NurseReview.Org - Precautions

TRANSMISSION-BASED PRECAUTIONS ISOLATION PRECAUTION GUIDELINES FOR HOSPITALS KEY CONCEPTS you will learn include: • What the reasons for the new Transmission-Based Precautions are • What Transmission-Based Precautions are designed to do • What preventive processes and practices are recommended for each route of infection transmission • How to effectively use Transmission-Based Precautions BACKGROUND Although the spread of infectious diseases in hospitals has been recognized for many years, understanding how to prevent nosocomial infections and implementing policies and practices that are successful has been more difficult. The transmission of nosocomial infections requires three elements: a source of infecting microorganisms, a susceptible host and a mode of transmission. The human source of nosocomial infections may be patients, hospital personnel or, less often, visitors. These people may have infectious diseases, be in the incubation period (no symptoms), or may be chronic carriers. Other sources of infecting microorganisms are inanimate objects that become contaminated, (e.g., instruments) and the environment, including air and water. Susceptible hosts are those patients, hospital personnel and, less often, visitors who may become infected. Resistance among people to infecting microorganisms varies; for example, some are immune, others get infected and become asymptomatic carriers; and still others get infected and develop a clinical disease. Factors such as age, underlying diseases, treatment with certain drugs (e.g., antimicrobials, corticosteroids and other immunosupressive agents) and irradiation play a role in this process. The three main routes of infection transmission in hospitals are airborne, droplet and contact. An infecting microorganism, however, can be transmitted by more than one route. For example, varicella (chicken pox) is transmitted both by the airborne and contact route at different stages of the disease. The purpose of this is to explain how Transmission-Based Precautions are used in the hospital to minimize the risk of clients, patients, visitors and staff becoming infected while dealing with the healthcare system. 1

Transmission-Based Precautions: Isolation Precaution Guidelines for Hospitals DEFINITIONS • Airborne transmission. Transfer of particles 5 µm or less in size into the air, either as airborne droplets or dust particles containing the infectious microoganism; can be produced by coughing, sneezing, talking or procedures such as bronchoscopy or suctioning; can remain in the air for up to several hours and be spread widely within a room or over longer distances. Special air handling and ventilation are needed to prevent airborne transmission. • Droplet transmission. Contact of the mucous membranes of the nose, mouth or conjunctivae of the eye with infectious particles larger than 5 µm in size; can be produced by coughing, sneezing, talking or procedures such as bronchoscopy or suctioning. Droplet transmission requires close contact between the source and the susceptible person because particles remain airborne briefly and travel only about 3 feet (1 meter) or less. • Contact transmission. Infectious agent (bacteria, virus or parasite) transmitted directly or indirectly from one infected or colonized person to a susceptible host (patient), often on the contaminated hands of a health worker. • Colonization. Pathogenic (illness- or disease-causing) organisms are present in a person (i.e., they can be detected by culturing or other tests) but are not causing symptoms or clinical findings (i.e., cellular changes or damage). Coming in contact with and acquiring new organisms, while increasing the risk of infection, usually does not lead to infection because the body’s natural defense mechanism (the immune system) is able to tolerate and/or destroy them. Thus, when organisms are transmitted from one person to another, colonization rather than infection is generally the result. Colonized persons, however, can be a major source of transfer of pathogens to other persons (cross-contamination) especially if the organisms persist in the person (chronic carrier), such as with HIV, HBV and HCV TRANSMISSION-BASED PRECAUTIONS The new isolation guidelines issued by CDC in 1996 involve a two-level Note: Protective isolation approach: Standard Precautions, which apply to all clients and patients of immunocompromised attending healthcare facilities, and Transmission-Based Precautions, patients, such as those with which apply only to hospitalized patients (Garner and HICPAC 1996). AIDS, is not an effective way to reduce the risk of This new system retains the best features of both Universal Precautions cross-infection (Manangan (UP) and Body Substance Isolation (BSI) and replaces the cumbersome et al 2001). disease-specific isolation precautions with three sets of Transmission- Based Precautions (air, droplet or contact). 2

