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TABLE 1. HISTORY OF GUIDELINES FOR ISOLATION PRECAUTIONS IN HOSPITALS*
YEAR (Ref) DOCUMENT ISSUED COMMENT 1970 1099 Isolation Techniques for Use in Hospitals, 1st ed. - Introduced seven isolation precaution categories with color-coded cards: Strict, Respiratory, Protective, Enteric, Wound and Skin, Discharge, and Blood - No user decision-making required - Simplicity a strength; over isolation prescribed for some infections 1975 1100 Isolation Techniques for Use in Hospitals, 2nd ed. - Same conceptual framework as 1st edition 1983 1101 CDC Guideline for Isolation Precautions in Hospitals - Provided two systems for isolation: category-specific and disease-specific - Protective Isolation eliminated; Blood Precautions expanded to include Body Fluids - Categories included Strict, Contact, Respiratory, AFB, Enteric, Drainage/Secretion, Blood and Body Fluids - Emphasized decision-making by users 1985-88 780, 896 Universal Precautions - Developed in response to HIV/AIDS epidemic - Dictated application of Blood and Body Fluid precautions to all patients, regardless of infection status - Did not apply to feces, nasal secretions, sputum, sweat, tears, urine, or vomitus unless contaminated by visible blood - Added personal protective equipment to protect HCWs from mucous membrane exposures - Handwashing recommended immediately after glove removal - Added specific recommendations for handling needles and other sharp devices; concept became integral to OSHA’s 1991 rule on occupational exposure to blood-borne pathogens in healthcare settings
YEAR (Ref) DOCUMENT ISSUED COMMENT 1987 1102 Body Substance Isolation - Emphasized avoiding contact with all moist and potentially infectious body substances except sweat even if blood not present - Shared some features with Universal Precautions -Weak on infections transmitted by large droplets or by contact with dry surfaces - Did not emphasize need for special ventilation to contain airborne infections - Handwashing after glove removal not specified in the absence of visible soiling 1996 1 Guideline for Isolation Precautions in Hospitals - Prepared by the Healthcare Infection Control Practices Advisory Committee (HICPAC) - Melded major features of Universal Precautions and Body Substance Isolation into Standard Precautions to be used with all patients at all times - Included three transmission-based precaution categories: airborne, droplet, and contact - Listed clinical syndromes that should dictate use of empiric isolation until an etiological diagnosis is established
* Derived from Garner ICHE 1996
TABLE 2. CLINICAL SYNDROMES OR CONDITIONS WARRANTING EMPIRIC TRANSMISSION-BASED PRECAUTIONS IN ADDITION TO STANDARD PRECAUTIONS PENDING CONFIRMATION OF DIAGNOSIS* Clinical Syndrome or Condition† Potential Pathogens‡ Empiric Precautions (Always includes Standard Precautions) DIARRHEA Acute diarrhea with a likely infectious cause in an incontinent or diapered patient Enteric pathogens§ Contact Precautions (pediatrics and adult) MENINGITIS Neisseria meningitidis Enteroviruses M. tuberculosis Droplet Precautions for first 24 hrs of antimicrobial therapy; mask and face protection for intubation Contact Precautions for infants and children Airborne Precautions if pulmonary infiltrate Airborne Precautions plus Contact Precautions if potentially infectious draining body fluid present RASH OR EXANTHEMS, GENERALIZED, ETIOLOGY UNKNOWN Petechial/ecchymotic with fever (general) - If positive history of travel to an area with an ongoing outbreak of VHF in the 10 days before onset of fever Neisseria meningitides Ebola, Lassa, Marburg viruses Droplet Precautions for first 24 hrs of antimicrobial therapy Droplet Precautions plus Contact Precautions, with face/eye protection, emphasizing safety sharps and barrier precautions when blood exposure likely. Use N95 or higher respiratory protection when aerosol-generating procedure performed Vesicular Varicella-zoster, herpes simplex, variola (smallpox), vaccinia viruses Vaccinia virus Airborne plus Contact Precautions; Contact Precautions only if herpes simplex, localized zoster in an immunocompetent host or vaccinia viruses most likely Maculopapular with cough, coryza and fever Rubeola (measles) virus Airborne Precautions
Clinical Syndrome or Condition† Potential Pathogens‡ Empiric Precautions (Always includes Standard Precautions) RESPIRATORY INFECTIONS Cough/fever/upper lobe pulmonary infiltrate in an HIV-negative patient or a patient at low risk for human immunodeficiency virus (HIV) infection M. tuberculosis, Respiratory viruses, S. pneumoniae, S. aureus (MSSA or MRSA) Airborne Precautions plus Contact precautions Cough/fever/pulmonary infiltrate in any lung location in an HIV-infected patient or a patient at high risk for HIV infection M. tuberculosis, Respiratory viruses, S. pneumoniae, S. aureus (MSSA or MRSA) Airborne Precautions plus Contact Precautions Use eye/face protection if aerosol-generating procedure performed or contact with respiratory secretions anticipated. If tuberculosis is unlikely and there are no AIIRs and/or respirators available, use Droplet Precautions instead of Airborne Precautions Tuberculosis more likely in HIV-infected individual than in HIV negative individual Cough/fever/pulmonary infiltrate in any lung location in a patient with a history of recent travel (10-21 days) to countries with active outbreaks of SARS, avian influenza M. tuberculosis, severe acute respiratory syndrome virus (SARS-CoV), avian influenza Airborne plus Contact Precautions plus eye protection. If SARS and tuberculosis unlikely, use Droplet Precautions instead of Airborne Precautions. Respiratory infections, particularly bronchiolitis and pneumonia, in infants and young children Respiratory syncytial virus, parainfluenza virus, adenovirus, influenza virus, Human metapneumovirus Contact plus Droplet Precautions; Droplet Precautions may be discontinued when adenovirus and influenza have been ruled out Skin or Wound Infection Abscess or draining wound that cannot be covered Staphylococcus aureus (MSSA or MRSA), group A streptococcus Contact Precautions Add Droplet Precautions for the first 24 hours of appropriate antimicrobial therapy if invasive Group A streptococcal disease is suspected * Infection control professionals should modify or adapt this table according to local conditions. To ensure that appropriate empiric precautions are implemented always, hospitals must have systems in place to evaluate patients routinely according to these criteria
as part of their preadmission and admission care.
