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1. TRANSMISSION-BASED PRECAUTIONS
ISOLATION PRECAUTION GUIDELINES FOR HOSPITALS
KEY CONCEPTS you will learn include:
• What the reasons for the new Transmission-Based Precautions are
• What Transmission-Based Precautions are designed to do
• What preventive processes and practices are recommended for each
route of infection transmission
• How to effectively use Transmission-Based Precautions
BACKGROUND
Although the spread of infectious diseases in hospitals has been
recognized for many years, understanding how to prevent nosocomial
infections and implementing policies and practices that are successful has
been more difficult. The transmission of nosocomial infections requires
three elements: a source of infecting microorganisms, a susceptible host
and a mode of transmission.
The human source of nosocomial infections may be patients, hospital
personnel or, less often, visitors. These people may have infectious
diseases, be in the incubation period (no symptoms), or may be chronic
carriers. Other sources of infecting microorganisms are inanimate objects
that become contaminated, (e.g., instruments) and the environment,
including air and water.
Susceptible hosts are those patients, hospital personnel and, less often,
visitors who may become infected. Resistance among people to infecting
microorganisms varies; for example, some are immune, others get infected
and become asymptomatic carriers; and still others get infected and
develop a clinical disease. Factors such as age, underlying diseases,
treatment with certain drugs (e.g., antimicrobials, corticosteroids and other
immunosupressive agents) and irradiation play a role in this process.
The three main routes of infection transmission in hospitals are airborne,
droplet and contact. An infecting microorganism, however, can be
transmitted by more than one route. For example, varicella (chicken pox)
is transmitted both by the airborne and contact route at different stages of
the disease.
The purpose of this is to explain how Transmission-Based Precautions are
used in the hospital to minimize the risk of clients, patients, visitors and
staff becoming infected while dealing with the healthcare system.
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2. Transmission-Based Precautions: Isolation Precaution Guidelines for Hospitals
DEFINITIONS
• Airborne transmission. Transfer of particles 5 µm or less in size into
the air, either as airborne droplets or dust particles containing the
infectious microoganism; can be produced by coughing, sneezing,
talking or procedures such as bronchoscopy or suctioning; can remain
in the air for up to several hours and be spread widely within a room or
over longer distances. Special air handling and ventilation are needed
to prevent airborne transmission.
• Droplet transmission. Contact of the mucous membranes of the nose,
mouth or conjunctivae of the eye with infectious particles larger than 5
µm in size; can be produced by coughing, sneezing, talking or
procedures such as bronchoscopy or suctioning. Droplet transmission
requires close contact between the source and the susceptible person
because particles remain airborne briefly and travel only about 3 feet
(1 meter) or less.
• Contact transmission. Infectious agent (bacteria, virus or parasite)
transmitted directly or indirectly from one infected or colonized person
to a susceptible host (patient), often on the contaminated hands of a
health worker.
• Colonization. Pathogenic (illness- or disease-causing) organisms are
present in a person (i.e., they can be detected by culturing or other
tests) but are not causing symptoms or clinical findings (i.e., cellular
changes or damage). Coming in contact with and acquiring new
organisms, while increasing the risk of infection, usually does not lead
to infection because the body’s natural defense mechanism (the
immune system) is able to tolerate and/or destroy them. Thus, when
organisms are transmitted from one person to another, colonization
rather than infection is generally the result. Colonized persons,
however, can be a major source of transfer of pathogens to other
persons (cross-contamination) especially if the organisms persist in the
person (chronic carrier), such as with HIV, HBV and HCV
TRANSMISSION-BASED PRECAUTIONS
The new isolation guidelines issued by CDC in 1996 involve a two-level
Note: Protective isolation
approach: Standard Precautions, which apply to all clients and patients
of immunocompromised
attending healthcare facilities, and Transmission-Based Precautions,
patients, such as those with
which apply only to hospitalized patients (Garner and HICPAC 1996).
