# 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings

Jane D. Siegel, MD; Emily Rhinehart, RN MPH CIC; Marguerite Jackson, PhD; Linda Chiarello, RN MS; the Healthcare In fection Control Practices Advisory Committee

Acknowledgement: The authors and HICPAC gr atefully 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 I nfectious Agents in Healthcare Settings http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf

1Healthcare Infection Control Practices Advisory Committee (HICPAC):

Chair Patrick J. Brennan, MD
Professor of Medicine
Division of Infectious Diseases University of Pennsylvania Medical School

Executive Secretary Michael Bell, MD Division of Healthcare Quality Promotion
National Center for Infectious Diseases
Centers for Disease Control and Prevention

Members BRINSKO, Vicki L., RN, BA
Infection Control Coordinator Vanderbilt University Medical Center

DELLINGER, E. Patchen., MD Professor of Surgery University of Washington School of
Medicine

ENGEL, Jeffrey, MD
Head General Communicable Disease
Control
Branch North Carolina State Epidemiologist

GORDON, Steven M., MD Chairman, Department of Infections
Diseases Hospital Epidemiologist
Cleveland Clinic Foundation Department of Infectious Disease

HARRELL, Lizzie J., PhD, D(ABMM) Research Professor of Molecular Genetics, Microbiology and Pathology Associate Director, Clinical Microbiology Duke University Medical Center

O’BOYLE, Carol, PhD, RN Assistant Professor, School of Nursing University of Minnesota

PEGUES, David Alexander, MD
Division of Infectious Diseases
David Geffen School of Medicine at UCLA PERROTTA, Dennis M. PhD., CIC Adjunct Associate Professor of Epidemiology University of Texas School of Public Health Texas A&M University School of Rural
Public
Health

PITT, Harriett M., MS, CIC, RN Director, Epidemiology Long Beach Memorial Medical Center

RAMSEY, Keith M., MD
Professor of Medicine
Medical Director of Infection Control The Brody School of Medicine at East
Carolina University

SINGH, Nalini, MD, MPH
Professor of Pediatrics Epidemiology and International Health The George Washington University
Children’s National
Medical Center

STEVENSON, Kurt Brown, MD, MPH
Division of Infectious Diseases Department of Internal Medicine The Ohio State University Medical Center

SMITH, Philip W., MD Chief, Section of Infectious Diseases Department of Internal Medicine University of Nebraska Medical Center

HICPAC membership (past)

Robert A. Weinstein, MD (Chair) Cook County Hospital Chicago, IL

Jane D. Siegel, MD (Co-Chair) University of Texas Southwestern Medical
Center Dallas, TX

Michele L. Pearson, MD (Executive Secretary)
Centers for Disease Control and Prevention Atlanta, GA

2Raymond Y.W. Chinn, MD Sharp Memorial Hospital San Diego, CA

Alfred DeMaria, Jr, MD Massachusetts Department of Public Health Jamaica Plain, MA

James T. Lee, MD, PhD University of Minnesota Minneapolis, MN

William A. Rutala, PhD, MPH University of North Carolina Health Care System Chapel Hill, NC

William E. Scheckler, MD University of Wisconsin Madison, WI

Beth H. Stover, RN Kosair Children’s Hospital Louisville, KY

Marjorie A. Underwood, RN, BSN CIC
Mt. Diablo Medical Center Concord, CA

HICPAC Liaisons William B. Baine, MD Liaison to Agency for Healthcare Quality
Research

Joan Blanchard, RN, MSN, CNOR Liaison to Association of periOperative Registered Nurses

Patrick J. Brennan, MD
Liaison to Board of Scientific Counselors

Nancy Bjerke, RN, MPH, CIC
Liaison to Association of Professionals in
Infection Prevention and Control

Jeffrey P. Engel, MD Liaison to Advisory Committee on
Elimination of
Tuberculosis

David Henderson, MD
Liaison to National Institutes of Health Lorine J. Jay MPH, RN, CPHQ
Liaison to Healthcare Resources Services
Administration

Stephen F. Jencks, MD, MPH
Liaison to Center for Medicare and Medicaid
Services

Sheila A. Murphey, MD Liaison to Food and Drug Administration

Mark Russi, MD, MPH Liaison to American College of Occupational
and
Environmental Medicine

Rachel L. Stricof, MPH Liaison to Advisory Committee on
Elimination of
Tuberculosis

Michael L. Tapper, MD Liaison to Society for Healthcare Epidemiology of
America

Robert A. Wise, MD
Liaison to Joint Commission on the
Accreditation of Healthcare Organizations

Authors’ Associations Jane D. Siegel, MD
Professor of Pediatrics Department of Pediatrics University of Texas Southwestern Medical
Center

Emily Rhinehart RN MPH CIC CPHQ
Vice President AIG Consultants, Inc.

Marguerite Jackson, RN PhD CIC Director, Administrative Unit, National
Tuberculosis Curriculum Consortium,Department of
Medicine University of California San Diego

Linda Chiarello, RN MS Division of Healthcare Quality Promotion National Center for Infectious Diseases,
CDC

3

### TABLE OF CONTENTS

Executive Summary ...........................................................................................7

Abbreviations ...................................................................................................11
Part I : Review of the Scientific Data Rega rding Transmission of Infectious Agents in Healthcare Settings

................................................................................................................ 12
I.A. Evolution of t he 2007 docum ent

........................................................................................ 12
I.B. Rationale for Standard and Transmission-Based Precautions in healthcare settings

........ 14
I.B.1. Source of infecti ous agents

....................................................................................... 14
I.B.2. Susceptible hosts

................................................................................................. ..... 14
I.B.3. Modes of tran smissi on

............................................................................................ . 15
I.B.3.a. Contac t transmi ssion

................................................................................... .. 15
I.B.3.a.i . Direct contact transmi ssion

............................................................ 1 6
I.B.3.a.ii. Indirect contact tr ansmission

......................................................... 16 I.B.3.b. Droplet transmission

.................................................................................. .. 17
I.B.3.c. Airbor ne transmi ssion

................................................................................. .. 18
I.B.3.d. Emer ging issues and controversies c oncerning bioaerosols and airborne transmission of infectious agents

.......... .......................... ........... 19
I.B.3.d.i . Transmission from patients..............................

... 19
I.B.3.d.ii. Transmission from the environment.....................20
I.B.3.e. Other sour ces of infe ction

.............................. .......................................20 I.C. Infectious agents of special infection c ontrol interest for heal thcare se ttings

..................... 20
I.C.1. Epidemiolo gically important organisms........................................21
I.C.1.a. Clostridium difficile

........................................................................................ 21 I.C.1.b. Multidrug-resist ant organisms(MDROs)............................................22 I.C.2. Agent s of biot errorism

............................................................................................ ... 23
I.C .3. Prions

........................................................................................................... ........... 24
I.C.4. Severe acute respiratory syndr ome (SAR S)

............................................................. 26
I.C.5 . Monkeypox

......................................................................................................... ...... 28
I.C.6. Noroviruses..........................................................................................28
I.C.7. Hemo rrhagic fever viruses...............................................................

...... .. 29 I.D. Transmission risks associated with specific types of healthcare se ttings

.......................... 31
I.D. 1. Hosp itals

........................................................................................................ .......... 31
I.D.1.a. Intensive care units

.................................................................................. .... 31
I.D.1.b. Burn units

............................................................................................ ......... 32
I.D.1.c. Pediat rics

............................................................................................ ......... 33
I.D.2. Non- acute care se ttings............

............................................................................. 34 I.D.2.a. Long term care

....................................................................................... ..... 34
I.D .2.b. Ambulatory care se ttings

............................................................................. 3 5
I.D.2.c. Home care

............................................................................................. ...... 36
I.D.2.d. Other sites of healthcare de livery

............................................................... 37
I.E. Transmission risks associated with special patient populati ons

....................................... 38
I.E.1. Imm unocompromised pat ients

................................................................................. 38 I.E.2. Cyst ic fibrosis patients

......................................................................................... .... 39

4I.F. New therapies with potential transmissible infect ious agent s

........................................... 39
I.F. 1. Gene ther apy

..................................................................................................... ...... 39
I.F.2. Infections Tr ansmitted through Blood, Or gans and Tissues

.............. .................. .... 40 I.F.3. Xenotransplant ation and tissue allografts

................................................................ 40

Part II. Fundamental Elements to Prevent Transmission of Infectious Agents in Healthcare Settings

................................................................................................................ 41

II.A. Healthcare system components that in fluence the effectiveness of

precautions to prev ent transmi ssion

.............................................................................. 41

II.A.1. Admi nistrative measures........................................................41
II.A.1.a. Scope of Work and Staffing Ne eds for Infection Control Professionals (ICP).....................

.................................................................... 42
II.A.1.a.i. Infecti on Control Liaison Nurse......

...................... 43
II.A.1. b. Bedside nurse staffing....................................................43
II.A.1.c. Clinical microbi ology laboratory support...

......... ................ .. 43
II.A.2. Inst itutional safety culture and or ganizational characteristics.........45
II.A.3. Adherence of heal thcare personnel to recommended guidelines....45
II.B. Surveillance for healthcare-asso ciated infections (HAIs).......................46
II.C. Education of healthcare wo rkers, patients, and familie s

................................................. 47
II.D. H and hygi ene

........................................................................................................... ....... 49 II.E. Personal protective equipm ent for healthcare personne l

................................................ 49
II.E.1. Glov es

........................................................................................................ ........... 50
II.E.2. Isolation gowns

..................................................................................................... 51
II.E.3. Face protec tion: masks, goggles, face shields...........................52
II.E.3.a. Masks..................................................................

.. 52
II.E.3.b. Goggles, face shields................................................52
II.E.4. Respiratory protection

........................................................................................ ... 53 II.F. Safe work practices to prev ent HCW exposure to bloodborne pat hogens

.................... 55 II.F.1. Prevention of needl esticks and other sharps-r elated inju ries

................................ 55
II.F.2. Prevention of mucous membr ane contac t

............................................................. 56
II.F.2.a. Precautions duri ng aerosol-generating procedures.........56
II.G. Pati ent plac ement

..................................................................................................... ..... 56 II.G.1. Hospital s and long-term care setti ngs

.................................................................. 56
II.G.2. Ambulatory ca re settings

...................................................................................... 58
II .G.3. Home care

..................................................................................................... ....... 59
II.H. Trans port of pat ients

................................................................................................. ..... 59
II.I. Envir onmental m easures

................................................................................................ . 60 II.J. Patient care equipm ent, instruments/ devices

................................................................. 61
II.K. Text iles and la undry

.................................................................................................. ..... 61

II.L. Solid waste..............................................................................62

II.M. Dishware and eating ut ensils

......................................................................................... 6 2 II.N. Adjunc tive m easures

................................................................................................... .. 63
II.N .1. Chemopr ophylaxis

.............................................................................................. .. 63
II.N .2. Immunopr ophylaxis

............................................................................................. .. 63

5II.N.3. Management of visitors......................................................64
II.N.3.a. Visitors as sources of infection..................................64
II.N.3.b. Use of barrier precautions by visitors........................

.. 65

Part III. HICPAC Precautions to Pr event Transmission of Infectious Agents

................... 66

III.A. Standar d Precaut ions

................................................................................................. .. 66

III. A.1.New Standard Precaut ions for patients...................................................67
II I.A.1.a. Respiratory Hy giene/Cough Et iquette

........................................................... 67
III.A.1.b. Safe Inje ction Practices................................................................ 68
III.A.1.c. Infection Control Practices for Spec ial Lumbar Puncture Procedures......69
III.B. Transmission- Based Precaut ions

................................................................................. 69
III.B. 1. Contact Precaut ions

.......................................................................................... ... 70
III.B. 2. Droplet Precaut ions

.......................................................................................... ... 70
III.B. 3. Airborne Infection Is olation Prec autions

............................................................... 71 III.C. Syndromic or empiric applicat ion of Transmission-B ased Precaut ions

......................... 71
III.D. Discontinuat ion of prec autions

...................................................................................... 7 2
III.E. Application of Transmission-Bas ed Precautions in ambulatory and home care
setti ngs

....................................................................................................................... .............. 72
III.F. Protective environment (PE)

......................................................................................... 7 3

Part IV : Recommendations

.................................................................................................... 74

Appendix A. Type and duration of precautions needed for selected infections and
condi tions

................................................................................................ ............ 93

Tables Table 1. Recent history of guidelines for prevention of healthca re-associated infections

.... .. Table 2. Clinical syndr omes or conditions warranting additional empiric transmissionbased precautions pending confirma tion of diagnosis.......................................
Table 3. Infection control considerations for high-priority (CDC Category A) diseases that

Table 4. Recommendations for applicatio n of Standard Precautions for the care of all may result from bioterrorist attacks or are considered to be bioterrorist threats

..

patients in all healt hcare setti ngs

......................................................................... .. Table 5. Components of a Protective En vironment

.............................................................

Figure Sequence for donning and removing PPE

................................................................

Glossary

................................................................................................................

Reference s

............................................................................................................................

6EXECUTIVE SUMMARY

The Guideline for Isolation Precautions: Preventi ng 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, am bulatory care, free- standing specialty care sites, long-term care) created a need for recommendations that can be applied in all healthcare settings using co mmon 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 infe ctions“ is replaced by “healthcareassociated infections” (HAI s) to reflect t he 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, communityassociated MRSA [CA-MRSA]), developm ent 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 Hygi ene/Cough Etiquette grew out of observations during the SARS outbreaks w here failure to implement simple source control measures with patients, visitors, and healthcare personnel with respiratory symptoms may have contributed to SARS co ronavirus (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 Pr ecautions. The addition of a mask for certain spinal injections grew from re cent evidence of an associated risk for developing meningitis caused by respiratory flora.
4. The accumulated evidence that environm ental controls decrease the risk of lifethreatening fungal infections in the mo st severely immunocompromised patients (allogeneic hematopoietic ste m-cell transplant patients) led to the update on the components of the Protecti ve Environment (PE).
5. Evidence that organizational characterist ics (e.g., nurse staffing levels and composition, establishment of a safety culture) influence healthcare personnel
adherence to recommended infection cont rol practices, and therefore are important factors in preventing transmissi on of infectious agents, led to a new

7emphasis and recommendations for adm inistrative involvement in the development and support of in fection control programs.
6. Continued increase in the incidence of HAIs caused by multidrug-resistant organisms (MDROs) in all healthcar e settings and the expanded body of knowledge concerning prevention of tr ansmission of MDROs created a need for more specific recommendations for surveillance and control of these pathogens that would be practical and effective in various types of healthcare settings.

This document is intended for use by infection control staff, healthcare epidemiologists, healthcare administrators, nurse s, other healthcare providers, and persons responsible for developing, implementing, and ev aluating infection control prog rams for healthcare settings
across the continuum of care. The reader is referred to other guidelines and websites for
more detailed information and for recommendations concerning specialized infection control problems.

Parts I - III: Review of the Scientific Data Re garding Transmission of Infectious Agents in Healthcare Settings Part I reviews the relevant scientific literature that supports the recommended prevention and control practices. As with the 1996 guideline,
the modes and factors that infl uence transmission risks are described in detail. New to the
section on transmission are discussions of bioaerosols and of how droplet and airborne transmission may contribute to infection trans mission. This became a concern during the SARS outbreaks of 2003, when transmission associated with aerosol-generating procedures was observed. Also new is a definition of “epidemio logically important organisms” that was developed to assist in the identification of clusters of infections that require investigation (i.e. mu ltidrug-resistant organisms, C. difficile) . Several other pathogens that hold special infect ion control interest (i.e., norovirus, SARS, Category A bioterrorist agents, prions, monkeypox, and the hemorrhagic fever viruses) also are discussed to present new information and infecti on control lessons learned from experience with these agents. This section of the guideli ne also presents information on infection risks associated with specific healthcare settings and patient populations.

Part II updates information on the basic principles of hand hygi ene, barrier precautions, safe work practices and isolation practices that were included in previous guidelines. However, new to this guideline, is important information on healthcare system components that influence transmission risks, including t hose under the influence of healthcare administrators. An important administrative priority that is described is the need for appropriate infection control staffing to meet the ever-expanding role of infection control professionals in the moder n, complex healthcare system . Evidence presented also demonstrates another administrative concern, the importance of nurse staffing levels, including numbers of appropriate ly trained nurses in ICUs for preventing HAIs. The role of the clinical microbiology laboratory in supporti ng infection control is described to emphasize
the need for this service in healthcare facilit es. Other factors that influence transmission risks are discussed i.e., healthcare worker adherence to recommended infection control practices, organizational safety culture or climate, educ ation and training Discussed for the first time in an isolation gui deline is surveillance of healthcare-associated infections. The information presented will be usef ul to new infection control professionals as

8well as persons involved in designing or res ponding to state programs fo r public reporting of
HAI rates.

Part III describes each of the categories of precautions developed by the Healthcare Infection Control Practices Advisory Co mmittee (HICPAC) and the Centers for Disease Control and Prevention (CDC) and provides guidance for their application in various healthcare settings. The categories of Tr ansmission-Based Precautions are unchanged
from those in the 1996 guideline: Contact, Droplet, and Air borne. One important change is the recommendation to don the indicated pers onal protective equipment (gowns, gloves, mask) upon entry into the patient’s room for patients who are on Contact and/or Droplet
Precautions since the nature of the interact ion with the patient cannot be predicted with certainty and contaminated envir onmental surfaces are importa nt sources for transmission of pathogens. In addition, the Protective Environment ( PE) for allogeneic hem atopoietic stem cell transplant patients, descr ibed in previous guide lines, has been updated.

Tables, Appendices, and other Information
There are several tables that summarize im portant information: 1) a summary of the evolution of this document; 2) guidance on using empiric isolation precautions according to a clinical syndrome; 3) a summary of infe ction control recommendations for category A agents of bioterrorism; 4) components of St andard Precautions and recommendations for their application; 5) components of the Protective Environment; and 6) a glossary of definitions used in this guideline. New in this guideline is a figure that shows a recommended sequence for donning and removing per sonal protective equipment used for isolation precautions to optimiz e safety and prevent self-contam ination during removal.

Appendix A: Type and Duration of Precauti ons Recommended for Selected Infections and Conditions Appendix A consists of an updated alphabetical list of most infectious agents and clinical conditions for which isolation precautions are recommended. A preamble to the Appendix provides a rationale for recommending the use of one or more Transmission-Based Precautions, in addition to Standard Precauti ons, based on a review of the literature and evidence demonstrating a real or potential risk for person-to-person transmission in healthcare settings.The type and duration of recommended precautions are presented with additional comments concerning the use of adjunctive measures or other relevant considerations to prevent transmission of the s pecific agent. Relevant citations are included.

Pre- Publication of th e Guideline on Preventing Transmission of MDROs New to this guideline is a comprehensive review and detailed recommendations for prevention of transmission of MDROs. This portion of the guideline was published electronically in October 2006 and updated in November, 2006 (Siegel JD, Rhinehart E, Jackson M, Chiarello L and HICPAC. Management of Multidrug-Resist ant Organisms in Healthcare Settings 2006 www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf ), and is considered a part of the Guidel ine for Isolation Precautions. Th is section provides a detailed review of the complex topic of MDRO contro l in healthcare settings and is intended to provide a context for evaluation of MDRO at individual healthcare se ttings. A rationale and

9institutional requirements for developing an effective MDRO control program are summarized. Although the focus of this guideline is on measures to prevent transmission of MDROs in healthcare settings, information conc erning the judicious use of antimicrobial agents is presented since such practices are intricat ely related to the size of the reservoir of
MDROs which in turn influences transmission (e.g. colonization pressure). There are two
tables that summarize reco mmended prevention and control practices using the following seven categories of interventions to control MDROs: administrative measures, education of healthcare personnel, judicious anti microbial use, surveillance, infection control precautions, environmental measures, and decol onization. Recommendations for each category apply to and are adapted for the various healthcare settings. With the increasing incidence and prevalence of MDROs, all healthcare facilities must prioritize effective control of MDRO transmission. Facilities should identify prevalent MDROs at the facility, implement control measures, assess the effectiveness of c ontrol programs, and dem onstrate decreasing
MDRO rates. A set of intens ified MDRO prevention interventions is presented to be added 1) if the incidence of transmission of a target MDRO is NOT decreasing despite implementation of basic MDRO infect ion control measures, and 2) when the first case(s) of an epidemiologically important MDRO is identified within a healthcare facility.

Summary This updated guideline responds to changes in healthcare delivery and addresses new concerns about transmission of infectious agent s to patients and healthcare workers in the
United States and infection contro l. The primary objective of the guideline is to improve the safety of the nation’s healthcare deliver y system by reducing the rates of HAIs.

10Abbreviations Used in the Guideline

AIIR Airborne infection isolation room
CDC Centers for Diseas e Control and Prevention CF Cystic fibrosis
CJD Creutzfeld-Jakob Disease
CLSI Clin ical Laboratory Standards Institute ESBL Extended spectrum beta-lactamases FDA Food and Drug Administration
HAI Healthcare-associated infections HBV Hepatitis B virus HCV Hepatitis C virus HEPA High efficiency parti culate air [filtration]
HICPAC Healthcare Infection Cont rol Practices Advisory Committee HIV Human immunodeficiency virus
HCW Healthcare worker HSCT Hematopoetic stem-cell transplant
ICU Intensive care unit LTCF Long-term care facility MDRO Multidrug-resistant organism MDR-GNB Multidrug-resist ant gram-negative bacilli
MRSA Methicillin-resistant Staphylococcus aureus
NCCLS National Co mmittee for Clinical Laboratory Standards
NICU Neonatal intensive care unit NIOSH National Institute for Occupational Safety and Health, CDC
NNIS National Nosocomial Infection Surveillance NSSP Nonsusceptible Streptococcus pneumoniae OSHA Occupational Safety and Health Administration
PICU Pediatric intensive care unit PPE Personal protective equipment RSV Respiratory syncytial virus SARS Severe acquired respiratory syndrome
vCJD variant Creutzfeld-Jakob Disease VRE Vancomycin-resistant enterococci WHO World Health Organization

11

### Part I: Review of Scientific Data Regarding Transmission of Infectious Agents in Healthcare Settings

I.A. Evolution of the 2007 Document
The Guideline for Isolation Precautions: Pr eventing Transmission of Infectious Agents in Healthcare Settings 2007 builds upon a series of isolation and infection prevention documents promul gated since 1970. These previous documents are
summarized and referenced in Table 1 and in Part I of the 1996 Guideline for Isolation Precautions in Hospitals 1

. Objectives and methods The objectives of this guideline are to 1) provide
infection control recommendations for all components of the healthcare delivery system, including hospitals, long-term care facilities, ambulatory care, home care and hospice; 2) reaffirm Standard Precaut ions as the foundation for preventing transmission during patient care in a ll healthcare settings; 3) reaffirm the importance of implementi ng Transmission-Based Precautions based on the clinical presentation or syndrome and likely pathogens until the infectious etiology has been determined (Table 2); and 4) provide epidemio logically sound and, whenever possible, evidence-based recommendations. This guideline is designed for use by individuals who are charged with administering infection control programs in hospitals and other healthcare settings. The information also will be useful for other healthcare personnel, healthcare administrators, and anyone needing information about infection control measures to prevent transmi ssion of infectious agents. Commonly used abbreviations are provided on page 12 and terms used in the guideline are defined in the Glossary (page 137).
Med-line and Pub Med were used to sear ch for relevant studies published in English, focusing on those published since 1996. Much of the evidence cited for preventing transmission of infectious agent s in healthcare settings is derived from studies that used “quasi-experim ental designs”, also referred to as nonrandomized, pre- post-intervention study designs 2

. Although these types of studies can provide valuable information regarding the effectiveness of various interventions, several factors decrease the certainty of a ttributing improved outcome to a specific intervention. These include: difficulties in controlling for important confounding variabl es; the use of multiple interventions during an outbreak; and results that are explained by the statistical principle of regression to the mean, (e.g., improvement ov er time without any intervention) 3

. Observational studies remain relevant and have been used to evaluate infection
control interventions 4, 5 . The quality of studies, consistency of results and correlation with results from randomized, controlled trials when available were considered during the lit erature review and assi gnment of evidence-based categories (See Part IV: Recommendations ) to the recommendations in this guideline. Several authors have summarized properties to consider when evaluating studies for the purpose of det ermining if the results should change practice or in designing new studies 2, 6, 7

.

12Changes or clarificati ons in terminology This guideline contains four changes in terminology fr om the 1996 guideline:

 The term nosocomial infection is retained to refer only to infections acquired in hospitals. The term healthcare-associated infection (HAI) is used to refer to infections associated with healthcare delivery in any setting (e.g., hospitals, l ong-term care facilities, ambulatory settings, home care). This term reflects the inabilit y to determine with certainty where the pathogen is acquired since patients may be colonized with or exposed to potential pathogens outside of the heal thcare setting, before receiving health care, or may develop infecti ons caused by those pathogens when exposed to the conditions associated with delivery of healthcare. Additionally, patients frequently move among the various settings within a healthcare system 8

.

 A new addition to the practice re commendations for Standard Precautions
is Respiratory Hygiene/Cough Etiquette . While Standard Precautions generally apply to the recommended pr actices of healthcare personnel during patient care, Respiratory Hy giene/Cough Etiquette applies broadly to all persons who enter a healthca re setting, including healthcare personnel, patients and visitors. Thes e recommendations evolved from observations during the SARS epidemic that failure to implement basic source control measures with patients, visitors, and healthcare personnel with signs and symptoms of respiratory tract infection may have contributed to SARS coronavirus (SAR S-CoV) transmission. This concept has been incorporated into CDC planning documents for SARS and pandemic influenza 9, 10

.

 The term “Airborne Precautions” has been supplemented with the term

“ Airborne Infection Isolation Room (AIIR) ” for consistency with the
Guidelines for Environmental Infecti on Control in Healthcare Facilities 11

, the Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings 2005 12 and the American Institute of Architects (AIA) guidelines for desi gn and construction of hospitals, 2006

13

 A set of prevention measures termed Protective Environment has been added to the precautions used to prev ent HAIs. These measures, which
have been defined in other guidelines , consist of engineering and design
interventions that decrease the risk of exposure to environmental fungi for severely immunocompromised all ogeneic hematiopoietic stem cell transplant (HSCT) patients during their highest risk phase, usually the first 100 days post transplant, or longer in the presence of graft-versus-host
disease 11, 13-15 . Recommendations for a Protective Environment apply only to acute care hospitals that provide care to HSCT patients.

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 separatel y in November 2006, and are available
online at www.cdc.gov/ncidod/dhqp/index.html . Several other HICPAC

13guidelines 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 HealthcareAssociated Pneumonia , and Guideline for Infection Control in Healthcare
Personnel 11, 14, 16, 17 . In combination, these provide comprehensive guidance on the primary infection cont rol measures for ensuring a safe environment for patients and healthcare personnel.

This guideline does not discuss in detail s pecialized 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 Transmissi on of Mycobacterium tuberculosis in
Health-Care Facilities 2005

, Guidelines for Infection Control in Dental HealthCare Settings and Infection Control Recommendations for Patients with Cystic
Fibrosis 12, 18-20 . An exception has been made by including abbreviated guidance
for a Protective Environment used fo r allogeneic HSCT recipients because components of the Protecti ve 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 Facilities 11, 15

.

I.B. Rationale for Standard and Transmission-Based Precautions in healthcare settings

Transmission of infectious agents within a healthcare setting requires three elements: a source (or reservoir) of in fectious agents, a susceptible host with a portal of entry receptive to the agen t, and a mode of transmission for the agent.
This section describes the interrelationshi p of these elements in the epidemiology
of HAIs.

I.B.1. Sources of infectious agents Infectious agents transmitted during healthcare derive primarily from human sources but inanimate environmental sources also are implicated in transmissi on. Human reservoirs include patients

20-28 , healthcare personnel 29-35 17, 36-39 , and household members and other
visitors 40-45 . Such source individuals may have active infections, may be in the asymptomatic and/or incubat ion period of an infectious disease, or may be transiently or chronically colonized with pathogenic microorganisms, particularly in the respiratory and gastrointestinal tracts. The endogenous flora of patients (e.g., bacteria residing in the respiratory or gastrointe stinal tract) also are the
source of HAIs 46-54

.

I.B.2. Susceptible hosts Infection is the result of a complex interrelationship between a potential host and an infectious agent. Most of the factors that
influence infection and the occurrence and seve rity of disease are related to the host. However, characteristics of the hos t-agent interaction as it relates to

14pathogenicity, virulence and antigenicity are also importan t, as are the infectious dose, mechanisms of disease pr oduction and route of exposure 55 . There is a spectrum of possible outcomes following exposure to an infectious agent. Some persons exposed to pathogenic microorgani sms never develo p symptomatic disease while others become severely ill and even die. Some individuals are prone to becoming transiently or permanently colonized but remain asymptomatic. Still others progress from colonization to symptomatic disease either immediately following exposure, or after a period of asymptomatic
colonization. The immune state at the ti me of exposure to an infectious agent, interaction between pathogens, and virulence factors intrinsic to the agent are important predictors of an indi viduals’ outcome. Host factors such as extremes of age and underlying disease (e.g. diabetes 56, 57 ), human immunodeficiency virus/acquired immune deficiency syndrome [HIV/AIDS] 58, 59 , malignancy, and transplants 18, 60, 61 can increase susceptibility to infection as do a variety of
medications that alter the normal flora (e.g., antimicr obial agents, gastric acid suppressants, corticosteroids, antir ejection drugs, antineoplastic agents, and immunosuppressive drugs). Surgical pr ocedures and radiation therapy impair
defenses of the skin and other involved organ systems. Indwelling devices such as urinary catheters, endot racheal tubes, central venous and arterial catheters 62-

64 and synthetic implants facilitate devel opment of HAIs by allowing potential pathogens to bypass local defenses that would ordinarily impede their invasion and by providing surfaces for developm ent of bioflms that may facilitate adherence of microorganism s and protect from antimicrobial activity 65 . Some infections associated with invasive procedur es result from transmission within the healthcare facility; others arise from the patient’s endogenous flora 46-50 . High-risk patient populations with noteworthy risk fa ctors for infection are discussed further in Sections I.D, I.E., and I.F.

I.B.3. Modes of transmission Several classes of pathogens can cause infection, including bacteria, viruses, f ungi, parasites, and prions. The modes of transmission vary by type of organism and some infectious agents may be transmitted by more than one route: some are transmitted primar ily by direct or indirect contact, (e.g., Herpes simplex virus [HSV], respiratory syncytial virus, Staphylococcus aureus ), others by the droplet, (e.g., influenza virus, B. pertussis ) or airborne routes (e.g., M. tuberculosis) . Other infectious agents, such as bloodborne viruses (e.g., hepatitis B and C viruses [HBV, HCV] and HIV are transmitted rarely in healthcare settings , via percutaneous or mucous membrane exposure. Importantly, not all infectious agents are transmitted from person to person. These are distinguished in Appendix A. The three principal routes of
transmission are summarized below.

I.B.3.a

. Contact transmission The most common mode of transmission,
contact transmission is divided into tw o subgroups: direct contact and indirect
contact.

15I.B.3.a.i. Direct contact transmission Direct transmission occurs when microorganisms are transferred from one infected person to another person without a contaminated intermediate object or person. Opportunities for direct contact transmission between pati ents and healthcare personnel have been summarized in the Guideline for Infection Control in Healthcare Personnel, 1998

17 and include:

• blood or other blood-containing body fluids from a patient directly enters a caregiver’s body through contact with a mucous membrane 66 or breaks (i.e., cuts, abrasions) in the skin 67

.

• mites from a scabies-infested pati ent are transferred to the skin of a caregiver while he/she is having direct ungloved contact with the patient’s skin 68, 69

.

• a healthcare provider develops her petic whitlow on a finger after contact with HSV when providing oral care to a patient without using gloves or HSV is transmitted to a pat ient from a herpetic whitlow on an ungloved hand of a healthcare worker (HCW) 70, 71

.

I.B.3.a.ii. Indirect contact transmission Indirect transmission involves the transfer of an infectious agent through a contaminated intermediate object or person. In the absence of a point-source out break, it is difficult to determine how
indirect transmission occurs. However, extensive evidence cited in the Guideline for Hand Hygiene in Health-Care Settings suggests that the contaminated hands of healthcare personnel are important contributors to indirect contact
transmission 16 . Examples of opportunities for indirect contact transmission
include:

• Hands of healthcare personnel may transmit pathogens after touching an infected or colonized body site on one patient or a contaminated inanimate object, if hand hygiene is not performed before touching another patient. 72, 73

.

• Patient-care devices (e.g., electronic thermometers, glucose monitoring devices) may transmit pathogens if devices contaminated with blood or body fluids are shar ed between patients without cleaning and disinfecting between patients 74 75-77

.

• Shared toys may become a vehicle fo r transmitting respiratory viruses (e.g., respirator y syncytial virus 24, 78, 79 or pathogenic bacteria (e.g., Pseudomonas aeruginosa 80 ) among pediatric patients.

• Instruments that are inadequat ely cleaned between patients before disinfection or sterilization (e.g., e ndoscopes or surgical instruments)

81-85 or that have manufa cturing defects that interfere with the effectiveness of reprocessing 86, 87 may transmit bacterial and viral pathogens. Clothing, uniforms, laboratory coats, or isolation gowns used as personal protective equipment (PPE) , may become contaminated with potential pathogens after care of a patient colonized or in fected with an infectious agent, (e.g., MRSA

88 , VRE 89 , and C. difficile 90 . Although contaminated clothing has not been

16implicated directly in transmission, the potential exists for soiled garments to transfer infectious agents to successive patients.

