Isolation Guidelines Health
Isolation Guidelines Health
Isolation Guidelines Health
html
Acknowledgement: The authors and HICPAC gratefully acknowledge Dr. Larry Strausbaugh for
his many contributions and valued guidance in the preparation of this guideline.
Suggested citation: Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection
Control Practices Advisory Committee, 2007 Guideline for Isolation Precautions: Preventing
Transmission of Infectious Agents in Healthcare Settings
https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html
Mumps Update [October 2017]: The Healthcare Infection Control Practices Advisory
Committee (HICPAC) voted to change the recommendation of isolation for persons with
mumps from 9 days to 5 days based on a 2008 MMWR report.
(https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5740a3.htm accessed September
2018).
Ebola Virus Disease Update [August 2014]: The recommendations in this guideline for
Ebola has been superseded by these CDC documents:
• Infection Prevention and Control Recommendations for Hospitalized Patients with
Known or Suspected Ebola Virus Disease in U.S. Hospitals
(https://www.cdc.gov/vhf/ebola/clinicians/evd/infection-control.html accessed September
2018)
• Interim Guidance for Environmental Infection Control in Hospitals for Ebola Virus
(https://www.cdc.gov/vhf/ebola/clinicians/cleaning/hospitals.html accessed September
2018)
See CDC’s Ebola Virus Disease website (https://www.cdc.gov/vhf/ebola/ accessed
September 2018) for current information on how Ebola virus is transmitted.
Ebola Virus Disease for Healthcare Workers [2014]: Updated recommendations for
healthcare workers can be found at Ebola: for Clinicians
(https://www.cdc.gov/vhf/ebola/clinicians/index.html accessed September 2018).
Measles Update [November 2011]: Updated recommendations can be found at
Immunization of Healthcare Personnel: Recommendations of the ACIP
(https://www.cdc.gov/mmwr/pdf/rr/rr6007.pdf accessed September 2018).
Tdap Vaccine Recommendations Update [2018]: Current recommendations can be
found at Tdap / Td ACIP Vaccine Recommendations
(https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/dtap.html accessed September
2018).
TABLE OF CONTENTS
Part II: Fundamental Elements Needed to Prevent Transmission of Infectious Agents in Healthcare
Settings ............................................................................................................................................................. 41
II.A. Healthcare System Components that Influence the Effectiveness of Precautions to Prevent
Transmission......................................................................................................................................................... 41
II.A.1. Administrative measures. ...................................................................................................................41
II.A.1.a.Scope of work and staffing needs for infection control professionals. ..................................41
II.A.1.a.i. Infection control nurse liaison. .............................................................................................43
II.A.1.b. Bedside nurse staffing. ...............................................................................................................43
II.A.1.c. Clinical microbiology laboratory support. ..................................................................................43
II.A.2. Institutional safety culture and organizational characteristics. ......................................................44
II.A.3. Adherence of healthcare personnel to recommended guidelines. ...............................................45
II.B. Surveillance for Healthcare-Associated Infections (HAIs) ..................................................................... 46
II.C. Education of HCWs, Patients, and Families ............................................................................................ 47
II.D. Hand Hygiene ............................................................................................................................................... 48
II.E. Personal Protective Equipment (PPE) for Healthcare Personnel ......................................................... 49
II.E.1. Gloves....................................................................................................................................................49
II.E.2. Isolation gowns.....................................................................................................................................50
II.E.3. Face protection: masks, goggles, face shields................................................................................51
II.E.3.a. Masks. ...........................................................................................................................................51
II.E.3.b. Goggles, face shields. .................................................................................................................52
II.E.4. Respiratory protection. ........................................................................................................................53
II.F. Safe Work Practices to Prevent HCW Exposure to Bloodborne Pathogens ....................................... 55
II.F.1. Prevention of needlesticks and other sharps-related injuries. .......................................................55
II.F.2. Prevention of mucous membrane contact. .......................................................................................55
II.F.2.a. Precautions during aerosol-generating procedures. ...............................................................55
II.G. Patient Placement ....................................................................................................................................... 56
II.G.1. Hospitals and long-term care settings. .............................................................................................56
II.G.2. Ambulatory settings.............................................................................................................................58
II.G.3. Home care. ...........................................................................................................................................58
II.H. Transport of Patients ................................................................................................................................... 59
II.I. Environmental Measures .............................................................................................................................. 59
II.J. Patient Care Equipment and Instruments/Devices .................................................................................. 60
II.K. Textiles and Laundry ................................................................................................................................... 61
II.L. Solid Waste ................................................................................................................................................... 62
II.M. Dishware and Eating Utensils.................................................................................................................... 62
II.N. Adjunctive Measures ................................................................................................................................... 62
II.N.1. Chemoprophylaxis. ..............................................................................................................................62
II.N.2. Immunoprophylaxis. ............................................................................................................................63
II.N. 3. Management of visitors......................................................................................................................64
Appendix A: ...................................................................................................................................................... 94
Type and Duration of Precautions Recommended for Selected Infections and Conditions ..................... 94
Table 1. History of Guidelines for Isolation Precautions in Hospitals* ....................................................... 115
Table 2. Clinical Syndromes or Conditions Warranting Empiric Transmission-Based Precautions in
Addition to Standard Precautions. ................................................................................................................... 116
Table 3. Infection Control Considerations for High-Priority (CDC Category A) Diseases that May
Result from Bioterrorist Attacks or are Considered to be Bioterrorist Threats .......................................... 118
Table 4. Recommendations for Application of Standard Precautions for the Care of All Patients in All
Healthcare Settings............................................................................................................................................ 122
Table 5. Components of a Protective Environment ...................................................................................... 123
I. Patients: allogeneic hematopoeitic stem cell transplant (HSCT) only ................................................123
II. Standard and Expanded Precautions ....................................................................................................123
III. Engineering ...............................................................................................................................................123
IV. Surfaces ....................................................................................................................................................124
V. Other ...........................................................................................................................................................124
Figure. Example of Safe Donning and Removal of Personal Protective Equipment (PPE).................... 125
References:..................................................................................................................................................... 134
Executive Summary
The Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in
Healthcare Settings 2007 updates and expands the 1996 Guideline for Isolation
Precautions in Hospitals. The following developments led to revision of the 1996
guideline:
1. The transition of healthcare delivery from primarily acute care hospitals to other
healthcare settings (e.g., home care, ambulatory care, free-standing specialty care
sites, long-term care) created a need for recommendations that can be applied in all
healthcare settings using common principles of infection control practice, yet can be
modified to reflect setting-specific needs. Accordingly, the revised guideline
addresses the spectrum of healthcare delivery settings. Furthermore, the term
“nosocomial infections” is replaced by “healthcare-associated infections” (HAIs) to
reflect the changing patterns in healthcare delivery and difficulty in determining the
geographic site of exposure to an infectious agent and/or acquisition of infection.
2. The emergence of new pathogens (e.g., SARS-CoV associated with the severe
acute respiratory syndrome [SARS], Avian influenza in humans), renewed concern
for evolving known pathogens (e.g., C. difficile, noroviruses, community-associated
MRSA [CA-MRSA]), development of new therapies (e.g., gene therapy), and
increasing concern for the threat of bioweapons attacks, established a need to
address a broader scope of issues than in previous isolation guidelines.
3. The successful experience with Standard Precautions, first recommended in the
1996 guideline, has led to a reaffirmation of this approach as the foundation for
preventing transmission of infectious agents in all healthcare settings. New additions
to the recommendations for Standard Precautions are Respiratory Hygiene/Cough
Etiquette and safe injection practices, including the use of a mask when performing
certain high-risk, prolonged procedures involving spinal canal punctures (e.g.,
myelography, epidural anesthesia). The need for a recommendation for Respiratory
Hygiene/Cough Etiquette grew out of observations during the SARS outbreaks
where failure to implement simple source control measures with patients, visitors,
and healthcare personnel with respiratory symptoms may have contributed to SARS
coronavirus (SARS-CoV) transmission. The recommended practices have a strong
evidence base. The continued occurrence of outbreaks of hepatitis B and hepatitis C
viruses in ambulatory settings indicated a need to re-iterate safe injection practice
recommendations as part of Standard Precautions. The addition of a mask for
certain spinal injections grew from recent evidence of an associated risk for
developing meningitis caused by respiratory flora.
4. The accumulated evidence that environmental controls decrease the risk of life-
threatening fungal infections in the most severely immunocompromised patients
(allogeneic hematopoietic stem-cell transplant patients) led to the update on the
components of the Protective Environment (PE).
5. Evidence that organizational characteristics (e.g., nurse staffing levels and
composition, establishment of a safety culture) influence healthcare personnel
adherence to recommended infection control practices, and therefore are important
factors in preventing transmission of infectious agents, led to a new emphasis and
recommendations for administrative involvement in the development and support of
infection control programs.
Appendix A: Type and Duration of Precautions Recommended for Selected Infections and
Conditions
Summary
This updated guideline responds to changes in healthcare delivery and addresses new
concerns about transmission of infectious agents to patients and healthcare workers in
the United States and infection control. The primary objective of the guideline is to
improve the safety of the nation’s healthcare delivery system by reducing the rates of
HAIs.
Scope. This guideline, like its predecessors, focuses primarily on interactions between
patients and healthcare providers. The Guidelines for the Prevention of MDRO Infection
were published separately in November 2006, and are available online at Management
of Multidrug-Resistant Organisms in Healthcare Settings
(https://www.cdc.gov/infectioncontrol/guidelines/mdro/ accessed May 2016). Several
other HICPAC guidelines to prevent transmission of infectious agents associated with
healthcare delivery are cited; e.g., Guideline for Hand Hygiene, Guideline for
Environmental Infection Control, Guideline for Prevention of Healthcare-Associated
Pneumonia, and Guideline for Infection Control in Healthcare Personnel11, 14, 16, 17. In
combination, these provide comprehensive guidance on the primary infection control
measures for ensuring a safe environment for patients and healthcare personnel.
This guideline does not discuss in detail specialized infection control issues in defined
populations that are addressed elsewhere, (e.g., Recommendations for Preventing
Transmission of Infections among Chronic Hemodialysis Patients , Guidelines for
Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Facilities
2005, Guidelines for Infection Control in Dental Health-Care Settings and Infection
Control Recommendations for Patients with Cystic Fibrosis12, 18-20. An exception has
been made by including abbreviated guidance for a Protective Environment used for
allogeneic HSCT recipients because components of the Protective Environment have
been more completely defined since publication of the Guidelines for Preventing
Opportunistic Infections Among HSCT Recipients in 2000 and the Guideline for
Environmental Infection Control in Healthcare Facilities11, 15.
• mites from a scabies-infested patient are transferred to the skin of a caregiver while
he/she is having direct ungloved contact with the patient’s skin68, 69.
• a healthcare provider develops herpetic whitlow on a finger after contact with HSV
when providing oral care to a patient without using gloves or HSV is transmitted to a
patient from a herpetic whitlow on an ungloved hand of a healthcare worker
(HCW)70, 71.
transmission, the potential exists for soiled garments to transfer infectious agents to
successive patients.
Droplet size is another variable under discussion. Droplets traditionally have been
defined as being >5 µm in size. Droplet nuclei, particles arising from desiccation of
suspended droplets, have been associated with airborne transmission and defined as
≤5 µm in size105 , a reflection of the pathogenesis of pulmonary tuberculosis which is not
generalizeable to other organisms. Observations of particle dynamics have
demonstrated that a range of droplet sizes, including those with diameters of 30µm or
greater, can remain suspended in the air109. The behavior of droplets and droplet nuclei
affect recommendations for preventing transmission. Whereas fine airborne particles
containing pathogens that are able to remain infective may transmit infections over long
Rarely, pathogens that are not transmitted routinely by the droplet route are dispersed
into the air over short distances. For example, although S. aureus is transmitted most
frequently by the contact route, viral upper respiratory tract infection has been
associated with increased dispersal of S. aureus from the nose into the air for a
distance of 4 feet under both outbreak and experimental conditions and is known as the
“cloud baby” and “cloud adult” phenomenon118-120.
For certain other respiratory infectious agents, such as influenza130, 131 and rhinovirus104,
and even some gastrointestinal viruses (e.g., norovirus132 and rotavirus133 ) there is
some evidence that the pathogen may be transmitted via small-particle aerosols, under
natural and experimental conditions. Such transmission has occurred over distances
longer than 3 feet but within a defined airspace (e.g., patient room), suggesting that it is
unlikely that these agents remain viable on air currents that travel long distances. AIIRs
are not required routinely to prevent transmission of these agents. Additional issues
concerning examples of small particle aerosol transmission of agents that are most
frequently transmitted by the droplet route are discussed below.
In contrast to the strict interpretation of an airborne route for transmission (i.e., long
distances beyond the patient room environment), short distance transmission by small
particle aerosols generated under specific circumstances (e.g., during endotracheal
intubation) to persons in the immediate area near the patient has been demonstrated.
Also, aerosolized particles <100 µm can remain suspended in air when room air current
velocities exceed the terminal settling velocities of the particles109. SARS-CoV
transmission has been associated with endotracheal intubation, noninvasive positive
pressure ventilation, and cardio-pulmonary resuscitation93, 94, 96, 98, 141. Although the most
frequent routes of transmission of noroviruses are contact and food and waterborne
routes, several reports suggest that noroviruses may be transmitted through
aerosolization of infectious particles from vomitus or fecal material142, 143, 147, 148. It is
hypothesized that the aerosolized particles are inhaled and subsequently swallowed.
Roy and Milton proposed a new classification for aerosol transmission when evaluating
routes of SARS transmission:
1. obligate: under natural conditions, disease occurs following transmission of the
agent only through inhalation of small particle aerosols (e.g., tuberculosis);
2. preferential: natural infection results from transmission through multiple routes, but
small particle aerosols are the predominant route (e.g., measles, varicella); and
3. opportunistic: agents that naturally cause disease through other routes, but under
special circumstances may be transmitted via fine particle aerosols149.
agents associated with severe disease and no known treatment often result in more
extreme prevention strategies than may be necessary; therefore, recommended
precautions could change as the epidemiology of an emerging infection is defined and
controversial issues are resolved.
I.B.3.d.ii. Transmission from the environment. Some airborne infectious agents are
derived from the environment and do not usually involve person-to-person transmission.
For example, anthrax spores present in a finely milled powdered preparation can be
aerosolized from contaminated environmental surfaces and inhaled into the respiratory
tract150, 151. Spores of environmental fungi (e.g., Aspergillus spp.) are ubiquitous in the
environment and may cause disease in immunocompromised patients who inhale
aerosolized (e.g., via construction dust) spores152, 153. As a rule, neither of these
organisms is subsequently transmitted from infected patients. However, there is one
well-documented report of person-to-person transmission of Aspergillus sp. in the ICU
setting that was most likey due to the aerosolization of spores during wound
debridement154. A Protective Environment refers to isolation practices designed to
decrease the risk of exposure to environmental fungal agents in allogeneic HSCT
patients11, 14, 15, 155-158.
I.B.3.e. Other sources of infection. Transmission of infection from sources other than
infectious individuals include those associated with common environmental sources or
vehicles (e.g., contaminated food, water, or medications (e.g., intravenous fluids).
Although Aspergillus spp. have been recovered from hospital water systems159, the role
of water as a reservoir for immunosuppressed patients remains uncertain. Vectorborne
transmission of infectious agents from mosquitoes, flies, rats, and other vermin also can
occur in healthcare settings. Prevention of vector borne transmission is not addressed in
this document.
enhanced control measures because of the risk of additional cases and severity of
illness associated with these infections. Antimicrobial resistance
• Resistance to first-line therapies (e.g., MRSA, VISA, VRSA, VRE, ESBL-producing
organisms).
• Common and uncommon microorganisms with unusual patterns of resistance within
a facility (e.g., the first isolate of Burkholderia cepacia complex or Ralstonia spp. in
non-CF patients or a quinolone-resistant strain of Pseudomonas aeruginosa in a
facility).
• Difficult to treat because of innate or acquired resistance to multiple classes of
antimicrobial agents (e.g., Stenotrophomonas maltophilia, Acinetobacter spp.).
• Association with serious clinical disease, increased morbidity and mortality (e.g.,
MRSA and MSSA, group A streptococcus)
• A newly discovered or reemerging pathogen
Since 2001, outbreaks and sporadic cases of C. difficile with increased morbidity and
mortality have been observed in several U.S. states, Canada, England and the
Netherlands168-172. The same strain of C. difficile has been implicated in these
outbreaks173. This strain, toxinotype III, North American PFGE type 1, and PCR-ribotype
027 (NAP1/027) has been found to hyperproduce toxin A (16 fold increase) and toxin B
(23 fold increase) compared with isolates from 12 different pulsed-field gel
electrophoresisPFGE types. A recent survey of U.S. infectious disease physicians found
that 40% perceived recent increases in the incidence and severity of C. difficile
The prevention and control of MDROs is a national priority - one that requires that all
healthcare facilities and agencies assume responsibility and participate in community-
wide control programs176, 177. A detailed discussion of this topic and recommendations
I.C.2. Agents of bioterrorism. CDC has designated the agents that cause anthrax,
smallpox, plague, tularemia, viral hemorrhagic fevers, and botulism as Category A (high
priority) because these agents can be easily disseminated environmentally and/or
transmitted from person to person; can cause high mortality and have the potential for
major public health impact; might cause public panic and social disruption; and require
special action for public health preparedness202. General information relevant to
infection control in healthcare settings for Category A agents of bioterrorism is
summarized in Table 3. Consult [This link is no longer active: www.bt.cdc.gov. Similar
information may be found at CDC Bioterrorism Agents/Diseases
(https://emergency.cdc.gov/agent/agentlist.asp accessed May 2016.)] for additional,
updated Category A agent information as well as information concerning Category B
and C agents of bioterrorism and updates. Category B and C agents are important but
are not as readily disseminated and cause less morbidity and mortality than Category A
agents.
Healthcare facilities confront a different set of issues when dealing with a suspected
bioterrorism event as compared with other communicable diseases. An understanding
of the epidemiology, modes of transmission, and clinical course of each disease, as well
as carefully drafted plans that provide an approach and relevant websites and other
resources for disease-specific guidance to healthcare, administrative, and support
personnel, are essential for responding to and managing a bioterrorism event. Infection
control issues to be addressed include:
1. identifying persons who may be exposed or infected;
2. preventing transmission among patients, healthcare personnel, and visitors;
3. providing treatment, chemoprophylaxis or vaccine to potentially large numbers of
people;
4. protecting the environment including the logistical aspects of securing sufficient
numbers of AIIRs or designating areas for patient cohorts when there are an
insufficient number of AIIRs available;
5. providing adequate quantities of appropriate personal protective equipment; and
6. identifying appropriate staff to care for potentially infectious patients (e.g., vaccinated
healthcare personnel for care of patients with smallpox).
The response is likely to differ for exposures resulting from an intentional release
compared with naturally occurring disease because of the large number persons that
can be exposed at the same time and possible differences in pathogenicity.
A variety of sources offer guidance for the management of persons exposed to the most
likely agents of bioterrorism. Federal agency websites (e.g., [This link is no longer
active: www.usamriid.army.mil/publications/index.html. Similar information may be
found at USAMRIID: Biodefense Solutions to Protect our Nation
(http://www.usamriid.army.mil/ accessed May 2016).], [This link is no longer active:
Prion diseases in animals include scrapie in sheep and goats, bovine spongiform
encephalopathy (BSE, or “mad cow disease”) in cattle, and chronic wasting disease in
deer and elk236. BSE, first recognized in the United Kingdom (UK) in 1986, was
associated with a major epidemic among cattle that had consumed contaminated meat
and bone meal.
