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 Infection Control Practices Advisory 

Committee 

Acknowledgement: The authors and HICPAC gratefully acknowledge Dr. Larry Strausbaugh 

for his many contributions and valued guidance in the preparation of this guideline. 

Suggested citation: Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection 

Control Practices Advisory Committee, 2007 Guideline for Isolation Precautions: Preventing 

Transmission of Infectious Agents in Healthcare Settings 

http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf 

1
 
Healthcare 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 

2
 
Raymond 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 Regarding Transmission of Infectious Agents in 

Healthcare Settings................................................................................................................12 

I.A. Evolution of the 2007 document ........................................................................................12 

I.B. Rationale for Standard and Transmission-Based Precautions in healthcare settings........14

 I.B.1. Source of infectious agents.......................................................................................14 

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

 I.B.3. Modes of transmission .............................................................................................15
 

I.B.3.a. Contact transmission.....................................................................................15 

 I.B.3.a.i. Direct contact transmission ............................................................16 

I.B.3.a.ii. Indirect contact transmission .........................................................16
 

I.B.3.b. Droplet transmission ....................................................................................17 

 I.B.3.c. Airborne transmission...................................................................................18 

I.B.3.d. Emerging issues and controversies concerning 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 sources of infection .....................................................................20 

I.C. Infectious agents of special infection control interest for healthcare settings.....................20 

 I.C.1. Epidemiologically important organisms........................................21 

I.C.1.a. Clostridium difficile........................................................................................21 

 I.C.1.b. Multidrug-resistant organisms(MDROs)............................................22 

 I.C.2. Agents of bioterrorism...............................................................................................23 

 I.C.3. Prions ......................................................................................................................24 

 I.C.4. Severe acute respiratory syndrome (SARS).............................................................26 

 I.C.5. Monkeypox ...............................................................................................................28 

 I.C.6. Noroviruses..........................................................................................28

 I.C.7. Hemorrhagic fever viruses.......................................................................29
 

I.D. Transmission risks associated with specific types of healthcare settings .......................... 31 

 I.D.1. Hospitals..................................................................................................................31 

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

 I.D.1.b. Burn units.....................................................................................................32 

 I.D.1.c. Pediatrics .....................................................................................................33 

 I.D.2. Non-acute care settings.........................................................................................34 

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

 I.D.2.b. Ambulatory care settings .............................................................................35 

 I.D.2.c. Home care ...................................................................................................36 

 I.D.2.d. Other sites of healthcare delivery ...............................................................37 

 I.E. Transmission risks associated with special patient populations.......................................38 

 I.E.1. Immunocompromised patients .................................................................................38 

 I.E.2. Cystic fibrosis patients .............................................................................................39 

4
 
 I.F. New therapies with potential transmissible infectious agents...........................................39 

 I.F.1. Gene therapy ...........................................................................................................39 

 I.F.2. Infections Transmitted through Blood, Organs and Tissues................................ ....40 

 I.F.3. Xenotransplantation and tissue allografts ................................................................40 

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

Healthcare Settings................................................................................................................41 

II.A. Healthcare system components that influence the effectiveness of 

precautions to prevent transmission ..............................................................................41 

II.A.1. Administrative measures........................................................41

 II.A.1.a. Scope of Work and Staffing Needs for Infection Control Professionals
 

(ICP).........................................................................................42 

II.A.1.a.i. Infection Control Liaison Nurse............................43 

 II.A.1.b. Bedside nurse staffing....................................................43 

 II.A.1.c. Clinical microbiology laboratory support............................ ..43 

II.A.2. Institutional safety culture and organizational characteristics.........45 

II.A.3. Adherence of healthcare personnel to recommended guidelines....45 

 II.B. Surveillance for healthcare-associated infections (HAIs).......................46 

 II.C. Education of healthcare workers, patients, and families .................................................47 

 II.D. Hand hygiene..................................................................................................................49 

 II.E. Personal protective equipment for healthcare personnel................................................49 

II.E.1. Gloves...................................................................................................................50 

 II.E.2. Isolation gowns .....................................................................................................51 

II.E.3. Face protection: 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 prevent HCW exposure to bloodborne pathogens ....................55 

 II.F.1. Prevention of needlesticks and other sharps-related injuries ................................55 

 II.F.2. Prevention of mucous membrane contact.............................................................56 

II.F.2.a. Precautions during aerosol-generating procedures.........56 

 II.G. Patient placement..........................................................................................................56 

 II.G.1. Hospitals and long-term care settings ..................................................................56 

 II.G.2. Ambulatory care settings ......................................................................................58 

 II.G.3. Home care............................................................................................................59 

 II.H. Transport of patients......................................................................................................59 

 II.I. Environmental measures.................................................................................................60

 II.J. Patient care equipment, instruments/devices .................................................................61 

 II.K. Textiles and laundry.......................................................................................................61 

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

 II.M. Dishware and eating utensils.........................................................................................62 

 II.N. Adjunctive measures .....................................................................................................63 

 II.N.1. Chemoprophylaxis ................................................................................................63 

 II.N.2. Immunoprophylaxis...............................................................................................63 

5
 II.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 Prevent Transmission of Infectious Agents ...................66 

 III.A. Standard Precautions ...................................................................................................66 

 III.A.1.New Standard Precautions for patients...................................................67 

 III.A.1.a. Respiratory Hygiene/Cough Etiquette...........................................................67 

III.A.1.b. Safe Injection Practices................................................................ 68

 III.A.1.c. Infection Control Practices for Special Lumbar Puncture Procedures......69 

 III.B. Transmission-Based Precautions .................................................................................69 

 III.B.1. Contact Precautions.............................................................................................70 

 III.B.2. Droplet Precautions .............................................................................................70

 III.B.3. Airborne Infection Isolation Precautions...............................................................71 

 III.C. Syndromic or empiric application of Transmission-Based Precautions.........................71 

 III.D. Discontinuation of precautions......................................................................................72 

III.E. Application of Transmission-Based Precautions in ambulatory and home care 

settings.....................................................................................................................................72 

 III.F. Protective environment (PE) .........................................................................................73 

Part IV: Recommendations....................................................................................................74 

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

 conditions ............................................................................................................93 

Tables

 Table 1. Recent history of guidelines for prevention of healthcare-associated infections......

 Table 2. Clinical syndromes or conditions warranting additional empiric transmissionbased precautions pending confirmation of diagnosis....................................... 

 Table 3. Infection control considerations for high-priority (CDC Category A) diseases that 

Table 4. Recommendations for application of Standard Precautions for the care of all 

may result from bioterrorist attacks or are considered to be bioterrorist threats ..

patients in all healthcare settings........................................................................... 

 Table 5. Components of a Protective Environment ............................................................. 

Figure Sequence for donning and removing PPE ................................................................

Glossary................................................................................................................

References............................................................................................................................ 

6
EXECUTIVE SUMMARY 

The Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in 

Healthcare Settings 2007 updates and expands the 1996 Guideline for Isolation Precautions 

in Hospitals. The following developments led to revision of the 1996 guideline: 

1. The transition of healthcare delivery from primarily acute care hospitals to other 

healthcare settings (e.g., home care, ambulatory care, free-standing specialty 

care sites, long-term care) created a need for recommendations that can be 

applied in all healthcare settings using common principles of infection control 

practice, yet can be modified to reflect setting-specific needs. Accordingly, the 

revised guideline addresses the spectrum of healthcare delivery settings. 

Furthermore, the term “nosocomial infections“ is replaced by “healthcareassociated infections” (HAIs) to reflect the changing patterns in healthcare 

delivery and difficulty in determining the geographic site of exposure to an 

infectious agent and/or acquisition of infection. 

2. The emergence of new pathogens (e.g., SARS-CoV associated with the severe 

acute respiratory syndrome [SARS], Avian influenza in humans), renewed 

concern for evolving known pathogens (e.g., C. difficile, noroviruses, communityassociated MRSA [CA-MRSA]), development of new therapies (e.g., gene 

therapy), and increasing concern for the threat of bioweapons attacks, established 

a need to address a broader scope of issues than in previous isolation guidelines. 

3. The successful experience with Standard Precautions, first recommended in the 

1996 guideline, has led to a reaffirmation of this approach as the foundation for 

preventing transmission of infectious agents in all healthcare settings. New 

additions to the recommendations for Standard Precautions are Respiratory 

Hygiene/Cough Etiquette and safe injection practices, including the use of a mask 

when performing certain high-risk, prolonged procedures involving spinal canal 

punctures (e.g., myelography, epidural anesthesia). The need for a 

recommendation for Respiratory Hygiene/Cough Etiquette grew out of 

observations during the SARS outbreaks where failure to implement simple 

source control measures with patients, visitors, and healthcare personnel with 

respiratory symptoms may have contributed to SARS coronavirus (SARS-CoV) 

transmission. The recommended practices have a strong evidence base. The 

continued occurrence of outbreaks of hepatitis B and hepatitis C viruses in 

ambulatory settings indicated a need to re-iterate safe injection practice 

recommendations as part of Standard Precautions. The addition of a mask for 

certain spinal injections grew from recent evidence of an associated risk for 

developing meningitis caused by respiratory flora. 

4. The accumulated evidence that environmental controls decrease the risk of lifethreatening fungal infections in the most severely immunocompromised patients 

(allogeneic hematopoietic stem-cell transplant patients) led to the update on the 

components of the Protective Environment (PE). 

5. Evidence that organizational characteristics (e.g., nurse staffing levels and 

composition, establishment of a safety culture) influence healthcare personnel 

adherence to recommended infection control practices, and therefore are 

important factors in preventing transmission of infectious agents, led to a new 

7
 
emphasis and recommendations for administrative involvement in the 

development and support of infection control programs. 

6. Continued increase in the incidence of HAIs caused by multidrug-resistant 

organisms (MDROs) in all healthcare settings and the expanded body of 

knowledge concerning prevention of transmission of MDROs created a need for 

more specific recommendations for surveillance and control of these pathogens 

that would be practical and effective in various types of healthcare settings. 

This document is intended for use by infection control staff, healthcare epidemiologists, 

healthcare administrators, nurses, other healthcare providers, and persons responsible for 

developing, implementing, and evaluating infection control programs for healthcare settings 

across the continuum of care. The reader is referred to other guidelines and websites for 

more detailed information and for recommendations concerning specialized infection control 

problems. 

Parts I - III: Review of the Scientific Data Regarding 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 influence 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 transmission. 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 “epidemiologically important 

organisms” that was developed to assist in the identification of clusters of infections that 

require investigation (i.e. multidrug-resistant organisms, C. difficile). Several other 

pathogens that hold special infection 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 infection control lessons learned from experience 

with these agents. This section of the guideline also presents information on infection risks 

associated with specific healthcare settings and patient populations. 

Part II updates information on the basic principles of hand hygiene, 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 those 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 modern, complex healthcare system. Evidence presented also 

demonstrates another administrative concern, the importance of nurse staffing levels, 

including numbers of appropriately trained nurses in ICUs for preventing HAIs. The role of 

the clinical microbiology laboratory in supporting infection control is described to emphasize 

the need for this service in healthcare facilites. Other factors that influence transmission 

risks are discussed i.e., healthcare worker adherence to recommended infection control 

practices, organizational safety culture or climate, education and training 

Discussed for the first time in an isolation guideline is surveillance of healthcare-associated 

infections. The information presented will be useful to new infection control professionals as 

8
 
well as persons involved in designing or responding to state programs for public reporting of 

HAI rates. 

Part III describes each of the categories of precautions developed by the Healthcare 

Infection Control Practices Advisory Committee (HICPAC) and the Centers for Disease 

Control and Prevention (CDC) and provides guidance for their application in various 

healthcare settings. The categories of Transmission-Based Precautions are unchanged 

from those in the 1996 guideline: Contact, Droplet, and Airborne. One important change is 

the recommendation to don the indicated personal 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 interaction with the patient cannot be predicted with 

certainty and contaminated environmental surfaces are important sources for transmission 

of pathogens. 

In addition, the Protective Environment (PE) for allogeneic hematopoietic stem cell 

transplant patients, described in previous guidelines, has been updated. 

Tables, Appendices, and other Information 

There are several tables that summarize important 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 infection control recommendations for category A 

agents of bioterrorism; 4) components of Standard 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 personal protective equipment used for 

isolation precautions to optimize safety and prevent self-contamination during removal. 

Appendix A: Type and Duration of Precautions 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 Precautions, 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 specific agent. Relevant citations are included. 

Pre- Publication of the 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-Resistant Organisms in 

Healthcare Settings 2006 www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf), and is 

considered a part of the Guideline for Isolation Precautions. This section provides a detailed 

review of the complex topic of MDRO control in healthcare settings and is intended to 

provide a context for evaluation of MDRO at individual healthcare settings. A rationale and 

9
 
institutional requirements for developing an effective MDRO control program are 

summarized. Although the focus of this guideline is on measures to prevent transmission of 

MDROs in healthcare settings, information concerning the judicious use of antimicrobial 

agents is presented since such practices are intricately related to the size of the reservoir of 

MDROs which in turn influences transmission (e.g. colonization pressure). There are two 

tables that summarize recommended prevention and control practices using the following 

seven categories of interventions to control MDROs: administrative measures, education of 

healthcare personnel, judicious antimicrobial use, surveillance, infection control precautions, 

environmental measures, and decolonization. Recommendations for each category apply 

to and are adapted for the various healthcare settings. With the increasing incidence and 

prevalence of MDROs, all healthcare facilities must prioritize effective control of MDRO 

transmission. Facilities should identify prevalent MDROs at the facility, implement control 

measures, assess the effectiveness of control programs, and demonstrate decreasing 

MDRO rates. A set of intensified 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 infection 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 agents to patients and healthcare workers in the 

United States and infection control. The primary objective of the guideline is to improve the 

safety of the nation’s healthcare delivery system by reducing the rates of HAIs. 

10
 
 

 

Abbreviations Used in the Guideline 

AIIR Airborne infection isolation room 

CDC Centers for Disease Control and Prevention 

CF Cystic fibrosis 

CJD Creutzfeld-Jakob Disease 

CLSI Clinical 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 particulate air [filtration] 

HICPAC Healthcare Infection Control 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-resistant gram-negative bacilli 

MRSA Methicillin-resistant Staphylococcus aureus 

NCCLS National Committee 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: Preventing Transmission of Infectious 

Agents in Healthcare Settings 2007 builds upon a series of isolation and infection 

prevention documents promulgated since 1970. These previous documents are 

summarized and referenced in Table 1 and in Part I of the 1996 Guideline for 

Isolation Precautions in Hospitals 1. 

Objectives and methods The objectives of this guideline are to 1) provide 

infection control recommendations for all components of the healthcare delivery 

system, including hospitals, long-term care facilities, ambulatory care, home care 

and hospice; 2) reaffirm Standard Precautions as the foundation for preventing 

transmission during patient care in all healthcare settings; 3) reaffirm the 

importance of implementing 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 epidemiologically 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 transmission 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 search for relevant studies published in 

English, focusing on those published since 1996. Much of the evidence cited for 

preventing transmission of infectious agents in healthcare settings is derived 

from studies that used “quasi-experimental 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 attributing improved 

outcome to a specific intervention. These include: difficulties in controlling for 

important confounding variables; 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 over 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 literature review and assignment 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 determining if the results should change 

practice or in designing new studies 2, 6, 7. 

12
 
Changes or clarifications in terminology This guideline contains four 

changes in terminology from 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, long-term care facilities, ambulatory settings, home 

care). This term reflects the inability to determine with certainty where the 

pathogen is acquired since patients may be colonized with or exposed to 

potential pathogens outside of the healthcare setting, before receiving 

health care, or may develop infections 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 recommendations for Standard Precautions 

is Respiratory Hygiene/Cough Etiquette. While Standard Precautions 

generally apply to the recommended practices of healthcare personnel 

during patient care, Respiratory Hygiene/Cough Etiquette applies broadly 

to all persons who enter a healthcare setting, including healthcare 

personnel, patients and visitors. These 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 (SARS-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 Infection Control in Healthcare Facilities 11, 

the Guidelines for Preventing the Transmission of Mycobacterium 

tuberculosis in Health-Care Settings 200512 and the American Institute of 

Architects (AIA) guidelines for design and construction of hospitals, 2006 

13 

	 A set of prevention measures termed Protective Environment has been 

added to the precautions used to prevent 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 allogeneic 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 separately in November 2006, and are available 

online at www.cdc.gov/ncidod/dhqp/index.html. Several other HICPAC 

13
 
guidelines to prevent transmission of infectious agents associated with 

healthcare delivery are cited; e.g., Guideline for Hand Hygiene, Guideline for 

Environmental Infection Control, Guideline for Prevention of HealthcareAssociated Pneumonia, and Guideline for Infection Control in Healthcare 

Personnel 11, 14, 16, 17. In combination, these provide comprehensive guidance on 

the primary infection control measures for ensuring a safe environment for 

patients and healthcare personnel. 

This guideline does not discuss in detail specialized infection control issues in 

defined populations that are addressed elsewhere, (e.g., Recommendations for 

Preventing Transmission of Infections among Chronic Hemodialysis Patients , 

Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in 

Health-Care Facilities 2005, Guidelines for Infection Control in Dental 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 for allogeneic HSCT recipients because 

components of the Protective Environment have been more completely defined 

since publication of the Guidelines for Preventing Opportunistic Infections Among 

HSCT Recipients in 2000 and the Guideline for Environmental Infection Control 

in Healthcare 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 infectious agents, a susceptible host with a 

portal of entry receptive to the agent, and a mode of transmission for the agent. 

This section describes the interrelationship 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 transmission. 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 incubation 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 gastrointestinal 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 severity of disease are related to the 

host. However, characteristics of the host-agent interaction as it relates to 

14
 
pathogenicity, virulence and antigenicity are also important, as are the infectious 

dose, mechanisms of disease production and route of exposure 55. There is a 

spectrum of possible outcomes following exposure to an infectious agent. Some 

persons exposed to pathogenic microorganisms never develop 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 time of exposure to an infectious agent, 

interaction between pathogens, and virulence factors intrinsic to the agent are 

important predictors of an individuals’ 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., antimicrobial agents, gastric acid 

suppressants, corticosteroids, antirejection drugs, antineoplastic agents, and 

immunosuppressive drugs). Surgical procedures and radiation therapy impair 

defenses of the skin and other involved organ systems. Indwelling devices such 

as urinary catheters, endotracheal tubes, central venous and arterial catheters 62-

64 and synthetic implants facilitate development of HAIs by allowing potential 

pathogens to bypass local defenses that would ordinarily impede their invasion 

and by providing surfaces for development of bioflms that may facilitate 

adherence of microorganisms and protect from antimicrobial activity 65. Some 

infections associated with invasive procedures result from transmission within the 

healthcare facility; others arise from the patient’s endogenous flora 46-50. High-risk 

patient populations with noteworthy risk factors 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, fungi, 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 primarily 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 two subgroups: direct contact and indirect 

contact. 

15
 
I.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 patients 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 patient 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 herpetic whitlow on a finger after 

contact with HSV when providing oral care to a patient without using 

gloves or HSV is transmitted to a patient from a herpetic whitlow on an 

ungloved hand of a healthcare worker (HCW) 70, 71. 

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 outbreak, 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 shared between patients without cleaning 

and disinfecting between patients74 75-77 . 

•	 Shared toys may become a vehicle for transmitting respiratory viruses 

(e.g., respiratory syncytial virus 24, 78, 79 or pathogenic bacteria (e.g., 

Pseudomonas aeruginosa 80) among pediatric patients. 

•	 Instruments that are inadequately cleaned between patients before 

disinfection or sterilization (e.g., endoscopes or surgical instruments) 

81-85 or that have manufacturing 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 infected with an infectious agent, (e.g., MRSA 

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

16
 
implicated 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 indirect contact routes. However, in 

contrast to contact transmission, respiratory droplets carrying infectious 

pathogens transmit infection when they travel directly from the respiratory tract of 

the infectious individual to susceptible mucosal surfaces of the recipient, 

generally over short distances, necessitating facial protection. Respiratory 

droplets are generated when an infected person coughs, sneezes, or talks 91, 92 

or during procedures such as suctioning, 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 portals of entry for respiratory viruses 

106. The maximum distance for droplet transmission is currently unresolved, 

although pathogens transmitted by the droplet 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 epidemiologic and simulated studies of 

selected infections 103, 104. Using this distance for donning masks has been 

effective in preventing transmission of infectious 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 propelled from the source, the density of 

respiratory secretions, environmental factors such as temperature 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 patient” 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 the patient’s room, especially 

when exposure to emerging or highly virulent pathogens is likely. More studies 

are needed to improve understanding of droplet transmission under various 

circumstances. 

Droplet size is another variable under discussion. Droplets traditionally have 

been defined as being >5 μm in size. Droplet nuclei, particles arising from 

desiccation of suspended droplets, have been associated with airborne 

transmission and defined as <5 μm in size 105 , a reflection of the pathogenesis of 

pulmonary tuberculosis which is not generalizeable to other organisms. 

Observations of particle dynamics have demonstrated that a range of droplet 

sizes, including those with diameters of 30μm or greater, can remain suspended 

17
 
in the air 109 . The behavior of droplets and droplet nuclei affect 

recommendations for preventing transmission. Whereas fine airborne particles 

containing pathogens that are able to remain infective may transmit infections 

over long distances, requiring AIIR to prevent its dissemination within a facility; 

organisms transmitted by the droplet route 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 coronavirus (SARS-CoV) 21, 96, 

113, group A streptococcus 114, and Neisseria meningitidis 95, 103, 115. Although 

respiratory syncytial virus may be transmitted 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 short distances. For example, although S. aureus is 

transmitted most frequently by the contact route, viral upper respiratory tract 

infection has been associated with increased dispersal of S. aureus from the 

nose into the air for a distance of 4 feet under both outbreak and experimental 

conditions and is known as the “cloud baby” and “cloud adult” phenomenon118-120 . 

I.B.3.c. Airborne transmission Airborne transmission occurs by 

dissemination of either airborne droplet nuclei or small particles 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 transmitted by the airborne 

route requires the use of special air handling 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 transmission for smallpox 108, 128, 129. In addition to AIIRs, 

respiratory protection with NIOSH 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 infectious 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 longer than 3 feet but within a defined 

18
 
airspace (e.g., patient room), suggesting that it is unlikely that these agents 

remain viable on air currents that travel long distances. AIIRs are not required 

routinely to prevent transmission of these agents. Additional issues concerning 

examples of small particle aerosol transmission of agents that are most 

frequently transmitted by the droplet route are discussed below. 

I.B.3.d. Emerging issues concerning airborne transmission of infectious 

agents. 

I.B.3.d.i. Transmission from patients The emergence of SARS in 2002, the 

importation of monkeypox into the United States in 2003, and the emergence of 

avian influenza present challenges to the assignment of isolation categories 

because of conflicting information and uncertainty 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 rooms were used in one center 144 However, 

inhalational transmission could not be excluded 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 tuberculosis during the 

influenza pandemic of 1957-’58 have been used to suggest airborne 

transmission 145, 146. 

In contrast to the strict interpretation of an airborne route for transmission (i.e., 

long distances beyond the patient room environment), short distance 

transmission by small particle aerosols generated under specific circumstances 

(e.g., during endotracheal intubation) to persons in the immediate area near the 

patient has been demonstrated. Also, aerosolized particles <100 μm can remain 

suspended in air when room air current velocities exceed the terminal settling 

velocities of the particles 109. SARS-CoV transmission has been associated with 

endotracheal intubation, noninvasive positive 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 inhaled and subsequently swallowed. 