I.B.3.b. Droplet transmission Droplet transmission is , technically, a form of contact transmission, and some infectious agents transmitted by the droplet route also may be transmitted by the direct and i ndirect contact routes. However, in contrast to contact transmission, re spiratory droplets carrying infectious pathogens transmit infection when they travel directly from the respiratory tract of the infectious individual to susceptib le mucosal surfaces of the recipient, generally over short distances, necessita ting facial protection. Respiratory droplets are generated when an infected person coughs, sneezes, or talks 91, 92 or during procedures such as suct ioning, endotracheal intubation, 93-96 , cough induction by chest physiotherapy 97 and cardiopulmonary resuscitation 98, 99

. Evidence for droplet transmission comes from epidemiological studies of disease
outbreaks 100-103 , experimental studies 104 and from information on aerosol dynamics 91, 105 . Studies have shown that the nasal mucosa, conjunctivae and less frequently the mouth, are susceptible po rtals of entry for respiratory viruses

106

. The maximum distance for droplet transmission is currently unresolved, although pathogens transmitted by the dr oplet route have not been transmitted through the air over long distances, in contrast to the airborne pathogens discussed below. Historically, the area of defined risk has been a distance of < 3 feet around the patient and is based on epide miologic and simulated studies of
selected infections 103, 104 . Using this distance for donning masks has been effective in preventing transmission of in fectious agents via the droplet route. However, experimental studies with smallpox 107, 108 and investigations during the global SARS outbreaks of 2003 101 suggest that droplets from patients with these two infections could reach persons located 6 feet or more from their source. It is likely that the distance droplets travel depends on the velocity and mechanism by which respiratory droplets are propel led from the source, the density of respiratory secretions, environmental fact ors such as temper ature and humidity, and the ability of the pathogen to maintain infectivity over that distance 105 . Thus,
a distance of < 3 feet around the patient is best viewed as an example of what is meant by “a short distance from a pat ient” and should not be used as the sole
criterion for deciding when a mask should be donned to protect from droplet exposure. Based on these considerations, it may be prudent to don a mask when
within 6 to 10 feet of the patient or upon entry into t he patient’s room, especially when exposure to emerging or highly viru lent pathogens is likely. More studies are needed to improve under standing of droplet transmission under various
circumstances.

Droplet size is another variable under discussion. Droplets traditionally have been defined as being >5 μm in size. Dr oplet nuclei, particles arising from desiccation of suspended droplets, have been associated with airborne
transmission and defined as < 5 μm in size 105 , a reflection of the pathogenesis of pulmonary tuberculosis which is not generalizeable to other organisms. Observations of particle dynamics hav e demonstrated that a range of droplet sizes, including those with diameters of 30μm or greater, can remain suspended

17in the air 109 . The behavior of droplets and droplet nuclei affect recommendations for preventing transmissi on. Whereas fine airborne particles containing pathogens that are able to rema in infective may transmit infections over long distances, requiring AIIR to prev ent its dissemination within a facility; organisms transmitted by the droplet rout e do not remain infective over long distances, and therefore do not require special air handling and ventilation. Examples of infectious agents that are transmitted via the droplet route include Bordetella pertussis 110

, influenza virus 23 , adenovirus 111 , rhinovirus 104

, Mycoplasma pneumoniae 112 , SARS-associated cor onavirus (SARS-CoV) 21, 96,

113 , group A streptococcus 114 , and Neisseria meningitidis 95, 103, 115 . Although respiratory syncytial virus may be transmitt ed by the droplet route, direct contact with infected respiratory secretions is the most important determinant of
transmission and consistent adherence to Standard plus Contact Precautions prevents transmission in healthcare settings 24, 116, 117

.
Rarely, pathogens that are not transmitted routinely by the droplet route are dispersed into the air over shor t distances. For example, although S. aureus is transmitted most frequently by the contact route, viral upper respiratory tract
infection has been associated wit h 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” phenomenon 118-120

.

I.B.3.c. Airborne transmission Airborne transmission occurs by
dissemination of either airbor ne droplet nuclei or small pa rticles in the respirable size range containing infectious agents that remain infective over time and distance (e.g., spores of Aspergillus spp, and Mycobacterium tuberculosis ). Microorganisms carried in this manner may be dispersed over long distances by air currents and may be inhaled by susceptible individuals who have not had face-to-face contact with (or been in the same room with) the infectious individual

121-124 . Preventing the spread of pathogens that are tran smitted by the airborne route requires the use of special air handl ing and ventilation systems (e.g., AIIRs) to contain and then safely remove the infectious agent 11, 12 . Infectious agents to which this applies include Mycobacterium tuberculosis 124-127 , rubeola virus (measles) 122 , and varicella-zoster virus (chickenpox) 123 . In addition, published data suggest the possibility that variola virus (smallpox) may be transmitted over long distances through the air under unusual circumstances and AIIRs are recommended for this agent as well; however , droplet and contact routes are the more frequent routes of tr ansmission for smallpox 108, 128, 129 . In addition to AIIRs, respiratory protection with N IOSH certified N95 or higher level respirator is recommended for healthcare personnel entering the AIIR to prevent acquisition of airborne infectious agents such as M. tuberculosis 12

.
For certain other respiratory infe ctious agents, such as influenza 130, 131 and
rhinovirus 104 , and even some gastrointestinal viruses (e.g., norovirus 132 and
rotavirus 133 ) 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 lo nger than 3 feet but within a defined

18airspace (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 transmi ssion of these agents. Addi tional issues concerning examples of small particle aerosol transmission of agents that are most frequently transmitted by the dropl et route are discussed below.

I.B.3.d. Emerging issues concerning airb orne transmission of infectious agents.

I.B.3.d.i. Transmission from patients The emergence of SARS in 2002, the importation of monkeypox into the Unit ed States in 2003, and the emergence of avian influenza present challenges to the assignment of is olation categories because of conflicting information and unc ertainty about possible routes of transmission. Although SARS-CoV is transmitted primarily by contact and/or droplet routes, airborne transmission over a limited distance (e.g. within a room), has been suggested, though not proven 134-141 . This is true of other infectious agents such as influenza virus 130 and noroviruses 132, 142, 143 . Influenza viruses are transmitted primarily by close contact with respiratory droplets 23, 102 and acquisition by healthcare personnel has been prevented by Droplet Precautions, even when positive pressure r ooms were used in one center 144 However,
inhalational transmission could not be exclu ded in an outbreak of influenza in the passengers and crew of a single aircraft 130 . Observations of a protective effect of UV lights in preventing influenza among patients with tuber culosis during the influenza pandemic of 1957-’58 have been used to suggest airborne
transmission 145, 146

. In contrast to the strict interpretation of an airbor ne 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 μ m can remain suspended in air when room air current velocities exceed the terminal settling velocities of the particles 109 . SARS-CoV transmission has been associated with endotracheal intubation, noninvasive positiv e pressure ventilation, and cardiopulmonary resuscitation 93, 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 material 142, 143, 147, 148 . It is hypothesized that the aerosolized particles are i nhaled and subsequently swallowed.

Roy and Milton proposed a new classifica tion 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. meas les, varicella); and 3) opportunistic : agents that naturally cause disease through other r outes, but under spec ial circumstances

19may be transmitted via fine particle aerosols 149 . This conceptual framework can explain rare occurrences of air borne transmission of agents that are transmitted most frequently by other routes (e.g., smallpox, SARS, influenza, noroviruses). Concerns about unknown or possible rout es of transmission of agents associated
with severe disease and no known treatm ent often result in more extreme prevention strategies than may be necessary; therefore, recommended precautions could change as the epidemio logy 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-toperson transmission. For example, anthrax spores present in a finely milled powdered preparation can be aerosolized from contaminated environmental surfaces and inhaled into the respiratory tract 150, 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) spores 152, 153 . As a rule, neither of these organisms is subsequently transmitted from infected pat ients. However, there is one welldocumented report of person- to-person transmission of Aspergillus sp. in the ICU setting that was most likey due to the aerosolization of s pores during wound
debridement 154 . A Protective Environment refers to isolation practices designed to decrease the risk of exposure to environmental fungal agents in allogeneic HSCT patients 11, 14, 15, 155-158

. Environmental sources of respirator y pathogens (eg. Legionella) transmitted to humans through a common aerosol source is distinct from direct patient-topatient transmission.

I.B.3.e. Other sources of infection Transmission of infection from sources
other than infectious individual s 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 systems 159 , the role of water as a reservoir for immunosuppressed patients remains uncertain. Vectorborne transmission of infectious agents from mos quitoes, flies, rats, and other vermin also can occur in healthcare settings. Prevention of vector borne transmission is not addressed in
this document.

I.C. Infectious agents of special infection control interest for healthcare settings

Several infectious agents with important infection control implications that either were not discussed extensively in previ ous isolation guide lines or have emerged recently are discussed below. These ar e epidemiologically important organisms (e.g., C. difficile )

, agents of bioterrorism, prio ns, SARS-CoV, monkeypox, noroviruses, and the hemorrhagic fever vi ruses. Experience with these agents has broadened the understanding of m odes of transmission and effective

20preventive measures. Thes e agents are included for purposes of information and, for some (i.e., SARS-CoV, monkey pox), because of the lessons that have been learned about preparedness planning and responding effectively to new
infectious agents



## .

I.C.1. Epidemiologically important organisms Any infectious agents transmitted in healthcare settings ma y, under defined conditions, become targeted for control because they are epidemiologica lly important. C. difficile is specifically discussed below because of wide recognition of its current importance in U.S. healthcare facilitie s. In determining what constitutes an “epidemiologically im portant organism”, the follo wing characteristics apply:

• A propensity for transmission withi n healthcare facilities based on published reports and the occurrence of temporal or geographic clusters of > 2 patients, (e.g., C..difficile , norovirus, respiratory syncytial virus (RSV), influenza, rotavirus, Enterobacter spp; Serratia spp., group A streptococcus). A single case of healthcare-associated invasive disease caused by certain pathogens (e.g., gr oup A streptococcus post-operatively
14, 163 160 , in burn units 161 , or in a LTCF 162 ; Legionella sp.

, Aspergillus sp. 164 ) is generally considered a tri gger for investigation and 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, ESBLproducing organisms).

• Common and uncommon microorgani sms 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 di sease, increased morbidity and mortality (e.g., MRSA and MSSA, group A streptococcus)

• A newly discovered or reemerging pathogen

I.C.1.a. C.difficile C. difficile is a spore-forming gram positive anaerobic bacillus
that was first isolated fr om stools of neonates in 1935 165 and identified as the most commonly identified causative agent of antibiotic-associated diarrhea and pseudomembranous colitis in 1977 166 . This pathogen is a major cause of
healthcare-associated diarrhea and has been responsible for many large outbreaks in healthcare settings that were ex tremely difficult to control. Important
factors that contribute to healthcare-a ssociated outbreaks in clude environmental contamination, persistence of spores for prolonged periods of time, resistance of spores to routinely used disinfectants and antiseptics, hand carriage by healthcare personnel to other patients, and exposure of pat ients to frequent
courses of antim icrobial agents 167 . Antimicrobials most frequently associated

21with increased risk of C. difficile include third generation cephalosporins, clindamycin, vancomyci n, and fluoroquinolones.

Since 2001, outbreaks and sporadic cases of C. difficile with increased morbidity and mortality have been observed in severa l U.S. states, Canada, England and
the Netherlands 168-172 . The same strain of C. difficile has been implicated in
these outbreaks 173 . 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% perceiv ed recent increases in the incidence and severity of C. difficile disease 174 . Standardization of testing methodology and
surveillance definitions is needed for accu rate comparisons of trends in rates among hospitals 175 . It is hypothesized that the incidence of disease and apparent heightened transmissibility of this new strain may be due, at least in part, to the greater producti on of toxins A and B, increasing the severity of diarrhea and resulting in more environm ental contamination. Considering the greater morbidity, morta lity, length of stay, and costs associated with C. difficile disease in both acute care and long term care facilities, control of this pathogen is now even more important than previ ously. Prevention of transmission focuses on syndromic application of Contact Precautions for patients with diarrhea, accurate identification of patients, env ironmental measures (e.g., rigorous cleaning of patient rooms) and consistent hand hygiene. Use of soap and water,
rather than alcohol based handrubs, for mechanical re moval of spores from hands, and a bleach-containing disinf ectant (5000 ppm) for environmental disinfection, may be valuable when there is transmission in a healthcare facility. See Appendix A for sp ecific recommendations.

I.C.1. b. Multidrug-Resistant Organisms (MDROs) In general, MDROs are defined as microorganisms – pr edominantly bacteria – that are resistant to one or more classes of antimicrobial agents 176 . Although the names of certain MDROs suggest resistance to only one agent (e.g., methicillin-resistant Staphylococcus

aureus [MRSA], vancomycin resistant enteroc occus [VRE]), these pathogens are usually resistant to all but a few commerc ially available antimic robial agents. This
latter feature defines MDROs that ar e considered to be epidemiologically important and deserve special attention in healthcare facilities 177 . Other MDROs of current concern include multidrug-resistant Streptococcus pneumoniae (MDRSP) which is resistant to penicill in and other broad- spectrum agents such as macrolides and fluroquinolones, mult idrug-resistant gr am-negative bacilli (MDR- GNB), especially those producin g extended spectrum beta-lactamases (ESBLs); and strains of S. aureus that are intermediate or resistant to vancomycin (i.e., VISA and VRSA) 178-197 198

.
MDROs are transmitted by the same r outes as antimicrobial susceptible infectious agents. Patient-to-patient tr ansmission in healthcare settings, usually via hands of HCWs, has been a major fact or accounting for the increase in MDRO incidence and prevalence, especia lly for MRSA and VRE in acute care

22facilities 199-201 . Preventing the emergence and transmission of these pathogens requires a comprehensive approach that includes administrative involvement and measures (e.g., nurse staffing, communication systems, performance improvement processes to ensure adher ence to recommended infection control measures), education and training of medical and other healthcare personnel, judicious antibiotic use, comprehens ive surveillance for targeted MDROs, application of infection c ontrol precautions during pat ient care, environmental measures (e.g., cleaning and disinfection of the patient ca re environment and equipment, dedicated single- patient-use of non-cr itical equipment), and decolonization therapy when appropriate.

The prevention and control of MDROs is a national priority - one that requires that all healthcare facilities and agencies as sume responsibility and participate in community-wide control programs 176, 177 . A detailed discussion of this topic and recommendations for prevention was published in 2006 may be found at http://www.cdc.gov/ncidod/dhqp/ pdf/ar/mdroGuideline2006.pdf

I.C.2. Agents of bioterrorism CDC has designated the agents that cause anthrax, smallpox, plague, tularemia, vi ral hemorrhagic fevers, and botulism as Category A (high priority) because t hese agents can be easily disseminated environmentally and/or transmitted from person to person; can cause high mortality and have the potential for majo r public health impact; might cause public panic and social disruption; and require special action for public health preparedness 202 . General information relevant to infection control in healthcare settings for Category A agents of bioterrorism is summarized in Table 3. Consult www.bt.cdc.gov for additional, updated Ca tegory A agent information as well as information concerning Category B and C agents of bioterrorism and updates. Category B and C agents are im portant but are not as readily disseminated and cause less morbidity and mort ality than Category A agents.

Healthcare facilities confront a diff erent set of issues when dealing with a suspected bioterrorism event as com pared with other comm unicable diseases. An understanding of the epidemiology, m odes 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) ident ifying 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 envir onment including the logist ical aspects of securing
sufficient numbers of AIIRs or designating areas for patient cohorts when there
are an insufficient number of AIIRs ava ilable;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

23care of patients with smallpox). The re sponse 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 bioterrori sm. Federal agency websites (e.g., www.usamriid.army.mil/publications/index.html

, www.bt.cdc.gov ) and state and county health department web sites should be consulted for the most up-to-date information. Sources of information on specific agents include: anthrax 203 ; smallpox 204-206 ; plague 207, 208 ; botulinum toxin 209 ; tularemia 210 ; and hemorrhagic fever viruses: 211, 212

.

I.C.2.a. Pre-event administration of smallpox (vaccinia) vaccine to healthcare personnel Vaccination of personnel in preparation for a possible smallpox exposure has important infection control implications 213-215 . These
include the need for meticulous screeni ng for vaccine contraindications in persons who are at increased risk for adv erse vaccinia events; containment and monitoring of the vaccination site to prevent transmission in the healthcare setting and at home; and the management of patients with vaccinia-related
adverse events 216, 217 . The pre-event U.S. smallpox vaccination program of 2003 is an example of the effectiveness of carefully developed recommendations for both screening potential vaccinees for contra indications and vaccination site care and monitoring. Approxim ately 760,000 individuals were vaccinated in the Department of Defense and 40,000 in the civilian or public health populations from December 2002 to February 2005, including approximately 70,000 who worked in healthcare settings. There were no cases of eczema vaccinatum, progressive vaccinia, fetal vaccinia, or c ontact transfer of vaccinia in healthcare settings or in military workplaces 218, 219 . Outside the healthcare setting, there
were 53 cases of contact transfer from military vaccinees to close personal contacts (e.g., bed partners or contacts during participation in sports such as wrestling 220 ). All contact transfers were from individuals who were not following
recommendations to cover their vaccinatio n sites. Vaccinia virus was confirmed by culture or PCR in 30 cases, and two of the confirmed cases resulted from tertiary transfer. All recipients, includi ng one breast-fed infant, recovered without complication. Subsequent studies using viral culture and PCR techniques have confirmed the effectiveness of semipe rmeable dressings to contain vaccinia 221-

224

. This experience emphasizes the im portance of ensuring that newly vaccinated healthcare personnel adhere to recommended vaccination-site care, especially if they are to care for hi gh-risk patients. Recommendations for preevent smallpox vaccination of healthcare personnel and vaccinia-related infection control recommendations are published in the MMWR 216, 225 with updates posted
on the CDC bioterrorism web site 205

.

I.C.3. Prions Creutzfeldt-Jakob disease (CJD) is a rapidly progressive, degenerative, neurologic disorder of humans with an incidence in the United States of approximately 1 person/million population/year 226, 227

24( www.cdc.gov/ncidod/diseases/cjd/cjd.htm ). CJD is believed to be caused by a transmissible proteinaceous infectious agent termed a prion. Infectious prions are isoforms of a host-encoded glycoprotein known as the prion protein. The incubation period (i.e., time between exposure and and onset of symptoms) varies from two years to many decades. However, death typically occurs within 1 year of the onset of symptoms. A pproximately 85% of CJD cases occur sporadically with no known environmental source of infection and 10% are familial. Iatrogenic transmission has occurr ed with most resulti ng from treatment with human cadaveric pituitary-der ived growth hormone or gonadotropin 228, 229

, from implantation of contami nated human dura mater grafts 230 or from corneal transplants 231 ). Transmission has been linked to the use of contaminated neurosurgical instruments or stereotactic electroenc ephalogram electrodes 232,

233 , 234 , 235

.
Prion diseases in animals include scrapi e in sheep and goats, bovine spongiform encephalopathy (BSE, or “m ad cow disease”) in catt le, and chronic wasting
disease in deer and elk 236 . BSE, first recognized in t he United Kingdom (UK) in 1986, was associated with a major epidem ic among cattle that had consumed
contaminated meat and bone meal.

The possible transmission of BSE to hum ans causing variant CJD (vCJD) was first described in 1996 and subsequent ly found to be associated with consumption of BSE-contaminated cattl e products primarily in the United Kingdom. There is strong epidemiologic and laboratory evidence for a causal
association between the caus ative agent of BSE and vCJD 237 . 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 dur ing the years of a large outbreak of BSE (1980-96) and may have consumed contam inated cattle products during that time (www.cdc.gov/ncidod/diseases/cjd /cjd.htm). Although there has been no indigenously acquired vCJD in the Unit ed States, the sporadic occurrence of BSE in cattle in North America has height ened awareness of the possibility that
such infections could occur and have l ed to increased surveillance activities. Updated information may be found on the following website: www.cdc.gov/ncidod/diseases/cjd/cjd.htm . The public health impact of prion
diseases has been reviewed 238

.

vCJD in humans has different clinical and pathologic characteristics from sporadic or classic CJD 239

, 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 s ensory 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 patients 240 . 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 ai rborne routes. Ongoing blood safety
surveillance in the U.S. has not detected sporadic CJD transmission through

25blood transfusion 241-243

. However, bloodborne transmission of vCJD is believed to have occurred in two UK patients 244, 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: http://www.fda.gov/cber/gdlns/cjdvcjd.htm ;

http://www.fda.gov/cber/gdlns/cjdvcjdq&a.htm

.

Standard Precautions are used when cari ng for patients with suspected or confirmed CJD or vCJD. However, s pecial precautions are recommended for tissue handling in the histology labo ratory and for conducting an autopsy, embalming, and for contact with a body that has undergone autopsy 246

. Recommendations for reprocessing surgical instruments to prevent transmission of CJD in healthcare settings have been published by the World Health Organization (WHO) and are curr ently under review at CDC.

Questions concerning notification of pati ents potentially exposed to CJD or vCJD through contaminated instruments and bloo d products from patients with CJD or vCJD or at risk of having vCJD may aris e. The risk of transmission associated with such exposures is believed to be extremely low but may vary based on the specific circumstance. Therefore consul tation on appropriate options is advised. The United Kingdom has developed seve ral documents that clinicians and patients in the US may find useful ( http://www.hpa.org.uk/infections/topi cs_az/cjd/information_documents.htm ).

I.C.4. Severe Acute Respir atory Syndrome (SARS) SARS is a newly discovered respiratory disease that emer ged in China late in 2002 and spread to
several countries 135, 140 ; Mainland China, Hong K ong, Hanoi, Singapore, and Toronto were affected significantly. SARS is caused by SARS CoV, a previously unrecognized member of t he coronavirus family 247, 248 . The incubation period from exposure to the onset of symptoms is 2 to 7 days but can be as long as 10 days and uncommonly even longer 249 . The illness is initially difficult to distinguish from other common respiratory infections. Signs and symptoms usually include fever >38.0 o C and chills and rigors, sometimes accompanied by headache, myalgia, and mild to severe respiratory symptoms. Radiographic finding of atypical pneumonia is an import ant clinical indicato r of possible SARS. Compared with adults, children have been affected less frequently, have milder disease, and are less likel y to transmit SARS-CoV 135, 249-251 . The overall case fatality rate is approximately 6. 0%; underlying disease and advanced age increase the risk of mortality ( www.who.int/csr/sarsarchive/2003_05_07a/en/ ).

Outbreaks in healthcare settings, wit h transmission to large numbers of healthcare personnel and patients have been a striking feat ure of SARS; undiagnosed, infectious patients and visitors were important initiators of these
outbreaks 21, 252-254 . The relative contribution of pot ential modes of transmission is not precisely known. There is ample evidence for droplet and contact
transmission 96, 101, 113 ; however, opportunistic air borne transmission cannot be
excluded 101, 135-139, 149, 255 . For example, exposu re to aerosol-generating

26procedures (e.g., endotracheal intubation, suctioning) was associated with transmission of infection to large numbers of healthcare personnel outside of the
United States 93, 94, 96, 98, 253 .Therefore, aerosolization of small infectious particles generated during these and other similar procedures could be a risk factor for
transmission to others within a multi-bed room or shared airspace. A review of the infection control literature gener ated from the SARS outbreaks of 2003 concluded that the greatest risk of transmission is to those who have close contact, are not properly trained in use of protective infection control procedures, do not consistently use PPE; and that N95 or higher respirators may offer additional protection to those expos ed to aerosol- generating procedures and high risk activities 256, 257 . Organizational and individual factors that affected adherence to infection control practice s for SARS also were identified 257

.
Control of SARS requires a coordinat ed, dynamic response by multiple disciplines in a healthcare setting 9 . Early detection of cases is accomplished by screening persons with symptoms of a respiratory infection for history of travel to areas experiencing community transmissi on or contact wit h SARS patients, followed by implementation of Respiratory Hygiene/Cough Etiquette (i.e., placing a mask over the patient’s nose and mouth) and physical separation from other patients in common waiting areas.The precise combination of precautions to protect healthcare personnel has not been determined. At the time of this publication, CDC recommends Standard Pr ecautions, with emphasis on the use of hand hygiene, Contact Precautions wit h emphasis on environmental cleaning due to the detection of SARS CoV RNA by PCR on surfaces in rooms occupied by SARS patients 138, 254, 258 , Airborne Precautions

, including use of fit-tested NIOSH-approved N95 or higher level respirators, and eye protection 259 . In Hong Kong, the use of Droplet and Contact Pr ecautions, which included use of a mask but not a respirator, was effectiv e in protecting healthcare personnel 113 . However, in Toronto, consistent use of an N95 resp irator was slightly more protective than
a mask 93 . It is noteworthy that there was no transmission of SARS-CoV to public hospital workers in Vietnam despite inconsistent use of infection control measures, including use of PPE, which sugge sts other factors (e.g., severity of disease, frequency of high risk procedures or events, environmental features) may influence opportunities for transmission 260

.
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 repor ted after the first series of outbreaks in the winter and spring of 2003 261, 262 . Studies of the SARS
outbreaks of 2003 and transmissions that o ccurred in the laboratory re-affirm the
effectiveness of recommended infection c ontrol precautions and highlight the importance of consistent adherence to these measures.

Lessons from the SARS outbreaks are useful for planning to respond to future public health crises, such as pandemic influenza and biote rrorism events. Surveillance for cases among patients and healthcare personnel, ensuring availability of adequate supplies and staffi ng, and limiting access to healthcare

27facilities were important factors in the response to SARS that have been
summarized 9 . Guidance for infection control pr ecautions in various settings is
available at www.cdc.gov/ncidod/sars

.

I.C.5. Monkeypox Monkeypox is a rare viral disease found mostly in the rain
forest countries of Central and West Africa. The disease is caused by an orthopoxvirus that is similar in appearanc e 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. Infecti on in the prairie dogs was subsequently
traced to their contact with a shipment of animals from Africa, including giant
Gambian rats 263 . This outbreak demonstrates t he importance of recognition and prompt reporting of unusual disease presentations by clinicians to enable prompt
identification of the etiol ogy; and the potential of epizootic diseases to spread
from animal reservoirs to humans th rough personal and occupational exposure

264

.
Limited data on transmission of monkey pox are available. Transmission from
infected animals and humans is believed to occur primarily through direct contact with lesions and respiratory secretions; airborne transmission from animals to humans is unlikely but cannot be excluded, and may have occurred in veterinary practices (e.g., during administration of nebulized medications to ill prairie dogs

265 ). Among humans, four instances of mo nkeypox transmission within hospitals have been reported in Africa among children, usually related to sharing the same
ward or bed 266, 267 . Additional recent literatur e documents transmission of Congo Basin monkeypox in a hospital compound for an extended number of generations

268

.

There has been no evidence of airbor ne or any other person-to-person transmission of monkeypox in the United States, and no new cases of monkeypox have been identified since the outbreak in June 2003 269 . The outbreak strain is a clade of monkeypox distinct from the Congo Basin clade and may have different epidemiologic pr operties (including human-to-human transmission potential) from monkey pox strains of the Congo Basin 270 ; this awaits further study. Smallpox vaccine is 85% protective against Congo Basin monkeypox 271 . Since there is an associated case fatality rate of < 10%, administration of smallpox vaccine within 4 days to individuals who have had direct exposure to patients or ani mals with monkeypox is a reasonable
consideration 272 . For the most current information on monkeypox, see www.cdc.gov/ncidod/monkeypox/clinicians.htm

.

I.C.6. Noroviruses Noroviruses, formerly referred to as Norwalk-like viruses, are
members of the Caliciviridae family. These agents are transmitted via
contaminated food or wate r and from person-to-pers on, causing explosive outbreaks of gastrointestinal disease 273 . Environmental contamination also has been documented as a contributing fact or in ongoing transmission during
outbreaks 274, 275 . Although noroviruses cannot be propagated in cell culture,

28DNA detection by molecular diagnostic techniques has facilitated a greater appreciation of their role in out breaks of gastrointestinal disease 276 . Reported outbreaks in hospitals 132, 142, 277 , nursing homes 275, 278-283 , cruise ships 284, 285

, hotels 143, 147 , schools 148 , and large crowded shelters established for hurricane

evacuees 286 , demonstrate their highly contagious nature, the disruptive impact they have in healthcare facilities and the community, and the difficulty of controlling outbreaks in settings wher e 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 case 287

.
The average incubation peri od for gastroenteritis caused by noroviruses is 12-48
hours and the clinical c ourse lasts 12-60 hours 273 . Illness is characterized by acute onset of nausea, vomiting, abdomin al cramps, and/or diarrhea. The disease is largely self-limited; rarely , death caused by severe dehydration can occur, particularly among the elderl y with debilitating health conditions.

The epidemiology of norovirus outbreaks shows that even though primary cases may result from exposure to a fecally-c ontaminated food or water, secondary and tertiary cases often result from person- to-person transmission that is facilitated by contamination of fomites 273, 288 and dissemination of infectious particles, especially during the process of vomiting 132, 142, 143, 147, 148, 273, 279, 280 . Widespread, persistent and inapparent contamination of the env ironment and fomites can make outbreaks extremely difficult to control 147, 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 feet 147 . It is hypothesized that infectious particles ma y be aerosolized from vomitus, inhaled, and swallowed. In addition, individuals who are responsible for cleaning the environment may be at increased risk of in fection. Development of disease and transmission may be facilitated by the lo w infectious dose (i.e., <100 viral particles) 289 and the resistance of these viru ses 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 effe ctive against feline calicivirus was used for environmental cleaning in one outbreak 275, 293 . There are insufficient data to determine the efficacy of alcohol-based hand rubs against noroviruses when the hands are not visibly soiled 294 . Absence of disease in certain individuals during an outbreak may be explained by protection from infection conferred by the B histo-blood group antigen 295 . Consultation on outbreaks of gastroenteritis is available through CDC’s Division of Viral and Rickettsial Diseases 296

.

I.C.7. Hemorrhagic fever viruses (HFV) The hemorrhagic fever viruses are a mixed group of viruses that cause seri ous 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 (Filo viridae), Lassa virus (Arenaviridae), Crimean-Congo hemorrhagic feve r and Rift Valley Fever virus (Bunyaviridae),

29and Dengue and Yellow feve r viruses (Flaviviridae) 212, 297 . These viruses are
transmitted to humans via contact with infe cted animals or via arthropod vectors.
While none of these viruses is endemic in the United States, outbreaks in affected countries provide potential opportu nities for importation by infected humans and animals. Furthermore, there are concerns that some of these agents could be used as bioweapons 212 . Person-to-person transmission is documented for Ebola, Marburg, Lassa and Crimean- Congo hemorrhagic fever viruses. In resource-limited healthcare settings, trans mission of these agents to healthcare personnel, patients and visitors has been described and in some outbreaks has accounted for a large proportion of cases 298-300 . 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 contact 301

.
Evidence concerning the transmission of HFVs has been summarized 212, 302

. Person-to-person transmission is associat ed primarily with di rect blood and body fluid contact. Percutaneous exposure to c ontaminated blood carries a particularly high risk for transmission and increased mortality 303, 304 . The finding of large numbers of Ebola viral particles in t he skin and the lumina of sweat glands has
raised concern that transmi ssion could occur from direct contact with intact skin though epidemiologic evidence to support this is lacking 305 . Postmortem handling of infected bodies is an important risk for transmission 301, 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 passengers 308

.
In the laboratory setting, animals have been infected experiment ally with Marburg
or Ebola viruses via direct inoculati on of the nose, mout h and/or conjunctiva 309,

310 and by using mechanically gener ated virus-containing aerosols 311, 312

. Transmission of Ebola virus among laborat ory primates in an animal facility has
been described 313 . Secondarily infected animals were in individual cages and separated by approximately 3 meters. Although the possibi lity of airborne transmission was suggested, the authors were not able to exclude droplet or
indirect contact transmission in this incidental observation.

Guidance on infection control precautions for HVFs that are transmitted personto-person have been published by CDC 1, 211 and by the Johns Hopkins Center for Civilian Biodefense Strategies 212 . The most recent recommendations at the time of publication of this document we re 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 prac tices, and safe burial practices 299, 306 . The preponderance of evidence on HFV transmission indicates that Standard, Contact and Droplet Precautions with eye pr otection are effective in protecting

30healthcare personnel and visitors who ma y 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. goggl es 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, broncho scopy, suctioning, autopsy procedures involving oscillating saws). N95 or hi gher level respirators may provide added protection for individuals in a room dur ing 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, precaut ions are initiated upon presentation and then modified as mo re 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 pot entially weaponized hemorrhagic fever virus is unpredictable.

I.D. Transmission risks associated with specific types of healthcare settings

Numerous factors influence differences in transmission risks among the various healthcare settings. These include the popul ation characteristics (e.g., increased susceptibility to infections, type and preval ence of indwelling devices), intensity of care, exposure to environmental sour ces, length of stay, and frequency of interaction between patients/residents with each other and with HCWs. These factors, as well as organizational prio rities, goals, and resources, influence how different healthcare settings adapt trans mission prevention guidelines to meet their specific needs 315, 316 . Infection control management decisions are informed by data regarding institutional experienc e/epidemiology, trends in community and institutional HAIs, local, regional, and national epidemiology, and emerging
infectious disease threats.

I.D.1. Hospitals Infection transmission risks are pr esent in all hospital settings. However, certain hospital settings and patient populations have unique conditions that predispose patients to in fection and merit special mention. These
are often sentinel sites for the emergence of new tr ansmission risks that may be unique to that setting or pr esent opportunities for transmi ssion to other settings in the hospital.