The possible transmission of BSE to humans causing variant CJD (vCJD) was first
described in 1996 and subsequently found to be associated with consumption of BSE-
contaminated cattle products primarily in the United Kingdom. There is strong
epidemiologic and laboratory evidence for a causal association between the causative
agent of BSE and vCJD237. Although most cases of vCJD have been reported from the
UK, a few cases also have been reported from Europe, Japan, Canada, and the United
States. Most vCJD cases worldwide lived in or visited the UK during the years of a large
outbreak of BSE (1980-96) and may have consumed contaminated cattle products
during that time (Creutzfeldt-Jakob Disease, Classic (CJD)
(https://www.cdc.gov/prions/cjd/index.html accessed May 2016) [Current version of this
document may differ from original.]). Although there has been no indigenously acquired
vCJD in the United States, the sporadic occurrence of BSE in cattle in North America
has heightened awareness of the possibility that such infections could occur and have
led to increased surveillance activities. Updated information may be found on the
following website: Creutzfeldt-Jakob Disease, Classic (CJD)
(https://www.cdc.gov/prions/cjd/index.html accessed May 2016) [Current version of this
document may differ from original.]. The public health impact of prion diseases has
been reviewed 238.
vCJD in humans has different clinical and pathologic characteristics from sporadic or
classic CJD239, including the following:
1. younger median age at death: 28 (range 16-48) vs. 68 years;
2. longer duration of illness: median 14 months vs. 4-6 months;
3. increased frequency of sensory symptoms and early psychiatric symptoms with
delayed onset of frank neurologic signs; and
4. detection of prions in tonsillar and other lymphoid tissues from vCJD patients but not
from sporadic CJD patients240.
Similar to sporadic CJD, there have been no reported cases of direct human-to-human
transmission of vCJD by casual or environmental contact, droplet, or airborne routes.
Ongoing blood safety surveillance in the U.S. has not detected sporadic CJD
transmission through blood transfusion241-243. However, bloodborne transmission of
vCJD is believed to have occurred in two UK patients244, 245. The following FDA
websites provide information on steps that are being taken in the US to protect the
blood supply from CJD and vCJD: [This link is no longer active:
Standard Precautions are used when caring for patients with suspected or confirmed
CJD or vCJD. However, special precautions are recommended for tissue handling in the
histology laboratory and for conducting an autopsy, embalming, and for contact with a
body that has undergone autopsy246. Recommendations for reprocessing surgical
instruments to prevent transmission of CJD in healthcare settings have been published
by the World Health Organization (WHO) and are currently under review at CDC.
SARS-CoV also has been transmitted in the laboratory setting through breaches in
recommended laboratory practices. Research laboratories where SARS-CoV was under
investigation were the source of most cases reported after the first series of outbreaks
in the winter and spring of 2003261, 262. Studies of the SARS outbreaks of 2003 and
transmissions that occurred in the laboratory re-affirm the effectiveness of
Lessons from the SARS outbreaks are useful for planning to respond to future public
health crises, such as pandemic influenza and bioterrorism events. Surveillance for
cases among patients and healthcare personnel, ensuring availability of adequate
supplies and staffing, and limiting access to healthcare facilities were important factors
in the response to SARS that have been summarized9. Guidance for infection control
precautions in various settings is available at [This link is no longer active:
www.cdc.gov/ncidod/sars. Similar information may be found at CDC Severe Acute
Respiratory Syndrome (SARS), (https://www.cdc.gov/sars/index.html accessed
September 2018.)].
I.C.5. Monkeypox. Monkeypox is a rare viral disease found mostly in the rain forest
countries of Central and West Africa. The disease is caused by an orthopoxvirus that is
similar in appearance to smallpox but causes a milder disease. The only recognized
outbreak of human monkeypox in the United States was detected in June 2003 after
several people became ill following contact with sick pet prairie dogs. Infection in the
prairie dogs was subsequently traced to their contact with a shipment of animals from
Africa, including giant Gambian rats263. This outbreak demonstrates the importance of
recognition and prompt reporting of unusual disease presentations by clinicians to
enable prompt identification of the etiology; and the potential of epizootic diseases to
spread from animal reservoirs to humans through personal and occupational
exposure264.
established for hurricane evacuees286, demonstrate their highly contagious nature, the
disruptive impact they have in healthcare facilities and the community, and the difficulty
of controlling outbreaks in settings where people share common facilites and space. Of
note, there is nearly a 5 fold increase in the risk to patients in outbreaks where a patient
is the index case compared with exposure of patients during outbreaks where a staff
member is the index case287.
The average incubation period for gastroenteritis caused by noroviruses is 12-48 hours
and the clinical course lasts 12-60 hours273. Illness is characterized by acute onset of
nausea, vomiting, abdominal cramps, and/or diarrhea. The disease is largely self-
limited; rarely, death caused by severe dehydration can occur, particularly among the
elderly with debilitating health conditions.
The epidemiology of norovirus outbreaks shows that even though primary cases may
result from exposure to a fecally-contaminated food or water, secondary and tertiary
cases often result from person-to-person transmission that is facilitated by
contamination of fomites273, 288 and dissemination of infectious particles, especially
during the process of vomiting132, 142, 143, 147, 148, 273, 279, 280. Widespread, persistent and
inapparent contamination of the environment and fomites can make outbreaks
extremely difficult to control147, 275, 284.These clinical observations and the detection of
norovirus DNA on horizontal surfaces 5 feet above the level that might be touched
normally suggest that, under certain circumstances, aerosolized particles may travel
distances beyond 3 feet147. It is hypothesized that infectious particles may be
aerosolized from vomitus, inhaled, and swallowed. In addition, individuals who are
responsible for cleaning the environment may be at increased risk of infection.
Development of disease and transmission may be facilitated by the low infectious dose
(i.e., <100 viral particles)289 and the resistance of these viruses to the usual cleaning
and disinfection agents (i.e., may survive ≤10 ppm chlorine)290-292. An alternate phenolic
agent that was shown to be effective against feline calicivirus was used for
environmental cleaning in one outbreak275, 293. There are insufficient data to determine
the efficacy of alcohol-based hand rubs against noroviruses when the hands are not
visibly soiled294. Absence of disease in certain individuals during an outbreak may be
explained by protection from infection conferred by the B histo-blood group antigen295.
Consultation on outbreaks of gastroenteritis is available through CDC’s Division of Viral
and Rickettsial Diseases296.
I.C.7. Hemorrhagic fever viruses (HFV). The hemorrhagic fever viruses are a mixed
group of viruses that cause serious disease with high fever, skin rash, bleeding
diathesis, and in some cases, high mortality; the disease caused is referred to as viral
hemorrhagic fever (VHF). Among the more commonly known HFVs are Ebola and
Marburg viruses (Filoviridae), Lassa virus (Arenaviridae), Crimean-Congo hemorrhagic
fever and Rift Valley Fever virus (Bunyaviridae), and Dengue and Yellow fever viruses
(Flaviviridae)212, 297. These viruses are transmitted to humans via contact with infected
animals or via arthropod vectors. While none of these viruses is endemic in the United
States, outbreaks in affected countries provide potential opportunities for importation by
infected humans and animals. Furthermore, there are concerns that some of these
agents could be used as bioweapons212. Person-to-person transmission is documented
for Ebola, Marburg, Lassa and Crimean-Congo hemorrhagic fever viruses. In resource-
limited healthcare settings, transmission of these agents to healthcare personnel,
patients and visitors has been described and in some outbreaks has accounted for a
large proportion of cases298-300. Transmissions within households also have occurred
among individuals who had direct contact with ill persons or their body fluids, but not to
those who did not have such contact301.
Evidence concerning the transmission of HFVs has been summarized212, 302. Person-to-
person transmission is associated primarily with direct blood and body fluid contact.
Percutaneous exposure to contaminated blood carries a particularly high risk for
transmission and increased mortality303, 304. The finding of large numbers of Ebola viral
particles in the skin and the lumina of sweat glands has raised concern that
transmission could occur from direct contact with intact skin though epidemiologic
evidence to support this is lacking305. Postmortem handling of infected bodies is an
important risk for transmission301, 306, 307. In rare situations, cases in which the mode of
transmission was unexplained among individuals with no known direct contact , have
led to speculation that airborne transmission could have occurred 298. However, airborne
transmission of naturally occurring HFVs in humans has not been seen. In one study of
airplane passengers exposed to an in-flight index case of Lassa fever, there was no
transmission to any passengers308.
In the laboratory setting, animals have been infected experimentally with Marburg or
Ebola viruses via direct inoculation of the nose, mouth and/or conjunctiva309, 310 and by
using mechanically generated virus-containing aerosols311, 312. Transmission of Ebola
virus among laboratory primates in an animal facility has been described313. Secondarily
Guidance on infection control precautions for HVFs that are transmitted person-to-
person have been published by CDC1, 211 and by the Johns Hopkins Center for Civilian
Biodefense Strategies212. The most recent recommendations at the time of publication
of this document were posted on the CDC website on 5/19/05 314. Inconsistencies
among the various recommendations have raised questions about the appropriate
precautions to use in U.S. hospitals. In less developed countries, outbreaks of HFVs
have been controlled with basic hygiene, barrier precautions, safe injection practices,
and safe burial practices299, 306. The preponderance of evidence on HFV transmission
indicates that Standard, Contact and Droplet Precautions with eye protection are
effective in protecting healthcare personnel and visitors who may attend an infected
patient. Single gloves are adequate for routine patient care; double-gloving is advised
during invasive procedures (e.g., surgery) that pose an increased risk for blood
exposure. Routine eye protection (i.e. goggles or face shield) is particularly important.
Fluid-resistant gowns should be worn for all patient contact. Airborne Precautions are
not required for routine patient care; however, use of AIIRs is prudent when procedures
that could generate infectious aerosols are performed (e.g., endotracheal intubation,
bronchoscopy, suctioning, autopsy procedures involving oscillating saws). N95 or higher
level respirators may provide added protection for individuals in a room during aerosol-
generating procedures (Table 3, Appendix A). When a patient with a syndrome
consistent with hemorrhagic fever also has a history of travel to an endemic area,
precautions are initiated upon presentation and then modified as more information is
obtained (Table 2). Patients with hemorrhagic fever syndrome in the setting of a
suspected bioweapon attack should be managed using Airborne Precautions, including
AIIRs, since the epidemiology of a potentially weaponized hemorrhagic fever virus is
unpredictable.
I.D.1. Hospitals. Infection transmission risks are present in all hospital settings. However,
certain hospital settings and patient populations have unique conditions that predispose
patients to infection and merit special mention. These are often sentinel sites for the
emergence of new transmission risks that may be unique to that setting or present
opportunities for transmission to other settings in the hospital.
I.D.1.a. Intensive care units. Intensive care units (ICUs) serve patients who are
immunocompromised by disease state and/or by treatment modalities, as well as
patients with major trauma, respiratory failure and other life-threatening conditions (e.g.,
myocardial infarction, congestive heart failure, overdoses, strokes, gastrointestinal
bleeding, renal failure, hepatic failure, multi-organ system failure, and the extremes of
age). Although ICUs account for a relatively small proportion of hospitalized patients,
infections acquired in these units accounted for >20% of all HAIs317. In the National
Nosocomial Infection Surveillance (NNIS) system, 26.6% of HAIs were reported from
ICU and high risk nursery (NICU) patients in 2002 (NNIS, unpublished data). This
patient population has increased susceptibility to colonization and infection, especially
with MDROs and Candida sp.318, 319, because of underlying diseases and conditions,
the invasive medical devices and technology used in their care (e.g., central venous
catheters and other intravascular devices, mechanical ventilators, extracorporeal
membrane oxygenation (ECMO), hemodialysis/-filtration, pacemakers, implantable left
ventricular assist devices), the frequency of contact with healthcare personnel,
prolonged length of stay, and prolonged exposure to antimicrobial agents320-331.
Furthermore, adverse patient outcomes in this setting are more severe and are
associated with a higher mortality332. Outbreaks associated with a variety of bacterial,
fungal and viral pathogens due to common-source and person-to-person transmissions
are frequent in adult and pediatric ICUs31, 333-336, 337, 338.
I.D.1.b. Burn units. Burn wounds can provide optimal conditions for colonization,
infection, and transmission of pathogens; infection acquired by burn patients is a
frequent cause of morbidity and mortality320, 339, 340. In patients with a burn injury
involving ≥30% of the total body surface area (TBSA), the risk of invasive burn wound
infection is particularly high341, 342. Infections that occur in patients with burn injury
involving <30% TBSA are usually associated with the use of invasive devices.
Methicillin-susceptible Staphylococcus aureus, MRSA, enterococci, including VRE,
gram-negative bacteria, and candida are prevalent pathogens in burn infections53, 340,
343-350 and outbreaks of these organisms have been reported351-354. Shifts over time in
the predominance of pathogens causing infections among burn patients often lead to
changes in burn care practices343, 355-358. Burn wound infections caused by Aspergillus
sp. or other environmental molds may result from exposure to supplies contaminated
during construction359 or to dust generated during construction or other environmental
disruption360.
organisms. Its use for burn care is discouraged based on demonstrated associations
between use of contaminated hydrotherapy equipment and infections. Burn wound
infections and colonization, as well as bloodstream infections, caused by multidrug-
resistant P. aeruginosa361, A. baumannii362, and MRSA352 have been associated with
hydrotherapy; excision of burn wounds in operating rooms is preferred.
Advances in burn care, specifically early excision and grafting of the burn wound, use of
topical antimicrobial agents, and institution of early enteral feeding, have led to
decreased infectious complications. Other advances have included prophylactic
antimicrobial usage, selective digestive decontamination (SDD), and use of
antimicrobial-coated catheters (ACC), but few epidemiologic studies and no efficacy
studies have been performed to show the relative benefit of these measures 357.
Close physical contact between healthcare personnel and infants and young children
(eg. cuddling, feeding, playing, changing soiled diapers, and cleaning copious
uncontrolled respiratory secretions) provides abundant opportunities for transmission of
infectious material. Practices and behaviors such as congregation of children in play
areas where toys and bodily secretions are easily shared and family members rooming-
in with pediatric patients can further increase the risk of transmission. Pathogenic
bacteria have been recovered from toys used by hospitalized patients379; contaminated
bath toys were implicated in an outbreak of multidrug-resistant P. aeruginosa on a
pediatric oncology unit80. In addition, several patient factors increase the likelihood that
infection will result from exposure to pathogens in healthcare settings (e.g., immaturity
of the neonatal immune system, lack of previous natural infection and resulting
immunity, prevalence of patients with congenital or acquired immune deficiencies,
congenital anatomic anomalies, and use of life-saving invasive devices in neontal and
pediatric intensive care units)63. There are theoretical concerns that infection risk will
increase in association with innovative practices used in the NICU for the purpose of
improving developmental outcomes, Such factors include co-bedding380 and kangaroo
care381 that may increase opportunity for skin-to-skin exposure of multiple gestation
infants to each other and to their mothers, respectively; although infection risk smay
actually be reduced among infants receiving kangaroo care382. Children who attend
child care centers383, 384 and pediatric rehabilitation units385 may increase the overall
burden of antimicrobial resistance (eg. by contributing to the reservoir of community-
associated MRSA [CA-MRSA])386-391. Patients in chronic care facilities may have
increased rates of colonization with resistant GNBs and may be sources of introduction
of resistant organisms to acute care settings50.
I.D.2.a. Long-term care. The designation LTCF applies to a diverse group of residential
settings, ranging from institutions for the developmentally disabled to nursing homes for
the elderly and pediatric chronic-care facilities393-395. Nursing homes for the elderly
predominate numerically and frequently represent long-term care as a group of facilities.
Approximately 1.8 million Americans reside in the nation’s 16,500 nursing homes.396
Estimates of HAI rates of 1.8 to 13.5 per 1000 resident-care days have been reported
with a range of 3 to 7 per 1000 resident-care days in the more rigorous studies397-401.
The infrastructure described in the Department of Veterans Affairs nursing home care
units is a promising example for the development of a nationwide HAI surveillance
system for LTCFs402.
LCTFs are different from other healthcare settings in that elderly patients at increased
risk for infection are brought together in one setting and remain in the facility for
extended periods of time; for most residents, it is their home. An atmosphere of
community is fostered and residents share common eating and living areas, and
participate in various facility-sponsored activities403, 404. Since able residents interact
freely with each other, controlling transmission of infection in this setting is
challenging405. Residents who are colonized or infected with certain microorganisms
are, in some cases, restricted to their room. However, because of the psychosocial risks
associated with such restriction, it has been recommended that psychosocial needs be
balanced with infection control needs in the LTCF setting406-409. Documented LTCF
outbreaks have been caused by various viruses (e.g., influenza virus35, 410-412,
rhinovirus413, adenovirus [conjunctivitis]414, norovirus278, 279 275, 281) and bacteria (e.g.,
group A streptococcus162, B. pertussis415, non-susceptible S. pneumoniae197, 198, other
MDROs, and Clostridium difficile416) These pathogens can lead to substantial morbidity
and mortality, and increased medical costs; prompt detection and implementation of
effective control measures are required.
Risk factors for infection are prevalent among LTCF residents395, 417, 418. Age-related
declines in immunity may affect responses to immunizations for influenza and other
infectious agents, and increase susceptibility to tuberculosis. Immobility, incontinence,
dysphagia, underlying chronic diseases, poor functional status, and age-related skin
changes increase susceptibility to urinary, respiratory and cutaneous and soft tissue
infections, while malnutrition can impair wound healing419-423. Medications (e.g., drugs
that affect level of consciousness, immune function, gastric acid secretions, and normal
flora, including antimicrobial therapy) and invasive devices (e.g., urinary catheters and
feeding tubes) heighten susceptibility to infection and colonization in LTCF residents424-
426. Finally, limited functional status and total dependence on healthcare personnel for
activities of daily living have been identified as independent risk factors for infection401,
417, 427 and for colonization with MRSA428, 429 and ESBL-producing K. pneumoniae430.
Several position papers and review articles have been published that provide guidance
on various aspects of infection control and antimicrobial resistance in LTCFs406-408, 431-
436. The Centers for Medicare and Medicaid Services (CMS) have established
Because residents of LTCFs are hospitalized frequently, they can transfer pathogens
between LTCFs and healthcare facilities in which they receive care8, 438-441. This is also
true for pediatric long-term care populations. Pediatric chronic care facilities have been
associated with importing extended-spectrum cephalosporin-resistant, gram-negative
bacilli into one PICU50. Children from pediatric rehabilitation units may contribute to the
reservoir of community-associated MRSA385, 389-391.
I.D.2.b. Ambulatory care. In the past decade, healthcare delivery in the United States
has shifted from the acute, inpatient hospital to a variety of ambulatory and community-
There are few data on the risk of HAIs in ambulatory care settings, with the exception of
hemodialysis centers18, 444, 445. Transmission of infections in outpatient settings has
been reviewed in three publications446-448. Goodman and Solomon summarized 53
clusters of infections associated with the outpatient setting from 1961-1990 446. Overall,
29 clusters were associated with common source transmission from contaminated
solutions or equipment, 14 with person-to-person transmission from or involving
healthcare personnel and ten associated with airborne or droplet transmission among
patients and healthcare workers. Transmission of bloodborne pathogens (i.e., hepatitis
B and C viruses and, rarely, HIV) in outbreaks, sometimes involving hundreds of
patients, continues to occur in ambulatory settings. These outbreaks often are related to
common source exposures, usually a contaminated medical device, multi-dose vial, or
intravenous solution82, 449-453. In all cases, transmission has been attributed to failure to
adhere to fundamental infection control principles, including safe injection practices and
aseptic technique.This subject has been reviewed and recommended infection control
and safe injection practices summarized454.