Roy and Milton proposed a new classification for aerosol transmission when 

evaluating routes of SARS transmission: 1) obligate: under natural conditions, 

disease occurs following transmission of the agent only through inhalation of 

small particle aerosols (e.g., tuberculosis); 2) preferential: natural infection results 

from transmission through multiple routes, but small particle aerosols are the 

predominant route (e.g. measles, varicella); and 3) opportunistic: agents that 

naturally cause disease through other routes, but under special circumstances 

19
 
may be transmitted via fine particle aerosols 149. This conceptual framework can 

explain rare occurrences of airborne transmission of agents that are transmitted 

most frequently by other routes (e.g., smallpox, SARS, influenza, noroviruses). 

Concerns about unknown or possible routes of transmission of agents associated 

with severe disease and no known treatment often result in more extreme 

prevention strategies than may be necessary; therefore, recommended 

precautions could change as the epidemiology of an emerging infection is 

defined and controversial issues are resolved. 

I.B.3.d.ii. Transmission from the environment Some airborne infectious 

agents are derived from the environment and do not usually involve person-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 patients. 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 spores 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 respiratory 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 individuals include those associated with common 

environmental sources or vehicles (e.g. contaminated food, water, or medications 

(e.g. intravenous fluids). Although Aspergillus spp. have been recovered from 

hospital water systems 159, the role of water as a reservoir for 

immunosuppressed patients remains uncertain. Vectorborne transmission of 

infectious agents from mosquitoes, flies, rats, and other vermin also can occur in 

healthcare settings. Prevention of vector borne transmission is not addressed in 

this document. 

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 previous isolation guidelines or have emerged 

recently are discussed below. These are epidemiologically important organisms 

(e.g., C. difficile), agents of bioterrorism, prions, SARS-CoV, monkeypox, 

noroviruses, and the hemorrhagic fever viruses. Experience with these agents 

has broadened the understanding of modes of transmission and effective 

20
 
preventive measures. These agents are included for purposes of information 

and, for some (i.e., SARS-CoV, monkeypox), 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 may, under defined conditions, become 

targeted for control because they are epidemiologically important. C. difficile is 

specifically discussed below because of wide recognition of its current 

importance in U.S. healthcare facilities. In determining what constitutes an 

“epidemiologically important organism”, the following characteristics apply: 

•	 A propensity for transmission within 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., group A streptococcus post-operatively 

160 14, 163 , in burn units 161, or in a LTCF 162; Legionella sp. , Aspergillus sp.

164 ) is generally considered a trigger 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 microorganisms with unusual patterns of 

resistance within a facility (e.g., the first isolate of Burkholderia cepacia 

complex or Ralstonia spp. in non-CF patients or a quinolone-resistant 

strain of Pseudomonas aeruginosa in a facility). 

•	 Difficult to treat because of innate or acquired resistance to multiple 

classes of antimicrobial agents (e.g., Stenotrophomonas maltophilia, 

Acinetobacter spp.). 

•	 Association with serious clinical disease, increased morbidity and mortality 

(e.g., MRSA and MSSA, group A streptococcus) 

•	 A newly discovered or reemerging pathogen 

I.C.1.a. C.difficile C. difficile is a spore-forming gram positive anaerobic bacillus 

that was first isolated from 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 extremely difficult to control. Important 

factors that contribute to healthcare-associated outbreaks include 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 patients to frequent 

courses of antimicrobial agents 167 . Antimicrobials most frequently associated 

21
 
with increased risk of C. difficile include third generation cephalosporins, 

clindamycin, vancomycin, and fluoroquinolones. 

Since 2001, outbreaks and sporadic cases of C. difficile with increased morbidity 

and mortality have been observed in several U.S. states, Canada, England and 

the 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% perceived recent increases in the incidence 

and severity of C. difficile disease174. Standardization of testing methodology and 

surveillance definitions is needed for accurate 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 production of toxins A and B, increasing the severity of 

diarrhea and resulting in more environmental contamination. Considering the 

greater morbidity, mortality, 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 previously. Prevention of transmission focuses 

on syndromic application of Contact Precautions for patients with diarrhea, 

accurate identification of patients, environmental measures (e.g., rigorous 

cleaning of patient rooms) and consistent hand hygiene. Use of soap and water, 

rather than alcohol based handrubs, for mechanical removal of spores from 

hands, and a bleach-containing disinfectant (5000 ppm) for environmental 

disinfection, may be valuable when there is transmission in a healthcare facility. 

See Appendix A for specific recommendations. 

I.C.1. b. Multidrug-Resistant Organisms (MDROs) In general, MDROs are 

defined as microorganisms – predominantly bacteria – that are resistant to one or 

more classes of antimicrobial agents176. Although the names of certain MDROs 

suggest resistance to only one agent (e.g., methicillin-resistant Staphylococcus 

aureus [MRSA], vancomycin resistant enterococcus [VRE]), these pathogens are 

usually resistant to all but a few commercially available antimicrobial agents. This 

latter feature defines MDROs that are considered to be epidemiologically 

important and deserve special attention in healthcare facilities177. Other MDROs 

of current concern include multidrug-resistant Streptococcus pneumoniae 

(MDRSP) which is resistant to penicillin and other broad-spectrum agents such 

as macrolides and fluroquinolones, multidrug-resistant gram-negative bacilli 

(MDR- GNB), especially those producing extended spectrum beta-lactamases 

(ESBLs); and strains of S. aureus that are intermediate or resistant to 

vancomycin (i.e., VISA and VRSA)178-197 198 . 

MDROs are transmitted by the same routes as antimicrobial susceptible 

infectious agents. Patient-to-patient transmission in healthcare settings, usually 

via hands of HCWs, has been a major factor accounting for the increase in 

MDRO incidence and prevalence, especially for MRSA and VRE in acute care 

22
 
facilities199-201 . 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 adherence to recommended infection control 

measures), education and training of medical and other healthcare personnel, 

judicious antibiotic use, comprehensive surveillance for targeted MDROs, 

application of infection control precautions during patient care, environmental 

measures (e.g., cleaning and disinfection of the patient care environment and 

equipment, dedicated single-patient-use of non-critical 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 assume responsibility and participate in 

community-wide control programs176, 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, viral hemorrhagic fevers, and botulism as 

Category A (high priority) because these agents can be easily disseminated 

environmentally and/or transmitted from person to person; can cause high 

mortality and have the potential for major public health impact; might cause 

public panic and social disruption; and require special action for public health 

preparedness202. General information relevant to infection control in healthcare 

settings for Category A agents of bioterrorism is summarized in Table 3. Consult 

www.bt.cdc.gov for additional, updated Category A agent information as well as 

information concerning Category B and C agents of bioterrorism and updates. 

Category B and C agents are important but are not as readily disseminated and 

cause less morbidity and mortality than Category A agents. 

Healthcare facilities confront a different set of issues when dealing with a 

suspected bioterrorism event as compared with other communicable diseases. 

An understanding of the epidemiology, modes of transmission, and clinical 

course of each disease, as well as carefully drafted plans that provide an 

approach and relevant websites and other resources for disease-specific 

guidance to healthcare, administrative, and support personnel, are essential for 

responding to and managing a bioterrorism event. Infection control issues to be 

addressed include: 1) identifying persons who may be exposed or infected; 2) 

preventing transmission among patients, healthcare personnel, and visitors; 3) 

providing treatment, chemoprophylaxis or vaccine to potentially large numbers of 

people; 4) protecting the environment including the logistical aspects of securing 

sufficient numbers of AIIRs or designating areas for patient cohorts when there 

are an insufficient number of AIIRs available;5) providing adequate quantities of 

appropriate personal protective equipment; and 6) identifying appropriate staff to 

care for potentially infectious patients (e.g., vaccinated healthcare personnel for 

23
 
care of patients with smallpox). The response is likely to differ for exposures 

resulting from an intentional release compared with naturally occurring disease 

because of the large number persons that can be exposed at the same time and 

possible differences in pathogenicity. 

A variety of sources offer guidance for the management of persons exposed to 

the most likely agents of bioterrorism. Federal agency websites (e.g., 

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 screening for vaccine contraindications in 

persons who are at increased risk for adverse 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 contraindications and vaccination site care 

and monitoring. Approximately 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 contact 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 vaccination sites. Vaccinia virus was confirmed 

by culture or PCR in 30 cases, and two of the confirmed cases resulted from 

tertiary transfer. All recipients, including one breast-fed infant, recovered without 

complication. Subsequent studies using viral culture and PCR techniques have 

confirmed the effectiveness of semipermeable dressings to contain vaccinia 221-

224. This experience emphasizes the importance of ensuring that newly 

vaccinated healthcare personnel adhere to recommended vaccination-site care, 

especially if they are to care for high-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. Approximately 85% of CJD cases occur 

sporadically with no known environmental source of infection and 10% are 

familial. Iatrogenic transmission has occurred with most resulting from treatment 

with human cadaveric pituitary-derived growth hormone or gonadotropin 228, 229, 

from implantation of contaminated human dura mater grafts 230 or from corneal 

transplants 231). Transmission has been linked to the use of contaminated 

neurosurgical instruments or stereotactic electroencephalogram electrodes 232, 

233 , 234 , 235. 

Prion diseases in animals include scrapie in sheep and goats, bovine spongiform 

encephalopathy (BSE, or “mad cow disease”) in cattle, and chronic wasting 

disease in deer and elk 236. BSE, first recognized in the United Kingdom (UK) in 

1986, was associated with a major epidemic among cattle that had consumed 

contaminated meat and bone meal. 

The possible transmission of BSE to humans causing variant CJD (vCJD) was 

first described in 1996 and subsequently found to be associated with 

consumption of BSE-contaminated cattle products primarily in the United 

Kingdom. There is strong epidemiologic and laboratory evidence for a causal 

association between the causative agent of BSE and 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 during the years of a large outbreak of BSE 

(1980-96) and may have consumed contaminated cattle products during that 

time (www.cdc.gov/ncidod/diseases/cjd/cjd.htm). Although there has been no 

indigenously acquired vCJD in the United States, the sporadic occurrence of 

BSE in cattle in North America has heightened awareness of the possibility that 

such infections could occur and have led to increased surveillance activities. 

Updated information may be found on the following website: 

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 sensory symptoms and early 

psychiatric symptoms with delayed onset of frank neurologic signs; and 4) 

detection of prions in tonsillar and other lymphoid tissues from vCJD patients but 

not from sporadic CJD 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 airborne routes. Ongoing blood safety 

surveillance in the U.S. has not detected sporadic CJD transmission through 

25
 
blood 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 caring for patients with suspected or 

confirmed CJD or vCJD. However, special precautions are recommended for 

tissue handling in the histology laboratory and for conducting an autopsy, 

embalming, and for contact with a body that has undergone 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 currently under review at CDC. 

Questions concerning notification of patients potentially exposed to CJD or vCJD 

through contaminated instruments and blood products from patients with CJD or 

vCJD or at risk of having vCJD may arise. The risk of transmission associated 

with such exposures is believed to be extremely low but may vary based on the 

specific circumstance. Therefore consultation on appropriate options is advised. 

The United Kingdom has developed several documents that clinicians and 

patients in the US may find useful 

(http://www.hpa.org.uk/infections/topics_az/cjd/information_documents.htm). 

I.C.4. Severe Acute Respiratory Syndrome (SARS) SARS is a newly 

discovered respiratory disease that emerged in China late in 2002 and spread to 

several countries 135, 140; Mainland China, Hong Kong, Hanoi, Singapore, and 

Toronto were affected significantly. SARS is caused by SARS CoV, a previously 

unrecognized member of the 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 >38.0o

C and chills and rigors, sometimes accompanied by 

headache, myalgia, and mild to severe respiratory symptoms. Radiographic 

finding of atypical pneumonia is an important clinical indicator of possible SARS. 

Compared with adults, children have been affected less frequently, have milder 

disease, and are less likely 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, with transmission to large numbers of 

healthcare personnel and patients have been a striking feature of SARS; 

undiagnosed, infectious patients and visitors were important initiators of these 

outbreaks 21, 252-254. The relative contribution of potential modes of transmission is 

not precisely known. There is ample evidence for droplet and contact 

transmission 96, 101, 113; however, opportunistic airborne transmission cannot be 

excluded 101, 135-139, 149, 255. For example, exposure to aerosol-generating 

26
 
procedures (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 generated 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 exposed to aerosol- generating procedures and 

high risk activities 256, 257. Organizational and individual factors that affected 

adherence to infection control practices for SARS also were identified 257. 

Control of SARS requires a coordinated, 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 transmission or contact with 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 Precautions, with emphasis on the use 

of hand hygiene, Contact Precautions with 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 Precautions, which included use of a mask 

but not a respirator, was effective in protecting healthcare personnel113. However, 

in Toronto, consistent use of an N95 respirator 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 suggests 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 reported 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 occurred in the laboratory re-affirm the 

effectiveness of recommended infection control 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 bioterrorism events. 

Surveillance for cases among patients and healthcare personnel, ensuring 

availability of adequate supplies and staffing, and limiting access to healthcare 

27
 
facilities were important factors in the response to SARS that have been 

summarized 9

. Guidance for infection control precautions in various settings is 

available at www.cdc.gov/ncidod/sars. 

I.C.5. Monkeypox Monkeypox is a rare viral disease found mostly in the rain 

forest countries of Central and West Africa. The disease is caused by an 

orthopoxvirus that is similar in appearance to smallpox but causes a milder 

disease. The only recognized outbreak of human monkeypox in the United 

States was detected in June 2003 after several people became ill following 

contact with sick pet prairie dogs. Infection in the prairie dogs was subsequently 

traced to their contact with a shipment of animals from Africa, including giant 

Gambian rats 263. This outbreak demonstrates the importance of recognition and 

prompt reporting of unusual disease presentations by clinicians to enable prompt 

identification of the etiology; and the potential of epizootic diseases to spread 

from animal reservoirs to humans through personal and occupational exposure 

264 . 

 Limited data on transmission of monkeypox are available. Transmission from 

infected animals and humans is believed to occur primarily through direct contact 

with lesions and respiratory 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 monkeypox transmission within hospitals 

have been reported in Africa among children, usually related to sharing the same 

ward or bed 266, 267. Additional recent literature documents transmission of Congo 

Basin monkeypox in a hospital compound for an extended number of generations 

268 . 

There has been no evidence of airborne 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 properties (including human-to-human 

transmission potential) from monkeypox 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 animals 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 water and from person-to-person, causing explosive 

outbreaks of gastrointestinal disease 273. Environmental contamination also has 

been documented as a contributing factor in ongoing transmission during 

outbreaks 274, 275. Although noroviruses cannot be propagated in cell culture, 

28
 
DNA detection by molecular diagnostic techniques has facilitated a greater 

appreciation of their role in outbreaks 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 where people share common facilites and 

space. Of note, there is nearly a 5 fold increase in the risk to patients in 

outbreaks where a patient is the index case compared with exposure of patients 

during outbreaks where a staff member is the index case 287. 

The average incubation period for gastroenteritis caused by noroviruses is 12-48 

hours and the clinical course lasts 12-60 hours 273. Illness is characterized by 

acute onset of nausea, vomiting, abdominal cramps, and/or diarrhea. The 

disease is largely self-limited; rarely, death caused by severe dehydration can 

occur, particularly among the elderly with debilitating health conditions. 

The epidemiology of norovirus outbreaks shows that even though primary cases 

may result from exposure to a fecally-contaminated food or water, secondary and 

tertiary cases often result from person-to-person transmission that is facilitated 

by contamination of 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 environment 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 may be aerosolized from vomitus, inhaled, 

and swallowed. In addition, individuals who are responsible for cleaning the 

environment may be at increased risk of infection. Development of disease and 

transmission may be facilitated by the low infectious dose (i.e., <100 viral 

particles) 289 and the resistance of these viruses to the usual cleaning and 

disinfection agents (i.e., may survive < 10 ppm chlorine) 290-292. An alternate 

phenolic agent that was shown to be effective against feline calicivirus was used 

for environmental cleaning in one 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 serious disease with high fever, skin rash, 

bleeding diathesis, and in some cases, high mortality; the disease caused is 

referred to as viral hemorrhagic fever (VHF). Among the more commonly known 

HFVs are Ebola and Marburg viruses (Filoviridae), Lassa virus (Arenaviridae), 

Crimean-Congo hemorrhagic fever and Rift Valley Fever virus (Bunyaviridae), 

29
 
and Dengue and Yellow fever viruses (Flaviviridae) 212, 297. These viruses are 

transmitted to humans via contact with infected animals or via arthropod vectors. 

While none of these viruses is endemic in the United States, outbreaks in 

affected countries provide potential opportunities for importation by infected 

humans and animals. Furthermore, there are concerns that some of these agents 

could be used as bioweapons 212. Person-to-person transmission is documented 

for Ebola, Marburg, Lassa and Crimean-Congo hemorrhagic fever viruses. In 

resource-limited healthcare settings, transmission of these agents to healthcare 

personnel, patients and visitors has been described and in some outbreaks has 

accounted for a large proportion of 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 associated primarily with direct blood and body 

fluid contact. Percutaneous exposure to contaminated blood carries a particularly 

high risk for transmission and increased mortality 303, 304. The finding of large 

numbers of Ebola viral particles in the skin and the lumina of sweat glands has 

raised concern that transmission could occur from direct contact with intact skin 

though epidemiologic evidence to support this is 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 passengers308 . 

In the laboratory setting, animals have been infected experimentally with Marburg 

or Ebola viruses via direct inoculation of the nose, mouth and/or conjunctiva 309, 

310 and by using mechanically generated virus-containing aerosols 311, 312. 

Transmission of Ebola virus among laboratory primates in an animal facility has 

been described 313. Secondarily infected animals were in individual cages and 

separated by approximately 3 meters. Although the possibility 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 were posted on the CDC website on 5/19/05 

314. Inconsistencies among the various recommendations have raised questions 

about the appropriate precautions to use in U.S. hospitals. In less developed 

countries, outbreaks of HFVs have been controlled with basic hygiene, barrier 

precautions, safe injection practices, and safe burial practices 299, 306. The 

preponderance of evidence on HFV transmission indicates that Standard, 

Contact and Droplet Precautions with eye protection are effective in protecting 

30
 
healthcare personnel and visitors who may attend an infected patient. Single 

gloves are adequate for routine patient care; double-gloving is advised during 

invasive procedures (e.g., surgery) that pose an increased risk for blood 

exposure. Routine eye protection (i.e. goggles or face shield) is particularly 

important. Fluid-resistant gowns should be worn for all patient contact. Airborne 

Precautions are not required for routine patient care; however, use of AIIRs is 

prudent when procedures that could generate infectious aerosols are performed 

(e.g., endotracheal intubation, bronchoscopy, suctioning, autopsy procedures 

involving oscillating saws). N95 or higher level respirators may provide added 

protection for individuals in a room during aerosol-generating procedures (Table 

3, Appendix A). When a patient with a syndrome consistent with hemorrhagic 

fever also has a history of travel to an endemic area, precautions are initiated 

upon presentation and then modified as more information is obtained (Table 2). 

Patients with hemorrhagic fever syndrome in the setting of a suspected 

bioweapon attack should be managed using Airborne Precautions, including 

AIIRs, since the epidemiology of a potentially weaponized hemorrhagic fever 

virus is unpredictable. 

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

settings 

 Numerous factors influence differences in transmission risks among the various 

healthcare settings. These include the population characteristics (e.g., increased 

susceptibility to infections, type and prevalence of indwelling devices), intensity of 

care, exposure to environmental sources, length of stay, and frequency of 

interaction between patients/residents with each other and with HCWs. These 

factors, as well as organizational priorities, goals, and resources, influence how 

different healthcare settings adapt transmission prevention guidelines to meet 

their specific needs 315, 316. Infection control management decisions are informed 

by data regarding institutional experience/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 present in all hospital settings. 

However, certain hospital settings and patient populations have unique 

conditions that predispose patients to infection and merit special mention. These 

are often sentinel sites for the emergence of new transmission risks that may be 

unique to that setting or present opportunities for transmission to other settings in 

the hospital. 

I.D.1.a. Intensive Care Units Intensive care units (ICUs) serve patients who are 

immunocompromised by disease state and/or by treatment modalities, as well as 

patients with major trauma, respiratory failure and other life-threatening 

conditions (e.g., myocardial infarction, congestive heart failure, overdoses, 

strokes, gastrointestinal bleeding, renal failure, hepatic failure, multi-organ 

system failure, and the extremes of age). Although ICUs account for a relatively 

31
 
small 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 HAIs were reported from ICU and high risk 

nursery (NICU) patients in 2002 (NNIS, unpublished data). This patient 

population has increased susceptibility to colonization and infection, especially 

with MDROs and Candida sp. 318, 319, because of underlying diseases and 

conditions, the invasive medical devices and technology used in their care (e.g. 

central venous catheters and other intravascular devices, mechanical ventilators, 

extracorporeal membrane oxygenation (ECMO), hemodialysis/-filtration, 

pacemakers, implantable left ventricular assist devices), the frequency of contact 

with healthcare personnel, prolonged length of stay, and prolonged exposure to 

antimicrobial 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 transmissions 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 infection 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-negative 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 lead to changes in burn care practices 343, 

355-358. Burn wound infections caused by Aspergillus sp. or other environmental 

molds may result from exposure 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 hydrotherapy; excision of burn wounds in 

operating rooms is preferred. 

Advances in burn care, specifically early excision and grafting of the burn wound, 

use of topical antimicrobial agents, and institution of early enteral feeding, have 

led to decreased infectious complications. Other advances have included 

prophylactic antimicrobial usage, selective digestive decontamination (SDD), and 

use of antimicrobial-coated catheters (ACC), but few epidemiologic studies and 

no efficacy studies have been performed to show the relative benefit of these 

357 measures . 

32
 
There is no consensus on the most effective infection control practices to prevent 

transmission of infections to and from patients 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 separate 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 routine care of burn patients. One 

retrospective study demonstrated efficacy and cost effectiveness of a simplified 

barrier isolation protocol for wound colonization, emphasizing handwashing and 

use of gloves, caps, masks and plastic impermeable 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 epidemiology 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 NNIS 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 epidemics (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, playing, changing soiled diapers, and cleaning 

copious uncontrolled respiratory secretions) provides abundant opportunities for 

transmission of infectious material. Practices and behaviors such as 

congregation of children in play areas where toys and bodily secretions are easily 

shared and family members rooming-in with pediatric patients can further 

increase the risk of transmission. Pathogenic bacteria have been recovered from 

toys used by hospitalized 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 healthcare settings (e.g., immaturity of the 

neonatal immune system, lack of previous natural infection and resulting 

immunity, prevalence of patients with congenital or acquired immune 

deficiencies, congenital anatomic anomalies, and use of life-saving invasive 

devices in neontal and pediatric intensive care units) 63. There are theoretical 

concerns that infection risk will increase in association with innovative practices 

used in the NICU for the purpose of improving developmental outcomes, Such 

factors include co-bedding 380 and kangaroo care 381 that may increase 

opportunity for skin-to-skin exposure of multiple gestation infants to each other 

and to their mothers, respectively; although infection risk smay actually be 

33
 
reduced 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 resistance (eg. by contributing to the reservoir of 

community-associated MRSA [CA-MRSA]) 386-391 . Patients in chronic care 

facilities may have increased rates of colonization with resistant GNBs and may 

be sources of introduction of resistant organisms to acute care settings 50. 

I.D.2. Nonacute healthcare settings Healthcare is provided in various settings 

outside of hospitals including facilities, such as long-term care facilities (LTCF) 

(e.g. nursing homes), homes for the developmentally disabled, settings where 

behavioral health services are provided, rehabilitation centers and hospices392 . 

In addition, healthcare may be provided in nonhealthcare settings such as 

workplaces with occupational health clinics, 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 implementing an infection control program. 