I.D.1.a. Intensive Care Units Intensive care units (I CUs) 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

31small proportion of hospitalized patients, infections acquired in these units accounted for >20% of all HAIs 317 . In the National Nosocomial Infection Surveillance (NNIS) system, 26.6% of HA Is were reported from ICU and high risk nursery (NICU) patients in 2002 (NNI S, unpublished data). This patient population has increased suscept ibility 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 a ssist devices), the frequency of contact with healthcare personnel, prolonged length of stay, and prolong ed exposure to antimicrobial agents 320-331 . Furthermore, adverse patient outcomes in this setting are more severe and are associated with a higher mortality 332 . Outbreaks associated with a variety of bacterial, fungal and viral pathogens due to commonsource and person-to-person transmissi ons are frequent in adult and pediatric
ICUs 31, 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 mortality 320, 339, 340 . In patients with a burn injury involving > 30% of the total body surface area (TBSA), the risk of
invasive burn wound infect ion is particularly high 341, 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-negat ive bacteria, and candida are prevalent pathogens in burn infections 53, 340, 343-350 and outbreaks of these organisms have been reported 351-354 . Shifts over time in the predominance of pathogens causing infections among burn patients often l ead to changes in burn care practices 343,

355-358 . Burn wound infections caused by Aspergillussp. or other environmental molds may result from ex posure to supplies contaminated during construction 359 or to dust generated during construction or other environmental disruption 360

.
Hydrotherapy equipment is an important environmental reservoir of gramnegative 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. aeruginosa 361

, A. baumannii 362 , and
MRSA 352 have been associated with hydrother apy; 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, select ive digestive decontamination (SDD), and use of antimicrobial-coated catheters (A CC), but few epidemiologic studies and no efficacy studies have been performed to show the relative benefit of these

357 measures

.

32There is no consensus on the most effectiv e infection control practices to prevent transmission of infections to and from pat ients with serious burns (e.g., singlebed rooms 358 , laminar flow 363 and high efficiency particulate air filtration [HEPA]

360 or maintaining burn patients in a separ ate unit without exposure to patients or equipment from other units 364 ). There also is controversy regarding the need for and type of barrier precautions for r outine care of burn patients. One retrospective study demonstrated effica cy and cost effectiveness of a simplified barrier isolation protocol for wound colonization, emphasizing handwashing and use of gloves, caps, masks and plastic im permeable aprons (rather than isolation gowns) for direct patient contact 365 . However, there have been no studies that
define the most effective combination of infection control precautions for use in burn settings. Prospective studies in this area are needed.

I.D.1.c. Pediatrics Studies of the epidemiol ogy of HAIs in children have identified unique infection control issues in this population 63, 64, 366-370 . Pediatric intensive care unit (PICU) patients and the lowest birthweight babies in the highrisk nursery (HRN) monitored in the NNI S system have had high rates of central
venous catheter-associated bloodstream infections 64, 320, 369-372 . Additionally, there is a high prevalence of community -acquired infections among hospitalized infants and young children who have not yet become immune either by vaccination or by natural infection. The result is more patients and their sibling
visitors with transmissible infections present in pediatric healthcare settings, especially during seasonal ep idemics (e.g., pertussis 36, 40, 41 , respiratory viral infections including those caused by RSV 24 , influenza viruses 373 , parainfluenza
virus 374 , human metapneumovirus 375 , and adenoviruses 376 ; rubeola [measles]

34 , varicella [chickenpox] 377 , and rotavirus 38, 378 ).

Close physical contact between healthcare personnel and infants and young children (eg. cuddling, feeding, playi ng, changing soiled diapers, and cleaning copious uncontrolled respiratory secret ions) provides abundant opportunities for
transmission of infectious material . Practices and behaviors such as congregation of children in play areas wher e toys and bodily secretions are easily shared and family members rooming-in with pediatric patients can further
increase the risk of transmission. Pa thogenic bacteria have been recovered from toys used by hospitalized patients 379 ; contaminated bath toys were implicated in an outbreak of multidrug-resistant P. aeruginosa on a pediatric oncology unit 80

. In addition, several patient factors increase the likelihood that infection will result from exposure to pathogens in healthca re settings (e.g., im maturity of the neonatal immune system, lack of previ ous natural infection and resulting immunity, prevalence of patients wit h congenital or acquired immune deficiencies, congenital anatomic anomalies, and use of life-saving invasive devices in neontal and pediat ric 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 impr oving developmental outcomes, Such factors include co-bedding 380 and kangaroo care 381 that may increase opportunity for skin-to-skin exposure of mult iple gestation infants to each other and to their mothers, respectively; although infection risk smay actually be

33reduced among infants receiving kangaroo care 382 . Children who attend child
care centers 383, 384 and pediatric rehabilitation units 385 may increase the overall
burden of antimicrobial resi stance (eg. by contributi ng 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 settings 50

.

I.D.2. Nonacute healthcare settings Healthcare is provided in various settings outside of hospitals including facilities, su ch as long-term care facilities (LTCF) (e.g. nursing homes), homes for the dev elopmentally disabled, settings where behavioral health services are provided, rehabilitation centers and hospices 392

. In addition, healthcare may be provi ded in nonhealthcare settings such as workplaces with occupational health clin ics, adult day care centers, assisted living facilities, homeless shelters, jails and prisons, school clinics and infirmaries. Each of these settings has unique circumstances and population risks to consider when designing and impl ementing an infection control program. Several of the most common settings and their particular challenges are
discussed below. While this Guidelin e does not address each setting, the principles and strategies provided ma y be adapted and applied as appropriate.

I.D.2.a. Long-term care The designation LTCF applies to a diverse group of residential settings, ranging from institutions for the devel opmentally disabled to nursing homes for the elderly and pediatric chronic-care facilities 393-395 . Nursing homes for the elderly predominate num erically and frequently represent longterm care as a group of facilities. Appr oximately 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 report ed with a range of 3 to 7 per 1000 resident-care days in the more rigorous studies 397-401 . The infrastructure described in the Department of Veterans Affairs nursing home care units is a promising example for the development of a nat ionwide HAI surveillance system
for LTCFs 402

.

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 vari ous facility-sponsored activities 403, 404 . Since able residents interact freely with each ot her, controlling transmission of infection in this setting is challenging 405 . Residents who are colonized or infected with certain microorganisms are, in some case s, restricted to their room. However, because of the psychosocial risks associat ed with such restriction, it has been recommended that psychosocial needs be bal anced with infection control needs in the LTCF setting 406-409 . Documented LTCF outbreaks have been caused by various viruses (e.g., influenza virus 35, 410-412 , rhinovirus 413 , adenovirus (conjunctivitis) 414 , norovirus 278, 279 275, 281 ) and bacteria, including group A streptococcus 162

, B. pertussis 415 , non-susceptible S. pneumoniae 197, 198 , other MDROs, and Clostridium difficile 416 ) These pathogens can lead to substantial

34morbidity and mortality, and increased me dical costs; prompt detection and implementation of effective c ontrol measures are required.

Risk factors for infection are prevalent among LTCF residents 395, 417, 418 . Agerelated declines in immunity may affect responses to immunizations for influenza and other infectious agents, and increas e 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 infe ctions, while malnutrition can impair wound healing 419-423 . 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 residents 424-426

. Finally, limited functional status and total dependence on healthcare personnel for activities of daily living have been identified as independent risk factors for
infection 401, 417, 427 and for colonization with MRSA 428, 429 and ESBL-producing K. pneumoniae 430 . Several position papers and review articles have been published that provide guidance on various aspects of infection contro l and antimicrobial
resistance in LTCFs 406-408, 431-436 . The Centers for Medicare and Medicaid Services (CMS) have established regulatio ns for the prevention of infection in
LTCFs 437

.
Because residents of LTCFs are hospi talized frequently, they can transfer pathogens between LTCFs and healthcare facilit ies in which they receive care 8,

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 PICU 50 . Children from pediatric rehabilitation units may contri bute to the reservoir of communityassociated MRSA 385, 389-391

.

I.D.2.b. Ambulatory Care In the past decade, healthcare delivery in the United States has shifted from the acute, inpat ient hospital to a variety of ambulatory and community-based settings, including t he home. Ambulatory care is provided in hospital-based outpatient clinics, nonhospital-based clinics and physician offices, public health clinics, free-standi ng dialysis centers, ambulatory surgical centers, urgent care centers, and many others. In 2000, there were 83 million visits to hospital outpatient clinics and more than 823 million visits to physician
offices 442 ; ambulatory care now accounts for most patient encounters with the health care system 443 . In these settings, adapting transmission prevention guidelines is challenging because pat ients remain in common areas for prolonged periods waiting to be seen by a healthcare provider or awaiting admission to the hospital, examination or treatment rooms are turned around quickly with limited cleaning, and infect ious patients may not be recognized immediately. Furthermore, immunoco mpromised patients often receive chemotherapy in infusion rooms where t hey stay for extended periods of time along with other types of patients.

35There are few data on the risk of HAIs in ambulatory care settings, with the exception of hemodialysis centers 18 , 444, 445 . Transmission of infections in outpatient settings has been reviewed in three publications 446-448 . Goodman and
Solomon summarized 53 clusters of infe ctions 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 personto-person transmission from or in volving healthcare personnel and ten
associated with airborne or droplet transmission among patients and healthcare workers. Transmission of bloodborne pat hogens (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 cont aminated medical device, multi-dose vial, or intravenous solution 82, 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 summarized 454

.

Airborne transmission of M.tuberculosis and measles in ambulatory settings, most frequently emergency dep artments, has been reported 34, 127, 446, 448, 455-457

. Measles virus was transmitted in physici an offices and other outpatient settings during an era when immunization rates we re low and measles outbreaks in the community were occurring regularly 34, 122, 458 . Rubella has been transmitted in the outpatient obstetric setting 33 ; there are no published reports of varicella transmission in the outpatient setti ng. In the ophthalmology setting

, adenovirus type 8 epidemic keratoconjunctivitis has been transmitted via incompletely disinfected ophthalmology equi pment and/or from healthcare workers to patients, presumably by contaminated hands 17, 446, 448, 459-462

.
If transmission in outpatient settings is to be prevented, screening for potentially infectious symptomatic and asymptomatic individuals, especially those who may be at risk for transmitting airborne infectious agents (e.g., M. tuberculosis, varicella-zoster virus, rubeola [measles]), is necessary at the start of the initial patient encounter. Upon identification of a potentially infectious patient, implementation of prevention measur es, including prompt separation of potentially infectious patients and implementation of appropriate control measures (e.g., Respiratory Hygiene/ Cough Etiquette and Transmission-Based Precautions) can decrease transmission risks 9, 12 . Transmission of MRSA and VRE in outpatient settings has not been r eported, but the association of CAMRSA in healthcare personnel working in an outpatient HIV clinic with
environmental CA-MRSA contamination in t hat clinic, suggests the possibility of transmission in that setting 463 . Patient-to-patient transmission of Burkholderia species and Pseudomonas aeruginosa in outpatient clinics for adults and children with cystic fibrosis has been confirmed 464, 465

.

I.D.2.c. Home Care Home care in the United Stat es is delivered by over 20,000 provider agencies that in clude home health agencies, hospices, durable medical equipment providers, home infusion therapy services, and personal care and

36support 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 am bulatory peritoneal dialysis (CAPD).

The incidence of infection in home care patients, other t han those associated with infusion therapy is not well studied 466-471 . However, data collection and
calculation of infection rates hav e 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 surve illance can be performed in this setting 475

. Draft definitions for home care as sociated infections have been developed 476

.
Transmission risks during home care are presumed to be minimal. The main transmission risks to home care patient s are from an infe ctious healthcare provider or contaminated equipment; pr oviders also can be exposed to an infectious patient during home visits. Sinc e home care involves patient care by a limited number of personnel in settings wit hout multiple pat ients or shared equipment, the potential reservoir of pat hogens is reduced. Infections of home care providers, that could pose a risk to home care patients include infections transmitted by the airborne or droplet r outes (e.g., chickenpox, tuberculosis, influenza), and skin infestations (e.g., scabies 69 and lice) and infections (e.g.,impetigo) transmitted by direct or indirect contact. Th ere are no published
data on indirect transmission of MDROs fr om one home care patient to another, although this is theoretical ly possible if contaminat ed equipment is transported from an infected or colonized patient and used on another patient. Of note, investigation of the first case of VISA in homecare 186 and the first 2 reported
cases of VRSA 178, 180, 181, 183 found no evidence of tr ansmission of VISA or
VRSA to other home care re cipients. Home health care also may contribute to antimicrobial resistance; a review of outpatient vancomycin use found 39% of recipients did not receive the antibioti c according to recommended guidelines 477

.
Although most home care agencies impl ement 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 guidance 478, 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 hom e health agencies continue to observe “nursing bag technique,” a practice that prescribes the use of barriers between the nursing bag and environmental surfaces in the home 480 . While the home environment may not always appear clean, the use of barriers between two noncritical surfaces has been questioned 481, 482 . Opportunites exist to conduct
research in home care related to infection transmission risks 483

.

I.D.2.d. Other sites of healthcare delivery Facilities that are not primarily healthcare settings but in which health care is delivered include clinics in correctional facilities and shelters. Both settings can have suboptimal features,

37such as crowded conditions and poor v entilation. Economically disadvantaged individuals who may have chronic illnes ses and healthcare problems related to alcoholism, injection drug use, poor nutrition, and/or inadequate shelter often receive their primary healthcare at sites such as these 484 . Infectious diseases of special concern for transmission incl ude 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 diseases 286, 485-488 . A high index of suspicion fo r tuberculosis and CA-MRSA in these populations is needed as outbreaks in these settings or among the populations they serve have been reported 489-497

.
Patient encounters in these types of fac ilities provide an opportunity to deliver
recommended immunizations and screen for M

. tuberculosis infection in addition to diagnosing and treating acute illnesses 498 . Recommended infection control measures in these non-traditional areas designated for healthcare delivery are the same as for other ambulatory care se ttings. Therefore, these settings must be equipped to observe Standard Precautions and, when indicated,
Transmission-based Precautions.

I.E. Transmission risks associated wi th special patient populations

As new treatments emerge for complex diseases, unique infection control challenges associated with special patient populatio ns need to be addressed.

I.E.1. Immunocompromised patients Patients who have congenital primary immune deficiencies or acquired di sease (eg. treatment-induced immune deficiencies) are at increased risk for numerous types of infections while receiving healthcare and may be locat ed throughout the healthcare facility. The specific defects of the immune system dete rmine 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, immunocompr omised patients can be cared for in the same environment as other patients; however, it is always advisable to minimize exposure to other patients with transmissi ble infections such as influenza and other respiratory viruses 499, 500 . The use of more intense chemotherapy regimens for treatment of childhood l eukemia may be associated with prolonged periods of neutropenia and suppression of other components of the immune system, extending the period of infect ion risk and raising the concern that additional precautions may be indicated for select groups 501, 502 . With the application of newer and more intense i mmunosuppressive therapies for a variety of medical conditions (e.g., rheumatologic disease 503, 504 , inflammatory bowel
disease 505 ), immunosuppressed pati ents are likely to be more widely distributed throughout a healthcare facility rather than localized to single patient units (e.g.

38hematology-oncology). Guidelines for prevent ing infections in certain groups of immunocompromised pati ents have been published 15, 506, 507

.
Published data provide evi dence to support placing allogeneic HSCT patients in
a Protective Environment 15, 157, 158 . Also, three guidelines have been developed that address the special requirements of these immunocom promised patients, including use of antimicrobial prophylaxi s and engineering controls to create a Protective Environment for the pr evention of infections caused by Aspergillus spp. and other environmental fungi 11, 14, 15 . As more intense chemotherapy regimens associated with prolonged periods of neutropenia or graft-versus-host disease are implemented, the period of risk and duration of environmental protection may need to be prolon ged beyond the traditional 100 days 508

.

I.E.2. Cystic fibrosis patients Patients with cystic fibr osis (CF) require special consideration when developing infection control guidelines. Compared to other patients, CF patients require additional protection to prevent transmission from contaminated respirat ory therapy equipment 509-513 . Infectious agents such as Burkholderia cepacia complex and P. aeruginosa 464, 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 outcome 519, 520

.
Person-to-person transmission of B. cepacia complex has been demonstrated among children 517 and adults 521 with CF in healthcare settings 464, 522 , during
various social contacts 523 , most notably attendance at camps for patients with
CF 524 , and among siblings with CF 525 . Successful infection control measures used to prevent transmission of respirator y secretions include segregation of CF patients from each other in ambulatory and hospital settings (including use of private rooms with separ ate showers), environmental decontamination of surfaces and equipment contaminated with re spiratory secretions , elimination of group chest physiotherapy sessions, and disbanding of CF camps 97, 526 . The Cystic Fibrosis Foundation published a consensus document with evidencebased recommendations for infection c ontrol practices for CF patients 20

.

I.F. New therapies associated with pot entially transmissible infectious agents

I.F.1. Gene therapy Gene therapy has has been attempted using a number of different viral vectors, including no nreplicating retroviruses, adenoviruses, adenoassociated viruses, and rep lication-competent strains of poxviruses. Unexpected adverse events have restricted the prev alence of gene therapy protocols.

The infectious hazards of gene therapy are theoretical at this time, but require meticulous surveillance due to the possibl e occurrence of in vivo recombination

39and the subsequent emergence of a transmi ssible genetically altered pathogen. Greatest concern attends the use of rep lication-competent viruses, especially vaccinia. As of the time of publication, no reports have described transmission of a vector virus from a gene therapy recipi ent to another individual, but surveillance is ongoing. Recommendations for monitoring infection control issues throughout the course of gene therapy trials have been published 527-529

.

I.F.2. Infections transmitted thr ough blood, organs and other tissues The potential hazard of transmitting infectious pathogens through biologic products is a small but ever present risk, despi te donor screening. Reported infections transmitted by transfusion or transplantat ion include West Nile Virus infection 530 cytomegalovirus infection 531 , Creutzfeldt-Jacob disease 230 , hepatitis C 532

, infections with Clostridium spp

. 533 and group A streptococcus 534 , malaria 535

, babesiosis 536 , Chagas disease 537 , lymphocytic choriomeningitis 538 , and rabies
539, 540 . Therefore, it is import ant to consider receipt of biologic products when evaluating patients for potentia l sources of infection.

I.F.3. Xenotransplantation The transplantation of nonhuman cells, tissues, and organs into humans potentially expos es patients to zoonotic pathogens.
Transmission of known zoonotic infections (e.g., trichinosis from porcine tissue), constitutes one concern, but also of concer n is the possibility that transplantation of nonhuman cells, tissues, or organs may tr ansmit previously unknown zoonotic infections (xenozoonoses) to immunos uppressed human recipients. Potential infections that might accompany trans plantation of porcine organs have been
described 541 . Guidelines from the U.S. P ublic Health Service address many
infectious diseases and infection contro l issues that surround the developing field of xenotransplantation 542 ); work in this area is ongoing.

40

## Part II:

Fundamental elements needed to prevent transmission of infectious agents in healthcare settings

II.A. Healthcare system components that influence the effectiveness of precautions to prevent transmission

II.A.1. Administrative measures Healthcare organizations can demonstrate a commitment to preventing transmission of infectious agents by incorporating infection control into the objectives of the organization’s patie nt and occupational safety programs 543-547

. An infrastructure to gu ide, support, and monitor
adherence to Standard and Transmi ssion-Based Precautions 434, 548, 549 will facilitate fulfillment of the organization’ s mission and achievement of the Joint
Commission on Accreditation of Healthcare Organization’s patient safety goal to
decrease HAIs 550 . Policies and procedures that explain how Standard and
Transmission-Based Precautions are applied, including systems used to identify and communicate information about pati ents with potentially transmissible infectious agents, are e ssential to ensure the success of these measures and may vary according to the char acteristics of the organization.

A key administrative measure is provis ion of fiscal and human resources for maintaining infection control and occupational health programs that are responsive to emerging needs. Specif ic components include bedside nurse 551 and infection prevention and control professional (ICP) staffing levels 552

, inclusion of ICPs in facility construction and design decisions 11 , clinical microbiology laboratory support 553, 554 , adequate supplies and equipment including facility ventilation systems 11 , adherence monitoring 555 , assessment and correction of system failures that contribute to transmission 556, 557 , and provision of feedback to healthcare personnel and senior administrators 434, 548,

549, 558 . The positive influence of instituti onal leadership has been demonstrated repeatedly in studies of HCW adherence to recommended hand hygiene practices 176, 177, 434, 548, 549, 559-564 . Healthcare administrator involvement in infection control processes can impr ove administrators’ awareness of the rationale and resource requirements fo r following recommended infection control practices.

Several administrative factors may affect the transmission of infectious agents in healthcare settings: institutional culture, individual worker behavior, and the work
environment. Each of these areas is suitable for performance improvement monitoring and incorporation into t he organization’s patient safety goals 543, 544,

546, 565

.

41II.A.1.a.Scope of work and staffing needs fo r 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 No socomial 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% lo wer rate of four infections studied (CVC-associated bloodstream infecti ons, 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 1982 567-569 by the Certification B oard of Infection Control (CBIC), and has been re-assessed ever y five years since that time 558, 570-572 . The findings of these task analyses have been used to develop and update the
Infection Control Certificati on Examination, offered for t he 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 su rgery 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, respir atory protection fit testing, and
administration of other vaccines as indicated, such as smallpox vaccine in 2003; 3) preparedness planning for annual influen za outbreaks, pandemic influenza, SARS, bioweapons attacks; 4) adherence monitoring for selected infection control practices; 5) oversight of risk assessment and implementation of prevention measures associ ated with construction and r enovation; 6) prevention of transmission of MDROs; 7) evaluatio n of new medical pr oducts that could be
associated with increased infe ction risk. e.g.,intravenous infusion materials; 9) communication with the public, facility staff, and state and local health departments concerning infection control-related issues; and 10) participation in
local and multi-center research projects 434, 549, 552, 558, 573, 574

.
None of the CBIC job analyses addressed specific staffing requirements for the identified tasks, although the surve ys 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
21 st 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

42Nosocomial 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 hospitals 573, 575 . The foregoing
demonstrates that infection control st affing can no longer be based on patient census alone, but rather must be det ermined by the scope of the program, characteristics of the pat ient population, complexity of the healthcare system, tools available to assist personnel to perform essential tasks (e.g., electronic tracking and laboratory support for surv eillance), and unique or urgent needs of the institution and community 552 . Furthermore, appropriate training is required to optimize the quality of work performed 558, 572, 576

.

II.A.1.a.i. Infection Control Nurse Liaison Designating a bedside nurse on a patient care unit as an infection control liaison or “link nurse” is reported to be an effective adjunct to enhance infect ion control at the unit level 577-582 . Such individuals receive training in basic infection control and have frequent communication with the ICPs, but maintain their primary role as bedside caregiver on their units. The infecti on control nurse liaison increases the
awareness of infection control at the unit leve l. He or she is especially effective in implementation of new policies or contro l interventions because of the rapport with individuals on the unit, an understanding of unit-specific challenges, and ability to promote strategies that are most likely to be successful in that unit. This position is an adjunct to, not a replacement for, fully trained ICPs. Furthermore,
the infection control liaison nurses s hould not be counted when considering ICP staffing.

II.A.1.b. Bedside nurse staffing There is increasing evi dence that the level of bedside nurse-staffing influences the quality of patient care 583, 584 . If there are adequate nursing staff, it is more likely t hat infection control practices, including hand hygiene and Standard and Transmission- Based Precautions, will be given appropriate attention and applied correctly and consistently 552 . A national multicenter study reported strong and cons istent inverse relationships between nurse staffing and five adverse outcomes in medical patients, two of which were HAIs: urinary tract infections and pneumonia 583 . The association of nursing staff shortages with increased rates of HA Is has been demonstrated in several outbreaks in hospitals and long term care settings, and with increased transmission of hepatitis C virus in dialysis units 22, 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 studies 590, 596 , the composition of the nursing staff (“pool” or “f loat” vs. regular staff nurse s) influenced the rate of primary bloodstream infections, with an in creased infection rate occurring when the proportion of regular nurses de creased and pool nurses increased.

II.A.1.c. Clinical micr obiology laboratory support The critical role of the clinical microbiology laboratory in infe ction control and healthcare epidemiology
is described well 553, 554, 598-600 and is supported by the Infectious Disease Society

43of America policy statement on consolidation of clinical microbiology laboratories published in 2001 553 . The clinical microbiology laboratory contributes to preventing transmission of infectious diseas es in healthcare settings by promptly detecting and reporting epidemio logically important or ganisms, identifying emerging patterns of antimicrobial resistanc e, and assisting in assessment of the effectiveness of recommended precautions to limit transmi ssion during outbreaks

598

. Outbreaks of infections may be recognized first by laboratorians 162

. Healthcare organizations need to ensur e 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 t hose 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 organi zations 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 r eports) required to support
infection control.

Several key functions of the clinical micr obiology laboratory are relevant to this guideline:

• Antimicrobial susceptibility by testi ng 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 patterns 603, 604 , and for the preparation, analysis, and distribution of periodic cumulative antimicrobial susceptibility summary reports 605-607 . While not required, clinical la boratories ideally should have access to rapid genotypic identificati on of bacteria and their antibiotic resistance genes 608

.

• 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 discont inuing active surveillance programs and optimize the use of l aboratory resources.

• Molecular typing, on-site or outsourc ed, in order to investigate and control
healthcare-associated outbreaks 609

.

• Application of rapid diagnostic tests to support clinical decisions involving patient treatment, room se lection, and implementati on of control measures including barrier precautions and use of vaccine or chemoprophylaxis agents (e.g., influenza 610-612 , B. pertussis 613 , RSV 614, 615 , and
enteroviruses 616 ). The microbiologist provides guidance to limit rapid testing to clinical situations in which rapid results influence patient

44management decisions, as well as prov iding oversight of point-of-care testing performed by non-laboratory healthcare workers 617

.

• Detection and rapid reporting of epi demiologically important organisms, including those that are reportabl e to public health agencies.

• Implementation of a quality control pr ogram that ensures testing services are appropriate for the population serv ed, and stringently evaluated for sensitivity, specificity, appl icability, and feasibility.

• Participation in a multidisciplin ary team to develop and maintain an effective institutional program for t he judicious use of antimicrobial agents
618, 619

.

II.A.2. Institutional safety cultur e and organizational characteristics Safety culture (or safety climate) refers to a work environment where a shared commitment to safety on the part of management and the workforce is
understood and followed 557, 620, 621 . The authors of the In stitute of Medicine Report, To Err is Human 543 , acknowledge that causes of medical error are multifaceted but emphasize r epeatedly the pivotal role of system failures and the benefits of a safety culture. A safety culture is created through 1) the actions management takes to improve patient and work er safety; 2) work er participation in safety planning; 3) the availability of appropriate protective equipment; 4) influence of group norms regarding accept able safety practices; and 5) the organization’s socialization process for new personnel. Safety and patient outcomes can be enhanced by improving or creating organizational characteristics within patient care units as demonstrated by studies of surgical
ICUs 622, 623 . Each of these factors has a direct bearing on adherence to transmission prevention recommendations 257 . Measurement of an institutional culture of safety is useful for designing improvements in healthcare 624, 625

. Several hospital-based studies have linke d measures of safety culture with both employee adherence to safe practices and reduced exposures to blood and body
fluids 626-632 . One study of hand hygiene practices concluded that improved adherence requires integration of infection control into the organization’s safety
culture 561 . Several hospitals that are part of the Veterans Administration Healthcare System have taken specific steps toward improving the safety culture, including error reporting mechanisms, performing root cause analysis on problems identified, providing safety incentives, and employee education. 633-635

.

II.A.3. Adherence of healthcare personnel to recommended guidelines
Adherence to recommended infection contro l practices decreases transmission of infectious agents in healthcare settings 116, 562, 636-640 . However, several
observational studies have shown lim ited adherence to recommended practices by healthcare personnel 559, 640-657 . Observed adherence to universal precautions ranged from 43% to 89% 641, 642, 649, 651, 652 . However, the degree of adherence depended frequently on the practice that was assessed and, for glove use, the circumstance in which they were used. Appropriate glove use has ranged from a low of 15% 645 to a high of 82% 650 . However, 92% and 98% adherence with glove use have been reported during arterial blood gas collection and

45resuscitation, respectively, procedures where there may be considerable blood
contact 643, 656 . Differences in observed adherence have been reported among occupational groups in the same healthcare facility 641 and between experienced and nonexperienced professionals 645 . In surveys of health care personnel, selfreported adherence was generally higher t han that reported in observational studies. Furthermore, where an observat ional component was included with a self-reported survey, self-perceived adher ence was often greater than observed
adherence 657 . Among nurses and physicians, increasing years of experience is a negative predictor of adherence 645, 651 . Education to improve adherence is the primary intervention that has been studied. While positive changes in knowledge and attitude have been demonstrated, 640, 658 , there often has been limited or no accompanying change in behavior 642, 644 . Self-reported adherence is higher in groups that have received an educational intervention 630, 659 . Educational interventions that incorporated vi deotaping and performance feedback were successful in improving adherence during the period of study; the long-term
effect of these interventions is not known 654 .The use of videotape also served to identify system problems (e.g., communica tion and access to personal protective equipment) that otherwise may not have been recognized. Use of engineering controls and facility design concepts for improving adherence is gaining interest. While introduction of automated sinks had a negative impact on consistent adherence to hand washing 660 , use of electronic monitoring and voice prompts to remind healthcare workers to perform hand hygiene, and improving accessibility to hand hygiene products, increased adherence and contributed to a decrease in HAIs in one study 661 . More information is needed regarding how technology might improve adherence. Improving adherence to infection contro l practices requires a multifaceted approach that incorporates continuous asse ssment of both the i ndividual and the
work environment 559, 561 . Using several behavioral theories, Kretzer and Larson concluded that a single intervention (e.g ., a handwashing campaign or putting up new posters about transmission precautio ns) would likely be ineffective in improving healthcare personnel adherence 662 . Improvement requires that the organizational leadership make prevention an institutional priority and integrate infection control practices into the organization’s safety culture 561 . A recent
review of the literature conc luded that variations in organizational factors (e.g., safety climate, policies and procedures, education and training) and individual factors (e.g., knowledge, perceptions of risk, past experience) were determinants of adherence to infection control guidelin es for protection against SARS and other respiratory pathogens 257

.

II.B. Surveillance for healthcare-asso ciated infections (HAIs)

Surveillance is an essential tool for case-f inding of single pati ents or clusters of patients who are infected or coloniz ed with epidemiologically important organisms (e.g., susceptible bacteria such as S. aureus, S. pyogenes [Group A streptococcus] or Enterobacter-Klebsie lla spp; MRSA, VRE, and other MDROs;
C. difficile ; RSV; influenza virus) for whic h transmission-based precautions may

46be required. Surveillance is defined as the ongoing, systematic collection, analysis, interpretation, and disseminati on of data regarding a health-related event for use in public health action to reduce morbidity and mortality and to improve health 663 . The work of Ignaz Semmelweis that described the role of person-to-person transmission in puerperal sepsis is t he earliest example of the use of surveillance data to reduce transmission of infectious agents 664

. Surveillance of both process measures and the infection rates to which they are linked are important for eval uating the effectiveness of in fection prevention efforts and identifying indications for change 555, 665-668

.
The Study on the Efficacy of Nosocomial Infection Control (SENIC) found that
different combinations of in fection control practices resulted in reduced rates of nosocomial surgical site infections, pneumonia, urinary tract infections, and bacteremia in acute care hospitals 566 ; 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 LTCFs 398, 434, 669, 670 and in
home care 470-473 . The essential elements of a surveillance system are: 1) standardized definitions; 2) identification of patient populations at risk for infection; 3) statistical analysis (e.g. risk-adjustment, calculation of rates using appropriate denominators, trend analysis us ing methods such as statistical process control charts); and 4) feedback of results to the primary caregivers 671-

676

. Data gathered through surveillance of high-risk populations, device use, procedures, and/or facility locations (e.g ., ICUs) are useful for detecting
transmission trends 671-673 . Identification of clusters of infections should be followed by a systematic epidemiologic in vestigation to determine commonalities in persons, places, and time; and guide implementation of interventions and
evaluation of the effectiveness of those interventions.

Targeted surveillance based on the highes t risk areas or patients has been preferred over facility-wide surveillance fo r the most effective use of resources
673, 676 . However, surveillance for certain epidemiologically im portant organisms may need to be facility-wide. Surveillance methods will continue to evolve as healthcare delivery systems change 392, 677 and user-friendly electronic tools become more widely available for electronic tracking and trend analysis 674, 678,

679

. Individuals with experience in healthca re epidemiology and infection control should be involved in selecting software packages for data aggregation and analysis to assure that the need for effici ent and accurate HAI surveillance will be
met. Effective surveillance is increasin gly important as legislation requiring public reporting of HAI rates is passed and states work to develop effective systems to support such legislation 680

.

II.C. Education of HCWs, patients, and families

Education and training of healthcare per sonnel are a prerequisite for ensuring that policies and procedur es for Standard and Transmission-Based Precautions are understood and practiced. Understanding the scientific rationale for the

47precautions will allow HCWs to apply procedures correctly, as well as safely modify precautions based on changing requ irements, resources, or healthcare settings 14, 655, 681-688 . In one study, the likelihood of HCWs developing SARS was strongly associated with less than 2 hours of infection control training and lack of understanding of infecti on control procedures 689 . Education about the important role of vaccines (e.g., influenza, measles, varicella, pertussis, pneumococcal) in protecting healthcare personnel, their pat ients, and family members can help improve vaccination rates 690-693

.
Education on the principles and prac tices for preventing transmission of infectious agents should begin during traini ng in the health professions and be provided to anyone who has an opportunity for contact with patients or medical equipment (e.g., nursing and medical sta ff; therapists and technicians, including respiratory, physical, occupational, radiology, and cardiology personnel; phlebotomists; housekeeping and main tenance staff; and students). In healthcare facilities, education and training on Standard and Transmission-Based Precautions are typically provided at t he time of orientation and should be repeated as necessary to maintain co mpetency; updated education and training are necessary when policies and procedures are revised or when there is a special circumstance, such as an outbreak that requires modification of current practice or adoption of new recommendat ions. Education and training materials and methods appropriate to the HCW’s level of responsibility, individual learning habits, and language needs, can impr ove the learning experience 658, 694-702

.
Education programs for healthcare per sonnel have been associated with sustained improvement in adherence to bes t practices and a related decrease in
device-associated HAIs in t eaching and non-teaching settings 639, 703 and in medical and surgical ICUs {Cooper smith, 2002 #2149; Babcock, 2004 #2126; Berenholtz, 2004 #2289; 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 HCW s knowledge,and adherence to recommended practices are necessary to achieve the desired changes and to identify continuing education needs 562, 704-708 . Effectiveness of this approach for isolation practices has been demonstrated for control of RSV
116, 684

.
Patients, family members, and visitors can be partners in preventing transmission of infections in healthcare settings 9, 42, 709-711 . Information about Standard Precautions, especially hand hygiene, Re spiratory Hygiene/Cough Etiquette, vaccination (especially against influenza) and other routine infection prevention strategies may be incorporated into pat ient information materials that are provided upon admission to the healthcare facility. Additional information about Transmission-Based Precautions is best prov ided at the time they are initiated. Fact sheets, pamphlets, and other print ed material may include information on
the rationale for the additi onal precautions, risks to household members, room assignment for Transmission-Based Prec autions purposes, explanation about the use of personal protective equipment by HCWs, and directions for use of

48such equipment by family members and visitors. Such information may be particularly helpful in the home envir onment where household members often have primary responsibility for adher ence to recommended infection control practices. Healthcare personnel must be available and prepared to explain this material and answer questions as needed.

