Isolation Guidelines


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  • Expanded Precautions

    General principles

    In addition to Standard Precautions, use Expanded 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 Alphabetical Listing of Organisms and Diseases).

    Contact precautions

    • Use Contact Precautions as recommended in Alphabetical Listing of Organisms and Diseases for patients with known or suspected infections or evidence of syndromes that represent an increased risk for contact transmission, including colonization or infection with multi-drug resistant organisms (MDROs).
    • Patient placement
      • In acute care settings, place patients who may require Contact Precautions in a single patient room. Apply the following hierarchy of alternatives when single-patient rooms are in short supply:
        • Prioritize patients with conditions that may facilitate transmission (e.g., uncontained drainage, stool incontinence) for single-patient room placement.
        • Place together (cohort) in the same room patients who are infected or colonized with the same pathogen and are suitable roommates (e.g., at low risk for acquiring an infection or for an adverse outcome should transmission occur).
          • Ensure that patients are physically separated (i.e.,>3 feet) from each other. Draw the privacy curtain between beds to minimize opportunity for direct contact.
          • Change protective attire and perform hand hygiene between patients.
           
        • 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).
        • In long-term care settings, make decisions regarding patient placement on a case-by-case basis, balancing infection risks to other patients in the room and the potential adverse psychosocial impact on the infected or colonized patient.
        • In ambulatory settings, place patients who require Contact Precautions in an examination room or cubicle as soon as possible.
         
       
    • Hand hygiene and gloves
      • Observe hand hygiene practices and wear gloves according to Standard Precautions and whenever touching the patient’s intact skin (http://www.cdc.gov/sars/index.html) or surfaces and articles in close proximity to the patient (e.g., medical equipment or bed rails).
       
    • Gowns     
      • Wear a gown whenever anticipating that clothing will have direct contact with the patient or potentially contaminated environmental surfaces or items in the patient's room. Remove the gown and observe hand hygiene before leaving the patient's environment (http://www.cdc.gov/sars/index.html).
      • After gown removal, ensure that clothing and skin do not contact potentially contaminated environmental surfaces to avoid transfer of micro-organisms to other patients or environmental surfaces.
       
    • Patient transport
      • Limit transport and movement of patients outside of the room to medically necessary purposes. When transport is required, ensure that infected or colonized areas of the patient are contained and covered.
      • Remove contaminated PPE and perform hand hygiene prior to transporting patient on contact precautions.
      • Don clean PPE to handle the patient when the transport destination has been reached.
       
    • Patient care equipment
      • Manage patient care equipment according to Standard Precautions
      • Use disposable patient care items (e.g. blood pressure cuffs) wherever possible or implement patient-dedicated use of non-critical equipment to avoid sharing between patients. If use of common equipment or items is unavoidable, clean and disinfect them before use on another patient.
       
    • Environmental measures
      • Ensure that rooms of patients on Contact Precautions are given cleaning priority with a focus on frequent (e.g., at least daily) cleaning and disinfection of high touch surfaces (e.g., bed rails, bedside commodes, faucet handles, doorknobs, carts, charts) and equipment in the immediate vicinity of the patient
       
    • Discontinue Contact Precautions after signs and symptoms have resolved or according to pathogen-specific recommendations in Alphabetical Listing of Organisms and Diseases.

    Droplet precautions

    • Use Droplet Precautions as recommended in Alphabetical Listing of Organisms and Diseases for patients known or suspected to be infected with micro-organisms transmitted by respiratory droplets (large-particle droplets [>5 µm in size] that can be generated by the patient during coughing, sneezing, talking or the performance of cough-inducing procedures)
    • Patient placement
      • In acute care settings, place patients who require Droplet Precautions in a single patient room (http://www.cdc.gov/sars/index.html). Apply the following hierarchy of alternatives when single patient rooms are in short supply:
        • Prioritize patients with conditions that may facilitate transmission (e.g., uncontained drainage, stool incontinence) for single-patient room placement.
        • Place together (cohort) in the same room patients who are infected or colonized with the same organism and are suitable roommates (e.g., low risk for acquiring an infection or at low risk for an adverse outcome should transmission occur).
         