I.D.2.c. Home care. Home care in the United States is delivered by over 20,000
provider agencies that include home health agencies, hospices, durable medical
equipment providers, home infusion therapy services, and personal care and support
services providers. Home care is provided to patients of all ages with both acute and
chronic conditions. The scope of services ranges from assistance with activities of daily
living and physical and occupational therapy to the care of wounds, infusion therapy,
and chronic ambulatory peritoneal dialysis (CAPD).
The incidence of infection in home care patients, other than those associated with
infusion therapy is not well studied466-471. However, data collection and calculation of
infection rates have been accomplished for central venous catheter-associated
bloodstream infections in patients receiving home infusion therapy 470-474 and for the risk
of blood contact through percutaneous or mucosal exposures, demonstrating that
surveillance can be performed in this setting475. Draft definitions for home care
associated infections have been developed476.
Transmission risks during home care are presumed to be minimal. The main
transmission risks to home care patients are from an infectious healthcare provider or
contaminated equipment; providers also can be exposed to an infectious patient during
home visits. Since home care involves patient care by a limited number of personnel in
settings without multiple patients or shared equipment, the potential reservoir of
pathogens is reduced. Infections of home care providers, that could pose a risk to home
care patients include infections transmitted by the airborne or droplet routes (e.g.,
chickenpox, tuberculosis, influenza), and skin infestations (e.g., scabies69 and lice) and
infections (e.g.,impetigo) transmitted by direct or indirect contact. There are no
published data on indirect transmission of MDROs from one home care patient to
another, although this is theoretically possible if contaminated equipment is transported
from an infected or colonized patient and used on another patient. Of note, investigation
of the first case of VISA in homecare186 and the first 2 reported cases of VRSA178, 180, 181,
183 found no evidence of transmission of VISA or VRSA to other home care recipients.
Home health care also may contribute to antimicrobial resistance; a review of outpatient
vancomycin use found 39% of recipients did not receive the antibiotic according to
recommended guidelines477.
Although most home care agencies implement policies and procedures to prevent
transmission of organisms, the current approach is based on the adaptation of the 1996
Guideline for Isolation Precautions in Hospitals 1 as well as other professional
guidance478, 479. This issue has been very challenging in the home care industry and
practice has been inconsistent and frequently not evidence-based. For example, many
home health agencies continue to observe “nursing bag technique,” a practice that
prescribes the use of barriers between the nursing bag and environmental surfaces in
the home480. While the home environment may not always appear clean, the use of
barriers between two non-critical surfaces has been questioned481, 482. Opportunites
exist to conduct research in home care related to infection transmission risks483.
I.D.2.d. Other sites of healthcare delivery. Facilities that are not primarily healthcare
settings but in which healthcare is delivered include clinics in correctional facilities and
shelters. Both settings can have suboptimal features, such as crowded conditions and
poor ventilation. Economically disadvantaged individuals who may have chronic
illnesses and healthcare problems related to alcoholism, injection drug use, poor
nutrition, and/or inadequate shelter often receive their primary healthcare at sites such
as these484. Infectious diseases of special concern for transmission include tuberculosis,
scabies, respiratory infections (e.g., N. meningitides, S. pneumoniae), sexually
transmitted and bloodborne diseases (e.g.,HIV, HBV, HCV, syphilis, gonorrhea),
hepatitis A virus (HAV), diarrheal agents such as norovirus, and foodborne diseases286,
485-488. A high index of suspicion for tuberculosis and CA-MRSA in these populations is
needed as outbreaks in these settings or among the populations they serve have been
reported489-497.
determine the types of infections that are most likely to be acquired (e.g., viral infections
are associated with T-cell defects and fungal and bacterial infections occur in patients
who are neutropenic). As a general group, immunocompromised patients can be cared
for in the same environment as other patients; however, it is always advisable to
minimize exposure to other patients with transmissible infections such as influenza and
other respiratory viruses499, 500. The use of more intense chemotherapy regimens for
treatment of childhood leukemia may be associated with prolonged periods of
neutropenia and suppression of other components of the immune system, extending the
period of infection risk and raising the concern that additional precautions may be
indicated for select groups501, 502. With the application of newer and more intense
immunosuppressive therapies for a variety of medical conditions (e.g., rheumatologic
disease503, 504, inflammatory bowel disease505), immunosuppressed patients are likely to
be more widely distributed throughout a healthcare facility rather than localized to single
patient units (e.g., hematology-oncology). Guidelines for preventing infections in certain
groups of immunocompromised patients have been published15, 506, 507.
I.E.2. Cystic fibrosis patients. Patients with cystic fibrosis (CF) require special
consideration when developing infection control guidelines. Compared to other patients,
CF patients require additional protection to prevent transmission from contaminated
respiratory therapy equipment509-513. Infectious agents such as Burkholderia cepacia
complex and P. aeruginosa464, 465, 514, 515 have unique clinical and prognostic
significance. In CF patients, B. cepacia infection has been associated with increased
morbidity and mortality 516-518, while delayed acquisition of chronic P.aeruginosa
infection may be associated with an improved long-term clinical outcome519, 520.
The infectious hazards of gene therapy are theoretical at this time, but require
meticulous surveillance due to the possible occurrence of in vivo recombination and the
subsequent emergence of a transmissible genetically altered pathogen. Greatest
concern attends the use of replication-competent viruses, especially vaccinia. As of the
time of publication, no reports have described transmission of a vector virus from a
gene therapy recipient to another individual, but surveillance is ongoing.
Recommendations for monitoring infection control issues throughout the course of gene
therapy trials have been published527-529.
I.F.2. Infections transmitted through blood, organs and other tissues. The potential
hazard of transmitting infectious pathogens through biologic products is a small but ever
present risk, despite donor screening. Reported infections transmitted by transfusion or
transplantation include West Nile Virus infection530 cytomegalovirus infection531,
Creutzfeldt-Jacob disease230, hepatitis C 532, infections with Clostridium spp. 533 and
group A streptococcus534, malaria535, babesiosis536, Chagas disease537, lymphocytic
choriomeningitis538, and rabies539, 540. Therefore, it is important to consider receipt of
biologic products when evaluating patients for potential sources of infection.
A key administrative measure is provision of fiscal and human resources for maintaining
infection control and occupational health programs that are responsive to emerging
needs. Specific components include bedside nurse551 and infection prevention and
control professional (ICP) staffing levels552, inclusion of ICPs in facility construction and
design decisions11, clinical microbiology laboratory support553, 554, adequate supplies
and equipment including facility ventilation systems11, adherence monitoring555,
assessment and correction of system failures that contribute to transmission556, 557, and
provision of feedback to healthcare personnel and senior administrators434, 548, 549, 558.
The positive influence of institutional leadership has been demonstrated repeatedly in
studies of HCW adherence to recommended hand hygiene practices176, 177, 434, 548, 549,
559-564. Healthcare administrator involvement in infection control processes can improve
II.A.1.a.Scope of work and staffing needs for infection control professionals. The
effectiveness of infection surveillance and control programs in preventing nosocomial
infections in United States hospitals was assessed by the CDC through the Study on
the Efficacy of Nosocomial Infection Control (SENIC Project) conducted 1970-76 566. In
a representative sample of US general hospitals, those with a trained infection control
physician or microbiologist involved in an infection control program, and at least one
infection control nurse per 250 beds, were associated with a 32% lower rate of four
infections studied (CVC-associated bloodstream infections, ventilator-associated
pneumonias, catheter-related urinary tract infections, and surgical site infections).
Since that landmark study was published, responsibilities of ICPs have expanded
commensurate with the growing complexity of the healthcare system, the patient
populations served, and the increasing numbers of medical procedures and devices
used in all types of healthcare settings. The scope of work of ICPs was first assessed in
1982567-569 by the Certification Board of Infection Control (CBIC), and has been re-
assessed every five years since that time558, 570-572. The findings of these task analyses
have been used to develop and update the Infection Control Certification Examination,
offered for the first time in 1983. With each survey, it is apparent that the role of the ICP
is growing in complexity and scope, beyond traditional infection control activities in
acute care hospitals. Activities currently assigned to ICPs in response to emerging
challenges include:
1. surveillance and infection prevention at facilities other than acute care hospitals e.g.,
ambulatory clinics, day surgery centers, long term care facilities, rehabilitation
centers, home care;
2. oversight of employee health services related to infection prevention, e.g.,
assessment of risk and administration of recommended treatment following
exposure to infectious agents, tuberculosis screening, influenza vaccination,
respiratory protection fit testing, and administration of other vaccines as indicated,
such as smallpox vaccine in 2003;
3. preparedness planning for annual influenza outbreaks, pandemic influenza, SARS,
bioweapons attacks;
4. adherence monitoring for selected infection control practices;
5. oversight of risk assessment and implementation of prevention measures associated
with construction and renovation;
6. prevention of transmission of MDROs;
7. evaluation of new medical products that could be associated with increased infection
risk. e.g.,intravenous infusion materials;
8. communication with the public, facility staff, and state and local health departments
concerning infection control-related issues; and
9. participation in local and multi-center research projects434, 549, 552, 558, 573, 574.
None of the CBIC job analyses addressed specific staffing requirements for the
identified tasks, although the surveys did include information about hours worked; the
2001 survey included the number of ICPs assigned to the responding facilities 558.
There is agreement in the literature that 1 ICP per 250 acute care beds is no longer
adequate to meet current infection control needs; a Delphi project that assessed staffing
needs of infection control programs in the 21st century concluded that a ratio of 0.8 to
1.0 ICP per 100 occupied acute care beds is an appropriate level of staffing 552. A
survey of participants in the National Nosocomial Infections Surveillance (NNIS) system
found the average daily census per ICP was 115 316. Results of other studies have been
similar: 3 per 500 beds for large acute care hospitals, 1 per 150-250 beds in long term
care facilities, and 1.56 per 250 in small rural hospitals573, 575. The foregoing
demonstrates that infection control staffing can no longer be based on patient census
alone, but rather must be determined by the scope of the program, characteristics of the
patient population, complexity of the healthcare system, tools available to assist
personnel to perform essential tasks (e.g., electronic tracking and laboratory support for
II.A.1.b. Bedside nurse staffing. There is increasing evidence that the level of bedside
nurse-staffing influences the quality of patient care583, 584. If there are adequate nursing
staff, it is more likely that infection control practices, including hand hygiene and
Standard and Transmission-Based Precautions, will be given appropriate attention and
applied correctly and consistently552. A national multicenter study reported strong and
consistent inverse relationships between nurse staffing and five adverse outcomes in
medical patients, two of which were HAIs: urinary tract infections and pneumonia583.
The association of nursing staff shortages with increased rates of HAIs has been
demonstrated in several outbreaks in hospitals and long term care settings, and with
increased transmission of hepatitis C virus in dialysis units22, 418, 551, 585-597. In most
cases, when staffing improved as part of a comprehensive control intervention, the
outbreak ended or the HAI rate declined. In two studies590, 596, the composition of the
nursing staff (“pool” or “float” vs. regular staff nurses) influenced the rate of primary
bloodstream infections, with an increased infection rate occurring when the proportion of
regular nurses decreased and pool nurses increased.
II.A.1.c. Clinical microbiology laboratory support. The critical role of the clinical
microbiology laboratory in infection control and healthcare epidemiology is described
well553, 554, 598-600 and is supported by the Infectious Disease Society of America policy
statement on consolidation of clinical microbiology laboratories published in 2001 553.
The clinical microbiology laboratory contributes to preventing transmission of infectious
diseases in healthcare settings by promptly detecting and reporting epidemiologically
important organisms, identifying emerging patterns of antimicrobial resistance, and
assisting in assessment of the effectiveness of recommended precautions to limit
transmission during outbreaks598. Outbreaks of infections may be recognized first by
laboratorians162. Healthcare organizations need to ensure the availability of the
recommended scope and quality of laboratory services, a sufficient number of
appropriately trained laboratory staff members, and systems to promptly communicate
epidemiologically important results to those who will take action (e.g., providers of
clinical care, infection control staff, healthcare epidemiologists, and infectious disease
consultants)601. As concerns about emerging pathogens and bioterrorism grow, the role
of the clinical microbiology laboratory takes on even greater importance. For healthcare
organizations that outsource microbiology laboratory services (e.g., ambulatory care,
home care, LTCFs, smaller acute care hospitals), it is important to specify by contract
the types of services (e.g., periodic institution-specific aggregate susceptibility reports)
required to support infection control.
Several key functions of the clinical microbiology laboratory are relevant to this
guideline:
• Antimicrobial susceptibility by testing and interpretation in accordance with current
guidelines developed by the National Committee for Clinical Laboratory Standards
(NCCLS), known as the Clinical and Laboratory Standards Institute (CLSI) since
2005 602, for the detection of emerging resistance patterns603, 604, and for the
preparation, analysis, and distribution of periodic cumulative antimicrobial
susceptibility summary reports605-607. While not required, clinical laboratories ideally
should have access to rapid genotypic identification of bacteria and their antibiotic
resistance genes608.
• Performance of surveillance cultures when appropriate (including retention of
isolates for analysis) to assess patterns of infection transmission and effectiveness
of infection control interventions at the facility or organization. Microbiologists assist
in decisions concerning the indications for initiating and discontinuing active
surveillance programs and optimize the use of laboratory resources.
• Molecular typing, on-site or outsourced, in order to investigate and control
healthcare-associated outbreaks609.
• Application of rapid diagnostic tests to support clinical decisions involving patient
treatment, room selection, and implementation of control measures including barrier
precautions and use of vaccine or chemoprophylaxis agents (e.g., influenza610-612, B.
pertussis613, RSV614, 615, and enteroviruses616). The microbiologist provides guidance
to limit rapid testing to clinical situations in which rapid results influence patient
management decisions, as well as providing oversight of point-of-care testing
performed by non-laboratory healthcare workers617.
• Detection and rapid reporting of epidemiologically important organisms, including
those that are reportable to public health agencies.
• Implementation of a quality control program that ensures testing services are
appropriate for the population served, and stringently evaluated for sensitivity,
specificity, applicability, and feasibility.
• Participation in a multidisciplinary team to develop and maintain an effective
institutional program for the judicious use of antimicrobial agents618, 619.
Use of engineering controls and facility design concepts for improving adherence is
gaining interest. While introduction of automated sinks had a negative impact on
The Study on the Efficacy of Nosocomial Infection Control (SENIC) found that different
combinations of infection control practices resulted in reduced rates of nosocomial
surgical site infections, pneumonia, urinary tract infections, and bacteremia in acute
care hospitals566; however, surveillance was the only component essential for reducing
all four types of HAIs. Although a similar study has not been conducted in other
healthcare settings, a role for surveillance and the need for novel strategies have been
described in LTCFs398, 434, 669, 670 and in home care470-473. The essential elements of a
surveillance system are:
1. standardized definitions;
2. identification of patient populations at risk for infection;
Targeted surveillance based on the highest risk areas or patients has been preferred
over facility-wide surveillance for the most effective use of resources 673, 676. However,
surveillance for certain epidemiologically important organisms may need to be facility-
wide. Surveillance methods will continue to evolve as healthcare delivery systems
change392, 677 and user-friendly electronic tools become more widely available for
electronic tracking and trend analysis674, 678, 679. Individuals with experience in
healthcare epidemiology and infection control should be involved in selecting software
packages for data aggregation and analysis to assure that the need for efficient and
accurate HAI surveillance will be met. Effective surveillance is increasingly important as
legislation requiring public reporting of HAI rates is passed and states work to develop
effective systems to support such legislation680.
Education programs for healthcare personnel have been associated with sustained
improvement in adherence to best practices and a related decrease in device-
associated HAIs in teaching and non-teaching settings639, 703 and in medical and
surgical ICUs {Coopersmith, 2002 #2149; Babcock, 2004 #2126; Berenholtz, 2004
#2289; [This link is no longer active: www.ihi.org/IHI/Programs/Campaign], #2563}
Several studies have shown that, in addition to targeted education to improve specific
practices, periodic assessment and feedback of the HCWs knowledge,and adherence
to recommended practices are necessary to achieve the desired changes and to identify
continuing education needs562, 704-708. Effectiveness of this approach for isolation
practices has been demonstrated for control of RSV116, 684.
The effectiveness of hand hygiene can be reduced by the type and length of
fingernails559, 718, 719. Individuals wearing artifical nails have been shown to harbor more
pathogenic organisms, especially gram negative bacilli and yeasts, on the nails and in
the subungual area than those with native nails720, 721. In 2002, CDC/HICPAC
recommended (Category IA) that artificial fingernails and extenders not be worn by
healthcare personnel who have contact with high-risk patients (e.g., those in ICUs,
ORs) due to the association with outbreaks of gram-negative bacillus and candidal
infections as confirmed by molecular typing of isolates30, 31, 559, 722-725.The need to restrict
the wearing of artificial fingernails by all healthcare personnel who provide direct patient
care or by healthcare personnel who have contact with other high risk groups (e.g.,
oncology, cystic fibrosis patients), has not been studied, but has been recommended by
some experts20. At this time such decisions are at the discretion of an individual facility’s
infection control program. There is less evidence that jewelry affects the quality of hand
hygiene. Although hand contamination with potential pathogens is increased with ring-
wearing559, 726, no studies have related this practice to HCW-to-patient transmission of
pathogens.
II.E.1. Gloves. Gloves are used to prevent contamination of healthcare personnel hands
when
1. anticipating direct contact with blood or body fluids, mucous membranes, nonintact
skin and other potentially infectious material;
2. having direct contact with patients who are colonized or infected with pathogens
transmitted by the contact route e.g., VRE, MRSA, RSV559, 727, 728; or
3. handling or touching visibly or potentially contaminated patient care equipment and
environmental surfaces72, 73, 559.
Gloves can protect both patients and healthcare personnel from exposure to infectious
material that may be carried on hands73. The extent to which gloves will protect
healthcare personnel from transmission of bloodborne pathogens (e.g., HIV, HBV, HCV)
following a needlestick or other pucture that penetrates the glove barrier has not been
determined. Although gloves may reduce the volume of blood on the external surface of
a sharp by 46-86% 729, the residual blood in the lumen of a hollowbore needle would not
be affected; therefore, the effect on transmission risk is unknown.
Gloves manufactured for healthcare purposes are subject to FDA evaluation and
clearance730. Nonsterile disposable medical gloves made of a variety of materials (e.g.,
latex, vinyl, nitrile) are available for routine patient care731. The selection of glove type
for non-surgical use is based on a number of factors, including the task that is to be
performed, anticipated contact with chemicals and chemotherapeutic agents, latex
sensitivity, sizing, and facility policies for creating a latex-free environment17, 732-734. For
contact with blood and body fluids during non-surgical patient care, a single pair of
gloves generally provides adequate barrier protection734. However, there is considerable
variability among gloves; both the quality of the manufacturing process and type of
material influence their barrier effectiveness735. While there is little difference in the
barrier properties of unused intact gloves736, studies have shown repeatedly that vinyl
gloves have higher failure rates than latex or nitrile gloves when tested under simulated
and actual clinical conditions731, 735-738. For this reason either latex or nitrile gloves are
preferable for clinical procedures that require manual dexterity and/or will involve more
than brief patient contact. It may be necessary to stock gloves in several sizes. Heavier,
reusable utility gloves are indicated for non-patient care activities, such as handling or
cleaning contaminated equipment or surfaces11, 14, 739.
When gloves are worn in combination with other PPE, they are put on last. Gloves that
fit snugly around the wrist are preferred for use with an isolation gown because they will
cover the gown cuff and provide a more reliable continuous barrier for the arms, wrists,
and hands. Gloves that are removed properly will prevent hand contamination (Figure).
