isolation precautions in health care facilities

Isolation Precautions

76

Isolation Precautions in Health Care Facilities (HCF)

Introduction

As highlighted in the chapter on Importance of Infection Control in the Health Care Setting, there are three elements needed to allow transmission of microorganisms within a health care facility. These are a source of the microorganism (e.g., patients, personnel, visitors, equipment or the inanimate environment), a susceptible host and a mode of transmission. The former two elements are more difficult to control or prevent; therefore, the emphasis on interrupting transmission is to prevent the mode of transmission. This is accomplished by two main tiers of precautions: Standard Precautions (SP) and Transmission-Based Precautions. Standard precautions (SP) are the primary strategy for preventing transmission of microorganisms to patients, personnel, and others in the health care facility (HCF). They are applied to all patients because microorganisms are likely present in patients with recognized and unrecognized infection. In addition, far greater numbers of patients are colonized with epidemiologically important microorganisms in HCF than those with clinical signs of infection. The purpose of this chapter is to outline components of SP and Transmission-based precautions. The latter are designed for patients with documented or suspected infection with communicable or epidemiologically important pathogens for which additional precautions beyond SP are needed to interrupt transmission. 9 The aim of isolating a patient is to prevent the spread of communicable diseases.

Some key aspects of transmission-based precautious include: • An understanding of the epidemiology of communicable diseases is

helpful to assist with decisions regarding specific isolation precaution procedures. 47

• The essence of a successful isolation policy is to create a barrier between the patient and other people, e.g., staff and patients. Isolating the patient in a single cubicle or in a room with en suite facilities, when available, is optimal.

• A high index of suspicion-often using clinical clues alone at the time of admission- should trigger an assessment for need for precautions


77

beyond SP. Appropriate infection precautions must commence on clinical suspicion; laboratory confirmation is not necessary.

• All the recommendations of an isolation precautions program should be based on the real capabilities of the hospital. A continuing education program must first be directed to nurses, as they are the personnel with the greatest physical contact with patients. 48 In addition, HCP should recognize that isolation precautions have disadvantages for the patient including negative psychological aspects of separation from others and additional equipment for care.

Note: If more than one patient is affected (e.g. in an outbreak) they should be nursed together in one room (cohort isolation) and looked after by dedicated staff. 9 Limited movement and transport of isolated patients is essential. They must leave their rooms only for essential purposes in order to minimize spread in the hospital. 11

Notification of Communicable Diseases to District Health Office Medical practitioners attending patients known to be suffering from or suspected to be suffering from a notifiable communicable disease, have an obligation to inform the District Surveillance Unit (at the district health office). It is also important that all such cases are reported to a member of the Infection Control Team. This should be done as soon as possible. Notification should occur on clinical suspicion of the disease and not dependent on laboratory confirmation. 11

Transmission of Infection Microorganisms are transmitted in HCF by several routes and the same microorganism may be transmitted by more than one route. There are five main routes of transmission:

• Contact a) Direct-contact: Direct body surface-to-body surface contact and physical transfer of microorganisms between susceptible host and infected or colonized person. b) Indirect-contact: Contact of a susceptible host with a contaminated intermediate object, usually inanimate, such as a contaminated instrument, needle, or dressing, or contaminated hands of HCP.

• Droplet: Droplets generated by the infected person by cough, sneeze, talking,


78

or during a procedure such as suctioning the person’s respiratory tract travel a short distance (1-2 meters) and are deposited on a susceptible host’s conjunctivae, nasal mucosa, or mouth.

• Airborne Dissemination of either droplet nuclei (small particle residue <5 microns) or dust particles containing microorganisms into the air are then inhaled by a susceptible host. This can occur over significant distances via normal air and ventilation systems.

• Common vehicle Transmission via contaminated food, water, medications, blood products, devices, and equipment.

• Vector-borne Transmission of microorganisms via mosquitoes, flies, ticks, etc.

Neither common vehicle nor vector-borne transmission play a significant role in typical hospital-associated infections (HAI) and will not be discussed here.