      • Ensure that patients are physically separated (i.e., >3 feet) from each other. Draw the privacy curtain between beds to minimize opportunity for transmission or sharing of items.
      • Change PPE and perform hand hygiene between patients.
        • Avoid placing patients on Droplet Precautions in the same room with patients who are at increased risk for infection (e.g., immunocompromised or have an anticipated prolonged length of stay).
          b. In residential care settings, make decisions regarding patient placement on a case-by-case basis, balancing infection risks to other patients in the room and the potential adverse psychosocial impact on the infected or colonized patient.
         
      • In ambulatory settings, place patients who may require Droplet Precautions in an examination room or cubicle as soon as possible. Instruct patients and accompanying individuals to follow recommendations for respiratory hygiene/cough etiquette.(www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm).
       
    • Mask and eye protection for healthcare personnel
      • Wear a surgical mask for close patient contact (e.g., within 3 feet)
      • No recommendation for wearing eye protection in addition to a surgical mask for close contact with patients who require Droplet Precautions for conditions other than SARS or avian influenza and as recommended for Standard Precautions.
      • For patients with suspected SARS (http://www.cdc.gov/sars/index.html) or Avian influenza (http://www.cdc.gov/flu/avianflu/), wear both eye protection (e.g., goggles or face shield) and respiratory protection (e.g., NIOSH-approved N95 or higher).
       
    • Patient transport
      • Limit movement and transport of the patient outside of the room to medically necessary purposes.
      • Instruct patient to wear a surgical mask and follow respiratory hygiene/cough etiquette during transport.
      • No mask is required for person handling transport.
       
    • Discontinue Droplet Precautions after signs and symptoms have resolved or according to pathogen-specific recommendations in Alphabetical Listing of Organisms and Diseases.

    Airborne infection isolation precautions

    • Use AII as recommended in Alphabetical Listing of Organisms and Diseases for patients known or suspected to be infected with infectious agents transmitted person-to-person by the airborne route e.g., tuberculosis , measles, chicken pox, smallpox, viral hemorrhagic fevers and SARS (http://www.cdc.gov/sars/index.html).
    • Patient placement
      • In acute care hospitals or residential settings, place the patient in an AII that should be a single patient room equipped with the following:
        • Continuous, monitored negative air pressure (2.5 Pa [0.01 inch water gauge]) in relation to the air pressure in the corridor. Monitor air pressure daily with visual indicators (e.g., smoke tubes, flutter strips) placed in the room with the door closed.
        • At least six (existing facility) or 12 (new construction) air changes per hour.
        • Direct exhaust of air to the outside. If it is not possible to exhaust the air from an AII room directly to the outside, the air may be returned through HEPA filters to the air-handling system serving exclusively the isolation room.
        • Keep the room door closed when not required for entry and exit.
        • When a private room is not available or in the event of an outbreak or exposure where large numbers of patients require AII precautions, consult infection control before patient placement to determine the safety of alternative rooms that do not meet engineering requirements for AII and/or cohorting patients together based on clinical diagnosis in areas with the lowest risk of airborne transmission.
         
      • In ambulatory settings:
        • Develop systems (e.g., triage, signs) to identify and segregate patients with known or suspected infections that require AII precautions as soon as possible after entry into a health care setting, including emergency departments (http://www.cdc.gov/sars/index.html).
        • Place a surgical mask on the patient immediately and maintain until the patient has been placed in an AII room.
        • Place patients in appropriately ventilated AII rooms when available. If such rooms are not available, place these patients in an examination room at the farthest distance from other patient rooms, preferably one that is at the end of the ventilation circuit and place a portable HEPA filter in the room. Once the patient leaves, the room should remain vacant for the appropriate time according to the number of air changes per hour, usually one hour, to allow for a full exchange of air.
        • When hospital admission is indicated, place patients with confirmed or suspected airborne-transmitted infections in AII rooms. If AII rooms are not available, transfer to another facility that has AII rooms.
         
       
    • Use of personal protective equipment
      • Restrict susceptible health-care personnel from entering the rooms of patients known or suspected to have measles (rubeola), varicella (chicken pox), or smallpox if other immune health-care personnel are available.
      • Wear fit-tested NIOSH-approved respiratory protection (N95 respirator or higher) when entering the room or home of a patient when the following diseases are suspected or confirmed:
        • Infectious pulmonary or laryngeal tuberculosis or draining tuberculous skin lesions.
        • Smallpox (vaccinated and unvaccinated), viral hemorrhagic fevers, SARS (http://www.cdc.gov/sars/index.html).
          • Respiratory protection is recommended for all health-care personnel, even 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).