Hand hygiene following glove removal further ensures that the hands will not carry
potentially infectious material that might have penetrated through unrecognized tears or
that could contaminate the hands during glove removal559, 728, 741.
II.E.2. Isolation gowns. Isolation gowns are used as specified by Standard and
Transmission-Based Precautions, to protect the HCW’s arms and exposed body areas
and prevent contamination of clothing with blood, body fluids, and other potentially
infectious material24, 88, 262, 744-746. The need for and type of isolation gown selected is
based on the nature of the patient interaction, including the anticipated degree of
contact with infectious material and potential for blood and body fluid penetration of the
barrier. The wearing of isolation gowns and other protective apparel is mandated by the
OSHA Bloodborne Pathogens Standard739. Clinical and laboratory coats or jackets worn
over personal clothing for comfort and/or purposes of identity are not considered PPE.
When applying Standard Precautions, an isolation gown is worn only if contact with
blood or body fluid is anticipated. However, when Contact Precautions are used (i.e., to
prevent transmission of an infectious agent that is not interrupted by Standard
Precautions alone and that is associated with environmental contamination), donning of
both gown and gloves upon room entry is indicated to address unintentional contact
with contaminated environmental surfaces54, 72, 73, 88. The routine donning of isolation
gowns upon entry into an intensive care unit or other high-risk area does not prevent or
influence potential colonization or infection of patients in those areas365, 747-750.
Isolation gowns are always worn in combination with gloves, and with other PPE when
indicated. Gowns are usually the first piece of PPE to be donned. Full coverage of the
arms and body front, from neck to the mid-thigh or below will ensure that clothing and
exposed upper body areas are protected. Several gown sizes should be available in a
healthcare facility to ensure appropriate coverage for staff members. Isolation gowns
should be removed before leaving the patient care area to prevent possible
contamination of the environment outside the patient’s room. Isolation gowns should be
removed in a manner that prevents contamination of clothing or skin (Figure). The outer,
“contaminated”, side of the gown is turned inward and rolled into a bundle, and then
discarded into a designated container for waste or linen to contain contamination.
II.E.3.a. Masks. Masks are used for three primary purposes in healthcare settings:
1. placed on healthcare personnel to protect them from contact with infectious material
from patients e.g., respiratory secretions and sprays of blood or body fluids,
consistent with Standard Precautions and Droplet Precautions;
2. placed on healthcare personnel when engaged in procedures requiring sterile
technique to protect patients from exposure to infectious agents carried in a
healthcare worker’s mouth or nose, and
3. placed on coughing patients to limit potential dissemination of infectious respiratory
secretions from the patient to others (i.e., Respiratory Hygiene/Cough Etiquette).
Masks may be used in combination with goggles to protect the mouth, nose and eyes,
or a face shield may be used instead of a mask and goggles, to provide more complete
protection for the face, as discussed below. Masks should not be confused with
particulate respirators that are used to prevent inhalation of small particles that
may contain infectious agents transmitted via the airborne route as described
below.
The mucous membranes of the mouth, nose, and eyes are susceptible portals of entry
for infectious agents, as can be other skin surfaces if skin integrity is compromised (e.g.,
by acne, dermatitis)66, 751-754. Therefore, use of PPE to protect these body sites is an
important component of Standard Precautions. The protective effect of masks for
exposed healthcare personnel has been demonstrated93, 113, 755, 756. Procedures that
generate splashes or sprays of blood, body fluids, secretions, or excretions (e.g.,
endotracheal suctioning, bronchoscopy, invasive vascular procedures) require either a
face shield (disposable or reusable) or mask and goggles93-95, 96, 113, 115, 262, 739, 757.The
wearing of masks, eye protection, and face shields in specified circumstances when
blood or body fluid exposures are likely to occur is mandated by the OSHA Bloodborne
Pathogens Standard739. Appropriate PPE should be selected based on the anticipated
level of exposure.
Two mask types are available for use in healthcare settings: surgical masks that are
cleared by the FDA and required to have fluid-resistant properties, and procedure or
isolation masks758 #2688. No studies have been published that compare mask types to
determine whether one mask type provides better protection than another. Since
procedure/isolation masks are not regulated by the FDA, there may be more variability
in quality and performance than with surgical masks. Masks come in various shapes
(e.g., molded and non-molded), sizes, filtration efficiency, and method of attachment
(e.g., ties, elastic, ear loops). Healthcare facilities may find that different types of masks
are needed to meet individual healthcare personnel needs.
II.E.3.b. Goggles, face shields. Guidance on eye protection for infection control has
been published759. The eye protection chosen for specific work situations (e.g., goggles
or face shield) depends upon the circumstances of exposure, other PPE used, and
personal vision needs. Personal eyeglasses and contact lenses are NOT considered
adequate eye protection (NIOSH Eye Protection for Infection Control
(https://www.cdc.gov/niosh/topics/eye/eye-infectious.html accessed May 2016) [Current
version of this document may differ from original.]). NIOSH states that, eye protection
must be comfortable, allow for sufficient peripheral vision, and must be adjustable to
ensure a secure fit. It may be necessary to provide several different types, styles, and
sizes of protective equipment. Indirectly-vented goggles with a manufacturer’s anti-fog
coating may provide the most reliable practical eye protection from splashes, sprays,
and respiratory droplets from multiple angles. Newer styles of goggles may provide
better indirect airflow properties to reduce fogging, as well as better peripheral vision
and more size options for fitting goggles to different workers. Many styles of goggles fit
adequately over prescription glasses with minimal gaps. While effective as eye
protection, goggles do not provide splash or spray protection to other parts of the face.
likely that there will be a splash or spray of any respiratory secretions or other body
fluids as defined in Standard Precautions.
Removal of a face shield, goggles and mask can be performed safely after gloves have
been removed, and hand hygiene performed. The ties, ear pieces and/or headband
used to secure the equipment to the head are considered “clean” and therefore safe to
touch with bare hands. The front of a mask, goggles and face shield are considered
contaminated (Figure).
Procedures for safe removal of respirators are provided (Figure). In some healthcare
settings, particulate respirators used to provide care for patients with M. tuberculosis are
reused by the same HCW. This is an acceptable practice providing the respirator is not
damaged or soiled, the fit is not compromised by change in shape, and the respirator
has not been contaminated with blood or body fluids. There are no data on which to
base a recommendation for the length of time a respirator may be reused.
Since 1991, when OSHA first issued its Bloodborne Pathogens Standard to protect
healthcare personnel from blood exposure, the focus of regulatory and legislative
activity has been on implementing a hierarchy of control measures. This has included
focusing attention on removing sharps hazards through the development and use of
engineering controls. The federal Needlestick Safety and Prevention Act signed into law
in November, 2000 authorized OSHA's revision of its Bloodborne Pathogens Standard
to more explicitly require the use of safety-engineered sharp devices786. CDC has
provided guidance on sharps injury prevention787, 788, including for the design,
implementation and evaluation of a comprehensive sharps injury prevention program789.
addition to wearing PPE, are used to protect mucous membranes and non-intact skin
from contact with potentially infectious material. These include keeping gloved and
ungloved hands that are contaminated from touching the mouth, nose, eyes, or face;
and positioning patients to direct sprays and splatter away from the face of the
caregiver. Careful placement of PPE before patient contact will help avoid the need to
make PPE adjustments and possible face or mucous membrane contamination during
use.
When there are only a limited number of single-patient rooms, it is prudent to prioritize
them for those patients who have conditions that facilitate transmission of infectious
material to other patients (e.g., draining wounds, stool incontinence, uncontained
secretions) and for those who are at increased risk of acquisition and adverse outcomes
resulting from HAI (e.g., immunosuppression, open wounds, indwelling catheters,
anticipated prolonged length of stay, total dependence on HCWs for activities of daily
living)15, 24, 43, 430, 794, 795.
Single-patient rooms are always indicated for patients placed on Airborne Precautions
and in a Protective Environment and are preferred for patients who require Contact or
Droplet Precautions23, 24, 410, 435, 796, 797. During a suspected or proven outbreak caused
by a pathogen whose reservoir is the gastrointestinal tract, use of single patient rooms
with private bathrooms limits opportunities for transmission, especially when the
colonized or infected patient has poor personal hygiene habits, fecal incontinence, or
cannot be expected to assist in maintaining procedures that prevent transmission of
microorganisms (e.g., infants, children, and patients with altered mental status or
developmental delay). In the absence of continued transmission, it is not necessary to
provide a private bathroom for patients colonized or infected with enteric pathogens as
long as personal hygiene practices and Standard Precautions, especially hand hygiene
and appropriate environmental cleaning, are maintained. Assignment of a dedicated
commode to a patient,and cleaning and disinfecting fixtures and equipment that may
have fecal contamination (e.g., bathrooms, commodes798, scales used for weighing
diapers) and the adjacent surfaces with appropriate agents may be especially important
when a single-patient room can not be used since environmental contamination with
intestinal tract pathogens is likely from both continent and incontinent patients54, 799.
Results of several studies to determine the benefit of a single-patient room to prevent
transmission of Clostridium difficile are inconclusive 167, 800-802. Some studies have
shown that being in the same room with a colonized or infected patient is not
necessarily a risk factor for transmission791, 803-805. However, for children, the risk of
healthcare-associated diarrhea is increased with the increased number of patients per
room806. Thus, patient factors are important determinants of infection transmission risks,
and the need for a single-patient room and/or private bathroom for any patient is best
determined on a case-by-case basis.
Cohorting is the practice of grouping together patients who are colonized or infected
with the same organism to confine their care to one area and prevent contact with other
patients. Cohorts are created based on clinical diagnosis, microbiologic confirmation
when available, epidemiology, and mode of transmission of the infectious agent. It is
generally preferred not to place severely immunosuppressed patients in rooms with
other patients. Cohorting has been used extensively for managing outbreaks of MDROs
including MRSA22, 807, VRE638, 808, 809, MDR-ESBLs810; Pseudomonas aeruginosa29;
methicillin-susceptible Staphylococcus aureus811; RSV812, 813; adenovirus
keratoconjunctivitis814; rotavirus815; and SARS816. Modeling studies provide additional
support for cohorting patients to control outbreaks Talon817-819. However, cohorting often
is implemented only after routine infection control measures have failed to control an
outbreak.
close physical contact that occurs during their care, increases infection transmission
risks for patients and personnel in this setting24, 795.
Patients with underlying conditions that increase their susceptibility to infection (e.g.,
those who are immunocompromised43, 44 or have cystic fibrosis20) require special efforts
to protect them from exposures to infected patients in common waiting areas. By
informing the receptionist of their infection risk upon arrival, appropriate steps may be
taken to further protect them from infection. In some cystic fibrosis clinics, in order to
avoid exposure to other patients who could be colonized with B. cepacia, patients have
been given beepers upon registration so that they may leave the area and receive
notification to return when an examination room becomes available832.
II.G.3. Home care. In home care, the patient placement concerns focus on protecting
others in the home from exposure to an infectious household member. For individuals
who are especially vulnerable to adverse outcomes associated with certain infections, it
may be beneficial to either remove them from the home or segregate them within the
home. Persons who are not part of the household may need to be prohibited from visiting
during the period of infectivity. For example, if a patient with pulmonary tuberculosis is
contagious and being cared for at home, very young children (<4 years of age)833 and
immunocompromised persons who have not yet been infected should be removed or
excluded from the household. During the SARS outbreak of 2003, segregation of
infected persons during the communicable phase of the illness was beneficial in
preventing household transmission249, 834.
For tuberculosis, additional precautions may be needed in a small shared air space
such as in an ambulance12.
important to include computers and personal digital assistants (PDAs) used in patient
care in policies for cleaning and disinfection of non-critical items. The literature on
contamination of computers with pathogens has been summarized850 and two reports
have linked computer contamination to colonization and infections in patients851, 852.
Although keyboard covers and washable keyboards that can be easily disinfected are in
use, the infection control benefit of those items and optimal management have not been
determined.
In home care, it is preferable to remove visible blood or body fluids from durable
medical equipment before it leaves the home. Equipment can be cleaned on-site using
a detergent/disinfectant and, when possible, should be placed in a single plastic bag for
transport to the reprocessing location20, 739.
1. not shaking the items or handling them in any way that may aerosolize infectious
agents;
2. avoiding contact of one’s body and personal clothing with the soiled items being
handled; and
3. containing soiled items in a laundry bag or designated bin. When laundry chutes are
used, they must be maintained to minimize dispersion of aerosols from
contaminated items11.
The methods for handling, transporting, and laundering soiled textiles are determined by
organizational policy and any applicable regulations739; guidance is provided in the
Guidelines for Environmental Infection Control11. Rather than rigid rules and regulations,
hygienic and common sense storage and processing of clean textiles is
recommended11, 857. When laundering occurs outside of a healthcare facility, the clean
items must be packaged or completely covered and placed in an enclosed space during
transport to prevent contamination with outside air or construction dust that could
contain infectious fungal spores that are a risk for immunocompromised patients11.
determine the safety of home laundering of HCW uniforms, but no increase in infection
rates was observed in the one published study858 and no pathogens were recovered
from home- or hospital-laundered scrubs in another study859. In the home, textiles and
laundry from patients with potentially transmissible infectious pathogens do not require
special handling or separate laundering, and may be washed with warm water and
detergent11, 858, 859.
Detailed discussion of judicious use of antimicrobial agents is beyond the scope of this
document; however the topic is addressed in the Management of Multidrug- Resistant
Organisms in Healthcare Settings 2006
(https://www.cdc.gov/infectioncontrol/guidelines/mdro/ accessed May 2016).
Another form of chemoprophylaxis is the use of topical antiseptic agents. For example,
triple dye is used routinely on the umbilical cords of term newborns to reduce the risk of
colonization, skin infections, and omphalitis caused by S. aureus, including MRSA, and
group A streptococcus868, 869. Extension of the use of triple dye to low birth weight
infants in the NICU was one component of a program that controlled one longstanding
MRSA outbreak22. Topical antiseptics are also used for decolonization of healthcare
personnel or selected patients colonized with MRSA, using mupirocin as discussed in
the MDRO guideline870 867, 871-873.
Transmission of B. pertussis in healthcare facilities has been associated with large and
costly outbreaks that include both healthcare personnel and patients17, 36, 41, 100, 683, 827,
880, 881. HCWs who have close contact with infants with pertussis are at particularly high
risk because of waning immunity and, until 2005, the absence of a vaccine that could be
used in adults. However, two acellular pertussis vaccines were licensed in the United
States in 2005, one for use in individuals aged 11-18 and one for use in ages 10-64
years882. Provisional ACIP recommendations at the time of publication of this document
include adolescents and adults, especially those with contact with infants < 12 months
of age and healthcare personnel with direct patient contact883 884.
Immunization of children and adults will help prevent the introduction of vaccine-
preventable diseases into healthcare settings. The recommended immunization
schedule for children is published annually in the January issues of the Morbidity
Mortality Weekly Report with interim updates as needed885, 886. An adult immunization
schedule also is available for healthy adults and those with special immunization needs
due to high risk medical conditions887.
Some vaccines are also used for postexposure prophylaxis of susceptible individuals,
including varicella888, influenza611, hepatitis B778, and smallpox225 vaccines17, 874. In the
future, administration of a newly developed S. aureus conjugate vaccine (still under
investigation) to selected patients may provide a novel method of preventing healthcare-
associated S. aureus, including MRSA, infections in high-risk groups (e.g., hemodialysis
patients and candidates for selected surgical procedures)889, 890.
Immune globulin preparations also are used for postexposure prophylaxis of certain
infectious agents under specified circumstances (e.g., varicella-zoster virus [VZIG],
hepatitis B virus [HBIG], rabies [RIG], measles and hepatitis A virus [IG]17, 833, 874). The
RSV monoclonal antibody preparation, Palivizumab, may have contributed to controlling
a nosocomial outbreak of RSV in one NICU , but there is insufficient evidence to
support a routine recommendation for its use in this setting891.
II.N.3.a. Visitors as sources of infection. Visitors have been identified as the source
of several types of HAIs (e.g., pertussis40, 41, M. tuberculosis42, 892, influenza, and other
respiratory viruses24, 43, 44, 373 and SARS 21, 252-254). However, effective methods for visitor
screening in healthcare settings have not been studied. Visitor screening is especially
important during community outbreaks of infectious diseases and for high risk patient
units. Sibling visits are often encouraged in birthing centers, post partum rooms and in
pediatric inpatient units, ICUs, and in residential settings for children; in hospital
settings, a child visitor should visit only his or her own sibling. Screening of visiting
siblings and other children before they are allowed into clinical areas is necessary to
prevent the introduction of childhood illnesses and common respiratory infections.
Screening may be passive through the use of signs to alert family members and visitors
with signs and symptoms of communicable diseases not to enter clinical areas. More
active screening may include the completion of a screening tool or questionnaire which
elicits information related to recent exposures or current symptoms. That information is
reviewed by the facility staff and the visitor is either permitted to visit or is excluded833.
Family and household members visiting pediatric patients with pertussis and
tuberculosis may need to be screened for a history of exposure as well as signs and
symptoms of current infection. Potentially infectious visitors are excluded until they
receive appropriate medical screening, diagnosis, or treatment. If exclusion is not
considered to be in the best interest of the patient or family (i.e., primary family
members of critically or terminally ill patients), then the symptomatic visitor must wear a
mask while in the healthcare facility and remain in the patient’s room, avoiding exposure
to others, especially in public waiting areas and the cafeteria.
Visitor screening is used consistently on HSCT units15, 43. However, considering the
experience during the 2003 SARS outbreaks and the potential for pandemic influenza,
developing effective visitor screening systems will be beneficial9. Education concerning
Respiratory Hygiene/Cough Etiquette is a useful adjunct to visitor screening.
II.N.3.b. Use of barrier precautions by visitors. The use of gowns, gloves, or masks
by visitors in healthcare settings has not been addressed specifically in the scientific
literature. Some studies included the use of gowns and gloves by visitors in the control
of MDRO’s, but did not perform a separate analysis to determine whether their use by
visitors had a measurable impact893-895. Family members or visitors who are providing
care or having very close patient contact (e.g., feeding, holding) may have contact with
other patients and could contribute to transmission if barrier precautions are not used
correctly. Specific recommendations may vary by facility or by unit and should be
determined by the level of interaction.
Standard Precautions combine the major features of Universal Precautions (UP)780, 896
and Body Substance Isolation (BSI)640 and are based on the principle that all blood,
body fluids, secretions, excretions except sweat, nonintact skin, and mucous
membranes may contain transmissible infectious agents. Standard Precautions include
a group of infection prevention practices that apply to all patients, regardless of
suspected or confirmed infection status, in any setting in which healthcare is delivered
(Table 4). These include: hand hygiene; use of gloves, gown, mask, eye protection, or
face shield, depending on the anticipated exposure; and safe injection practices. Also,
equipment or items in the patient environment likely to have been contaminated with
infectious body fluids must be handled in a manner to prevent transmission of infectious
agents (e.g., wear gloves for direct contact, contain heavily soiled equipment, properly
clean and disinfect or sterilize reusable equipment before use on another patient).
The application of Standard Precautions during patient care is determined by the nature
of the HCW-patient interaction and the extent of anticipated blood, body fluid, or
pathogen exposure. For some interactions (e.g., performing venipuncture), only gloves
may be needed; during other interactions (e.g., intubation), use of gloves, gown, and
face shield or mask and goggles is necessary. Education and training on the principles
and rationale for recommended practices are critical elements of Standard Precautions
Standard Precautions are also intended to protect patients by ensuring that healthcare
personnel do not carry infectious agents to patients on their hands or via equipment
used during patient care.
