Jane D. Siegel, md; Emily Rhinehart, rn mph cic; Marguerite Jackson, PhD; Linda Chiarello, rn ms; the Healthcare Infection Control Practices Advisory Committee




НазваниеJane D. Siegel, md; Emily Rhinehart, rn mph cic; Marguerite Jackson, PhD; Linda Chiarello, rn ms; the Healthcare Infection Control Practices Advisory Committee
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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 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 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

. 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

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

. 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 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

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.

.

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.

. 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

. 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

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.
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