1. Riley, May Mei-Sheng RN, ACNP, CCRN, CCTN, MSN
  2. Flood, Annemarie RN, CIC, BSN

Article Content

Much has changed in infection control since the CDC issued guidelines for isolation precautions in 1996. The CDC's latest isolation guideline addresses broader issues, including new pathogens such as severe acute respiratory syndrome coronavirus (SARS-CoV) and avian influenza virus in humans, evolving pathogens such as Clostridium difficile, noroviruses, community-associated methicillin-resistant Staphylococcus aureus (MRSA), and bioterrorist threats.


The revised CDC guideline applies to all healthcare settings, including acute care hospitals, long-term-care facilities, ambulatory care, home healthcare, and freestanding specialty care sites. In this article, we'll highlight the major changes.



Healthcare facilities should use standard definitions to monitor the incidence of epidemiologically important organisms such as multidrug-resistant organisms (MDROs), C. difficile, and targeted healthcare-associated infections (HAIs) that have a substantial effect on patient outcomes and for which there are effective evidence-based interventions. Nurses in each unit should get feedback on HAI rates so that strategies to reduce these rates can be developed, implemented, and evaluated for effectiveness. Effective surveillance is increasingly important as more states are requiring that HAI rates be reported.


Standard precautions: The foundation

Standard precautions, including hand hygiene, remain the foundation of infection control. Hand hygiene was highlighted in a previously published guideline. Here are new additions to standard precautions:


* Respiratory hygiene/cough etiquette. In response to the 2003 SARS outbreaks, respiratory hygiene/cough etiquette is recommended for patients and visitors with signs and symptoms of respiratory infection. This should start at the first point of encounter, such as the ED waiting and reception areas. Respiratory hygiene/cough etiquette includes hand hygiene, infection source control measures (covering mouth and nose while coughing or sneezing, use and proper disposal of tissues, use of surgical masks for coughing patients when community respiratory infections are prevalent), posting signs with instructions for patients and visitors in languages appropriate to the population served, and educating staff, patients, and visitors.


* Safe injection practices. This recommendation is a response to four large outbreaks of hepatitis B and hepatitis C in U.S. healthcare facilities. Medications from one syringe must not be administered to multiple patients even if the needle or cannula is changed. All syringes, needles and cannulas must be sterile, single-use items. Never reinsert used needles into multiple-dose vials and solution containers. Using single-dose rather than multiple-dose vials is preferable, especially when you're administering medication to multiple patients.


* Wearing surgical masks when performing certain lengthy, high-risk spinal canal or subdural space procedures. Droplet transmission of oral flora from healthcare providers to patients was suspected of causing eight cases of postmyelographic meningitis reported in 2004. To prevent such occurrences, the CDC recommends that all healthcare providers participating in the procedure wear surgical masks when performing a lumbar puncture, intrathecal chemotherapy, myelogram, or spinal or epidural anesthesia.



Environmental care

Because environmental controls reduce the risk of fungal infections in severely immunocompromised patients, the revised guideline includes an update on the components of the protective environment. The protective environment is a patient-care area designed to minimize fungal exposure for patients undergoing allogeneic hematopoietic stem cell transplant. This area has positive air pressure relative to the exterior (so air flows out of the room), high-efficiency particulate air (HEPA) filtration, more than 12 air exchanges/hour, and minimal passage of air into the room.


Pathogens are commonly found on environmental surfaces, including bed rails, bedside commodes, and over-bed tables, as well as on frequently touched surfaces such as doorknobs. Such surfaces should be frequently cleaned using an Environmental Protection Agency (EPA)-registered disinfectant effective against the most common pathogens. Toys provided for pediatric patients or children in waiting areas must be cleaned and disinfected regularly.


Transmission-based precautions

Because viral shedding can be protracted among immunosuppressed patients with acute viral illness, transmission-based precautions should be extended until the acute illness is resolved in these patients. For example, in immunosuppressed patients with parainfluenza virus infection or respiratory syncytial virus infection, maintain contact precautions until results from a reliable antigen test result are obtained.


Decide patient placement on a case-by-case basis in long-term care and similar settings. Consider such factors as risk of infection transmission to patients in the same room and psychological effects on the infected patient.


For a patient on contact precautions, clean and disinfect his room at least once a day. Concentrate on high-touch areas and equipment near the patient. Recommendations for the use of contact precautions in cases of colonization or infection with MDROs are detailed in a separate publication.


Ensure that patients are separated by more than 3 feet (90 cm). Drawing curtains between beds reduces the opportunities for transmitting infections via direct contact. In outpatient areas, place a patient with an MDRO in an exam room as soon as possible.