III.A.1. New elements of standard precautions. Infection control problems that are
identified in the course of outbreak investigations often indicate the need for new
recommendations or reinforcement of existing infection control recommendations to
protect patients. Because such recommendations are considered a standard of care
and may not be included in other guidelines, they are added here to Standard
Precautions. Three such areas of practice that have been added are: Respiratory
Hygiene/Cough Etiquette, safe injection practices, and use of masks for insertion of
catheters or injection of material into spinal or epidural spaces via lumbar puncture
procedures (e.g., myelogram, spinal or epidural anesthesia). While most elements of
Standard Precautions evolved from Universal Precautions that were developed for
protection of healthcare personnel, these new elements of Standard Precautions focus
on protection of patients.
Covering sneezes and coughs and placing masks on coughing patients are proven
means of source containment that prevent infected persons from dispersing respiratory
secretions into the air107, 145, 898, 899. Masking may be difficult in some settings, (e.g.,
pediatrics, in which case, the emphasis by necessity may be on cough etiquette900.
Physical proximity of <3 feet has been associated with an increased risk for
transmission of infections via the droplet route (e.g., N. meningitidis103 and group A
streptococcus114 and therefore supports the practice of distancing infected persons from
others who are not infected. The effectiveness of good hygiene practices, especially
hand hygiene, in preventing transmission of viruses and reducing the incidence of
respiratory infections both within and outside901-903 healthcare settings is summarized in
several reviews559, 717, 904.
III.A.1.b. Safe injection practices. The investigation of four large outbreaks of HBV and
HCV among patients in ambulatory care facilities in the United States identified a need to
define and reinforce safe injection practices453. The four outbreaks occurred in a private
medical practice, a pain clinic, an endoscopy clinic, and a hematology/oncology clinic. The
primary breaches in infection control practice that contributed to these outbreaks were
1. reinsertion of used needles into a multiple-dose vial or solution container (e.g., saline
bag) and
2. use of a single needle/syringe to administer intravenous medication to multiple
patients.
In one of these outbreaks, preparation of medications in the same workspace where
used needle/syringes were dismantled also may have been a contributing factor. These
and other outbreaks of viral hepatitis could have been prevented by adherence to basic
principles of aseptic technique for the preparation and administration of parenteral
medications 453, 454. These include the use of a sterile, single-use, disposable needle
and syringe for each injection given and prevention of contamination of injection
equipment and medication. Whenever possible, use of single-dose vials is preferred
Outbreaks related to unsafe injection practices indicate that some healthcare personnel
are unaware of, do not understand, or do not adhere to basic principles of infection
control and aseptic technique. A survey of US healthcare workers who provide
medication through injection found that 1% to 3% reused the same needle and/or syringe
on multiple patients905. Among the deficiencies identified in recent outbreaks were a lack
of oversight of personnel and failure to follow-up on reported breaches in infection control
practices in ambulatory settings. Therefore, to ensure that all healthcare workers
understand and adhere to recommended practices, principles of infection control and
aseptic technique need to be reinforced in training programs and incorporated into
institutional polices that are monitored for adherence454.
with infection control personnel is recommended to assess the various risks associated
with other patient placement options (e.g., cohorting, keeping the patient with an
existing roommate). Spatial separation of ≥3 feet and drawing the curtain between
patient beds is especially important for patients in multi-bed rooms with infections
transmitted by the droplet route. Healthcare personnel wear a mask (a respirator is not
necessary) for close contact with infectious patient; the mask is generally donned upon
room entry. Patients on Droplet Precautions who must be transported outside of the
room should wear a mask if tolerated and follow Respiratory Hygiene/Cough Etiquette.
The duration of Contact Precautions for patients who are colonized or infected with
MDROs remains undefined. MRSA is the only MDRO for which effective decolonization
regimens are available867. However, carriers of MRSA who have negative nasal cultures
after a course of systemic or topical therapy may resume shedding MRSA in the weeks
that follow therapy934, 935. Although early guidelines for VRE suggested discontinuation
of Contact Precautions after three stool cultures obtained at weekly intervals proved
negative740, subsequent experiences have indicated that such screening may fail to
detect colonization that can persist for >1 year27, 936-938. Likewise, available data indicate
that colonization with VRE, MRSA939, and possibly MDR-GNB, can persist for many
months, especially in the presence of severe underlying disease, invasive devices, and
recurrent courses of antimicrobial agents.
It may be prudent to assume that MDRO carriers are colonized permanently and
manage them accordingly. Alternatively, an interval free of hospitalizations,
antimicrobial therapy, and invasive devices (e.g., 6 or 12 months) before reculturing
patients to document clearance of carriage may be used. Determination of the best
strategy awaits the results of additional studies. See the 2006 HICPAC/CDC MDRO
guideline 927 for discussion of possible criteria to discontinue Contact Precautions for
patients colonized or infected with MDROs.
III.E. Application of Transmission-Based Precautions in Ambulatory and Home
Care Settings Although Transmission-Based Precautions generally apply in all
healthcare settings, exceptions exist. For example, in home care, AIIRs are not
The latter is based on molecular typing studies that have found indistinguishable strains
of Aspergillus terreus in patients with hematologic malignancies and in potted plants in
the vicinity of the patients942-944. The desired quality of air may be achieved without
incurring the inconvenience or expense of laminar airflow15, 157. To prevent inhalation of
fungal spores during periods when construction, renovation, or other dust-generating
activities that may be ongoing in and around the health-care facility, it has been advised
that severely immunocompromised patients wear a high-efficiency respiratory-protection
device (e.g., an N95 respirator) when they leave the Protective Environment11, 14, 945).
The use of masks or respirators by HSCT patients when they are outside of the
Protective Environment for prevention of environmental fungal infections in the absence
of construction has not been evaluated. A Protective Environment does not include the
use of barrier precautions beyond those indicated for Standard and Transmission-
Based Precautions. No published reports support the benefit of placing solid organ
transplants or other immunocompromised patients in a Protective Environment.
I. Administrative Responsibilities
Healthcare organization administrators should ensure the implementation of
recommendations in this section.
I.A. Incorporate preventing transmission of infectious agents into the objectives of the
organization’s patient and occupational safety programs543-546, 561, 620, 626, 946.
Category IB/IC
I.B. Make preventing transmission of infectious agents a priority for the healthcare
organization. Provide administrative support, including fiscal and human
resources for maintaining infection control programs434, 548, 549, 559, 561, 566, 662, 552,
562-564, 946. Category IB/IC
I.B.1. Assure that individuals with training in infection control are employed by or
are available by contract to all healthcare facilities so that the infection
control program is managed by one or more qualified individuals552, 566 316, 575,
947 573, 576, 946. Category IB/IC
I.B.7. Provide human and fiscal resources to meet occupational health needs
related to infection control (e.g., healthcare personnel immunization, post-
exposure evaluation and care, evaluation and management of healthcare
personnel with communicable infections739 12, 17, 879-881, 955, 134, 690. Category
IB/IC
I.B.8. In all areas where healthcare is delivered, provide supplies and equipment
necessary for the consistent observance of Standard Precautions, including
hand hygiene products and personal protective equipment (e.g., gloves,
gowns, face and eye protection)739, 559, 946. Category IB/IC
I.B.9. Develop and implement policies and procedures to ensure that reusable
patient care equipment is cleaned and reprocessed appropriately before use
on another patient11, 956, 957, 958, 959, 836, 87, 11, 960, 961. Category IA/IC
I.C. Develop and implement processes to ensure oversight of infection control
activities appropriate to the healthcare setting and assign responsibility for
oversight of infection control activities to an individual or group within the
healthcare organization that is knowledgeable about infection control 434, 549, 566.
Category II
I.D. Develop and implement systems for early detection and management (e.g., use
of appropriate infection control measures, including isolation precautions, PPE)
of potentially infectious persons at initial points of patient encounter in outpatient
settings (e.g., triage areas, emergency departments, outpatient clinics, physician
offices) and at the time of admission to hospitals and long-term care facilities
(LTCF)9, 122, 134, 253, 827. Category IB
I.E. Develop and implement policies and procedures to limit patient visitation by persons
with signs or symptoms of a communicable infection. Screen visitors to high-risk
patient care areas (e.g., oncology units, hematopoietic stem cell transplant [HSCT]
units, intensive care units, other severely immunocompromised patients) for
possible infection43 24, 41, 962, 963.Category IB
I.F. Identify performance indicators of the effectiveness of organization-specific
measures to prevent transmission of infectious agents (Standard and
Transmission-Based Precautions), establish processes to monitor adherence to
those performance measures and provide feedback to staff members704 739 705 708
666, 964 667 668 555. Category IB
II.B. Provide instructional materials for patients and visitors on recommended hand
hygiene and Respiratory Hygiene/Cough Etiquette practices and the application
of Transmission-Based Precautions9, 709, 710, 963. Category II
III. Surveillance
III.A. Monitor the incidence of epidemiologically-important organisms and targeted
HAIs that have substantial impact on outcome and for which effective preventive
interventions are available; use information collected through surveillance of
high-risk populations, procedures, devices and highly transmissible infectious
agents to detect transmission of infectious agents in the healthcare facility566, 671,
672, 675, 687, 919, 967, 968 673 969 970. Category IA
III.B. Apply the following epidemiologic principles of infection surveillance671, 967 673 969
663 664. Category IB
IV.A.5. Do not wear artificial fingernails or extenders if duties include direct contact
with patients at high risk for infection and associated adverse outcomes
(e.g., those in ICUs or operating rooms) 30, 31, 559, 722-724. Category IA
IV.A.5.a. Develop an organizational policy on the wearing of non-natural
nails by healthcare personnel who have direct contact with patients
outside of the groups specified above 984. Category II
IV.B.1.c. Before leaving the patient’s room or cubicle, remove and discard
PPE 18, 739. Category IB/IC
IV.B.2. Gloves
IV.B.2.a. Wear gloves when it can be reasonably anticipated that contact
with blood or other potentially infectious materials, mucous
membranes, nonintact skin, or potentially contaminated intact skin
(e.g., of a patient incontinent of stool or urine) could occur 18, 728, 739,
741, 780, 985. Category IB/IC
IV.B.2.b. Wear gloves with fit and durability appropriate to the task 559, 731, 732,
739, 986, 987. Category IB
IV.E.3. Wear PPE (e.g., gloves, gown), according to the level of anticipated
contamination, when handling patient-care equipment and
instruments/devices that is visibly soiled or may have been in contact with
blood or body fluids18, 739, 975. Category IB/IC
pathogens, including those that are in close proximity to the patient (e.g., bed
rails, over bed tables) and frequently-touched surfaces in the patient care
environment (e.g., door knobs, surfaces in and surrounding toilets in
patients’ rooms) on a more frequent schedule compared to that for other
surfaces (e.g., horizontal surfaces in waiting rooms)11 73, 740, 746, 993, 994 72, 800,
835 995. Category IB
IV.F.3. Use EPA-registered disinfectants that have microbiocidal (i.e., killing) activity
against the pathogens most likely to contaminate the patient-care
environment. Use in accordance with manufacturer’s instructions842-844, 956,
996. Category IB/IC
V. Transmission-Based Precautions
V.A. General Principles
V.A.1. In addition to Standard Precautions, use Transmission-Based Precautions
for patients with documented or suspected infection or colonization with
highly transmissible or epidemiologically-important pathogens for which
medical equipment, bed rails)72, 73, 88, 837. Don gloves upon entry into
the room or cubicle. Category IB
V.B.3.b. Gowns
V.B.3.b.i. Wear a gown whenever anticipating that clothing will
have direct contact with the patient or potentially
contaminated environmental surfaces or equipment in
close proximity to the patient. Don gown upon entry into
the room or cubicle. Remove gown and observe hand
hygiene before leaving the patient-care environment24, 88,
134, 745, 837. Category IB
V.B.3.b.ii. After gown removal, ensure that clothing and skin do not
contact potentially contaminated environmental surfaces
that could result in possible transfer of microorganism to
other patients or environmental surfaces72, 73. Category II
V.B.4. Patient transport
V.B.4.a. In acute care hospitals and long-term care and other residential
settings, limit transport and movement of patients outside of the
room to medically-necessary purposes. Category II
V.B.4.b. When transport or movement in any healthcare setting is necessary,
ensure that infected or colonized areas of the patient’s body are
contained and covered. Category II
V.B.4.c. Remove and dispose of contaminated PPE and perform hand
hygiene prior to transporting patients on Contact Precautions.
Category II
V.B.4.d. Don clean PPE to handle the patient at the transport destination.
Category II
V.B.5. Patient-care equipment and instruments/devices
V.B.5.a. Handle patient-care equipment and instruments/devices according
to Standard Precautions739, 836. Category IB/IC
V.B.5.b. In acute care hospitals and long-term care and other residential
settings, use disposable noncritical patient-care equipment (e.g.,
blood pressure cuffs) or implement patient-dedicated use of such
equipment. If common use of equipment for multiple patients is
unavoidable, clean and disinfect such equipment before use on
another patient 24, 88, 796, 836, 837, 854, 1016. Category IB
V.B.5.c. In home care settings
V.B.5.c.i. Limit the amount of non-disposable patient-care
equipment brought into the home of patients on Contact
Precautions. Whenever possible, leave patient-care
equipment in the home until discharge from home care
services. Category II
V.B.5.c.ii. If noncritical patient-care equipment (e.g., stethoscope)
cannot remain in the home, clean and disinfect items
before taking them from the home using a low- to
intermediate-level disinfectant. Alternatively, place
contaminated reusable items in a plastic bag for
transport and subsequent cleaning and disinfection.
Category II
V.B.5.d. In ambulatory settings, place contaminated reusable noncritical
patient-care equipment in a plastic bag for transport to a soiled
utility area for reprocessing. Category II
V.B.6. Environmental measures
Ensure that rooms of patients on Contact Precautions are prioritized for
frequent cleaning and disinfection (e.g., at least daily) with a focus on
frequently-touched surfaces (e.g., bed rails, overbed table, bedside
commode, lavatory surfaces in patient bathrooms, doorknobs) and
equipment in the immediate vicinity of the patient11, 24, 88, 746, 837. Category IB
V.B.7. Discontinue Contact Precautions after signs and symptoms of the infection
have resolved or according to pathogen-specific recommendations in
Appendix A. Category IB
VI.C. For patients who require a Protective Environment, implement the following (see
Table 5)11, 15
Edit [February 2017]: An § indicates text that was edited for clarity. The edit does
not constitute change to the intent of the recommendations.
VI.F.4.c. If an anteroom is not available, place the patient in an AIIR and use
portable, industrial-grade HEPA filters in the room to enhance
filtration of spores1042. Category II
Appendix A:
Available from: https://www.cdc.gov/infectioncontrol/guidelines/isolation/
Preamble The mode(s) and risk of transmission for each specific disease agent included in
Appendix A were reviewed. Principle sources consulted for the development of disease-specific
recommendations for Appendix A included infectious disease manuals and textbooks [833, 1043,
1044]. The published literature was searched for evidence of person-to-person transmission in
healthcare and non-healthcare settings with a focus on reported outbreaks that would assist in
developing recommendations for all settings where healthcare is delivered. Criteria used to assign
Transmission-Based Precautions categories follow:
• A Transmission-Based Precautions category was assigned if there was strong evidence for
person-to-person transmission via droplet, contact, or airborne routes in healthcare or non-
healthcare settings and/or if patient factors (e.g., diapered infants, diarrhea, draining wounds)
increased the risk of transmission
• Transmission-Based Precautions category assignments reflect the predominant mode(s) of
transmission
• If there was no evidence for person-to-person transmission by droplet, contact or airborne
routes, Standard Precautions were assigned
• If there was a low risk for person-to-person transmission and no evidence of healthcare-
associated transmission, Standard Precautions were assigned
• Standard Precautions were assigned for bloodborne pathogens (e.g., hepatitis B and C viruses,
human immunodeficiency virus) as per CDC recommendations for Universal Precautions
issued in 1988 [780]. Subsequent experience has confirmed the efficacy of Standard
Precautions to prevent exposure to infected blood and body fluid [778, 779, 866].
Additional information relevant to use of precautions was added in the comments column to assist
the caregiver in decision-making. Citations were added as needed to support a change in or
provide additional evidence for recommendations for a specific disease and for new infectious
agents (e.g., SARS-CoV, avian influenza) that have been added to Appendix A. The reader may
refer to more detailed discussion concerning modes of transmission and emerging pathogens in
the background text and for MDRO control in Appendix B (Management of Multidrug-Resistant
Organisms in Healthcare Settings (https://www.cdc.gov/infectioncontrol/guidelines/mdro/ accessed
May 2016)).
Type of Duration of
Infection/Condition Precaution Precaution Precautions/Comments
Actinomycosis Standard n/a Not transmitted from person to person.
Adenovirus infection (see n/a n/a n/a
agent-specific guidance under
Gastroenteritis, Conjunctivitis,
Pneumonia)
Amebiasis Standard n/a Person-to-person transmission is rare. Transmission in
settings for the mentally challenged and in a family group has
been reported [1045]. Use care when handling diapered
infants and mentally challenged persons [1046].
Anthrax Standard n/a Infected patients do not generally pose a transmission risk.
Anthrax Standard n/a Transmission through non-intact skin contact with draining
Cutaneous lesions possible, therefore use Contact Precautions if large
amount of uncontained drainage. Handwashing with soap
and water preferable to use of waterless alcohol-based
antiseptics since alcohol does not have sporicidal activity
[983].
Anthrax Standard n/a Not transmitted from person to person.
Pulmonary
Anthrax n/a Until Until decontamination of environment complete [203]. Wear
Environmental: environment respirator (N95 mask or PAPRs), protective clothing;
aerosolizable spore- completely decontaminate persons with powder on them (Notice to
containing powder or other decontaminated Readers: Occupational Health Guidelines for Remediation
substance Workers at Bacillus anthracis-Contaminated Sites — United
States, 2001–2002
(https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5135a3.h
tm accessed September 2018).)
Hand hygiene: Handwashing for 30-60 seconds with soap
and water or 2% chlorhexidine gluconate after spore contact
(alcohol handrubs inactive against spores [983].)
Postexposure prophylaxis following environmental exposure:
60 days of antimicrobials (either doxycycline, ciprofloxacin, or
levofloxacin) and Postexposure vaccine under IND.
Antibiotic-associated colitis (see n/a n/a n/a
Clostridium difficile)
Arthropod-borne Standard n/a Not transmitted from person to person except rarely by
• viral encephalitides (eastern, transfusion, and for West Nile virus by organ transplant,
western, Venezuelan equine breastmilk or transplacentally [530, 1047]. Install screens in
encephalomyelitis; St Louis, windows and doors in endemic areas.
California encephalitis; West
Use DEET-containing mosquito repellants and clothing to
Nile Virus) and
cover extremities.
• viral fevers (dengue, yellow
fever, Colorado tick fever)
Ascariasis Standard n/a Not transmitted from person to person.
Aspergillosis Standard n/a Contact Precautions and Airborne if massive soft tissue
infection with copious drainage and repeated irrigations
required [154].
Avian influenza (see Influenza, n/a n/a n/a
Avian below)
Type of Duration of
Infection/Condition Precaution Precaution Precautions/Comments
Babesiosis Standard n/a Not transmitted from person to person, except rarely by
transfusion.
Blastomycosis, North American, Standard n/a Not transmitted from person to person.
cutaneous or pulmonary
Botulism Standard n/a Not transmitted from person to person.
Bronchiolitis (see Respiratory Contact + Duration of Use mask according to Standard Precautions.
Infections in infants and young Standard illness
children)
Brucellosis (undulant, Malta, Standard n/a Not transmitted from person to person, except rarely via
Mediterranean fever) banked spermatozoa and sexual contact [1048, 1049].