            Wear nose/mouth protection upon entering the room of a patient known or suspected of having measles (rubeola), varicella, or disseminated zoster (immune and susceptible) for consistency and because of the difficulties in establishing definite immunity in all health care personnel.
           
        • No recommendation for the type of protection to use (e.g., N95 respirator or surgical mask) for exposure to measles and varicella viruses. 
          • Employees who wear mustaches, beards or sideburns should keep them trimmed appropriately and well groomed. Those who shave their facial hair should make every effort to maintain a clean shaven look. Employees whose jobs require exposure to potentially infectious patients, necessitating use of a respirator are prohibited from having facial hair that interferes with the seal.
           
        • Immunize susceptible persons as soon as possible following contact with a patient with smallpox, measles, or varicella as follows:
          • Administer smallpox vaccine to exposed susceptible persons within 4 days after exposure.
          • Administer measles vaccine to exposed susceptible persons within 72 hours or administer immunoglobulin within 6 days after exposure
          • Administer varicella vaccine to exposed susceptible persons within 120 hours after exposure or administer varicella immune globulin (VZIG) 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 delivery or within 48 hours after delivery.
           
         
       
    • Patient transport
      • Limit the movement and transport of patients who require AII precautions to medically necessary purposes.
      • If transport or movement outside an AII room is necessary, place a surgical mask on the patient. For patients with skin lesions associated with varicella or smallpox or draining skin lesions caused by M. tuberculosis, cover the patient to prevent aerosolization or contact with the infectious agent present in skin lesions.
      • Wear respiratory protection when transporting patients who require AII precautions.
        • Discontinue AII precautions after signs and symptoms have resolved or according to pathogen-specific recommendations in Alphabetical Listing of Organisms and Disease.
        • For additional guidance in management of patients with suspected or confirmed tuberculosis, see Management of Tuberculosis Suspects.
        • Protective Environment (PE) (Table 1)

    Protective eyewear (table 1)

    • Place allogeneic hematopoietic stem cell transplant (HSCT) patients in a PE as defined in the “Guideline to Prevent Opportunistic Infections in HSCT Patients," the “Guideline for Environmental Infection Control in Health-Care Facilities” and the “Guidelines for Preventing Health-Care-Associated Pneumonia, 2003” to reduce exposure to environmental fungi, (e.g. Aspergillus sp)
    • No recommendation for placing other patients identified in a facility as being at increased risk for environmental fungal infections, (e.g., aspergillosis) in a PE.
    • For patients who require a PE, implement the following components (Table 5):
      • Filtered incoming air using central or point-of-use high efficiency particulate air (HEPA) filters capable of removing 99.7% of particles 0.3 µm in diameter (the most penetrating particle size)
      • Directed room airflow with supply on one side of the room across the patient and out through exhaust on the other side of the room.
      • Positive air pressure in room relative to the corridor (pressure differential of >2.5 Pa [0.01-inch water gauge])
      • Well-sealed rooms to prevent infiltration of air from the outside.
      • At least 12 air changes per hour.
      • Lowered dust levels by using smooth surfaces and finishes that can be scrubbed rather than textured materials, (i.e. carpet, upholstery, cloth), wet dusting of horizontal surfaces, and routinely cleaning crevices and sprinkler heads.
      • Avoidance of carpeting in hallways and patient rooms in areas housing immunocompromised patients.
      • Use of vacuum cleaner equipped with HEPA filters.
      • Prohibition of dried and fresh flowers and potted plants.
       
    • Minimize the length of time that patients who require a PE are outside their rooms for diagnostic procedures and other activities
      • 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 PE. Ensure that patients are instructed on respirator use.
      • No recommendation on fit testing of patients who are using respirators. unresolved issue
      • In the absence of construction, no recommendation for use of particulate respirators when leaving the PE.
    • Take measures to protect patients who require a PE room and who also have an airborne infectious disease (e.g. tuberculosis, acute varicella-zoster).
      • Ensure that the patient’s room is designed to maintain positive pressure
      • Use an anteroom to ensure appropriate air-balance relationships and 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.
      • If an anteroom is not available, place the patient in an AII room and use portable, industrial-grade HEPA filters to enhance filtration of spores in the room.
       
    • Use PPE (e.g., gloves, gown and mask) according to Standard Precautions. Use Expanded Precautions only if the patient has a suspected or proven infection for which Expanded Precautions is indicated.