II.D. Hand hygiene

Hand hygiene has been cited frequently as the single most important practice to reduce the transmission of infectious agents in healthcare settings 559, 712, 713 and
is an essential element of Standard Precautions. The term “hand hygiene” includes both handwashing with either plain or antiseptic-containing soap and water, and use of alcohol-based products (gel s, rinses, foams) that do not require
the use of water. In the absence of visible soiling of hands, approved alcoholbased products for hand disinfection are pr eferred over antimic robial or plain soap and water because of their superior micr obiocidal activity, reduced drying of the skin, and convenience 559 . Improved hand hygiene practices have been
associated with a sustained decrease in the incidence of MRSA and VRE infections primarily in the ICU 561, 562, 714-717 . The scientific rationale, indications, methods, and products for hand hygiene ar e summarized in other publications
559, 717

.
The effectiveness of hand hygiene can be reduced by the type and length of fingernails 559, 718, 719 . Individuals wearing artifi cal nails have been shown to harbor more pathogenic organisms, especially gram negative bacilli and yeasts, on the nails and in the subungual ar ea than those with native nails 720, 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 wit h outbreaks of gramnegative bacillus and candidal infections as confirmed by molecular typing of
isolates 30, 31, 559, 722-725 .The need to restrict the wearing of artificial fingernails by all healthcare personnel who provide dire ct patient care or by healthcare personnel who have contact with other hi gh risk groups (e.g., oncology, cystic fibrosis patients), has not been studi ed, but has been recommended by some experts 20 . 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 co ntamination with potential pathogens is increased with ring-wearing 559, 726 , no studies have related this practice to HCW-to-patient transmission of pathogens.

II.E. Personal protective equipment (PPE) for healthcare personnel

PPE refers to a variety of barriers and resp irators used alone or in combination to protect mucous membranes, airways, skin, and clothing from contact with infectious agents. The selection of PPE is based on the nature of the patient

49interaction and/or the likely mode(s) of transmission. Guidance on the use of PPE is discussed in Part III. A suggested procedure for donning and removing PPE that will prevent skin or clothing cont amination is presented in the Figure. Designated containers for used disposable or reusable PPE should be placed in
a location that is convenient to the site of removal to facilitate disposal and
containment of contaminated materials. Hand hygiene is always the final step after removing and disposing of PPE. The following sections highlight the primary uses and methods for selecting this equipment.

II.E.1. Gloves Gloves are used to prevent contamination of healthcare personnel hands when 1) anticipating dire ct 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 r oute e.g., VRE, MRSA, RSV 559, 727, 728 ; or 3) handling or touching visibly or potentially contaminated patient care equipment and
environmental surfaces 72, 73, 559 . Gloves can protect both patients and healthcare personnel from exposure to infectious material that may be carried on hands 73

. The extent to which gloves will protect healthcare pers onnel from transmission of bloodborne pathogens (e.g., HI V, HBV, HCV) following a needlestick or other pucture that penetrates the glove barri er has not been determined. Although gloves may reduce the volume of blood on the external surfac e 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 purpos es are subject to FDA evaluation and
clearance 730 . Nonsterile disposable medical gloves made of a variety of materials (e.g., latex, vinyl, nitrile) are available for routine patient care 731 . The selection of glove type for non-surgical use is based on a number of factors, including the task that is to be perform ed, anticipated contact with chemicals and chemotherapeutic agents, latex sensitivity, sizing, and fac ility policies for creating
a latex-free environment 17, 732-734 . For contact with blood and body fluids during non-surgical patient care, a single pair of gloves generally provides adequate barrier protection 734 . However, there is considerable variability among gloves; both the quality of the manuf acturing process and type of material influence their
barrier effectiveness 735 . While there is little difference in the barrier properties of unused intact gloves 736 , studies have shown repeatedly that vinyl gloves have higher failure rates than latex or nitrile gloves when tested under simulated and
actual clinical conditions 731, 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 gl oves are indicated for non-patient care activities, such as handling or cleaning contaminated equipment or surfaces 11, 14,

. During patient care, transmission of infectious organisms can be reduced by adhering to the principles of working from “clean” to “dirty”, and confining or limiting contamination to surfaces that ar e directly needed for patient care. It may be necessary to change gloves during the care of a single patient to prevent

50 739cross-contamination of body sites 559, 740 . It also may be necessary to change gloves if the patient interaction also involves touching portable computer keyboards or other mobile equipment that is transport ed from room to room. Discarding gloves between patients is necessary to prevent transmission of infectious material. Gloves must not be washed for subsequent reuse because microorganisms cannot be removed reliably from glove surfaces and continued glove integrity cannot be ens ured. Furthermore, glove reuse has been associated
with transmission of MRSA and gram-negative bacilli 741-743

. When gloves are worn in combination with other PPE, they are put on last. Gloves that fit snugly around the wrist ar e 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 c ontamination (Figure). H and hygiene following glove
removal further ensures that the hands will not carry potentially infectious material that might have penetrated th rough unrecognized tear s or that could contaminate the hands during glove removal 559, 728, 741

.

II.E.2. Isolation gowns Isolation gowns are used as specified by Standard and Transmission-Based Precautions, to prot ect the HCW’s arms and exposed body areas and prevent contaminat ion of clothing with bloo d, body fluids, and other potentially infectious material 24, 88, 262, 744-746 . The need for and type of isolation gown selected is based on the nature of t he patient interaction, including the anticipated degree of contac t with infectious material and potential for blood and body fluid penetration of the barrier. T he wearing of isolation gowns and other protective apparel is mandated by the OSHA Bloodborne Pathogens Standard

739

. Clinical and laboratory coats or jackets worn over personal clothing for comfort and/or purposes of i dentity are not considered PPE. When applying Standard Precauti ons, an isolation gown is worn only if contact with blood or body fluid is anticipated. However, w hen Contact Precautions are used (i.e., to prevent transmission of an infe ctious agent that is not interrupted by
Standard Precautions alone and that is associated with environmental contamination), donning of both gown and gl oves upon room entry is indicated to
address unintentional cont act with contaminated environmental surfaces 54, 72, 73,

88

. The routine donning of is olation 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 areas 365, 747-750

.
Isolation gowns are always worn in combination with gloves, and with other PPE when indicated. Gowns are usually t he 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 protect ed. Several gown sizes should be available in a healthcare facility to ensure appropriate coverage
for staff members. Isolat ion gowns should be removed before leaving the patient care area to prevent possible contami nation 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, “c ontaminated”, side of the

51gown 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. Face protection: masks, goggles, face shields

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 Pr ecautions and Droplet Precautions; 2) placed on healthcare personnel when enga ged 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 respir atory secretions fr om 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 goggle s, 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, nos e, and eyes are susceptible portals of entry for infectious agents, as can be other skin surf aces 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
demonstrated 93, 113, 755, 756 . Procedures that generate splashes or sprays of blood, body fluids, secretions, or excr etions (e.g., endotracheal suctioning, bronchoscopy, invasive vascular procedures) require either a face shield (disposable or reusabl e) or mask and goggles 93-95, 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 lik ely to occur is mandated by the OSHA Bloodborne Pathogens Standard 739 . 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 masks 758 #2688 . No studies have been published that compare mask types to determine whether one mask type provides better protection than another. Si nce procedure/isolation ma sks are not regulated by the FDA, there may be more variab ility 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 healt hcare personnel needs.

II.E.3.b. Goggles, face shields Guidance on eye protection for infection control has been published 759 . The eye protection chosen fo r specific work situations (e.g., goggles or face shield) depends upon the circumstances of exposure, other

52PPE used, and personal vision needs. Personal eyeglasses and contact lenses
are NOT considered adequate eye protection ( www.cdc.gov/niosh/topics/eye/eye-infectious.html ). NIOSH states that, eye protection must be comfortabl e, allow for sufficient peri pheral vision, and must be adjustable to ensure a secure fit. It may be necessary to provide several different types, styles, and sizes of pr otective equipment. Indirectly-vented goggles with a manufacturer’s anti-fog c oating 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. The role of goggles, in addition to a mask, in preventing exposure to infectious agents transmitted via resp iratory droplets has been studied only for RSV. Reports published in the mid-1980s dem onstrated that eye protection reduced occupational transmission of RSV 760, 761 . Whether this was due to preventing hand-eye contact or respiratory droplet -eye contact has not been determined. However, subsequent studies demonstrated that RSV tr ansmission is effectively prevented by adherence to Standard plus Co ntact Precations and that for this virus routine use of goggles is not necessary 24, 116, 117, 684, 762 . It is important to remind healthcare personnel that even if Droplet Precautions are not recommended for a specific respiratory tract pathogen, protection for the eyes, nose and mouth by using a mask and goggle s, or face shield alone, is necessary when it is likely that ther e will be a splash or spray of any respiratory secretions or other body fluids as def ined in Standard Precautions Disposable or non-disposable face shields may be used as an alternative to goggles 759 . As compared with goggles, a face shield can provide protection to other facial areas in addition to the eyes . Face shields extending from chin to crown provide better face and eye protec tion from splashes and sprays; face shields that wrap around the sides may r educe splashes around the edge of the
shield. 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 equi pment to the head are considered
“clean” and therefore safe to touch with bare hands. T he front of a mask, goggles
and face shield are consider ed contaminated (Figure).

II.E.4. Respiratory protection The subject of respirator y protection as it applies to preventing transmission of airborne infectious agents, including the need for and frequency of fit-testing is under scientif ic review and was the subject of a CDC workshop in 2004 763 . Respiratory protection curr ently requires the use of a respirator with N95 or higher filtration to prevent inhalation of infectious particles. Information about respirators and respiratory protection programs is summarized

53in the Guideline for Preventing Transmission of Mycobacterium tuberculosis in Health-care Settings, 2005 (CDC.MMWR 2005; 54: RR-17 12 ). Respiratory protection is broadly regulated by OSHA under the general industry standard for respiratory protection (29CFR1910.134) 764 which requires that U.S. employers in all employment settings im plement a program to protect employees
from inhalation of toxic materials. OS HA program components include medical clearance to wear a respirator; provisio n and use of appropriate respirators, including fit-tested NIOSH-certified N95 and higher particulate filtering respirators; education on respirator use and periodic re-evaluation of the respiratory protection program . When selecting particula te respirators, models with inherently good fit characteristics (i.e ., those expected to provide protection factors of 10 or more to 95% of wear ers) are preferred and could theoretically relieve the need for fit testing 765, 766 . Issues pertaining to respiratory protection remain the subject of ongoing debate. In formation on various types of respirators may be found at www.cdc.gov/niosh/nppt l/respirators/respsars.html and in published studies 765, 767, 768

. A user-seal check (formerly called a “fit check”) should be performed by the wearer of a respirator each time a respirator is donned to minimize air leakage around the facepiece 769 . The optimal frequency of fit-testng has not been determined; re-t esting may be indicated if there is a change in facial features of the wearer, onset of a medical condition that would affect respiratory function in the wearer, or a change in the model or size of the initially assigned respirator 12

. Respiratory protection was first recomm ended for protection of preventing U.S. healthcare personnel from exposure to M. tuberculosis in 1989. That
recommendation has been maintained in two successive revisions of the
Guidelines for Prevention of Transmission of Tuberculosis in Hospitals and other Healthcare Settings 12, 126 . The incremental benefit fr om respirator use, in
addition to administrative and engineering controls (i.e., AIIRs, early recognition of patients likely to have tuberculosi s and prompt placement in an AIIR, and maintenance of a patient with suspected tuberculosis in an AIIR until no longer infectious), for preventing transmission of airborne infectious agents (e.g., M. tuberculosis) is undetermined. Although some studies have demonstrated effective prevention of M. tuberculosis transmission in hospitals where surgical masks, instead of respirators, were used in conjunction with other administrative and engineering controls 637, 770, 771 , CDC currently recommends N95 or higher level respirators for personnel exposed to patients with suspected or confirmed tuberculosis. Currently this is also true for other diseases that could be transmitted through the airbor ne route, including SARS 262 and smallpox 108, 129,

772 , until inhalational transmission is better defined or healthcare-specific protective equipment more suitable for fo r preventing infection are developed. Respirators are also currently recomm ended to be worn during the performance of aerosol-generating procedur es (e.g., intubation, bronchoscopy, suctioning) on patients withSARS Co-V infection, avi an influenza and pandemic influenza (See Appendix A). Although Airborne Precautions are recommended for preventing airborne
transmission of measles and varicella-zos ter viruses, t here are no data upon

54which to base a recommendation for respir atory protection to protect susceptible personnel against these two infections; tran smission of varicella-zoster virus has been prevented among pediatric patients usi ng negative pressure isolation alone

773

. Whether respiratory protection (i.e., wearing a particulate respirator) would enhance protection from these viruses has not been studied. Since the majority of healthcare personnel have natural or ac quired immunity to these viruses, only immune personnel generally care fo r patients with these infections 774-777

. Although there is no evidence to suggest that masks are not adequate to protect healthcare personnel in these settings , for purposes of consistency and simplicity, or because of difficulties in ascertaining immunity, some facilities may require the use of respirators for entry into all AIIRs, regardless of the specific infectious agent.

Procedures for safe remova l of respirators are prov ided (Figure). In some healthcare settings, particulate respirat ors used to provide care for patients with
M. tuberculosis are reused by the same HCW. Th is 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 contaminat ed with blood or body fluids. There are no data on which to base a recommendation for the length of time a respirat or may be reused.

II.F. Safe work practices to prevent HCW exposure to bloodborne pathogens

II.F.1. Prevention of needlesticks and other sharps-related injuries Injuries due to needles and other sharps have been associated with transmission of HBV, HCV and HIV to healthcare personnel 778, 779 . The prevention of sharps injuries has always been an essential element of Universal and now Standard
Precautions 1, 780 . These include measures to handle needles and other sharp devices in a manner that will prevent inju ry to the user and to others who may encounter the device during or after a procedure. These measures apply to routine patient care and do not address t he prevention of sharps injuries and other blood exposures during surgical an d other invasive procedures that are
addressed elsewhere 781-785

. Since 1991, when OSHA first iss ued its Bloodborne Pathogens Standard to protect healthcare personnel from blood exposure, the focus of regulatory and legislative activity has been on impl ementing a hierarchy of control measures. This has included focusing a ttention on removing sharps hazards through the development and use of engi neering 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 devices 786 . CDC has provided guidance on sharps injury prevention 787, 788 , including for the design, implementation and evaluation of a comp rehensive sharps injury prevention

789 program

.

55II.F.2. Prevention of mucous membrane contact Exposure of mucous membranes of the eyes, nose and mout h to blood and body fluids has been
associated with the transm ission of bloodborne viruses and other infectious agents to healthcare personnel 66, 752, 754, 779 . The prevention of mucous membrane exposures has always been an element of Universal and now
Standard Precautions for routine patient care 1, 753 and is subject to OSHA bloodborne pathogen regulations. Safe work practices, in addition to wearing PPE, are used to protect mucous memb ranes and non-intact skin from contact with potentially infectious material. T hese include keeping gloved and ungloved
hands that are contaminated from touchi ng the mouth, nose, eyes, or face; and positioning patients to direct sprays and splatter away from the face of the caregiver. Careful plac ement of PPE before patient contact will help avoid the need to make PPE adjustments and possi ble face or mucous membrane contamination during use. In areas where the need for resuscitation is unpredictable, mouthpieces, pocket resuscitation masks with one-way valves, and other ventilation devices provide
an alternative to mouth-to-mouth resusci tation, preventing exposure of the caregiver’s nose and mouth to oral and re spiratory fluids during the procedure.

II.F.2.a. Precautions during aerosol-generating procedures The performance of procedures that can generate small particle aeros ols (aerosol-generating procedures), such as bronchoscopy , endotracheal intubation, and open suctioning of the respiratory tract, have been associated with transmission of infectious agents to healthcare personnel, including M. tuberculosis 790 , SARSCoV 93, 94, 98 and N. meningitidis 95 . Protection of the eyes, nose and mouth, in addition to gown and gloves, is reco mmended during perfo rmance of these procedures in accordance with Standard Pr ecautions. Use of a particulate respirator is recommended during aerosol-generating procedures when the aerosol is likely to contain M. tuberculosis , SARS-CoV, or avian or pandemic
influenza viruses.

II.G. Patient placement

II.G.1. Hospitals and long-term care settings Options for patient placement include single patient room s, two patient rooms, and mu lti-bed wards. Of these, single patient rooms are pr efered when there is a conc ern about transmission of an infectious agent. Although some studies have failed to demonstrate the efficacy of single patient rooms to prevent HAIs 791

, other published studies, including one commissioned by the Americ an Institute of Ar chitects and the Facility Guidelines Institute, have doc umented a beneficial relationship between private rooms and reduction in infecti ous and noninfectious adverse patient
outcomes 792, 793 . The AIA notes that private r ooms are the trend in hospital planning and design. However, most hospi tals and long-term care facilities have multi-bed rooms and must consider many co mpeting priorities when determining the appropriate room placement for patient s (e.g., reason for admission; patient characteristics, such as age, gender, mental status; staffing needs; family

56requests; psychosocial factors; reimburse ment concerns). In the absence of obvious infectious diseases that require specified airborne infection isolation rooms (e.g., tuberculosis, SARS, chi ckenpox), the risk of transmission of infectious agents is not always cons idered when making placement decisions

. When there are only a limited nu mber 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 catheter s, anticipated prolonged length of stay, total dependence on HCWs for activities of daily living) 15, 24, 43, 430, 794, 795

. Single-patient rooms ar e always indicated for patients placed on Airborne
Precautions and in a Protective Environment and are preferred for patients who require Contact or Droplet Precautions 23, 24, 410, 435, 796, 797 . During a suspected or proven outbreak caused by a pathogen whose reservoir is the gastrointestinal tract, use of single pati ent rooms with priv ate bathrooms limits opportunities for transmission, especially when the colonized or infected patient has poor personal hygiene habits, fecal incontinence, or c annot 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 enter ic pathogens as long as personal hygiene practices and Standard Precautions, es pecially 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, commodes 798 , scales used for weighing diapers) and the adjacent su rfaces with appropriate age nts may be especially important when a single- patient room can not be used since environmental
contamination with intesti nal tract pathogens is likely from both continent and incontinent patients 54, 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
transmission 791, 803-805 . However, for children, t he risk of healthcare-associated
diarrhea is increased with the increas ed number of patients per room 806 . 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 togethe r patients who are colonized or infected with the same organism to confine their care to one area and prevent contact with other patients. Cohorts ar e created based on c linical diagnosis, microbiologic confirmation when ava ilable, epidemiology, and mode of transmission of the infectious agent. It is gen erally preferred not to place severely immunosuppressed patients in rooms with other patients. Cohorting has been used extensively for managing outb reaks of MDROs including MRSA 22, 807 , VRE
638, 808, 809 , MDR-ESBLs 810 ; Pseudomonas aeruginosa 29 ; methicillin-susceptible

57Staphylococcus aureus 811 ; RSV 812, 813 ; adenovirus keratoconjunctivitis 814 ; rotavirus 815 ; and SARS 816 . Modeling studies provide additional support for cohorting patients to control outbreaks Talon 817-819 . However, cohorting often is implemented only after routine infection control measures have failed to control
an outbreak. Assigning or cohorting healthca re personnel to care only for patients infected or colonized with a single target pathogen limi ts further transmission of the target pathogen to uninfected patients 740, 819 but is difficult to achieve in the face of current staffing shortages in hospitals 583 and residential healthcare sites 820-822

. However, when continued transmission is occurring after implementing routine infection control measures and creating patient cohorts, cohorting of healthcare personnel may be beneficial.

During the seasons when RSV, human metapneumovirus 823 , parainfluenza, influenza, other respiratory viruses 824 , and rotavirus are circulating in the community, cohorting based on the present ing clinical syndr ome is often a priority in facilities that care for infants and young children 825 . For example, during the respiratory virus season, inf ants may be cohorted based soley on the clinical diagnosis of bronc hiolitis due to the logistical difficulties and costs associated with requiring micr obiologic confirmation prio r to room placement, and the predominance of RSV duri ng most of the season. However, when available, single patient rooms are always preferred since a comm on clinical presentation (e.g., bronchiolitis), can be caused by more than one infectious agent 823, 824, 826

. Furthermore, the inability of infants and children to contain body fluids, and the close physical contact that occurs dur ing their care, increases infection transmission risks for patients and personnel in this setting 24, 795

.

II.G.2. Ambulatory settings Patients actively infected with or incubating
transmissible infectious diseases are s een frequently in ambulat ory settings (e.g., outpatient clinics, physicians’ offices, emergency departments) and potentially expose healthcare personnel and other pat ients, family members and visitors 21,

34, 127, 135, 142, 827 . In response to the global outbreak of SARS in 2003 and in preparation for pandemic influenza, healthcare providers working in outpatient settings are urged to implement source containment measures (e.g., asking couging patients to wear a surgical ma sk or cover their coughs with tissues) to prevent transmission of resp iratory infections, beginning at the point of initial patient encounter 9, 262, 828 as described below in section III.A.1.a. Signs can be posted at the entrance to facilities or at the reception or registration desk requesting that the patient or individua ls accompanying the patient promptly inform the receptionist if there are symptoms of a resp iratory infection (e.g., cough, flu-like illness, increased production of respiratory secretions). The presence of diarrhea, skin rash, or known or suspected exposure to a transmissible disease (e.g., measles, per tussis, chickenpox, tuberculosis) also could be added. Placement of potentially infectious patients without delay in an
examination room lim its the number of exposed indi viduals, e.g., in the common waiting area.

58In waiting areas, maintaining a distance between symptomatic and nonsymptomatic patients (e.g., >3 feet), in addition to source control measures, may limit exposures. However, infections transmitted via the airborne route (e.g., M
tuberculosis , measles, chickenpox) require additional precautions 12, 125, 829

. Patients suspected of having such an in fection can wear a surgical mask for source containment, if tolerated, and s hould be placed in an examination room, preferably an AIIR, as soon as possible. If this is not possible, having the patient wear a mask and segregate him/herself from other patients in the waiting area will reduce opportunities to expose others. Since the person(s) accompanying the patient also may be infectious, applic ation of the same infection control precautions may need to be extended to thes e persons if they are symptomatic
21, 252, 830 . For example, family members accompanying children admitted with suspected M. tuberculosis have been found to have unsuspected pulmonary tuberculosis with cavitary lesions, even when asymptomatic 42, 831

. Patients with underlying condition s that increase their susceptibility to infection (e.g., those who are immunocompromised 43, 44 or have cystic fibrosis 20 ) require special efforts to protect them from exposures to infected patients in common waiting areas. By informing the receptioni st of their infection risk upon arrival, appropriate steps may be taken to further pr otect them from infection. In some cystic fibrosis clinics, in order to avoi d 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 rece ive notification to return when an
examination room becomes available 832

.

II.G.3. Home care In home care, the patient placement concerns focus on protecting others in the home from expos ure to an infectious household member.
For individuals who are especially vulner able 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 ar e not part of the household may need to be prohibited from visiting dur ing 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 ill ness was beneficial in preventing
household transmission 249, 834

.

II.H. Transport of patientsSeveral principles are used to guide transport of patients requiring TransmissionBased Precautions. In the inpatient and residential settings these include 1) limiting transport of such patients to e ssential purposes, such as diagnostic and therapeutic procedures that cannot be performed in the patient’s room; 2) when transport is necessary, using appropriate barriers on the patient (e.g., mask, gown, wrapping in sheets or use of im pervious dressings to cover the affected area(s) when infectious skin lesions or drainage are present, consistent with the route and risk of transmission; 3) notifying healthcare personnel in the receiving

59area of the impending arrival of the patient and of the precautions necessary to prevent transmission; and 4) for patient s being transported outside the facility, informing the receiving facility and the m edi-van or emergency vehicle personnel in advance about the type of Transmission-Based Precautions being used. For tuberculosis, additional pr ecautions may be needed in a small shared air space
such as in an ambulance 12

.

II.I. Environmental measures Cleaning and disinfecting non-critical surfaces in patient-care areas are part of Standard Precautions. In general, thes e procedures do not need to be changed for patients on Transmission-Based Precauti ons. The cleaning and disinfection of all patient-care areas is important fo r frequently touched surfaces, especially those closest to the patient, that ar e most likely to be contaminated (e.g., bedrails, bedside tables, commodes, door knobs, sinks, surfaces and equipment in close proximity to the patient) 11, 72, 73, 835 . The frequency or intensity of cleaning may need to change based on the patient’s level of hygiene and the degree of
environmental contamination and for certain for infectious agents whose
reservoir is the intestinal tract 54 . This may be especially true in LTCFs and pediatric facilities where patients wit h stool and urine incontinence are encountered more frequently. Also, increased frequency of cleaning may be
needed in a Protective Environment to minimize dust accumulation 11 . Special recommendations for cleaning and disinfecti ng environmental surfaces in dialysis centers have been published 18 . In all healthcare settings, administrative, staffing and scheduling activities should prioritize the proper cleaning and disinfection of surfaces that could be implicated in trans mission. During a suspected or proven outbreak where an environmental reservoir is suspected, routine cleaning procedures should be reviewed, and the need for additional trained cleaning staff
should be assessed. Adherence should be monitored and reinforced to promote consistent and correct cleaning is performed.

EPA-registered disinfectant s or detergents/disinfect ants that best meet the overall needs of the healthcare facility for routine cleaning and disinfection should
be selected 11, 836 . In general, use of the existing facility detergent/disinfectant according to the manufacturer’s re commendations for amount, dilution, and
contact time is sufficient to remove pathogens from surfaces of rooms where
colonized or infected individuals were housed. This includes those pathogens that are resistant to multiple clas ses of antimicrobial agents (e.g., C. difficile

, VRE, MRSA, MDR-GNB 11, 24, 88, 435, 746, 796, 837 ). Most often, environmental reservoirs of pathogens during outbreaks are related to a failure to follow recommended procedures for cleaning and di sinfection rather than the specific cleaning and disinfectant agents used 838-841

. Certain pathogens (e.g., rotavirus, noroviruses, C. difficile ) may be resistant to some routinely used hospital disinfectants 275, 292, 842-847 .The role of specific disinfectants in limiting transmissi on of rotavirus has been demonstrated experimentally 842 . Also, since C. difficile may display increased levels of spore production when exposed to non-chlorine- based cleaning agents, and the spores are more resistant than veget ative cells to commonly used surface disinfectants,

60some investigators have recommended t he use of a 1:10 dilution of 5.25% sodium hypochlorite (household bleac h) and water for routine environmental disinfection of rooms of patients with C. difficile when there is continued
transmission 844, 848 . In one study, the use of a hypochlorite solution was
associated with a decrease in rate s of C. difficile infections 847 . The need to change disinfectants based on the pr esence of these organisms can be
determined in consultation with the infection control committee 11, 847, 848

. Detailed recommendations for disinfecti on and sterilization of surfaces and medical equipment that have been in contact with prion-c ontaining tissue or high risk body fluids, and for cleaning of blood and body substance spills, are
available in the Guidelines for Environm ental Infection Control in Health-Care
Facilities 11 and in the Guideline for Disinfection and Sterilization 848

.

II.J. Patient care equipment and instruments/devices Medical equipment and in struments/devices must be cleaned and maintained according to the manufacturers’ instructions to prevent patient-to-patient transmission of infectious agents 86, 87, 325, 849 . Cleaning to remove organic material must always precede high level di sinfection and steriliz ation of critical
and semi-critical instruments and devices be cause residual proteinacous material
reduces the effectiveness of the di sinfection and sterilization processes 836, 848

. Noncritical equipment, such as commodes, intravenous pumps, and ventilators, must be thoroughly cleaned and disinfected before use on another patient. All such equipment and devices should be han dled in a manner t hat will prevent HCW and environmental contact with potentia lly infectious material. It is important to include com puters and personal digital assistants (PDAs) used in patient care in policies for cleaning and di sinfection of non-crit ical items. The
literature on contamination of com puters with pathogens has been summarized

850 and two reports have linked computer contamination to colonization and infections in patients 851, 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 all healthcare settings, providing patients who are on Transmission-Based
Precautions with dedicated noncritical m edical equipment (e.g., stethoscope, blood pressure cuff, electronic thermometer) has been beneficial for preventing
transmission 74, 89, 740, 853, 854 . When this is not possible, disinfection after use is recommended. Consult other guidelines for detailed guidance in developing specific protocols for cleaning and r eprocessing medical equipment and patient care items in both routine and special circumstances 11, 14, 18, 20, 740, 836, 848

. In home care, it is preferable to remove visible blood or body fluids from durable medical equipment before it leaves t he home. Equipment can be cleaned on-site using a detergent/disinfectant and, when possi ble, should be placed in a single plastic bag for transport to the reprocessing location 20, 739

.

II.K. Textiles and laundry Soiled textiles, including bedding, towels, and patient or resident clothing may be contaminated with pathogenic microorganisms. However, the risk of disease

61transmission is negligible if they are handled, transported, and laundered in a
safe manner 11, 855, 856 . Key principles for handling soiled laundry are 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 aeros ols from contaminated items 11 . The methods for handling, transporting, and laundering soiled textiles are determined by organizational policy and any applicable regulations 739 ; guidance is provided in
the Guidelines for Environmental Infection Control 11 . Rather than rigid rules and regulations, hygienic and common sense st orage and processing of clean textiles
is recommended 11, 857 . When laundering occurs outside of a healthcare facility, the clean items must be packaged or co mpletely covered and placed in an enclosed space during transpor t to prevent contaminat ion with outside air or
construction dust that could contain infect ious fungal spores that are a risk for immunocompromised patients 11

. Institutions are required to launder garments used as personal protective equipment and uniforms visibly soiled with blood or infective material 739 . There are few data to determine the safety of home laundering of HCW uniforms, but no increase in infection rates was observed in the one published study 858 and no pathogens were recovered from home- or hospital-laundered scrubs in another study 859

. In the home, textiles and laundry from patients wit h potentially transmissible infectious pathogens do not require special handling or separate laundering, and may be washed with warm water and detergent 11, 858, 859

.

II.L. Solid waste
The management of solid wa ste emanating from the heal thcare environment is subject to federal and st ate regulations for medi cal and non-medical waste 860,

861

. No additional precautions are needed fo r non-medical solid waste that is being removed from rooms of patients on Transmission-Based Precautions. Solid waste may be contained in a single bag (as compared to using two bags) of sufficient strength. 862

.

II.M. Dishware and eating utensils The combination of hot water and detergent s used in dishwashers is sufficient to decontaminate dishware and eating utensils. Therefore, no special precautions are needed for dishware (e.g., dishes, gla sses, cups) or eati ng utensils; reusable dishware and utensils may be used for patients requiring Transmission-Based
Precautions. In the home and other co mmunal settings, eating utensils and drinking vessels that are being used s hould not be shared, consistent with principles of good personal hygiene and for the purpose of preventing transmission of respiratory viruses, Herpes simplex virus, and infectious agents that infect the gastrointestinal tract and are transmitted by the fecal/oral route (e.g., hepatitis A virus, noroviruses). If adequate resources for cleaning utensils and dishes are not available, disp osable products may be used.

62II.N. Adjunctive measures Important adjunctive measures that ar e not considered prim ary components of programs to prevent transmission of infectious agents, but improve the effectiveness of such programs, include 1) antimicrobial management programs; 2) postexposure chemoprophylaxis with anti viral or antibacterial agents; 3) vaccines used both for pre and postexposur e prevention; and 4) screening and restricting visitors with signs of transm issible infections. Detailed discussion of judicious use of antimicrobial agents is beyond the scope of this document; however the topic is addressed in the MDRO section (Managem ent of MultidrugResistant Organisms in Healthcare Settings 2006. www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf ).

II.N.1. Chemoprophylaxis Antimicrobial agents and t opical antiseptics may be used to prevent infection and potential out breaks of selected agents. Infections for which postexposure chemoprophylaxis is recommended under defined
conditions include B. pertussis 17, 863 , N. meningitidis 864 , B. anthracis after environmental exposure to aeosolizable material 865

, influenza virus 611

, HIV 866

, and group A streptococcus 160 . Orally administered ant imicrobials may also be
used under defined circumstances for MR SA decolonization of patients or healthcare personnel 867

. Another form of chemoprophylaxis is the use of topical antiseptic agents. For example, triple dye is used routinely on t he umbilical cords of term newborns to reduce the risk of colonization, skin in fections, and omphalitis caused by S.

aureus , including MRSA, and group A streptococcus 868, 869 . Extension of the use of triple dye to low birth weight in fants in the NICU was one component of a program that controlled one longstanding MRSA outbreak 22 . Topical antiseptics
are also used for decolonization of health care personnel or selected patients colonized with MRSA, using mupirocin as discussed in the MDRO guideline 870

867, 871-873

.