Don personal protective equipment (PPE) before entering the room of a patient on contact or droplet precautions because pathogens are often transmitted via contaminated environmental surfaces and interactions with patients are unpredictable. Figures illustrating the sequence for safely donning and removing PPE have been added to the revised guideline.


Protective environment

As outlined in previous guidelines, patients receiving allogeneic hematopoietic stem cell transplants should be placed in a protective environment to eliminate exposure to environmental fungi. No recommendation for placement in a protective environment is made for patients having other medical conditions associated with heightened risk of environmental fungal infections.


Patients requiring a protective environment should remain in their rooms except as required for diagnostic or therapeutic procedures that can't be performed in the room. To prevent inhaling infectious particles during periods of construction in healthcare facilities, patients who can tolerate a respirator should be provided respiratory protection when leaving the room.


Air entering the room should be filtered by a HEPA filter. Rooms should be well sealed and have 12 or more air exchanges/hour. Clean, filtered air should travel from one side of the room across the patient's bed and exit on the opposite side of the room.


Positive pressure in the patient's room relative to the corridor should be maintained, and daily visual confirmation of airflow patterns (such as by flutter strips) should be documented. Horizontal surfaces should be wet dusted daily, using cloth moistened with an EPA-registered facility-approved disinfectant. Avoid dusting methods that disperse dust. Rooms and hallways should be uncarpeted and free from upholstered furniture, potted plants, and fresh or dried flowers. Use a HEPA-filtered vacuum when vacuuming is necessary.



Eliminating MDROs has become a national priority. All healthcare facilities should participate in a community-based MDRO control program. The priority MDROs mentioned in the new guideline are MRSA, vancomycin-resistant enterococci, multidrug-resistant Streptococcus pneumoniae, multidrug-resistant Gram-negative bacilli producing extended-spectrum beta-lactamases, vancomycin-resistant S. aureus, and vancomycin-intermediate S. aureus. A separate guideline discusses MDRO transmission control.


Selected infections and conditions

The new guideline updated the table of precautions needed for selected infections and conditions. Among the infections and conditions added are:


* C. difficile. The guideline recommends not sharing electronic thermometers if a patient has this infection. Frequently clean and disinfect the patient's environment, using hypochlorite solution as a disinfectant if transmission continues. Wash your hands with soap and water. (Alcohol-based hand rubs have no sporicidal activity.) The hand hygiene guideline addresses how to perform hand hygiene.


* seasonal influenza. The guideline recommends a single patient room when available and not placing the patient with high-risk patients. The patient should wear a mask when being transported out of his room. Guidelines already exist for infection control of avian and pandemic influenza.



Bioterrorism attacks

A table addresses infection control considerations for high-priority bioterrorist attacks. Anthrax, botulism, Ebola and other hemorrhagic fever viruses, plague, smallpox, and tularemia are listed because these agents can be quickly transmitted from person to person. These diseases also cause very high mortality and public panic.


For example, to protect against smallpox, all healthcare providers should have a National Institute for Occupational Safety and Health-approved N95 respirator or higher respiratory protection, even if they've been vaccinated. This reflects concerns about the potential for genetically engineered viruses to be used in bioterrorism attacks or exposure to a very large viral load.


Administrative responsibilities

Facility administrators must make infection control a priority, incorporating an infection control program into the organization's patient-care objectives and occupational safety goals. The number of infection control professionals a healthcare facility needs should be based on factors such as the scope of the infection control professional's practice, the size and complexity of the facility, and the patient population served.


Infection prevention must be considered when determining bedside nurse staffing levels and composition, especially in high-risk units. Infection control nurses or their designees should have the authority to make patient placement choices and to institute transmission-based precautions (contact precautions, airborne precautions, and droplet precautions) when needed.


Staying current

By following the latest CDC guideline, you can help keep your patients safe from HAIs.




Centers for Disease Control and Prevention. Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007. June 2007.


Centers for Disease Control and Prevention. Management of Multidrug-Resistant Organisms in Healthcare Settings, 2006.


Guideline for Hand Hygiene in Health-Care Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR. 2002;51(RR16):1-56.


Guidelines for Environmental Infection Control in Health-Care Facilities. Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). MMWR. 2003;52(RR10):1-42.


Guidelines for Preventing Health-Care-Associated Pneumonia, 2003. Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR. 2004;53(RR03):1-36.


Guidelines for Preventing Opportunistic Infections among Hematopoietic Stem Cell Transplant Recipients. Recommendations of CDC, the Infectious Disease Society of America, and the American Society of Blood and Marrow Transplantation. MMWR. 2000;49(RR10):1-128.


Interim Recommendations for Infection Control in Health-Care Facilities Caring for Patients with Known or Suspected Avian Influenza. May 21, 2004.