Routes of transmission of infection from infected hospital patients: • Hands of the HCP (the most common route);

• Contact with contaminated instruments;

• Exposure of the respiratory tract;

• Environmental factors (dust, fluids) and skin scales. (Environmental factors contribute when the colonization rates are high and when the bacteria are widely dispersed).

[For more details see chapter “Importance and Purpose of Infection Control in the Health Care Setting”]

Standard Precautions (SP) A significant proportion of infectious diseases can be incubating, can cause no symptoms, or can result in chronic infection (e.g. hepatitis C virus) among patients who are exposed to these pathogens. SP is the foundation of protection for personnel against exposure to infectious agents during all patient care activity. SP is a system of precautions that is designed to reduce the risk of transmission of blood-borne pathogens and other pathogens present in body substances. Terminology applied to precautions against blood-borne pathogens that often is confused with SP, is universal precautions (UP). UP were developed originally to focus attention on precautions against occupational exposure to body fluids that were likely to contain blood-borne pathogens (i.e. blood, semen and vaginal secretions, cerebrospinal, pericardial, peritoneal, pleural, and synovial fluids, and


79

other body fluids visibly contaminated with blood). 49, 50 UP against blood-borne pathogens did not apply to feces, nasal secretions, sputum, sweat, tears, urine, or vomitus unless visibly contaminated with blood. In the mid-1980s a group of infection control professionals in the US developed a system of precautions called body substance isolation (BSI) whose aim was to interrupt transmission of endemic infection in HCFs and to protect HCP and others. BSI was applied to all moist and potentially infectious body substances (blood, secretions and excretions) and surfaces and equipment -if contaminated. SP is a synthesis of these two systems. They apply to: 1) blood; 2) all body fluids, secretions, and excretions regardless of whether they contain visible blood, 3) nonintact skin, 4) mucous membranes and contaminated surfaces or equipment. The components of SP are discussed earlier in chapter 1 “Importance of Infection Control in the Health Care Setting”, page 22.

Practical Issues and Considerations Hand Hygiene Hand hygiene is essential in reducing the risk of infection transmission from patient to patient or from one site to another site on the same patient. Routine handwashing or antiseptic hand wash should be performed promptly between patient contacts, after contact with infective material (blood, body fluids, secretions or excretion), and after contact with contaminated items used for patient care. Hands should be washed or an alcohol based handrub should be used immediately after removing gloves.

Covering Cuts Cover cuts or areas of broken skin with waterproof dressings while at work. Health care personnel with large areas of broken skin must avoid invasive procedures. Staff with eczema or other skin conditions or with large wounds which cannot be adequately protected by plastic gloves or impermeable dressings should refrain from patient care and from handling patient care equipment until the condition resolves.

Personnel Protective Equipment (PPE) Appropriate PPE, e.g., gloves, masks, gowns, protective eyewear, should be worn for the procedures that are likely to generate droplets, splashes, or sprays of blood or body fluids in order to protect skin and mucous membranes. (For more details see below: PPE for Isolation Procedures)


80

Safe Use of Sharps Avoid sharps usage whenever possible. If the use of sharps is necessary, then sharps must be used and handled with care. Never leave sharps lying around; dispose of them carefully into a designated sharps container. HCP should be instructed that it is the personal responsibility of the person using a sharp to dispose of it safely as soon as possible after use or to ensure that it has been safely discarded. [For more details see chapter “Waste Management II Sharps Disposal”]

Monitoring Staff Health It is important that HCP are appropriately and adequately immunized against infectious diseases, both for their own protection and for the protection of others. Staff who are suffering from a known or suspected infectious disease must report this to the Occupational Health Department, which will advise on the management and on exclusion from work if necessary. Sharps injuries and any exposure of non-intact skin, conjunctiva, or mucous membrane to blood or high-risk body fluids should be recorded and reported to a responsible person from the Occupational Health Department. [For more details see chapter “Occupational Safety and Employee Health”]

Removing Spills of Blood and Body Fluids Spillage of blood and body fluids must be cleaned carefully and promptly using a safe method including protective measures for housekeeping staff.