AIDS, is not an effective
way to reduce the risk of This new system retains the best features of both Universal Precautions
cross-infection (Manangan (UP) and Body Substance Isolation (BSI) and replaces the cumbersome
et al 2001).
disease-specific isolation precautions with three sets of Transmission-
Based Precautions (air, droplet or contact).
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3. Transmission-Based Precautions: Isolation Precaution Guidelines for Hospitals
In all situations, whether used alone or in combination,
Transmission-Based Precautions must be used in conjunction with
the Standard Precautions (Garner and HICPAC 1996).
Airborne Precautions These precautions are designed to reduce the nosocomial transmission of
particles 5 µm or less in size that can remain in the air for several hours
and be widely dispersed (Table 1). Microorganisms spread wholly or
partly by the airborne route include tuberculosis (TB), chicken pox
(varicella virus) and measles (rubeola virus). Airborne precautions are
recommended for patients with either known or suspected infections with
these agents. For example, an HIV-infected person with a cough, night
sweats or fever, and clinical or x-ray findings in the lungs should go on
airborne precautions until TB is ruled out.
Where TB is prevalent, it is important to have a mechanism to quickly
assess patients with suspected TB because delayed diagnosis, resulting in
lack of isolation, has been shown to be an important factor in hospital-
based transmission. In this situation, airborne precautions are the last
defense in reducing the risk of TB transmission.
Table 1. Airborne Precautions
Used in addition to Standard Precautions for a patient known or suspected to be infected
with microorganisms transmitted by the airborne route.
PATIENT PLACEMENT
• Private room.
• Door closed.
• Room air is exhausted to the outside (negative air pressure)
using fan or other filtration system.
• If private room not available, place patient in room with patient
having active infection with the same disease, but with no other
infection.
RESPIRATORY PROTECTION
• Wear face shield (or goggles and surgical mask)
• If TB known or suspected, wear particulate respirator (if
available).
• If chicken pox or measles:
- Immune persons, no mask required.
- Susceptible persons, do not enter room.
• Remove PPE (face shield) after leaving the room and place in a
plastic bag or waste container with tight-fitting lid.
PATIENT TRANSPORT
• Limit transport of patient to essential purposes only.
• During transport, patient must wear surgical mask.
• Notify area receiving patient.
Adapted from: Infection Control Signs, www.etnacomm.com, ETNA Communications,
Chicago, IL. Copyright 2000.
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4. Transmission-Based Precautions: Isolation Precaution Guidelines for Hospitals
Droplet Precautions These precautions reduce the risks for nosocomial transmission of
pathogens spread wholly or partly by droplets larger than 5 µm in size
(e.g., H. influenzae and N. meningitides meningitis; M. pneumoniae, flu,
mumps and rubella viruses). Other conditions include diphtheria, pertussis
(whooping cough), pneumonic plague and strep pharyngitis (scarlet fever
in infants and young children).
Droplet precautions are simpler than airborne precautions because the
particles only remain in the air for a short time and travel only a few feet;
therefore, contact with the source must be close for a susceptible host to
become infected (Table 2).
Table 2. Droplet Precautions
Use in addition to Standard Precautions for a patient known or suspected to be infected
with microorganisms transmitted by large-particle droplets (larger than 5 µm).
PATIENT PLACEMENT
• Private room; door may be left open.
• If private room not available, place patient in room with patient
having active infection with the same disease, but with no other
infection.
• If neither option is available, maintain separation of at least 3
feet between patients.
RESPIRATORY PROTECTION
• Wear mask if within three feet of patient.
PATIENT TRANSPORT
• Limit transport of patient to essential purposes only.
• During transport, patient must wear surgical mask.
• Notify area receiving patient.
Adapted from: Infection Control Signs, www.etnacomm.com, ETNA Communications,
Chicago, IL. Copyright 2000.
Contact Precautions These precautions reduce the risk of transmission of organisms from an
infected or colonized patient through direct or indirect contact (Table 3).