II.N.2. Immunoprophylaxis Certain immunizations recommended for susceptible healthcare personnel have dec reased the risk of infection and the potential for transmission in healthcare facilities 17, 874 . The OSHA mandate that requires employers to offer hepatitis B vaccination to HCWs played a substantial role in the sharp decline in incide nce of occupational HBV infection 778, 875 . The use of varicella vaccine in healthcare personnel has decreased the need to place susceptible HCWs on administrative leave following exposure to patients with
varicella 775 . Also, reports of healthcare-asso ciated transmission of rubella in
obstetrical clinics 33, 876 and measles in acute care settings 34 demonstrate the importance of immunization of suscept ible healthcare personnel against childhood diseases. Many states have requirements for HCW vaccination for
measles and rubella in the absence of ev idence of immunity. Annual influenza vaccine campaigns targeted to patients and healthcare personnel in LTCFs and acute-care settings have been instrumental in preventing or lim iting institutional

63outbreaks and increasing attention is being directed toward improving influenza
vaccination rates in healthcare personnel 35 , 611, 690, 877, 878 , 879

. Transmission of B. pertussis in healthcare facilities has been associated with large and costly outbreaks that incl ude both healthcare personnel and patients 17,

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 Un ited States in 2005, one for use in individuals aged 11-18 and one for use in ages 10-64 years 882 . 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 contact 883 884

. Immunization of children and adults will he lp prevent the introduction of vaccinepreventable 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 needed 885, 886 . An adult
immunization schedule also is available for healthy adults and those with special immunization needs due to high risk medical conditions 887

. Some vaccines are also used for poste xposure prophylaxis of susceptible individuals, including varicella 888 , influenza 611 , hepatitis B 778 , and smallpox 225

vaccines 17, 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 viru s [HBIG], rabies [RIG], measles and hepatitis A virus [IG] 17, 833, 874 ). The RSV monoclonal antibody preparation, Palivizumab, may have contributed to controlling a nosocomia l outbreak of RSV in one NICU , but there is insufficient evidence to support a routine recommendation for its use in this setting 891

.

II.N. 3. Management of visitors

II.N.3.a. Visitors as sources of infection Visitors have been identified as the source of several types of HAIs (e.g., pertussis 40, 41

, M. tuberculosis 42, 892

, influenza, and other respiratory viruses 24, 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 siblin g. 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.

64Screening may be passive through the use of signs to alert family members and visitors with signs and sympt oms of communicable diseases not to enter clinical areas. More active screening may include th e completion of a screening tool or questionnaire which elicits information rela ted to recent exposures or current symptoms. That informati on is reviewed by the facilit y staff and the visitor is either permitted to visit or is excluded 833

. Family and household members visiting pediatric patients with pertussis and tuberculosis may need to be screened for a hist ory of exposure as well as signs and symptoms of current infection. Potent ially infectious visitors are excluded until they receive appropriate medical scr eening, 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 terminal ly ill patients), then the symptomatic visitor must wear a mask wh ile 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 units 15, 43 . However, considering the experience during t he 2003 SARS outbreaks and the potential for pandemic influenza, developing effective visi tor screening systems will be beneficial 9

. Education concerning Resp iratory Hygiene/Cough Etiquette is a useful adjunct to visitor screening.

II.N.3.b. Use of barrier pr ecautions 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 impact 893-895 . Family members or visitors who are providing ca re 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.

65

### Part III: Precautions to Prevent Transmission of Infectious Agents

There are two tiers of HI CPAC/CDC precautions to prevent transmission of infectious agents, Standard Precauti ons and Transmission-Based Precautions. Standard Precautions are intended to be appli ed to the care of all patients in all healthcare settings, regardle ss of the suspected or confirmed presence of an infectious agent. Implementation of Standard Precautions constitutes the primary strategy for the prevention of healthcare-associated transmission of infectious agents among pa tients and healthcare personnel

. Transmission-Based Precautions are for patients who are known or suspected to
be infected or colonized with infe ctious agents, including certain epidemiologically important pathogens, which require additional control measures to effectively prevent transmissi on. Since the infecting agent often is
not known at the time of admission to a healthcare facility, Transmission-Based Precautions are used empirically, accord ing to the clinical syndrome and the likely etiologic agents at the time , and then modified when the pathogen is
identified or a transmissible in fectious etiology is ruled out. Examples of this syndromic approach are presented in T able 2. The HICPAC/CDC Guidelines
also include recommendations for creat ing a Protective Environment for allogeneic HSCT patients. The specific elements of Standard and Transmission-Based Precautions are discussed in Part II of this guideline. In Part III, the circ umstances in which Standard Precautions, Transmission-Bas ed Precautions, and a Protective Environment are applied are discussed. See Tables 4 and 5 for summaries of the key elements of these sets of precautions

III.A. Standard Precautions Standard Precautions combine the major features of Universal Precautions (UP) 780, 896 and Body Substance Isolation (BSI) 640 and are based on the principle t hat all blood, body fluids , secretions, excretions except sweat, nonintact skin, and mucous membranes may contain transmissible infectious agents. Standard Precautions include a group of in fection prevention practices that apply to all pat ients, regardless of suspec ted 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 sa fe injection practices. Also, equipment or items in the patient environment likel y to have been contaminated with infectious body fluids must be handl ed in a manner to prevent transmission of infectious agents (e.g. wear gloves fo r direct contact, contain heavily soiled equipment, properly clean and disinfect or sterilize reusable equipment before use on another patient). The application of Standard Pr ecautions during patient care is determined by the nature of the HCW-patient interaction and the extent of antic ipated blood, body fluid, or pathogen exposu re. For some intera ctions (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

66recommended practices are critical el ements of Standard Precautions because they facilitate appropriate decision -making and promote adherence when HCWs
are faced with new circumstances 655, 681-686 . An example of the importance of
the use of Standard Precautions is intubation, especially under emergency circumstances when infectious agents ma y not be suspected, but later are identified (e.g., SARS-CoV, N. meningitides ). The application of Standard
Precautions is described below and summarized in Table 4. Guidance on donning and removing gloves, gowns and ot her PPE is presented in the Figure.
Standard Precautions are also intended to protect patients by ensuring that healthcare personnel do not carry infecti ous 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 reinforcem ent of existing infection control recommendations to protect patients. Because such recommendations are considered a standard of care and may not be included in ot her guidelines, they
are added here to Standard Precautions. Three such areas of practice that have been added are: Respiratory Hy giene/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 pr ocedures (e.g., myelogram, spinal or epidural anesthesia). While most element s of Standard Precautio ns evolved from
Universal Precautions that were deve loped for protection of healthcare personnel, these new elements of Standard Precautions fo cus on protection of patients.

III.A.1.a. Respiratory Hygiene/Cough Etiquette The transmission of SARSCoV in emergency department s by patients and their fa mily members during the widespread SARS outbreaks in 2003 high lighted the need for vigilance and prompt implementation of infection control measures at the first point of encounter within a healthcare setting (e .g., reception and triage areas in emergency departments, outpatient clinics, and physician offices) 21, 254, 897 . The strategy proposed has been termed Re spiratory Hygiene/Cough Etiquette 9, 828 and is intended to be incorporated into infection control practices as a new component of Standard Precautions. The st rategy is targeted at patients and accompanying family members and fr iends with undiagnosed transmissible respiratory infections, and applies to any person with signs of illness including cough, congestion, rhinorrhea, or increas ed production of respir atory secretions when entering a healthcare facility 40, 41, 43 . The term cough etiquette is derived
from recommended source control measures for M. tuberculosis 12, 126

. The elements of Respiratory Hygiene/C ough Etiquette include 1) education of healthcare facility staff, pat ients, and visitors; 2) pos ted signs, in language(s) appropriate to the population served, with instructions to patients and accompanying family members or friends; 3) source control measures (e.g., covering the mouth/nose with a tissue w hen coughing and prompt disposal of used tissues, using surgical masks on the coughing person when tolerated and

67appropriate); 4) hand hygiene after contact with respiratory secretions; and 5) spatial separation, ideally >3 feet, of persons with respiratory infections in common waiting areas when possible. Covering sneezes and coughs and placing masks on coughing patients are pr oven means of source containment that prevent infected persons from dispersi ng respiratory secretions into the air
107, 145, 898, 899 . Masking may be difficult in some se ttings, (e.g., pediatrics, in which case, the emphasis by necessity may be on cough etiquette 900 . Physical proximity of <3 feet has been associat ed with an increased risk for transmission of infections via the droplet route (e.g., N. meningitidis 103 and group A streptococcus 114 and therefore supports the prac tice of distancing infected persons from others who are not infect ed. The effectiveness of good hygiene practices, especially hand hygiene, in preventing transmission of viruses and reducing the incidence of respirator y infections both within and outside 901-903 healthcare settings is summa rized in several reviews 559, 717, 904

. These measures should be effective in decreasing the risk of transmission of pathogens contained in large re spiratory droplets (e.g., influenza virus 23

, adenovirus 111

, B. pertussis 827 and Mycoplasma pneumoniae 112 . Although fever will be present in many respiratory infections, patients with pertussis and mild upper respiratory tract infections are o ften afebrile. Theref ore, the absence of fever does not always exclude a respirator y infection. Patients who have asthma, allergic rhinitis, or chronic obstructi ve lung disease also may be coughing and sneezing. While these patients often are not infectious, cough etiquette measures are prudent. Healthcare personnel are advised to obser ve Droplet Precautions (i.e., wear a mask) and hand hygiene when examining an d caring for patients with signs and symptoms of a respiratory in fection. Healthcare personnel who have a respiratory
infection are advised to avoid direct patient contact, especially with high risk patients. If this is not possible, t hen a mask should be worn while providing patient care.

III.A.1.b. Safe Injection Practices The investigation of fo ur large outbreaks of HBV and HCV among patients in ambulatory ca re facilities in the United States identified a need to define and reinforce safe injection practices 453 . The four outbreaks occurred in a private medica l practice, a pain clinic, an endoscopy clinic, and a hematology/oncology clinic . The primary breaches in infection control practice that contributed to thes e outbreaks were 1) reinsertion of used needles into a multiple-dose vial or so lution container (e.g., saline bag) and 2) use of a single needle/syringe to administe r intravenous medication to multiple patients. In one of these outbreaks, pr eparation of medications in the same workspace where used needle/syringes we re dismantled also may have been a contributing factor. Thes e and other outbreaks of vira l hepatitis could have been prevented by adherence to basic princi ples 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 cont amination of injection equipment and medication.

68Whenever possible, use of single-dose vials is preferred over multiple-dose vials, especially when medications will be administered to multiple patients. Outbreaks related to unsafe injection prac tices indicate that some healthcare personnel are unaware of, do not under stand, or do not adhere to basic principles of infection control and aseptic technique. A survey of US healthcare workers who provide medication through in jection found that 1% to 3% reused the same needle and/or syr inge on multiple patients 905 . Among the deficiencies
identified in recent outbreaks were a lack of oversight of per sonnel and failure to follow-up on reported breaches in infect ion 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 adherence 454

.

III.A.1.c. Infection Control Practices for Special Lumbar Puncture
Procedues In 2004, CDC investigated eight cases of post-myelography meningitis that either were reported to CDC or identifie d through a survey of the Emerging Infections Network of the Infe ctious Disease Society of America. Blood and/or cerebrospinal fluid of all eight cases yielded streptococcal species consistent with oropharyngeal flora and there were changes in the CSF indices
and clinical status indicative of bacteri al meningitis. Equipment and products used during these procedures (e.g., contra st media) were excluded as probable
sources of contaminati on. Procedural details av ailable for seven cases determined that antiseptic skin preparat ions and sterile gloves had been used. However, none of the clinicians wore a fa ce mask, giving rise to the speculation that droplet transmission of oralpharyngeal flora was the most likely explanation for these infections. Bacterial meningit is following myelogram and other spinal procedures (e.g., lumbar puncture, spinal and epidural anesthesia, intrathecal chemotherapy) has been reported previously 906-915 . As a result, the question of whether face masks should be worn to prev ent droplet spread of oral flora during spinal procedures (e.g., myelogram, lu mbar puncture, spinal anesthesia) has
been debated 916, 917 . Face masks are effective in limiting the dispersal of oropharyngeal droplets 918 and are recommended for the placement of central
venous catheters 919 . In October 2005, the Heal thcare Infection Control Practices Advisory Committee (HICPAC) reviewed the evidence and concluded that there is sufficient experience to wa rrant the additional pr otection of a face mask for the individual placing a catheter or injecting material into the spinal or epidural space.

III.B

. Transmission-Based Precautions There are three categories of
Transmission-Based Precautions: Contact Precautions, Droplet Precautions, and
Airborne Precautions. Transmission-Bas ed Precautions are used when the route(s) of transmission is (are) no t completely interrupted using Standard
Precautions alone. For some diseases t hat have multiple routes of transmission (e.g., SARS), more than one Transmission-Based Precautions category may be used. When used either singly or in co mbination, they are always used in

69addition to Standard Precautions. See Appendix A for recommended precautions for specific infections. When Transmi ssion-Based Precautions are indicated, efforts must be made to counteract possible adverse effects on patients (i.e., anxiety, depression and ot her mood disturbances 920-922 , perceptions of stigma

923 , reduced contact with clinical staff 924-926 , and increases in preventable
adverse events 565 in order to improve acceptance by the patients and adherence by HCWs.

III.B.1. Contact Precautions Contact Precautions are intended to prevent transmission of infectious agents, incl uding epidemiologi cally important microorganisms, which are spread by direct or indirect contact with the patient or the patient’s environment as descri bed in I.B.3.a. The specific agents and
circumstance for which Contact Precautions are indicated are found in Appendix
A. The application of Contact Precautions for patients infect ed or colonized with
MDROs is described in the 2006 HICPAC/CDC MDRO guideline 927 . Contact Precautions also apply where the pres ence of excessive wound drainage, fecal incontinence, or other discharges from the body suggest an increased potentialfor extensive environmental contamination and risk of transmission. A singlepatient room is preferred for patients who require Contact Precautions. When a single-patient room is not available, consultation wit h 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). In multi-patient rooms, > 3 feet spatial sepa ration between beds is advised to reduce the opportunities for inadv ertent sharing of items between the infected/colonized patient and other patients. Healthca re personnel caring for patients on Contact Precautions wear a gow n and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient’s environment. Donning PPE upon room entry and discarding before exiting the patient room is done to cont ain pathogens, especially those that have been implicated in transmission through envir onmental contamination (e.g., VRE,
C. difficile, noroviruses and other intestinal tract pathogens; RSV) 54, 72, 73, 78, 274,

275, 740

.

III.B.2. Droplet Precautions Droplet Precautions are intended to prevent transmission of pathogens spread thr ough close respiratory or mucous membrane contact with respir atory secretions as described in I.B.3.b. Because these pathogens do not remain infectious over long distances in a healthcare facility, special air handling and ventilati on are not required to prevent droplet transmission. Infectious agents for which Droplet Precautions are indicated are found in Appendix A and include B. pertussis

, influenza virus, adenovirus, rhinovirus, N. meningitides , and group A streptococcus (for the first 24 hours of antimicrobial therapy). A single patient r oom is preferred for patients who require Droplet Precautions. When a single-patient room is not available, consultation 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

70the curtain between patient beds is especia lly important for patients in multi-bed
rooms with infections transmi tted by the droplet route. Healthcare personnel wear a mask (a respirator is not necessary) fo r close contact with infectious patient; the mask is generally donned up on room entry. Patients on Droplet Precautions who must be transported outside of the r oom should wear a mask if tolerated and follow Respiratory Hygiene/Cough Etiquette.

III.B.3. Airborne Precautions Airborne Precautions prevent transmission of infectious agents that remain infecti ous over long distances when suspended in the air (e.g., rubeola virus [measle s], varicella virus [chickenpox], M. tuberculosis, and possibly SARS-CoV) as described in I.B.3 .c and Appendix A. The preferred placement for patients who require Ai rborne Precautions is in an airborne infection isolation room (AIIR). An AIIR is a single-patient r oom that is equipped with special air handling and v entilation capacity that m eet the American Institute of Architects/Facility Guidelines Instit ute (AIA/FGI) standar ds for AIIRs (i.e., monitored negative pressure relative to the surrounding area, 12 air exchanges per hour for new construction and renovation and 6 air exchanges per hour for existing facilities, air exhausted direct ly to the outside or recirculated through HEPA filtration before return) 12, 13 . Some states require the availability of such rooms in hospitals, emergency department s, and nursing homes that care for patients with M. tuberculosis . A respiratory protection program that includes education about use of respirators, fit-test ing, and user seal checks is required in any facility with AIIRs. In settings where Airborne Precautions cannot be implemented due to limited engineering re sources (e.g., physician offices), masking the patient, placing the patient in a private room (e.g., office examination room) with the door closed, and providing N95 or highe r level respirators or masks if respirators are not available for healthcare personnel will reduce the
likelihood of airborne transmi ssion until the patient is either transferred to a facility with an AIIR or returned to t he home environment, as deemed medically appropriate. Healthcare personnel caring for patients on Airborne Precautions wear a mask or respirator, depending on th e disease-specific recommendations (Respiratory Protection II.E .4, Table 2, and Appendix A), that is donned prior to room entry. Whenever possible, non-imm une HCWs should not care for patients with vaccine-preventable airborne diseas es (e.g., measles, chickenpox, and smallpox).

III.C. Syndromic and em piric applications of Transmission-Based
Precautions Diagnosis of many infections r equires laboratory confirmation. Since laboratory tests, especially thos e that depend on culture techniques, often require two or more days for completion, Transmission-Based Precautions must be implemented while test results are pendi ng based on the clinical presentation and likely pathogens. Use of appropriate Tr ansmission-Based Precautions at the time a patient develops symptoms or signs of transmissible infection, or arrives at a healthcare facility for care, reduces tr ansmission opportunities. While it is not possible to identify prospectively all patients needing Transmission-Based Precautions, certain clinical syndromes and conditions carry a sufficiently high

71risk to warrant their use empirically wh ile confirmatory te sts are pending (Table 2). Infection control professionals ar e encouraged to modify or adapt this table according to local conditions.

III.D. Discontinuation of Transmi ssion-Based Precautions TransmissionBased Precautions remain in effect for limited periods of time (i.e., while the risk for transmission of the infectious agent per sists or for the duration of the illness (Appendix A). For most infectious diseases, this dur ation reflects known patterns of persistence and shedding of infecti ous agents associated with the natural history of the infectious process and its treatment. For some diseases (e.g., pharyngeal or cutaneous diphtheria, R SV), Transmission-Based Precautions
remain in effect until culture or antigen-detection test results document eradication of the pathogen and, for RSV, symptomatic disease is resolved. For other diseases, (e.g., M. tuberculosis ) state laws and regulations, and healthcare facility policies, may dictat e the duration of precautions 12 ). In immunocompromised patients, viral shedding can persist for prolonged periods of time (many weeks to months) and transmission to others may occur during that time; therefore, the duration of contact and/or droplet precautions may be prolonged for many weeks 500, 928-933

. 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 available 867 . 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 therapy 934, 935 . Although early guidelines for VRE suggested discontinuation of Contac t Precautions after three
stool cultures obtained at w eekly intervals proved negative 740 , subsequent experiences have indicated that such screening may fail to detect colonization that can persist for >1 year 27, 936-938 . Likewise, available data indicate that colonization with VRE, MRSA 939 , and possibly MDR-GNB, can persist for many months, especially in the presence of severe underlying disease, invasive devices, and recurrent course s of antimicrobial agents. It may be prudent to assume that MDRO ca rriers are colonized permanently and manage them accordingly. Alternatively, an interval free of hospitalizations, antimicrobial therapy, and invasive dev ices (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 pati ents colonized or infected with MDROs.

III.E. Application of Transmission-B ased Precautions in ambulatory and home care settings Although Transmission-Based Precautions generally apply in all healthcare settings, excepti ons exist. For example, in home care, AIIRs are not available. Furthermore, family members already exposed to
diseases such as varicella and tubercu losis would not use masks or respiratory protection, but visiting HCWs would need to use such protection. Similarly, management of patients colonized or in fected with MDROs may necessitate

72Contact Precautions in acute care hospi tals and in some LTCFs when there is continued transmission, but the risk of tr ansmission in ambulatory care and home care, has not been defined. Consistent us e of Standard Precaut ions may suffice in these settings, but more information is needed.

III.F. Protective Environment A Protective Environment is designed for allogeneic HSCT patients to minimize f ungal spore counts in the air and reduce
the risk of invasive environmental fungal infections (see Table 5 for specifications) 11, 13-15 . The need for such controls has been demonstrated in studies of aspergillus outbreaks associated with construction 11, 14, 15, 157, 158 . As defined by the American Insi tute of Architecture 13 and presented in detail in the
Guideline for Environmental Infection Control 2003 11, 861 , air quality for HSCT patients is improved through a combination of environmental controls that include 1) HEPA filtration of incoming air; 2) dire cted room air flow; 3) positive room air pressure relative to the corridor; 4) we ll-sealed rooms (including sealed walls, floors, ceilings, windows, electrical outlets) to prevent flow of air from the outside; 5) ventilation to provide > 12 air changes per hour; 6) stra tegies to minimize dust (e.g., scrubbable surfaces rather than upholstery 940 and carpet 941 , and routinely cleaning crevices and sprinkler heads); and 7) prohibiting dried and fresh flowers and potted plants in the rooms of HSCT patients. The latter is based on molecular typing studies that have found indistinguishable strains of Aspergillus
terreus in patients with hematologic malign ancies and in potted plants in the vicinity of the patients 942-944 . The desired quality of ai r may be achieved without incurring the inconvenience or expense of laminar airflow 15, 157 . To prevent inhalation of fungal spores during periods when construction, r enovation, 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 dev ice (e.g., an N95 respirator) when they
leave the Protective Environment 11, 14, 945 ). The use of masks or respirators by HSCT patients when they are outside of the Protective Environment for prevention of environmental f ungal infections in the absence of construction has
not been evaluated. A Protective Environm ent does not include the use of barrier precautions beyond those indicated for Standard and Transmission-Based Precautions. No published reports suppor t the benefit of placing solid organ transplants or other immunoc ompromised patients in a Protective Environment.

73

### Part IV:

Recommendations
These recommendations are designed to prevent transmission of infectious agents among patients and healthcare personnel in all settings where healthcare
is delivered

. As in other CDC/HICPAC guidelines, each recommendation is categorized on the basis of existing sci entific data, theoretical rationale, applicability, and when possible, economic impact. The CDC/HICPAC system for categorizing recommendations is as follows: Category IA Strongly recommended for impl ementation and st rongly supported by well-designed experimental, clinic al, or epidemiologic studies. Category IB Strongly recommended for implementation and supported by some experimental, clinical, or epidemiologic studies and a strong theoretical rationale. Category IC Required for implementation, as mandated by federal and/or state regulation or standard. Category II Suggested for implementation and supported by suggestive clinical or epidemiologic studies or a theoretical rationale.
No recommendation ; unresolved issue. Practi ces for which insufficient evidence or no consensus regarding efficacy exists.

I. Administrative Responsibilities Healthcare organization administrator s should ensure the implementation of
recommendations in this section.
I.A. Incorporate preventing transmissi on of infectious agents into the objectives of the organization’s pati ent and occupational safety programs
543-546, 561, 620, 626, 946

. Category IB/IC
I.B. Make preventing transmission of in fectious agents a priority for the healthcare organization. Provide admin istrative support, including fiscal
and human resources for maintaini ng infection control programs 434, 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 c ontract to all healthcare facilities
so that the infection control program is m anaged by one or more qualified individuals 552, 566 316, 575, 947 573, 576, 946

. Category IB/IC
I.B.1.a. Determine the specific infection control full-time equivalents (FTEs) according to the scope of the infection control program, the complexity of the healthca re facility or system, the characteristics of the patient population, the unique or urgent needs of the facility and community, and proposed staffing levels based on survey results and recommendations from professional organizations 434, 549 552, 566 316, 569, 573, 575 948 949

. Category IB
I.B.2. Include prevention of healthcare-a ssociated infections (HAI) as one
determinant of bedside nurse sta ffing levels and composition,

74especially in high-risk units 585-589 590 592 593 551, 594, 595 418, 596, 597 583

. Category IB
I.B.3. Delegate authority to infection control personnel or their designees (e.g., patient care unit charge nur ses) for making infection control decisions concerning patient placement and assignment of
Transmission-Based Precautions 549 434, 857, 946

. Category IC
I.B.4. Involve infection control per sonnel in decisions on facility construction and design, determination of AIIR and Protective Environment capacity needs and environmental assessments 11, 13,

950 951 12

. Category IB/IC
I.B.4.a. Provide ventilation systems required for a sufficient number of AIIRs (as determined by a ri sk assessment) and Protective Environments in healthcare facilities that provide care to patients for whom such rooms are indicated, according to published recommendations 11-13, 15

. Category IB/IC
I.B.5. Involve infection control per sonnel in the selection and postimplementation evaluation of me dical equipment and supplies and changes in practice that c ould affect the risk of HAI 952, 953

. Category
IC
I.B.6. Ensure availability of human and fiscal resources to provide clinical microbiology laboratory support, including a sufficient number of medical technologists trained in microbiology, appropriate to the healthcare setting, for monitoring transmission of microorganisms, planning and conducting epidemiologic investigations, and detecting emerging pathogens. Ident ify resources for performing surveillance cultures, rapid diagno stic testing for viral and other selected pathogens, preparation of antimicrobial susceptibility summary reports, trend analysis, and molecular typing of clustered isolates (performed either on-site or in a reference laboratory) and use these resources according to facility-specific epidemiologic needs, in consultation with clinical microbiologists 553, 609, 610, 612, 617,

954 614 603, 615, 616 605 599 554 598, 606, 607

. Category IB
I.B.7. Provide human and fiscal resour ces to meet occupational health needs related to infection control (e.g., healthcare personnel immunization, post-exposure eval uation and care, evaluation and management of healthcare personnel with communicable infections

739 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 cons istent 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 policie s and procedures to ensure that reusable patient care equipment is cleaned and reprocessed

87 11, appropriately before us e on another patient 11, 956 957, 958 959 836

960 961

. Category IA/IC

75I.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 kn owledgeable 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 c ontrol measures, including isolation precautions, PPE) of potentially infecti ous persons at initial points of patient encounter in outpatient setti ngs (e.g., triage areas, emergency departments, outpatient clinics, physici an 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 pr ocedures 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 call transplant [HSCT] units, in tensive care units, other severely immunocompromised patients) for possible infection 43 24, 41, 962,

963

. Category IB
I.F. Identify performance indicators ofthe effectiveness of organizationspecific measures to prevent tran smission of infectious agents (Standard and Transmission-Based Precautions), establish processes to monitor adherence to those performance measur es and provide feedback to staff
members 704 739 705 708 666, 964 667 668 555

. Category IB

II. Education and Training
II.A. Provide job- or task-specific education and training on preventing transmission of infectious agents associated with healthcare during orientation to the healthcare facility; update information periodically during ongoing education programs. Target all healthcare personnel for education and training, including but not limited to medical, nursing, clinical technicians, laboratory sta ff; property service (housekeeping), laundry, maintenance and dietary worker s; students, contract staff and volunteers. Document competency init ially and repeatedly, as appropriate, for the specific staff positions. Develop a system to ensure that healthcare personnel employed by outside agenc ies meet these education and training requirements through program s offered by the agencies or by participation in the healthcare facility’s program designed for full-time personnel 126, 559, 561, 562, 655, 681-684, 686, 688, 689, 702, 893, 919, 965

. Category IB
II.A.1. Include in education and traini ng programs, information concerning use of vaccines as an adjunctive infection control measure 17, 611,

690, 874

. Category IB
II.A.2. Enhance education and training by applying principles of adult learning, using reading level and language appropriate material for the target audience, and using onlin e educational tools available to
the institution 658, 694, 695, 697, 698, 700, 966

. Category IB

76II.B. Provide instructional materials fo r patients and visitors on recommended hand hygiene and Respiratory Hygiene/C ough Etiquette practices and the application of Transmissi on-Based Precautions 9, 709, 710, 963

. Category II

III. Surveillance
III.A. Monitor the incidence of epidem iologically-important organisms and targeted HAIs that have substant ial 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 facility 566, 671, 672, 675, 687, 919, 967, 968 673 969 970

. Category IA
III.B. Apply the following ep idemiologic principles of infection surveillance 671, 967

673 969 663 664

. Category IB

y Use standardized definitions of infection

y Use laboratory-based data (when available)

y Collect epidemiologically-important va riables (e.g., patient locations and/or clinical service in hospitals and other large multi-unit facilities, population-specific risk factors [e .g., low birth-weight neonates], underlying conditions that predispos e to serious adverse outcomes)

y Analyze data to identify trends that may indicated increased rates of
transmission

y Feedback information on trends in t he incidence and prevalence of HAIs, probable risk factors, and prevent ion strategies and their impact to the appropriate healthcare provi ders, organization administrators, and as required by local and state health authorities
III.C. Develop and implement strategi es to reduce risks for transmission and
evaluate effectiveness 566, 673, 684, 970 963 971

. Category IB
III.D. When transmission of epidemiologica lly-important organisms continues despite implementation and docum ented adherence to infection prevention and control strategies, obtain consultation from persons knowledgeable in infection control and healthcare epidemiology to review
the situation and recommend additi onal measures for control 566 247 687

. Category IB
III.E. Review periodically information on community or regional trends in the incidence and prevalence of epidemio logically-important organisms (e.g., influenza, RSV, pertussis, invasive group A streptococcal disease, MRSA, VRE) (including in other healthcare fa cilities) that may impact transmission of organisms within the facility 398, 687, 972, 973 974

. Category II

IV. Standard Precautions Assume that every person is potentia lly infected or colonized with an organism that could be transmitted in the healthcare setting and apply the following infection control practices during the delivery of health care.
IV.A. Hand Hygiene

77IV.A.1. During the delivery of healthca re, avoid unnecessary touching of surfaces in close proximity to the patient to prevent both
contamination of clean hands fr om environmental surfaces and transmission of pathogens from contaminated hands to surfaces 72,

73 739, 800, 975{CDC, 2001 #970

. Category IB/IC
IV.A.2. When hands are visibly dirty, contaminated with proteinaceous material, or visibly soiled with bl ood or body fluids, wash hands with either a nonantimicrobial soap and water or an antimicrobial soap
and water 559

. Category IA
IV.A.3. If hands are not visibly soiled, or after removing visible material with nonantimicrobial soap and water, decontaminate hands in the
clinical situations described in IV .A.2.a-f. The preferred method of
hand decontamination is with an alcohol-based hand rub 562, 978

. Alternatively, hands may be wash ed with an antimicrobial soap and water. Frequent use of alcohol-based hand rub immediately following handwashing with nonant imicrobial soap may increase the frequency of dermatitis 559

. Category IB Perform hand hygiene:
IV.A.3.a. Before having direct contact with patients 664, 979

. Category IB
IV.A.3.b. After contact with blood, body fluids or excretions, mucous membranes, nonintact skin, or wound dressings 664

. Category IA
IV.A.3.c. After contact with a patient’s intact skin (e.g., when taking a pulse or blood pressure or lifting a patient) 167, 976, 979, 980

. Category IB
IV.A.3.d. If hands will be moving from a contaminated-body site to a clean-body site during patient care. Category II
IV.A.3.e. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient 72, 73, 88, 800, 981

982

. Category II
IV.A.3.f. After removing gloves 728, 741, 742

. Category IB
IV.A.4. Wash hands with non-antimicr obial soap and water or with antimicrobial soap and water if contact with spores (e.g., C. difficile

or Bacillus anthracis ) is likely to have occurred. The physical action of washing and rinsing hands under such circumstances is recommended because alcohols, chlorhexidine, iodophors, and other antiseptic agents have poor activity against spores 559, 956, 983

. Category II
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 weari ng of non-natural nails by healthcare personnel who have direct contact with patients outside of the gr oups specified above 984

. Category II
IV.B. Personal protective equipment (PPE) (see Figure)
IV.B.1. Observe the followi ng principles of use:

78IV.B.1.a. Wear PPE, as described in IV.B.2-4,when the nature of the anticipated patient interaction i ndicates that contact with blood or body fluids may occur 739, 780, 896

. Category IB/IC
IV.B.1.b. Prevent contamination of clothing and skin during the process of removing PPE (see Figure). 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 in fectious materials, mucous membranes, nonintact skin, or pot entially 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.B.2.b.i. Wear disposable medical examination gloves for providing direct patient care.
IV.B.2.b.ii. Wear disposable medica l examination gloves or reusable utility gloves for cleaning t he environment or medical equipment.
IV.B.2.c. Remove gloves after contact with a patient and/or the surrounding environment (includi ng medical equipment) using proper technique to prevent hand contamination (see Figure). Do not wear the same pair of gl oves for the care of more than one patient. Do not wash gloves for the purpose of reuse since this practice has been associated with transmission of pathogens 559, 728, 741-743, 988

. Category IB
IV.B.2.d. Change gloves during patient care if the hands will move from a contaminated body-site (e.g., per ineal area) to a clean body-site (e.g., face). Category II
IV.B.3. Gowns
IV.B.3.a. Wear a gown, that is appropr iate to the task, to protect skin and prevent soiling or contaminati on of clothing during procedures and patient-care activities when contact with blood, body fluids, secretions, or excret ions is anticipated 739, 780, 896

. Category
IB/IC
IV.B.3.a.i. Wear a gown for direct patient contact if the patient has
uncontained secretions or excretions 24, 88, 89, 739, 744 Category IB/IC
IV.B.3.a.ii. Remove gown and per form hand hygiene before leaving the patient’s environment 24, 88, 89, 739, 744 Category IB/IC
IV.B.3.b. Do not reuse gowns, even for repeated contacts with the same patient. Category II
IV.B.3.c

. Routine donning of gowns upon entrance into a high risk unit (e.g., ICU, NICU, HSCT unit) is not indicated 365, 747-750

. Category IB
IV.B.4. Mouth, nose, eye protection

79IV.B.4.a. Use PPE to protect the mu cous membranes of the eyes, nose and mouth during procedures and pati ent-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions and excretions. Select masks, goggles, face shields, and combinations of each according to the need anticipated by the task performed 113, 739, 780, 896