Several of the most common settings and their particular challenges are 

discussed below. While this Guideline does not address each setting, the 

principles and strategies provided may 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 developmentally disabled to 

nursing homes for the elderly and pediatric chronic-care facilities 393-395. Nursing 

homes for the elderly predominate numerically and frequently represent longterm care as a group of facilities. Approximately 1.8 million Americans reside in 

the nation’s 16,500 nursing homes 396. Estimates of HAI rates of 1.8 to 13.5 per 

1000 resident-care days have been reported with a range of 3 to 7 per 1000 

resident-care days in the more rigorous 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 nationwide 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 various facility-sponsored activities 403, 404. Since 

able residents interact freely with each other, controlling transmission of infection 

in this setting is challenging 405. Residents who are colonized or infected with 

certain microorganisms are, in some cases, restricted to their room. However, 

because of the psychosocial risks associated with such restriction, it has been 

recommended that psychosocial needs be balanced with infection control needs 

in the LTCF 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 

34
 
morbidity and mortality, and increased medical costs; prompt detection and 

implementation of effective control measures are required. 

 Risk factors for infection are prevalent among LTCF residents 395, 417, 418. Agerelated declines in immunity may affect responses to immunizations for influenza 

and other infectious agents, and increase susceptibility to tuberculosis. 

Immobility, incontinence, dysphagia, underlying chronic diseases, poor functional 

status, and age-related skin changes increase susceptibility to urinary, 

respiratory and cutaneous and soft tissue infections, while malnutrition can impair 

wound 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 control and antimicrobial 

resistance in LTCFs 406-408, 431-436. The Centers for Medicare and Medicaid 

Services (CMS) have established regulations for the prevention of infection in 

LTCFs 437. 

Because residents of LTCFs are hospitalized frequently, they can transfer 

pathogens between LTCFs and healthcare facilities 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 contribute 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, inpatient hospital to a variety of ambulatory 

and community-based settings, including the home. Ambulatory care is provided 

in hospital-based outpatient clinics, nonhospital-based clinics and physician 

offices, public health clinics, free-standing dialysis centers, ambulatory surgical 

centers, urgent care centers, and many others. In 2000, there were 83 million 

visits to hospital outpatient clinics 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 patients 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 infectious patients may not be recognized 

immediately. Furthermore, immunocompromised patients often receive 

chemotherapy in infusion rooms where they stay for extended periods of time 

along with other types of patients. 

35
 
There 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 infections associated with the outpatient 

setting from 1961-1990 446. Overall, 29 clusters were associated with common 

source transmission from contaminated solutions or equipment, 14 with personto-person transmission from or involving healthcare personnel and ten 

associated with airborne or droplet transmission among patients and healthcare 

workers. Transmission of bloodborne pathogens (i.e., hepatitis B and C viruses 

and, rarely, HIV) in outbreaks, sometimes involving hundreds of patients, 

continues to occur in ambulatory settings. These outbreaks often are related to 

common source exposures, usually a contaminated medical device, multi-dose 

vial, or intravenous 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 departments, has been reported 34, 127, 446, 448, 455-457. 

Measles virus was transmitted in physician offices and other outpatient settings 

during an era when immunization rates were 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 setting. In the ophthalmology setting, adenovirus 

type 8 epidemic keratoconjunctivitis has been transmitted via incompletely 

disinfected ophthalmology equipment 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 measures, 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 reported, but the association of CAMRSA in healthcare personnel working in an outpatient HIV clinic with 

environmental CA-MRSA contamination in that 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 States is delivered by over 20,000 

provider agencies that include home health agencies, hospices, durable medical 

equipment providers, home infusion therapy services, and personal care and 

36
 
support services providers. Home care is provided to patients of all ages with 

both acute and chronic conditions. The scope of services ranges from assistance 

with activities of daily living and physical and occupational therapy to the care of 

wounds, infusion therapy, and chronic ambulatory peritoneal dialysis (CAPD). 

The incidence of infection in home care patients, other than those associated 

with infusion therapy is not well studied 466-471 . However, data collection and 

calculation of infection rates have been accomplished for central venous 

catheter-associated bloodstream infections in patients receiving home infusion 

therapy 470-474 and for the risk of blood contact through percutaneous or mucosal 

exposures, demonstrating that surveillance can be performed in this setting 475. 

Draft definitions for home care associated infections have been developed 476. 

Transmission risks during home care are presumed to be minimal. The main 

transmission risks to home care patients are from an infectious healthcare 

provider or contaminated equipment; providers also can be exposed to an 

infectious patient during home visits. Since home care involves patient care by a 

limited number of personnel in settings without multiple patients or shared 

equipment, the potential reservoir of pathogens is reduced. Infections of home 

care providers, that could pose a risk to home care patients include infections 

transmitted by the airborne or droplet routes (e.g., chickenpox, tuberculosis, 

influenza), and skin infestations (e.g., scabies 69 and lice) and infections 

(e.g.,impetigo) transmitted by direct or indirect contact. There are no published 

data on indirect transmission of MDROs from one home care patient to another, 

although this is theoretically possible if contaminated equipment is transported 

from an infected or colonized patient and used on another patient. Of note, 

investigation of the first case of VISA in homecare 186 and the first 2 reported 

cases of VRSA 178, 180, 181, 183 found no evidence of transmission of VISA or 

VRSA to other home care recipients. Home health care also may contribute to 

antimicrobial resistance; a review of outpatient vancomycin use found 39% of 

recipients did not receive the antibiotic according to recommended guidelines 477. 

Although most home care agencies implement policies and procedures to 

prevent transmission of organisms, the current approach is based on the 

adaptation of the 1996 Guideline for Isolation Precautions in Hospitals 1

 as well 

as other professional 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 home health agencies continue to observe 

“nursing bag technique,” a practice that prescribes the use of barriers between 

the nursing bag and environmental surfaces in the home 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 healthcare is delivered include clinics in 

correctional facilities and shelters. Both settings can have suboptimal features, 

37
 
such as crowded conditions and poor ventilation. Economically disadvantaged 

individuals who may have chronic illnesses and healthcare problems related to 

alcoholism, injection drug use, poor nutrition, and/or inadequate shelter often 

receive their primary healthcare at sites such as these 484. Infectious diseases of 

special concern for transmission include tuberculosis, scabies, respiratory 

infections (e.g., N. meningitides, S. pneumoniae), sexually transmitted and 

bloodborne diseases (e.g.,HIV, HBV, HCV, syphilis, gonorrhea), hepatitis A virus 

(HAV), diarrheal agents such as norovirus, and foodborne diseases 286, 485-488. A 

high index of suspicion for tuberculosis and CA-MRSA in these populations is 

needed as outbreaks in these settings or among the populations they serve have 

been reported 489-497. 

Patient encounters in these types of facilities 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 settings. Therefore, these settings must 

be equipped to observe Standard Precautions and, when indicated, 

Transmission-based Precautions. 

I.E. Transmission risks associated with special patient populations 

As new treatments emerge for complex diseases, unique infection control 

challenges associated with special patient populations need to be addressed. 

I.E.1. Immunocompromised patients Patients who have congenital primary 

immune deficiencies or acquired disease (eg. treatment-induced immune 

deficiencies) are at increased risk for numerous types of infections while 

receiving healthcare and may be located throughout the healthcare facility. The 

specific defects of the immune system determine the types of infections that are 

most likely to be acquired (e.g., viral infections are associated with T-cell defects 

and fungal and bacterial infections occur in patients who are neutropenic). As a 

general group, immunocompromised patients can be cared for in the same 

environment as other patients; however, it is always advisable to minimize 

exposure to other patients with transmissible infections such as influenza and 

other respiratory viruses 499, 500. The use of more intense chemotherapy 

regimens for treatment of childhood leukemia may be associated with prolonged 

periods of neutropenia and suppression of other components of the immune 

system, extending the period of infection risk and raising the concern that 

additional precautions may be indicated for select groups 501, 502. With the 

application of newer and more intense immunosuppressive therapies for a variety 

of medical conditions (e.g., rheumatologic disease 503, 504, inflammatory bowel 

disease 505), immunosuppressed patients are likely to be more widely distributed 

throughout a healthcare facility rather than localized to single patient units (e.g. 

38
 
hematology-oncology). Guidelines for preventing infections in certain groups of 

immunocompromised patients have been published 15, 506, 507. 

Published data provide evidence 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 immunocompromised patients, 

including use of antimicrobial prophylaxis and engineering controls to create a 

Protective Environment for the prevention 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 prolonged beyond the traditional 100 days 508. 

I.E.2. Cystic fibrosis patients Patients with cystic fibrosis (CF) require special 

consideration when developing infection control guidelines. Compared to other 

patients, CF patients require additional protection to prevent transmission from 

contaminated respiratory therapy 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 respiratory secretions include segregation of CF 

patients from each other in ambulatory and hospital settings (including use of 

private rooms with separate showers), environmental decontamination of 

surfaces and equipment contaminated with respiratory secretions, elimination of 

group chest physiotherapy sessions, and disbanding of CF camps 97, 526. The 

Cystic Fibrosis Foundation published a consensus document with evidencebased recommendations for infection control practices for CF patients 20. 

I.F. New therapies associated with potentially transmissible infectious 

agents 

I.F.1. Gene therapy Gene therapy has has been attempted using a number of 

different viral vectors, including nonreplicating retroviruses, adenoviruses, adenoassociated viruses, and replication-competent strains of poxviruses. Unexpected 

adverse events have restricted the prevalence of gene therapy protocols. 

The infectious hazards of gene therapy are theoretical at this time, but require 

meticulous surveillance due to the possible occurrence of in vivo recombination 

39
 
and the subsequent emergence of a transmissible genetically altered pathogen. 

Greatest concern attends the use of replication-competent viruses, especially 

vaccinia. As of the time of publication, no reports have described transmission of 

a vector virus from a gene therapy recipient to another individual, but surveillance 

is ongoing. Recommendations for monitoring infection control issues throughout 

the course of gene therapy trials have been published 527-529 . 

I.F.2. Infections transmitted through blood, organs and other tissues The 

potential hazard of transmitting infectious pathogens through biologic products is 

a small but ever present risk, despite donor screening. Reported infections 

transmitted by transfusion or transplantation include West Nile Virus 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 important to consider receipt of biologic products when 

evaluating patients for potential sources of infection. 

I.F.3. Xenotransplantation The transplantation of nonhuman cells, tissues, and 

organs into humans potentially exposes patients to zoonotic pathogens. 

Transmission of known zoonotic infections (e.g., trichinosis from porcine tissue), 

constitutes one concern, but also of concern is the possibility that transplantation 

of nonhuman cells, tissues, or organs may transmit previously unknown zoonotic 

infections (xenozoonoses) to immunosuppressed human recipients. Potential 

infections that might accompany transplantation of porcine organs have been 

described 541 . Guidelines from the U.S. Public Health Service address many 

infectious diseases and infection control 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 patient and occupational 

safety programs 543-547. An infrastructure to guide, support, and monitor 

adherence to Standard and Transmission-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 patients with potentially transmissible 

infectious agents, are essential to ensure the success of these measures and 

may vary according to the characteristics of the organization. 

A key administrative measure is provision of fiscal and human resources for 

maintaining infection control and occupational health programs that are 

responsive to emerging needs. Specific components include bedside 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 institutional 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 improve administrators’ awareness of the 

rationale and resource requirements for 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 the organization’s patient safety goals 543, 544, 

546, 565. 

41
 
II.A.1.a.Scope of work and staffing needs for infection control professionals 

The effectiveness of infection surveillance and control programs in preventing 

nosocomial infections in United States hospitals was assessed by the CDC 

through the Study on the Efficacy of Nosocomial Infection Control (SENIC 

Project) conducted 1970-76 566. In a representative sample of US general 

hospitals, those with a trained infection control physician or microbiologist 

involved in an infection control program, and at least one infection control nurse 

per 250 beds, were associated with a 32% lower rate of four infections studied 

(CVC-associated bloodstream infections, ventilator-associated pneumonias, 

catheter-related urinary tract infections, and surgical site infections). 

Since that landmark study was published, responsibilities of ICPs have expanded 

commensurate with the growing complexity of the healthcare system, the patient 

populations served, and the increasing numbers of medical procedures and 

devices used in all types of healthcare settings. The scope of work of ICPs was 

first assessed in 1982 567-569 by the Certification Board of Infection Control 

(CBIC), and has been re-assessed every five years since that time 558, 570-572. The 

findings of these task analyses have been used to develop and update the 

Infection Control Certification Examination, offered for the first time in 1983. With 

each survey, it is apparent that the role of the ICP is growing in complexity and 

scope, beyond traditional infection control activities in acute care hospitals. 

Activities currently assigned to ICPs in response to emerging challenges include: 

1) surveillance and infection prevention at facilities other than acute care 

hospitals e.g., ambulatory clinics, day surgery centers, long term care facilities, 

rehabilitation centers, home care; 2) oversight of employee health services 

related to infection prevention, e.g. assessment of risk and administration of 

recommended treatment following exposure to infectious agents, tuberculosis 

screening, influenza vaccination, respiratory protection fit testing, and 

administration of other vaccines as indicated, such as smallpox vaccine in 2003; 

3) preparedness planning for annual influenza outbreaks, pandemic influenza, 

SARS, bioweapons attacks; 4) adherence monitoring for selected infection 

control practices; 5) oversight of risk assessment and implementation of 

prevention measures associated with construction and renovation; 6) prevention 

of transmission of MDROs; 7) evaluation of new medical products that could be 

associated with increased infection risk. e.g.,intravenous infusion materials; 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 surveys did include information about hours 

worked; the 2001 survey included the number of ICPs assigned to the 

responding facilities 558 . There is agreement in the literature that 1 ICP per 250 

acute care beds is no longer adequate to meet current infection control needs; a 

Delphi project that assessed staffing needs of infection control programs in the 

21st century concluded that a ratio of 0.8 to 1.0 ICP per 100 occupied acute care 

beds is an appropriate level of staffing 552. A survey of participants in the National 

42
 
Nosocomial Infections Surveillance (NNIS) system found the average daily 

census per ICP was 115 316. Results of other studies have been similar: 3 per 

500 beds for large acute care hospitals, 1 per 150-250 beds in long term care 

facilities, and 1.56 per 250 in small rural hospitals 573, 575. The foregoing 

demonstrates that infection control staffing can no longer be based on patient 

census alone, but rather must be determined by the scope of the program, 

characteristics of the patient population, complexity of the healthcare system, 

tools available to assist personnel to perform essential tasks (e.g., electronic 

tracking and laboratory support for surveillance), 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 infection 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 infection control nurse liaison increases the 

awareness of infection control at the unit level. He or she is especially effective in 

implementation of new policies or control 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 should not be counted when considering ICP 

staffing. 

II.A.1.b. Bedside nurse staffing There is increasing evidence 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 that 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 consistent 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 HAIs 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 “float” vs. regular staff nurses) influenced the rate of 

primary bloodstream infections, with an increased infection rate occurring when 

the proportion of regular nurses decreased and pool nurses increased. 

II.A.1.c. Clinical microbiology laboratory support The critical role of the 

clinical microbiology laboratory in infection control and healthcare epidemiology 

is described well 553, 554, 598-600 and is supported by the Infectious Disease Society 

43
 
of America policy statement on consolidation of clinical microbiology laboratories 

published in 2001 553. The clinical microbiology laboratory contributes to 

preventing transmission of infectious diseases in healthcare settings by promptly 

detecting and reporting epidemiologically important organisms, identifying 

emerging patterns of antimicrobial resistance, and assisting in assessment of the 

effectiveness of recommended precautions to limit transmission during outbreaks 

598. Outbreaks of infections may be recognized first by laboratorians 162. 

Healthcare organizations need to ensure the availability of the recommended 

scope and quality of laboratory services, a sufficient number of appropriately 

trained laboratory staff members, and systems to promptly communicate 

epidemiologically important results to those who will take action (e.g., providers 

of clinical care, infection control staff, healthcare epidemiologists, and infectious 

disease consultants) 601. As concerns about emerging pathogens and 

bioterrorism grow, the role of the clinical microbiology laboratory takes on even 

greater importance. For healthcare organizations that outsource microbiology 

laboratory services (e.g., ambulatory care, home care, LTCFs, smaller acute care 

hospitals), it is important to specify by contract the types of services (e.g., 

periodic institution-specific aggregate susceptibility reports) required to support 

infection control. 

Several key functions of the clinical microbiology laboratory are relevant to this 

guideline: 

•	 Antimicrobial susceptibility by testing and interpretation in accordance with 

current guidelines developed by the National Committee for Clinical 

Laboratory Standards (NCCLS), known as the Clinical and Laboratory 

Standards Institute (CLSI) since 2005 602, for the detection of emerging 

resistance patterns 603, 604, and for the preparation, analysis, and 

distribution of periodic cumulative antimicrobial susceptibility summary 

reports 605-607. While not required, clinical laboratories ideally should have 

access to rapid genotypic identification 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 discontinuing active surveillance programs 

and optimize the use of laboratory resources. 

•	 Molecular typing, on-site or outsourced, in order to investigate and control 

healthcare-associated outbreaks 609. 

•	 Application of rapid diagnostic tests to support clinical decisions involving 

patient treatment, room selection, and implementation of control measures 

including barrier precautions and use of vaccine or chemoprophylaxis 

agents (e.g., 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 

44
 
management decisions, as well as providing oversight of point-of-care 

testing performed by non-laboratory healthcare workers 617. 

•	 Detection and rapid reporting of epidemiologically important organisms, 

including those that are reportable to public health agencies. 

•	 Implementation of a quality control program that ensures testing services 

are appropriate for the population served, and stringently evaluated for 

sensitivity, specificity, applicability, and feasibility. 

•	 Participation in a multidisciplinary team to develop and maintain an 

effective institutional program for the judicious use of antimicrobial agents 

618, 619. 

II.A.2. Institutional safety culture and organizational characteristics Safety 

culture (or safety climate) refers to a work environment where a shared 

commitment to safety on the part of management and the workforce is 

understood and followed 557, 620, 621. The authors of the Institute of Medicine 

Report, To Err is Human 543, acknowledge that causes of medical error are 

multifaceted but emphasize repeatedly 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 worker safety; 2) worker participation 

in safety planning; 3) the availability of appropriate protective equipment; 4) 

influence of group norms regarding acceptable safety practices; and 5) the 

organization’s socialization process for new personnel. Safety and patient 

outcomes can be enhanced by improving 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 linked 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 control practices decreases transmission 

of infectious agents in healthcare settings 116, 562, 636-640. However, several 

observational studies have shown limited 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 

45
 
resuscitation, 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 healthcare personnel, selfreported adherence was generally higher than that reported in observational 

studies. Furthermore, where an observational component was included with a 

self-reported survey, self-perceived adherence was often greater than observed 

adherence 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 videotaping 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., communication 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 control practices requires a multifaceted 

approach that incorporates continuous assessment of both the individual 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 precautions) 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 concluded 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 guidelines for protection against SARS and 

other respiratory pathogens 257. 

II.B. Surveillance for healthcare-associated infections (HAIs) 

Surveillance is an essential tool for case-finding of single patients or clusters of 

patients who are infected or colonized with epidemiologically important 

organisms (e.g., susceptible bacteria such as S. aureus, S. pyogenes [Group A 

streptococcus] or Enterobacter-Klebsiella spp; MRSA, VRE, and other MDROs; 

C. difficile; RSV; influenza virus) for which transmission-based precautions may 

46
 
be required. Surveillance is defined as the ongoing, systematic collection, 

analysis, interpretation, and dissemination 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 the 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 evaluating the effectiveness of infection 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 infection 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 using 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 investigation 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 highest risk areas or patients has been 

preferred over facility-wide surveillance for the most effective use of resources 

673, 676. However, surveillance for certain epidemiologically important organisms 

may need to be facility-wide. Surveillance methods will continue to evolve as 

healthcare delivery systems 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 healthcare epidemiology and infection control 

should be involved in selecting software packages for data aggregation and 

analysis to assure that the need for efficient and accurate HAI surveillance will be 

met. Effective surveillance is increasingly important as legislation requiring 

public reporting of HAI rates is passed and states work to develop effective 

systems to support such legislation 680. 

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

Education and training of healthcare personnel are a prerequisite for ensuring 

that policies and procedures for Standard and Transmission-Based Precautions 

are understood and practiced. Understanding the scientific rationale for the 

47
 
precautions will allow HCWs to apply procedures correctly, as well as safely 

modify precautions based on changing requirements, 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 infection control procedures 689. Education about the important 

role of vaccines (e.g., influenza, measles, varicella, pertussis, pneumococcal) in 

protecting healthcare personnel, their patients, and family members can help 

improve vaccination rates 690-693. 

Education on the principles and practices for preventing transmission of 

infectious agents should begin during training 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 staff; therapists and technicians, including 

respiratory, physical, occupational, radiology, and cardiology personnel; 

phlebotomists; housekeeping and maintenance staff; and students). In 

healthcare facilities, education and training on Standard and Transmission-Based 

Precautions are typically provided at the time of orientation and should be 

repeated as necessary to maintain competency; updated education and training 

are necessary when policies and procedures are revised or when there is a 

special circumstance, such as an outbreak that requires modification of current 

practice or adoption of new recommendations. Education and training materials 

and methods appropriate to the HCW’s level of responsibility, individual learning 

habits, and language needs, can improve the learning experience 658, 694-702. 

Education programs for healthcare personnel have been associated with 

sustained improvement in adherence to best practices and a related decrease in 

device-associated HAIs in teaching and non-teaching settings 639, 703 and in 

medical and surgical ICUs {Coopersmith, 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 HCWs 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, Respiratory Hygiene/Cough Etiquette, 

vaccination (especially against influenza) and other routine infection prevention 

strategies may be incorporated into patient information materials that are 

provided upon admission to the healthcare facility. Additional information about 

Transmission-Based Precautions is best provided at the time they are initiated. 

Fact sheets, pamphlets, and other printed material may include information on 

the rationale for the additional precautions, risks to household members, room 

assignment for Transmission-Based Precautions purposes, explanation about 

the use of personal protective equipment by HCWs, and directions for use of 

48
 
such equipment by family members and visitors. Such information may be 

particularly helpful in the home environment where household members often 

have primary responsibility for adherence 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 (gels, 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 preferred over antimicrobial or plain 

soap and water because of their superior microbiocidal 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 are 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 artifical nails have been shown to 

harbor more pathogenic organisms, especially gram negative bacilli and yeasts, 

on the nails and in the subungual area than those with native 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 with 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 direct patient care or by healthcare 

personnel who have contact with other high risk groups (e.g., oncology, cystic 

fibrosis patients), has not been studied, but has been recommended by some 

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 contamination 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 respirators 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 

49
 
interaction 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 contamination 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 direct contact with blood or body fluids, 

mucous membranes, nonintact skin and other potentially infectious material; 2) 

having direct contact with patients who are colonized or infected with pathogens 

transmitted by the contact route e.g., VRE, MRSA, 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 personnel from transmission of 

bloodborne pathogens (e.g., HIV, HBV, HCV) following a needlestick or other 

pucture that penetrates the glove barrier has not been determined. Although 

gloves may reduce the volume of blood on the external surface of a sharp by 46-

86% 729, the residual blood in the lumen of a hollowbore needle would not be 

affected; therefore, the effect on transmission risk is unknown. 

Gloves manufactured for healthcare purposes are subject to FDA evaluation and 

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 performed, anticipated contact with chemicals and 

chemotherapeutic agents, latex sensitivity, sizing, and facility 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 manufacturing 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 gloves 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 are directly needed for patient care. It may 

be necessary to change gloves during the care of a single patient to prevent 

50
 

739 
cross-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 transported 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 ensured. 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 are preferred for use with an isolation 

gown because they will cover the gown cuff and provide a more reliable 

continuous barrier for the arms, wrists, and hands. Gloves that are removed 

properly will prevent hand contamination (Figure). Hand hygiene following glove 

removal further ensures that the hands will not carry potentially infectious 

material that might have penetrated through unrecognized tears or that could 

contaminate the hands during glove removal 559, 728, 741. 