Provide antimicrobial prophylaxis following laboratory
exposure [1050].
Campylobacter gastroenteritis n/a n/a n/a
(see Gastroenteritis)
Candidiasis, all forms including Standard n/a n/a
mucocutaneous
Cat-scratch fever (benign Standard n/a Not transmitted from person to person.
inoculation lymphoreticulosis)
Cellulitis Standard n/a n/a
Chancroid (soft chancre) (H. Standard n/a Transmitted sexually from person to person.
ducreyi)
Chickenpox (see Varicella) n/a n/a n/a
Chlamydia trachomatis Standard n/a n/a
Conjunctivitis
Chlamydia trachomatis Standard n/a n/a
Genital (lymphogranuloma
venereum)
Chlamydia trachomatis Standard n/a n/a
Pneumonia (infants ≤3
mos. of age)
Chlamydia pneumoniae Standard n/a Outbreaks in institutionalized populations reported, rarely
[1051, 1052].
Cholera (see Gastroenteritis) n/a n/a n/a
Closed-cavity infection Standard n/a Contact Precautions if there is copious uncontained
Open drain in place; limited drainage.
or minor drainage
Closed-cavity infection Standard n/a n/a
No drain or closed drainage
system in place
Clostridium botulinum Standard n/a Not transmitted from person to person.
Clostridium difficile (see Contact + Duration of n/a
Gastroenteritis, C. difficile) Standard illness
Clostridium perfringens Standard n/a Not transmitted from person to person.
Food poisoning
Clostridium perfringens Standard n/a Transmission from person to person rare; 1 outbreak in a
Gas gangrene surgical setting reported [1053]. Use Contact Precautions if
wound drainage is extensive.
Type of Duration of
Infection/Condition Precaution Precaution Precautions/Comments
Coccidioidomycosis (valley Standard n/a Not transmitted from person to person except under
fever) extraordinary circumstances, because the infectious
Draining lesions arthroconidial form of Coccidioides immitis is not produced in
humans [1054].
Coccidioidomycosis (valley Standard n/a Not transmitted from person to person except under
fever) extraordinary circumstances, (e.g., inhalation of aerosolized
Pneumonia tissue phase endospores during necropsy, transplantation of
infected lung) because the infectious arthroconidial form of
Coccidioides immitis is not produced in humans [1054, 1055].
Colorado tick fever Standard n/a Not transmitted from person to person.
Congenital rubella Contact + Until 1 yr of age Standard Precautions if nasopharyngeal and urine cultures
Standard repeatedly negative after 3 mos. of age.
Conjunctivitis Standard n/a n/a
Acute bacterial
Conjunctivitis Standard n/a n/a
Acute bacterial
Chlamydia
Conjunctivitis Standard n/a n/a
Acute bacterial
Gonococcal
Conjunctivitis Contact + Duration of Adenovirus most common; enterovirus 70 [1056], Coxsackie
Acute viral (acute Standard illness virus A24 [1057] also associated with community outbreaks.
hemorrhagic) Highly contagious; outbreaks in eye clinics, pediatric and
neonatal settings, institutional settings reported. Eye clinics
should follow Standard Precautions when handling patients
with conjunctivitis. Routine use of infection control measures
in the handling of instruments and equipment will prevent the
occurrence of outbreaks in this and other settings. [460, 461,
814, 1058-1060].
Corona virus associated with n/a n/a n/a
SARS (SARS-CoV) (see
Severe Acute Respiratory
Syndrome)
Coxsackie virus disease (see n/a n/a n/a
enteroviral infection)
Creutzfeldt-Jakob disease Standard n/a Use disposable instruments or special
(CJD, vCJD) sterilization/disinfection for surfaces, objects contaminated
with neural tissue if CJD or vCJD suspected and has not
been R/O; No special burial procedures. [1061]
Croup (see Respiratory n/a n/a n/a
Infections in infants and young
children)
Crimean-Congo Fever (see Standard n/a n/a
Viral Hemorrhagic Fever)
Cryptococcosis Standard n/a Not transmitted from person to person, except rarely via
tissue and corneal transplant. [1062, 1063]
Cryptosporidiosis (see n/a n/a n/a
Gastroenteritis)
Cysticercosis Standard n/a Not transmitted from person to person.
Type of Duration of
Infection/Condition Precaution Precaution Precautions/Comments
Cytomegalovirus infection, Standard n/a No additional precautions for pregnant HCWs.
including in neonates and
immunosuppressed patients
Decubitus ulcer (see Pressure n/a n/a n/a
Ulcer)
Dengue fever Standard n/a Not transmitted from person to person.
Diarrhea, acute-infective n/a n/a n/a
etiology suspected (see
Gastroenteritis)
Diphtheria Contact + Until off Until 2 cultures taken 24 hours apart negative.
Cutaneous Standard antimicrobial
treatment and
culture-negative
Diphtheria Droplet + Until off Until 2 cultures taken 24 hours apart negative.
Pharyngeal Standard antimicrobial
treatment and
culture-negative
Ebola virus (see Viral n/a n/a
Hemorrhagic Fevers) Ebola Virus Disease for Healthcare Workers [2014]:
Updated recommendations for healthcare workers can be
found at Ebola: for Clinicians
(https://www.cdc.gov/vhf/ebola/clinicians/index.html
accessed September 2018).
Echinococcosis (hydatidosis) Standard n/a Not transmitted from person to person.
Echovirus (see Enteroviral n/a n/a n/a
Infection)
Encephalitis or n/a n/a n/a
encephalomyelitis (see specific
etiologic agents)
Endometritis (endomyometritis) Standard n/a n/a
Enterobiasis (pinworm disease, Standard n/a n/a
oxyuriasis)
Enterococcus species (see n/a n/a n/a
Multidrug-Resistant Organisms
if epidemiologically significant
or vancomycin-resistant)
Enterocolitis, C. difficile (see n/a n/a n/a
Gastroenteritis, C. difficile)
Enteroviral infections (i.e., Standard n/a Use Contact Precautions for diapered or incontinent children
Group A and B Coxsackie for duration of illness and to control institutional outbreaks.
viruses and Echo viruses)
(excludes polio virus)
Epiglottitis, due to Haemophilus Droplet + Until 24 hours See specific disease agents for epiglottitis due to other
influenzae type b Standard after initiation of etiologies.
effective therapy
Epstein-Barr virus infection, Standard n/a n/a
including infectious
mononucleosis
Erythema infectiosum (also see n/a n/a n/a
Parvovirus B19)
Type of Duration of
Infection/Condition Precaution Precaution Precautions/Comments
Escherichia coli gastroenteritis n/a n/a n/a
(see gastroenteritis)
Food poisoning Standard n/a Not transmitted from person to person.
Botulism
Food poisoning Standard n/a Not transmitted from person to person.
C. perfringens or welchii
Food poisoning Standard n/a Not transmitted from person to person.
Staphylococcal
Furunculosis, staphylococcal Standard n/a Contact if drainage not controlled. Follow institutional policies
if MRSA.
Furunculosis, staphylococcal Contact + Duration of n/a
Infants and young children Standard illness (with
wound lesions,
until wounds
stop draining)
Gangrene (gas gangrene) Standard n/a Not transmitted from person to person.
Gastroenteritis Standard n/a Use Contact Precautions for diapered or incontinent persons
for the duration of illness or to control institutional outbreaks
for gastroenteritis caused by all of the agents below.
Gastroenteritis Standard n/a Use Contact Precautions for diapered or incontinent persons
Adenovirus for the duration of illness or to control institutional outbreaks.
Gastroenteritis Standard n/a Use Contact Precautions for diapered or incontinent persons
Campylobacter species for the duration of illness or to control institutional outbreaks.
Gastroenteritis Standard n/a Use Contact Precautions for diapered or incontinent persons
Cholera (Vibrio cholerae) for the duration of illness or to control institutional outbreaks.
Gastroenteritis Contact + Duration of Discontinue antibiotics if appropriate. Do not share electronic
C. difficile Standard illness thermometers; [853, 854] ensure consistent environmental
cleaning and disinfection. Hypochlorite solutions may be
required for cleaning if transmission continues [847].
Handwashing with soap and water preferred because of the
absence of sporicidal activity of alcohol in waterless
antiseptic handrubs [983].
Gastroenteritis Standard n/a Use Contact Precautions for diapered or incontinent persons
Cryptosporidium species for the duration of illness or to control institutional outbreaks.
Gastroenteritis Standard n/a Use Contact Precautions for diapered or incontinent persons
E. coli for the duration of illness or to control institutional outbreaks.
Enteropathogenic O157:H7
and other Shiga toxin-producing
strains
Gastroenteritis Standard n/a Use Contact Precautions for diapered or incontinent persons
E. coli for the duration of illness or to control institutional outbreaks.
Other species
Gastroenteritis Standard n/a Use Contact Precautions for diapered or incontinent persons
Giardia lamblia for the duration of illness or to control institutional outbreaks.
Type of Duration of
Infection/Condition Precaution Precaution Precautions/Comments
Gastroenteritis Standard n/a Use Contact Precautions for a minimum of 48 hours after the
Noroviruses resolution of symptoms or to control institutional outbreaks.
Persons who clean areas heavily contaminated with feces or
vomitus may benefit from wearing masks since virus can be
aerosolized from these body substances [142, 147 148];
ensure consistent environmental cleaning and disinfection
with focus on restrooms even when apparently unsoiled [273,
1064]. Hypochlorite solutions may be required when there is
continued transmission [290-292]. Alcohol is less active, but
there is no evidence that alcohol antiseptic handrubs are not
effective for hand decontamination [294].
Cohorting of affected patients to separate airspaces and
toilet facilities may help interrupt transmission during
outbreaks.
Gastroenteritis Contact + Duration of Ensure consistent environmental cleaning and disinfection
Rotavirus Standard illness and frequent removal of soiled diapers. Prolonged shedding
may occur in both immunocompetent and
immunocompromised children and the elderly [932, 933].
Gastroenteritis Standard n/a Use Contact Precautions for diapered or incontinent persons
Salmonella species for the duration of illness or to control institutional outbreaks.
(including S. typhi)
Gastroenteritis Standard n/a Use Contact Precautions for diapered or incontinent persons
Shigella species (Bacillary for the duration of illness or to control institutional outbreaks.
dysentery)
Gastroenteritis Standard n/a Use Contact Precautions for diapered or incontinent persons
Vibrio parahaemolyticus for the duration of illness or to control institutional outbreaks.
Gastroenteritis Standard n/a Use Contact Precautions for diapered or incontinent persons
Viral (if not covered for the duration of illness or to control institutional outbreaks.
elsewhere)
Gastroenteritis Standard n/a Use Contact Precautions for diapered or incontinent persons
Yersinia enterocolitica for the duration of illness or to control institutional outbreaks.
German measles (see Rubella; n/a n/a n/a
see Congenital Rubella)
Giardiasis (see Gastroenteritis) n/a n/a n/a
Gonococcal ophthalmia Standard n/a n/a
neonatorum (gonorrheal
ophthalmia, acute conjunctivitis
of newborn)
Gonorrhea Standard n/a n/a
Granuloma inguinale Standard n/a n/a
(Donovanosis, granuloma
venereum)
Guillain-Barré syndrome Standard n/a Not an infectious condition.
Haemophilus influenzae (see n/a n/a n/a
disease-specific
recommendations)
Hand, foot, and mouth disease n/a n/a n/a
(see Enteroviral Infection)
Hansen’s Disease (see n/a n/a n/a
Leprosy)
Hantavirus pulmonary Standard n/a Not transmitted from person to person.
syndrome
Type of Duration of
Infection/Condition Precaution Precaution Precautions/Comments
Helicobacter pylori Standard n/a n/a
Hepatitis, viral Standard n/a Provide hepatitis A vaccine postexposure as recommended.
Type A [1065]
Hepatitis, viral Contact + n/a Maintain Contact Precautions in infants and children <3
Type A-Diapered or Standard years of age for duration of hospitalization; for children 3-14
incontinent patients yrs. of age for 2 weeks after onset of symptoms; >14 yrs. of
age for 1 week after onset of symptoms [833, 1066, 1067].
Hepatitis, viral Standard n/a See specific recommendations for care of patients in
Type B-HBsAg positive; hemodialysis centers. [778]
acute or chronic
Hepatitis, viral Standard n/a See specific recommendations for care of patients in
Type C and other hemodialysis centers. [778]
unspecified non-A, non-B
Hepatitis, viral Standard n/a n/a
Type D (seen only with
hepatitis B)
Hepatitis, viral Standard n/a Use Contact Precautions for diapered or incontinent
Type E individuals for the duration of illness. [1068]
Hepatitis, viral Standard n/a n/a
Type G
Herpangina (see Enteroviral n/a n/a n/a
Infection)
Hookworm Standard n/a n/a
Herpes simplex (Herpesvirus Standard n/a n/a
hominis)
Encephalitis
Herpes simplex (Herpesvirus Contact + Until lesions dry n/a
hominis) Standard and crusted
Mucocutaneous,
disseminated or primary,
severe
Herpes simplex (Herpesvirus Standard n/a n/a
hominis)
Mucocutaneous, recurrent
(skin, oral, genital)
Herpes simplex (Herpesvirus Contact + Until lesions dry Also, for asymptomatic, exposed infants delivered vaginally
hominis) Standard and crusted or by C-section and if mother has active infection and
Neonatal membranes have been ruptured for more than 4 to 6 hours
until infant surface cultures obtained at 24-36 hours of age
negative after 48 hours incubation. [1069, 1070]
Herpes zoster (varicella-zoster) Airborne + Duration of Susceptible HCWs should not enter room if immune
(shingles) Contact + illness caregivers are available; no recommendation for protection of
Disseminated disease in Standard immune HCWs; no recommendation for type of protection
any patient (i.e. surgical mask or respirator) for susceptible HCWs.
Localized disease in
immunocompromised
patient until disseminated
infection ruled out
Type of Duration of
Infection/Condition Precaution Precaution Precautions/Comments
Herpes zoster (varicella-zoster) Standard Until lesions dry Susceptible HCWs should not provide direct patient care
(shingles) and crusted when other immune caregivers are available.
Localized in patient with
intact immune system with
lesions that can be
contained/covered
Histoplasmosis Standard n/a Not transmitted from person to person.
Human immunodeficiency virus Standard n/a Postexposure chemoprophylaxis for some blood exposures
(HIV) [866].
Human metapneumovirus Contact + Duration of HAI reported [1071], but route of transmission not
Standard illness established [823]. Assumed to be Contact transmission as for
RSV since the viruses are closely related and have similar
clinical manifestations and epidemiology. Wear masks
according to Standard Precautions.
Impetigo Contact + Until 24 hours n/a
Standard after initiation of
effective therapy
Infectious mononucleosis Standard n/a n/a
Influenza n/a n/a See Prevention Strategies for Seasonal Influenza in
Human (seasonal Healthcare Settings
influenza) (https://www.cdc.gov/flu/professionals/infectioncontrol/health
caresettings.htm accessed September 2018). [Current
version of this document may differ from original.] for current
seasonal influenza guidance.
Influenza n/a n/a See [This link is no longer active:
Avian (e.g., H5N1, H7, H9 www.cdc.gov/flu/avian/professional/infect-control.htm. Similar
strains) information may be found at Interim Guidance for Infection
Control Within Healthcare Settings When Caring for
Confirmed Cases, Probable Cases, and Cases Under
Investigation for Infection with Novel Influenza A Viruses
Associated with Severe Disease
(https://www.cdc.gov/flu/avianflu/novel-flu-infection-
control.htm accessed September 2018)] for current avian
influenza guidance.
Influenza Droplet + n/a See [This link is no longer active:
Pandemic Influenza (also a Standard http://www.pandemicflu.gov. Similar information may be
human influenza virus) found at Interim Guidance for Infection Control Within
Healthcare Settings When Caring for Confirmed Cases,
Probable Cases, and Cases Under Investigation for Infection
with Novel Influenza A Viruses Associated with Severe
Disease (https://www.cdc.gov/flu/avianflu/novel-flu-infection-
control.htm accessed September 2018)] for current pandemic
influenza guidance.
Kawasaki syndrome Standard n/a Not an infectious condition.
Lassa fever (see Viral n/a n/a n/a
Hemorrhagic Fevers)
Legionnaires’ disease Standard n/a Not transmitted from person to person.
Leprosy Standard n/a n/a
Leptospirosis Standard n/a Not transmitted from person to person.
Lice Contact + Until 24 hours See [This link is no longer active:
Head (pediculosis) Standard after initiation of https://www.cdc.gov/ncidod/dpd/parasites/lice/default.htm.
effective therapy Similar information may be found at CDC’s Parasites – Lice
(https://www.cdc.gov/parasites/lice/index.html accessed
September 2018).]
Type of Duration of
Infection/Condition Precaution Precaution Precautions/Comments
Lice Standard n/a Transmitted person-to-person through infested clothing.
Body Wear gown and gloves when removing clothing; bag and
wash clothes according to CDC guidance Parasites – Lice
(https://www.cdc.gov/parasites/lice/index.html accessed
September 2018).
Lice Standard n/a Transmitted person-to-person through sexual contact. See
Pubic CDC’s Parasites – Lice
(https://www.cdc.gov/parasites/lice/index.html accessed
September 2018).
Listeriosis (Listeria Standard n/a Person-to-person transmission rare; cross-transmission in
monocytogenes) neonatal settings reported. [1072-1075]
Lyme disease Standard n/a Not transmitted from person to person.
Lymphocytic choriomeningitis Standard n/a Not transmitted from person to person.
Lymphogranuloma venereum Standard n/a n/a
Malaria Standard n/a Not transmitted from person to person, except through
transfusion rarely and through a failure to follow Standard
Precautions during patient care. [1076-1079] Install screens
in windows and doors in endemic areas. Use DEET-
containing mosquito repellants and clothing to cover
extremities.
Marburg virus disease (see n/a n/a n/a
Viral Hemorrhagic Fevers)
Measles (rubeola) Airborne + 4 days after
Standard onset of rash; Measles Update [November 2011]: Updated
duration of recommendations can be found at Immunization of
illness in Healthcare Personnel: Recommendations of the ACIP
immune (https://www.cdc.gov/mmwr/pdf/rr/rr6007.pdf accessed
compromised September 2018).
Susceptible HCWs should not enter room if immune care
providers are available; no recommendation for face
protection for immune HCW; no recommendation for type of
face protection for susceptible HCWs, i.e., mask or respirator
[1027, 1028]. For exposed susceptibles, postexposure
vaccine within 72 hours or immune globulin within 6 days
when available [17, 1032, 1034]. Place exposed susceptible
patients on Airborne Precautions and exclude susceptible
healthcare personnel.
Melioidosis, all forms Standard n/a Not transmitted from person to person.
Meningitis Standard n/a Contact for infants and young children.
Aseptic (nonbacterial or
viral; also see enteroviral
infections)
Meningitis Standard n/a n/a
Bacterial, gram-negative
enteric, in neonates
Meningitis Standard n/a n/a
Fungal
Meningitis Droplet + Until 24 hours n/a
Haemophilus influenzae, Standard after initiation of
type b known or suspected effective therapy
Meningitis Standard n/a n/a
Listeria monocytogenes
(See Listeriosis)
Type of Duration of
Infection/Condition Precaution Precaution Precautions/Comments
Meningitis Droplet + Until 24 hours See Meningococcal Disease below.