. Category IB/IC
IV.B.5. During aerosol-generating procedures (e.g., bronchoscopy, suctioning of the respiratory tr act [if not using in-line suction catheters], endotrachea l intubation) in pat ients who are not suspected of being infected with an agent for which respiratory protection is otherwise recommended (e.g., M. tuberculosis, SARS or hemorrhagic fever viruses), w ear one of the following: a face shield that fully covers the front and sides of the face, a mask with attached shield, or a mask and goggles (in addition to gloves and gown) 95, 96, 113, 126 93 94, 134

. Category IB
IV.C. Respiratory Hygiene/Cough Etiquette
IV.C.1. Educate healthcare personnel on the importance of source control measures to contain respiratory secretions to prevent droplet and fomite transmission of respiratory pathogens, especially during seasonal outbreaks of viral respiratory tract infections (e.g., influenza, RSV, adenovirus, parainf luenza virus) in communities 14,

24, 684 10, 262

. Category IB
IV.C.2. Implement the follo wing measures to contai n respiratory secretions in patients and accompanying in dividuals who have signs and symptoms of a respirator y infection, beginning at the point of initial encounter in a healthcare setting (e.g ., triage, reception and waiting areas in emergency departments, out patient clinics and physician offices) 20, 24, 145, 902, 989

. IV.C.2.a. Post signs at entrances and in strategic places (e.g., elevators, cafeterias) within ambulatory and inpatient settings with instructions to patients and ot her persons with symptoms of a respiratory infection to cover t heir mouths/noses when coughing or sneezing, use and dispose of tissues, and perform hand hygiene after hands have been in contact with respiratory
secretions. Category II
IV.C.2.b. Provide tissues and no-touc h receptacles (e.g.,foot-pedaloperated lid or open, plas tic-lined waste basket) for disposal of
tissues 20

. Category II
IV.C.2.c. Provide resources and inst ructions for performing hand hygiene in or near waiting areas in ambulatory and inpatient settings; provide conveniently-located dispensers of alcohol-based hand rubs and, where sinks are ava ilable, supplies for handwashing
559, 903

. Category IB
IV.C.2.d. During periods of increased pr evalence of respiratory infections in the community (e.g., as indicated by increased school absenteeism, increased number of patients seeking care for a

80respiratory infection), offe r masks to coughing patients and other symptomatic persons (e.g ., persons who accompany ill patients) upon entry into the facility or medical office 126, 899 898 and encourage them to maintain special separation, ideally a distance of at least 3 feet, from others in common waiting areas
23, 103, 111, 114 20, 134

. Category IB
IV.C.2.d.i. Some facilities may find it logistically easier to institute this recommendation year-round as a standard of practice. Category II
IV.D. Patient placement
IV.D.1. Include the potential for transmiss ion of infectious agents in patientplacement decisions. Place patients who pose a risk for transmission to others (e.g., uncont ained secretions, excretions or wound drainage; infants with suspected viral respiratory or gastrointestinal infections) in a single-patient room when available
24, 430, 435, 796, 797, 806, 990 410, 793

. Category IB
IV.D.2. Determine patient placement based on the following principles:

y Route(s) of transmission of the known or suspected infectious agent

y Risk factors for transmission in the infected patient

y Risk factors for adverse outcomes resulting from an HAI in other patients in the area or room being considered for patientplacement

y Availability of single-patient rooms

y Patient options for room-sharing (e.g., cohorting patients with the same infection) Category II
IV.E. Patient-care equipment and instruments/devices 956

IV.E.1. Establish policies and procedures for containing, transporting, and handling patient-care equipment and in struments/devices that may be contaminated with blood or body fluids 18, 739, 975

. Category IB/IC
IV.E.2. Remove organic material from critical and semi-critical instrument/devices, using recommended cleaning agents before high level disinfection and sterilization to enable effective disinfection and sterilization processes 836 991, 992

. Category IA
IV.E.3. Wear PPE (e.g., gloves, gown), a ccording to the level of anticipated contamination, when handling patient-care equipment and
instruments/devices that is vi sibly soiled or may have been in contact with blood or body fluids 18, 739, 975

. Category IB/IC
IV.F. Care of the environment 11

IV.F.1. Establish policies and procedures for routine and targeted cleaning
of environmental surfaces as indi cated by the level of patient contact and degree of soiling 11

. Category II
IV.F.2. Clean and disinfect surfaces t hat are likely to be contaminated with 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

81surrounding 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 disinfect ants that have microbiocidal (i.e., killing) activity against the pathogens most likely to contaminate the patient-care environment. Use in accordance with manufacturer’s
instructions 842-844, 956, 996

. Category IB/IC
IV.F.3.a. Review the efficacy of in-u se disinfectants when evidence of continuing transmission of an infe ctious agent (e.g ., rotavirus, C. difficile, norovirus) may indicate resistance to the in-use product and change to a more effective disinfectant as indicated 275, 842,

847

. Category II
IV.F.4. In facilities that provide heal th care to pediatric patients or have waiting areas with child play toys (e.g., obstetric/gynecology offices and clinics), establish policies and procedures for cleaning and disinfecting toys at regular intervals 379 80

. Category IB

• Use the following principles in developing this policy and procedures: Category II

y Select play toys that can be easily cleaned and disinfected

y Do not permit use of stuffed fu rry toys if they will be shared

y Clean and disinfect large st ationary toys (e.g., climbing equipment) at least weekly and whenever visibly soiled

y If toys are likely to be mouthed, rinse with water after disinfection; alternatively wash in a dishwasher

y When a toy requires cleaning and disinfection, do so immediately or store in a desig nated labeled container separate from toys that are clean and ready for use
IV.F.5. Include multi-use electronic equipment in policies and procedures for preventing contamination and for cleaning and disinfection, especially those items that are us ed by patients, those used during delivery of patient care, and mobile devices that are moved in and out of patient rooms frequently (e.g., daily) 850 851, 852, 997

. Category
IB
IV.F.5.a. No recommendation for use of removable protective covers or washable keyboards. Unresolved issue
IV.G. Textiles and laundry
IV.G.1. Handle used textiles and fabr ics with minimum agitation to avoid contamination of air, surfaces and persons 739, 998, 999

. Category
IB/IC
IV.G.2. If laundry chutes are used, ensur e that they are properly designed, maintained, and used in a manner to minimize dispersion of aerosols from contaminated laundry 11, 13, 1000, 1001

. Category IB/IC
IV.H. Safe injection practices The following recommendations apply to t he use of needles, cannulas that replace needles, and, where applicab le intravenous delivery systems 454

82IV.H.1. Use aseptic technique to avoi d contamination of sterile injection equipment 1002, 1003

. Category IA
IV.H.2. Do not administer medications from a syringe to multiple patients,
even if the needle or cannula on the syringe is changed. Needles, cannulae and syringes are sterile, si ngle-use items; they should not be reused for another patient nor to access a medication or solution that might be used fo r a subsequent patient 453, 919, 1004, 1005

. Category IA
IV.H.3. Use fluid infusion and administr ation sets (i.e., intravenous bags, tubing and connectors) for one patient only and dispose appropriately after use. Cons ider a syringe or needle/cannula
contaminated once it has been used to enter or connect to a patient’s intravenous infusion bag or administration set 453

. Category IB
IV.H.4. Use single-dose vials for par enteral medications whenever possible

453

. Category IA
IV.H.5. Do not administer medications from single-dose vials or ampules to multiple patients or combine leftover contents for later use 369 453,

1005

. Category IA
IV.H.6. If multidose vials must be used, both the needle or cannula and syringe used to access the multidose vial must be sterile 453, 1002

. Category IA
IV.H.7. Do not keep multidose vials in the immediate patient treatment area and store in accordance with the manufacturer’s recommendations; discard if sterility is compromised or questionable 453, 1003

. Category
IA
IV.H.8. Do not use bags or bottles of intravenous solution as a common source of supply for multiple patients 453, 1006

. Category IB
IV.I. Infection control practices for special lumbar puncture procedures Wear a surgical mask when placing a cat heter or injecting material into the spinal canal or subdural space (i.e., during myelograms, lumbar puncture and spinal or epidural anesthesia 906 907-909 910, 911 912-914, 918 1007

. Category
IB
IV.J. Worker safety Adhere to federal and state requirem ents for protection of healthcare personnel from exposure to bloodborne pathogens 739

. Category IC

V. Transmission-Based Precautions
V.A. General principles
V.A.1. In addition to Standard Prec autions, use Transmission-Based Precautions for patients with docum ented or suspected infection or colonization with highly transmissib le or epidemiologically-important pathogens for which additional pr ecautions are needed to prevent transmission (see Appendix A) 24, 93, 126, 141, 306, 806, 1008

. Category IA
V.A.2. Extend duration of Transmissi on-Based Precautions, (e.g., Droplet, Contact) for immunosuppressed pati ents with viral infections due to

83prolonged shedding of viral agents that may be transmitted to
others 928, 931-933, 1009-1011

. Category IA
V.B. Contact Precautions
V.B.1. Use Contact Precautions as recommended in Appendix A for patients with known or suspect ed infections or evidence of syndromes that represent an increased risk for contact transmission. For specific recommendations for use of Contact
Precautions for colonization or in fection with MDROs, go to the MDRO guideline: www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf 870

. V.B.2. Patient placement
V.B.2.a. In acute care hospitals , place patients who require Contact Precautions in a single-pat ient room when available 24, 687, 793, 796,

797, 806, 837, 893, 1012, 1013 Category IB When single-patient rooms are in short supply, apply the following principles for making dec isions on patient placement:

y Prioritize patients with condi tions that may facilitate transmission (e.g., uncontained drainage, stool incontinence) for single-patient room placement. Category II

y Place together in the same r oom (cohort) patients who are
infected or colonized wit h the same pathogen and are
suitable roommates 29, 638, 808, 811-813, 815, 818, 819 Category IB

y If it becomes necessary to place a patient who requires Contact Precautions in a room with a patient who is not
infected or colonized with the same infectious agent:

o Avoid placing patients on Contact Precautions in the same room with patients who have conditions that may increase the ri sk of adverse outcome
from infection or that may facilitate transmission (e.g., those who are immunocompromised, have open wounds, or have anticipated prolonged lengths of stay). Category II

o Ensure that patients are physically separated (i.e., >3 feet apart) from each other. Draw the privacy
curtain between beds to mi nimize opportunities for direct contact.) Category II

o Change protective attire and perform hand hygiene between contact with patients in the same room, regardless of whet her one or both patients
are on Contact Precautions 728, 741, 742, 988, 1014, 1015

. Category IB
V.B.2.b. In long-term care and other residential settings , make decisions regarding patient placement on a case-by-case basis, balancing infection risks to other patients in the room, the presence of risk
factors that increase the like lihood of transmission, and the

84potential adverse psychological impact on the infected or colonized patient 920, 921

. Category II
V.B.2.c. In ambulatory settings , place patients who require Contact
Precautions in an examination r oom or cubicle as soon as possible 20

. Category II
V.B.3. Use of personal protective equipment
V.B.3.a. Gloves Wear gloves whenever touching the patient’s intact skin 24, 89, 134, 559,

746, 837 or surfaces and articles in clos e proximity to the patient (e.g., 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 patien t. Don gown upon entry into the room or cubicle. Remove gown and observe hand hygiene before leaving t he patient-care environment 24, 88,

134, 745, 837

. Category IB
V.B.3.b.ii. After gown removal, ens ure that clothi ng and skin do not contact potentially contaminated environmental surfaces that could result in possible transfer of microorganism to other patients or environmental surfaces 72, 73

. Category II
V.B.4. Patient transport
V.B.4.a. In acute care hospitals and long-te rm 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 movem ent in any healthcare setting is necessary, ensure that infected or colonized areas of the patient’s body are c ontained and covered. Category II
V.B.4.c. Remove and dispose of contaminated PPE and perform hand hygiene prior to transporting pat ients on Contact Precautions. Category II
V.B.4.d. Don clean PPE to handl e the patient at the transport
destination. Category II
V.B.5. Patient-care equipm ent and instruments/devices
V.B.5.a. Handle pati ent-care equipment and instruments/devices according to Standard Precautions 739, 836

. Category IB/IC
V.B.5.b. In acute care hospitals and long-te rm 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 us e 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

85V.B.5.c.i. Limit the amount of non-disposable patient-care equipment brought into the hom e of patients on Contact Precautions. Whenever possi ble, leave patient-care equipment in the home until di scharge from home care
services. Category II
V.B.5.c.ii. If noncritical patient-c are equipment (e.g., stethoscope) cannot remain in the home, clean and disinfect items before taking them from t he home using a low- to
intermediate-level disinfect ant. 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 plasti c bag for transport to a soiled utility area for reprocessing. Category II
V.B.6. Environmental measures Ensure that rooms of patient s on Contact Precautions are prioritized for frequent cleaning and di sinfection (e.g., at least daily) with a focus on frequently-touched surfaces (e.g., bed rails, overbed table, bedside commode, la vatory surfaces in patient bathrooms, doorknobs) and equipment in the immediate vicinity of the patient 11, 24, 88, 746, 837

. Category IB
V.B.7. Discontinue Contact Precautio ns after signs and symptoms of the infection have resolved or according to pathogen-specific recommendations in Appendix A. Category IB
V.C. Droplet Precautions
V.C.1. Use Droplet Precautions as recommended in Appendix A for patients known or suspected to be infected with pathogens transmitted by respiratory droplets (i.e., large-particle droplets >5μ in size) that are generated by a patient who is coughing, sneezing or talking 14, 23, Steinberg, 1969 #1708, 41, 95, 103, 111, 112, 755, 756, 989, 1017

. Category IB
V.C.2. Patient placement
V.C.2.a. In acute care hospitals, place patients who require Droplet Precautions in a single-pati ent room when available Category II When single-patient rooms are in short supply, apply the following principles for making dec isions on patient placement:

y Prioritize patients who have excessive cough and sputum production for single-pati ent room placement Category II

y Place together in the same r oom (cohort) patients who are infected the same pathogen and are suitable roommates 814

816

. Category IB

y If it becomes necessary to place patients who require Droplet Precautions in a room with a patient who does not
have the same infection:

y Avoid placing patients on Droplet Precautions in the same room with patients wh o have conditions that may increase

86the risk of adverse outcome fr om infection or that may facilitate transmission (e.g., those who are immunocompromised, have or have anticipated prolonged lengths of stay). Category II

y Ensure that patients are physica lly separated (i.e., >3 feet apart) from each other. Draw the privacy curtain between beds to minimize opportunities for close contact 103, 104 410

. Category IB

y Change protective attire and perform hand hygiene between contact with patients in the same room, regardless of whether one patient or bot h patients are on Droplet
Precautions 741-743, 988, 1014, 1015

. Category IB
V.C.2.b. In long-term care and other residential settings , make decisions regarding patient placement on a case-by-case basis after considering infection risks to other patients in the room and
available alternatives 410

. Category II
V.C.2.c. In ambulatory settings , place patients who require Droplet
Precautions in an examination r oom or cubicle as soon as possible. Instruct patients to follow recommendations for Respiratory Hygiene/Cough Etiquette 447, 448 9, 828

. Category II
V.C.3. Use of personal protective equipment
V.C.3.a. Don a mask upon entry into the patient room or cubicle 14, 23, 41,

103, 111, 113, 115, 827

. Category IB
V.C.3.b. No recommendati on for routinely wearing eye protection (e.g., goggle or face shield), in additi on to a mask, for close contact with patients who require Droplet Precautions. Unresolved issue
V.C.3.c. For patients with suspected or proven SARS, avian influenza or pandemic influenza, refer to the fo llowing websites for the most current recommendations ( www. cdc .gov/ncidod/ sars / ;

www. cdc .gov/flu/ avian / ;www. pandemicflu

. gov / ) 134, 1018, 1019

V.C.4. Patient transport
V.C.4.a. In acute care hospitals and long-te rm care and other residential settings , limit transport and movement of patients outside of the room to medically-necessary purposes. Category II
V.C.4.b. If transport or mo vement in any healthcare setting is necessary, instruct patient to wear a mask and follow Respiratory Hygiene/Cough Etiquette www.cdc.gov/flu/professionals/inf ectioncontrol/resphygiene.htm )

. Category IB
V.C.4.c. No mask is required for per sons transporting patients on Droplet
Precautions. Category II
V.C.4.d. Discontinue Droplet Prec autions after signs and symptoms have resolved or according to pathogen-specific recommendations in Appendix A. Category IB
V.D. Airborne Precautions

87V.D.1. Use Airborne Precautions as recommended in Appendix A for patients known or suspected to be infected with infectious agents transmitted person-to-person by the airborne route (e.g., M
tuberculosis 12 , measles 34, 122, 1020 , chickenpox 123, 773, 1021

, disseminated herpes zoster 1022

. Category IA/IC
V.D.2. Patient placement
V.D.2.a. In acute care hospitals and long-term care settings , place patients who require Ai rborne Precautions in an AIIR that has been constructed in accordance with current guidelines 11-13

. Category IA/IC
V.D.2.a.i. Provide at least six (existing facility) or 12 (new construction/renovation) air changes per hour.
V.D.2.a.ii. Direct exhaust of air to the outside. If it is not possible to exhaust air from an AIIR directly to the outside, the air may be returned to the air-handling system or adjacent spaces if all air is directed through HEPA filters.
V.D.2.a.iii. Whenever an AIIR is in use for a patient on Airborne Precautions, monitor air pre ssure daily with visual indicators (e.g., smoke tubes, fl utter strips), regardless of the presence of differential pressure sensing devices (e.g., manometers) 11, 12, 1023, 1024

. V.D.2.a.iv. Keep the AIIR door cl osed when not required for entry
and exit.
V.D.2.b. When an AIIR is not available, transfer the patient to a facility
that has an available AIIR 12

. Category II
V.D.2.c. In the event of an outbreak or exposure involving large numbers of patients who require Airborne Precautions:

y Consult infection control professionals before patient placement to determine the safety of alternative room that do not meet engineering r equirements for an AIIR.

y Place together (cohort) patient s who are presumed to have the same infection( based on clinical presentation and diagnosis when known) in areas of the facility that are away from other patients, especially patients who are at increased risk for infection (e.g., i mmunocompromised patients).

y Use temporary portable solutions (e.g., exhaust fan) to create a negative pressure environment in the converted area of the facility. Discharge ai r directly to the outside,away from people and air intakes, or direct all the air through
HEPA filters before it is in troduced to other air spaces 12 Category II
V.D.2.d. In ambulatory settings : V.D.2.d.i. Develop systems (e.g., triage, signage) to identify patients with known or suspect ed infections that require Airborne Precautions upon entry into ambulatory settings
9, 12, 34, 127, 134

. Category IA

88V.D.2.d.ii. Place the patient in an AIIR as soon as possible. If an AIIR is not available, place a surgical mask on the patient and place him/her in an exam ination room. Once the patient leaves, the room should remain vacant for the appropriate time, generally one hour, to allow for a full exchange of air 11, 12, 122

. Category IB/IC
V.D.2.d.iii. Instruct patients with a known or suspected airborne infection to wear a surgical mask and observe Respiratory Hygiene/Cough Etiquette. Once in an AIIR, the mask may be removed; the mask should remain on if the patient is not in an AIIR 12, 107, 145, 899

. Category IB/IC
V.D.3. Personnel restrictions Restrict susceptible healthcare personnel from entering the rooms of patients known or suspected to have measles (rubeola), varicella (chickenpox), disseminated zoster, or smallpox if other immune healthcare personnel are available 17, 775

. Category IB
V.D.4. Use of PPE
V.D.4.a. Wear a fit-te sted NIOSH-approved N95 or higher level respirator for respiratory protection when en tering the room or home of a patient when the following diseases are suspected or confirmed:

y Infectious pulmonary or laryngeal tuberculosis or when infectious tuberculosis skin lesions are present and procedures that would aeroso lize viable organisms (e.g., irrigation, incision and drai nage, whirlpool tr eatments) are performed 12, 1025, 1026

. Category IB

y Smallpox (vaccinated and unv accinated). Respiratory protection is recommended for all healthcare personnel, including those with a document ed “take” after smallpox
vaccination due to the risk of a genetically engineered virus against which the vaccine may not provide protection, or of exposure to a very large vira l load (e.g., from high-risk aerosol-generating procedur es, immunocompromised patients, hemorrhagic or flat smallpox 108, 129

. Category II
V.D.4.b. No recommendation is made regarding the use of PPE by healthcare personnel who are presumed to be immune to measles (rubeola) or varicell a-zoster based on history of disease, vaccine, or serologi c testing when caring for an individual with known or suspected measles, chickenpox or disseminated zoster, due to difficult ies in establishing definite immunity 1027, 1028

. Unresolved issue
V.D.4.c. No recommendation is m ade regarding the type of personal protective equipment (i.e., su rgical mask or respiratory protection with a N95 or higher respirator) to be worn by susceptible healthcare personnel who must have contact with patients with known or suspect ed measles, chickenpox or disseminated herpes zoster. Unresolved issue

89V.D.5. Patient transport
V.D.5.a. In acute care hospitals and long-te rm care and other residential settings , limit transport and movement of patients outside of the room to medically-necessary purposes. Category II
V.D.5.b. If transport or movement outside an AIIR is necessary, instruct patients to wear a surgical ma sk, if possible, and observe Respiratory Hygiene/Cough Etiquette 12

. Category II
V.D.5.c. For patients with skin lesi ons associated with varicella or smallpox or draining skin lesions caused by M. tuberculosis

, cover the affected areas to prev ent aerosolization or contact with the infectious agent in skin lesions 108, 1025, 1026, 1029-1031

. Category IB
V.D.5.d. Healthcare personnel transpor ting patients who are on Airborne
Precautions do not need to wear a mask or respirator during transport if the patient is w earing a mask and infectious skin
lesions are covered. Category II V.D.6. Exposure management Immunize or provide the appr opriate immune globulin to susceptible persons as soon as possible following unprotected contact (i.e., exposed) to a pati ent with measles, varicella or smallpox: Category IA

y Administer measles vaccine to exposed susceptible persons within 72 hours after the exposure or administer immune globulin within six days of t he exposure event for high-risk persons in whom vaccine is contraindicated 17, 1032-1035

.

y Administer varicella vaccine to exposed susceptible persons within 120 hours after the expos ure or administer varicella immune globulin (VZIG or al ternative product), when available, within 96 hours fo r high-risk persons in whom
vaccine is contraindicated (e.g., immunocompromised patients, pregnant women, newborns whose mother’s varicella onset was <5 days before or within 48 hours after delivery 888, 1035-1037 ).

y Administer smallpox vaccine to exposed susceptible persons within 4 days after exposure 108, 1038-1040

. V.D.7. Discontinue Airborne Precautio ns according to pathogen-specific recommendations in Appendix A. Category IB
V.D.8. Consult CDC’s “Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005” 12 and
the “Guideline for Environmental In fection Control in Health-Care
Facilities” 11 for additional guidance on environment strategies for preventing transmission of tuberculosi s in healthcare settings. The environmental recommendations in these guidelines may be applied to patients with other infe ctions that require Airborne
Precautions.

90VI. Protective Environment (Table 4)
VI.A. Place allogeneic hematopoietic stem cell transplant (HSCT) patients in a
Protective Environment as descri bed in the “Guideline to Prevent Opportunistic Infections in HSCT Patients” 15 , the “Guideline for
Environmental Infection Control in Health-Care Facilities” 11 , and the “Guidelines for Preventing Health-C are-Associated Pneumonia, 2003” 14 to reduce exposure to environmental fungi (e.g., Aspergillus sp) 157, 158

. Category IB
VI.B. No recommendation for placing patient s with other medical conditions that
are associated with increased risk for environmental fungal infections (e.g., aspergillosis) in a Protective Environment 11

. Unresolved issue
VI.C. For patients who require a Prot ective Environment, implement the following (see Table 5) 11, 15

VI.C.1. Environmental controls
VI.C.1.a. Filtered incoming air using c entral or point-of-use high efficiency particulate (HEPA) filters capable of removing 99.97% of particles > 0.3 μm in diameter 13

. Category IB
VI.C.1.b. Directed room airflow with the air supply on one side of the
room that moves air across t he patient bed and out through an exhaust on the opposite side of the room 13

. Category IB
VI.C.1.c. Positive air pre ssure in room relative to the corridor (pressure
differential of >1 2.5 Pa [0.01-in water gauge]) 13

. Category IB
VI.C.1.c.i. Monitor air pressure daily with visual in dicators (e.g., smoke tubes, flutter strips) 11, 1024

. Category IA
VI.C.1.d. Well-sealed rooms that prevent infiltration of outside air 13

. Category IB
VI.C.1.e. At least 12 air changes per hour 13

. Category IB
VI.C.2. Lower dust levels by using smooth, nonporous surfaces and finishes that can be scrubbed, rat her than textured material (e.g., upholstery). Wet dust horizontal su rfaces whenever dust detected and routinely clean crevices and sprinkler heads where dust may
accumulate 940, 941

. Category II
VI.C.3. Avoid carpeting in hallw ays and patient rooms in areas 941

. Category IB
VI.C.4. Prohibit dried and fresh flowers and potted plants 942-944

. Category II
VI.D. Minimize the length of time t hat patients who require a Protective
Environment are outside their rooms for diagnostic procedures and other
activities 11, 158, 945

. Category IB
VI.E. During periods of construction, to prevent inhalation of respirable particles that could contain infectious spores, provide respiratory protection (e.g., N95 respirator) to patients who are medi cally fit to tolerate a respirator when they are required to leav e the Protective Environment 945 158

. Category II
VI.E.1.a. No recommendation for fit- testing of patients who are using respirators. Unresolved issue

91VI.E.1.b. No recommendation for use of particulate respirators when leaving the Protective Envi ronment in the absence of
construction. Unresolved issue
VI.F. Use of Standard and Transmission-Ba sed Precautions in a Protective
Environment.
VI.F.1. Use Standard Precautions as recommended for all patient
interactions. Category IA
VI.F.2. Implement Droplet and Cont act Precautions as recommended for diseases listed in Appendix A. Transmission-Based precautions for viral infections may need to be prolonged because of the patient’s immunocompromised state and prol onged shedding of viruses 930

1010 928, 932 1011

. Category IB
VI.F.3. Barrier precautions, (e.g., ma sks, gowns, gloves) are not required for healthcare personnel in the absence of suspected or confirmed infection in the patient or if t hey are not indicated according to
Standard Precautions 15

. Category II
VI.F.4. Implement Airborne Precaut ions for patients who require a
Protective Environment room and who also have an airborne infectious disease (e.g., pulmonary or laryngeal tuberculosis, acute varicella-zoster). Category IA
VI.F.4.a. Ensure that the Protective Environment is designed to maintain positive pressure 13

. Category IB
VI.F.4.b. Use an anteroom to further support the appropriate air-balance
relative to the corridor and the Protective Environment; provide independent exhaust of contaminat ed air to the outside or place
a HEPA filter in the exhaust duct if the return air must be
recirculated 13, 1041

. Category IB
VI.F.4.c. If an anteroom is not availabl e, place the patient in an AIIR and use portable, industrial-grade H EPA filters in the room to enhance filtration of spores 1042

