillus S ................

moniliformis disease, spirillum minus

disease).

Ralapsing fever....................... S ................

Resistant bacterial infection or

colonization (see multidrug-resistant

organisms)

Respiratory infectious disease, acute

(if not covered elsewhere):

Adults............................. S ................

Infants and young children\3\...... C DI

Respiratory syncytial virus infection, C DI

in infants and young children, and

immunocompromised adults.

Reye syndrome.......................... S ................

Rheumatic fever........................ S ................

Rickettsial fevers, tickborne (Rocky S ................

Mountain spotted fever, tickborne

typhus fever).

Rickettsialpox (vesicular S ................

rickettsiosis).

Ringworm (dermatophytosis, S ................

dermatomycosis, tinea.

Ritter's disease (Staphylococcal C\21\ DI

scalded skin syndrome.

Rocky Mountain spotted fever........... S ................

Roseola infantum (exanthem subitum).... S ................

Rotavirus infection (see

gastroenteritis)

Rubella (German measles) (also D F\22\

congenital rubella).

Salmonellosis (see gastroenteritis)

Scabies................................ C U\24\HRS

Scalded skin syndrome, staphylococcal C\21\ DI

(Ritter's diease).

Schistosomiasis (bilharziasis)......... S ................

Shigellois (see gastroenteritis)

Sporotrichosis......................... S ................

Spirillium minus disease (rat-bite S ................

fever).

Staphylococcal disease (S. aureus):

Skin, wound, or burn:

Major\1\....................... C DI

Minor or limited\2\............ S ................

Enterocolitis...................... S ................

Multidrug-resistant (see multidrug-

reistant organisms)

Pneumonia.......................... S ................

Scalded skin syndrome.............. C DI

Toxic shock syndrome............... S ................

Streptobacillus moniliformis disease S ................

(rat-bite fever).

Streptococcal disease (group A

Streptococcus):

Skin, wound, or burn:

Major\1\....................... C U24HRS

Minor or limited\2\............ S ................

Endometritis (puerperal sepsis).... S ................

Pharyngitis in infants and young D U24HRS

children.

Pneumonia in infants and young D U24HRS

children.

Scarlet fever in infants and young D U24HRS

children.

Streptococcal disease (group B S ................

Streptococcus), neonatal.

Streptococcal disease (not group A or S ................

B) unless covered elsewhere.

Multidrug-resistant (see multidrug-

resistant organisms)

Strongyloidiasis....................... S ................

Syphilis:

Skin and mucous membrane, including S ................

congenital, primary, secondary.

Latent (tertiary) and S ................

seropositivity without lesions.

Tapeworm disease:

Hymenolepis nana................... S ................

Taenia solium (pork)............... S ................

Other.............................. S ................

Tetanus................................ S ................

Tinea (fungus infection S ................

dermatophytosis, dermatomycosis,

ringworm).

Toxoplasmosis.......................... S ................

Toxic shock syndrome (Staphylococcal S ................

disease).

Trachoma, acute........................ S ................

Trench mouth (Vincent's angina)........ S ................

Trichinosis............................ S ................

Trichomoniasis......................... S ................

Trichuriasis (whipworm disease)........ S ................

Tuberculosis:

Extrapulmonary, draining lesion S

(including scrofula).

Extrapulmonary, meningitis\14\..... S

Pulmonary, confirmed or suspected A F\23\

or laryngeal disease.

Skin-test positive with no evidence S

of current pulmonary disease.

Tularemia:

Draining lesion.................... S

Pulmonary.......................... S

Typhoid (Salmonella typhi) fever (see

gastroenteritis)

Typhus, endemic and epidemic........... S

Urinary tract infection (including S

pyelonephritis), with or without

urinary catheter.

Varicella (chickenpox)................. A, C F\5\

Vibrio parahaemolyticus (see

gastroenteritis)

Vincent's angina (trench mouth)........ S

Viral diseases:

Respiratory (if not covered

elsewhere):

Adults......................... S

Infants and young children (see

respiratory infectious

disease, acute).