They are indicated for patients infected or colonized with enteric
pathogens (hepatitis A or echo viruses), herpes simplex and hemorrhagic
fever viruses and multidrug (antibiotic)-resistant bacteria. Interestingly,
chicken pox is spread both by the airborne and contact routes at different
stages of the illness. Among infants there are a number of viruses
transmitted by direct contact. In addition, Contact Precautions should be
implemented for patients with skin or eye infections that may be
contagious (e.g., draining abscesses, skin infections that are wet and
draining, herpes zoster, impetigo, conjunctivitis, scabies, lice and wound
infections).
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5. Transmission-Based Precautions: Isolation Precaution Guidelines for Hospitals
Table 3. Contact Precautions
Use in addition to Standard Precautions for a patient known or suspected to be infected
or colonized with microorganisms transmitted by direct contact with the patient or
indirect contact with environmental surfaces or patient care items.
PATIENT PLACEMENT
• Private room; door may be left open.
• If private room not available, place patient in room with patient
having active infection with the same microorganism, but with
no other infection.
GLOVING
• Wear clean, nonsterile examination gloves when entering
room.
• Change gloves after contact with infective material (e.g., fecal
materials or wound drainage).
• Remove gloves before leaving patient room.
HANDWASHING
• Wash hands with antibacterial agent or use alcohol-based
handrub after removing gloves.
• Do not touch potentially contaminated surfaces or items before
leaving the room.
GOWNS AND PROTECTIVE APPAREL
• Wear clean, nonsterile gown when entering patient room if you
anticipate contact with patient or if the patient is incontinent,
has diarrhea, an ileostomy, colostomy or wound drainage not
contained by a dressing.
• Remove gown before leaving room. Do not allow clothing to
contact potentially contaminated surfaces or items before
leaving the room.
PATIENT TRANSPORT
• Limit transport of patient to essential purposes only.
• During transport, ensure precautions are maintained to
minimize risk of transmission of organisms.
PATIENT CARE EQUIPMENT
• Reserve noncritical patient care equipment for use with a
single patient, if possible.
• Clean and disinfect any equipment shared among infected and
noninfected patients.
Adapted from: Infection Control Signs, www.etnacomm.com, ETNA Communications,
Chicago, IL. Copyright 2000.
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6. Transmission-Based Precautions: Isolation Precaution Guidelines for Hospitals
Empiric Use of In certain circumstances, if there is any question of an infectious process in
Transmission-Based a patient without a known diagnosis, implementing Transmission-Based
Precautions Precautions should be considered on an empiric basis until a definitive
diagnosis is made. Examples of the “empiric use” of Transmission-Based
Precautions as they apply to the three routes (air, droplet and contact) are
illustrated in Table 4. In addition, a complete listing of clinical syndromes
or conditions warranting the empiric use of Transmission-Based
Precautions is shown in Table 5. From time to time and based on local
conditions, other important infectious diseases should be considered for
addition to this list.
Table 4. Empiric Use of Transmission Based Precautions
AIRBORNE DROPLET CONTACT
• • •
rashes (vesicule or meningitis (fever, acute diarrhea in an
pustule) vomiting and stiff incontinent or
• neck) diapered patient
cough, fever and upper
• •
lobe chest findings hemorrhagic rash with diarrhea in adult with
(dullness and fever history of recent
•
decreased breath antibiotic use
severe, persistent
•
sounds) bronchitis and croup
cough during periods
• cough, fever and chest when pertussis is in infants and young
findings in any area in present in community children
• •
HIV-infected person or generalized rash of history of infection
at high-risk for HIV unknown cause with multi-resistant
organisms (except
tuberculosis)
• abscess or draining
wound that cannot be
covered
The use of Transmission-Based Precautions, including their empiric use in
selected circumstances, is designed to reduce the risk of airborne-, droplet-
Note: Unfortunately,
Unfortunately
and contact-transmitted infections between hospitalized patients and
“reminder signs” for
healthcare staff. To assist health workers in correctly implementing the
isolation patients do not
increase use (compliance) appropriate precautions, Table 6 provides a summary of the types of
with infection precautions isolation precautions and the illnesses for which each type of precaution is
(Manangan et al 2001).
recommended. In addition, Appendix I provides a complete listing of the
types and duration of the isolation precautions needed for the vast majority
of infectious diseases.
