2007 Guideline for Isolation Precautions

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

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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

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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

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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

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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

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