Transmission-Based Precautions: Isolation Precaution Guidelines for Hospitals In all situations, whether used alone or in combination, Transmission-Based Precautions must be used in conjunction with the Standard Precautions (Garner and HICPAC 1996). Airborne Precautions These precautions are designed to reduce the nosocomial transmission of particles 5 µm or less in size that can remain in the air for several hours and be widely dispersed (Table 1). Microorganisms spread wholly or partly by the airborne route include tuberculosis (TB), chicken pox (varicella virus) and measles (rubeola virus). Airborne precautions are recommended for patients with either known or suspected infections with these agents. For example, an HIV-infected person with a cough, night sweats or fever, and clinical or x-ray findings in the lungs should go on airborne precautions until TB is ruled out. Where TB is prevalent, it is important to have a mechanism to quickly assess patients with suspected TB because delayed diagnosis, resulting in lack of isolation, has been shown to be an important factor in hospital- based transmission. In this situation, airborne precautions are the last defense in reducing the risk of TB transmission. Table 1. Airborne Precautions Used in addition to Standard Precautions for a patient known or suspected to be infected with microorganisms transmitted by the airborne route. PATIENT PLACEMENT • Private room. • Door closed. • Room air is exhausted to the outside (negative air pressure) using fan or other filtration system. • If private room not available, place patient in room with patient having active infection with the same disease, but with no other infection. RESPIRATORY PROTECTION • Wear face shield (or goggles and surgical mask) • If TB known or suspected, wear particulate respirator (if available). • If chicken pox or measles: - Immune persons, no mask required. - Susceptible persons, do not enter room. • Remove PPE (face shield) after leaving the room and place in a plastic bag or waste container with tight-fitting lid. PATIENT TRANSPORT • Limit transport of patient to essential purposes only. • During transport, patient must wear surgical mask. • Notify area receiving patient. Adapted from: Infection Control Signs, www.etnacomm.com, ETNA Communications, Chicago, IL. Copyright 2000. 3

Transmission-Based Precautions: Isolation Precaution Guidelines for Hospitals Droplet Precautions These precautions reduce the risks for nosocomial transmission of pathogens spread wholly or partly by droplets larger than 5 µm in size (e.g., H. influenzae and N. meningitides meningitis; M. pneumoniae, flu, mumps and rubella viruses). Other conditions include diphtheria, pertussis (whooping cough), pneumonic plague and strep pharyngitis (scarlet fever in infants and young children). Droplet precautions are simpler than airborne precautions because the particles only remain in the air for a short time and travel only a few feet; therefore, contact with the source must be close for a susceptible host to become infected (Table 2). Table 2. Droplet Precautions Use in addition to Standard Precautions for a patient known or suspected to be infected with microorganisms transmitted by large-particle droplets (larger than 5 µm). PATIENT PLACEMENT • Private room; door may be left open. • If private room not available, place patient in room with patient having active infection with the same disease, but with no other infection. • If neither option is available, maintain separation of at least 3 feet between patients. RESPIRATORY PROTECTION • Wear mask if within three feet of patient. PATIENT TRANSPORT • Limit transport of patient to essential purposes only. • During transport, patient must wear surgical mask. • Notify area receiving patient. Adapted from: Infection Control Signs, www.etnacomm.com, ETNA Communications, Chicago, IL. Copyright 2000. Contact Precautions These precautions reduce the risk of transmission of organisms from an infected or colonized patient through direct or indirect contact (Table 3). They are indicated for patients infected or colonized with enteric pathogens (hepatitis A or echo viruses), herpes simplex and hemorrhagic fever viruses and multidrug (antibiotic)-resistant bacteria. Interestingly, chicken pox is spread both by the airborne and contact routes at different stages of the illness. Among infants there are a number of viruses transmitted by direct contact. In addition, Contact Precautions should be implemented for patients with skin or eye infections that may be contagious (e.g., draining abscesses, skin infections that are wet and draining, herpes zoster, impetigo, conjunctivitis, scabies, lice and wound infections). 4