II.E.2. Isolation gowns Isolation gowns are used as specified by Standard and 

Transmission-Based Precautions, to protect the HCW’s arms and exposed body 

areas and prevent contamination of clothing with blood, body fluids, and other 

potentially infectious material 24, 88, 262, 744-746. The need for and type of isolation 

gown selected is based on the nature of the patient interaction, including the 

anticipated degree of contact with infectious material and potential for blood and 

body fluid penetration of the barrier. The wearing of isolation gowns and other 

protective apparel is mandated by the OSHA Bloodborne Pathogens Standard 

739. Clinical and laboratory coats or jackets worn over personal clothing for 

comfort and/or purposes of identity are not considered PPE. 

When applying Standard Precautions, an isolation gown is worn only if contact 

with blood or body fluid is anticipated. However, when Contact Precautions are 

used (i.e., to prevent transmission of an infectious agent that is not interrupted by 

Standard Precautions alone and that is associated with environmental 

contamination), donning of both gown and gloves upon room entry is indicated to 

address unintentional contact with contaminated environmental surfaces 54, 72, 73, 

88. The routine donning of isolation gowns upon entry into an intensive care unit 

or other high-risk area does not prevent or influence potential colonization or 

infection of patients in those areas365, 747-750. 

Isolation gowns are always worn in combination with gloves, and with other PPE 

when indicated. Gowns are usually the first piece of PPE to be donned. Full 

coverage of the arms and body front, from neck to the mid-thigh or below will 

ensure that clothing and exposed upper body areas are protected. Several gown 

sizes should be available in a healthcare facility to ensure appropriate coverage 

for staff members. Isolation gowns should be removed before leaving the patient 

care area to prevent possible contamination of the environment outside the 

patient’s room. Isolation gowns should be removed in a manner that prevents 

contamination of clothing or skin (Figure). The outer, “contaminated”, side of the 

51
 
gown is turned inward and rolled into a bundle, and then discarded into a 

designated container for waste or linen to contain contamination. 

II.E.3. 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 Precautions and Droplet Precautions; 2) 

placed on healthcare personnel when engaged in procedures requiring sterile 

technique to protect patients from exposure to infectious agents carried in a 

healthcare worker’s mouth or nose, and 3) placed on coughing patients to limit 

potential dissemination of infectious respiratory secretions from the patient to 

others (i.e., Respiratory Hygiene/Cough Etiquette). Masks may be used in 

combination with goggles to protect the mouth, nose and eyes, or a face shield 

may be used instead of a mask and goggles, to provide more complete 

protection for the face, as discussed below. Masks should not be confused 

with particulate respirators that are used to prevent inhalation of small 

particles that may contain infectious agents transmitted via the airborne 

route as described below. 

The mucous membranes of the mouth, nose, and eyes are susceptible portals of 

entry for infectious agents, as can be other skin surfaces if skin integrity is 

compromised (e.g., by acne, dermatitis) 66, 751-754. Therefore, use of PPE to 

protect these body sites is an important component of Standard Precautions. The 

protective effect of masks for exposed healthcare personnel has been 

demonstrated 93, 113, 755, 756. Procedures that generate splashes or sprays of 

blood, body fluids, secretions, or excretions (e.g., endotracheal suctioning, 

bronchoscopy, invasive vascular procedures) require either a face shield 

(disposable or reusable) or mask and 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 likely 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. Since procedure/isolation masks are not regulated by 

the FDA, there may be more variability in quality and performance than with 

surgical masks. Masks come in various shapes (e.g., molded and non-molded), 

sizes, filtration efficiency, and method of attachment (e.g., ties, elastic, ear 

loops). Healthcare facilities may find that different types of masks are needed to 

meet individual healthcare personnel needs. 

II.E.3.b. Goggles, face shields Guidance on eye protection for infection control 

has been published 759. The eye protection chosen for specific work situations 

(e.g., goggles or face shield) depends upon the circumstances of exposure, other 

52
 
PPE 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 comfortable, allow for sufficient peripheral vision, and must be 

adjustable to ensure a secure fit. It may be necessary to provide several 

different types, styles, and sizes of protective equipment. Indirectly-vented 

goggles with a manufacturer’s anti-fog coating may provide the most reliable 

practical eye protection from splashes, sprays, and respiratory droplets from 

multiple angles. Newer styles of goggles may provide better indirect airflow 

properties to reduce fogging, as well as better peripheral vision and more size 

options for fitting goggles to different workers. Many styles of goggles fit 

adequately over prescription glasses with minimal gaps. While effective as eye 

protection, goggles do not provide splash or spray protection to other parts of the 

face. 

The role of goggles, in addition to a mask, in preventing exposure to infectious 

agents transmitted via respiratory droplets has been studied only for RSV. 

Reports published in the mid-1980s demonstrated 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 transmission is effectively 

prevented by adherence to Standard plus Contact 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 goggles, or face shield alone, is necessary 

when it is likely that there will be a splash or spray of any respiratory secretions 

or other body fluids as defined 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 protection from splashes and sprays; face 

shields that wrap around the sides may reduce 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 equipment to the head are considered 

“clean” and therefore safe to touch with bare hands. The front of a mask, goggles 

and face shield are considered contaminated (Figure). 

II.E.4. Respiratory protection The subject of respiratory protection as it applies 

to preventing transmission of airborne infectious agents, including the need for 

and frequency of fit-testing is under scientific review and was the subject of a 

CDC workshop in 2004 763. Respiratory protection currently 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 

53
 
in 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 implement a program to protect employees 

from inhalation of toxic materials. OSHA program components include medical 

clearance to wear a respirator; provision 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 particulate respirators, models 

with inherently good fit characteristics (i.e., those expected to provide protection 

factors of 10 or more to 95% of wearers) are preferred and could theoretically 

relieve the need for fit testing 765, 766. Issues pertaining to respiratory protection 

remain the subject of ongoing debate. Information on various types of respirators 

may be found at www.cdc.gov/niosh/npptl/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-testing 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 recommended 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 from respirator use, in 

addition to administrative and engineering controls (i.e., AIIRs, early recognition 

of patients likely to have tuberculosis 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 airborne route, including SARS 262 and smallpox 108, 129, 

772, until inhalational transmission is better defined or healthcare-specific 

protective equipment more suitable for for preventing infection are developed. 

Respirators are also currently recommended to be worn during the performance 

of aerosol-generating procedures (e.g., intubation, bronchoscopy, suctioning) on 

patients withSARS Co-V infection, avian influenza and pandemic influenza (See 

Appendix A). 

Although Airborne Precautions are recommended for preventing airborne 

transmission of measles and varicella-zoster viruses, there are no data upon 

54
 
which to base a recommendation for respiratory protection to protect susceptible 

personnel against these two infections; transmission of varicella-zoster virus has 

been prevented among pediatric patients using 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 acquired immunity to these viruses, only 

immune personnel generally care for 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 removal of respirators are provided (Figure). In some 

healthcare settings, particulate respirators used to provide care for patients with 

M. tuberculosis are reused by the same HCW. This is an acceptable practice 

providing the respirator is not damaged or soiled, the fit is not compromised by 

change in shape, and the respirator has not been contaminated with blood or 

body fluids. There are no data on which to base a recommendation for the length 

of time a respirator may be reused. 

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 injury 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 the prevention of sharps injuries and 

other blood exposures during surgical and other invasive procedures that are 

addressed elsewhere 781-785. 

Since 1991, when OSHA first issued its Bloodborne Pathogens Standard to 

protect healthcare personnel from blood exposure, the focus of regulatory and 

legislative activity has been on implementing a hierarchy of control 

measures. This has included focusing attention on removing sharps hazards 

through the development and use of engineering controls. The federal 

Needlestick Safety and Prevention Act signed into law in November, 2000 

authorized OSHA's revision of its Bloodborne Pathogens Standard to more 

explicitly require the use of safety-engineered sharp devices 786. CDC has 

provided guidance on sharps injury prevention 787, 788, including for the design, 

implementation and evaluation of a comprehensive sharps injury prevention 

789 program . 

55
 
II.F.2. Prevention of mucous membrane contact Exposure of mucous 

membranes of the eyes, nose and mouth to blood and body fluids has been 

associated with the transmission 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 membranes and non-intact skin from contact 

with potentially infectious material. These include keeping gloved and ungloved 

hands that are contaminated from touching the mouth, nose, eyes, or face; and 

positioning patients to direct sprays and splatter away from the face of the 

caregiver. Careful placement of PPE before patient contact will help avoid the 

need to make PPE adjustments and possible face or mucous membrane 

contamination during use. 

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 resuscitation, preventing exposure of the 

caregiver’s nose and mouth to oral and respiratory fluids during the procedure. 

II.F.2.a. Precautions during aerosol-generating procedures The performance 

of procedures that can generate small particle aerosols (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 recommended during performance of these 

procedures in accordance with Standard Precautions. 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 rooms, two patient rooms, and multi-bed wards. Of these, 

single patient rooms are prefered when there is a concern 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 American Institute of Architects and the 

Facility Guidelines Institute, have documented a beneficial relationship between 

private rooms and reduction in infectious and noninfectious adverse patient 

outcomes 792, 793. The AIA notes that private rooms are the trend in hospital 

planning and design. However, most hospitals and long-term care facilities have 

multi-bed rooms and must consider many competing priorities when determining 

the appropriate room placement for patients (e.g., reason for admission; patient 

characteristics, such as age, gender, mental status; staffing needs; family 

56
 
requests; psychosocial factors; reimbursement concerns). In the absence of 

obvious infectious diseases that require specified airborne infection isolation 

rooms (e.g., tuberculosis, SARS, chickenpox), the risk of transmission of 

infectious agents is not always considered when making placement decisions. 

When there are only a limited number of single-patient rooms, it is prudent to 

prioritize them for those patients who have conditions that facilitate transmission 

of infectious material to other patients (e.g., draining wounds, stool incontinence, 

uncontained secretions) and for those who are at increased risk of acquisition 

and adverse outcomes resulting from HAI (e.g., immunosuppression, open 

wounds, indwelling catheters, anticipated prolonged length of stay, total 

dependence on HCWs for activities of daily living) 15, 24, 43, 430, 794, 795. 

Single-patient rooms are always indicated for patients placed on Airborne 

Precautions and in a Protective Environment and are preferred for patients who 

require Contact or Droplet 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 patient rooms with private bathrooms limits opportunities for 

transmission, especially when the colonized or infected patient has poor personal 

hygiene habits, fecal incontinence, or cannot be expected to assist in maintaining 

procedures that prevent transmission of microorganisms (e.g., infants, children, 

and patients with altered mental status or developmental delay). In the absence 

of continued transmission, it is not necessary to provide a private bathroom for 

patients colonized or infected with enteric pathogens as long as personal hygiene 

practices and Standard Precautions, especially hand hygiene and appropriate 

environmental cleaning, are maintained. Assignment of a dedicated commode to 

a patient,and cleaning and disinfecting fixtures and equipment that may have 

fecal contamination (e.g., bathrooms, commodes 798, scales used for weighing 

diapers) and the adjacent surfaces with appropriate agents may be especially 

important when a single-patient room can not be used since environmental 

contamination with intestinal tract pathogens is likely from both continent and 

incontinent 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, the risk of healthcare-associated 

diarrhea is increased with the increased 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 together patients who are colonized or 

infected with the same organism to confine their care to one area and prevent 

contact with other patients. Cohorts are created based on clinical diagnosis, 

microbiologic confirmation when available, epidemiology, and mode of 

transmission of the infectious agent. It is generally preferred not to place severely 

immunosuppressed patients in rooms with other patients. Cohorting has been 

used extensively for managing outbreaks of MDROs including MRSA 22, 807, VRE

638, 808, 809, MDR-ESBLs 810; Pseudomonas aeruginosa 29; methicillin-susceptible 

57
 
Staphylococcus 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 healthcare personnel to care only for patients infected or 

colonized with a single target pathogen limits 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 presenting clinical syndrome is often a 

priority in facilities that care for infants and young children 825. For example, 

during the respiratory virus season, infants may be cohorted based soley on the 

clinical diagnosis of bronchiolitis due to the logistical difficulties and costs 

associated with requiring microbiologic confirmation prior to room placement, and 

the predominance of RSV during most of the season. However, when available, 

single patient rooms are always preferred since a common 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 during 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 seen frequently in ambulatory settings (e.g., 

outpatient clinics, physicians’ offices, emergency departments) and potentially 

expose healthcare personnel and other patients, family members and visitors 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 mask or cover their coughs with tissues) to 

prevent transmission of respiratory 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 individuals accompanying the patient promptly 

inform the receptionist if there are symptoms of a respiratory 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, pertussis, chickenpox, tuberculosis) also 

could be added. Placement of potentially infectious patients without delay in an 

examination room limits the number of exposed individuals, e.g., in the common 

waiting area. 

58
 
In 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 infection can wear a surgical mask for 

source containment, if tolerated, and should 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, application of the same infection control 

precautions may need to be extended to these 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 conditions 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 receptionist of their infection risk upon arrival, 

appropriate steps may be taken to further protect them from infection. In some 

cystic fibrosis clinics, in order to avoid exposure to other patients who could be 

colonized with B. cepacia, patients have been given beepers upon registration so 

that they may leave the area and receive notification to return when an 

examination room becomes available 832. 

II.G.3. Home care In home care, the patient placement concerns focus on 

protecting others in the home from exposure to an infectious household member. 

For individuals who are especially vulnerable to adverse outcomes associated 

with certain infections, it may be beneficial to either remove them from the home 

or segregate them within the home. Persons who are not part of the household 

may need to be prohibited from visiting during the period of infectivity. For 

example, if a patient with pulmonary tuberculosis is contagious and being cared 

for at home, very young children (<4 years of age) 833 and immunocompromised 

persons who have not yet been infected should be removed or excluded from the 

household. During the SARS outbreak of 2003, segregation of infected persons 

during the communicable phase of the illness was beneficial in preventing 

household transmission 249, 834. 

II.H. Transport of patients 

Several 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 essential 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 impervious 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 

59
 
area of the impending arrival of the patient and of the precautions necessary to 

prevent transmission; and 4) for patients being transported outside the facility, 

informing the receiving facility and the medi-van or emergency vehicle personnel 

in advance about the type of Transmission-Based Precautions being used. For 

tuberculosis, additional precautions 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, these procedures do not need to be changed 

for patients on Transmission-Based Precautions. The cleaning and disinfection of 

all patient-care areas is important for frequently touched surfaces, especially 

those closest to the patient, that are most likely to be contaminated (e.g., 

bedrails, bedside tables, commodes, doorknobs, 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 with 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 disinfecting 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 transmission. 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 disinfectants or detergents/disinfectants 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 recommendations 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 classes 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 disinfection rather than the specific 

cleaning and disinfectant agents used838-841 . 

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 transmission 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 vegetative cells to commonly used surface disinfectants, 

60
 
some investigators have recommended the use of a 1:10 dilution of 5.25% 

sodium hypochlorite (household bleach) and water for routine environmental 

disinfection of rooms of patients with C. difficile when there is continued 

transmission 844, 848. In one study, the use of a hypochlorite solution was 

associated with a decrease in rates of C. difficile infections 847. The need to 

change disinfectants based on the presence of these organisms can be 

determined in consultation with the infection control committee 11, 847, 848. 

Detailed recommendations for disinfection and sterilization of surfaces and 

medical equipment that have been in contact with prion-containing tissue or high 

risk body fluids, and for cleaning of blood and body substance spills, are 

available in the Guidelines for Environmental 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 instruments/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 disinfection and sterilization of critical 

and semi-critical instruments and devices because residual proteinacous material 

reduces the effectiveness of the disinfection 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 handled in a manner that will prevent 

HCW and environmental contact with potentially infectious material. It is 

important to include computers and personal digital assistants (PDAs) used in 

patient care in policies for cleaning and disinfection of non-critical items. The 

literature on contamination of computers with pathogens has been 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 medical 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 reprocessing 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 the home. Equipment can be cleaned on-site 

using a detergent/disinfectant and, when possible, should be placed in a single 

plastic bag for transport to the reprocessing 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 

61
 
transmission 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 aerosols 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 storage and processing of clean textiles 

is recommended 11, 857. When laundering occurs outside of a healthcare facility, 

the clean items must be packaged or completely covered and placed in an 

enclosed space during transport to prevent contamination with outside air or 

construction dust that could contain infectious fungal spores that are a risk for 

immunocompromised 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 with 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 waste emanating from the healthcare environment is 

subject to federal and state regulations for medical and non-medical waste 860, 

861. No additional precautions are needed for 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 detergents used in dishwashers is sufficient to 

decontaminate dishware and eating utensils. Therefore, no special precautions 

are needed for dishware (e.g., dishes, glasses, cups) or eating utensils; reusable 

dishware and utensils may be used for patients requiring Transmission-Based 

Precautions. In the home and other communal settings, eating utensils and 

drinking vessels that are being used should 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, disposable products may be used. 

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II.N. Adjunctive measures 

Important adjunctive measures that are not considered primary 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 antiviral or antibacterial agents; 3) 

vaccines used both for pre and postexposure prevention; and 4) screening and 

restricting visitors with signs of transmissible 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 (Management of MultidrugResistant Organisms in Healthcare Settings 2006. 

www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf). 

II.N.1. Chemoprophylaxis Antimicrobial agents and topical antiseptics may be 

used to prevent infection and potential outbreaks 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 material865, influenza virus611 , HIV 866, 

and group A streptococcus 160. Orally administered antimicrobials may also be 

used under defined circumstances for MRSA 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 the umbilical cords of term newborns to 

reduce the risk of colonization, skin infections, and omphalitis caused by S. 

aureus, including MRSA, and group A streptococcus 868, 869. Extension of the use 

of triple dye to low birth weight infants in the NICU was one component of a 

program that controlled one longstanding MRSA outbreak 22. Topical antiseptics 

are also used for decolonization of healthcare personnel or selected patients 

colonized with MRSA, using mupirocin as discussed in the MDRO guideline870 

867, 871-873. 

II.N.2. Immunoprophylaxis Certain immunizations recommended for 

susceptible healthcare personnel have decreased 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 incidence 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-associated transmission of rubella in 

obstetrical clinics 33, 876 and measles in acute care settings 34 demonstrate the 

importance of immunization of susceptible healthcare personnel against 

childhood diseases. Many states have requirements for HCW vaccination for 

measles and rubella in the absence of evidence of immunity. Annual influenza 

vaccine campaigns targeted to patients and healthcare personnel in LTCFs and 

acute-care settings have been instrumental in preventing or limiting institutional 

63
 
outbreaks 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 include 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 United 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 help 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 postexposure 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 virus [HBIG], rabies [RIG], measles and hepatitis A virus 

[IG] 17, 833, 874). The RSV monoclonal antibody preparation, Palivizumab, may 

have contributed to controlling a nosocomial outbreak of RSV in one NICU , but 

there is insufficient evidence to support a routine recommendation for its use in 

this 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 sibling. Screening of visiting siblings and 

other children before they are allowed into clinical areas is necessary to prevent 

the introduction of childhood illnesses and common respiratory infections. 

64
 
Screening may be passive through the use of signs to alert family members and 

visitors with signs and symptoms of communicable diseases not to enter clinical 

areas. More active screening may include the completion of a screening tool or 

questionnaire which elicits information related to recent exposures or current 

symptoms. That information is reviewed by the facility staff and the visitor is 

either permitted to visit or is excluded 833. 

Family and household members visiting pediatric patients with pertussis and 

tuberculosis may need to be screened for a history of exposure as well as signs 

and symptoms of current infection. Potentially infectious visitors are excluded 

until they receive appropriate medical screening, diagnosis, or treatment. If 

exclusion is not considered to be in the best interest of the patient or family (i.e., 

primary family members of critically or terminally ill patients), then the 

symptomatic visitor must wear a mask while in the healthcare facility and remain 

in the patient’s room, avoiding exposure to others, especially in public waiting 

areas and the cafeteria. 

Visitor screening is used consistently on HSCT units 15, 43. However, considering 

the experience during the 2003 SARS outbreaks and the potential for pandemic 

influenza, developing effective visitor screening systems will be beneficial 9. 

Education concerning Respiratory Hygiene/Cough Etiquette is a useful adjunct to 

visitor screening. 

II.N.3.b. Use of barrier precautions by visitors The use of gowns, gloves, or 

masks by visitors in healthcare settings has not been addressed specifically in 

the scientific literature. Some studies included the use of gowns and gloves by 

visitors in the control of MDRO’s, but did not perform a separate analysis to 

determine whether their use by visitors had a measurable impact 893-895. Family 

members or visitors who are providing care or having very close patient contact 

(e.g., feeding, holding) may have contact with other patients and could contribute 

to transmission if barrier precautions are not used correctly. Specific 

recommendations may vary by facility or by unit and should be determined by the 

level of interaction. 

65
 
Part III: 

Precautions to Prevent Transmission of Infectious Agents

There are two tiers of HICPAC/CDC precautions to prevent transmission of 

infectious agents, Standard Precautions and Transmission-Based Precautions. 

Standard Precautions are intended to be applied to the care of all patients in all 

healthcare settings, regardless of the suspected or confirmed presence of an 

infectious agent. Implementation of Standard Precautions constitutes the 

primary strategy for the prevention of healthcare-associated transmission 

of infectious agents among patients and healthcare personnel. 

Transmission-Based Precautions are for patients who are known or suspected to 

be infected or colonized with infectious agents, including certain 

epidemiologically important pathogens, which require additional control 

measures to effectively prevent transmission. Since the infecting agent often is 

not known at the time of admission to a healthcare facility, Transmission-Based 

Precautions are used empirically, according to the clinical syndrome and the 

likely etiologic agents at the time, and then modified when the pathogen is 

identified or a transmissible infectious etiology is ruled out. Examples of this 

syndromic approach are presented in Table 2. The HICPAC/CDC Guidelines 

also include recommendations for creating 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 circumstances in which 

Standard Precautions, Transmission-Based 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 that all blood, body fluids, secretions, excretions 

except sweat, nonintact skin, and mucous membranes may contain transmissible 

infectious agents. Standard Precautions include a group of infection prevention 

practices that apply to all patients, regardless of suspected or confirmed infection 

status, in any setting in which healthcare is delivered (Table 4). These include: 

hand hygiene; use of gloves, gown, mask, eye protection, or face shield, 

depending on the anticipated exposure; and safe injection practices. Also, 

equipment or items in the patient environment likely to have been contaminated 

with infectious body fluids must be handled in a manner to prevent transmission 

of infectious agents (e.g. wear gloves for direct contact, contain heavily soiled 

equipment, properly clean and disinfect or sterilize reusable equipment before 

use on another patient). 

The application of Standard Precautions during patient care is determined by the 

nature of the HCW-patient interaction and the extent of anticipated blood, body 

fluid, or pathogen exposure. For some interactions (e.g., performing 

venipuncture), only gloves may be needed; during other interactions (e.g., 

intubation), use of gloves, gown, and face shield or mask and goggles is 

necessary. Education and training on the principles and rationale for 

66
 
recommended practices are critical elements 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 may 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 other PPE is presented in the Figure. 

Standard Precautions are also intended to protect patients by ensuring that 

healthcare personnel do not carry infectious agents to patients on their hands or 

via equipment used during patient care. 

III.A.1. New Elements of Standard Precautions Infection control problems 

that are identified in the course of outbreak investigations often indicate the need 

for new recommendations or reinforcement of existing infection control 

recommendations to protect patients. Because such recommendations are 

considered a standard of care and may not be included in other guidelines, they 

are added here to Standard Precautions. Three such areas of practice that have 

been added are: Respiratory Hygiene/Cough Etiquette, safe injection practices, 

and use of masks for insertion of catheters or injection of material into spinal or 

epidural spaces via lumbar puncture procedures (e.g., myelogram, spinal or 

epidural anesthesia). While most elements of Standard Precautions evolved from 

Universal Precautions that were developed for protection of healthcare 

personnel, these new elements of Standard Precautions focus on protection of 

patients. 

