V.B.2.a. In acute care hospitals, place patients who require Contact Precautions in a single-patient room when available (Hall, 2000; Ostrowsky et al., 2001; Chang & Nelson, 2000; Byers et al., 2001; Ford-Jones et al., 1990; Boyce et al., 1994; Simor et al., 2002; Fierobe et al., 2001; Montesinos et al., 2003). (See also www.aia.org/aah_gd_hospcons.) Category IB

When single-patient rooms are in short supply, apply the following principles for making decisions on patient placement:

• Prioritize patients with conditions that may facilitate transmission (e.g., uncontained drainage, stool incontinence) for single-patient room placement. Category II
• Place together in the same room (cohort) patients who are infected or colonized with the same pathogen and are suitable roommates (Zawacki et al., 2004; Montecalvo et al., 1999; Jochimsen et al., 1999; Graham et al., 2002; Doherty et al., 1998; Hall et al., 1978; Grehn et al., 1990; Hotchkiss et al., 2005; Austin et al., 1999). Category IB
• 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:
  • 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
  • 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
  • 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 (Tenorio et al., 2001; Olsen et al., 1993; Doebbeling et al., 1988; Patterson et al., 1991; Poutanen et al., 2005; Yap et al., 2004). 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 (Catalano et al., 2003; Tarzi et al., 2001). 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 (Saiman, Siegel & Cystic Fibrosis Foundation, 2003). Category II

V.B.3. Use of personal protective equipment (PPE)

V.B.3.a. Gloves
Wear gloves whenever touching the patient's intact skin (Hall, 2000; Zachary et al., 2001; Boyce & Pittet, 2002; Gerding et al., 1994; Boyce et al., 1994) or surfaces and articles in close proximity to the patient (e.g., medical equipment, bed rails) (Bhalla et al., 2004; Duckro et al., 2005; Boyce et al., 1997; Boyce et al., 1994). Don gloves upon entry into the room or cubicle. (See also www.cdc.gov/ncidod/sars.) 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 (Hall, 2000; Boyce et al., 1997; Boyce et al., 1995; Boyce et al., 1994). (See also www.cdc.gov/ncidod/sars.) Category IB

V.B.3.ii. 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 (Bhalla et al., 2004; Duckro et al., 2005). 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 ("Occupational exposure," 2001; Rutala & Weber, 2004). 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 (Hall, 2000; Boyce et al., 1997; Chang & Nelson, 2000; Rutala & Weber, 2004; Boyce et al., 1994; Jernigan et al., 1998; Layton et al., 1993). 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

V.B.5.c.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 I

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 (Sehulster & Chinn, 2003; Hall, 2000; Boyce et al., 1997; Gerding et al., 1995; Boyce et al., 1994). 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 in the original guideline document. Category IB

V.C. Droplet Precautions

V.C.1. Use Droplet Precautions as recommended in Appendix A of the original guideline document for patients known or suspected to be infected with pathogens transmitted by respiratory droplets (i.e., large-particle droplets >5 micrometers in size) that are generated by a patient who is coughing, sneezing or talking (Tablan et al., 2004; Bridges, Kuehnert, & Hall, 2003; Christie et al., 1995; Gehanno et al., 1999; Feigin et al., 1982; Musher, 2003; Steinberg et al., 1969; Weaver, 1918; Weaver, 1919; Goldmann, 2001; Gilmore, Stuart, & Andrews, 2000). 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:

• Prioritize patients who have excessive cough and sputum production for single-patient room placement Category II
• Place together in the same room (cohort) patients who are infected the same pathogen and are suitable roommates (Buffington et al., 1993; Tan et al., 2004). Category IB
• If it becomes necessary to place patients who require Droplet Precautions in a room with a patient who does not have the same infection:
  • 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
  • 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 (Feigin et al., 1982; Dick et al., 1987; Drinka et al., 2003). Category IB
  • 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 (Olsen et al., 1993; Doebbeling et al., 1988; Maki et al., 1990; Patterson et al., 1991; Poutanen et al., 2005; Yap et al., 2004). 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 (Drinka et al., 2003). 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 (Nafziger et al., 1997; Herwaldt, Smith, & Carter, 1998; Srinivasan et al., 2004). (See also www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm.) 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 (Tablan et al., 2004; Bridges, Kuehnert, & Hall, 2003; Christie, et al., 1995; Feigin et al., 1982; Musher, 2003; Seto et al., 2003; CDC, 1978; Gehanno et al., 1999). 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 severe acute respiratory syndrome (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/.