Neisseria meningitidis Standard after initiation of
(meningococcal) known or effective therapy
suspected
Meningitis Standard n/a n/a
Streptococcus pneumoniae
Meningitis Standard n/a Concurrent, active pulmonary disease or draining cutaneous
M. tuberculosis lesions may necessitate addition of Contact and/or Airborne.
For children, Airborne Precautions until active tuberculosis
ruled out in visiting family members (see Tuberculosis
below). [42]
Meningitis Standard n/a n/a
Other diagnosed bacterial
Meningococcal disease: sepsis, Droplet + Until 24 hours Postexposure chemoprophylaxis for household contacts,
pneumonia, Meningitis Standard after initiation of HCWs exposed to respiratory secretions; postexposure
effective therapy vaccine only to control outbreaks. [15, 17]
Molluscum contagiosum Standard n/a n/a
Monkeypox Airborne + Airborne - Until See CDC’s Monkeypox website
Contact + monkeypox (https://www.cdc.gov/poxvirus/monkeypox/ accessed
Standard confirmed and September 2018). [Current version of this document may
smallpox differ from original.] for most current recommendations.
excluded Transmission in hospital settings unlikely [269]. Pre- and
Contact - Until postexposure smallpox vaccine recommended for exposed
lesions crusted HCWs.
Mucormycosis Standard n/a n/a
Multidrug-resistant organisms Contact + n/a MDROs judged by the infection control program, based on
(MDROs), infection or Standard local, state, regional, or national recommendations, to be of
colonization (e.g., MRSA, VRE, clinical and epidemiologic significance. Contact Precautions
VISA/VRSA, ESBLs, resistant recommended in settings with evidence of ongoing
S. pneumoniae) transmission, acute care settings with increased risk for
transmission or wounds that cannot be contained by
dressings. See recommendations for management options in
Management of Multidrug-Resistant Organisms In Healthcare
Settings, 2006 [870]. Contact state health department for
guidance regarding new or emerging MDRO.
Mumps (infectious parotitis) Droplet + Until 5 days after
Standard the onset of Mumps Update [October 2017]: The Healthcare
swelling Infection Control Practices Advisory Committee (HICPAC)
voted to change the recommendation of isolation for persons
with mumps from 9 days to 5 days based on a 2008 MMWR
report.
(https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5740a3.h
tm accessed September 2018).
After onset of swelling; susceptible HCWs should not provide
care if immune caregivers are available.
The below note has been superseded by the above
recommendation update
Note: (Recent assessment of outbreaks in healthy 18-24 year
olds has indicated that salivary viral shedding occurred early
in the course of illness and that 5 days of isolation after onset
of parotitis may be appropriate in community settings;
however the implications for healthcare personnel and high-
risk patient populations remain to be clarified.)
Type of Duration of
Infection/Condition Precaution Precaution Precautions/Comments
Mycobacteria, nontuberculosis n/a n/a Not transmitted person-to-person.
(atypical)
Mycobacteria, nontuberculosis Standard n/a
(atypical)
Pulmonary
Mycobacteria, nontuberculosis Standard n/a n/a
(atypical)
Wound
Mycoplasma pneumonia Droplet + Duration of n/a
Standard Illness
Necrotizing enterocolitis Standard n/a Contact Precautions when cases clustered temporally [1080-
1083].
Nocardiosis, draining lesions, or Standard n/a Not transmitted person-to-person.
other presentations
Norovirus (see Gastroenteritis) n/a n/a n/a
Norwalk agent Gastroenteritis n/a n/a n/a
(see Gastroenteritis)
Orf Standard n/a n/a
Parainfluenza virus infection, Contact + Duration of Viral shedding may be prolonged in immunosuppressed
respiratory in infants and young Standard illness patients [1009, 1010]. Reliability of antigen testing to
children determine when to remove patients with prolonged
hospitalizations from Contact Precautions uncertain.
Parvovirus B19 (Erythema Droplet + n/a Maintain precautions for duration of hospitalization when
infectiosum) Standard chronic disease occurs in an immunocompromised patient.
For patients with transient aplastic crisis or red-cell crisis,
maintain precautions for 7 days. Duration of precautions for
immunosuppressed patients with persistently positive PCR
not defined, but transmission has occurred [929].
Pediculosis (lice) Contact + Until 24 hours n/a
Standard after initiation of
effective therapy
after treatment
Pertussis (whooping cough) Droplet + Until 5 days after Single patient room preferred. Cohorting an option.
Standard initiation of Postexposure chemoprophylaxis for household contacts and
effective HCWs with prolonged exposure to respiratory secretions
antibiotic [863]. Recommendations for Tdap vaccine in adults under
therapy development.
Type of Duration of
Infection/Condition Precaution Precaution Precautions/Comments
Pneumonia Droplet + Duration of Outbreaks in pediatric and institutional settings reported [376,
Adenovirus Contact + illness 1084-1086]. In immunocompromised hosts, extend duration
Standard of Droplet and Contact Precautions due to prolonged
shedding of virus. [931]
Pneumonia Standard n/a n/a
Bacterial not listed
elsewhere (including gram-
negative bacterial)
Pneumonia Contact + Unknown Avoid exposure to other persons with CF; private room
B. cepacia in patients with Standard preferred. Criteria for D/C precautions not established. See
CF, including respiratory CF Foundation guideline. [20]
tract colonization
Pneumonia n/a n/a n/a
B. cepacia in patients
without CF (see Multidrug-
Resistant Organisms)
Pneumonia Standard n/a n/a
Chlamydia
Pneumonia Standard n/a n/a
Fungal
Pneumonia Standard n/a n/a
Haemophilus influenzae,
type b
Adults
Pneumonia Droplet + Until 24 hours n/a
Haemophilus influenzae, Standard after initiation of
type b effective therapy
Infants and children
Pneumonia Standard n/a n/a
Legionella spp.
Pneumonia Droplet + Until 24 hours See Meningococcal Disease above.
Meningococcal Standard after initiation of
effective therapy
Pneumonia n/a n/a n/a
Multidrug-resistant bacterial
(see Multidrug-Resistant
Organisms)
Pneumonia Droplet + Duration of n/a
Mycoplasma (primary Standard illness
atypical Pneumonia)
Pneumonia Standard n/a Use Droplet Precautions if evidence of transmission within a
Pneumococcal pneumonia patient care unit or facility. [196-198, 1087]
Pneumonia Standard n/a Avoid placement in the same room with an
Pneumocystis jiroveci immunocompromised patient.
(Pneumocystis carinii)
Pneumonia Standard n/a For MRSA, see MDROs.
Staphylococcus aureus
Pneumonia Droplet + Until 24 hours See Streptococcal Disease (group A Streptococcus) below
Streptococcus, group A Standard after initiation of Contact Precautions if skin lesions present.
Adults effective therapy
Pneumonia Droplet + Until 24 hours Contact Precautions if skin lesions present.
Streptococcus, group A Standard after initiation of
Infants and young children effective therapy
Type of Duration of
Infection/Condition Precaution Precaution Precautions/Comments
Pneumonia n/a n/a n/a
Varicella-Zoster (See
Varicella-Zoster)
Pneumonia Standard n/a n/a
Viral
Adults
Pneumonia n/a n/a n/a
Viral
Infants and young children
(see Respiratory Infectious
Disease, acute, or specific
viral agent)
Poliomyelitis Contact + Duration of n/a
Standard illness
Pressure ulcer (decubitus ulcer, Contact + Duration of Until drainage stops or can be contained by dressing.
pressure sore) infected Standard illness
Major
Pressure ulcer (decubitus ulcer, Standard n/a If dressing covers and contains drainage.
pressure sore) infected
Minor or limited
Prion disease (See Creutzfeld- n/a n/a n/a
Jacob Disease)
Psittacosis (ornithosis) Standard n/a Not transmitted from person to person.
(Chlamydia psittaci)
Q fever Standard n/a n/a
Rabies Standard n/a Person to person transmission rare; transmission via corneal,
tissue and organ transplants has been reported [539, 1088].
If patient has bitten another individual or saliva has
contaminated an open wound or mucous membrane, wash
exposed area thoroughly and administer postexposure
prophylaxis. [1089]
Rat-bite fever (Streptobacillus Standard n/a Not transmitted from person to person.
moniliformis disease, Spirillum
minus disease)
Relapsing fever Standard n/a Not transmitted from person to person.
Resistant bacterial infection or n/a n/a n/a
colonization (see Multidrug-
Resistant Organisms)
Respiratory infectious disease, Standard n/a n/a
acute (if not covered elsewhere)
Adults
Respiratory infectious disease, Contact + Duration of Also see syndromes or conditions listed in Table 2.
acute (if not covered elsewhere) Standard illness
Infants and young children
Respiratory syncytial virus Contact + Duration of Wear mask according to Standard Precautions [24] CB [116,
infection, in infants, young Standard illness 117]. In immunocompromised patients, extend the duration of
children and Contact Precautions due to prolonged shedding [928].
immunocompromised adults Reliability of antigen testing to determine when to remove
patients with prolonged hospitalizations from Contact
Precautions uncertain.
Reye’s syndrome Standard n/a Not an infectious condition.
Rheumatic fever Standard n/a Not an infectious condition.
Type of Duration of
Infection/Condition Precaution Precaution Precautions/Comments
Rhinovirus Droplet + Duration of Droplet most important route of transmission [104 1090].
Standard illness Outbreaks have occurred in NICUs and LTCFs [413, 1091,
1092]. Add Contact Precautions if copious moist secretions
and close contact likely to occur (e.g., young infants) [111,
833].
Rickettsial fevers, tickborne Standard n/a Not transmitted from person to person except through
(Rocky Mountain spotted fever, transfusion, rarely.
tickborne Typhus fever)
Rickettsialpox (vesicular Standard n/a Not transmitted from person to person.
rickettsiosis)
Ringworm (dermatophytosis, Standard n/a Rarely, outbreaks have occurred in healthcare settings, (e.g.,
dermatomycosis, tinea) NICU [1093], rehabilitation hospital [1094]. Use Contact
Precautions for outbreak.
Rocky Mountain spotted fever Standard n/a Not transmitted from person to person except through
transfusion, rarely.
Roseola infantum (exanthem Standard n/a n/a
subitum; caused by HHV-6)
Rotavirus infection (see n/a n/a n/a
Gastroenteritis)
Rubella (German measles) Droplet + Until 7 days after Susceptible HCWs should not enter room if immune
(also see Congenital Rubella) Standard onset of rash caregivers are available. No recommendation for wearing
face protection (e.g., a surgical mask) if immune. Pregnant
women who are not immune should not care for these
patients [17, 33]. Administer vaccine within 3 days of
exposure to non-pregnant susceptible individuals.
Place exposed susceptible patients on Droplet Precautions;
exclude susceptible healthcare personnel from duty from day
5 after first exposure to day 21 after last exposure,
regardless of postexposure vaccine.
Rubeola (see Measles) n/a n/a n/a
Salmonellosis (see n/a n/a n/a
Gastroenteritis)
Scabies Contact + Until 24 n/a
Standard
Scalded skin syndrome, Contact + Duration of See Staphylococcal Disease, scalded skin syndrome below.
staphylococcal Standard illness
Schistosomiasis (bilharziasis) Standard n/a n/a
Severe acute respiratory Airborne + Duration of Airborne preferred; Droplet if AIIR unavailable. N95 or higher
syndrome (SARS) Droplet + illness plus 10 respiratory protection; surgical mask if N95 unavailable; eye
Contact + days after protection (goggles, face shield); aerosol-generating
Standard resolution of procedures and “supershedders” highest risk for transmission
fever, provided via small droplet nuclei and large droplets [93, 94, 96].
respiratory
Vigilant environmental disinfection (see [This link is no longer
symptoms are
active: www.cdc.gov/ncidod/sars]. Similar information may be
absent or
found at CDC Severe Acute Respiratory Syndrome (SARS)
improving
(https://www.cdc.gov/sars/index.html accessed September
2018).)
Shigellosis (see Gastroenteritis) n/a n/a n/a
Type of Duration of
Infection/Condition Precaution Precaution Precautions/Comments
Smallpox (variola; see Vaccinia Airborne + Duration of Until all scabs have crusted and separated (3-4 weeks). Non-
for management of vaccinated Contact + illness vaccinated HCWs should not provide care when immune
persons) Standard HCWs are available; N95 or higher respiratory protection for
susceptible and successfully vaccinated individuals;
postexposure vaccine within 4 days of exposure protective
[108, 129, 1038-1040].
Sporotrichosis Standard n/a n/a
Spirillum minor disease (rat-bite Standard n/a Not transmitted from person to person.
fever)
Staphylococcal disease (S. Contact + Duration of Until drainage stops or can be contained by dressing.
aureus) Standard illness
Skin, wound, or burn
Major
Staphylococcal disease (S. Standard If dressing covers and contains drainage adequately.
aureus)
Skin, wound, or burn
Minor or limited
Staphylococcal disease (S. Standard n/a Use Contact Precautions for diapered or incontinent children
aureus) for duration of illness.
Enterocolitis
Staphylococcal disease (S. n/a n/a n/a
aureus)
Multidrug-resistant (see
Multidrug-Resistant
Organisms)
Staphylococcal disease (S. Standard n/a n/a
aureus)
Pneumonia
Staphylococcal disease (S. Contact + Duration of Consider healthcare personnel as potential source of
aureus) Standard illness nursery, NICU outbreak [1095].
Scalded skin syndrome
Staphylococcal disease (S. Standard n/a n/a
aureus)
Toxic shock syndrome
Streptobacillus moniliformis Standard n/a Not transmitted from person to person.
disease (rat-bite fever)
Streptococcal disease (group A Contact + Until 24 hours Until drainage stops or can be contained by dressing.
Streptococcus) Droplet + after initiation of
Skin, wound, or burn Standard effective therapy
Major
Streptococcal disease (group A Standard n/a If dressing covers and contains drainage.
Streptococcus)
Skin, wound, or burn
Minor or limited
Streptococcal disease (group A Standard n/a n/a
Streptococcus)
Endometritis (puerperal
sepsis)
Streptococcal disease (group A Droplet + Until 24 hours n/a
Streptococcus) Standard after initiation of
Pharyngitis in infants and effective therapy
young children
Type of Duration of
Infection/Condition Precaution Precaution Precautions/Comments
Streptococcal disease (group A Droplet + Until 24 hours n/a
Streptococcus) Standard after initiation of
Pneumonia effective therapy
Streptococcal disease (group A Droplet + Until 24 hours n/a
Streptococcus) Standard after initiation of
Scarlet fever in infants and effective therapy
young children
Streptococcal disease (group A Droplet + Until 24 hours Outbreaks of serious invasive disease have occurred
Streptococcus) Standard after initiation of secondary to transmission among patients and healthcare
Serious invasive disease effective therapy personnel [162, 972, 1096-1098].
Contact Precautions for draining wound as above; follow
recommendations for antimicrobial prophylaxis in selected
conditions [160].
Streptococcal disease (group B Standard n/a n/a
Streptococcus), neonatal
Streptococcal disease (not n/a n/a n/a
group A or B) unless covered
elsewhere
Multidrug-resistant (see
Multidrug-Resistant
Organisms)
Strongyloidiasis Standard n/a n/a
Syphilis Standard n/a n/a
Latent (tertiary) and
seropositivity without
lesions
Syphilis Standard n/a n/a
Skin and mucous
membrane, including
congenital, primary,
Secondary
Tapeworm disease Standard n/a Not transmitted from person to person.
Hymenolepis nana
Tapeworm disease Standard n/a n/a
Taenia solium (pork)
Tapeworm disease Standard n/a n/a
Other
Tetanus Standard n/a Not transmitted from person to person.
Tinea (e.g., dermatophytosis, Standard n/a Rare episodes of person-to-person transmission.
dermatomycosis, ringworm)
Toxoplasmosis Standard n/a Transmission from person to person is rare; vertical
transmission from mother to child, transmission through
organs and blood transfusion rare.
Toxic shock syndrome Standard n/a Droplet Precautions for the first 24 hours after
(staphylococcal disease, implementation of antibiotic therapy if Group A Streptococcus
streptococcal disease) is a likely etiology.
Trachoma, acute Standard n/a n/a
Transmissible spongiform n/a n/a n/a
encephalopathy (see
Creutzfeld-Jacob disease, CJD,
vCJD)
Type of Duration of
Infection/Condition Precaution Precaution Precautions/Comments
Trench mouth (Vincent’s Standard n/a n/a
angina)
Trichinosis Standard n/a n/a
Trichomoniasis Standard n/a n/a
Trichuriasis (whipworm Standard n/a n/a
disease)
Tuberculosis (M. tuberculosis) Airborne + n/a Discontinue precautions only when patient is improving
Extrapulmonary, draining Contact + clinically, and drainage has ceased or there are 3
lesion Standard consecutive negative cultures of continued drainage [1025,
1026]. Examine for evidence of active pulmonary
tuberculosis.
Tuberculosis (M. tuberculosis) Standard n/a Examine for evidence of pulmonary tuberculosis. For infants
Extrapulmonary, no and children, use Airborne until active pulmonary
draining lesion, Meningitis tuberculosis in visiting family members ruled out. [42]
Tuberculosis (M. tuberculosis) Airborne + n/a Discontinue precautions only when patient on effective
Pulmonary or laryngeal Standard therapy is improving clinically and has 3 consecutive sputum
disease, confirmed smears negative for acid-fast bacilli collected on separate
days (MMWR 2005; 54: RR-17 Guidelines for Preventing the
Transmission of Mycobacterium tuberculosis in Health-Care
Settings, 2005
(https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5417a1.htm
accessed September 2018) [12].
Tuberculosis (M. tuberculosis) Airborne + n/a Discontinue precautions only when the likelihood of infectious
Pulmonary or laryngeal Standard TB disease is deemed negligible, and either
disease, suspected
1. there is another diagnosis that explains the clinical
syndrome, or
2. the results of 3 sputum smears for AFB are negative.
Each of the 3 sputum specimens should be collected 8-24
hours apart, and at least 1 should be an early morning
specimen.
Tuberculosis (M. tuberculosis) Standard n/a n/a
Skin-test positive with no
evidence of current active
disease
Tularemia Standard n/a Not transmitted from person to person.
Draining lesion
Tularemia Standard n/a Not transmitted from person to person.
Pulmonary
Typhoid (Salmonella typhi) n/a n/a n/a
fever (see Gastroenteritis)
Typhus Standard n/a Transmitted from person to person through close personal or
Rickettsia prowazekii clothing contact.
(Epidemic or Louse-borne
Typhus)
Typhus Standard n/a Not transmitted from person to person.
Rickettsia typhi
Urinary tract infection (including Standard n/a n/a
pyelonephritis), with or without
urinary catheter
Type of Duration of
Infection/Condition Precaution Precaution Precautions/Comments
Vaccinia n/a n/a Only vaccinated HCWs have contact with active vaccination
sites and care for persons with adverse vaccinia events; if
unvaccinated, only HCWs without contraindications to
vaccine may provide care.
Vaccinia Standard n/a Vaccination recommended for vaccinators; for newly
Vaccination site care vaccinated HCWs: semi-permeable dressing over gauze until
(including autoinoculated scab separates, with dressing change as fluid accumulates,
areas) ~3-5 days; gloves, hand hygiene for dressing change;
vaccinated HCW or HCW without contraindication to vaccine
for dressing changes. [205, 221, 225].
Vaccinia (adverse events Contact + Until lesions dry For contact with virus-containing lesions and exudative
following vaccination) Standard and crusted, material.
Eczema vaccinatum scabs separated
Vaccinia (adverse events Contact + Until lesions dry For contact with virus-containing lesions and exudative
following vaccination) Standard and crusted, material.
Fetal vaccinia scabs separated
Vaccinia (adverse events Contact + Until lesions dry For contact with virus-containing lesions and exudative
following vaccination) Standard and crusted, material.