† Patients with the syndromes or conditions listed below may present with atypical signs or symptoms (e.g.neonates and adults with pertussis 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
‡ 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
§ These pathogens include enterohemorrhagic Escherichia coli O157:H7, Shigella spp, hepatitis A virus, noroviruses, rotavirus, C. difficile.
TABLE 3. INFECTION CONTROL CONSIDERATIONS FOR HIGH-PRIORITY (CDC CATEGORY A) DISEASES THAT MAY RESULT FROM BIOTERRORIST ATTACKS OR ARE CONSIDERED TO BE BIOTERRORIST THREATS (www.bt.cdc.gov) a a Abbreviations used in this table: RT = respiratory tract; GIT = gastrointestinal tract; CXR = chest x-ray; CT = computerized axial tomography; CSF = cerebrospinal fluid; and LD50 – lethal dose for 50% of experimental animals; HCWs = healthcare worker; BSL = biosafety level; PAPR = powered air purifying respirator; PCR = polymerase chain reaction; IHC = immunohistochemistry
Disease Anthrax Site(s) of Infection; Transmission Mode Cutaneous and inhalation disease have occurred in past bioterrorist incidents Cutaneous (contact with spores);RT (inhalation of spores);GIT (ingestion of spores - rare) Comment: Spores can be inhaled into the lower respiratory tract. The infectious dose of B. anthracis in humans by any route is not precisely known. In primates, the LD50 (i.e., the dose required to kill 50% of animals) for an aerosol challenge with B. anthracis is estimated to be 8,000–50,000 spores; the infectious dose may be as low as 1-3 spores Incubation Period Cutaneous: 1 to12 days; RT: Usually 1 to 7 days but up to 43 days reported; GIT: 15-72 hours Clinical Features Cutaneous: Painless, reddish papule, which develops a central vesicle or bulla in 1-2 days; over next 3-7 days lesion becomes pustular, and then necrotic, with black eschar; extensive surrounding edema. RT: initial flu-like illness for 1-3 days with headache, fever, malaise, cough; by day 4 severe dyspnea and shock, and is usually fatal (85%-90% if untreated; meningitis in 50% of RT cases. GIT: ; if intestinal form, necrotic, ulcerated edematous lesions develop in intestines with fever, nausea and vomiting, progression to hematemesis and bloody diarrhea; 25-60% fatal Diagnosis Cutaneous: Swabs of lesion (under eschar) for IHC, PCR and culture; punch biopsy for IHC, PCR and culture; vesicular fluid aspirate for Gram stain and culture; blood culture if systemic symptoms; acute and convalescent sera for ELISA serology RT: CXR or CT demonstrating wide mediastinal widening and/or pleural effusion, hilar abnormalities; blood for culture and PCR; pleural effusion for culture, PCR and IHC; CSF if meningeal signs present for IHC, PCR and culture; acute and convalescent sera for ELISA serology; pleural and/or bronchial biopsies IHC. GIT: blood and ascites fluid, stool samples, rectal swabs, and swabs of oropharyngeal lesions if present for culture, PCR and IHC
Disease Anthrax Infectivity Cutaneous: Person-to-person transmission from contact with lesion of untreated patient possible, but extremely rare. RT and GIT: Person-to-person transmission does not occur. Aerosolized powder, environmental exposures: Highly infectious if aerosolized Recommended Precautions Cutaneous: Standard Precautions; Contact Precautions if uncontained copious drainage. RT and GIT: Standard Precautions. Aerosolized powder, environmental exposures: Respirator (N95 mask or PAPRs), protective clothing; decontamination of persons with powder on them (http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5135a3.htm) Hand hygiene: Handwashing for 30-60 seconds with soap and water or 2% chlorhexidene gluconate after spore contact (alcohol handrubs inactive against spores [Weber DJ JAMA 2003; 289:1274]). Post-exposure prophylaxis following environmental exposure: 60 days of antimicrobials (either doxycycline, ciprofloxacin, or levofloxacin) and post-exposure vaccine under IND
Disease Botulism Site(s) of Infection; Transmission Mode GIT: Ingestion of toxin-containing food, RT: Inhalation of toxin containing aerosol cause disease. Comment: Toxin ingested or potentially delivered by aerosol in bioterrorist incidents. LD50 for type A is 0.001 μg/ml/kg. Incubation Period 1-5 days. Clinical Features Ptosis, generalized weakness, dizziness, dry mouth and throat, blurred vision, diplopia, dysarthria, dysphonia, and dysphagia followed by symmetrical descending paralysis and respiratory failure. Diagnosis Clinical diagnosis; identification of toxin in stool, serology unless toxin-containing material available for toxin neutralization bioassays. Infectivity Not transmitted from person to person. Exposure to toxin necessary for disease. Recommended Precautions Standard Precautions.