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 (See 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 in the original guideline document. Category IB

V.D Airborne Precautions

V.D.1. Use Airborne Precautions as recommended in Appendix A in the original guideline document for patients known or suspected to be infected with infectious agents transmitted person-to-person by the airborne route (e.g., Mycobacterium tuberculosis (Jensen et al., 2005), measles (Atkinson et al., 1991; Bloch et al., 1985; Ehresmann et al., 1995), chickenpox (LeClair et al., 1980; Anderson et al., 1985; Gustafson et al., 1982), disseminated herpes zoster (Hyams et al., 1984). 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 airborne infection isolation room (AIIR) that has been constructed in accordance with current guidelines (Sehulster & Chinn, 2003; Jensen et al., 2005; American Institute of Architects [AIA], 2006). Category IA/IC

V.D.2.a.i. Provide at least six (existing facility) or 12 (new construction/renovation) air changes per hour.

V.D.2.a.ii. 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 high-efficiency particulate air (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) (Sehulster & Chinn, 2003; Jensen et al., 2005; Pavelchak et al., 2000; Rice, Streifel, & Vesley, 2001).

V.D.2.a.iv. 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 (Jensen et al., 2005). Category II

V.D.2.c. In the event of an outbreak or exposure involving large numbers of patients who require Airborne Precautions:

• Consult infection control professionals before patient placement to determine the safety of alternative room that do not meet engineering requirements for an AIIR.
• 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).
• 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 (Jensen et al., 2005). 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 (Srinivasan et al., 2004; Jensen et al., 2005; Atkinson et al., 1991; Haley et al., 1989). (See also www.cdc.gov/ncidod/sars.) Category IA

V.D.2.d.ii. 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 (Sehulster & Chinn, 2003; Jensen et al., 2005; Bloch et al., 1985). 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 (Jensen et al., 2005; Downie et al., 1965; Riley, 1974; Thomas, 1961). 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 (Bolyard et al., 1998; Saiman et al., 2001). Category IB

V.D.4. Use of PPE

V.D.4.a. Wear a fit-tested National Institute for Occupational Safety and Health (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:

• 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 (Jensen et al., 2005; Hutton et al., 1990; Frampton, 1992). Category IB
• 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 (Fenner et al., 1988; Gelfand & Posch, 1971). 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 (Ammari, Bell, & Hodinka, 1993; Behrman et al., 2003). 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 (Jensen et al., 2005). 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 (Fenner et al., 1988; Hutton et al., 1990; Frampton, 1992; Josephson & Gombert, 1988; Brodkin, 1963; Suzuki et al., 2004). 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

• 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 (Bolyard et al., 1998; Ruuskanen, Salmi, & Halonen, 1978; Berkovich & Starr, 1963; Watson et al., 1998; Kroger et al., 2006).
• 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) ("Prevention of varicella," 1999; Kroger et al., 2006; Watson et al., 2000; Salzman & Garcia, 1998).
• Administer smallpox vaccine to exposed susceptible persons within 4 days after exposure (Fenner et al., 1988; CDC, 2001; Fulginiti et al., 2003; Dixon, 1948).

V.D.7. Discontinue Airborne Precautions according to pathogen-specific recommendations in Appendix A in the original guideline document. Category IB

V.D.8. Consult CDC's "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005" (Jensen et al., 2005) and the "Guideline for Environmental Infection Control in Health-Care Facilities" (Sehulster & Chinn, 2003) 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.

Definitions:

Strength of the Recommendations

The recommendations are categorized on the basis of existing scientific data, theoretical rational, applicability, and when possible, economic impact, as follows:

Category IA. Strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies.

Category IB. Strongly recommended for implementation and supported by some experimental, clinical, or epidemiologic studies and a strong theoretical rationale.

Category IC. Required for implementation, as mandated by federal and/or state regulation or standard.

Category II. Suggested for implementation and supported by suggestive clinical or epidemiologic studies or a theoretical rationale.

No recommendation; unresolved issue. Practices for which insufficient evidence or consensus regarding efficacy exists.

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