III.A.1.a. Respiratory Hygiene/Cough Etiquette The transmission of SARSCoV in emergency departments by patients and their family members during the 

widespread SARS outbreaks in 2003 highlighted 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 Respiratory Hygiene/Cough Etiquette 9, 828 

and is intended to be incorporated into infection control practices as a new 

component of Standard Precautions. The strategy is targeted at patients and 

accompanying family members and friends with undiagnosed transmissible 

respiratory infections, and applies to any person with signs of illness including 

cough, congestion, rhinorrhea, or increased production of respiratory 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/Cough Etiquette include 1) education of 

healthcare facility staff, patients, and visitors; 2) posted 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 when coughing and prompt disposal of 

used tissues, using surgical masks on the coughing person when tolerated and 

67
 
appropriate); 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 proven means of source containment 

that prevent infected persons from dispersing respiratory secretions into the air 

107, 145, 898, 899. Masking may be difficult in some settings, (e.g., pediatrics, in which 

case, the emphasis by necessity may be on cough etiquette 900. Physical 

proximity of <3 feet has been associated 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 practice of distancing infected 

persons from others who are not infected. The effectiveness of good hygiene 

practices, especially hand hygiene, in preventing transmission of viruses and 

reducing the incidence of respiratory infections both within and outside 901-903 

healthcare settings is summarized in several reviews 559, 717, 904. 

These measures should be effective in decreasing the risk of transmission of 

pathogens contained in large respiratory 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 often afebrile. Therefore, the absence of 

fever does not always exclude a respiratory infection. Patients who have asthma, 

allergic rhinitis, or chronic obstructive lung disease also may be coughing and 

sneezing. While these patients often are not infectious, cough etiquette 

measures are prudent. 

Healthcare personnel are advised to observe Droplet Precautions (i.e., wear a 

mask) and hand hygiene when examining and caring for patients with signs and 

symptoms of a respiratory infection. Healthcare personnel who have a respiratory 

infection are advised to avoid direct patient contact, especially with high risk 

patients. If this is not possible, then a mask should be worn while providing 

patient care. 

III.A.1.b. Safe Injection Practices The investigation of four large outbreaks of 

HBV and HCV among patients in ambulatory care facilities in the United States 

identified a need to define and reinforce safe injection practices 453. The four 

outbreaks occurred in a private medical practice, a pain clinic, an endoscopy 

clinic, and a hematology/oncology clinic. The primary breaches in infection 

control practice that contributed to these outbreaks were 1) reinsertion of used 

needles into a multiple-dose vial or solution container (e.g., saline bag) and 2) 

use of a single needle/syringe to administer intravenous medication to multiple 

patients. In one of these outbreaks, preparation of medications in the same 

workspace where used needle/syringes were dismantled also may have been a 

contributing factor. These and other outbreaks of viral hepatitis could have been 

prevented by adherence to basic principles of aseptic technique for the 

preparation and administration of parenteral medications 453, 454. These include 

the use of a sterile, single-use, disposable needle and syringe for each injection 

given and prevention of contamination of injection equipment and medication. 

68
 
Whenever 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 practices indicate that some healthcare 

personnel are unaware of, do not understand, or do not adhere to basic 

principles of infection control and aseptic technique. A survey of US healthcare 

workers who provide medication through injection found that 1% to 3% reused 

the same needle and/or syringe on multiple patients 905. Among the deficiencies 

identified in recent outbreaks were a lack of oversight of personnel and failure to 

follow-up on reported breaches in infection control practices in ambulatory 

settings. Therefore, to ensure that all healthcare workers understand and adhere 

to recommended practices, principles of infection control and aseptic technique 

need to be reinforced in training programs and incorporated into institutional 

polices that are monitored for 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 identified through a survey of the 

Emerging Infections Network of the Infectious 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 bacterial meningitis. Equipment and products 

used during these procedures (e.g., contrast media) were excluded as probable 

sources of contamination. Procedural details available for seven cases 

determined that antiseptic skin preparations and sterile gloves had been used. 

However, none of the clinicians wore a face mask, giving rise to the speculation 

that droplet transmission of oralpharyngeal flora was the most likely explanation 

for these infections. Bacterial meningitis 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 prevent droplet spread of oral flora during 

spinal procedures (e.g., myelogram, lumbar 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 Healthcare Infection Control 

Practices Advisory Committee (HICPAC) reviewed the evidence and concluded 

that there is sufficient experience to warrant the additional protection 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-Based Precautions are used when the 

route(s) of transmission is (are) not completely interrupted using Standard 

Precautions alone. For some diseases that have multiple routes of transmission 

(e.g., SARS), more than one Transmission-Based Precautions category may be 

used. When used either singly or in combination, they are always used in 

69
 
addition to Standard Precautions. See Appendix A for recommended precautions 

for specific infections. When Transmission-Based Precautions are indicated, 

efforts must be made to counteract possible adverse effects on patients (i.e., 

anxiety, depression and other 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, including epidemiologically important 

microorganisms, which are spread by direct or indirect contact with the patient or 

the patient’s environment as described 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 infected or colonized with 

MDROs is described in the 2006 HICPAC/CDC MDRO guideline 927 . Contact 

Precautions also apply where the presence of excessive wound drainage, fecal 

incontinence, or other discharges from the body suggest an increased potential 

for 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 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). In multi-patient rooms, >3 feet spatial separation between beds is 

advised to reduce the opportunities for inadvertent sharing of items between the 

infected/colonized patient and other patients. Healthcare personnel caring for 

patients on Contact Precautions wear a gown 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 contain pathogens, especially those that have 

been implicated in transmission through environmental 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 through close respiratory or mucous 

membrane contact with respiratory 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 ventilation 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 room 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 

70
 
the curtain between patient beds is especially important for patients in multi-bed 

rooms with infections transmitted by the droplet route. Healthcare personnel wear 

a mask (a respirator is not necessary) for close contact with infectious patient; 

the mask is generally donned upon room entry. Patients on Droplet Precautions 

who must be transported outside of the room should wear a mask if tolerated and 

follow Respiratory Hygiene/Cough Etiquette. 

III.B.3. Airborne Precautions Airborne Precautions prevent transmission of 

infectious agents that remain infectious over long distances when suspended in 

the air (e.g., rubeola virus [measles], 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 Airborne Precautions is in an airborne 

infection isolation room (AIIR). An AIIR is a single-patient room that is equipped 

with special air handling and ventilation capacity that meet the American Institute 

of Architects/Facility Guidelines Institute (AIA/FGI) standards for 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 directly to the outside or recirculated through 

HEPA filtration before return) 12, 13. Some states require the availability of such 

rooms in hospitals, emergency departments, and nursing homes that care for 

patients with M. tuberculosis. A respiratory protection program that includes 

education about use of respirators, fit-testing, and user seal checks is required in 

any facility with AIIRs. In settings where Airborne Precautions cannot be 

implemented due to limited engineering resources (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 higher level respirators or 

masks if respirators are not available for healthcare personnel will reduce the 

likelihood of airborne transmission until the patient is either transferred to a 

facility with an AIIR or returned to the home environment, as deemed medically 

appropriate. Healthcare personnel caring for patients on Airborne Precautions 

wear a mask or respirator, depending on the disease-specific recommendations 

(Respiratory Protection II.E.4, Table 2, and Appendix A), that is donned prior to 

room entry. Whenever possible, non-immune HCWs should not care for patients 

with vaccine-preventable airborne diseases (e.g., measles, chickenpox, and 

smallpox). 

III.C. Syndromic and empiric applications of Transmission-Based 

Precautions Diagnosis of many infections requires laboratory confirmation. 

Since laboratory tests, especially those that depend on culture techniques, often 

require two or more days for completion, Transmission-Based Precautions must 

be implemented while test results are pending based on the clinical presentation 

and likely pathogens. Use of appropriate Transmission-Based Precautions at the 

time a patient develops symptoms or signs of transmissible infection, or arrives at 

a healthcare facility for care, reduces transmission opportunities. While it is not 

possible to identify prospectively all patients needing Transmission-Based 

Precautions, certain clinical syndromes and conditions carry a sufficiently high 

71
 
risk to warrant their use empirically while confirmatory tests are pending (Table 

2). Infection control professionals are encouraged to modify or adapt this table 

according to local conditions. 

III.D. Discontinuation of Transmission-Based Precautions TransmissionBased Precautions remain in effect for limited periods of time (i.e., while the risk 

for transmission of the infectious agent persists or for the duration of the illness 

(Appendix A). For most infectious diseases, this duration reflects known patterns 

of persistence and shedding of infectious agents associated with the natural 

history of the infectious process and its treatment. For some diseases (e.g., 

pharyngeal or cutaneous diphtheria, RSV), 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 dictate the duration of precautions12). 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 Contact Precautions after three 

stool cultures obtained at weekly 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 courses of antimicrobial agents. 

It may be prudent to assume that MDRO carriers are colonized permanently and 

manage them accordingly. Alternatively, an interval free of hospitalizations, 

antimicrobial therapy, and invasive devices (e.g., 6 or 12 months) before 

reculturing patients to document clearance of carriage may be used. 

Determination of the best strategy awaits the results of additional studies. See 

the 2006 HICPAC/CDC MDRO guideline 927 for discussion of possible criteria to 

discontinue Contact Precautions for patients colonized or infected with MDROs. 

III.E. Application of Transmission-Based Precautions in ambulatory and 

home care settings Although Transmission-Based Precautions generally 

apply in all healthcare settings, exceptions exist. For example, in home care, 

AIIRs are not available. Furthermore, family members already exposed to 

diseases such as varicella and tuberculosis would not use masks or respiratory 

protection, but visiting HCWs would need to use such protection. Similarly, 

management of patients colonized or infected with MDROs may necessitate 

72
 
Contact Precautions in acute care hospitals and in some LTCFs when there is 

continued transmission, but the risk of transmission in ambulatory care and home 

care, has not been defined. Consistent use of Standard Precautions 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 fungal 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 Insitute 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) directed room air flow; 3) positive room air 

pressure relative to the corridor; 4) well-sealed rooms (including sealed walls, 

floors, ceilings, windows, electrical outlets) to prevent flow of air from the outside; 

5) ventilation to provide >12 air changes per hour; 6) strategies 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 malignancies and in potted plants in the 

vicinity of the patients 942-944. The desired quality of air may be achieved without 

incurring the inconvenience or expense of laminar airflow 15, 157. To prevent 

inhalation of fungal spores during periods when construction, renovation, or other 

dust-generating activities that may be ongoing in and around the health-care 

facility, it has been advised that severely immunocompromised patients wear a 

high-efficiency respiratory-protection device (e.g., an N95 respirator) when they 

leave the Protective 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 fungal infections in the absence of construction has 

not been evaluated. A Protective Environment does not include the use of barrier 

precautions beyond those indicated for Standard and Transmission-Based 

Precautions. No published reports support the benefit of placing solid organ 

transplants or other immunocompromised patients in a Protective Environment. 

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 scientific data, theoretical rationale, 

applicability, and when possible, economic impact. The CDC/HICPAC system for 

categorizing recommendations is as follows: 

Category IA Strongly recommended for implementation and strongly supported 

by well-designed experimental, clinical, or epidemiologic studies. 

Category IB Strongly recommended for implementation and supported by some 

experimental, clinical, or epidemiologic studies and a strong theoretical rationale. 

Category IC Required for implementation, as mandated by federal and/or state 

regulation or standard. 

Category II Suggested for implementation and supported by suggestive clinical 

or epidemiologic studies or a theoretical rationale. 

No recommendation; unresolved issue. Practices for which insufficient 

evidence or no consensus regarding efficacy exists. 

I. Administrative Responsibilities 

Healthcare organization administrators should ensure the implementation of 

recommendations in this section. 

I.A. Incorporate preventing transmission of infectious agents into the 

objectives of the organization’s patient and occupational safety programs 

543-546, 561, 620, 626, 946. Category IB/IC 

I.B. Make preventing transmission of infectious agents a priority for the 

healthcare organization. Provide administrative support, including fiscal 

and human resources for maintaining infection control 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 contract to all healthcare facilities 

so that the infection control program is managed 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 healthcare 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-associated infections (HAI) as one 

determinant of bedside nurse staffing levels and composition, 

74
 
especially 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 nurses) 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 personnel 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 risk 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 personnel in the selection and postimplementation evaluation of medical equipment and supplies and 

changes in practice that could 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. Identify resources for performing 

surveillance cultures, rapid diagnostic 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 resources to meet occupational health 

needs related to infection control (e.g., healthcare personnel 

immunization, post-exposure evaluation and care, evaluation and 

management of healthcare personnel with communicable 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 consistent observance of Standard 

Precautions, including hand hygiene products and personal 

protective equipment (e.g., gloves, gowns, face and eye protection) 

739 559 946 . Category IB/IC 

I.B.9. Develop and implement policies and procedures to ensure that 

reusable patient care equipment is cleaned and reprocessed 

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

960 961 . Category IA/IC 

75
 
I.C. Develop and implement processes to ensure oversight of infection control 

activities appropriate to the healthcare setting and assign responsibility for 

oversight of infection control activities to an individual or group within the 

healthcare organization that is knowledgeable about infection control 434, 

549, 566. Category II 

I.D. Develop and implement systems for early detection and management 

(e.g., use of appropriate infection control measures, including isolation 

precautions, PPE) of potentially infectious persons at initial points of 

patient encounter in outpatient settings (e.g., triage areas, emergency 

departments, outpatient clinics, physician offices) and at the time of 

admission to hospitals and long-term care facilities (LTCF) 9, 122, 134, 253, 827. 

Category IB 

I.E. Develop and implement policies and procedures to limit patient visitation 

by persons with signs or symptoms of a communicable infection. Screen 

visitors to high-risk patient care areas (e.g., oncology units, hematopoietic 

stem call transplant [HSCT] units, intensive care units, other severely 

immunocompromised patients) for possible infection 43 24, 41, 962, 

963.Category IB 

I.F. Identify performance indicators of the effectiveness of organizationspecific measures to prevent transmission of infectious agents (Standard 

and Transmission-Based Precautions), establish processes to monitor 

adherence to those performance measures and provide feedback to staff 

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 staff; property service (housekeeping), 

laundry, maintenance and dietary workers; students, contract staff and 

volunteers. Document competency initially and repeatedly, as appropriate, 

for the specific staff positions. Develop a system to ensure that healthcare 

personnel employed by outside agencies meet these education and 

training requirements through programs 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 training 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 online educational tools available to 

the institution 658, 694, 695, 697, 698, 700, 966. Category IB 

76
 
II.B. Provide instructional materials for patients and visitors on recommended 

hand hygiene and Respiratory Hygiene/Cough Etiquette practices and the 

application of Transmission-Based Precautions 9, 709, 710, 963. Category II 

III.Surveillance 

III.A. Monitor the incidence of epidemiologically-important organisms and 

targeted HAIs that have substantial impact on outcome and for which 

effective preventive interventions are available; use information collected 

through surveillance of high-risk populations, procedures, devices and 

highly transmissible infectious agents to detect transmission of infectious 

agents in the healthcare facility 566, 671, 672, 675, 687, 919, 967, 968 673 969 970. 

Category IA 

III.B. Apply the following epidemiologic 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 variables (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 predispose to serious adverse outcomes) 

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

transmission 

y	 Feedback information on trends in the incidence and prevalence of 

HAIs, probable risk factors, and prevention strategies and their impact 

to the appropriate healthcare providers, organization administrators, 

and as required by local and state health authorities 

III.C. Develop and implement strategies to reduce risks for transmission and 

evaluate effectiveness 566, 673, 684, 970 963 971. Category IB 

III.D. When transmission of epidemiologically-important organisms continues 

despite implementation and documented adherence to infection 

prevention and control strategies, obtain consultation from persons 

knowledgeable in infection control and healthcare epidemiology to review 

the situation and recommend additional measures for control 566 247 687 . 

Category IB 

III.E. Review periodically information on community or regional trends in the 

incidence and prevalence of epidemiologically-important organisms (e.g., 

influenza, RSV, pertussis, invasive group A streptococcal disease, MRSA, 

VRE) (including in other healthcare facilities) that may impact transmission 

of organisms within the facility 398, 687, 972, 973 974. Category II 

IV. Standard Precautions 

Assume that every person is potentially infected or colonized with an 

organism that could be transmitted in the healthcare setting and apply the 

following infection control practices during the delivery of health care. 

IV.A. Hand Hygiene 

77
 
IV.A.1. During the delivery of healthcare, avoid unnecessary touching of 

surfaces in close proximity to the patient to prevent both 

contamination of clean hands from environmental surfaces and 

transmission of pathogens from contaminated hands to surfaces72, 

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 blood 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 washed with an antimicrobial soap and 

water. Frequent use of alcohol-based hand rub immediately 

following handwashing with nonantimicrobial 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-antimicrobial 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 wearing of non-natural 

nails by healthcare personnel who have direct contact with 

patients outside of the groups specified above 984. Category II 

IV.B. Personal protective equipment (PPE) (see Figure) 

IV.B.1. Observe the following principles of use: 

78
 
IV.B.1.a. Wear PPE, as described in IV.B.2-4,when the nature of the 

anticipated patient interaction indicates 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 infectious materials, mucous 

membranes, nonintact skin, or potentially contaminated intact 

skin (e.g., of a patient incontinent of stool or urine) could occur 

18, 728, 739, 741, 780, 985. Category IB/IC 

IV.B.2.b. Wear gloves with fit and durability appropriate to the task 559, 731, 

732, 739, 986, 987. Category IB 

IV.B.2.b.i. Wear disposable medical examination gloves for 

providing direct patient care. 

IV.B.2.b.ii. Wear disposable medical examination gloves or reusable 

utility gloves for cleaning the environment or medical 

equipment. 

IV.B.2.c. Remove gloves after contact with a patient and/or the 

surrounding environment (including medical equipment) using 

proper technique to prevent hand contamination (see Figure). 

Do not wear the same pair of gloves 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., perineal area) to a clean body-site 

(e.g., face). Category II 

IV.B.3. Gowns 

IV.B.3.a. Wear a gown, that is appropriate to the task, to protect skin and 

prevent soiling or contamination of clothing during procedures 

and patient-care activities when contact with blood, body fluids, 

secretions, or excretions 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 perform 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 

79
 
IV.B.4.a. Use PPE to protect the mucous membranes of the eyes, nose 

and mouth during procedures and patient-care activities that are 

likely to generate splashes or sprays of blood, body fluids, 

secretions and excretions. 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 tract [if not using in-line suction 

catheters], endotracheal intubation) in patients 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), wear 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, parainfluenza virus) in communities 14, 

24, 684 10, 262. Category IB 

IV.C.2. Implement the following measures to contain respiratory secretions 

in patients and accompanying individuals who have signs and 

symptoms of a respiratory infection, beginning at the point of initial 

encounter in a healthcare setting (e.g., triage, reception and waiting 

areas in emergency departments, outpatient 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 other persons with symptoms of a 

respiratory infection to cover their mouths/noses when coughing 

or sneezing, use and dispose of tissues, and perform hand 

hygiene after hands have been in contact with respiratory 

secretions. Category II 

IV.C.2.b. Provide tissues and no-touch receptacles (e.g.,foot-pedaloperated lid or open, plastic-lined waste basket) for disposal of 

tissues 20. Category II 

IV.C.2.c. Provide resources and instructions for performing hand hygiene 

in or near waiting areas in ambulatory and inpatient settings; 

provide conveniently-located dispensers of alcohol-based hand 

rubs and, where sinks are available, supplies for handwashing 

559, 903. Category IB 

IV.C.2.d. During periods of increased prevalence of respiratory infections 

in the community (e.g., as indicated by increased school 

absenteeism, increased number of patients seeking care for a 

80
 
respiratory infection), offer 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 transmission of infectious agents in patientplacement decisions. Place patients who pose a risk for 

transmission to others (e.g., uncontained 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 instruments/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), according to the level of anticipated 

contamination, when handling patient-care equipment and 

instruments/devices that is visibly soiled or may have been in 

contact with blood or body 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 indicated by the level of patient 

contact and degree of soiling 11. Category II 

IV.F.2. Clean and disinfect surfaces that 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 

81
 
surrounding toilets in patients’ rooms) on a more frequent schedule 

compared to that for other surfaces (e.g., horizontal surfaces in 

waiting rooms) 11 73, 740, 746, 993, 994 72, 800, 835 995. Category IB 

IV.F.3. Use EPA-registered disinfectants that have microbiocidal (i.e., 

killing) activity against the pathogens most likely to contaminate the 

patient-care environment. Use in accordance with manufacturer’s 

instructions 842-844, 956, 996. Category IB/IC 

IV.F.3.a. Review the efficacy of in-use disinfectants when evidence of 

continuing transmission of an infectious 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 health 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 furry toys if they will be shared 

y Clean and disinfect large stationary 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 designated 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 used 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 fabrics 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, ensure 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 the use of needles, cannulas that 

replace needles, and, where applicable intravenous delivery systems 454 

82
 
IV.H.1. Use aseptic technique to avoid 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, single-use items; they should not 

be reused for another patient nor to access a medication or solution 

that might be used for a subsequent patient 453, 919, 1004, 1005. 

Category IA 

IV.H.3. Use fluid infusion and administration sets (i.e., intravenous bags, 

tubing and connectors) for one patient only and dispose 

appropriately after use. Consider 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 parenteral 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 catheter 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 requirements 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 Precautions, use Transmission-Based 

Precautions for patients with documented or suspected infection or 

colonization with highly transmissible or epidemiologically-important 

pathogens for which additional precautions are needed to prevent 

transmission (see Appendix A) 24, 93, 126, 141, 306, 806, 1008. Category IA 

V.A.2. Extend duration of Transmission-Based Precautions, (e.g., Droplet, 

Contact) for immunosuppressed patients with viral infections due to 

83
 
prolonged 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 suspected infections or evidence of 

syndromes that represent an increased risk for contact 

transmission. For specific recommendations for use of Contact 

Precautions for colonization or infection 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-patient 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 decisions on patient placement: 

y Prioritize patients with conditions that may facilitate 

transmission (e.g., uncontained drainage, stool incontinence) 

for single-patient room placement. Category II 

y Place together in the same room (cohort) patients who are 

infected or colonized with 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 risk of adverse outcome 

from infection or that may facilitate transmission 

(e.g., those who are immunocompromised, have 

open wounds, or have anticipated prolonged 

lengths of stay). Category II 

o	 Ensure that patients are physically separated (i.e., 

>3 feet apart) from each other. Draw the privacy 

curtain between beds to minimize opportunities for 

direct contact.) Category II 

o	 Change protective attire and perform hand 

hygiene between contact with patients in the same 

room, regardless of whether 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 likelihood of transmission, and the 

84
 
potential 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 room 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 close 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 patient. Don gown upon entry into 

the room or cubicle. Remove gown and observe hand 

hygiene before leaving the patient-care environment 24, 88, 

134, 745, 837. Category IB 

V.B.3.b.ii. After gown removal, ensure that clothing and skin do not 

contact potentially contaminated environmental surfaces 

that could result in possible transfer of microorganism to 

other patients or environmental surfaces 72, 73. Category II 

V.B.4. Patient transport 

V.B.4.a. In acute care hospitals and long-term care and other residential 

settings, limit transport and movement of patients outside of the 

room to medically-necessary purposes. Category II 

V.B.4.b. When transport or movement in any healthcare setting is 

necessary, ensure that infected or colonized areas of the 

patient’s body are contained and covered. Category II 

V.B.4.c. Remove and dispose of contaminated PPE and perform hand 

hygiene prior to transporting patients on Contact Precautions. 