Disease Ebola Hemorrhagic Fever Site(s) of Infection; Transmission Mode As a rule infection develops after exposure of mucous membranes or RT, or through broken skin or percutaneous injury. Incubation Period 2-19 days, usually 5-10 days Clinical Features Febrile illnesses with malaise, myalgias, headache, vomiting and diarrhea that are rapidly complicated by hypotension, shock, and hemorrhagic features. Massive hemorrhage in < 50% pts. Diagnosis Etiologic diagnosis can be made using RT-PCR, serologic detection of antibody and antigen, pathologic assessment with immunohistochemistry and viral culture with EM confirmation of morphology, Infectivity Person-to-person transmission primarily occurs through unprotected contact with blood and body fluids; percutaneous injuries (e.g., needlestick) associated with a high rate of transmission; transmission in healthcare settings has been reported but is prevented by use of barrier precautions. Recommended Precautions Hemorrhagic fever specific barrier precautions: If disease is believed to be related to intentional release of a bioweapon, epidemiology of transmission is unpredictable pending observation of disease transmission. Until the nature of the pathogen is understood and its transmission pattern confirmed, Standard, Contact and Airborne Precautions should be used. Once the pathogen is characterized, if the epidemiology of transmission is consistent with natural disease, Droplet Precautions can be substituted for Airborne Precautions. Emphasize: 1) use of sharps safety devices and safe work practices, 2) hand hygiene; 3) barrier protection against blood and body fluids upon entry into room (single gloves and fluid-resistant or impermeable gown, face/eye protection with masks, goggles or face shields); and 4) appropriate waste handling. Use N95 or higher respirators when performing aerosol-generating procedures. In settings where AIIRs are unavailable or the large numbers of patients cannot be accommodated by existing AIIRs, observe Droplet Precautions (plus Standard Precautions and Contact Precautions) and segregate patients from those not suspected of VHF infection. Limit blooddraws to those essential to care. See text for discussion and Appendix A for recommendations for naturally occurring VHFs.
Disease Plague2 Site(s) of Infection; Transmission Mode RT: Inhalation of respiratory droplets. Comment: Pneumonic plague most likely to occur if used as a biological weapon, but some cases of bubonic and primary septicemia may also occur. Infective dose 100 to 500 bacteria Incubation Period 1 to 6, usually 2 to 3 days. Clinical Features Pneumonic: fever, chills, headache, cough, dyspnea, rapid progression of weakness, and in a later stage hemoptysis, circulatory collapse, and bleeding diathesis Diagnosis Presumptive diagnosis from Gram stain or Wayson stain of sputum, blood, or lymph node aspirate; definitive diagnosis from cultures of same material, or paired acute/convalescent serology. Infectivity Person-to-person transmission occurs via respiratory droplets risk of transmission is low during first 20-24 hours of illness and requires close contact. Respiratory secretions probably are not infectious within a few hours after initiation of appropriate therapy. Recommended Precautions Standard Precautions, Droplet Precautions until patients have received 48 hours of appropriate therapy. Chemoprophylaxis: Consider antibiotic prophylaxis for HCWs with close contact exposure.
2 Pneumonic plague is not as contagious as is often thought. Historical accounts and contemporary evidence indicate that persons with plague usually only transmit the infection when the disease is in the end stage. These persons cough copious amounts of bloody sputum that contains many plague bacteria. Patients in the early stage of primary pneumonic plague (approximately the first 20–24 h) apparently pose little risk [1, 2]. Antibiotic medication rapidly clears the sputum of plague bacilli, so that a patient generally is not infective within hours after initiation of effective antibiotic treatment . This means that in modern times many patients will never reach a stage where they pose a significant risk to others. Even in the end stage of disease, transmission only occurs after close contact. Simple protective measures, such as wearing masks, good hygiene, and avoiding close contact, have been effective to interrupt transmission during many pneumonic plague outbreaks . In the United States, the last known cases of person to person transmission of pneumonic plague occurred in 1925 .
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|Peer reviewed by the Arizona Department of Commerce Economic Research Advisory Committee||Food and drug administration national institutes of health advisory Committee on: transmissible spongiform|