Cleaning and Disinfecting Patient Care Equipment Patient care equipment is either single-use disposable or re-usable. Single-use items should be discarded as clinical waste while non-disposable items should be appropriately cleaned and disinfected or sterilized before re-use.

Disposing of Waste Safely Waste from patients with a known or suspected infection should not be treated any differently than waste from patients without known infection. Studies of waste from patients under isolation precautions have shown it carries no greater microbial load than from those who are not on isolation precautions. [For more details see chapters ”Waste Management II Sharps Disposal” and “Environmental Cleaning”]


81

Collecting and Reprocessing Linen Safely Although soiled linen may be contaminated with pathogenic microorganisms, the risk of transmission is negligible. Soiled linen should be handled with a minimum of agitation and should be placed in a laundry bag. [For more details see “Linen Management”]

Cleaning the Environment Special attention must be given to ensure the environment is maintained in a clean state and is in line with good housekeeping practices.

• Terminal cleaning of the patient rooms should be carried out at the discharge of the patient before admitting another patient:

• When visibly soiled, all the surfaces and walls must be washed thoroughly with warm water and detergent and be dried (wiped over with a disinfectant if indicated).

• Launder all bed linen and cubicle curtains, etc. when visibly soiled

• The covers of bed mattresses and pillows should be wiped with warm water and detergent and dried thoroughly. Occasionally, a disinfectant may be indicated.

• Where special cleaning arrangements are required, the supervisor must be informed of the infection risk (not of the patient’s diagnosis) and of any protective measures necessary for the staff.

[For more information see chapter “Environmental Cleaning”]

Dishes, Glasses, Cups, and Eating Utensils No special precautions are needed for dishes, glasses, cups, or eating utensils. Either disposable or reusable dishes or utensils can be used for patients on isolation precautions. The combination of hot water and detergents used in hospital dishwashers is sufficient to decontaminate dishes, glasses, cups, and eating utensils.

PPE for Isolation Procedures The indications for the use of protective clothing for isolation aseptic procedures are uniform. Recommendations for protective clothing for different isolation categories are discussed later in the transmission based precautions sections. 9


82

Deceased Patients As a general rule the infection control precautions prescribed during life are continued after death. In cases where there is an infection risk from the body, a “Danger of Infection” label must be attached to the patient’s armband. If a person that is known to be infected or that is suspected to be infected dies, either in the hospital or elsewhere, it is the duty of those with knowledge of the case to ensure that those who handle the body are aware that there is a potential risk of infection that is minimized by using the appropriate control measures. Even without any information about the presence of infection in the deceased, SP should always be used. 11

Transmission-Based Precautions Whenever isolation of a patient is considered, assessment of risk should be carried out and the disadvantages should be weighed against the benefits. The placement of a patient into isolation should never be undertaken as a matter of convenience. Second tier precautions are designed only for patients that are known or suspected to be infected with highly transmissible or epidemiologically important pathogens for which additional precautions beyond “Standard Precautions” are needed in order to interrupt transmission in hospitals. 11, 48 Please note however that SP still need to be employed even for patients placed on transmission-based precautions.

There are three types of “Transmission-Based Precautions”: • Airborne precautions (prevent transmission by air current).

• Droplet precautions (prevent transmission by small and large droplets).

• Contact precautions (prevent transmission by direct or indirect contact).

• Combination of airborne and contact precautions

Airborne Precautions Airborne precautions (AP) are used for infections which are transmitted by droplet nuclei. Droplets are generated in the course of talking, coughing, or sneezing and during procedures that involve the respiratory tract such as suction, physiotherapy, intubation, or bronchoscopy. Small droplet nuclei size of ≤ 5µ can be widely dispersed by air currents and can reach the alveoli of the susceptible host and cause infection. Patients under airborne isolation precautions should be in a single room with negative airflow ventilation with respect to the surrounding areas. The door must be kept closed.


83

Examples of diseases in this category include: • Tuberculosis

• Measles

Large droplet nuclei particle size is ≥ 5µ in diameter containing infectious particles. These droplets do not remain suspended in the air long and travel only short distances. Transmission from larger droplets requires close contact (e.g. within 2 m) between the infected source and the recipient.