Transmission-Based Precautions: Isolation Precaution Guidelines for Hospitals Table 3. Contact Precautions Use in addition to Standard Precautions for a patient known or suspected to be infected or colonized with microorganisms transmitted by direct contact with the patient or indirect contact with environmental surfaces or patient care items. PATIENT PLACEMENT • Private room; door may be left open. • If private room not available, place patient in room with patient having active infection with the same microorganism, but with no other infection. GLOVING • Wear clean, nonsterile examination gloves when entering room. • Change gloves after contact with infective material (e.g., fecal materials or wound drainage). • Remove gloves before leaving patient room. HANDWASHING • Wash hands with antibacterial agent or use alcohol-based handrub after removing gloves. • Do not touch potentially contaminated surfaces or items before leaving the room. GOWNS AND PROTECTIVE APPAREL • Wear clean, nonsterile gown when entering patient room if you anticipate contact with patient or if the patient is incontinent, has diarrhea, an ileostomy, colostomy or wound drainage not contained by a dressing. • Remove gown before leaving room. Do not allow clothing to contact potentially contaminated surfaces or items before leaving the room. PATIENT TRANSPORT • Limit transport of patient to essential purposes only. • During transport, ensure precautions are maintained to minimize risk of transmission of organisms. PATIENT CARE EQUIPMENT • Reserve noncritical patient care equipment for use with a single patient, if possible. • Clean and disinfect any equipment shared among infected and noninfected patients. Adapted from: Infection Control Signs, www.etnacomm.com, ETNA Communications, Chicago, IL. Copyright 2000. 5

Transmission-Based Precautions: Isolation Precaution Guidelines for Hospitals Empiric Use of In certain circumstances, if there is any question of an infectious process in Transmission-Based a patient without a known diagnosis, implementing Transmission-Based Precautions Precautions should be considered on an empiric basis until a definitive diagnosis is made. Examples of the “empiric use” of Transmission-Based Precautions as they apply to the three routes (air, droplet and contact) are illustrated in Table 4. In addition, a complete listing of clinical syndromes or conditions warranting the empiric use of Transmission-Based Precautions is shown in Table 5. From time to time and based on local conditions, other important infectious diseases should be considered for addition to this list. Table 4. Empiric Use of Transmission Based Precautions AIRBORNE DROPLET CONTACT • • • rashes (vesicule or meningitis (fever, acute diarrhea in an pustule) vomiting and stiff incontinent or • neck) diapered patient cough, fever and upper • • lobe chest findings hemorrhagic rash with diarrhea in adult with (dullness and fever history of recent • decreased breath antibiotic use severe, persistent • sounds) bronchitis and croup cough during periods • cough, fever and chest when pertussis is in infants and young findings in any area in present in community children • • HIV-infected person or generalized rash of history of infection at high-risk for HIV unknown cause with multi-resistant organisms (except tuberculosis) • abscess or draining wound that cannot be covered The use of Transmission-Based Precautions, including their empiric use in selected circumstances, is designed to reduce the risk of airborne-, droplet- Note: Unfortunately, Unfortunately and contact-transmitted infections between hospitalized patients and “reminder signs” for healthcare staff. To assist health workers in correctly implementing the isolation patients do not increase use (compliance) appropriate precautions, Table 6 provides a summary of the types of with infection precautions isolation precautions and the illnesses for which each type of precaution is (Manangan et al 2001). recommended. In addition, Appendix I provides a complete listing of the types and duration of the isolation precautions needed for the vast majority of infectious diseases. 6