Category II 

V.B.4.d. Don clean PPE to handle the patient at the transport 

destination. Category II 

V.B.5. Patient-care equipment and instruments/devices 

V.B.5.a. Handle patient-care equipment and instruments/devices 

according to Standard Precautions 739, 836. Category IB/IC 

V.B.5.b. In acute care hospitals and long-term care and other residential 

settings, use disposable noncritical patient-care equipment 

(e.g., blood pressure cuffs) or implement patient-dedicated use 

of such equipment. If common use of equipment for multiple 

patients is unavoidable, clean and disinfect such equipment 

before use on another patient 24, 88, 796, 836, 837, 854, 1016. Category 

IB 

V.B.5.c. In home care settings 

85
 
V.B.5.c.i. Limit the amount of non-disposable patient-care 

equipment brought into the home of patients on Contact 

Precautions. Whenever possible, leave patient-care 

equipment in the home until discharge from home care 

services. Category II 

V.B.5.c.ii. If noncritical patient-care equipment (e.g., stethoscope) 

cannot remain in the home, clean and disinfect items 

before taking them from the home using a low- to 

intermediate-level disinfectant. Alternatively, place 

contaminated reusable items in a plastic bag for transport 

and subsequent cleaning and disinfection. Category II 

V.B.5.d. In ambulatory settings, place contaminated reusable noncritical 

patient-care equipment in a plastic bag for transport to a soiled 

utility area for reprocessing. Category II 

V.B.6. Environmental measures 

Ensure that rooms of patients on Contact Precautions are 

prioritized for frequent cleaning and disinfection (e.g., at least daily) 

with a focus on frequently-touched surfaces (e.g., bed rails, 

overbed table, bedside commode, lavatory surfaces in patient 

bathrooms, doorknobs) and equipment in the immediate vicinity of 

the patient 11, 24, 88, 746, 837. Category IB 

V.B.7. Discontinue Contact Precautions after signs and symptoms of the 

infection have resolved or according to pathogen-specific 

recommendations in Appendix A. Category IB 

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-patient room when available Category II 

When single-patient rooms are in short supply, apply the 

following principles for making decisions on patient placement: 

y Prioritize patients who have excessive cough and sputum 

production for single-patient room placement Category II 

y Place together in the same room (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 who have conditions that may increase 

86
 
the risk of adverse outcome from 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 physically 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 both 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 room 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 recommendation for routinely wearing eye protection (e.g., 

goggle or face shield), in addition 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 following 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-term 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 movement in any healthcare setting is necessary, 

instruct patient to wear a mask and follow Respiratory 

Hygiene/Cough Etiquette 

www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm) 

. Category IB 

V.C.4.c. No mask is required for persons transporting patients on Droplet 

Precautions. Category II 

V.C.4.d. Discontinue Droplet Precautions after signs and symptoms have 

resolved or according to pathogen-specific recommendations in 

Appendix A. Category IB 

V.D. Airborne Precautions 

87
 
V.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 Airborne 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 pressure daily with visual 

indicators (e.g., smoke tubes, flutter 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 closed 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 requirements for an AIIR. 

y	 Place together (cohort) patients 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., immunocompromised patients). 

y	 Use temporary portable solutions (e.g., exhaust fan) to 

create a negative pressure environment in the converted 

area of the facility. Discharge air directly to the outside,away 

from people and air intakes, or direct all the air through 

HEPA filters before it is introduced 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 suspected infections that require 

Airborne Precautions upon entry into ambulatory settings

9, 12, 34, 127, 134. Category IA 

88
 
V.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 examination 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-tested NIOSH-approved N95 or higher level respirator 

for respiratory protection when entering 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 aerosolize viable organisms (e.g., 

irrigation, incision and drainage, whirlpool treatments) are 

performed 12, 1025, 1026. Category IB 

y	 Smallpox (vaccinated and unvaccinated). Respiratory 

protection is recommended for all healthcare personnel, 

including those with a documented “take” after smallpox 

vaccination due to the risk of a genetically engineered virus 

against which the vaccine may not provide protection, or of 

exposure to a very large viral load (e.g., from high-risk 

aerosol-generating procedures, immunocompromised 

patients, hemorrhagic or flat smallpox 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 varicella-zoster based on history of 

disease, vaccine, or serologic testing when caring for an 

individual with known or suspected measles, chickenpox or 

disseminated zoster, due to difficulties in establishing definite 

immunity 1027, 1028. Unresolved issue 

V.D.4.c. No recommendation is made regarding the type of personal 

protective equipment (i.e., surgical 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 suspected measles, chickenpox or 

disseminated herpes zoster. Unresolved issue 

89
 
V.D.5. Patient transport 

V.D.5.a. In acute care hospitals and long-term care and other residential 

settings, limit transport and movement of patients outside of the 

room to medically-necessary purposes. Category II 

V.D.5.b. If transport or movement outside an AIIR is necessary, instruct 

patients to wear a surgical mask, if possible, and observe 

Respiratory Hygiene/Cough Etiquette 12. Category II 

V.D.5.c. For patients with skin lesions associated with varicella or 

smallpox or draining skin lesions caused by M. tuberculosis, 

cover the affected areas to prevent aerosolization or contact 

with the infectious agent in skin lesions 108, 1025, 1026, 1029-1031. 

Category IB 

V.D.5.d. Healthcare personnel transporting patients who are on Airborne 

Precautions do not need to wear a mask or respirator during 

transport if the patient is wearing a mask and infectious skin 

lesions are covered. Category II 

V.D.6. Exposure management 

Immunize or provide the appropriate immune globulin to 

susceptible persons as soon as possible following unprotected 

contact (i.e., exposed) to a patient 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 the 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 exposure or administer varicella 

immune globulin (VZIG or alternative product), when 

available, within 96 hours for high-risk persons in whom 

vaccine is contraindicated (e.g., immunocompromised 

patients, pregnant women, newborns whose mother’s 

varicella onset was <5 days before 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 Precautions 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 Infection Control in Health-Care 

Facilities” 11 for additional guidance on environment strategies for 

preventing transmission of tuberculosis in healthcare settings. The 

environmental recommendations in these guidelines may be 

applied to patients with other infections that require Airborne 

Precautions. 

90
 
VI. Protective Environment (Table 4) 

VI.A. Place allogeneic hematopoietic stem cell transplant (HSCT) patients in a 

Protective Environment as described 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-Care-Associated Pneumonia, 2003” 14 

to reduce exposure to environmental fungi (e.g., Aspergillus sp) 157, 158. 

Category IB 

VI.B. No recommendation for placing patients 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 Protective Environment, implement the 

following (see Table 5) 11, 15 

VI.C.1. Environmental controls 

VI.C.1.a. Filtered incoming air using central 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 the patient bed and out through an 

exhaust on the opposite side of the room 13. Category IB 

VI.C.1.c. Positive air pressure in room relative to the corridor (pressure 

differential of >12.5 Pa [0.01-in water gauge]) 13. Category IB 

VI.C.1.c.i. Monitor air pressure daily with visual indicators (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, rather than textured material (e.g., 

upholstery). Wet dust horizontal surfaces whenever dust detected 

and routinely clean crevices and sprinkler heads where dust may 

accumulate 940, 941. Category II 

VI.C.3. Avoid carpeting in hallways 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 that 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 medically fit to tolerate a respirator 

when they are required to leave the Protective Environment 945 158 . 

Category II 

VI.E.1.a. No recommendation for fit-testing of patients who are using 

respirators. Unresolved issue 

91
 
VI.E.1.b. No recommendation for use of particulate respirators when 

leaving the Protective Environment in the absence of 

construction. Unresolved issue 

VI.F. Use of Standard and Transmission-Based 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 Contact 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 prolonged shedding of viruses 930 

1010 928, 932 1011. Category IB 

VI.F.3. Barrier precautions, (e.g., masks, gowns, gloves) are not required 

for healthcare personnel in the absence of suspected or confirmed 

infection in the patient or if they are not indicated according to 

Standard Precautions 15. Category II 

VI.F.4. Implement Airborne Precautions 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 contaminated 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 available, place the patient in an AIIR and 

use portable, industrial-grade HEPA filters in the room to 

enhance filtration of spores 1042. Category II 

92
 
Appendix A: 

Preamble The mode(s) and risk of transmission for each specific disease agent included in Appendix Principle sources consulted for the development of disease-specific recommendations for Appendix A disease manuals and textbooks 833, 1043, 1044. The published literature was searched for evidence of pertransmission in healthcare and non-healthcare settings with a focus on reported outbreaks that would recommendations for all settings where healthcare is delivered. Criteria used to assign Transmission-Bcategories follow:

• A Transmission-Based Precautions category was assigned if there was strong evidence for per

transmission via droplet, contact, or airborne routes in healthcare or non-healthcare settings anfactors (e.g., diapered infants, diarrhea, draining wounds) increased the risk of transmission 

• Transmission-Based Precautions category assignments reflect the predominant mode(s) of tran• If there was no evidence for person-to-person transmission by droplet, contact or airborne route

Precautions were assigned 

• If there was a low risk for person-to-person transmission and no evidence of healthcare-associa

Standard Precautions were assigned 

• Standard Precautions were assigned for bloodborne pathogens (e.g., hepatitis B and C viruses, 

immunodeficiency virus) as per CDC recommendations for Universal Precautions issued in 198experience has confirmed the efficacy of Standard Precautions to prevent exposure to infected fluid 778, 779, 866. 

Additional information relevant to use of precautions was added in the comments column to assist the 

decision-making. Citations were added as needed to support a change in or provide additional evidencrecommendations for a specific disease and for new infectious agents (e.g., SARS-CoV, avian influenzadded to Appendix A. The reader may refer to more detailed discussion concerning modes of transmispathogens in the background text and for MDRO control in Appendix B. 

93
APPENDIX A1

TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS 

Infection/Condition Precautions

Type 

*

Duration † Comments

Abscess  Draining, major C DI No dressing or containment of dra

contained by dressing 

 Draining, minor or limited S Dressing covers and contains draiAcquired human immunodeficiency syndrome (HIV) S Post-exposure chemoprophylaxis Actinomycosis S Not transmitted from person to perAdenovirus infection ( see agent-specific guidance under gastroenteritis, conjuctivitis, pneumonia) Amebiasis S 

Person to person transmission is rmentally challenged and in a famil

care when handling diapered infan

1046

. 

Anthrax S Infected patients do not generally  Cutaneous S 

Transmission through non-intact spossible, therefore use Contact Pruncontained drainage. Handwashito use of waterless alcohol based 

1 Type 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 treatment and culture-negative; DI, duration of illness (with wound lesions, DI m

draining); DE, until environment completely decontaminated; U, until time specified in hours (hrs) after initiation of effective therapy; establishing eradication of pathogen has not been determined

94
APPENDIX A1

TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS 

Infection/Condition Precautions

Type 

*

Duration † Comments

have sporicidal activity 983. 

 Pulmonary S Not transmitted from person to per Environmental: aerosolizable spore-containing powder or other  substance DE 

Until decontamination of environm

(N95 mask or PAPRs), protective with powder on them (http://www.cdc.gov/mmwr/previewHand hygiene: Handwashing for 3or 2% chlorhexidene gluconate aftinactive against spores 983. 

Post-exposure prophylaxis follodays of antimicrobials (either doxylevofloxacin) and post-exposure v

Antibiotic-associated colitis (see Clostridium difficile) Arthropod-borne viral encephalitides (eastern, western, Venezuelan equine encephalomyelitis; St Louis, California encephalitis; West Nile Virus) and viral fevers (dengue, yellow fever, Colorado tick fever) 

S 

Not transmitted from person to perand for West Nile virus by organ trtransplacentally 530, 1047. Install scre

endemic areas Use DEET-containing mosquito reextremities 

Ascariasis S Not transmitted from person to perAspergillosis S Contact Precautions and Airborne 

infection with copious drainage an

Avian influenza (see influenza, avian below) Babesiosis S Not transmitted from person to perBlastomycosis, North American, cutaneous or pulmonary S Not transmitted from person to perBotulism S Not transmitted from person to perBronchiolitis (see respiratory infections in infants and young children) C DI Use mask according to Standard P

95
APPENDIX A1

TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS 

Infection/Condition Precautions

Type 

*

Duration † Comments

Brucellosis (undulant, Malta, Mediterranean fever) S 

Not transmitted from person to per

spermatozoa and sexual contact 1

prophylaxis following laboratory ex

Campylobacter gastroenteritis (see gastroenteritis) Candidiasis, all forms including mucocutaneous S Cat-scratch fever (benign inoculation lymphoreticulosis) S Not transmitted from person to perCellulitis S Chancroid (soft chancre) (H. ducreyi) S Transmitted sexually from person Chickenpox (see varicella) Chlamydia trachomatis Conjunctivitis S  Genital (lymphogranuloma venereum) S  Pneumonia (infants < 3 mos. of age)) S Chlamydia pneumoniae S Outbreaks in institutionalized popuCholera (see gastroenteritis) Closed-cavity infection  Open drain in place; limited or minor drainage S Contact Precautions if there is cop No drain or closed drainage system in place S Clostridium

C. botulinum S Not transmitted from person to perC. difficile (see Gastroenteritis, C. difficile) C DI C. perfringens

 Food poisoning S Not transmitted from person to per Gas gangrene S Transmission from person to perso

setting reported 1053. Use Contact 

96
APPENDIX A1

TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS 

Infection/Condition Precautions

Type 

*

Duration † Comments

extensive. 

Coccidioidomycosis (valley fever)  Draining lesions S 

Not transmitted from person to percircumstances because the infectiCoccidioides immitis is not produc

 Pneumonia S 

Not transmitted from person to percircumstances, (e.g., inhalation of endospores during necropsy, transthe infectious arthroconidial form o

produced in humans 1054, 1055. 

Colorado tick fever S Not transmitted from person to perCongenital rubella C Until 1 yr of age Standard Precautions if nasophary

neg. after 3 mos. of age 

Conjunctivitis  Acute bacterial S 

Chlamydia S 

 Gonococcal S  Acute viral (acute hemorrhagic) C DI 

Adenovirus most common; enterov

1057) also associated with commun

outbreaks in eye clinics, pediatric asettings reported. Eye clinics shouwhen handling patients with conjucontrol measures in the handling oprevent the occurrence of outbrea

1058, 1059 461, 1060

. 

Corona virus associated with SARS (SARS-CoV) (see severe acute  respiratory syndrome) 

97
APPENDIX A1

TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS 

Infection/Condition Precautions

Type 

*

Duration † Comments

Coxsackie virus disease (see enteroviral infection) Creutzfeldt-Jakob disease  CJD, vCJD S 

Use disposable instruments or spe

surfaces, objects contaminated wisuspected and has not been R/O; 

1061

Croup (see respiratory infections in infants and young children) Crimean-Congo Fever (see Viral Hemorrhagic Fever) S Cryptococcosis S Not transmitted from person to per

corneal transplant 1062, 1063

Cryptosporidiosis (see gastroenteritis) Cysticercosis S Not transmitted from person to perCytomegalovirus infection, including in neonates and immunosuppressed patients S No additional precautions for pregDecubitus ulcer (see Pressure ulcer) Dengue fever S Not transmitted from person to perDiarrhea, acute-infective etiology suspected (see gastroenteritis) Diphtheria  Cutaneous C CN Until 2 cultures taken 24 hrs. apart  Pharyngeal D CN Until 2 cultures taken 24 hrs. apart Ebola virus (see viral hemorrhagic fevers) Echinococcosis (hydatidosis) S Not transmitted from person to perEchovirus (see enteroviral infection) Encephalitis or encephalomyelitis (see specific etiologic agents) Endometritis (endomyometritis) S Enterobiasis (pinworm disease, oxyuriasis) S Enterococcus species (see multidrug-resistant organisms if 

98
APPENDIX A1

TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS 

Infection/Condition Precautions

Type 

*

Duration † Comments

epidemiologically significant or vancomycin resistant) Enterocolitis, C. difficile (see C. difficile, gastroenteritis) Enteroviral infections (i.e., Group A and B Coxsackie viruses and Echo viruses) (excludes polio virus) S 

Use Contact Precautions for diapeduration of illness and to control in

Epiglottitis, due to Haemophilus influenzae type b D U 24 hrs See specific disease agents for epEpstein-Barr virus infection, including infectious mononucleosis S Erythema infectiosum (also see Parvovirus B19) Escherichia coli gastroenteritis (see gastroenteritis) Food poisoning  Botulism S Not transmitted from person to per

C. perfringens or welchii S Not transmitted from person to per

 Staphylococcal S Not transmitted from person to perFurunculosis, staphylococcal S Contact if drainage not controlled.  Infants and young children C DI Gangrene (gas gangrene) S Not transmitted from person to perGastroenteritis S 

Use Contact Precautions for diapeduration of illness or to control instgastroenteritis caused by all of the 

 Adenovirus S Use Contact Precautions for diape

duration of illness or to control inst

Campylobacter species S Use Contact Precautions for diape

duration of illness or to control inst

 Cholera (Vibrio cholerae) S Use Contact Precautions for diape

duration of illness or to control inst

C. difficile C DI Discontinue antibiotics if appropria

thermometers 853, 854; ensure cons

99
APPENDIX A1

TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS 

Infection/Condition Precautions

Type 

*

Duration † Comments

disinfection. Hypochlorite solutions transmission continues 847. Handw

preferred because of the absence waterless antiseptic handrubs 983. 

Cryptosporidium species S Use Contact Precautions for diape

duration of illness or to control inst

E. coli

 Enteropathogenic O157:H7 and other shiga toxin-producing  Strains S Use Contact Precautions for diape

duration of illness or to control inst

 Other species S Use Contact Precautions for diape

duration of illness or to control inst

Giardia lamblia S Use Contact Precautions for diape

duration of illness or to control inst

 Noroviruses S 

Use Contact Precautions for diapeduration of illness or to control inst

clean areas heavily contaminated from wearing masks since virus casubstances 142, 147 148; ensure cons

disinfection with focus on restroom

273, 1064). Hypochlorite solutions ma

continued transmission 290-292. Alco

evidence that alcohol antiseptic hadecontamination 294. Cohorting of 

airspaces and toilet facilities may houtbreaks. 

 Rotavirus C DI Ensure consistent environmental c

frequent removal of soiled diapers

100
APPENDIX A1

TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS 

Infection/Condition Precautions

Type 

*

Duration † Comments

both immunocompetent and immuelderly 932, 933. 

Salmonella species (including S. typhi) S Use Contact Precautions for diape

duration of illness or to control inst

Shigella species (Bacillary dysentery) S Use Contact Precautions for diape

duration of illness or to control inst

Vibrio parahaemolyticus S Use Contact Precautions for diape

duration of illness or to control inst

 Viral (if not covered elsewhere) S Use Contact Precautions for diape

duration of illness or to control inst

Yersinia enterocolitica S Use Contact Precautions for diape

duration of illness or to control inst

German measles (see rubella; see congenital rubella) Giardiasis (see gastroenteritis) Gonococcal ophthalmia neonatorum (gonorrheal ophthalmia,  acute conjunctivitis of newborn) S Gonorrhea S Granuloma inguinale (Donovanosis, granuloma venereum) S Guillain-Barré’ syndrome S Not an infectious condition Haemophilus influenzae (see disease-specific recommendations) Hand, foot, and mouth disease (see enteroviral infection) Hansen’s Disease (see Leprosy) Hantavirus pulmonary syndrome S Not transmitted from person to perHelicobacter pylori S Hepatitis, viral  Type A S Provide hepatitis A vaccine post-e Diapered or incontinent patients C Maintain Contact Precautions in in

101
APPENDIX A1

TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS 

Infection/Condition Precautions

Type 

*

Duration † Comments

for duration of hospitalization; for cafter onset of symptoms; >14 yrs. symptoms 833, 1066, 1067. 

 Type B-HBsAg positive; acute or chronic S See specific recommendations for 

centers 778

 Type C and other unspecified non-A, non-B S See specific recommendations for 

centers 778

 Type D (seen only with hepatitis B) S  Type E S Use Contact Precautions for diape

duration of illness 1068

 Type G S Herpangina (see enteroviral infection) Hookworm S Herpes simplex (Herpesvirus hominis)  Encephalitis S  Mucocutaneous, disseminated or primary, severe C Until lesions dry and crusted  Mucocutaneous, recurrent (skin, oral, genital) S  Neonatal C Until lesions dry and crusted 

Also, for asymptomatic, exposed isection and if mother has active inruptured for more than 4 to 6 hrs uat 24-36 hrs. of age negative after 

Herpes zoster (varicella-zoster) (shingles)  Disseminated disease in any patient  Localized disease in immunocompromised patient until disseminated infection ruled out 

A,C DI 

Susceptible HCWs should not ente

available; no recommendation for recommendation for type of protecfor susceptible HCWs. 

102
APPENDIX A1

TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS 

Infection/Condition Precautions

Type 

*

Duration † Comments

 Localized in patient with intact immune system with lesions that can  be contained/covered S DI Susceptible HCWs should not prov

immune caregivers are available. 

Histoplasmosis S Not transmitted from person to perHuman immunodeficiency virus (HIV) S Post-exposure chemoprophylaxis Human metapneumovirus C DI 

HAI reported 1071, but route of tran

Assumed to be Contact transmissclosely related and have similar clepidemiology. Wear masks accord

Impetigo C U 24 hrs Infectious mononucleosis S Influenza  Human (seasonal influenza) D 

5 days except DI in immuno compromised persons 

Single patient room when available high-risk patients; mask patient whchemoprophylaxis/vaccine to cont

and gloves according to Standard important in pediatric settings. Duimmunocompromised patients canof viral shedding (i.e. for several wimplications for transmission are u

 Avian (e.g., H5N1, H7, H9 strains)) See www.cdc.gov/flu/avian/profes

avian influenza guidance. 

 Pandemic influenza (also a human influenza virus) D 

5 days from onset of symptoms 

See http://www.pandemicflu.gov fo

guidance. 

Kawasaki syndrome S Not an infectious condition Lassa fever (see viral hemorrhagic fevers) 

103
APPENDIX A1

TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS 

Infection/Condition Precautions

Type 

*

Duration † Comments

Legionnaires’ disease S Not transmitted from person to perLeprosy S Leptospirosis S Not transmitted from person to perLice http://www.cdc.gov/ncidod/dpd/pa Head (pediculosis) C U 24 hrs  Body S 

Transmitted person to person throand gloves when removing clothinto CDC guidance above 

 Pubic S Transmitted person to person throListeriosis (listeria monocytogenes) S Person-to-person transmission rar

settings reported 1072, 1073 1074, 1075

Lyme disease S Not transmitted from person to perLymphocytic choriomeningitis S Not transmitted from person to perLymphogranuloma venereum S Malaria S 

Not transmitted from person to perrarely and through a failure to follopatient care 1076-1079. Install screen

areas. Use DEET-containing mosqextremities 

Marburg virus disease (see viral hemorrhagic fevers) Measles (rubeola) A 

4 days after 

onset of rash; DI 

in immune 

compromised 

Susceptible HCWs should not enteare available; no recommendation HCW; no recommendation for type HCWs, i.e., mask or respirator 1027

post-exposure vaccine within 72 hwhen available 17, 1032, 1034. Place e

Airborne Precautions and exclude 

104
APPENDIX A1

TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS 

Infection/Condition Precautions

Type 

*

Duration † Comments

from duty from day 5 after first expregardless of post-exposure vacci

Melioidosis, all forms S Not transmitted from person to perMeningitis  Aseptic (nonbacterial or viral; also see enteroviral infections) S Contact for infants and young child Bacterial, gram-negative enteric, in neonates S  Fungal S 

Haemophilus influenzae, type b known or suspected D U 24 hrs Listeria monocytogenes (See Listeriosis) S Neisseria meningitidis (meningococcal) known or suspected D U 24 hrs See meningococcal disease below Streptococcus pneumoniae S M. tuberculosis S 

Concurrent, active pulmonary disemay necessitate addition of ContaFor children, airborne precautions visiting family members (see tuber

 Other diagnosed bacterial S Meningococcal disease: sepsis, pneumonia, meningitis D U 24 hrs 

Postexposure chemoprophylaxis fexposed to respiratory secretions; control outbreaks 15, 17. 