Examples of diseases in this category include: • Meningococcal meningitis

• Pertussis

• Streptococcal pharyngitis, and

• Multidrug resistant Streptococcus pneumoniae

Table 7: Summary of Airborne Precautions

Location

• A single room under negative pressure ventilation with a wash hand basin and preferably with an en suite toilet.

• The door must be kept closed at all times except during necessary entrances and exits.

• Unnecessary items of equipment must be removed before the patient occupies the room.

• Disposable paper towels and an antiseptic/detergent hand cleanser in an elbow operated pump dispenser should be provided.

Staff When applicable, only personnel that have immunity against varicella and measles should care for these patients.

Visitors All visitors must seek advice from the nurse-in-charge of the ward before visiting the patient.

Protective clothing

• A high efficiency mask, if available, should be worn when entering the room of a patient with known or suspected tuberculosis.

• Other PPE should be used consistent with SP.


84

Table 7: Summary of Airborne Precautions (continued)

Hand hygiene

Hands must be washed with an antiseptic preparation and must be dried thoroughly with a disposable paper towel, or use a waterless alcohol hand rub/gel

• AFTER touching the patient or potentially contaminated items,

• AFTER removing gloves, and

• BEFORE taking care of another patient.

Linen No special handling is needed for used or soiled linen.

Inter-departmental visits

Limit the movement and the transport of the patient to essential purposes only. Seek advice of the Infection Control team

Laboratory specimens

No special labeling or precautions are needed.

Last offices

The infection control precautions employed during life must be continued after death. In the case of open tuberculosis, the body must be labeled with a ”Danger of infection” label on the wrapping sheet or shroud and on the information sheet.

Droplet Precautions For those infections which are spread by large droplets.

Examples • Pneumonic plague

• Influenza

• Rubella

• Invasive miningococcal disease (meningitis, pneumonia meningococcemia etc.)


85

Table 8: Summary of Droplet Precautions

Location A private room with a wash hand basin and an en suite toilet is necessary.

Staff No exclusions.

Visitors Visitors must always report to the nurse in charge before entering the room.

PPE Put on a standard mask prior to entering the isolation room.

Hand hygiene

Hands must be washed with an antiseptic preparation and must be dried thoroughly with a disposable paper towel or washed with a waterless alcohol hand rub/gel:

• AFTER contact with the patient or potentially contaminated items,



Decontamination and waste disposal

No specific precautions.

Contact Precautions (CP) These precautions are used for patients to prevent the transmission of communicable diseases and of epidemiologically important microorganisms which are causing infection or colonization and which are transmitted by direct patient contact or by indirect contact with the patient or the patient’s environment, excretion, and secretion.

Examples of these infections include: • Respiratory syncytial virus

• Disseminated herpes simplex (e.g., neonatal)

• Streptococcal and staphylococcal infections (e.g., major skin infection)

• Methicillin-resistant Staphylococcus aureus (MRSA)

• Multi-resistant Gram-negative bacteria,

• Vancomycin resistant enterococci (VRE)

• Clostridium difficile associated diarrhea


86

Table 9: Summary of Contact Precautions

Location

A single room with an en suite toilet is necessary if the infective agent might be disseminated into the environment or if the microorganism has epidemiological importance at the HCF.

Staff There are no special qualifications for personnel.

Visitors Visitors must always report to the nurse-in-charge before entering the room.

PPE

Non-sterile, disposable gloves are needed when there is contact with an infected site, with dressings, or with secretions.

A mask when performing procedures that may generate aerosols or when performing suctioning is recommended.

Hand hygiene

Hands must be washed with an antiseptic preparation and must be dried thoroughly with a disposable paper towel or washed with a waterless alcohol hand rub especially:

• AFTER contact with the patient or potentially contaminated items,



Linen No special handling is needed for used or soiled linen.

Decontamination and waste disposal

• Non-disposable items should be sent to Sterile Service Department (SSD) for disinfection/sterilization.

• Waste: Contaminated waste is disposed of as clinical waste according to local policy.

