July 3, 2007 — The US Centers for Disease Control and Prevention (CDC) have revised their guidelines for preventing transmission of infectious agents in hospitals and healthcare settings. The new "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 revised guidelines are addressed to infection control staff, healthcare epidemiologists, healthcare administrators, nurses, other healthcare providers, and other persons responsible for developing, implementing, and evaluating infection control programs in a variety of healthcare settings.
"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," write Jane D. Siegel, MD, and colleagues from the Healthcare Infection Control Practices Advisory Committee. "The emergence of new pathogens (e.g., SARS-CoV [coronavirus] associated with the severe acute respiratory syndrome [SARS], Avian influenza in humans), renewed concern for evolving known pathogens (e.g., C. [Clostridium] difficile, noroviruses, community-associated MRSA [CA-MRSA [methicillin-resistant Staphylococcus aureus]), 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."
The Standard Precautions recommendations first introduced in the 1996 guideline are reinforced as the foundation for preventing transmission of infectious agents in all healthcare settings. New additions to these recommendations 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.
Increasing evidence that environmental controls lower the risk for life-threatening fungal infections in the most severely immunocompromised patients led to updated recommendations on the components of the Protective Environment (PE). The revised guidelines emphasize administrative involvement in the development and support of infection control programs to improve adherence to recommended infection control practices.
"Continued increase in the incidence of HAIs [healthcare-associated infections] 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," the authors write.
The guidelines describe specific infection control considerations for high-priority (CDC category A) diseases that may result from bioterrorist attacks or that are considered to be bioterrorist threats. These include anthrax, botulism, Ebola hemorrhagic fever, plague, smallpox, and tularemia.
Specific Standard Precautions recommendations for all patients in all healthcare settings are as follows:
Hand hygiene should be performed after touching blood, body fluids, secretions, excretions, and contaminated items, both immediately after removing gloves and between patient contacts.
Personal PE should include gloves for touching blood, body fluids, secretions, excretions, contaminated items, mucous membranes, and nonintact skin; gown during patient procedures and activities involving contact of clothing or exposed skin with blood or body fluids, secretions, and excretions.
Mask, eye protection (goggles), and face shield should be worn during procedures such as suctioning or endotracheal intubation that are associated with splashes or sprays of blood, body fluids, secretions. For patients with suspected or proven infections transmitted by respiratory aerosols, such as SARS, a fit-tested N95 or higher respirator should also be worn.
Soiled patient-care equipment, textiles, and laundry should be handled appropriately to prevent transfer of microorganisms to others and to the environment (wear gloves if visibly contaminated, and perform hand hygiene).
Procedures should be developed and implemented for routine care, cleaning, and disinfecting environmental surfaces, especially frequently touched surfaces in patient care areas.
Used needles should not be recapped, bent, broken, or manipulated by hand. A 1-handed scoop technique only should be used when recapping is required. Safety features should be used when available, and used "sharps" should be placed in a puncture-resistant container.
For patient resuscitation, a mouthpiece, resuscitation bag, and other ventilation devices are needed to prevent contact with the mouth and oral secretions.
Single-patient rooms are preferred for patients at increased risk for transmission, who are likely to contaminate the environment, who do not maintain appropriate hygiene, and/or who are at increased risk of acquiring infection or having an adverse outcome following infection.
Respiratory hygiene and cough etiquette should include source containment of infectious respiratory secretions in symptomatic patients, starting with emergency triage and reception areas and clinician offices. Those who are sneezing or coughing should cover their mouth and nose, use tissues and dispose of them in no-touch receptacles, practice hand hygiene after soiling their hands with respiratory secretions, and wear surgical masks or keep more than 3 feet away from others.
Specific recommendations for components of a PE are as follows:
Patients undergoing allogeneic hematopoietic stem cell transplant should remain in a PE room except for required procedures that cannot be performed in the room, and they should use respiratory protection such as an N95 respirator when leaving the PE.
Standard and expanded precautions are hand hygiene before and after patient contact. Although gown, gloves, and mask are not required for healthcare workers or visitors for routine entry into the room, these are indicated according to Standard Precautions and as indicated for suspected or proven infections for which Transmission-Based Precautions are recommended.
Engineering features should include central or point-of-use high-efficiency particulate air (HEPA; 99.97% efficiency) filters that can remove particles 0.3 µm in diameter for supply (incoming) air; well-sealed rooms; properly constructed windows, doors, and intake and exhaust ports; smooth ceilings free of fissures, open joints, and crevices; walls sealed above and below the ceiling; repairs of any leakage detected; ventilation to maintain more than 12 air changes per hour; directed air flow with air supply and exhaust grills located so that clean, filtered air enters from 1 side of the room, flows across the patient's bed, and exits on the opposite side of the room; positive room air pressure relative to the hallway; pressure differential of greater than 2.5 Pa (0.01-inch water gauge); daily visual monitoring of air flow patterns; self-closing door on all room exits; and back-up ventilation equipment.
Patients needing both a PE and airborne infection isolation should have an anteroom to provide proper air balance relationships and independent exhaust of contaminated air to the outside, or a HEPA filter should be placed in the exhaust duct. In place of an anteroom, the patient may be placed in an airborne infection isolation room with portable ventilation units and industrial-grade HEPA filters to enhance filtration of spores.
Horizontal surfaces should be wet-dusted daily with cloths moistened with Environmental Protection Agency–registered hospital disinfectant and detergent. Methods that stir up dust should be avoided, as should carpeting in patient rooms or hallways, upholstered furniture and furnishings, and fresh or dried flowers or potted plants in PE rooms or areas. When vacuum cleaning is needed, the vacuum should be equipped with HEPA filters.
CDC Web site. Published online June 2007.
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