Whooping cough (pertussis)............. D F\18\

Wound infections:

Major\1\........................... C DI

Minor or limited\2\................ S

Yersinia enterocolitica gastroenteritis

(see gastroenteritis)

Zoster (varicella-zoster):

Localized in immunocompromised A, C F\5\

patient, disseminated.

Localized in normal patient........ S

Zygomycosis (phycomycosis, S

mucormycosis).

------------------------------------------------------------------------

\1\No dressing or dressing does not adequately contain drainage.

\2\Dressing covers and adequately contains drainage.

\3\Also see syndromes or conditions listed in Table 2.

\4\Install screens in windows and doors in endemic areas.

\5\Maintain precautions until all lesions are crusted. Use varicella

zoster immune globulin (VZIG) when appropriate, and discharge exposed

susceptible patients before the 10th day after exposure, if possible.

Place remaining exposed susceptible patients on precautions beginning

10 days after exposure and continue until 21 days after last exposure

(up to 28 days if VZIG has been given). Susceptible persons should

stay out of room of patients on precautions.

\6\Place infant on precautions during any admission until 1 year of age

unless nasopharyngeal and urine cultures are negative for virus after

age 3 months.

\7\Additional special precautions are necessary for handling and

decontamination of blood, body fluids and tissues, and contaminated

items from patients with confirmed or suspected disease. See latest

College of American Pathologists (Northfield, Illinois) guidelines or

other references.

\8\Until two cultures taken at least 24 hours apart are negative.

\9\Use contact precautions for diapered or incontinent children 92-93

For additional prevention and control strategies.

\14\Patient should be examined for evidence of current (active)

pulmonary tuberculosis. If evidence exists, additional precautions are

necessary (see tuberculosis).

\15\Resistant bacteria judged by the infection control program, based on

current state, regional, or national recommendations, to be of special

clinical and epidemiologic significance.

\16\For 9 days after onset of swelling.

\17\Maintain precautions for duration of hospitalization when chronic

disease occurs in an immunodeficient patient. For patients with

transient aplastic crisis or red cell crisis, maintain precautions for

7 days.

\18\Maintain precautions until 5 days after patient is placed on

effective therapy.

\19\Avoid placement in the same room with an immunocompromised patient.

\20\Avoid cohorting or placement in the same room with a CF patient who

is not infected or colonized with P. cepacia.

\21\Blistering is due to the hematogenous dissemination of toxin, not to

presence of organisms in the blisters. However, such patients may be

heavily colonized with staphylococci because of their skin problems;

thus, contact precautions are recommended.

\22\Until 7 days after onset of rash.

\23\Discontinue precautions only when TB patient is on effective

therapy, is improving clinically, and has 3 consecutive negative

sputum smears collected on different days, or TB is ruled out. Also

see CDC Guidelines for Preventing the Transmission of Tuberculosis in

Health-Care Facilities.\23\

*Type of Precautions

A--Airborne.

C--Contact.

D--Droplet.

S--Standard.

When A, C, and D are specified, also use S.

Duration of Precautions

CN--Until off antibiotics and culture negative.

DH--Duration of hospitalization.

DI--Duration of illness (with wound lesions, DI means until they stop

draining).

U--Until time specified in hours (HRS) after initiation of effective

therapy.

F--See footnote number.

References

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12. Pizzo PA. The value of protective isolation in preventing

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suspected viral hemorrhagic fever. MMWR 1988;37(3S):1-16.

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22. Centers for Disease Control and Prevention. Draft guidelines

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52850.

23. Centers for Disease Control and Prevention. Guidelines for

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1994;59(208):54242-54303.

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686,691-695.

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1986;35:221-223.

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patients. MMWR 1987;36:285-289.

27. Centers for Disease Control. Recommendations for prevention

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[FR Doc. 94-27472 Filed 11-4-94; 8:45 am]

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