Molluscum contagiosum S Monkeypox A,C 

A-Until 

monkeypox 

confirmed and 

smallpox 

excluded 

C-Until lesions 

crusted 

Use See www.cdc.gov/ncidod/monrecommendations. Transmission i

and post-exposure smallpox vacciHCWs 

105
APPENDIX A1

TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS 

Infection/Condition Precautions

Type 

*

Duration † Comments

Mucormycosis S Multidrug-resistant organisms (MDROs), infection or colonization  (e.g., MRSA, VRE, VISA/VRSA, ESBLs, resistant S. pneumoniae) S/C 

MDROs judged by the infection con

regional, or national recommendatiepidemiologic significance. Contacsettings with evidence of ongoing twith increased risk for transmission contained by dressings. See recomoptions in Management of MultidruHealthcare Settings, 2006 870. Cont

guidance regarding new or emergin

Mumps (infectious parotitis) D U 9 days 

After onset of swelling; susceptible immune caregivers are available. Note: (Recent assessment of outbindicated that salivary viral sheddiillness and that 5 days of isolation appropriate in community settingshealthcare personnel and high-risk clarified.) 

Mycobacteria, nontuberculosis (atypical) Not transmitted person-to-person  Pulmonary S  Wound S Mycoplasma pneumonia D DI Necrotizing enterocolitis S Contact Precautions when cases cNocardiosis, draining lesions, or other presentations S Not transmitted person-to-person Norovirus (see gastroenteritis) Norwalk agent gastroenteritis (see gastroenteritis) Orf S 

106
APPENDIX A1

TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS 

Infection/Condition Precautions

Type 

*

Duration † Comments

Parainfluenza virus infection, respiratory in infants and young children C DI 

Viral shedding may be prolonged i

1010. Reliability of antigen testing to 

with prolonged hospitalizations fro

Parvovirus B19 (Erythema infectiosum) D 

 Maintain precautions for duration o disease occurs in an immunocomp transient aplastic crisis or red-cell c days. Duration of precautions for im persistently positive PCR not defin

929

. 

Pediculosis (lice) C U 24 hrs after treatment Pertussis (whooping cough) D U 5 days 

Single patient room preferred. Cohchemoprophylaxis for household cexposure to respiratory secretions 

vaccine in adults under developme

Pinworm infection (Enterobiasis) S Plague (Yersinia pestis)  Bubonic S  Pneumonic D U 48 hrs Antimicrobial prophylaxis for exposPneumonia  Adenovirus D, C DI 

Outbreaks in pediatric and instituti

immunocompromised hosts, extenPrecautions due to prolonged shed

 Bacterial not listed elsewhere (including gram-negative bacterial) S 

B. cepacia in patients with CF, including 

 respiratory tract colonization C Unknown 

Avoid exposure to other persons wCriteria for D/C precautions not esguideline 20

107
APPENDIX A1

TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS 

Infection/Condition Precautions

Type 

*

Duration † Comments

B. cepacia in patients without CF(see 

 Multidrug-resistant organisms) 

Chlamydia S 

 Fungal S 

Haemophilus influenzae, type b 

 Adults S  Infants and children D U 24 hrs 

Legionella spp. S 

 Meningococcal D U 24 hrs See meningococcal disease above  Multidrug-resistant bacterial (see multidrug-resistant organisms) 

Mycoplasma (primary atypical pneumonia) D DI 

 Pneumococcal pneumonia S Use Droplet Precautions if evidenc

care unit or facility 196-198, 1087

Pneumocystis jiroveci (Pneumocystis carinii ) S Avoid placement in the same room 

patient. 

Staphylococcus aureus S For MRSA, see MDROs Streptococcus, group A 

 Adults D U 24 hrs See streptococcal disease (group 

Contact precautions if skin lesions 

 Infants and young children D U 24 hrs Contact Precautions if skin lesions  Varicella-zoster (See Varicella-Zoster)  Viral  Adults S  Infants and young children (see respiratory infectious disease,  acute, or specific viral agent) Poliomyelitis C DI Pressure ulcer (decubitus ulcer, pressure sore) infected 

108
APPENDIX A1

TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS 

Infection/Condition Precautions

Type 

*

Duration † Comments

 Major C DI If no dressing or containment of dr

be contained by dressing 

 Minor or limited S If dressing covers and contains draPrion disease (See Creutzfeld-Jacob Disease) Psittacosis (ornithosis) (Chlamydia psittaci) S Not transmitted from person to perQ fever S Rabies S 

Person to person transmission rarand organ transplants has been re

another individual or saliva has comucous membrane, wash exposed postexposure prophylaxis. 1089

Rat-bite fever (Streptobacillus moniliformis disease, Spirillum minus

disease) S Not transmitted from person to per

Relapsing fever S Not transmitted from person to perResistant bacterial infection or colonization (see multidrug-resistant organisms) Respiratory infectious disease, acute (if not covered elsewhere)  Adults S  Infants and young children C DI Also see syndromes or conditions Respiratory syncytial virus infection, in infants,  young children and immunocompromised adults C DI 

Wear mask according to Standard 

immunocompromised patients, extPrecautions due to prolonged shed

testing to determine when to remohospitalizations from Contact Prec

Reye's syndrome S Not an infectious condition Rheumatic fever S Not an infectious condition Rhinovirus D DI Droplet most important route of tra

109
APPENDIX A1

TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS 

Infection/Condition Precautions

Type 

*

Duration † Comments

occurred in NICUs and LTCFs 413, 

copious moist secretions and close infants) 111, 833. 

Rickettsial fevers, tickborne (Rocky Mountain spotted fever, tickborne typhus fever) S Not transmitted from person to per

rarely 

Rickettsialpox (vesicular rickettsiosis) S Not transmitted from person to perRingworm (dermatophytosis, dermatomycosis, tinea) S Rarely, outbreaks have occurred i

1093, rehabilitation hospital 1094. Use 

Ritter's disease (staphylococcal scalded skin syndrome) C DI See staphylococcal disease, scaldRocky Mountain spotted fever S Not transmitted from person to per

rarely 

Roseola infantum (exanthem subitum; caused by HHV-6) S Rotavirus infection (see gastroenteritis) Rubella (German measles) ( also see congenital rubella) D U 7 days after onset of rash 

Susceptible HCWs should not ente

available. No recommendation for surgical mask) if immune. Pregnanshould not care for these patients 

three days of exposure to non-preexposed susceptible patients on Dsusceptible healthcare personnel fexposure to day 21 after last expovaccine. 

Rubeola (see measles) Salmonellosis (see gastroenteritis) Scabies C U 24 Scalded skin syndrome, staphylococcal C DI See staphylococcal disease, scaldSchistosomiasis (bilharziasis) S 

110
APPENDIX A1

TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS 

Infection/Condition Precautions

Type 

*

Duration † Comments

Severe acute respiratory syndrome (SARS) A, D,C 

DI plus 10 days after resolution offever, provided respiratory symptoms are absent or improving 

Airborne Precautions preferred; D 

respiratory protection; surgical ma(goggles, face shield); aerosol-gen“supershedders” highest risk for traand large droplets 93, 94, 96.Vigilant 

www.cdc.gov/ncidod/sars) 

Shigellosis (see gastroenteritis) Smallpox (variola; see vaccinia for management of vaccinated persons) A,C DI 

Until all scabs have crusted and sevaccinated HCWs should not provavailable; N95 or higher respiratorsuccessfully vaccinated individualsdays of exposure protective 108, 129

Sporotrichosis S Spirillum minor disease (rat-bite fever) S Not transmitted from person to perStaphylococcal disease (S aureus)  Skin, wound, or burn  Major C DI No dressing or dressing does not c Minor or limited S Dressing covers and contains drai Enterocolitis S Use Contact Precautions for diape

duration of illness 

 Multidrug-resistant (see multidrug-resistant organisms)  Pneumonia S  Scalded skin syndrome C DI Consider healthcare personnel as 

outbreak 1095. 

 Toxic shock syndrome S Streptobacillus moniliformis disease (rat-bite fever) S Not transmitted from person to per

111
APPENDIX A1

TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS 

Infection/Condition Precautions

Type 

*

Duration † Comments

Streptococcal disease (group A streptococcus)  Skin, wound, or burn  Major C,D U 24 hrs No dressing or dressing does not c Minor or limited S Dressing covers and contains drai Endometritis (puerperal sepsis) S  Pharyngitis in infants and young children D U 24 hrs  Pneumonia D U 24 hrs  Scarlet fever in infants and young children D U 24 hrs  Serious invasive disease D U24 hrs 

Outbreaks of serious invasive disetransmission among patients and 

Contact Precautions for draining wantimicrobial prophylaxis in selecte

Streptococcal disease (group B streptococcus), neonatal S Streptococcal disease (not group A or B) unless covered elsewhere S  Multidrug-resistant (see multidrug-resistant organisms) Strongyloidiasis S Syphilis  Latent (tertiary) and seropositivity without lesions S  Skin and mucous membrane, including congenital, primary,  Secondary S Tapeworm disease 

Hymenolepis nana S Taenia solium (pork) S 

 Other S 

Not transmitted from person to per

Tetanus S Not transmitted from person to perTinea (e.g., dermatophytosis, dermatomycosis, ringworm) S Rare episodes of person-to-person 

112
APPENDIX A1

TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS 

Infection/Condition Precautions

Type 

*

Duration † Comments

Toxoplasmosis S 

Transmission from person to persomother to child, transmission throurare 

Toxic shock syndrome (staphylococcal disease, streptococcal disease) S Droplet Precautions for the first 24 

antibiotic therapy if Group A strept

Trachoma, acute S Transmissible spongiform encephalopathy (see Creutzfeld-Jacob disease, CJD, vCJD) Trench mouth (Vincent's angina) S Trichinosis S Trichomoniasis S Trichuriasis (whipworm disease) S Tuberculosis (M. tuberculosis)  Extrapulmonary, draining lesion) A,C 

Discontinue precautions only when drainage has ceased or there are 

of continued drainage 1025, 1026. Exa

pulmonary tuberculosis. 

 Extrapulmonary, no draining lesion, meningitis S 

Examine for evidence of pulmonarchildren, use Airborne Precautions in visiting family members ruled ou

 Pulmonary or laryngeal disease, confirmed A 

Discontinue precautions only when improving clinically and has three 

negative for acid-fast bacilli collect54: RR-17 http://www.cdc.gov/mmwr/preview

417a1_e ) 12. 

 Pulmonary or laryngeal disease, suspected A Discontinue precautions only when 

113
APPENDIX A1

TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS 

Infection/Condition Precautions

Type 

*

Duration † Comments

disease is deemed negligible, and that explains the clinical syndrome smears for AFB are negative. Eacshould be collected 8-24 hours apearly morning specimen 

 Skin-test positive with no evidence of current active disease S Tularemia  Draining lesion S Not transmitted from person to per Pulmonary S Not transmitted from person to perTyphoid (Salmonella typhi) fever (see gastroenteritis) Typhus 

Rickettsia prowazekii (Epidemic or Louse-borne typhus) S Transmitted from person to person 

contact 

Rickettsia typhi S Not transmitted from person to per

Urinary tract infection (including pyelonephritis), with or without urinary catheter S Vaccinia (vaccination site, adverse events following vaccination) *

Only vaccinated HCWs have contacare for persons with adverse vaccHCWs without contraindications to 

 Vaccination site care (including autoinoculated areas) S 

Vaccination recommended for vacHCWs: semi-permeable dressing owith dressing change as fluid accuhygiene for dressing change; vacccontraindication to vaccine for dres

 Eczema vaccinatum C  Fetal vaccinia C  Generalized vaccinia C 

Until lesions dry and crusted, scabs separated

For contact with virus-containing le

114
APPENDIX A1

TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS 

Infection/Condition Precautions

Type 

*

Duration † Comments

 Progressive vaccinia C  Postvaccinia encephalitis S  Blepharitis or conjunctivitis S/C Use Contact Precautions if there is  Iritis or keratitis S  Vaccinia-associated erythema multiforme (Stevens Johnson  Syndrome) S Not an infectious condition  Secondary bacterial infection (e.g., S. aureus, group A beta  hemolytic streptococcus S/C Follow organism-specific (strep, st

recommendations and consider m

Varicella Zoster A,C 

Until lesions dry 

and crusted 

Susceptible HCWs should not ente

available; no recommendation for no recommendation for type of prorespirator for susceptible HCWs. Ivaricella pneumonia, prolong duraillness. Post-exposure prophylaxis

ASAP but within 120 hours; for sus

vaccine is contraindicated (immunwomen, newborns whose mother’s 

delivery or within 48 hrs after delivwithin 96 hours; if unavailable, use exposed susceptible persons and healthcare workers beginning 8 dafter last exposure or 28 if receivevaccination. 1036. 

Variola (see smallpox) Vibrio parahaemolyticus (see gastroenteritis) Vincent's angina (trench mouth) S Viral hemorrhagic fevers S, D, C DI Single-patient room preferred. Em

115
APPENDIX A1

TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS 

Infection/Condition Precautions

Type 

*

Duration † Comments

due to Lassa, Ebola, Marburg, Crimean-Congo fever viruses devices and safe work practices, 2

against blood and body fluids upon fluid-resistant or impermeable gowgoggles or face shields); and 4) apor higher respirators when performLargest viral load in final stages of occur; additional PPE, including docoverings may be used, especially options for cleaning and laundry aofficials immediately if Ebola is sus

3 for Ebola as a bioterrorism agen

Viral respiratory diseases (not covered elsewhere)  Adults S  Infants and young children (see respiratory infectious disease,  acute) Whooping cough (see pertussis) Wound infections  Major C DI No dressing or dressing does not c Minor or limited S Dressing covers and contains draiYersinia enterocolitica gastroenteritis (see gastroenteritis) Zoster (varicella-zoster) (see herpes zoster) Zygomycosis (phycomycosis, mucormycosis) S Not transmitted person-to-person 

116
TABLE 1. HISTORY OF GUIDELINES FOR ISOLATION PRECAUTIONS IN HOSPITALS* 

YEAR 

(Ref) 

DOCUMENT ISSUED COMMENT 

1970 

1099

Isolation Techniques for Use in Hospitals, 1st ed. 

- Introduced seven isolation precaution categories 

cards: Strict, Respiratory, Protective, Enteric, WDischarge, and Blood 

- No user decision-making required - Simplicity a strength; over isolation prescribed fo

1975 

1100

Isolation Techniques for Use in Hospitals, 2nd ed. 

- Same conceptual framework as 1st edition 

1983 

1101

CDC Guideline for Isolation Precautions in Hospitals 

- Provided two systems for isolation: category-spe

specific 

- Protective Isolation eliminated; Blood Precaution

Body Fluids 

- Categories included Strict, Contact, Respiratory

Drainage/Secretion, Blood and Body Fluids 

- Emphasized decision-making by users 

1985-88 

780, 896

Universal Precautions - Developed in response to HIV/AIDS epidemic 

- Dictated application of Blood and Body Fluid pre

regardless of infection status 

- Did not apply to feces, nasal secretions, sputum

vomitus unless contaminated by visible blood 

- Added personal protective equipment to protect 

membrane exposures 

- Handwashing recommended immediately after g- Added specific recommendations for handling ne

devices; concept became integral to OSHA’s 19exposure to blood-borne pathogens in healthcar

117
1987 

1102

Body Substance Isolation - Emphasized avoiding contact with all moist and 

body substances except sweat even if blood not 

- Shared some features with Universal Precaution- Weak on infections transmitted by large droplets 

surfaces 

- Did not emphasize need for special ventilation to 

infections 

- Handwashing after glove removal not specified i

visible soiling 

1996 

1

Guideline for Isolation Precautions in Hospitals 

- Prepared by the Healthcare Infection Control Pra

Committee (HICPAC) 

- Melded major features of Universal Precautions 

Substance Isolation into Standard Precautions to patients at all times 

- Included three transmission-based precaution ca

droplet, and contact 

- Listed clinical syndromes that should dictate use 

until an etiological diagnosis is established 

* Derived from Garner ICHE 1996 

118
TABLE 2. CLINICAL SYNDROMES OR CONDITIONS WARRANTING EMPIRIC TRANSMISSION-BASED 

ADDITION TO STANDARD PRECAUTIONS PENDING CONFIRMATION OF DIAGNOSIS* 

Clinical Syndrome or Condition† Potential Pathogens‡

Empiric Precautions (Always iPrecautions)

DIARRHEA Acute diarrhea with a likely infectious cause in an incontinent or diapered patient 

Enteric pathogens§ Contact Precautions (pediatrics 

MENINGITIS 

Neisseria meningitidis Enteroviruses M. tuberculosis

Droplet Precautions for first 24 htherapy; mask and face protectioContact Precautions for infants aAirborne Precautions if pulmonaAirborne Precautions plus Conta

potentially infectious draining bo

RASH OR EXANTHEMS, GENERALIZED, ETIOLOGY UNKNOWN Petechial/ecchymotic with fever (general)  - If positive history of travel to an area with an ongoing outbreak of VHF in the 10 days before onset of fever 

Neisseria meningitides Ebola, Lassa, Marburg viruses

Droplet Precautions for first 24 hDroplet Precautions plus Contacface/eye protection, emphasizing precautions when blood exposuhigher respiratory protection wheprocedure performed 

119
Vesicular Varicella-zoster, herpes 

simplex, variola (smallpox), vaccinia viruses Vaccinia virus 

Airborne plus Contact PrecautioContact Precautions only if herpzoster in an immunocompetent hmost likely 

Maculopapular with cough, coryza and fever Rubeola (measles) virus Airborne Precautions 

120
Clinical Syndrome or Condition† Potential Pathogens‡ Empiric Precautions (Always 

Precautions)

RESPIRATORY INFECTIONSCough/fever/upper lobe pulmonary infiltrate in an HIV-negative patient or a patient at low risk for human immunodeficiency virus (HIV) infection 

M. tuberculosis, Respiratory viruses, S. pneumoniae, S. aureus(MSSA or MRSA)

Airborne Precautions plus Conta

Cough/fever/pulmonary infiltrate in any lung location in an HIV-infected patient or a patient at high risk for HIV infection 

M. tuberculosis, Respiratory viruses, S. pneumoniae, S. aureus (MSSA or MRSA) 

Airborne Precautions plus ContaUse eye/face protection if aerosperformed or contact with respiranticipated. If tuberculosis is unlikely and therespirators available, use DropleAirborne Precautions Tuberculosis more likely in HIV-HIV negative individual 

Cough/fever/pulmonary infiltrate in any lung location in a patient with a history of recent travel (10-21 days) to countries with active outbreaks of SARS, avian influenza 

M. tuberculosis, severe acute respiratory syndrome virus (SARSCoV), avian influenza 

Airborne plus Contact PrecautioIf SARS and tuberculosis unlikeinstead of Airborne Precautions

Respiratory infections, particularly bronchiolitis and pneumonia, in infants and young children 

Respiratory syncytial virus, parainfluenza virus, adenovirus, influenza virus, Human metapneumovirus 

Contact plus Droplet Precautionbe discontinued when adenoviruruled out 

121
Skin or Wound Infection 

Abscess or draining wound that cannot be covered 

Staphylococcus aureus(MSSA or MRSA), group A streptococcus 

Contact Precautions Add Droplet Precautions for the appropriate antimicrobial therapstreptococcal disease is suspec

* Infection control professionals should modify or adapt this table according to local conditions. To ensure tha

precautions are implemented always, hospitals must have systems in place to evaluate patients routinely aas part of their preadmission and admission care. 

† Patients with the syndromes or conditions listed below may present with atypical signs or symptoms (e.g.ne

pertussis may not have paroxysmal or severe cough). The clinician's index of suspicion should be guided bconditions in the community, as well as clinical 

 judgment. ‡ The organisms listed under the column "Potential Pathogens" are not intended to represent the complete, o

diagnoses, but rather possible etiologic agents that require additional precautions beyond Standard Precauruled out. 

 § These pathogens include enterohemorrhagic Escherichia coli O157:H7, Shigella spp, hepatitis A virus, nor

difficile. 

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TABLE 3. 

INFECTION CONTROL CONSIDERATIONS FOR HIGH-PRIORITY (CDC CATEGORY A) DISEASES RESULT FROM BIOTERRORIST ATTACKS OR ARE CONSIDERED TO BE BIOTERRORIST THRE(www.bt.cdc.gov) aa Abbreviations used in this table: RT = respiratory tract; GIT = gastrointestinal tract; CXR = chest x-ray

computerized axial tomography; CSF = cerebrospinal fluid; and LD50 – lethal dose for 50% of experime

HCWs = healthcare worker; BSL = biosafety level; PAPR = powered air purifying respirator; PCR = poreaction; IHC = immunohistochemistry Disease Anthrax Site(s) of Infection; Transmission Mode Cutaneous and inhalation disease have occurred in past bioterrorist incidents 

Cutaneous (contact with spores);RT (inhalation of spores);GIT (ingestion of spore

Comment: Spores can be inhaled into the lower respiratory tract. The infectious dhumans by any route is not precisely known. In primates, the LD50 (i.e., the dose 

animals) for an aerosol challenge with B. anthracis is estimated to be 8,000–50,00dose may be as low as 1-3 spores 

Incubation Period

Cutaneous: 1 to12 days; RT: Usually 1 to 7 days but up to 43 days reported; GIT: 

Clinical Features 

Cutaneous: Painless, reddish papule, which develops a central vesicle or bulla in 

days lesion becomes pustular, and then necrotic, with black eschar; extensive sur

RT: initial flu-like illness for 1-3 days with headache, fever, malaise, cough; by day shock, and is usually fatal (85%-90% if untreated; meningitis in 50% of RT cases. 

GIT: ; if intestinal form, necrotic, ulcerated edematous lesions develop in intestines vomiting, progression to hematemesis and bloody diarrhea; 25-60% fatal 

Diagnosis Cutaneous: Swabs of lesion (under eschar) for IHC, PCR and culture; punch biop

culture; vesicular fluid aspirate for Gram stain and culture; blood culture if systemic 

123
convalescent sera for ELISA serology 

RT: CXR or CT demonstrating wide mediastinal widening and/or pleural effusion, for culture and PCR; pleural effusion for culture, PCR and IHC; CSF if meningeal s

PCR and culture; acute and convalescent sera for ELISA serology; pleural and/or GIT: blood and ascites fluid, stool samples, rectal swabs, and swabs of oropharynculture, PCR and IHC 

Infectivity Cutaneous: Person-to-person transmission from contact with lesion of untreated p

extremely rare. RT and GIT: Person-to-person transmission does not occur. Aerosolized powder, environmental exposures: Highly infectious if aerosolized 

Recommended Precautions 

Cutaneous: Standard Precautions; Contact Precautions if uncontained copious dr

RT and GIT: Standard Precautions. Aerosolized powder, environmental exposures: Respirator (N95 mask or PAPR

decontamination of persons with 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% chlorh

spore contact (alcohol handrubs inactive against spores [Weber DJ JAMA 2003; 2Post-exposure prophylaxis following environmental exposure: 60 days of antdoxycycline, ciprofloxacin, or levofloxacin) and post-exposure vaccine under IND 

Disease BotulismSite(s) of Infection; Transmission Mode 

GIT: Ingestion of toxin-containing food, RT: Inhalation of toxin containing aerosComment: Toxin ingested or potentially delivered by aerosol in bioterrorist incid0.001 μg/ml/kg. 

Incubation Period 1-5 days. Clinical Features Ptosis, generalized weakness, dizziness, dry mouth and throat, blurred vision, d

dysphonia, and dysphagia followed by symmetrical descending paralysis and re

124
Diagnosis Clinical diagnosis; identification of toxin in stool, serology unless toxin-containin

toxin neutralization bioassays. 