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7. Transmission-Based Precautions: Isolation Precaution Guidelines for Hospitals
Table 5. Clinical Syndromes or Conditions to Be Considered for “Empiric Use” of Transmission-Based Precautions
CLINICAL SYNDROME OR CONDITIONA POTENTIAL EMPIRIC
PATHOGENSB PRECAUTIONS
Diarrhea
Enteric pathogens c
Acute diarrhea with a likely infectious cause in an incontinent or Contact
diapered patient
Diarrhea in an adult with a history of recent antibiotic use Clostridium difficile Contact
Meningitis Neisseria meningitidis Droplet
Rash or exanthems, generalized, etiology unknown
Petechial/ecchymotic with fever Neisseria meningitidis Droplet
Vesicular Varicella (chicken pox) Airborne and Contact
Maculopapular with coryza and fever Rubeola (measles) Airborne
Respiratory infections
Cough/fever/upper lobe pulmonary infiltrate in an HIV-negative Mycobacterium Airborne
patient or a patient at low risk for HIV infection tuberculosis
Cough/fever/pulmonary infiltrate in any lung location in an HIV- Mycobacterium Airborne
infected patient or a patient at high risk for HIV infection tuberculosis
Paroxysmal or severe persistent cough during periods of Bordetella pertussis Droplet
pertussis activity
Respiratory infections, particularly bronchiolitis and croup, in Respiratory syncytial or Contact
infants and young children parainfluenza virus
Risk of multidrug-resistant microorganisms
Resistant bacteriad
History of infection or colonization with multidrug-resistant Contact
organisms d
Resistant bacteriad
Skin, wound, or urinary tract infection in a patient with a recent Contact
hospital or nursing home stay in a facility where multidrug-
resistant organisms are prevalent
Skin or wound infection Staphylococcus aureus, Contact
group A streptococcus
a
Patients with the syndromes or conditions listed below may present with atypical signs or symptoms (e.g., pertussis in
neonates and adults 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 judgment.
b
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 ruled out.
c
These pathogens include enterohemorrhagic Escherichia coli O157:H7, Shigella, hepatitis A, and rotavirus.
d
Resistant bacteria judged by the infection control program, based on current state, regional, or national recommendations,
to be of special clinical or epidemiological significance.
Adapted from: Garner and HICPAC 1996.
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8. Transmission-Based Precautions: Isolation Precaution Guidelines for Hospitals
Table 6. Summary of Types of Precautions and Patients Requiring the Precautions
Standard Precautions
Use Standard Precautions for the care of all patients.
Airborne Precautions
In addition to Standard Precautions, use Airborne Precautions for patients known or suspected to have serious illnesses transmitted
by airborne droplet nuclei. Examples of such illnesses include:
Measles
Varicella (including disseminated zoster)a
Tuberculosis b
Droplet Precautions
In addition to Standard Precautions, use Droplet Precautions for patients known or suspected to have serious illnesses transmitted by
large particle droplets. Examples of such illnesses include:
Invasive Haemophilus influenzae type b disease, including meningitis, pneumonia, epiglottitis, and sepsis
Invasive Neisseria meningitidis disease, including meningitis, pneumonia, and sepsis
Other serious bacterial respiratory infections spread by droplet transmission, including:
Diphtheria (pharyngeal)
Mycoplasma pneumonia
Pertussis
Pneumonic plague
Streptococcal (group A) pharyngitis, pneumonia, or scarlet fever in infants and young children
Serious viral infections spread by droplet transmission, including:
Adenovirus a
Influenza
Mumps
Parvovirus B19
Rubella
Contact Precautions
In addition to Standard Precautions, use Contact Precautions for patients known or suspected to have serious illnesses easily
transmitted by direct patient contact or by contact with items in the patient's environment. Examples of such illnesses include:
Gastrointestinal, respiratory, skin, or wound infections or colonization with multidrug-resistant bacteria judged by the infection
control program, based on current state, regional, or national recommendations, to be of special clinical and epidemiologic
significance.