. Category II

92Appendix A:PreambleThe 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 infectiousdisease manuals and textbooks833, 1043, 1044. The published literature was searched for evidence of person-to-persontransmission in healthcare and non-healthcare settings with a focus on reported outbreaks that would assist in developingrecommendations for all settings where healthcare is delivered.Criteria used to assign Transmission-Based Precautionscategories follow:•A Transmission-Based Precautions category was assigned if there was strong evidence for person-to-persontransmission via droplet, contact, or airborne routes in healthcare or non-healthcare settings and/or if patientfactors (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, StandardPrecautions 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, humanimmunodeficiency virus) as per CDC recommendationsfor Universal Precautions issued in 1988780. Subsequentexperience has confirmed the efficacyof Standard Precautions to prevent exposure to infected blood and bodyfluid778, 779, 866.Additional information relevantto use of precautions was added in the comments column to assist the caregiver indecision-making. Citations were added as needed to support a change in or provide additional evidence forrecommendations for a specific disease and for new infectiousagents (e.g., SARS-CoV, avian influenza) that have beenadded to Appendix A. The reader may referto more detailed discussion concerningmodes of transmission and emergingpathogens in the background text and forMDRO control in Appendix B.93APPENDIX A1TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONSInfection/ConditionPrecautionsType*Duration†CommentsAbscessDraining, majorCDINo dressing or containment of drainage; until drainage stops or can becontained by dressingDraining, minor or limitedSDressing covers and contains drainageAcquired human immunodeficiency syndrome (HIV)SPost-exposure chemoprophylaxis for some blood exposures866.ActinomycosisSNot transmitted from person to personAdenovirus infection ( see agent-specific guidance undergastroenteritis, conjuctivitis, pneumonia)AmebiasisSPerson to person transmission is rare. Transmission in settings for thementally challenged and in a family group has been reported1045. Usecare when handling diapered infants and mentally challenged persons1046.AnthraxSInfected patients do not generally pose a transmission risk.CutaneousSTransmission through non-intact skin contact with draining lesionspossible, therefore use ContactPrecautions if large amount ofuncontained drainage. Handwashing with soap and water preferableto use of waterless alcohol based antiseptics since alcohol does not1Type of Precautions: A, Airborne Precautions; C, Contact; D, Droplet; S, Standard; when A, C, and D are specified, also use S.† Duration of precautions: CN, until off antimicrobial treatmentand culture-negative; DI, duration of illness (with wound lesions, DI means until wounds stopdraining); DE, until environment completely decontaminated; U,until time specified in hours (hrs) after initiation of effective therapy; Unknown: criteria forestablishing eradication of pathogen has not been determined94APPENDIX A1TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONSInfection/ConditionPrecautionsType*Duration†Commentshave sporicidal activity983.PulmonarySNot transmitted from person to personEnvironmental: aerosolizable spore-containing powder or othersubstanceDEUntil decontamination of environment complete203. Wear respirator(N95 mask or PAPRs), protectiveclothing; decontaminate personswith powder on them(http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5135a3.htm)Hand hygiene:Handwashing for 30-60 seconds with soap and wateror 2% chlorhexidene gluconate after spore contact (alcohol handrubsinactive against spores983.Post-exposure prophylaxis following environmental exposure: 60days of antimicrobials (either doxycycline, ciprofloxacin, orlevofloxacin) and post-exposure vaccine under INDAntibiotic-associated colitis (seeClostridium difficile)Arthropod-borne viral encephalitides (eastern, western, Venezuelanequine encephalomyelitis; St Louis, California encephalitis; West NileVirus) and viral fevers (dengue, yellow fever, Colorado tick fever)SNot transmitted from person to person except rarely by transfusion,and for West Nile virus by organ transplant, breastmilk ortransplacentally530, 1047. Install screens in windows and doors inendemic areasUse DEET-containing mosquito repellants and clothing to coverextremitiesAscariasisSNot transmitted from person to personAspergillosisSContact Precautions and Airborne Precautions if massive soft tissueinfection with copious drainage and repeated irrigations required154.Avian influenza (see influenza, avian below)BabesiosisSNot transmitted from personto person except rarely by transfusion,Blastomycosis, North American, cutaneous or pulmonarySNot transmitted from person to personBotulismSNot transmitted from person to personBronchiolitis (see respiratory infections in infants and youngchildren)CDIUse mask according to Standard Precautions.95APPENDIX A1TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONSInfection/ConditionPrecautionsType*Duration†CommentsBrucellosis (undulant, Malta, Mediterranean fever)SNot transmitted from person toperson except rarely via bankedspermatozoa and sexual contact1048, 1049. Provid antimicrobialprophylaxis following laboratory exposure1050.Campylobactergastroenteritis (see gastroenteritis)Candidiasis, all forms including mucocutaneousSCat-scratch fever (benign inoculation lymphoreticulosis)SNot transmitted from person to personCellulitisSChancroid (soft chancre) (H. ducreyi)STransmitted sexually from person to personChickenpox (see varicella)Chlamydia trachomatisConjunctivitisSGenital (lymphogranuloma venereum)SPneumonia (infants<3 mos. of age))SChlamydia pneumoniaeSOutbreaks in institutionalized populations reported, rarely1051, 1052Cholera (see gastroenteritis)Closed-cavity infectionOpen drain in place; limited or minor drainageSContact Precautions if there is copious uncontained drainageNo drain or closed drainage system in placeSClostridiumC. botulinumSNot transmitted from person to personC. difficile(see Gastroenteritis,C. difficile)CDIC. perfringensFood poisoningSNot transmitted from person to personGas gangreneSTransmission from person to person rare; one outbreak in a surgicalsetting reported1053. Use Contact Precautions if wound drainage is96APPENDIX A1TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONSInfection/ConditionPrecautionsType*Duration†Commentsextensive.Coccidioidomycosis (valley fever)Draining lesionsSNot transmitted from person to person except under extraordinarycircumstances because the infectious arthroconidial form ofCoccidioides immitisis not produced in humans1054.PneumoniaSNot transmitted from person to person except under extraordinarycircumstances, (e.g., inhalation of aerosolized tissue phaseendospores during necropsy, transplantation of infected lung) becausethe infectious arthroconidial form ofCoccidioides immitisis notproduced in humans1054, 1055.Colorado tick feverSNot transmitted from person to personCongenital rubellaCUntil 1 yr of ageStandard Precautions if nasopharyngeal and urine cultures repeatedlyneg. after 3 mos. of ageConjunctivitisAcute bacterialSChlamydiaSGonococcalSAcute viral (acute hemorrhagic)CDIAdenovirus most common; enterovirus 701056, Coxsackie virus A241057) also associated with community outbreaks. Highly contagious;outbreaks in eye clinics, pediatric and neonatal settings, institutionalsettings reported. Eye clinics should follow Standard Precautionswhen handling patients with conjunctivitis. Routine use of infectioncontrol measures in the handlingof instruments and equipment willprevent the occurrence of outbreaks in this and other settings.460, 814,1058, 1059461, 1060.Corona virus associated with SARS (SARS-CoV) (see severe acuterespiratory syndrome)97APPENDIX A1TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONSInfection/ConditionPrecautionsType*Duration†CommentsCoxsackie virus disease (see enteroviral infection)Creutzfeldt-Jakob diseaseCJD, vCJDSUse disposable instruments or special sterilization/disinfection forsurfaces, objects contaminated with neural tissue if CJD or vCJDsuspected and has not been R/O; No special burial procedures1061Croup (see respiratory infections in infants and young children)Crimean-Congo Fever (see Viral Hemorrhagic Fever)SCryptococcosisSNot transmitted from person to person, except rarely via tissue andcorneal transplant1062, 1063Cryptosporidiosis (see gastroenteritis)CysticercosisSNottransmitted from person to personCytomegalovirus infection, including in neonates andimmunosuppressed patientsSNo additional precautions for pregnant HCWsDecubitus ulcer (see Pressure ulcer)Dengue feverSNot transmitted from person to personDiarrhea, acute-infective etiology suspected (see gastroenteritis)DiphtheriaCutaneousCCNUntil 2 cultures taken 24 hrs. apart negativePharyngealDCNUntil 2 cultures taken 24 hrs. apart negativeEbola virus (see viral hemorrhagic fevers)Echinococcosis (hydatidosis)SNot transmitted from person to personEchovirus (see enteroviral infection)Encephalitis or encephalomyelitis (see specific etiologic agents)Endometritis (endomyometritis)SEnterobiasis (pinworm disease, oxyuriasis)SEnterococcusspecies (see multidrug-resistant organisms if98APPENDIX A1TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONSInfection/ConditionPrecautionsType*Duration†Commentsepidemiologically significant or vancomycin resistant)Enterocolitis,C. difficile(seeC. difficile,gastroenteritis)Enteroviral infections (i.e., Group A and B Coxsackie viruses andEcho viruses) (excludes polio virus)SUse Contact Precautions for diapered or incontinent children forduration of illness and to control institutional outbreaksEpiglottitis, due toHaemophilus influenzaetype bDU 24 hrsSee specific disease agents for epiglottitis due to other etiologies)Epstein-Barr virus infection, including infectious mononucleosisSErythema infectiosum (also see Parvovirus B19)Escherichia coligastroenteritis (see gastroenteritis)Food poisoningBotulismSNot transmitted from person to personC. perfringens or welchiiSNot transmitted from person to personStaphylococcalSNot transmitted from person to personFurunculosis, staphylococcalSContact if drainage not controlled. Follow institutional policies if MRSAInfants and young childrenCDIGangrene (gas gangrene)SNot transmitted from person to personGastroenteritisSUse Contact Precautions for diapered or incontinent persons for theduration of illness or to control institutional outbreaks forgastroenteritis caused byall of the agents belowAdenovirusSUse Contact Precautions for diapered or incontinent persons for theduration of illness or to control institutional outbreaksCampylobacterspeciesSUse Contact Precautions for diapered or incontinent persons for theduration of illness or to control institutional outbreaksCholera(Vibrio cholerae)SUse Contact Precautions for diapered or incontinent persons for theduration of illness or to control institutional outbreaksC. difficileCDIDiscontinue antibiotics if appropriate. Do not share electronicthermometers853, 854; ensure consistent environmental cleaning and99APPENDIX A1TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONSInfection/ConditionPrecautionsType*Duration†Commentsdisinfection. Hypochlorite solutions may be required for cleaning iftransmission continues847. Handwashing with soap and waterpreferred because of the absence ofsporicidal activity of alcohol inwaterless antiseptic handrubs983.Cryptosporidium speciesSUse Contact Precautions for diapered or incontinent persons for theduration of illness or to control institutional outbreaksE. coliEnteropathogenic O157:H7 and other shiga toxin-producingStrainsSUse Contact Precautions for diapered or incontinent persons for theduration of illness or to control institutional outbreaksOther speciesSUse Contact Precautions for diapered or incontinent persons for theduration of illness or to control institutional outbreaksGiardia lambliaSUse Contact Precautions for diapered or incontinent persons for theduration of illness or to control institutional outbreaksNorovirusesSUse Contact Precautions for diapered or incontinent persons for theduration of illness or to control institutional outbreaks. Persons whoclean areas heavily contaminated with feces or vomitus may benefitfrom wearing masks since virus can be aerosolized from these bodysubstances142, 147148; ensure consistent environmental cleaning anddisinfection with focus on restrooms even when apparently unsoiled273, 1064). Hypochlorite solutions may be required when there iscontinued transmission290-292. Alcohol is less active, but there is noevidence that alcohol antiseptichandrubs are not effective for handdecontamination294. Cohorting of affected patients to separateairspaces and toilet facilities may help interrupt transmission duringoutbreaks.RotavirusCDIEnsure consistent environmental cleaning and disinfection andfrequent removal of soiled diapers. Prolonged shedding may occur in100APPENDIX A1TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONSInfection/ConditionPrecautionsType*Duration†Commentsboth immunocompetent and immunocompromised children and theelderly932, 933.Salmonellaspecies (includingS. typhi)SUse Contact Precautions for diapered or incontinent persons for theduration of illness or to control institutional outbreaksShigellaspecies (Bacillary dysentery)SUse Contact Precautions for diapered or incontinent persons for theduration of illness or to control institutional outbreaksVibrio parahaemolyticusSUse Contact Precautions for diapered or incontinent persons for theduration of illness or to control institutional outbreaksViral (if not covered elsewhere)SUse Contact Precautions for diapered or incontinent persons for theduration of illness or to control institutional outbreaksYersinia enterocoliticaSUse Contact Precautions for diapered or incontinent persons for theduration of illness or to control institutional outbreaksGerman measles (see rubella; see congenital rubella)Giardiasis (see gastroenteritis)Gonococcal ophthalmia neonatorum (gonorrheal ophthalmia,acute conjunctivitis of newborn)SGonorrheaSGranuloma inguinale (Donovanosis,granuloma venereum)SGuillain-Barré’ syndromeSNot an infectious conditionHaemophilus influenzae(see disease-specific recommendations)Hand, foot, and mouth disease (seeenteroviral infection)Hansen’s Disease (see Leprosy)Hantavirus pulmonary syndromeSNot transmitted from person to personHelicobacter pyloriSHepatitis, viralType ASProvide hepatitis A vaccine post-exposure as recommended1065Diapered or incontinent patientsCMaintain Contact Precautions in infants and children <3 years of age101APPENDIX A1TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONSInfection/ConditionPrecautionsType*Duration†Commentsfor duration of hospitalization; for children 3-14 yrs. of age for 2 weeksafter onset of symptoms; >14 yrs. of age for 1 week after onset ofsymptoms833, 1066, 1067.Type B-HBsAg positive; acute or chronicSSee specific recommendations for care of patients in hemodialysiscenters778Type C and other unspecified non-A, non-BSSee specific recommendations for care of patients in hemodialysiscenters778Type D (seen only with hepatitis B)SType ESUse Contact Precautions for diaperedor incontinent individuals for theduration of illness1068Type GSHerpangina (see enteroviral infection)HookwormSHerpes simplex (Herpesvirus hominis)EncephalitisSMucocutaneous, disseminated or primary, severeCUntil lesions dryand crustedMucocutaneous, recurrent (skin, oral, genital)SNeonatalCUntil lesions dryand crustedAlso, for asymptomatic, exposed infants delivered vaginally or by Csection and if mother has active infection and membranes have beenruptured for more than 4 to 6 hrs until infant surface cultures obtainedat 24-36 hrs. of age negative after 48 hrs incubation1069, 1070Herpes zoster (varicella-zoster) (shingles)Disseminated disease in any patientLocalized disease in immunocompromised patient until disseminatedinfection ruled outA,CDISusceptible HCWs should not enterroom if immune caregivers areavailable; no recommendation for protection of immune HCWs; norecommendation for type of protection, i.e. surgical mask or respirator;for susceptible HCWs.102APPENDIX A1TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONSInfection/ConditionPrecautionsType*Duration†CommentsLocalized in patient with intactimmune system with lesions that canbe contained/coveredSDISusceptible HCWs should not provide direct patient care when otherimmune caregivers are available.HistoplasmosisSNot transmitted from person to personHuman immunodeficiency virus (HIV)SPost-exposure chemoprophylaxis for some blood exposures866.Human metapneumovirusCDIHAI reported1071, but route of transmission not established823.Assumed to be Contact transmission as for RSV since the viruses areclosely related and have similar clinical manifestations andepidemiology. Wear masks according to Standard Precautions..ImpetigoCU 24 hrsInfectious mononucleosisSInfluenzaHuman (seasonal influenza)D5 days except DIin immunocompromisedpersonsSingle patient room when available or cohort; avoid placement withhigh-risk patients; mask patient when transported out of room;chemoprophylaxis/vaccine to control/prevent outbreaks611. Use gownand gloves according to Standard Precautions may be especiallyimportant in pediatric settings. Duration of precautions forimmunocompromised patients cannot be defined; prolonged durationof viral shedding (i.e. for several weeks) has been observed;implications for transmission are unknown930.Avian (e.g., H5N1, H7, H9 strains))Seewww.cdc.gov/flu/avian/professional/infect-control.htmfor currentavian influenza guidance.Pandemic influenza (also a human influenza virus)D5 days fromonset ofsymptomsSeehttp://www.pandemicflu.govfor current pandemic influenzaguidance.Kawasaki syndromeSNot an infectious conditionLassa fever (see viral hemorrhagic fevers)103APPENDIX A1TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONSInfection/ConditionPrecautionsType*Duration†CommentsLegionnaires’ diseaseSNot transmitted from person to personLeprosySLeptospirosisSNot transmitted from person to personLicehttp://www.cdc.gov/ncidod/dpd/parasites/lice/default.htmHead (pediculosis)CU24 hrsBodySTransmitted person to person through infested clothing. Wear gownand gloves when removing clothing; bag and wash clothes accordingto CDC guidance abovePubicSTransmitted person to person through sexual contactListeriosis (listeria monocytogenes)SPerson-to-person transmission rare; cross-transmission in neonatalsettings reported1072, 10731074, 1075Lyme diseaseSNot transmitted from person to personLymphocytic choriomeningitisSNot transmitted from person to personLymphogranuloma venereumSMalariaSNot transmitted from person to person except through transfusionrarely and through a failure to follow Standard Precautions duringpatient care1076-1079. Install screens in windows and doors in endemicareas. Use DEET-containing mosquito repellants and clothing to coverextremitiesMarburg virus disease (see viral hemorrhagic fevers)Measles (rubeola)A4 days afteronset of rash; DIin immunecompromisedSusceptible HCWs should not enterroom if immune care providersare available; no recommendation for face protection for immuneHCW; no recommendation for type offace protection for susceptibleHCWs, i.e., mask or respirator1027, 1028. For exposed susceptibles,post-exposure vaccine within 72 hrs. or immune globulin within 6 dayswhen available17, 1032, 1034. Place exposed susceptible patients onAirborne Precautions and exclude susceptible healthcare personnel104APPENDIX A1TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONSInfection/ConditionPrecautionsType*Duration†Commentsfrom duty from day 5 after first exposure to day 21 after last exposure,regardless of post-exposure vaccine17.Melioidosis, all formsSNot transmitted from person to personMeningitisAseptic (nonbacterial or viral; also see enteroviral infections)SContact for infants and young childrenBacterial, gram-negative enteric, in neonatesSFungalSHaemophilus influenzae, type b known or suspectedDU 24 hrsListeria monocytogenes(See Listeriosis)SNeisseria meningitidis(meningococcal) known or suspectedDU24 hrsSee meningococcal disease belowStreptococcus pneumoniaeSM. tuberculosisSConcurrent, active pulmonary disease or draining cutaneous lesionsmay necessitate addition of Contact and/or Airborne Precautions;For children, airborne precautions until active tuberculosis ruled out invisiting family members (see tuberculosis below)42Other diagnosed bacterialSMeningococcal disease: sepsis, pneumonia, meningitisDU 24 hrsPostexposure chemoprophylaxis for household contacts, HCWsexposed to respiratory secretions; postexposure vaccine only tocontrol outbreaks15, 17.Molluscum contagiosumSMonkeypoxA,CA-Untilmonkeypoxconfirmed andsmallpoxexcludedC-Until lesionscrustedUse See www.cdc.gov/ncidod/monkeypox for most currentrecommendations. Transmission in hospital settings unlikely269. Preand post-exposure smallpox vaccine recommended for exposedHCWs105APPENDIX A1TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONSInfection/ConditionPrecautionsType*Duration†CommentsMucormycosisSMultidrug-resistant organisms (MDROs), infection or colonization(e.g., MRSA, VRE, VISA/VRSA, ESBLs, resistantS. pneumoniae)S/CMDROs judged by the infection control program, based on local, state,regional, or national recommendations, to be of clinical andepidemiologic significance. Contact Precautions recommended insettings with evidence of ongoing transmission, acute care settingswith increased risk for transmission or wounds that cannot becontained by dressings. See recommendations for managementoptions in Management of Multidrug-Resistant Organisms InHealthcare Settings, 2006870. Contact state health department forguidance regarding new or emerging MDRO.Mumps (infectious parotitis)DU 9 daysAfter onset of swelling; susceptible HCWs should not provide care ifimmune caregivers are available.Note: (Recent assessment of outbreaks in healthy 18-24 year olds hasindicated that salivary viral shedding occurred early in the course ofillness and that 5 days of isolation after onset of parotitis may beappropriate in community settings; however the implications forhealthcare personnel and high-risk patient populations remain to beclarified.)Mycobacteria, nontuberculosis (atypical)Not transmitted person-to-personPulmonarySWoundSMycoplasmapneumoniaDDINecrotizing enterocolitisSContact Precautions when cases clustered temporally1080-1083.Nocardiosis, draining lesions, or other presentationsSNot transmitted person-to-personNorovirus (see gastroenteritis)Norwalk agent gastroenteritis (see gastroenteritis)OrfS106APPENDIX A1TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONSInfection/ConditionPrecautionsType*Duration†CommentsParainfluenza virus infection, respiratory in infants and young childrenCDIViral shedding may be prolonged in immunosuppressed patients1009,1010. Reliability of antigen testing to determine when to remove patientswith prolonged hospitalizations fromContact Precautions uncertain.Parvovirus B19 (Erythema infectiosum)DMaintainprecautions for duration of hospitalization when chronicdisease occurs in an immunocompromised patient. For patients withtransientaplastic crisis or red-cell crisis, maintain precautions for 7days.Duration of precautions for immunosuppressed patients withpersistently positive PCR not defined, buttransmission has occurred929.Pediculosis (lice)CU 24 hrs aftertreatmentPertussis (whooping cough)DU 5 daysSingle patient room preferred. Cohorting an option. Post-exposurechemoprophylaxis for household contacts and HCWs with prolongedexposure to respiratory secretions863. Recommendations for Tdapvaccine in adults under development.Pinworm infection (Enterobiasis)SPlague(Yersinia pestis)BubonicSPneumonicDU 48 hrsAntimicrobial prophylaxis for exposed HCW207.PneumoniaAdenovirusD, CDIOutbreaks in pediatric and institutional settings reported376, 1084-1086. Inimmunocompromised hosts, extendduration of Droplet and ContactPrecautions due to prolonged shedding of virus931Bacterial not listed elsewhere (including gram-negative bacterial)SB. cepaciain patients with CF, includingrespiratory tract colonizationCUnknownAvoid exposure to other persons with CF; private room preferred.Criteria for D/C precautions not established. See CF Foundationguideline20107APPENDIX A1TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONSInfection/ConditionPrecautionsType*Duration†CommentsB. cepaciain patients without CF(seeMultidrug-resistant organisms)ChlamydiaSFungalSHaemophilus influenzae, type bAdultsSInfants and childrenDU 24 hrsLegionellaspp.SMeningococcalDU 24 hrsSee meningococcal disease aboveMultidrug-resistant bacterial (see multidrug-resistant organisms)Mycoplasma(primary atypical pneumonia)DDIPneumococcal pneumoniaSUse Droplet Precautionsif evidence of transmission within a patientcare unit or facility196-198, 1087Pneumocystis jiroveci(Pneumocystis carinii)SAvoid placement in the same room with an immunocompromisedpatient.Staphylococcus aureusSFor MRSA, see MDROsStreptococcus, group AAdultsDU 24 hrsSee streptococcal disease (group A streptococcus) belowContact precautions if skin lesions presentInfants and young childrenDU 24 hrsContact Precautions if skin lesions presentVaricella-zoster (See Varicella-Zoster)ViralAdultsSInfants and young children(see respiratory infectious disease,acute, or specific viral agent)PoliomyelitisCDIPressure ulcer (decubitus ulcer, pressure sore) infected108APPENDIX A1TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONSInfection/ConditionPrecautionsType*Duration†CommentsMajorCDIIf no dressing or containment of drainage; until drainage stops or canbe contained by dressingMinor or limitedSIf dressing covers and contains drainagePrion disease (See Creutzfeld-Jacob Disease)Psittacosis (ornithosis) (Chlamydia psittaci)SNot transmitted from person to personQ feverSRabiesSPerson to person transmission rare; transmission via corneal, tissueand organ transplants has been reported539, 1088. If patient has bittenanother individual or saliva has contaminated an open wound ormucous membrane, wash exposed area thoroughly and administerpostexposure prophylaxis.1089Rat-bite fever (Streptobacillus moniliformisdisease,Spirillum minusdisease)SNot transmitted from person to personRelapsing feverSNot transmitted from person to personResistant bacterial infection or colonization (see multidrug-resistantorganisms)Respiratory infectious disease, acute (if not covered elsewhere)AdultsSInfants and young childrenCDIAlsosee syndromes or conditions listed in Table 2Respiratory syncytial virus infection, in infants,young children and immunocompromised adultsCDIWear mask according to Standard Precautions24CB116, 117. Inimmunocompromised patients, extend the duration of ContactPrecautions due to prolonged shedding928). Reliability of antigentesting to determine when to remove patients with prolongedhospitalizations from Contact Precautions uncertain.Reye's syndromeSNot an infectious conditionRheumatic feverSNot an infectious conditionRhinovirusDDIDroplet most important route of transmission1041090. Outbreaks have109APPENDIX A1TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONSInfection/ConditionPrecautionsType*Duration†Commentsoccurred in NICUs and LTCFs413, 1091, 1092. Add Contact Precautions ifcopious moist secretions and closecontact likely to occur (e.g., younginfants)111, 833.Rickettsial fevers, tickborne (RockyMountain spotted fever, tickbornetyphus fever)SNot transmitted from person to person except through transfusion,rarelyRickettsialpox (vesicular rickettsiosis)SNot transmitted from person to personRingworm (dermatophytosis, dermatomycosis, tinea)SRarely, outbreaks have occurred in healthcare settings, (e.g., NICU1093, rehabilitation hospital1094. Use Contact Precautions for outbreak.Ritter's disease (staphylococcal scalded skin syndrome)CDISee staphylococcal disease, scalded skin syndrome belowRocky Mountain spotted feverSNot transmitted from person to person except through transfusion,rarelyRoseola infantum (exanthem subitum; caused by HHV-6)SRotavirus infection (see gastroenteritis)Rubella (German measles) ( also see congenital rubella)DU 7 days afteronset of rashSusceptible HCWs should not enterroom if immune caregivers areavailable. No recommendation for wearing face protection (e.g., asurgical mask) if immune. Pregnant women who are not immuneshould not care for these patients17, 33. Administer vaccine withinthree days of exposure to non-pregnant susceptible individuals. Placeexposed susceptible patients onDroplet Precautions; excludesusceptible healthcare personnel from duty from day 5 after firstexposure to day 21 after last exposure, regardless of post-exposurevaccine.Rubeola (see measles)Salmonellosis (see gastroenteritis)ScabiesCU 24Scalded skin syndrome, staphylococcalCDISee staphylococcal disease, scalded skin syndrome below)Schistosomiasis (bilharziasis)S110APPENDIX A1TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONSInfection/ConditionPrecautionsType*Duration†CommentsSevere acute respiratory syndrome (SARS)A, D,CDI plus 10 daysafter resolution offever, providedrespiratorysymptoms areabsent orimprovingAirborne Precautionspreferred; D if AIIR unavailable. N95 or higherrespiratory protection; surgical mask if N95 unavailable; eye protection(goggles, face shield); aerosol-generating procedures and“supershedders” highest risk for transmission via small droplet nucleiand large droplets93, 94, 96.Vigilant environmental disinfection (seewww.cdc.gov/ncidod/sars)Shigellosis (see gastroenteritis)Smallpox (variola; see vaccinia for management of vaccinatedpersons)A,CDIUntil all scabs have crusted and separated (3-4 weeks). Nonvaccinated HCWs should not provide care when immune HCWs areavailable; N95 or higher respiratory protection for susceptible andsuccessfully vaccinated individuals;postexposure vaccine within 4days of exposure protective108, 129, 1038-1040.SporotrichosisSSpirillum minordisease (rat-bite fever)SNot transmitted from person to personStaphylococcal disease (S aureus)Skin, wound, or burnMajorCDINo dressing ordressing does not contain drainage adequatelyMinor or limitedSDressing covers and contains drainage adequatelyEnterocolitisSUse Contact Precautions for diapered or incontinent children forduration of illnessMultidrug-resistant (see multidrug-resistant organisms)PneumoniaSScalded skin syndromeCDIConsider healthcare personnel aspotential source of nursery, NICUoutbreak1095.Toxic shock syndromeSStreptobacillus moniliformisdisease (rat-bite fever)SNot transmitted from person to person111APPENDIX A1TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONSInfection/ConditionPrecautionsType*Duration†CommentsStreptococcal disease (group A streptococcus)Skin, wound, or burnMajorC,DU 24 hrsNo dressingor dressing does not contain drainage adequatelyMinor or limitedSDressing covers and contains drainage adequatelyEndometritis (puerperal sepsis)SPharyngitis in infants and young childrenDU 24 hrsPneumoniaDU 24 hrsScarlet fever in infants and young childrenDU 24 hrsSerious invasive diseaseDU24 hrsOutbreaks of serious invasive disease have occurred secondary totransmission among patients and healthcare personnel162, 972, 1096-1098Contact Precautions for draining wound as above; follow rec. forantimicrobial prophylaxis in selected conditions160.Streptococcal disease (group B streptococcus), neonatalSStreptococcal disease (not group A orB) unless covered elsewhereSMultidrug-resistant (see multidrug-resistant organisms)StrongyloidiasisSSyphilisLatent (tertiary) and seropositivity without lesionsSSkin and mucous membrane, including congenital, primary,SecondarySTapeworm diseaseHymenolepis nanaSTaenia solium(pork)SOtherSNot transmitted from person to personTetanusSNot transmitted from person to personTinea (e.g., dermatophytosis, dermatomycosis, ringworm)SRare episodes of person-to-person transmission112APPENDIX A1TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONSInfection/ConditionPrecautionsType*Duration†CommentsToxoplasmosisSTransmission from person to person israre; vertical transmission frommother to child, transmission through organs and blood transfusionrareToxic shock syndrome (staphylococcal disease, streptococcaldisease)SDroplet Precautions for the first 24 hours after implementation ofantibiotic therapy if Group A streptococcus is a likely etiologyTrachoma, acuteSTransmissible spongiform encephalopathy (see Creutzfeld-Jacobdisease, CJD, vCJD)Trench mouth (Vincent's angina)STrichinosisSTrichomoniasisSTrichuriasis (whipworm disease)STuberculosis(M. tuberculosis)Extrapulmonary, draining lesion)A,CDiscontinue precautions only when patient is improving clinically, anddrainage has ceased or there arethree consecutivenegative culturesof continued drainage1025, 1026. Examine for evidence of activepulmonary tuberculosis.Extrapulmonary, no draining lesion, meningitisSExamine for evidence of pulmonary tuberculosis. For infants andchildren, use Airborne Precautions until active pulmonary tuberculosisin visiting family members ruled out42Pulmonary or laryngeal disease, confirmedADiscontinue precautions only whenpatient on effective therapy isimproving clinically and has three consecutive sputum smearsnegative for acid-fast bacilli collected on separate days(MMWR 2005;54: RR-17http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5417a1.htm?s_cid=rr5417a1_e)12.Pulmonary or laryngeal disease, suspectedADiscontinue precautions only when the likelihood of infectious TB113APPENDIX A1TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONSInfection/ConditionPrecautionsType*Duration†Commentsdisease is deemed negligible, and either 1) there is another diagnosisthat explains the clinical syndromeor 2) the results of three sputumsmears for AFB are negative. Each of the three sputum specimensshould be collected 8-24 hours apart, and at least one should be anearly morning specimenSkin-test positive with no evidence of current active diseaseSTularemiaDraining lesionSNot transmitted from person to personPulmonarySNot transmitted from person to personTyphoid (Salmonella typhi) fever (see gastroenteritis)TyphusRickettsia prowazekii(Epidemic or Louse-borne typhus)STransmitted from person to personthrough close personal or clothingcontactRickettsia typhiSNot transmitted from person to personUrinary tract infection (including pyelonephritis), with or withouturinary catheterSVaccinia (vaccination site, adverse events following vaccination)*Only vaccinated HCWs have contact with active vaccination sites andcare for persons with adverse vaccinia events; if unvaccinated, onlyHCWs without contraindicationsto vaccine may provide care.Vaccination site care (including autoinoculated areas)SVaccination recommended for vaccinators; for newly vaccinatedHCWs: semi-permeable dressing overgauze until scab separates,with dressing change as fluid accumulates, ~3-5 days; gloves, handhygiene for dressing change; vaccinated HCW or HCW withoutcontraindication to vaccine for dressing changes205, 221, 225.Eczema vaccinatumCFetal vacciniaCGeneralized vacciniaCUntil lesions dryand crusted,scabs separatedFor contact with virus-containing lesions and exudative material114APPENDIX A1TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONSInfection/ConditionPrecautionsType*Duration†CommentsProgressive vacciniaCPostvaccinia encephalitisSBlepharitis or conjunctivitisS/CUse Contact Precautions if there is copious drainageIritis or keratitisSVaccinia-associated erythema multiforme (Stevens JohnsonSyndrome)SNot an infectious conditionSecondary bacterial infection (e.g., S. aureus, group A betahemolytic streptococcusS/CFollow organism-specific (strep, staph most frequent)recommendations and consider magnitude of drainageVaricella ZosterA,CUntil lesions dryand crustedSusceptible HCWs should not enterroom if immune caregivers areavailable; no recommendation for face protection of immune HCWs;no recommendation for type of protection, i.e. surgical mask orrespirator for susceptible HCWs. In immunocompromised host withvaricella pneumonia, prolong duration of precautions for duration ofillness. Post-exposure prophylaxis:provide post-exposure vaccineASAP but within 120 hours; for susceptible exposed persons for whomvaccine is contraindicated (immunocompromised persons, pregnantwomen, newborns whose mother’s varicella onset is<5days beforedelivery or within 48 hrs after delivery) provide VZIG, when available,within 96 hours; if unavailable, useIVIG, Use Airborne Precautions forexposed susceptible persons andexclude exposed susceptiblehealthcare workers beginning 8 days after first exposure until 21 daysafter last exposure or 28 if received VZIG, regardless of postexposurevaccination.1036.Variola (see smallpox)Vibrioparahaemolyticus (see gastroenteritis)Vincent's angina (trench mouth)SViral hemorrhagic feversS, D, CDISingle-patient room preferred. Emphasize: 1) use of sharps safety115APPENDIX A1TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONSInfection/ConditionPrecautionsType*Duration†Commentsdue to Lassa, Ebola, Marburg, Crimean-Congo fever virusesdevices and safe work practices, 2) hand hygiene; 3) barrier protectionagainst blood and body fluids upon entry into room (single gloves andfluid-resistant or impermeable gown, face/eye protection with masks,goggles or face shields); and 4) appropriate waste handling. Use N95or higher respirators when performing aerosol-generating procedures.Largest viral load in final stages of illness when hemorrhage mayoccur; additional PPE, including double gloves, leg and shoecoverings may be used, especially inresource-limited settings whereoptions for cleaning and laundry are limited. Notify public healthofficials immediately if Ebola is suspected212, 314, 740, 772Also see Table3 for Ebola as a bioterrorism agentViral respiratory diseases (not covered elsewhere)AdultsSInfants and young children (see respiratory infectious disease,acute)Whooping cough (see pertussis)Wound infectionsMajorCDINo dressing or dressing does not contain drainage adequatelyMinor or limitedSDressing covers and contains drainage adequatelyYersinia enterocoliticagastroenteritis (see gastroenteritis)Zoster (varicella-zoster)(see herpes zoster)Zygomycosis (phycomycosis, mucormycosis)SNot transmitted person-to-person116TABLE 1. HISTORY OF GUIDELINES FORISOLATION PRECAUTIONS IN HOSPITALS*YEAR(Ref)DOCUMENT ISSUEDCOMMENT19701099Isolation Techniques for Use inHospitals, 1sted.- Introduced seven isolation precaution categories with color-codedcards: Strict, Respiratory, Protective, Enteric, Wound and Skin,Discharge, and Blood- No user decision-making required- Simplicity a strength; over isolation prescribed for some infections19751100Isolation Techniques for Use inHospitals, 2nded.- Same conceptual framework as 1stedition19831101CDC Guideline for Isolation Precautionsin Hospitals- Provided two systems for isolation: category-specific and diseasespecific- Protective Isolation eliminated; Blood Precautions expanded to includeBody Fluids- Categories included Strict, Contact, Respiratory, AFB, Enteric,Drainage/Secretion, Blood and Body Fluids- Emphasized decision-making by users1985-88780, 896Universal Precautions- Developedin response to HIV/AIDS epidemic- Dictated application ofBlood and Body Fluid precautions to all patients,regardless of infection status- Did not apply to feces, nasal secretions, sputum, sweat, tears, urine, orvomitus unless contaminated by visible blood- Added personal protective equipment to protect HCWs from mucousmembrane exposures- Handwashing recommended immediately after glove removal- Added specific recommendations forhandling needles and other sharpdevices; concept became integral to OSHA’s 1991 rule on occupationalexposure to blood-borne pathogens in healthcare settings11719871102Body Substance Isolation- Emphasized avoiding contact with allmoist and potentially infectiousbody 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 drysurfaces- Did not emphasize need for specialventilation to contain airborneinfections- Handwashing after glove removal not specified in the absence ofvisible soiling19961Guideline for Isolation Precautions inHospitals- Prepared by the Healthcare Infection Control Practices AdvisoryCommittee (HICPAC)- Melded major features of Universal Precautions and BodySubstance Isolation into StandardPrecautions to be used with allpatients at all times- Included three transmission-based precaution categories: airborne,droplet, and contact- Listed clinical syndromes that should dictate use of empiric isolationuntil an etiological diagnosis is established* Derived from Garner ICHE 1996118TABLE 2. CLINICAL SYNDROMES OR CONDITIONS WARRANTING EMPIRIC TRANSMISSION-BASED PRECAUTIONS INADDITION TO STANDARD PRECAUTIONS PENDINGCONFIRMATION OF DIAGNOSIS*Clinical Syndrome or Condition†Potential Pathogens‡Empiric Precautions (Always includes StandardPrecautions)DIARRHEAAcute diarrhea with a likely infectious cause in anincontinent ordiapered patientEnteric pathogens§Contact Precautions (pediatrics and adult)MENINGITISNeisseria meningitidisEnterovirusesM. tuberculosisDroplet Precautions for first 24 hrs of antimicrobialtherapy; mask and face protection for intubationContact Precautions for infants and childrenAirborne Precautions if pulmonary infiltrateAirborne Precautions plusContact Precautions ifpotentially infectious draining body fluid presentRASH OR EXANTHEMS, GENERALIZED, ETIOLOGY UNKNOWNPetechial/ecchymotic with fever (general)- If positive history of travel to an area with anongoing outbreak of VHF in the 10 days beforeonset of feverNeisseria meningitidesEbola, Lassa, MarburgvirusesDroplet Precautions for first 24hrs of antimicrobial therapyDroplet Precautions plusContact Precautions, withface/eye protection, emphasizing safety sharps and barrierprecautions when blood exposure likely. Use N95 orhigher respiratory protection when aerosol-generatingprocedure performed119VesicularVaricella-zoster,herpessimplex,variola(smallpox), vacciniavirusesVaccinia virusAirborne plus Contact Precautions;Contact Precautions only ifherpes simplex,localizedzoster in an immunocompetent host or vaccinia virusesmost likelyMaculopapular with cough, coryza and feverRubeola (measles) virusAirborne Precautions120Clinical Syndrome or Condition†Potential Pathogens‡Empiric Precautions (Always includes StandardPrecautions)RESPIRATORY INFECTIONSCough/fever/upper lobe pulmonary infiltrate in anHIV-negative patient or apatient at low risk forhuman immunodeficiency virus (HIV) infectionM. tuberculosis,Respiratory viruses,S.pneumoniae, S. aureus(MSSA or MRSA)Airborne Precautions plus Contact precautionsCough/fever/pulmonary infiltrate in any lunglocation in an HIV-infected patient or a patient athigh risk for HIV infectionM. tuberculosis,Respiratory viruses,S.pneumoniae, S. aureus(MSSA or MRSA)Airborne Precautions plus Contact PrecautionsUse eye/face protection if aerosol-generating procedureperformed or contact withrespiratory secretionsanticipated.If tuberculosis is unlikely andthere are no AIIRs and/orrespirators available, use Droplet Precautions instead ofAirborne PrecautionsTuberculosis more likely in HIV-infected individual than inHIV negative individualCough/fever/pulmonary infiltrate in any lunglocation in a patient with a history of recent travel(10-21 days) to countrieswith active outbreaks ofSARS, avian influenzaM. tuberculosis,severeacute respiratorysyndrome virus (SARSCoV), avian influenzaAirborne plus Contact Precautions plus eye protection.If SARS and tuberculosis unlikely, use Droplet Precautionsinstead of Airborne Precautions.Respiratory infections, particularly bronchiolitisand pneumonia, in infants and young childrenRespiratory syncytialvirus,parainfluenza virus,adenovirus, influenzavirus,Human metapneumovirusContact plus Droplet Precautions; Droplet Precautions maybe discontinued when adenovirus and influenza have beenruled out121Skin or Wound InfectionAbscess or draining wound that cannot becoveredStaphylococcus aureus(MSSA or MRSA),groupA streptococcusContact PrecautionsAdd Droplet Precautions for the first 24 hours ofappropriate antimicrobial therapy if invasive Group Astreptococcal disease is suspected* Infection control professionals should modify or adapt this table according to localconditions. To ensure that appropriate empiricprecautions are implemented always, hospitalsmust have systems in place to evaluate patients routinely according to these criteriaas part of their preadmission and admission care.† Patients with the syndromes or conditionslisted below may present with atypical signsor symptoms (e.g.neonates and adults withpertussis may not have paroxysmal or severe cough). The clinician's index of suspicion should be guided by the prevalence of specificconditions in the community, as well as clinicaljudgment.‡ 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 thatrequire additional precautions beyondStandard Precautions until they canberuled out.§ These pathogens include enterohemorrhagicEscherichia coliO157:H7,Shigella spp,hepatitis A virus, noroviruses, rotavirus,C.difficile.122TABLE 3.INFECTION CONTROL CONSIDERATIONS FOR HIGH-PRIORITY (CDC CATEGORY A) DISEASES THAT MAYRESULT FROM BIOTERRORIST ATTACKS OR ARE CONSIDERED TO BE BIOTERRORIST THREATS(www.bt.cdc.gov)aaAbbreviations used in this table: RT= respiratory tract; GIT = gastrointestinal tract; CXR = chest x-ray; CT =computerized axial tomography; CSF = cerebrospinal fluid; and LD50– lethal dose for 50% of experimental animals;HCWs = healthcare worker; BSL = biosafety level; PAPR =powered air purifying respirator; PCR = polymerase chainreaction; IHC = immunohistochemistryDiseaseAnthraxSite(s) ofInfection;TransmissionModeCutaneous andinhalationdisease haveoccurred in pastbioterroristincidentsCutaneous(contact with spores);RT(inhalation of spores);GIT(ingestion of spores - rare)Comment:Spores can be inhaled into the lower respiratory tract. The infectious dose ofB. anthracisinhumans by any route is not precisely known. In primates, the LD50 (i.e., the doserequired to kill 50% ofanimals) for an aerosol challenge withB. anthracisis estimated to be 8,000–50,000 spores; the infectiousdose may be as low as 1-3 sporesIncubationPeriodCutaneous: 1 to12 days;RT: Usually 1 to 7 days but up to 43 days reported;GIT: 15-72 hoursClinicalFeaturesCutaneous:Painless, reddish papule, which develops a centralvesicle or bulla in 1-2 days; over next 3-7days lesion becomes pustular, and then necrotic, with black eschar; extensive surrounding edema.RT:initial flu-like illness for 1-3days with headache, fever, malaise, cough; by day 4 severe dyspnea andshock, and is usually fatal (85%-90% if untreated; meningitis in50% of RT cases.GIT: ; if intestinal form, necrotic, ulcerated edematous lesions develop in intestines with fever, nausea andvomiting, progression to hematemesisand bloody diarrhea; 25-60% fatalDiagnosisCutaneous:Swabs of lesion (under eschar) for IHC,PCR and culture; punch biopsy for IHC, PCR andculture; vesicular fluid aspiratefor Gram stain and culture; blood culture if systemic symptoms; acute and123convalescent sera for ELISA serologyRT:CXR or CT demonstrating wide mediastinal wideningand/or pleural effusion, hilar abnormalities; bloodfor culture and PCR; pleural effusionfor culture, PCR and IHC; CSF ifmeningeal signs present for IHC,PCR and culture; acute and convalescentsera for ELISA serology; pleuraland/or bronchial biopsies IHC.GIT:blood and ascites fluid, stool samples, rectal swabs,and swabs of oropharyngeal lesions if present forculture, PCR and IHCInfectivityCutaneous:Person-to-person transmission from contact withlesion of untreated patient possible, butextremely rare.RT and GIT:Person-to-person transmission does not occur.Aerosolized powder, environmental exposures:Highly infectious if aerosolizedRecommendedPrecautionsCutaneous: Standard Precautions; Contact Precautionsif uncontained copious drainage.RT and GIT:Standard Precautions.Aerosolized powder, environmental exposures:Respirator (N95 mask or PAPRs), protective clothing;decontamination of personswith powder on them(http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5135a3.htm)Hand hygiene:Handwashing for 30-60 seconds with soap and water or 2% chlorhexidene gluconate afterspore contact (alcohol handrubs inactive againstspores [Weber DJ JAMA 2003; 289:1274]).Post-exposure prophylaxis following environmental exposure: 60 days of antimicrobials (eitherdoxycycline, ciprofloxacin, or levofloxacin) and post-exposure vaccine under INDDiseaseBotulismSite(s) of Infection;TransmissionModeGIT:Ingestion of toxin-containing food,RT:Inhalation of toxin containing aerosol cause disease.Comment:Toxin ingested or potentially delivered byaerosol in bioterrorist incidents. LD50for type A is0.001μg/ml/kg.Incubation Period1-5 days.Clinical FeaturesPtosis, generalized weakness, dizziness, dry mouth and throat, blurredvision, diplopia, dysarthria,dysphonia, and dysphagia followed by symmetricaldescending paralysis and respiratory failure.124DiagnosisClinical diagnosis; identification of toxin in stool, serology unless toxin-containing material available fortoxin neutralization bioassays.InfectivityNot transmitted from person to person. Exposure to toxin necessary for disease.RecommendedPrecautionsStandard Precautions.DiseaseEbola Hemorrhagic FeverSite(s) of Infection;TransmissionModeAs a rule infection develops after exposure of mucousmembranes or RT, or through broken skin orpercutaneous injury.Incubation Period2-19 days, usually 5-10 daysClinical FeaturesFebrile illnesses with malaise, myalgias, headache, vomiting and diarrhea that are rapidly complicatedby hypotension, shock, and hemorrhagic features. Massive hemorrhage in < 50% pts.DiagnosisEtiologic diagnosis can be made usingRT-PCR, serologic detection of antibody and antigen, pathologicassessment with immunohistochemistry and viral culture with EM confirmation of morphology,InfectivityPerson-to-person transmission primarily occurs through unprotected contact with blood and body fluids;percutaneous injuries (e.g., needlestick) associatedwith a high rate of transmission; transmission inhealthcare settings has been reported but is prevented by use of barrier precautions.RecommendedPrecautionsHemorrhagic fever specific barrier precautions: If disease is believed to be related to intentionalrelease of a bioweapon, epidemiology of transmission is unpredictable pending observation of diseasetransmission. Until the nature ofthe pathogen is understood and its transmission pattern confirmed,Standard, Contact and AirbornePrecautions should be used. Once thepathogen is characterized, if theepidemiology of transmission is consistent with natural disease, Droplet Precautions can be substitutedfor Airborne Precautions. Emphasize: 1)use of sharps safety devices and safe work practices, 2) handhygiene; 3) barrier protection against blood and body fluids upon entry intoroom (single gloves and fluidresistant 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-generatingprocedures. In settings where AIIRs are unavailable or the large numbers of patients cannot beaccommodated by existing AIIRs, observe Droplet Precautions (plus Standard Precautions and ContactPrecautions) and segregate patients from those not suspected of VHFinfection. Limit blooddraws tothose essential to care. See text for discussionand Appendix A for recommendations for naturally125occurring VHFs.DiseasePlague2Site(s) ofInfection;TransmissionModeRT:Inhalation of respiratory droplets.Comment: Pneumonic plague most likely to occur if used asa biological weapon, but some cases ofbubonic and primary septicemia may also occur. Infective dose 100 to 500 bacteriaIncubation Period1 to 6, usually 2 to 3 days.Clinical FeaturesPneumonic: fever, chills, headache, cough, dyspnea, rapid progression of weakness, and in a later stagehemoptysis, circulatory collapse, and bleeding diathesisDiagnosisPresumptive diagnosis from Gram stain or Wayson stain of sputum, blood, or lymph node aspirate;definitive diagnosis from culturesof same material, or pairedacute/convalescent serology.InfectivityPerson-to-person transmission occursvia 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 afew hours after initiation of appropriate therapy.RecommendedPrecautionsStandard Precautions, Droplet Precautions until patients have received 48hours of appropriate therapy.Chemoprophylaxis:Consider antibiotic prophylaxis for HCWs with close contact exposure.2Pneumonic plague is not as contagious as is often thought. Historical accounts and contemporary evidence indicate that personswith plague usually onlytransmit the infection when the disease is in the end stage. These persons cough copious amounts of bloody sputum that containsmany plague bacteria. Patientsin the early stage of primary pneumonic plague (approximately the first 20–24 h) apparently pose little risk [1, 2]. Antibioticmedication rapidly clears thesputum of plague bacilli, so that a patient generally is notinfective within hours after initiation of effective antibiotic treatment [3]. This means that in moderntimes 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 closecontact. Simple protective measures, such as wearing masks, good hygiene, and avoiding close contact, have been effective to interrupt transmission during manypneumonic plague outbreaks [2]. In the United States, the last known cases of person to person transmission of pneumonic plagueoccurred in1925 [2].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): 1166-11723. Butler TC. Plague and other Yersinia infections. In: Greenough WB, ed. Current topics in infectious disease. New York: Plenum Medical Book Company,1983.126DiseaseSmallpoxSite(s) of Infection;TransmissionModeRTInhalation of droplet or, rarely, aerosols; and skin lesions (contact with virus).Comment:If used as a biological weapon, natural disease, which has not occurred since 1977, willlikely result.Incubation Period7 to 19 days (mean 12 days)Clinical FeaturesFever, malaise, backache, headache, and often vomiting for 2-3 days; then generalized papular ormaculopapular rash (more on face and extremities), which becomes vesicular (on day 4 or 5) andthen pustular; lesions all in same stage.DiagnosisElectron microscopy of vesicular fluid or culture of vesicular fluid by WHO approved laboratory(CDC); detection by PCR available onlyin select LRN labs, CDC and USAMRIDInfectivitySecondary attack rates up to 50% in unvaccinated persons; infected persons may transmit diseasefrom time rash appears until all lesions have crusted over (about3 weeks); greatest infectivityduring first 10 days of rash.RecommendedPrecautionsCombined use of Standard,Contact, and Airborne Precautionsbuntil all scabs have separated (3-4weeks).Only immune HCWs to care for pts; post-exposure vaccine within 4 days.Vaccinia:HCWs cover vaccination site with gauze andsemi-permeable dressing until scabseparates (>21 days). Observe hand hygiene.Adverse events with virus-containing lesions:Standard plus Contact Precautions until alllesions crustedbTransmission by the airborne route is a rare event; Airborne Precautions is recommended when possible, but in theevent of mass exposures, barrier precautions and containment within a designated area are most important204, 212.cVaccinia adverse events with lesions containinginfectious virus include inadvertentautoinoculation, ocular lesions(blepharitis, conjunctivitis), generalized vaccinia, progressive vaccinia, eczema vaccinatum; bacterial superinfection alsorequires addition of contact precautions if exudates cannot be contained216, 217.127DiseaseTularemiaSite(s) of Infection;TransmissionModeRT:Inhalation of aerosolized bacteria.GIT:Ingestion of food or drinkcontaminated with aerosolizedbacteria.Comment:Pneumonic or typhoidal disease likely to occur after bioterrorist event using aerosoldelivery. Infective dose 10-50 bacteriaIncubation Period2 to 10 days, usually 3 to 5 daysClinical FeaturesPneumonic: malaise, cough, sputum production, dyspnea;Typhoidal: fever, prostration, weightloss and frequently an associated pneumonia.DiagnosisDiagnosis usually made with serology on acute and convalescent serum specimens; bacterium canbe detected by PCR (LRN) or isolated from blood andother body fluids on cysteine-enriched mediaor mouse inoculation.InfectivityPerson-to-person spread is rare.Laboratory workers who encounter/handlecultures of this organism are at high risk for disease ifexposed.RecommendedPrecautionsStandard Precautions128TABLE 4.RECOMMENDATIONS FOR APPLICATION OF STANDARD PRECAUTIONS FOR THE CARE OF ALL PATIENTS INALL HEALTHCARE SETTINGS(See Sections II.D.-II.J. and III.A.1)COMPONENTRECOMMENDATIONSHand hygieneAfter touching blood,body fluids, secretions, excretions, contaminated items;immediately after removing gloves; between patient contacts.Personal protective equipment (PPE)GlovesFor touchingblood, body fluids, secretions, excretions, contaminated items; fortouching mucous membranes and nonintact skinGownDuring procedures and patient-care activities when contact of clothing/exposedskin with blood/body fluids, secretions, and excretions is anticipated..Mask, eye protection (goggles),face shield*During procedures and patient-care activities likely to generate splashes orsprays of blood, body fluids, secretions,especially suctioning, endotrachealintubationSoiled patient-care equipmentHandle in a manner that prevents transferof microorganisms to others and to theenvironment; wear gloves if visibly contaminated; perform hand hygiene.Environmental controlDevelop procedures for routine care, cleaning, and disinfection of environmentalsurfaces, especially frequently touched surfaces in patient-care areas.Textiles and laundryHandle in amanner that prevents transfer of microorganisms to others and to theenvironmentNeedles and other sharpsDo not recap, bend, break, or hand-manipulate used needles; if recapping isrequired, use a one-handed scoop techniqueonly; use safety features whenavailable; place used sharps in puncture-resistant containerPatient resuscitationUse mouthpiece, resuscitation bag, other ventilation devices to prevent contactwith mouth and oral secretions129Patient placementPrioritize for single-patient room if patient is atincreased risk of transmission, islikely to contaminate the environment, doesnot maintain appropriate hygiene, oris at increased risk of acquiring infection or developing adverse outcome followinginfection.Respiratory hygiene/cough etiquette(source containment of infectiousrespiratory secretions in symptomaticpatients, beginning atinitial point ofencounter e.g., triage and receptionareas in emergency departments andphysician offices)Instruct symptomatic personsto cover mouth/nose when sneezing/coughing; usetissues and dispose in no-touch receptacle; observe hand hygiene after soiling ofhands with respiratory secretions; wear surgical mask if tolerated or maintainspatial separation, >3 feet if possible.130* *During aerosol-generating procedures on patients with suspected or proven infections transmitted byrespiratory aerosols(e.g., SARS), wear a fit-tested N95 orhigher respirator in addition to gloves, gown,and face/eye protection.131TABLE 5. COMPONENTS OF A PROTECTIVE ENVIRONMENT (Adapted from MMWR 2003; 52 [RR-10])