Transmission-Based Precautions: Isolation Precaution Guidelines for Hospitals Table 5. Clinical Syndromes or Conditions to Be Considered for “Empiric Use” of Transmission-Based Precautions CLINICAL SYNDROME OR CONDITIONA POTENTIAL EMPIRIC PATHOGENSB PRECAUTIONS Diarrhea Enteric pathogens c Acute diarrhea with a likely infectious cause in an incontinent or Contact diapered patient Diarrhea in an adult with a history of recent antibiotic use Clostridium difficile Contact Meningitis Neisseria meningitidis Droplet Rash or exanthems, generalized, etiology unknown Petechial/ecchymotic with fever Neisseria meningitidis Droplet Vesicular Varicella (chicken pox) Airborne and Contact Maculopapular with coryza and fever Rubeola (measles) Airborne Respiratory infections Cough/fever/upper lobe pulmonary infiltrate in an HIV-negative Mycobacterium Airborne patient or a patient at low risk for HIV infection tuberculosis Cough/fever/pulmonary infiltrate in any lung location in an HIV- Mycobacterium Airborne infected patient or a patient at high risk for HIV infection tuberculosis Paroxysmal or severe persistent cough during periods of Bordetella pertussis Droplet pertussis activity Respiratory infections, particularly bronchiolitis and croup, in Respiratory syncytial or Contact infants and young children parainfluenza virus Risk of multidrug-resistant microorganisms Resistant bacteriad History of infection or colonization with multidrug-resistant Contact organisms d Resistant bacteriad Skin, wound, or urinary tract infection in a patient with a recent Contact hospital or nursing home stay in a facility where multidrug- resistant organisms are prevalent Skin or wound infection Staphylococcus aureus, Contact group A streptococcus a Patients with the syndromes or conditions listed below may present with atypical signs or symptoms (e.g., pertussis in neonates and adults may not have paroxysmal or severe cough). The clinician's index of suspicion should be guided by the prevalence of specific conditions in the community, as well as clinical judgment. b The organisms listed under the column “Potential Pathogens” are not intended to represent the complete, or even most likely, diagnoses, but rather possible etiologic agents that require additional precautions beyond Standard Precautions until they can be ruled out. c These pathogens include enterohemorrhagic Escherichia coli O157:H7, Shigella, hepatitis A, and rotavirus. d Resistant bacteria judged by the infection control program, based on current state, regional, or national recommendations, to be of special clinical or epidemiological significance. Adapted from: Garner and HICPAC 1996. 7

Transmission-Based Precautions: Isolation Precaution Guidelines for Hospitals Table 6. Summary of Types of Precautions and Patients Requiring the Precautions Standard Precautions Use Standard Precautions for the care of all patients. Airborne Precautions In addition to Standard Precautions, use Airborne Precautions for patients known or suspected to have serious illnesses transmitted by airborne droplet nuclei. Examples of such illnesses include: Measles Varicella (including disseminated zoster)a Tuberculosis b Droplet Precautions In addition to Standard Precautions, use Droplet Precautions for patients known or suspected to have serious illnesses transmitted by large particle droplets. Examples of such illnesses include: Invasive Haemophilus influenzae type b disease, including meningitis, pneumonia, epiglottitis, and sepsis Invasive Neisseria meningitidis disease, including meningitis, pneumonia, and sepsis Other serious bacterial respiratory infections spread by droplet transmission, including: Diphtheria (pharyngeal) Mycoplasma pneumonia Pertussis Pneumonic plague Streptococcal (group A) pharyngitis, pneumonia, or scarlet fever in infants and young children Serious viral infections spread by droplet transmission, including: Adenovirus a Influenza Mumps Parvovirus B19 Rubella Contact Precautions In addition to Standard Precautions, use Contact Precautions for patients known or suspected to have serious illnesses easily transmitted by direct patient contact or by contact with items in the patient's environment. Examples of such illnesses include: Gastrointestinal, respiratory, skin, or wound infections or colonization with multidrug-resistant bacteria judged by the infection control program, based on current state, regional, or national recommendations, to be of special clinical and epidemiologic significance. Enteric infections with a low infectious dose or prolonged environmental survival, including: Clostridium difficile For diapered or incontinent patients: enterohemorrhagic Escherichia coli O157:H7, Shigella, hepatitis A, or rotavirus Respiratory syncytial virus, parainfluenza virus, or enteroviral infections in infants and young children Skin infections that are highly contagious or that may occur on dry skin, including: Diphtheria (cutaneous) Herpes simplex virus (neonatal or mucocutaneous) Impetigo Major (noncontained) abscesses, cellulitis, or decubiti Pediculosis Scabies Staphylococcal furunculosis in infants and young children Zoster (disseminated or in the immunocompromised host)† Viral/hemorrhagic conjunctivitis Viral hemorrhagic infections (Ebola, Lassa, or Marburg)* * See the Appendix for a complete listing of infections requiring precautions, including appropriate footnotes. a Certain infections require more than one type of precaution. b See CDC “Guidelines for Preventing the Transmission of Tuberculosis in Health-Care Facilities.” Adapted from: Garner and HICPAC 1996. 8