Enteric infections with a low infectious dose or prolonged environmental survival, including:
Clostridium difficile
For diapered or incontinent patients: enterohemorrhagic Escherichia coli O157:H7, Shigella, hepatitis A, or rotavirus
Respiratory syncytial virus, parainfluenza virus, or enteroviral infections in infants and young children
Skin infections that are highly contagious or that may occur on dry skin, including:
Diphtheria (cutaneous)
Herpes simplex virus (neonatal or mucocutaneous)
Impetigo
Major (noncontained) abscesses, cellulitis, or decubiti
Pediculosis
Scabies
Staphylococcal furunculosis in infants and young children
Zoster (disseminated or in the immunocompromised host)†
Viral/hemorrhagic conjunctivitis
Viral hemorrhagic infections (Ebola, Lassa, or Marburg)*
* See the Appendix for a complete listing of infections requiring precautions, including appropriate footnotes.
a
Certain infections require more than one type of precaution.
b
See CDC “Guidelines for Preventing the Transmission of Tuberculosis in Health-Care Facilities.”
Adapted from: Garner and HICPAC 1996.
8

9. Type and Duration of Precautions Needed for Selected Infections and Conditions
REFERENCES
Garner JS and The Hospital Infection Control Practices Advisory
Committee (HICPAC). 1996. Guideline for isolation precautions in
hospitals. Infect Control Hosp Epidemiol 17(1): 53–80 and Am J Infect
Control 24(1): 24–52.
Infection Control Signs, www.etnacomm.com, ETNA Communications,
Chicago, IL. Copyright 2000.
Manangan LP et al. 2001. Infection control dogma: top 10 suspects. Infect.
Control Hosp Epidemiol 22(4): 243-247.
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10. Type and Duration of Precautions Needed for Selected Infections and Conditions
APPENDIX
TYPE AND DURATION OF PRECAUTIONS NEEDED FOR
SELECTED INFECTIONS AND CONDITIONS1
Precautions
Type * Duration†
Infection/Condition
Abscess
Draining, major a C DI
Draining, minor or limited b S
Acquired immunodeficiency syndrome c S
Actinomycosis S
Adenovirus infection, in infants and young children D,C DI
Amebiasis S
Anthrax
Cutaneous S
Pulmonary S
Antibiotic-associated colitis (see Clostridium difficile)
Arthropodborne viral encephalitides (eastern, western, Venezuelan equine
Sd
encephalomyelitis; St Louis, California encephalitis)
Sd
Arthropodborne viral fevers (dengue, yellow fever, Colorado tick fever)
Ascariasis S
Aspergillosis S
Babesiosis S
Blastomycosis, North American, cutaneous or pulmonary S
Botulism S
Bronchiolitis (see respiratory infections in infants and young children)
Brucellosis (undulant, Malta, Mediterranean fever) S
Campylobacter gastroenteritis (see gastroenteritis)
Candidiasis, all forms including mucocutaneous S
Cat-scratch fever (benign inoculation lymphoreticulosis) S
Cellulitis, uncontrolled drainage C DI
Chancroid (soft chancre) S
Chickenpox (varicella; see F e for varicella exposure) Fe
A,C
Chlamydia trachomatis
Conjunctivitis S
Genital S
Respiratory S
Cholera (see gastroenteritis)
Closed-cavity infection
Draining, limited or minor S
Not draining S
Clostridium
C botulinum S
C difficile C DI
C perfringens
1
Source: Garner JS and HICPAC 1996.