I. Patients: allogeneic hematopoeitic stem cell transplant (HSCT) only

• Maintain in PE room except for requi red diagnostic or therapeutic procedures

that cannot be performed in the room, e.g. radiology, operating room

• Respiratory protection e.g., N95 respir ator, for the patient when leaving PE

during periods of construction

II. Standard and Expanded Precautions

• Hand hygiene observed before and after patient contact

• Gown, gloves, mask NOT required for HCWs or visitors for r outine entry into

the room

• Use of gown, gloves, mask by HCWs and visitors according to Standard

Precautions and as indicated for sus pected or proven infections for which
Transmission-Based Prec autions are recommended

III. Engineering

• Central or point-of-use HEPA (99.97% efficiency) filters capable of removing

particles 0.3 μ m in diameter for s upply (incoming) air

• Well-sealed rooms

o Proper construction of windows, doors, and intake and exhaust ports

o Ceilings: smooth, free of fi ssures, open joints, crevices

o Walls sealed above and below the ceiling

o If leakage detected, locate source and make necessary repairs

• Ventilation to maintain > 12 ACH

• Directed air flow: air supply and exhaust gr ills located so that clean, filtered

air enters from one side of the room, flows across the patient’s bed, exits on opposite side of the room

• Positive room air pressure in relation to the corridor

o Pressure differential of >2.5 Pa [0.01” water gauge]

• Monitor and document results of air flow patterns daily using visual methods

(e.g., flutter strips, smoke tubes) or a hand held pressure gauge

• Self-closing door on all room exits

• Maintain back-up ventilation equipment (e.g ., portable units for fans or filters)

for emergency provision of ventilati on requirements for PE areas and take immediate steps to restore the fixed ventilation system

• For patients who require both a PE and Airborne Infection Isolation, use an

anteroom to ensure proper air bal ance relationships and provide independent exhaust of contaminated air to the outside or place a HEPA
filter in the exhaust duct. If an anteroom is not available, place patient in an AIIR and use portable ventilation units , industrial-grade HEPA filters to enhance filtration of spores.

132IV. Surfaces

• Daily wet-dusting of horizontal surfaces using cloths moistened with EPAregistered hospital disi nfectant/detergent

• Avoid dusting methods that disperse dust

• No carpeting in pati ent rooms or hallways

• No upholstered furniture and furnishings

V. Other

• No flowers (fresh or dried) or potted plants in PE rooms or areas

• Use vacuum cleaner equipped with HEPA filters when vacuum cleaning is

necessary

133

## Figure. Example of Safe Donning and Removal of Personal Protective Equipment (PPE) 

## 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



### SAFE WORK PRACTICES

■ Keep hands away from face

■ Work from clean to dirty

■ Limit surfaces touched

■ Change when torn or heavily contaminated

■ Perform hand hygiene

134

## REMOVING PPE

Remove PPE at doorway before leaving patient room or in anteroom

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!

135136GLOSSARY

Airborne infection isol ation room (AIIR). Formerly, negative pressure isolation room, an AIIR is a single-occupancy pati ent-care room used to isolate persons with a suspected or confirmed airborne infe ctious disease. Environmental factors
are controlled in AIIRs to minimize the transmission of infect ious agents that are usually transmitted from person to pers on by droplet nuclei associated with coughing or aerosolization of contaminated fluids. AIIRs should provide negative pressure in the room (so that air fl ows under the door gap into the room); and an air flow rate of 6-12 ACH ( 6 ACH fo r 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 2005; 54 [RR-17]).

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 fr om the U.S. Department of Health and
Human Services and the National Institutes of Health, is the primary source of guidance for creating airbor ne infection isolation room s (AIIRs) and protective environments (www.aia.org/aah).

Ambulatory care settings. Facilities that provide health care to patients who do not remain overnight (e.g., hospital-based outpatient clinics, nonhospital-based clinics and physician offices, urgent ca re centers, surgic enters, free-standing dialysis centers, public health clinics, imaging centers, ambulatory behavioral health and substance abuse clinics, physica l therapy and rehabilitation centers, and dental practices.

Bioaerosols

. An airborne dispersion of particles containing whole or parts of biological entities, such as bacteria, viru ses, 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. Infecti ous bioaerosols (i.e., those that contain biological agents capable of causi ng an infectious disease) can be generated from human sources (e.g., ex pulsion 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 dr y sources (e.g.,constuction dust with spores produced by Aspergillus spp.). Bioaerosols in clude large respiratory droplets and small dropl et 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 healthca re 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, th is 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 prev ent contact with susceptible patients (cohorting patients). During outbreaks, heal thcare personnel may be assigned to a cohort of patients to furt her limit opportunities for transmission (cohorting staff).

Colonization. Proliferation of microorganisms on or within body sites without detectable host immune response, cellular da mage, or clinical expression. The presence of a microorganism within a host may occur with varying duration, but may become a source of potential transmissi on. In many instances, colonization and carriage are synonymous.

Droplet nuclei. Microscopic particles < 5 μm in size that are the residue of evaporated droplets and ar e produced when a person coughs, sneezes, shouts, or sings. These particles can remain su spended in the air for prolonged periods
of time and can be carried on normal ai r currents in a room or beyond, to adjacent spaces or areas receiving exhaust air.

Engineering controls. Removal or isolation of a workplace hazard through technology. AIIRs, a Protective Envi ronment, engineered sharps injury prevention devices and shar ps containers are examples of engineering controls.

Epidemiologically important pathogens . Infectious agents that have one or more of the following characteristics: 1) are readily transmissible; 2) have a proclivity toward causing outbreaks; 3) may be associated with a severe outcome; or 4) are difficult to treat. Examples include Acinetobacter sp., Aspergillus sp.

, Burkholderia cepacia

, Clostridium difficile

, Klebsiella or Enterobacter sp., extended-spectrum-beta-lactamase producing gram negative bacilli [ESBLs], methicillin-resistant Staphylococcus aureus [MRSA]

, Pseudomonas aeruginosa, vancomycin-resistant enter ococci [VRE], methicillin
resistant Staphylococcus aureus [MRSA]

, vancomycin resistant Staphylococcus

aureus [VRSA] influenza virus, respiratory syn cytial virus [RSV], rotavirus, SARSCoV, noroviruses and the hemorrhagic fever viruses).

Hand hygiene. A general term that applies to any one of the following: 1) handwashing with plain (nonant imicrobial) soap and water); 2) antiseptic handwash (soap containing antiseptic agent s and water); 3) antiseptic handrub (waterless antiseptic product, most often al cohol-based, rubbed on all surfaces of hands); or 4) surgical hand antisepsis ( antiseptic handwash or antiseptic handrub performed preoperatively by surgical perso nnel to eliminate transient hand flora and reduce resident hand flora) 559

.Healthcare-associated infection (HAI). An infection that develops in a patient who is cared for in any setting where heal thcare is delivered (e.g., acute care hospital, chronic care facility, ambulato ry clinic, dialysis center, surgicenter, home) and is related to receiving health ca re (i.e., was not incubating or present at the time healthcare was provided) . In ambulatory and home settings, HAI would apply to any infection that is associated with a medical or surgical intervention. Since the geographic locati on of infection acquisition is often uncertain, the preferred term is considered to be healthcare- associated rather
than healthcare- acquired

.

Healthcare epidemiologist . A person whose primary training is medical (M.D., D.O.) and/or masters or doctorate-lev el epidemiology who has received advanced training in healthcare epidemio logy. Typically these professionals direct or provide consultation to an infect ion control program in a hospital, long term care facility (LTCF), or healthcare delivery system (also see infection control professional).

Healthcare personnel, healthcare worker (HCW). All paid and unpaid persons who work in a healthcare setting (e.g. any person who has professional or technical training in a healthcare-related field and provides patient care in a healthcare setting or any person who provid es services that support the delivery of healthcare such as dietary, housekeeping, engineering, maintenance personnel).

Hematopoietic stem cell transplantation (HSCT). Any transplantation of bloodor bone marrow-derived hematopoietic stem cells, regardless of donor type (e.g., allogeneic or autologous) or cell source (e.g., bone ma rrow, peripheral blood, or placental/umbilical cord blood); associated with periods of severe immunosuppression that vary with the s ource of the cells, the intensity of chemotherapy required, and the presence of graft ve rsus host disease (MMWR 2000; 49: RR-10).

High-efficiency particulat e air (HEPA) filter. An air filter that removes >99.97% of particles > 0.3μm (the most penetrating par ticle size) at a specified flow rate of air. HEPA filters may be integrated into the central air handling systems, installed at the point of use above the ceiling of a room, or used as portable units (MMW R 2003; 52: RR-10).

Home care. A wide-range of medical, nursing, rehabilitation, hospice and social services delivered to patients in their plac e of residence (e.g., private residence, senior living center, assisted living facilit y). Home health-care services include care provided by home health aides and ski lled nurses, respiratory therapists, dieticians, physicians, chaplains, and vol unteers; provision of durable medical equipment; home infusion therapy; and physical, speech, and occupational therapy.Immunocompromised patients. Those patients whose immune mechanisms are deficient because of congenital or acquired immunologic disorders (e.g., human immunodeficiency virus [HIV] infect ion, congenital immune deficiency syndromes), chronic diseases such as diabetes mellitus, cancer, emphysema, or cardiac failure, ICU care, malnutri tion, and immunosuppressive therapy of another disease process [e.g ., radiation, cytotoxic chemotherapy, anti-graftrejection medication, corticosteroids, monoclonal antibodies directed against a specific component of the immune system]) . The type of infections for which an immunocompromised patient has increased susceptibility is determined by the severity of immunosuppression and the specific component(s) of the immune system that is affected. Patients under going allogeneic HSCT and those with chronic graft versus host disease are c onsidered the most vulnerable to HAIs. Immunocompromised states also make it more difficult to diagnose certain infections (e.g., tuberculosis) and are associated with more severe clinical disease states than persons with the same infection and a normal immune system.

Infection. The transmission of microorganisms into a host after evading or overcoming defense mechanisms, resulti ng in the organism’s proliferation and invasion within host tissue(s). Host re sponses to infection may include clinical symptoms or may be subclini cal, with manifestations of disease mediated by direct organisms pathogenesis and/or a fu nction of cell-mediated or antibody responses that result in the destruction of host tissues.

Infection control and prevention professional (ICP). A person whose primary training is in either nursing, medical te chnology, microbiology, or epidemiology and who has acquired special training in in fection control. Responsibilities may include collection, analysis, and feedback of infection data and trends to healthcare providers; consultation on infection risk assessment, prevention and control strategies; performance of education and training activities; implementation of evidence-based infectio n control practices or those mandated by regulatory and licensing agencies; applicat ion of epidemiologic principles to improve patient outcomes; participation in planning renovation and construction projects (e.g., to ensure appropriate cont ainment of construction dust); evaluation of new products or procedures on patient outcomes; oversi ght of employee health services related to infection pr evention; implementation of preparedness plans; communication within the healthcare setting, with local and state health departments, and with the community at large concerning infection control issues; and participation in research. Cert ification in infection control (CIC) is available through the Certific ation Board of Infection Control and Epidemiology.

Infection control and prevention program

. A multidisciplinar y program that includes a group of activities to ens ure that recommended practices for the prevention of healthcare-associated infe ctions are implemented and followed by HCWs, making the healthcare setting safe from infection for patients andhealthcare personnel. The Joint Commissi on on Accreditation of Healthcare Organizations (JCAHO) requires the follo wing five components of an infection control program for accreditation: 1) surveillance : monitoring patients and healthcare personnel for acquisition of infection and/or colonization; 2) investigation: identification and analysis of infe ction problems or undesirable trends; 3) prevention : implementation of measures to prevent transmission of infectious agents and to reduce ri sks for device- and procedure-related infections; 4) control : evaluation and management of outbreaks; and 5) reporting: provision of information to external agencie s as required by st ate and federal law and regulation (www.jcaho.org). The infect ion control program staff has the ultimate authority to determine infecti on control policies for a healthcare organization with the approval of the organization’s governing body.

Long-term care facilities (LTCFs). An array of residential and outpatient facilities designed to meet the bio-psychosocial needs of per sons with sustained self-care deficits. These include skilled nursing facilities, chronic disease hospitals, nursing homes, foster a nd group homes, institutions for the developmentally disabled, residential care facilities, assisted living facilities, retirement homes, adult day health care fa cilities, rehabilitat ion centers, and longterm psychiatric hospitals.

Mask. A term that applies collectively to items used to cover the nose and mouth and includes both procedure masks and surgical masks (www.fda.gov/cdrh/ode/ guidance/094.html#4).

Multidrug-resistant organisms (MDROs). In general, bacteria that are
resistant to one or more classes of antim icrobial agents and usually are resistant to all but one or two commercially ava ilable antimicrobial agents (e.g., MRSA, VRE, extended spectrum beta-lactamas e [ESBL]-producing or intrinsically resistant gram-negative bacilli) 176

.

Nosocomial infection. A term that is derived fr om two Greek words “nosos” (disease) and “komeion” (to take care of ) and refers to any infection that develops during or as a resu lt of an admission to an acut e care facility (hospital) and was not incubating at the time of admission.

Personal protective equipment (PPE). A variety of barriers used alone or in combination to protect mucous membr anes, skin, and clothing from contact with infectious agents. PPE includes gloves, masks, respirators, goggles, face shields, and gowns.

Procedure Mask

. A covering for the nose and mouth that is intended for use in general patient care situations. These ma sks generally attach to the face with ear loops rather than ties or elastic. Unli ke surgical masks, procedure masks are not regulated by the Food and Drug Administration.Protective Environment. A specialized patient-care ar ea, usually in a hospital, that has a positive air flow relative to the corridor (i.e., air fl ows from the room to the outside adjacent space). The combinat ion of high-efficiency particulate air (HEPA) filtration, high numbers ( > 12) of air changes per hour (ACH), and minimal leakage of air into t he room creates an environm ent that can safely accommodate patients with a severely co mpromised immune sys tem (e.g., those who have received allogeneic hemopoietic stem-cell transplant [HSCT]) and decrease the risk of exposure to spores produced by environmental fungi. Other components include use of scrubbable surfac es instead of materials such as upholstery or carpeting, cleani ng to prevent dust accumula tion, and prohibition of fresh flowers or potted plants.

Quasi-experimental studies. Studies to evaluate interventions but do not use randomization as part of the study design. These studies are also referred to as nonrandomized, pre-post-intervention study designs. These studies aim to demonstrate causality between an in tervention and an outcome but cannot
achieve the level of confidence concer ning attributable benef it obtained through a randomized, controlled trial. In hospit als and public health settings, randomized control trials often cannot be implemented due to ethical, practical and urgency reasons; therefore, quasi-experimental design studies are used commonly. However, even if an intervention appears to be effective statistically, the question can be raised as to the possibility of altern ative explanations for the result.. Such study design is used when it is not logistic ally feasible or et hically possible to conduct a randomized, controlled trial, (e .g., during outbreaks). Within the classification of quasi-experimental study designs, there is a hierarchy of design features that may contribute to validit y 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 to protect them from inhalation exposure to airborne infectious agents that are < 5

μ m in size. These include infectious droplet nuclei fr om 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 Instit ute for Occupational Safety and Health (NIOSH) certifies respirators used in healthcare settings (www.cdc.gov/niosh/topics/resp irators/). 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 pressu re respirators. A listing of NIOSHapproved respirators can be found at www.cdc.gov/niosh/npptl/respirat ors/disp_part/particlist.html . Respirators must be used in conjunction with a complete Respiratory Protection Program, asrequired by the Occupational Safety and Health Administration (OSHA), that includes fit testing, trai ning, proper selection of re spirators, medical clearance and respirator maintenance.

Respiratory Hygiene/ Cough Etiquette. A combination of measures designed to minimize the transmission of respir atory pathogens via droplet or airborne routes in healthcare settings. The co mponents of Respiratory Hygiene/Cough Etiquette are 1) covering the mouth and nose during coughing and sneezing, 2) using tissues to contain respiratory secr etions with prompt disposal into a notouch receptacle, 3) offering a surgic al mask to persons who are coughing to
decrease contamination of the surrounding environment, and 4) turning the head away from others and maintaining spatia l separation, ideally >3 feet, when coughing. These measures are target ed to all patients with symptoms of respiratory infection and their acco mpanying family members or friends beginning at the point of initial encounter with a healthcare setting (e.g., reception/triage in emergency department s, ambulatory clinics, healthcare provider offices) 126 (Srinivasin A ICHE 2004; 25: 1020; www.cdc.gov/flu/professionals/inf ectioncontrol/resphygiene.htm).

Safety culture/climate. The shared perceptions of workers and management regarding the expectations of safety in the work environment. A hospital safety
climate includes the follo wing six organizational co mponents: 1) senior management support for safety programs; 2) absence of workplace barriers to safe work practices; 3) cleanliness and orderliness of the worksite; 4) minimal conflict and good communication among staff members; 5) frequent safetyrelated feedback/training by superviso rs; and 6) availability of PPE and engineering controls 620

.

Source Control

. The process of containing an in fectious agent either at the portal of exit from the body or within a confined space. The term is applied most frequently to containment of infectious agents transmitted by the respiratory route but could apply to other routes of transmissi on, (e.g., a draining wound, vesicular or bullous skin lesions). Respirator y Hygiene/Cough Etiquette that encourages individuals to “cover your cough” and/or wear a mask is a source control measure. The use of enclosing devices fo r local exhaust ventilation (e.g., booths for sputum induction or administrati on of aerosolized medication) is another example of source control.

Standard Precautions

. A group of infection prevention practices that apply to all patients, regardless of suspected or confirmed diagnosis or presumed
infection status. Standard Precautions is a combination and expansion of
Universal Precautions 780 and Body Substance Isolation 1102 . Standard Precautions is based on the principle that all blood, body fluids, secretions, excretions except swea t, nonintact skin, and mucous membranes may contain transmissible infectious agents. Standard Precautions includes hand hygiene, and depending on the anticipated exposure, use of gloves, gown, mask, eye protection, or face shield. Also, equipm ent or items in t he patient environmentlikely to have been contaminated with infe ctious fluids must be handled in a manner to prevent transmi ssion of infectious agents, (e.g. wear gloves for handling, contain heavily soiled equipm ent, properly clean and disinfect or sterilize reusable equipment bef ore use on another patient).

Surgical mask. A device worn over the mouth and nose by operating room personnel during surgical pr ocedures to protect both surgical patients and operating room personnel from transfe r of microorganisms and body fluids. Surgical masks also are used to protec t healthcare personnel from contact with large infectious droplets (>5 μ m in size). According to draft guidance issued by the Food and Drug Administration on May 15, 2003, surgical masks are evaluated using standardized testing procedures for fl uid resistance, bacterial filtration efficiency, differential pressure (air exchange), and flammability in order to mitigate the risks to heal th associated with the use of surgical masks. These specifications apply to any masks that are labeled surgical, laser, isolation, or dental or medical procedure (www.fda.gov/cdrh/ode/guidance/094.html#4). Surgical masks do not protect against inha lation of small particles or droplet nuclei and should not be confused with par ticulate respirators that are recommended for protection against selected airborne infectious agents, (e.g., Mycobacterium tuberculosis)

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