Combination of Airborne + Contact (A+C) Precautions This type of isolation is used to prevent transmission of diseases spread both by air and by contact and is used for patients with highly transmissible and dangerous infections.

Diseases requiring combination Airborne & Contact isolation include: • Chicken pox (Varicella).

• Others as determined by Hospital Infection Control team.


87

Table 10: Summary of Airborne & Contact precautions11

Location

Patients must be admitted into a single room under negative pressure ventilation and, if available, with an ante room with wash hand basin and en suite toilet facilities.

• The door must be kept closed except during necessary entrances and exits.

• Unnecessary items of equipment must be removed before the patient occupies the room.

• The mattress and pillows must have non-permeable, intact covers.

• Disposable paper towels and an antiseptic/detergent hand cleanser in an elbow operated pump dispenser must be provided.

• The patient’s charts should be kept outside the room.

Staff Minimize the number of personnel needed for care and assure those assigned are immune to the disease for which the patient is isolated, if applicable.

Visitors

Visitors must be kept to a minimum and must always report to the sister or nurse-in-charge before entering the room. Visitors must observe the same infection control precautions as personnel.

PPE

• Non-sterile gloves, a gown, or disposable apron, and a high-filtration mask, if available.

• Eye protection is needed for any procedure that might cause splashes of blood and body fluids.

Hand Hygiene

Hands must be washed or a hand rub containing an antiseptic applied:

• BEFORE leaving the room. This is extremely important.

• AFTER touching the patient or touching potentially contaminated items,

• AFTER removing gloves and AFTER removing protective clothing.

When leaving the room the door should be pushed open from the outside by an assistant in order to avoid touching the door handle which may be contaminated. When outside, repeat the hand-disinfection.


88

Table 10: Summary of Airborne & Contact precautions ( continued)

Decontamination and Waste Disposal

• Non-disposable items should be sent to Sterile Service Department (SSD) for disinfection/sterilization.

• Waste: Contaminated waste is disposed of as clinical waste according to local policy.

Laundry Routine laundering is sufficient for used linen.

Inter-departmental visits

The patient must not leave the room without prior consultation with the Infection Control Physician.

Laboratory specimens

• Routine procedures should be used for laboratory specimen.

• Special labeling is not indicated and only promotes a false sense of security.

Last offices

• The infection control measures employed during life must be continued after death.

• Any bleeding part must be covered with an occlusive dressing.

• The body must be transported in an appropriate sealed cadaver bag and labeled with a ”Danger of Infection”-sticker.


89

Table 11: Summary of components of standard infection control precautions and of transmission based precautions in isolation procedures: 51

Standard

Contact

Droplet

Airborne

Hand Hygiene √ √ √ √

Gloves

When likely to touch blood, body fluids and contaminated items

On entering room, during care

As per “Standard”


Mask

During procedures likely to generate contamination with blood and body fluids


As per “Standard” and if present within 1 meter of patient

On enteringthe room. Non-essential susceptible people should be excluded. For TB wear high-efficiency mask

Eye protection /face shield





Apron/gown


On entering if contact with patient or environment anticipated



Equipment √ √ √ √

Environment (Cleaning, etc.)

√ √ √ √

Linen √ √ √ √

Isolation room

Single room not required

Single room and minimize time outside

Single room, minimize time outside to when patient may wear mask

Single room with negative pressure ventilation, minimize time outside to when patient may wear mask. Exclude non-essential susceptible people

√ = According to description in text


90

Practical Guidance for Decision Makers on Isolation At any one time hospitals might have more patients with potentially transmissible infections needing isolation rooms than they have rooms available. Consistent and evidence-based decisions should therefore be made on prioritization for the use of such isolation. Limited resources available and competing priorities might make the decision difficult to make. In the absence of widely used accepted guidelines, these decisions may not be consistent. When faced with the need to prioritize the use of isolation facilities, the following factors, which influence transmission and its impact, should be considered, e.g., a risk assessment should be performed: 1. Advisory Committee of Dangerous Pathogens (ACDP) Classification of

Pathogens: The ACDP classification provides an acknowledged system of classifying organisms based on their transmissibility, pathogenicity, and on our ability to protect against or treat individual infections.