10

11. Type and Duration of Precautions Needed for Selected Infections and Conditions
Precautions
*
Duration†
Infection/Condition Type
Food poisoning S
Gas gangrene S
Coccidioidomycosis (valley fever)
Draining lesions S
Pneumonia S
Colorado tick fever S
Ff
Congenital rubella C
Conjunctivitis
Acute bacterial S
Chlamydia S
Gonococcal S
Acute viral (acute hemorrhagic) C DI
Coxsackievirus disease (see enteroviral infection)
Sg
Creutzfeldt-Jakob disease
Croup (see respiratory infections in infants and young children)
Cryptococcosis S
Cryptosporidiosis (see gastroenteritis)
Cysticercosis S
Cytomegalovirus infection, neonatal or immunosuppressed S
Decubitus ulcer, infected
Major a C DI
Minor or limited b S
Sd
Dengue
Diarrhea, acute-infective etiology suspected (see gastroenteritis)
Diphtheria
CN h
Cutaneous C
CN h
Pharyngeal D
Ci
Ebola viral hemorrhagic fever DI
Echinococcosis (hydatidosis) S
Echovirus (see enteroviral infection)
Encephalitis or encephalomyelitis (see specific etiologic agents)
Endometritis S
Enterobiasis (pinworm disease, oxyuriasis) S
Enterococcus species (see multidrug-resistant organisms if epidemiologically
significant or vancomycin resistant)
Enterocolitis, Clostridium difficile C DI
Enteroviral infections
Adults S
Infants and young children C DI
Epiglottitis, due to Haemophilus influenzae D U(24 hrs)
Epstein-Barr virus infection, including infectious mononucleosis S
Erythema infectiosum (also see Parvovirus B19) S
Escherichia coli gastroenteritis (see gastroenteritis)
Food poisoning
Botulism S
Clostridium perfringens or welchii S
Staphylococcal S
Furunculosis-staphylococcal
11

12. Type and Duration of Precautions Needed for Selected Infections and Conditions
Precautions
*
Duration†
Infection/Condition Type
Infants and young children C DI
Gangrene (gas gangrene) S
Gastroenteritis
Sj
Campylobacter species
Sj
Cholera
Clostridium difficile C DI
Sj
Cryptosporidium species
Escherichia coli
Sj
Enterohemorrhagic O157:H7
Diapered or incontinent C DI
Sj
Other species
Sj
Giardia lamblia
Sj
Rotavirus
Diapered or incontinent C DI
Sj
Salmonella species (including S typhi)
Sj
Shigella species
Diapered or incontinent C DI
Sj
Vibrio parahaemolyticus
Sj
Viral (if not covered elsewhere)
Sj
Yersinia enterocolitica
German measles (see rubella)
Giardiasis (see gastroenteritis)
Gonococcal ophthalmia neonatorum (gonorrheal ophthalmia, acute conjunctivitis of
S
newborn)
Gonorrhea S
Granuloma inguinale (donovanosis, granuloma venereum) S
Guillain-Barré‚ syndrome S
Hand, foot, and mouth disease (see enteroviral infection)
Hantavirus pulmonary syndrome S
Helicobacter pylori S
Ci
Hemorrhagic fevers (for example, Lassa and Ebola) DI
Hepatitis, viral
Type A S
Fk
Diapered or incontinent patients C
Type B-HBsAg positive S
Type C and other unspecified non-A, non-B S
Type E S
Herpangina (see enteroviral infection)
Herpes simplex (Herpesvirus hominis)
Encephalitis S
Neonatal l (see F l for neonatal exposure) C DI
Mucocutaneous, disseminated or primary, severe C DI
Mucocutaneous, recurrent (skin, oral, genital) S
Herpes zoster (varicella-zoster)
DI m
Localized in immunocompromised patient, or disseminated A,C
Sm
Localized in normal patient
Histoplasmosis S
HIV (see human immunodeficiency virus) S
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13. Type and Duration of Precautions Needed for Selected Infections and Conditions