Type and Duration of Precautions Needed for Selected Infections and Conditions REFERENCES Garner JS and The Hospital Infection Control Practices Advisory Committee (HICPAC). 1996. Guideline for isolation precautions in hospitals. Infect Control Hosp Epidemiol 17(1): 53–80 and Am J Infect Control 24(1): 24–52. Infection Control Signs, www.etnacomm.com, ETNA Communications, Chicago, IL. Copyright 2000. Manangan LP et al. 2001. Infection control dogma: top 10 suspects. Infect. Control Hosp Epidemiol 22(4): 243-247. 9

Type and Duration of Precautions Needed for Selected Infections and Conditions APPENDIX TYPE AND DURATION OF PRECAUTIONS NEEDED FOR SELECTED INFECTIONS AND CONDITIONS1 Precautions Type * Duration† Infection/Condition Abscess Draining, major a C DI Draining, minor or limited b S Acquired immunodeficiency syndrome c S Actinomycosis S Adenovirus infection, in infants and young children D,C DI Amebiasis S Anthrax Cutaneous S Pulmonary S Antibiotic-associated colitis (see Clostridium difficile) Arthropodborne viral encephalitides (eastern, western, Venezuelan equine Sd encephalomyelitis; St Louis, California encephalitis) Sd Arthropodborne viral fevers (dengue, yellow fever, Colorado tick fever) Ascariasis S Aspergillosis S Babesiosis S Blastomycosis, North American, cutaneous or pulmonary S Botulism S Bronchiolitis (see respiratory infections in infants and young children) Brucellosis (undulant, Malta, Mediterranean fever) S Campylobacter gastroenteritis (see gastroenteritis) Candidiasis, all forms including mucocutaneous S Cat-scratch fever (benign inoculation lymphoreticulosis) S Cellulitis, uncontrolled drainage C DI Chancroid (soft chancre) S Chickenpox (varicella; see F e for varicella exposure) Fe A,C Chlamydia trachomatis Conjunctivitis S Genital S Respiratory S Cholera (see gastroenteritis) Closed-cavity infection Draining, limited or minor S Not draining S Clostridium C botulinum S C difficile C DI C perfringens 1 Source: Garner JS and HICPAC 1996. 10

Type and Duration of Precautions Needed for Selected Infections and Conditions Precautions * Duration† Infection/Condition Type Food poisoning S Gas gangrene S Coccidioidomycosis (valley fever) Draining lesions S Pneumonia S Colorado tick fever S Ff Congenital rubella C Conjunctivitis Acute bacterial S Chlamydia S Gonococcal S Acute viral (acute hemorrhagic) C DI Coxsackievirus disease (see enteroviral infection) Sg Creutzfeldt-Jakob disease Croup (see respiratory infections in infants and young children) Cryptococcosis S Cryptosporidiosis (see gastroenteritis) Cysticercosis S Cytomegalovirus infection, neonatal or immunosuppressed S Decubitus ulcer, infected Major a C DI Minor or limited b S Sd Dengue Diarrhea, acute-infective etiology suspected (see gastroenteritis) Diphtheria CN h Cutaneous C CN h Pharyngeal D Ci Ebola viral hemorrhagic fever DI Echinococcosis (hydatidosis) S Echovirus (see enteroviral infection) Encephalitis or encephalomyelitis (see specific etiologic agents) Endometritis S Enterobiasis (pinworm disease, oxyuriasis) S Enterococcus species (see multidrug-resistant organisms if epidemiologically significant or vancomycin resistant) Enterocolitis, Clostridium difficile C DI Enteroviral infections Adults S Infants and young children C DI Epiglottitis, due to Haemophilus influenzae D U(24 hrs) Epstein-Barr virus infection, including infectious mononucleosis S Erythema infectiosum (also see Parvovirus B19) S Escherichia coli gastroenteritis (see gastroenteritis) Food poisoning Botulism S Clostridium perfringens or welchii S Staphylococcal S Furunculosis-staphylococcal 11