2. The probable route of transmission: Air-borne infections are those most likely to spread readily if not isolated; blood-borne infections are least likely to do so.

3. Evidence for transmission: Although 1) and 2) may suggest transmission, the emphasis placed on evidence-based medicine now supports a requirement to demonstrate that transmission of specific infections has indeed occurred in hospitals.

4. Occurrence of infection in the hospital: The incidence or prevalence of an infection/colonization in a hospital is frequently a consideration when deciding whether or not to isolate a patient. In a sporadic infection, isolation of a patient will have a higher priority than in endemic or epidemic situation.

5. Antibiotic resistance: Emergence of antibiotic resistant bacteria is one of the principal causes of the increased demand on isolation facilities.

6. Susceptibility of other patients: When deciding whether or not to isolate a case, the presence of a susceptible patient population promotes the isolation of the potential source of sepsis.

7. Dispersal characteristics of patient: While transmissibility of various infections has been addressed in 1,2, and 3, it is well recognized that for a given infection certain patients present greater transmission hazards than others.

The table below shows an example of a scoring system applied to risk assessment for the prioritization of potential isolation cases.


91

Table 12: Risk Assessment Scoring System for Assigning the Priority of Isolation (Lewisham Isolation Priority System-LIPS)

CRITERIA CLASSIFICATION SCORE COMMENTS

2 5

3 10 ACDP category

4 40

Air-borne 15

Droplet 10

Contact 5 Include fecal-oral transmission Route

Blood-borne 0

Published evidence 10

Consensus or likelihood

5

No consensus or likelihood

0 Evidence of transmission

No evidence - 10

Yes 5 Such as MRSA, GRE, etc. Significant resistance

No 0

Yes 10 Specific for various infections and patient populations

High susceptibility of other patients with

serious consequences No 0

Sporadic 0

Endemic -5 This reflects the burden of infection in the hospital and cohort measures are more applicable

Prevalence

Epidemic -5 See above

High risk 10 Only for contact and droplet transmission, e.g. eczema, fecal, incontinence, tracheostomy, etc.

Medium risk 5

Dispersal

Low risk 0

TOTAL SCORE


92

Category of priority for isolation Score

Low 0 – 20

Medium 21 – 39

High 40 - 50

Table 13: Isolation Precautions Reference Table Standard Precautions must be applied in all circumstances

Disease Type of isolation

precaution Infective Material

Duration of Isolation Comments

Acute Respiratory Infections

Droplet & Contact

Respiratory secretions and feces’

For 7 days after onset of illness

Infants and young children only

Anthrax Bacillus anthracis

Standard Respiratory and/or lesion secretions

Duration of illness No additional precautions

Chickenpox Airborne + Contact

Respiratory and/or lesion secretions

Until all lesions are crusted. For exposed, susceptible patients from 10 until 21 days after last day of exposure.

Persons susceptible to varicella should not enter the room

Disseminated Herpes Zoster

Airborne + Contact

Lesion secretions

Duration of hospitalization


Localized Herpes Zoster (Shingles) (immunosuppressed patient)

Airborne Lesion secretions



Localized Herpes Zoster (Shingles)

Standard Lesion secretions

Clostridium botulium

Standard Secretions No special precautions

Clostridium difficile Contact Feces, Pus Duration of illness

Creutzfeldt-Jakob disease

Standard Blood, brain, tissue, and spinal fluid


OR, Materiel Services, Pathology have specific procedures.


93

Table 13: Isolation Precautions Reference Table (continued)

Disease Type of

isolation precaution

Infective Material


Diphtheria (pharyngeal) Droplet Respiratory secretions

Until after 2 cultures, taken at least 24 hrs apart, are negative (following appropriate therapy

Erythema infectiosum (Fifth Disease) (also Parvovirus B19)

Standard Respiratory secretions

For 7 days after onset

Haemophilus influenzae pneumonia/meningitis, Pediatrics only

Droplet Respiratory secretions

Until after 24 hrs of appropriate antibiotic therapy

Hemorrhagic fevers (for example, Lassa and Ebola)

Contact Blood, body fluids, and respiratory secretions


Report immediately to epidemiological and surveillance unit

Hepatitis A Standard Feces may be For 7 days after onset of jaundice

Hepatitis A is most contagious before symptoms and jaundice appear.