Infectivity Not transmitted from person to person. Exposure to toxin necessary for diseaseRecommended Precautions 

Standard Precautions. 

Disease Ebola Hemorrhagic FeverSite(s) of Infection; Transmission Mode

As a rule infection develops after exposure of mucous membranes or RT, or thrpercutaneous injury. 

Incubation Period 2-19 days, usually 5-10 days Clinical Features Febrile illnesses with malaise, myalgias, headache, vomiting and diarrhea that a

by hypotension, shock, and hemorrhagic features. Massive hemorrhage in < 50

Diagnosis Etiologic diagnosis can be made using RT-PCR, serologic detection of antibody 

assessment with immunohistochemistry and viral culture with EM confirmation o

Infectivity Person-to-person transmission primarily occurs through unprotected contact wi

percutaneous injuries (e.g., needlestick) associated with a high rate of transmishealthcare settings has been reported but is prevented by use of barrier precau

Recommended Precautions 

Hemorrhagic fever specific barrier precautions: If disease is believed to be release of a bioweapon, epidemiology of transmission is unpredictable pending transmission. Until the nature of the pathogen is understood and its transmissioStandard, Contact and Airborne Precautions should be used. Once the pathogeepidemiology of transmission is consistent with natural disease, Droplet Precau

for Airborne Precautions. Emphasize: 1) use of sharps safety devices and safe hygiene; 3) barrier protection against blood and body fluids upon entry into room 

resistant or impermeable gown, face/eye protection with masks, goggles or face appropriate waste handling. Use N95 or higher respirators when performing aeprocedures. In settings where AIIRs are unavailable or the large numbers of paaccommodated by existing AIIRs, observe Droplet Precautions (plus Standard Precautions) and segregate patients from those not suspected of VHF infectionthose essential to care. See text for discussion and Appendix A for recommend

125
occurring VHFs. 

Disease Plague2Site(s) of Infection; Transmission Mode

RT: Inhalation of respiratory droplets. Comment: Pneumonic plague most likely to occur if used as a biological weapo

bubonic and primary septicemia may also occur. Infective dose 100 to 500 bacte

Incubation Period 1 to 6, usually 2 to 3 days. Clinical Features Pneumonic: fever, chills, headache, cough, dyspnea, rapid progression of weak

hemoptysis, circulatory collapse, and bleeding diathesis 

Diagnosis Presumptive diagnosis from Gram stain or Wayson stain of sputum, blood, or ly

definitive diagnosis from cultures of same material, or paired acute/convalescen

Infectivity Person-to-person transmission occurs via respiratory droplets risk of transmissio

24 hours of illness and requires close contact. Respiratory secretions probably few hours after initiation of appropriate therapy. 

Recommended Precautions 

Standard Precautions, Droplet Precautions until patients have received 48 hours 

Chemoprophylaxis: Consider antibiotic prophylaxis for HCWs with close conta

2 Pneumonic plague is not as contagious as is often thought. Historical accounts and contemporary evidence indicate that persons with 

transmit the infection when the disease is in the end stage. These persons cough copious amounts of bloody sputum that contains many in the early stage of primary pneumonic plague (approximately the first 20–24 h) apparently pose little risk [1, 2]. Antibiotic medication 

sputum of plague bacilli, so that a patient generally is not infective within hours after initiation of effective antibiotic treatment [3]. Thitimes many patients will never reach a stage where they pose a significant risk to others. Even in the end stage of disease, transmission contact. Simple protective measures, such as wearing masks, good hygiene, and avoiding close contact, have been effective to interrupt pneumonic plague outbreaks [2]. In the United States, the last known cases of person to person transmission of pneumonic plague occu

1. Wu L-T. A treatise on pneumonic plague. Geneva: League of Nations, 1926. III. Health. 2. Kool JL. Risk of person to person transmission of pneumonic plague. Clinical Infectious Diseases, 2005; 40 (8): 1166-1172 3. Butler TC. Plague and other Yersinia infections. In: Greenough WB, ed. Current topics in infectious disease. New York: Plenum Me1983. 

126
Disease Smallpox 

Site(s) of Infection; Transmission Mode

RT Inhalation of droplet or, rarely, aerosols; and skin lesions (contact with virus)

Comment: If used as a biological weapon, natural disease, which has not occulikely result.

Incubation Period 7 to 19 days (mean 12 days) Clinical Features Fever, malaise, backache, headache, and often vomiting for 2-3 days; then gen

maculopapular rash (more on face and extremities), which becomes vesicular (othen pustular; lesions all in same stage. 

Diagnosis Electron microscopy of vesicular fluid or culture of vesicular fluid by WHO appro

(CDC); detection by PCR available only in select LRN labs, CDC and USAMRID 

Infectivity Secondary attack rates up to 50% in unvaccinated persons; infected persons m

from time rash appears until all lesions have crusted over (about 3 weeks); grea

during first 10 days of rash. 

Recommended Precautions 

Combined use of Standard, Contact, and Airborne Precautionsb until all scabs h

weeks). Only immune HCWs to care for pts; post-exposure vaccine within 4 days. Vaccinia: HCWs cover vaccination site with gauze and semi-permeable dressin

separates (>21 days). Observe hand hygiene.

Adverse events with virus-containing lesions: Standard plus Contact Preca

lesions crusted 

b Transmission by the airborne route is a rare event; Airborne Precautions is recommended when poss

event of mass exposures, barrier precautions and containment within a designated area are most impo

c Vaccinia adverse events with lesions containing infectious virus include inadvertent autoinoculation, 

(blepharitis, conjunctivitis), generalized vaccinia, progressive vaccinia, eczema vaccinatum; bacterial srequires addition of contact precautions if exudates cannot be contained 216, 217. 

127
Disease Tularemia 

Site(s) of Infection; Transmission Mode

RT: Inhalation of aerosolized bacteria. GIT: Ingestion of food or drink contamina

bacteria. Comment: Pneumonic or typhoidal disease likely to occur after bioterrorist even

delivery. Infective dose 10-50 bacteria 

Incubation Period 2 to 10 days, usually 3 to 5 days Clinical Features Pneumonic: malaise, cough, sputum production, dyspnea; 

Typhoidal: fever, prostration, weight loss and frequently an associated pneumon

Diagnosis Diagnosis usually made with serology on acute and convalescent serum specim

be detected by PCR (LRN) or isolated from blood and other body fluids on cysteor mouse inoculation. 

Infectivity Person-to-person spread is rare. 

Laboratory workers who encounter/handle cultures of this organism are at high 

exposed. 

Recommended Precautions 

Standard Precautions 

128
TABLE 4. 

RECOMMENDATIONS FOR APPLICATION OF STANDARD PRECAUTIONS FOR THE CARE OF AALL HEALTHCARE SETTINGS (See Sections II.D.-II.J. and III.A.1) 

COMPONENT RECOMMENDATIONS 

Hand hygiene After touching blood, body fluids, secretions, excretions, conta

immediately after removing gloves; between patient contacts. 

Personal protective equipment (PPE)  Gloves For touching blood, body fluids, secretions, excretions, contam

touching mucous membranes and nonintact skin 

 Gown During procedures and patient-care activities when contact of 

skin with blood/body fluids, secretions, and excretions is antic

 Mask, eye protection (goggles),  face shield* 

During procedures and patient-care activities likely to generatsprays of blood, body fluids, secretions, especially suctioning, intubation 

Soiled patient-care equipment Handle in a manner that prevents transfer of microorganisms 

environment; wear gloves if visibly contaminated; perform han

Environmental control Develop procedures for routine care, cleaning, and disinfectio

surfaces, especially frequently touched surfaces in patient-car

Textiles and laundry Handle in a manner that prevents transfer of microorganisms 

environment 

Needles and other sharps Do not recap, bend, break, or hand-manipulate used needles; 

required, use a one-handed scoop technique only; use safety available; place used sharps in puncture-resistant container 

Patient resuscitation Use mouthpiece, resuscitation bag, other ventilation devices t

with mouth and oral secretions 

129
Patient placement Prioritize for single-patient room if patient is at increased risk o

likely to contaminate the environment, does not maintain appris at increased risk of acquiring infection or developing adversinfection. 

Respiratory hygiene/cough etiquette (source containment of infectious respiratory secretions in symptomatic patients, beginning at initial point of encounter e.g., triage and reception areas in emergency departments and physician offices) 

Instruct symptomatic persons to cover mouth/nose when sneetissues and dispose in no-touch receptacle; observe hand hyghands with respiratory secretions; wear surgical mask if toleraspatial separation, >3 feet if possible. 

130

* * During aerosol-generating procedures on patients with suspected or proven infections transmitted by 

(e.g., SARS), wear a fit-tested N95 or higher respirator in addition to gloves, gown,and face/eye prote
131
TABLE 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 required diagnostic or therapeutic procedures 

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

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

during periods of construction 

II. Standard and Expanded Precautions 

• Hand hygiene observed before and after patient contact 

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

the room 

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

Precautions and as indicated for suspected or proven infections for which 

Transmission-Based Precautions are recommended 

III. Engineering 

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

particles 0.3 μm in diameter for supply (incoming) air 

• Well-sealed rooms 

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

o Ceilings: smooth, free of fissures, open joints, crevices 

o Walls sealed above and below the ceiling 

o If leakage detected, locate source and make necessary repairs 

• Ventilation to maintain >12 ACH 

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

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

opposite side of the room 

• Positive room air pressure in relation to the corridor 

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

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

(e.g., flutter strips, smoke tubes) 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 ventilation requirements for PE areas and take 

immediate steps to restore the fixed ventilation system 

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

anteroom to ensure proper air balance relationships and provide 

independent exhaust of contaminated air to the outside or place a HEPA 

filter in the exhaust duct. If an anteroom is not available, place patient in an 

AIIR and use portable ventilation units, industrial-grade HEPA filters to 

enhance filtration of spores. 

132
IV. Surfaces 

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

• Avoid dusting methods that disperse dust 

• No carpeting in patient rooms or hallways 

• No upholstered furniture and furnishings 

V. Other 

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

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

necessary 

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! 

135
136
GLOSSARY 

Airborne infection isolation room (AIIR). Formerly, negative pressure isolation 

room, an AIIR is a single-occupancy patient-care room used to isolate persons 

with a suspected or confirmed airborne infectious disease. Environmental factors 

are controlled in AIIRs to minimize the transmission of infectious agents that are 

usually transmitted from person to person by droplet nuclei associated with 

coughing or aerosolization of contaminated fluids. AIIRs should provide negative 

pressure in the room (so that air flows under the door gap into the room); and an 

air flow rate of 6-12 ACH ( 6 ACH for existing structures, 12 ACH for new 

construction or renovation); and direct exhaust of air from the room to the outside 

of the building or recirculation of air through a HEPA filter before retruning to 

circulation (MMWR 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 from the U.S. Department of Health and 

Human Services and the National Institutes of Health, is the primary source of 

guidance for creating airborne infection isolation rooms (AIIRs) and protective 

environments (www.aia.org/aah). 

Ambulatory care settings. Facilities that provide health care to patients who do 

not remain overnight (e.g., hospital-based outpatient clinics, nonhospital-based 

clinics and physician offices, urgent care centers, surgicenters, free-standing 

dialysis centers, public health clinics, imaging centers, ambulatory behavioral 

health and substance abuse clinics, physical therapy and rehabilitation centers, 

and dental practices. 

Bioaerosols. An airborne dispersion of particles containing whole or parts of 

biological entities, such as bacteria, viruses, dust mites, fungal hyphae, or fungal 

spores. Such aerosols usually consist of a mixture of mono-dispersed and 

aggregate cells, spores or viruses, carried by other materials, such as respiratory 

secretions and/or inert particles. Infectious bioaerosols (i.e., those that contain 

biological agents capable of causing an infectious disease) can be 

generated from human sources (e.g., expulsion from the respiratory tract 

during coughing, sneezing, talking or singing; during suctioning or 

wound irrigation), wet environmental sources (e.g. HVAC and cooling 

tower water with Legionella) or dry sources (e.g.,constuction dust 

with spores produced by Aspergillus spp.). Bioaerosols include large respiratory 

droplets and small droplet nuclei (Cole EC. AJIC 1998;26: 453-64). 
Caregivers.. All persons who are not employees of an organization, are not paid, 

and provide or assist in providing healthcare to a patient (e.g., family member, 

friend) and acquire technical training as needed based on the tasks that must be 

performed. 

Cohorting. In the context of this guideline, this term applies to the practice of 

grouping patients infected or colonized with the same infectious agent together to 

confine their care to one area and prevent contact with susceptible patients 

(cohorting patients). During outbreaks, healthcare personnel may be assigned to 

a cohort of patients to further limit opportunities for transmission (cohorting staff). 

Colonization. Proliferation of microorganisms on or within body sites without 

detectable host immune response, cellular damage, or clinical expression. The 

presence of a microorganism within a host may occur with varying duration, but 

may become a source of potential transmission. In many instances, colonization 

and carriage are synonymous. 

Droplet nuclei. Microscopic particles < 5 μm in size that are the residue of 

evaporated droplets and are produced when a person coughs, sneezes, shouts, 

or sings. These particles can remain suspended in the air for prolonged periods 

of time and can be carried on normal air currents 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 Environment, engineered sharps injury 

prevention devices and sharps 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 enterococci [VRE], methicillin 

resistant Staphylococcus aureus [MRSA], vancomycin resistant Staphylococcus 

aureus [VRSA] influenza virus, respiratory syncytial 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 (nonantimicrobial) soap and water); 2) antiseptic 

handwash (soap containing antiseptic agents and water); 3) antiseptic handrub 

(waterless antiseptic product, most often alcohol-based, rubbed on all surfaces of 

hands); or 4) surgical hand antisepsis (antiseptic handwash or antiseptic handrub 

performed preoperatively by surgical personnel to eliminate transient 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 healthcare is delivered (e.g., acute care 

hospital, chronic care facility, ambulatory clinic, dialysis center, surgicenter, 

home) and is related to receiving health care (i.e., was not incubating or present 

at the time healthcare was provided). In ambulatory and home settings, HAI 

would apply to any infection that is associated with a medical or surgical 

intervention. Since the geographic location of infection acquisition is often 

uncertain, the 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-level epidemiology who has received 

advanced training in healthcare epidemiology. Typically these professionals 

direct or provide consultation to an infection control program in a hospital, long 

term care facility (LTCF), or healthcare delivery system (also see infection control 

professional). 

Healthcare personnel, healthcare worker (HCW). All paid and unpaid persons 

who work in a healthcare setting (e.g. any person who has professional or 

technical training in a healthcare-related field and provides patient care in a 

healthcare setting or any person who provides services that support the delivery 

of healthcare such as dietary, housekeeping, engineering, maintenance 

personnel). 

Hematopoietic stem cell transplantation (HSCT). Any transplantation of bloodor bone marrow-derived hematopoietic stem cells, regardless of donor type (e.g., 

allogeneic or autologous) or cell source (e.g., bone marrow, peripheral blood, or 

placental/umbilical cord blood); associated with periods of severe 

immunosuppression that vary with the source of the cells, the intensity of 

chemotherapy required, and the presence of graft versus host disease (MMWR 

2000; 49: RR-10). 

High-efficiency particulate air (HEPA) filter. An air filter that removes 

>99.97% of particles > 0.3μm (the most penetrating particle size) at a specified 

flow rate of air. HEPA filters may be integrated into the central air handling 

systems, installed at the point of use above the ceiling of a room, or used as 

portable units (MMWR 2003; 52: RR-10). 

Home care. A wide-range of medical, nursing, rehabilitation, hospice and social 

services delivered to patients in their place of residence (e.g., private residence, 

senior living center, assisted living facility). Home health-care services include 

care provided by home health aides and skilled nurses, respiratory therapists, 

dieticians, physicians, chaplains, and volunteers; 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] infection, congenital immune deficiency 

syndromes), chronic diseases such as diabetes mellitus, cancer, emphysema, or 

cardiac failure, ICU care, malnutrition, 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 undergoing allogeneic HSCT and those with 

chronic graft versus host disease are considered 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, resulting in the organism’s proliferation and 

invasion within host tissue(s). Host responses to infection may include clinical 

symptoms or may be subclinical, with manifestations of disease mediated by 

direct organisms pathogenesis and/or a function 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 technology, microbiology, or epidemiology 

and who has acquired special training in infection 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 infection control practices or those mandated 

by regulatory and licensing agencies; application of epidemiologic principles to 

improve patient outcomes; participation in planning renovation and construction 

projects (e.g., to ensure appropriate containment of construction dust); evaluation 

of new products or procedures on patient outcomes; oversight of employee 

health services related to infection prevention; 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. Certification in infection control (CIC) is 

available through the Certification Board of Infection Control and Epidemiology. 

Infection control and prevention program. A multidisciplinary program that 

includes a group of activities to ensure that recommended practices for the 

prevention of healthcare-associated infections are implemented and followed by 

HCWs, making the healthcare setting safe from infection for patients and 
healthcare personnel. The Joint Commission on Accreditation of Healthcare 

Organizations (JCAHO) requires the following five components of an infection 

control program for accreditation: 1) surveillance: monitoring patients and 

healthcare personnel for acquisition of infection and/or colonization; 2) 

investigation: identification and analysis of infection problems or undesirable 

trends; 3) prevention: implementation of measures to prevent transmission of 

infectious agents and to reduce risks for device- and procedure-related 

infections; 4) control: evaluation and management of outbreaks; and 5) reporting: 

provision of information to external agencies as required by state and federal law 

and regulation (www.jcaho.org). The infection control program staff has the 

ultimate authority to determine infection control policies for a healthcare 

organization with the approval of the organization’s governing body. 

Long-term care facilities (LTCFs). An array of residential and outpatient 

facilities designed to meet the bio-psychosocial needs of persons with sustained 

self-care deficits. These include skilled nursing facilities, chronic disease 

hospitals, nursing homes, foster and group homes, institutions for the 

developmentally disabled, residential care facilities, assisted living facilities, 

retirement homes, adult day health care facilities, rehabilitation centers, and longterm psychiatric hospitals. 

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 antimicrobial agents and usually are resistant 

to all but one or two commercially available antimicrobial agents (e.g., MRSA, 

VRE, extended spectrum beta-lactamase [ESBL]-producing or intrinsically 

resistant gram-negative bacilli) 176. 

Nosocomial infection. A term that is derived from two Greek words “nosos” 

(disease) and “komeion” (to take care of) and refers to any infection that 

develops during or as a result of an admission to an acute care facility (hospital) 

and was not incubating at the time of admission. 

Personal protective equipment (PPE). A variety of barriers used alone or in 

combination to protect mucous membranes, skin, and clothing from contact with 

infectious agents. PPE includes gloves, masks, respirators, goggles, face 

shields, and gowns. 

Procedure Mask. A covering for the nose and mouth that is intended for use in 

general patient care situations. These masks generally attach to the face with ear 

loops rather than ties or elastic. Unlike surgical masks, procedure masks are not 

regulated by the Food and Drug Administration. 
Protective Environment. A specialized patient-care area, usually in a hospital, 

that has a positive air flow relative to the corridor (i.e., air flows from the room to 

the outside adjacent space). The combination of high-efficiency particulate air 

(HEPA) filtration, high numbers (>12) of air changes per hour (ACH), and minimal 

leakage of air into the room creates an environment that can safely 

accommodate patients with a severely compromised immune system (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 surfaces instead of materials such as 

upholstery or carpeting, cleaning to prevent dust accumulation, 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 intervention and an outcome but cannot 

achieve the level of confidence concerning attributable benefit obtained through a 

randomized, controlled trial. In hospitals 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 alternative explanations for the result.. Such 

study design is used when it is not logistically feasible or ethically 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 validity of results (Harris et al. CID 2004:38: 

1586). 

Residential care setting. A facility in which people live, minimal medical care is 

delivered, and the psychosocial needs of the residents are provided for. 

Respirator. A personal protective device worn by healthcare personnel to 

protect them from inhalation exposure to airborne infectious agents that are < 5 

μm in size. These include infectious droplet nuclei from patients with M. 

tuberculosis, variola virus [smallpox], SARS-CoV), and dust particles that contain 

infectious particles, such as spores of environmental fungi (e.g., Aspergillus sp.). 

The CDC’s National Institute for Occupational Safety and Health (NIOSH) 

certifies respirators used in healthcare settings 

(www.cdc.gov/niosh/topics/respirators/). The N95 disposable particulate, air 

purifying, respirator is the type used most commonly by healthcare personnel. 

Other respirators used include N-99 and N-100 particulate respirators, powered 

air-purifying respirators (PAPRS) with high efficiency filters; and non-powered 

full-facepiece elastomeric negative pressure respirators. A listing of NIOSHapproved respirators can be found at 

www.cdc.gov/niosh/npptl/respirators/disp_part/particlist.html. Respirators must 

be used in conjunction with a complete Respiratory Protection Program, as 
required by the Occupational Safety and Health Administration (OSHA), that 

includes fit testing, training, proper selection of respirators, medical clearance 

and respirator maintenance. 

Respiratory Hygiene/ Cough Etiquette. A combination of measures designed 

to minimize the transmission of respiratory pathogens via droplet or airborne 

routes in healthcare settings. The components of Respiratory Hygiene/Cough 

Etiquette are 1) covering the mouth and nose during coughing and sneezing, 2) 

using tissues to contain respiratory secretions with prompt disposal into a notouch receptacle, 3) offering a surgical mask to persons who are coughing to 

decrease contamination of the surrounding environment, and 4) turning the head 

away from others and maintaining spatial separation, ideally >3 feet, when 

coughing. These measures are targeted to all patients with symptoms of 

respiratory infection and their accompanying family members or friends 

beginning at the point of initial encounter with a healthcare setting (e.g., 

reception/triage in emergency departments, ambulatory clinics, healthcare 

provider offices) 126 (Srinivasin A ICHE 2004; 25: 1020; 

www.cdc.gov/flu/professionals/infectioncontrol/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 following six organizational components: 1) senior 

management support for safety programs; 2) absence of workplace barriers to 

safe work practices; 3) cleanliness and orderliness of the worksite; 4) minimal 

conflict and good communication among staff members; 5) frequent safetyrelated feedback/training by supervisors; and 6) availability of PPE and 

engineering controls 620. 

Source Control. The process of containing an infectious 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 transmission, (e.g., a draining wound, vesicular 

or bullous skin lesions). Respiratory 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 for local exhaust ventilation (e.g., booths 

for sputum induction or administration 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 sweat, nonintact skin, and mucous membranes may contain 

transmissible infectious agents. Standard Precautions includes hand hygiene, 

and depending on the anticipated exposure, use of gloves, gown, mask, eye 

protection, or face shield. Also, equipment or items in the patient environment 
likely to have been contaminated with infectious fluids must be handled in a 

manner to prevent transmission of infectious agents, (e.g. wear gloves for 

handling, contain heavily soiled equipment, properly clean and disinfect or 

sterilize reusable equipment before use on another patient). 

Surgical mask. A device worn over the mouth and nose by operating room 

personnel during surgical procedures to protect both surgical patients and 

operating room personnel from transfer of microorganisms and body fluids. 

Surgical masks also are used to protect healthcare personnel from contact with 

large infectious droplets (>5 μm in size). According to draft guidance issued by 

the Food and Drug Administration on May 15, 2003, surgical masks are 

evaluated using standardized testing procedures for fluid resistance, bacterial 

filtration efficiency, differential pressure (air exchange), and flammability in order 

to mitigate the risks to health associated with the use of surgical masks. These 

specifications apply to any masks that are labeled surgical, laser, isolation, or 

dental or medical procedure (www.fda.gov/cdrh/ode/guidance/094.html#4). 

Surgical masks do not protect against inhalation of small particles or droplet 

nuclei and should not be confused with particulate respirators that are 

recommended for protection against selected airborne infectious agents, (e.g., 

Mycobacterium tuberculosis). 
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