Type and Duration of Precautions Needed for Selected Infections and Conditions Precautions * Duration† Infection/Condition Type Infants and young children C DI Gangrene (gas gangrene) S Gastroenteritis Sj Campylobacter species Sj Cholera Clostridium difficile C DI Sj Cryptosporidium species Escherichia coli Sj Enterohemorrhagic O157:H7 Diapered or incontinent C DI Sj Other species Sj Giardia lamblia Sj Rotavirus Diapered or incontinent C DI Sj Salmonella species (including S typhi) Sj Shigella species Diapered or incontinent C DI Sj Vibrio parahaemolyticus Sj Viral (if not covered elsewhere) Sj Yersinia enterocolitica German measles (see rubella) Giardiasis (see gastroenteritis) Gonococcal ophthalmia neonatorum (gonorrheal ophthalmia, acute conjunctivitis of S newborn) Gonorrhea S Granuloma inguinale (donovanosis, granuloma venereum) S Guillain-Barré‚ syndrome S Hand, foot, and mouth disease (see enteroviral infection) Hantavirus pulmonary syndrome S Helicobacter pylori S Ci Hemorrhagic fevers (for example, Lassa and Ebola) DI Hepatitis, viral Type A S Fk Diapered or incontinent patients C Type B-HBsAg positive S Type C and other unspecified non-A, non-B S Type E S Herpangina (see enteroviral infection) Herpes simplex (Herpesvirus hominis) Encephalitis S Neonatal l (see F l for neonatal exposure) C DI Mucocutaneous, disseminated or primary, severe C DI Mucocutaneous, recurrent (skin, oral, genital) S Herpes zoster (varicella-zoster) DI m Localized in immunocompromised patient, or disseminated A,C Sm Localized in normal patient Histoplasmosis S HIV (see human immunodeficiency virus) S 12

Type and Duration of Precautions Needed for Selected Infections and Conditions Precautions * Duration† Infection/Condition Type Hookworm disease (ancylostomiasis, uncinariasis) S Human immunodeficiency virus (HIV) infection c S Impetigo C U (24 hrs) Infectious mononucleosis S Dn Influenza DI Kawasaki syndrome S Ci Lassa fever DI Legionnaires' disease S Leprosy S Leptospirosis S Lice (pediculosis) C U (24 hrs) Listeriosis S Lyme disease S Lymphocytic choriomeningitis S Lymphogranuloma venereum S Sd Malaria Ci Marburg virus disease DI Measles (rubeola), all presentations A DI Melioidosis, all forms S Meningitis Aseptic (nonbacterial or viral meningitis; also see enteroviral infections) S Bacterial, gram-negative enteric, in neonates S Fungal S Haemophilus influenzae, known or suspected D U(24 hrs) Listeria monocytogenes S Neisseria meningitidis (meningococcal) known or suspected D U(24 hrs) Pneumococcal S Tuberculosis o S Other diagnosed bacterial S Meningococcal pneumonia D U(24 hrs) Meningococcemia (meningococcal sepsis) D U(24 hrs) Molluscum contagiosum S Mucormycosis S Multidrug-resistant organisms, infection or colonization p Gastrointestinal C CN Respiratory C CN Pneumococcal S Skin, wound, or burn C CN Fq Mumps (infectious parotitis) D Mycobacteria, nontuberculosis (atypical) Pulmonary S Wound S Mycoplasma pneumonia D DI Necrotizing enterocolitis S Nocardiosis, draining lesions or other presentations S Norwalk agent gastroenteritis (see viral gastroenteritis) Orf S Parainfluenza virus infection, respiratory in infants and young children C DI 13