Hepatitis B (including hepatitis B antigen HBsAg carrier)

Standard Blood and body fluids

Until patient is HBsAg-negative

Use caution when handling blood and blood-soiled articles. Take special care to avoid needlestick-injuries

Herpes simplex Standard Lesion secretions

For neonate or severe mucocutaneous – Contact Precautions

Herpes Zoster See Chickenpox

HIV, AIDS, Hepatitis C Standard Blood and body fluids

Use caution when handling blood and blood-soiled articles. Take special care to avoid needle stick injuries.


94





Viral influenza (A,B,C)


7 days after the symptoms

Group of patients during epidemics

Legionella Standard No person to person transmission

Lice (pediculosis) Contact Gown/glove for direct patient care x24 hrs after treatment

Measles (rubeola), all presentations

Airborne Respiratory secretions

For 5 days after rash; if patient is immunosuppressed, duration of hospitalization

Only susceptible persons should wear a mask, or if possible stay out of the room

Meningitis Aseptic (nonbacterial or viral meningitis)

Fungal Suspected or confirmed meningitis due to Neisseria meningitidis

See enterovirus infections

Droplet

Feces

Respiratory secretions

For 7 days after onset


Enteroviruses are the most common cause of aseptic meningitis

Mumps

(infectious parotitis)


Until 9 days after onset of swelling. Mask not required if immune

Personnel who are not susceptible do not have to wear a mask

MRSA (Methicillin resistant S. aureus infections) NRSA (Nafcillin resistant S. aureus infections)

Contact Until after 24 hrs of appropriate antibiotic therapy

Neisseria meningitidis, invasive (meningitis, pneumonia, sepsis)

Droplet Respiratory secretion



95





Parvovirus B19 (Fifth disease) (patients in aplastic crisis)

Droplet Blood and respiratory secretions

For 7 days if patient is in aplastic crisis. For duration of hospitalization when chronic disease occurs in an immune deficient patient

Pertussis (whooping cough)


Until after 5 days of appropriate antibiotic therapy

Pneumonic plague Standard Respiratory secretions

Duration of Hospitalization

Rabies Standard Respiratory secretions


Rubella (German measles)/ Rubella Syndrome


7 days after onset rash. [Infants with congenital Rubella may shed virus for months, call I.C.]

Mask not required if immune. Susceptible person should stay out of the room if possible

Scabies Contact Gown/glove for direct patient care x 24 hours after treatment

Small pox A+C Lesion secretions

Duration of Hospitalization

Streptococcus, Group A *Necrotizing Fasciitis, Wound

Respiratory, Pharyngitis

Contact

Droplet

Purulent material

Respiratory secretions

Until cultures are negative for group A streptococcus.

Until cultures are negative for group A streptococcus.


96





Tuberculosis Pulmonary, pharyngeal

Extrapulmonary

Airborne

Standard

Respiratory/AFB

Pus

Minimum of 14 days after chemotherapy is begun. Reduction in number of TB organisms on sputum smear and clinical response must also be present. If patient is smear negative and demonstrates clinical improvement, duration of precautions may be 5 days. If MDRTB, duration of hospitalization.

Varicella Zoster Airborne See chickenpox See chickenpox

Viral hemorrhagic infection (Ebola, Lassa, Marburg)

Contact Duration of hospitalization

Vancomycin Resistant Enterococcus (VRE)

Contact Duration of hospitalization or until original site and 3 perianal cultures are negative

Whooping cough (pertussis)


See pertussis

• If patient has any respiratory symptoms, implement Respiratory Secretion Precautions until group A streptococcal respiratory infection is ruled out.

isolation precautions in health care facilities

Documents

health care

susceptible

isolation

laboratory

communicable

standard precautions

clinical suspicion

contact