Generalized vaccinia scabs separated
Vaccinia (adverse events Contact + Until lesions dry For contact with virus-containing lesions and exudative
following vaccination) Standard and crusted, material.
Progressive vaccinia scabs separated
Vaccinia (adverse events Standard n/a n/a
following vaccination)
Postvaccinia encephalitis
Vaccinia (adverse events Contact + n/a Use Contact Precautions if there is copious drainage.
following vaccination) Standard
Blepharitis or conjunctivitis
Vaccinia (adverse events Standard n/a n/a
following vaccination)
Iritis or keratitis
Vaccinia (adverse events Standard n/a Not an infectious condition.
following vaccination)
Vaccinia-associated
erythema multiforme
(Stevens Johnson
Syndrome)
Vaccinia (adverse events Standard + n/a Follow organism-specific (strep, staph most frequent)
following vaccination) Contact recommendations and consider magnitude of drainage.
Secondary bacterial
infection (e.g., S. aureus,
group A beta hemolytic
Streptococcus)
Type of Duration of
Infection/Condition Precaution Precaution Precautions/Comments
Varicella Zoster Airborne + Until lesions dry Susceptible HCWs should not enter room if immune
Contact + and crusted caregivers are available; no recommendation for face
Standard protection of immune HCWs; no recommendation for type of
protection (i.e., surgical mask or respirator) for susceptible
HCWs.
In immunocompromised host with varicella pneumonia,
prolong duration of precautions for duration of illness.
Postexposure prophylaxis: provide postexposure vaccine
ASAP but within 120 hours; for susceptible exposed persons
for whom vaccine is contraindicated (immunocompromised
persons, pregnant women, newborns whose mother’s
varicella onset is <5 days before delivery or within 48 hours
after delivery) provide VZIG, when available, within 96 hours;
if unavailable, use IVIG.
Use Airborne for exposed susceptible persons and exclude
exposed susceptible healthcare workers beginning 8 days
after first exposure until 21 days after last exposure or 28 if
received VZIG, regardless of postexposure vaccination
[1036].
Variola (see smallpox) n/a n/a n/a
Vibrio parahaemolyticus (see n/a n/a n/a
Gastroenteritis)
Vincent’s angina (trench mouth) Standard n/a n/a
Viral hemorrhagic fevers due to Droplet + Duration of
Lassa, Ebola, Marburg, Contact + illness Ebola Virus Disease for Healthcare Workers [2014]:
Crimean-Congo fever viruses Standard Updated recommendations for healthcare workers can be
found at Ebola: for Clinicians
(https://www.cdc.gov/vhf/ebola/clinicians/index.html
accessed September 2018).
Single-patient room preferred. Emphasize:
1. use of sharps safety devices and safe work practices,
2. hand hygiene;
3. barrier protection against blood and body fluids upon entry
into room (single gloves and fluid-resistant or impermeable
gown, face/eye protection with masks, goggles or face
shields); and
4. appropriate waste handling.
Use N95 or higher respirators when performing aerosol-
generating procedures. Largest viral load in final stages of
illness when hemorrhage may occur; additional PPE,
including double gloves, leg and shoe coverings may be
used, especially in resource-limited settings where options
for cleaning and laundry are limited. Notify public health
officials immediately if Ebola is suspected [212, 314, 740,
772]. Also see Table 3C for Ebola as a bioterrorism agent.
Viral respiratory diseases (not Standard
covered elsewhere)
Adults
Type of Duration of
Infection/Condition Precaution Precaution Precautions/Comments
Viral respiratory diseases (not
covered elsewhere)
Infants and young children
(see Respiratory infectious
disease, acute)
Whooping cough (see n/a n/a
Pertussis)
Wound infections Contact + Duration of Until drainage stops or can be contained by dressing.
Major Standard illness
Wound infections Standard n/a If dressing covers and contains drainage
Minor or limited
Yersinia enterocolitica n/a n/a n/a
Gastroenteritis (see
Gastroenteritis)
Zoster (varicella-zoster) (see n/a n/a n/a
Herpes Zoster)
Zygomycosis (phycomycosis, Standard n/a Not transmitted person-to-person.
mucormycosis)
1983 CDC Guideline for Isolation • Provided two systems for isolation: category-specific and disease-
1101 Precautions in Hospitals specific
• Protective Isolation eliminated; Blood Precautions expanded to include
Body Fluids
• Categories included Strict, Contact, Respiratory, AFB, Enteric,
Drainage/Secretion, Blood and Body Fluids
• Emphasized decision-making by users
1985-88 Universal Precautions • Developed in response to HIV/AIDS epidemic
780, 896
• Dictated application of Blood and Body Fluid precautions to all patients,
regardless of infection status
• Did not apply to feces, nasal secretions, sputum, sweat, tears, urine, or
vomitus unless contaminated by visible blood
• Added personal protective equipment to protect HCWs from mucous
membrane exposures
• Handwashing recommended immediately after glove removal
• Added specific recommendations for handling needles and other sharp
devices; concept became integral to OSHA’s 1991 rule on occupational
exposure to blood-borne pathogens in healthcare settings
1987 Body Substance Isolation • Emphasized avoiding contact with all moist and potentially infectious
1102
body substances except sweat even if blood not present
• Shared some features with Universal Precautions
• Weak on infections transmitted by large droplets or by contact with dry
surfaces
• Did not emphasize need for special ventilation to contain airborne
infections
• Handwashing after glove removal not specified in the absence of visible
soiling
1996 Guideline for Isolation • Prepared by the Healthcare Infection Control Practices Advisory
1 Precautions in Hospitals Committee (HICPAC)
• Melded major features of Universal Precautions and Body Substance
Isolation into Standard Precautions to be used with all patients at all
times
• Included three transmission-based precaution categories: airborne,
droplet, and contact
• Listed clinical syndromes that should dictate use of empiric isolation until
an etiological diagnosis is established
* Infection control professionals should modify or adapt this table according to local conditions. To
ensure that appropriate empiric precautions are implemented always, hospitals must have
systems in place to evaluate patients routinely according to these criteria as part of their
preadmission and admission care.
† Patients with the syndromes or conditions listed below may present with atypical signs or
symptoms (e.g.neonates and adults with pertussis may not have paroxysmal or severe cough).
The clinician's index of suspicion should be guided by the prevalence of specific conditions in
the community, as well as clinical judgment.
‡ The organisms listed under the column "Potential Pathogens" are not intended to represent the
complete, or even most likely, diagnoses, but rather possible etiologic agents that require
additional precautions beyond Standard Precautions until they can be ruled out.
§ These pathogens include enterohemorrhagic Escherichia coli O157:H7, Shigella spp, hepatitis A
virus, noroviruses, rotavirus, C. difficile.
Table 3.
Infection Control Considerations for High-Priority (CDC Category A) Diseases
that May Result from Bioterrorist Attacks or are Considered to be Bioterrorist
Threats
[This link is no longer active: www.bt.cdc.gov. Similar information may be found at CDC
Bioterrorism Agents/Diseases (https://emergency.cdc.gov/agent/agentlist.asp accessed May
2016)]
Ebola Virus Disease for Healthcare Workers [2014]: Updated recommendations for healthcare
workers can be found at Ebola: for Clinicians (https://www.cdc.gov/vhf/ebola/clinicians/index.html
accessed September 2018).
Plague
Pneumonic plague is not as contagious as is often thought. Historical accounts and contemporary
evidence indicate that persons with plague usually transmit the infection only when the disease is
in the end stage. These persons cough copious amounts of bloody sputum that contains many
plague bacteria. Patients in the early stage of primary pneumonic plague (approximately the first
20–24 h) apparently pose little risk [1, 2]. Antibiotic medication rapidly clears the sputum of plague
bacilli, so that a patient generally is not infective within hours after initiation of effective antibiotic
treatment [3]. This means that in modern times many patients will never reach a stage where they
pose a significant risk to others. Even in the end stage of disease, transmission only occurs after
close contact. Simple protective measures, such as wearing masks, good hygiene, and avoiding
close contact, have been effective to interrupt transmission during many pneumonic plague
outbreaks [2]. In the United States, the last known cases of person to person transmission of
pneumonic plague occurred in 1925 [2].
Table 3D. Plague
Characteristics Additional Information
Site(s) of Infection; Respiratory Tract: Inhalation of respiratory droplets.
Transmission Mode Comment: Pneumonic plague most likely to occur if used as a biological weapon, but some
cases of bubonic and primary septicemia may also occur. Infective dose 100 to 500 bacteria
Incubation Period 1 to 6, usually 2 to 3 days.
Clinical Features Pneumonic: fever, chills, headache, cough, dyspnea, rapid progression of weakness, and in a
later stage hemoptysis, circulatory collapse, and bleeding diathesis
Diagnosis Presumptive diagnosis from Gram stain or Wayson stain of sputum, blood, or lymph node
aspirate; definitive diagnosis from cultures of same material, or paired acute/convalescent
serology.
Infectivity Person-to-person transmission occurs via respiratory droplets risk of transmission is low
during first 20-24 hours of illness and requires close contact. Respiratory secretions probably
are not infectious within a few hours after initiation of appropriate therapy.
Recommended Standard Precautions, Droplet Precautions until patients have received 48 hours of
Precautions appropriate therapy.
Chemoprophylaxis: Consider antibiotic prophylaxis for HCWs with close contact exposure.
1. Wu L-T. A treatise on pneumonic plague. Geneva: League of Nations, 1926. III. Health.
2. Kool JL. Risk of person to person transmission of pneumonic plague. Clinical Infectious
Diseases, 2005; 40 (8): 1166-1172
3. Butler TC. Plague and other Yersinia infections. In: Greenough WB, ed. Current topics in
infectious disease. New York: Plenum Medical Book Company, 1983.
Table 4.
Recommendations for Application of Standard Precautions for the Care of All
Patients in All Healthcare Settings
Component Recommendations
Hand hygiene After touching blood, body fluids, secretions, excretions, contaminated items;
immediately after removing gloves; between patient contacts.
Personal protective equipment (PPE) For touching blood, body fluids, secretions, excretions, contaminated items; for
touching mucous membranes and nonintact skin
Gloves
Personal protective equipment (PPE) During procedures and patient-care activities when contact of clothing/exposed
skin with blood/body fluids, secretions, and excretions is anticipated.
Gown
Personal protective equipment (PPE) During procedures and patient-care activities likely to generate splashes or
sprays of blood, body fluids, secretions, especially suctioning, endotracheal
Mask, eye protection intubation. During aerosol-generating procedures on patients with suspected or
(goggles), face shield proven infections transmitted by respiratory aerosols wear a fit-tested N95 or
higher respirator in addition to gloves, gown and face/eye protection.
Soiled patient-care equipment Handle in a manner that prevents transfer of microorganisms to others and to
the environment; wear gloves if visibly contaminated; perform hand hygiene.
Environmental control Develop procedures for routine care, cleaning, and disinfection of
environmental surfaces, especially frequently touched surfaces in patient-care
areas.
Textiles and laundry Handle in a manner that prevents transfer of microorganisms to others and to
the environment
Needles and other sharps Do not recap, bend, break, or hand-manipulate used needles; if recapping is
required, use a one-handed scoop technique only; use safety features when
available; place used sharps in puncture-resistant container
Patient resuscitation Use mouthpiece, resuscitation bag, other ventilation devices to prevent contact
with mouth and oral secretions
Patient placement Prioritize for single-patient room if patient is at increased risk of transmission, is
likely to contaminate the environment, does not maintain appropriate hygiene,
or is at increased risk of acquiring infection or developing adverse outcome
following infection.
Respiratory hygiene/cough etiquette Instruct symptomatic persons to cover mouth/nose when sneezing/coughing;
(source containment of infectious use tissues and dispose in no-touch receptacle; observe hand hygiene after
respiratory secretions in symptomatic soiling of hands with respiratory secretions; wear surgical mask if tolerated or
patients, beginning at initial point of maintain spatial separation, >3 feet if possible.
encounter e.g., triage and reception
areas in emergency departments and
physician offices)
Table 5.
Components of a Protective Environment
(Adapted from MMWR 2003; 52 [RR-10])
III. Engineering
IV. Surfaces
V. Other
Figure.
Example of Safe Donning and Removal of Personal Protective
Equipment (PPE)
For updated content see Sequence for Putting on Personal Protective Equipment
and How to Safely Remove Personal Protective Equipment
(https://www.cdc.gov/hai/pdfs/ppe/PPE-Sequence.pdf accessed May 2016).
Donning PPE
GOWN
• Fully cover torso from neck to
knees, arms to end of wrist,
and wrap around the back
• Fasten in back at neck and
waist
MASK OR RESPIRATOR
• Secure ties or elastic band at
middle of head and neck
• Fit flexible band to nose
bridge
• Fit snug to face and below
chin
• Fit-check respirator
GOGGLES/FACE SHIELD
• Put on face and adjust to fit
GLOVES
• Use non-sterile for isolation
• Select according to hand size
• Extend to cover wrist of
isolation gown
Removing PPE
GLOVES
• Outside of gloves are
contaminated!
• Grasp outside of glove with
opposite gloved hand; peel off
• Hold removed glove in gloved
hand
• Slide fingers of ungloved hand
under remaining glove at wrist
GOGGLES/FACE SHIELD
• Outside of goggles or face shield
are contaminated!
• To remove, handle by “clean”
head band or ear pieces
• Place in designated receptacle for
reprocessing or in waste container
GOWN
• Gown front and sleeves are
contaminated!
• Unfasten neck, then waist ties
• Remove gown using a peeling
motion; pull gown from each
shoulder toward the same hand
• Gown will turn inside out
• Hold removed gown away from
body, roll into a bundle and
discard into waste or linen
receptacle
MASK OR RESPIRATOR
• Front of mask/respirator is
contaminated – DO NOT TOUCH!
• Grasp ONLY bottom then top
ties/elastics and remove
• Discard in waste container
Hand Hygiene
Perform hand hygiene immediately
after removing all PPE!
Glossary
Airborne infection isolation room (AIIR). Formerly, negative pressure isolation room,
an AIIR is a single-occupancy patient-care room used to isolate persons with a
suspected or confirmed airborne infectious disease. Environmental factors are
controlled in AIIRs to minimize the transmission of infectious agents that are usually
transmitted from person to person by droplet nuclei associated with coughing or
aerosolization of contaminated fluids. AIIRs should provide negative pressure in the
room (so that air flows under the door gap into the room); and an air flow rate of 6-12
ACH (6 ACH for existing structures, 12 ACH for new construction or renovation); and
direct exhaust of air from the room to the outside of the building or recirculation of air
through a HEPA filter before retruning to circulation (MMWR 2003; 52 [RR-10]; MMWR
1994; 43 [RR-13]).
American Institute of Architects (AIA). A professional organization that develops
standards for building ventilation, The “2001Guidelines for Design and Construction of
Hospital and Health Care Facilities”, the development of which was supported by the
AIA, Academy of Architecture for Health, Facilities Guideline Institute, with assistance
from the U.S. Department of Health and Human Services and the National Institutes of
Health, is the primary source of guidance for creating airborne infection isolation rooms
(AIIRs) and protective environments (American Institute of Architects – Academy of
Architecture for Health (https://network.aia.org/academyofarchitectureforhealth/home
accessed May 2016) [Current version of this document may differ from original.])
Ambulatory care settings. Facilities that provide health care to patients who do not
remain overnight (e.g., hospital-based outpatient clinics, nonhospital-based clinics and
physician offices, urgent care centers, surgicenters, free-standing dialysis centers,
public health clinics, imaging centers, ambulatory behavioral health and substance
abuse clinics, physical therapy and rehabilitation centers, and dental practices.
Bioaerosols. An airborne dispersion of particles containing whole or parts of biological
entities, such as bacteria, viruses, dust mites, fungal hyphae, or fungal spores. Such
aerosols usually consist of a mixture of mono-dispersed and aggregate cells, spores or
viruses, carried by other materials, such as respiratory secretions and/or inert particles.
Infectious bioaerosols (i.e., those that contain biological agents capable of causing an
infectious disease) can be generated from human sources (e.g., expulsion from the
respiratory tract during coughing, sneezing, talking or singing; during suctioning or
wound irrigation), wet environmental sources (e.g., HVAC and cooling tower water with
Legionella) or dry sources (e.g., construction dust with spores produced by Aspergillus
spp.). Bioaerosols include large respiratory droplets and small droplet nuclei (Cole EC.
AJIC 1998;26: 453-64).
Caregivers. All persons who are not employees of an organization, are not paid, and
provide or assist in providing healthcare to a patient (e.g., family member, friend) and
acquire technical training as needed based on the tasks that must be performed.
Cohorting. In the context of this guideline, this term applies to the practice of grouping
patients infected or colonized with the same infectious agent together to confine their
care to one area and prevent contact with susceptible patients (cohorting patients).
a hierarchy of design features that may contribute to validity of results (Harris et al. CID
2004:38: 1586).
Residential care setting. A facility in which people live, minimal medical care is
delivered, and the psychosocial needs of the residents are provided for.
Respirator. A personal protective device worn by healthcare personnel over the nose
and mouth to protect them from acquiring airborne infectious diseases due to inhalation
of infectious airborne particles that are < 5 μm in size. These include infectious droplet
nuclei from patients with M. tuberculosis, variola virus [smallpox], SARS-CoV), and dust
particles that contain infectious particles, such as spores of environmental fungi (e.g.,
Aspergillus sp.). The CDC’s National Institute for Occupational Safety and Health
(NIOSH) certifies respirators used in healthcare settings (Personal Protective
Equipment for Healthcare Workers (https://www.cdc.gov/NIOSH/docs/2013-138/
accessed May 2016)). [Current version of this document may differ from original.]. The
N95 disposable particulate, air purifying, respirator is the type used most commonly by
healthcare personnel. Other respirators used include N-99 and N-100 particulate
respirators, powered air-purifying respirators (PAPRS) with high efficiency filters; and
non-powered full-facepiece elastomeric negative pressure respirators. A listing of
NIOSH-approved respirators can be found at [This link is no longer active:
www.cdc.gov/niosh/npptl/respirators/disp_part/particlist.html. Similar information may be
found at NIOSH Respirator Trusted-Source Information
(https://www.cdc.gov/niosh/npptl/topics/respirators/disp_part/respsource.html accessed
May 2016).]. Respirators must be used in conjunction with a complete Respiratory
Protection Program, as required by the Occupational Safety and Health Administration
(OSHA) that includes fit testing, training, proper selection of respirators, medical
clearance and respirator maintenance.
Respiratory Hygiene/ Cough Etiquette. A combination of measures designed to
minimize the transmission of respiratory pathogens via droplet or airborne routes in
healthcare settings. The components of respiratory hygiene/cough etiquette are
1. covering the mouth and nose during coughing and sneezing,
2. using tissues to contain respiratory secretions with prompt disposal into a no-touch
receptacle,
3. offering a surgical mask to persons who are coughing to decrease contamination of
the surrounding environment, and
4. turning the head away from others and maintaining spatial separation, ideally >3
feet, when coughing.
These measures are targeted to all patients with symptoms of respiratory infection and
their accompanying family members or friends beginning at the point of initial encounter
with a healthcare setting (e.g., reception/triage in emergency departments, ambulatory
clinics, healthcare provider offices)126 (Srinivasin A ICHE 2004; 25: 1020; Respiratory
Hygiene/Cough Etiquette in Healthcare Settings
(https://www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm accessed May
2016) [Current version of this document may differ from original.])
Safety culture. Shared perceptions of workers and management regarding the level of
safety in the work environment. A hospital safety climate includes the following six
organizational components:
Last update: September, 2018 Page 132 of 204
Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007)
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