Type and Duration of Precautions Needed for Selected Infections and Conditions Precautions * Duration† Infection/Condition Type Fr Parvovirus B19 D Pediculosis (lice) C U(24 hrs) Fs Pertussis (whooping cough) D Pinworm infection S Plague Bubonic S Pneumonic D U(72 hrs) Pleurodynia (see enteroviral infection) Pneumonia Adenovirus D,C DI Bacterial not listed elsewhere (including gram-negative bacterial) S Burkholderia cepacia in cystic fibrosis (CF) patients, St including respiratory tract colonization Chlamydia S Fungal S Haemophilus influenzae Adults S Infants and children (any age) D U(24 hrs) Legionella S Meningococcal D U(24 hrs) Multidrug-resistant bacterial (see multidrug-resistant organisms) Mycoplasma (primary atypical pneumonia) D DI Pneumococcal S Multidrug-resistant (see multidrug-resistant organisms) Su Pneumocystis carinii St Pseudomonas cepacia (see Burkholderia cepacia) Staphylococcus aureus S Streptococcus, group A Adults S Infants and young children D U(24hrs) Viral Adults S Infants and young children (see respiratory infectious disease, acute) Poliomyelitis S Psittacosis (ornithosis) S Q fever S Rabies S Rat-bite fever (Streptobacillus moniliformis disease, Spirillum minus disease) S Relapsing fever S Resistant bacterial infection or colonization (see multidrug-resistant organisms) Respiratory infectious disease, acute (if not covered elsewhere) Adults S Infants and young children c C DI Respiratory syncytial virus infection, in infants and C DI young children, and immunocompromised adults Reye's s yndrome S Rheumatic fever S Rickettsial fevers, tickborne (Rocky Mountain spotted fever, tickborne typhus fever) S 14

Type and Duration of Precautions Needed for Selected Infections and Conditions Precautions * Duration† Infection/Condition Type Rickettsialpox (vesicular rickettsiosis) S Ringworm (dermatophytosis, dermatomycosis, tinea) S Ritter's disease (staphylococcal scalded skin syndrome) S Rocky Mountain spotted fever S Roseola infantum (exanthem subitum) S Rotavirus infection (see gastroenteritis) Fv Rubella (German measles; also see congenital rubella) D Salmonellosis (see gastroenteritis) Scabies C U(24 hrs) Scalded skin syndrome, staphylococcal (Ritter's disease) S Schistosomiasis (bilharziasis) S Shigellosis (see gastroenteritis) Sporotrichosis S Spirillum minus disease (rat-bite fever) S Staphylococcal disease (S aureus) Skin, wound, or burn Major a C DI Minor or limited b S Sj Enterocolitis Multidrug-resistant (see multidrug-resistant organisms) Pneumonia S Scalded skin syndrome S Toxic shock syndrome S Streptobacillus moniliformis disease (rat-bite fever) S Streptococcal disease (group A streptococcus) Skin, wound, or burn Major a C U(24 hrs) Minor or limited b S Endometritis (puerperal sepsis) S Pharyngitis in infants and young children D U(24 hrs) Pneumonia in infants and young children D U(24 hrs) Scarlet fever in infants and young children D U(24 hrs) 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 Skin and mucous membrane, including congenital, primary, secondary S Latent (tertiary) and seropositivity without lesions S Tapeworm disease Hymenolepis nana S Taenia solium (pork) S Other S Tetanus S Tinea (fungus infection dermatophytosis, dermatomycosis, ringworm) S Toxoplasmosis S Toxic shock syndrome (staphylococcal disease) S Trachoma, acute S 15

Type and Duration of Precautions Needed for Selected Infections and Conditions Precautions * Duration† Infection/Condition Type Trench mouth (Vincent's angina) S Trichinosis S Trichomoniasis S Trichuriasis (whipworm disease) S Tuberculosis Extrapulmonary, draining lesion (including scrofula) S Extrapulmonary, meningitis o S Fw Pulmonary, confirmed or suspected or laryngeal disease A Skin-test positive with no evidence of current pulmonary disease S Tularemia Draining lesion S Pulmonary S Typhoid (Salmonella typhi) fever (see gastroenteritis) Typhus, endemic and epidemic S Urinary tract infection (including pyelonephritis), with or without urinary catheter S Fe Varicella (chickenpox) A,C Vibrio parahaemolyticus (see gastroenteritis) Vincent's angina (trench mouth) S Viral diseases Respiratory (if not covered elsewhere) Adults S Infants and young children (see respiratory infectious disease, acute) Fs Whooping cough (pertussis) D Wound infections Major a C DI Minor or limited b S Yersinia enterocolitica gastroenteritis (see gastroenteritis) Zoster (varicella-zoster) DI m Localized in immunocompromised patient, disseminated A,C Sm Localized in normal patient Zygomycosis (phycomycosis, mucormycosis) S 16

Isolation Precaution Guidelines for Hospitals Abbreviations: * Type of Precautions: A, Airborne; C, Contact; D, Droplet; S, Standard; when A, C, and D are specified, also use S. † Duration of precautions: CN, until off antibiotics and culture-negative; DI, duration of illness (with wound lesions, DI means until they stop draining); U, until time specified in hours (hrs) after initiation of effective therapy; F, see footnote. a No dressing or dressing does not contain drainage adequately. b Dressing covers and contains drainage adequately. c Also see syndromes or conditions listed in Table 2. d Install screens in windows and doors in endemic areas. e Maintain precautions until all lesions are crusted. The average incubation period for varicella is 10 to 16 days, with a range of 10 to 21 days. After exposure, use varicella zoster immune globulin (VZIG) when appropriate, and discharge susceptible patients if possible. Place exposed susceptible patients on Airborne Precautions beginning 10 days after exposure and continuing until 21 days after last exposure (up to 28 days if VZIG has been given). Susceptible persons should not enter the room of patients on precautions if other immune caregivers are available. f Place infant on precautions during any admission until 1 year of age, unless nasopharyngeal and urine cultures are negative for virus after age 3 months. g Additional special precautions are necessary for handling and decontamination of blood, body fluids and tissues, and contaminated items from patients with confirmed or suspected disease. See latest College of American Pathologists (Northfield, Illinois) guidelines or other references. h Until two cultures taken at least 24 hours apart are negative. i Call state health department and CDC for specific advice about management of a suspected case. During the 1995 Ebola outbreak in Zaire, interim recommendations were published.(97) Pending a comprehensive review of the epidemiologic data from the outbreak and evaluation of the interim recommendations, the 1988 guidelines for management of patients with suspected viral hemorrhagic infections (16) will be reviewed and updated if indicated. j Use Contact Precautions for diapered or incontinent children <6 years of age for duration of illness. k Maintain precautions in infants and children <3 years of age for duration of hospitalization; in children 3 to 14 years of age, until 2 weeks after onset of symptoms; and in others, until 1 week after onset of symptoms. l For infants delivered vaginally or by C-section and if mother has active infection and membranes have been ruptured for more than 4 to 6 hours. m Persons susceptible to varicella are also at risk for developing varicella when exposed to patients with herpes zoster lesions; therefore, susceptibles should not enter the room if other immune caregivers are available. n The quot;Guideline for Prevention of Nosocomial Pneumoniaquot; (95,96) recommends surveillance, vaccination, antiviral agents, and use of private rooms with negative air pressure as much as feasible for patients for whom influenza is suspected or diagnosed. Many hospitals encounter logistic difficulties and physical plant limitations when admitting multiple patients with suspected influenza during community outbreaks. If sufficient private rooms are unavailable, consider cohorting patients or, at the very least, avoid room sharing with high-risk patients. See “Guideline for Prevention of Nosocomial Pneumonia” (95,96) for additional prevention and control strategies. o Patient should be examined for evidence of current (active) pulmonary tuberculosis. If evidence exists, additional precautions are necessary (see tuberculosis). p Resistant bacteria judged by the infection control program, based on current state, regional, or national recommendations, to be of special clinical and epidemiologic significance. q For 9 days after onset of swelling. r Maintain precautions for duration of hospitalization when chronic disease occurs in an immunodeficient patient. For patients with transient aplastic crisis or red-cell crisis, maintain precautions for 7 days. s Maintain precautions until 5 days after patient is placed on effective therapy. t Avoid cohorting or placement in the same room with a CF patient who is not infected or colonized with B cepacia. Persons with CF who visit or provide care and are not infected or colonized with B cepacia may elect to wear a mask when within 3 ft of a colonized or infected patient. u Avoid placement in the same room with an immunocompromised patient. v Until 7 days after onset of rash. w Discontinue precautions only when TB patient is on effective therapy, is improving clinically, and has three consecutive negative sputum smears collected on different days, or TB is ruled out. Also see CDC “Guidelines for Preventing the Transmission of Tuberculosis in Health-Care Facilities.”(23) REFERENCES Garner JS and The Hospital Infection Control Practices Advisory Committee (HICPAC). 1996. Guideline for isolation precautions in hospitals. Infect Control Hosp Epidemiol 17(1): 53–80, and Am J Infect Control 24(1): 24–52. 17

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