Precautions
*
Duration†
Infection/Condition Type
Hookworm disease (ancylostomiasis, uncinariasis) S
Human immunodeficiency virus (HIV) infection c S
Impetigo C U (24 hrs)
Infectious mononucleosis S
Dn
Influenza DI
Kawasaki syndrome S
Ci
Lassa fever DI
Legionnaires' disease S
Leprosy S
Leptospirosis S
Lice (pediculosis) C U (24 hrs)
Listeriosis S
Lyme disease S
Lymphocytic choriomeningitis S
Lymphogranuloma venereum S
Sd
Malaria
Ci
Marburg virus disease DI
Measles (rubeola), all presentations A DI
Melioidosis, all forms S
Meningitis
Aseptic (nonbacterial or viral meningitis; also see enteroviral infections) S
Bacterial, gram-negative enteric, in neonates S
Fungal S
Haemophilus influenzae, known or suspected D U(24 hrs)
Listeria monocytogenes S
Neisseria meningitidis (meningococcal) known or suspected D U(24 hrs)
Pneumococcal S
Tuberculosis o S
Other diagnosed bacterial S
Meningococcal pneumonia D U(24 hrs)
Meningococcemia (meningococcal sepsis) D U(24 hrs)
Molluscum contagiosum S
Mucormycosis S
Multidrug-resistant organisms, infection or colonization p
Gastrointestinal C CN
Respiratory C CN
Pneumococcal S
Skin, wound, or burn C CN
Fq
Mumps (infectious parotitis) D
Mycobacteria, nontuberculosis (atypical)
Pulmonary S
Wound S
Mycoplasma pneumonia D DI
Necrotizing enterocolitis S
Nocardiosis, draining lesions or other presentations S
Norwalk agent gastroenteritis (see viral gastroenteritis)
Orf S
Parainfluenza virus infection, respiratory in infants and young children C DI
13

14. Type and Duration of Precautions Needed for Selected Infections and Conditions
Precautions
*
Duration†
Infection/Condition Type
Fr
Parvovirus B19 D
Pediculosis (lice) C U(24 hrs)
Fs
Pertussis (whooping cough) D
Pinworm infection S
Plague
Bubonic S
Pneumonic D U(72 hrs)
Pleurodynia (see enteroviral infection)
Pneumonia
Adenovirus D,C DI
Bacterial not listed elsewhere (including gram-negative bacterial) S
Burkholderia cepacia in cystic fibrosis (CF) patients,
St
including respiratory tract colonization
Chlamydia S
Fungal S
Haemophilus influenzae
Adults S
Infants and children (any age) D U(24 hrs)
Legionella S
Meningococcal D U(24 hrs)
Multidrug-resistant bacterial (see multidrug-resistant organisms)
Mycoplasma (primary atypical pneumonia) D DI
Pneumococcal S
Multidrug-resistant (see multidrug-resistant organisms)
Su
Pneumocystis carinii
St
Pseudomonas cepacia (see Burkholderia cepacia)
Staphylococcus aureus S
Streptococcus, group A
Adults S
Infants and young children D U(24hrs)
Viral
Adults S
Infants and young children (see respiratory infectious disease, acute)
Poliomyelitis S
Psittacosis (ornithosis) S
Q fever S
Rabies S
Rat-bite fever (Streptobacillus moniliformis disease, Spirillum minus disease) S
Relapsing fever S
Resistant bacterial infection or colonization (see multidrug-resistant organisms)
Respiratory infectious disease, acute (if not covered elsewhere)
Adults S
Infants and young children c C DI
Respiratory syncytial virus infection, in infants and
C DI
young children, and immunocompromised adults
Reye's s yndrome S
Rheumatic fever S
Rickettsial fevers, tickborne (Rocky Mountain spotted fever, tickborne typhus fever) S
14

15. Type and Duration of Precautions Needed for Selected Infections and Conditions
Precautions
*
Duration†
Infection/Condition Type
Rickettsialpox (vesicular rickettsiosis) S
Ringworm (dermatophytosis, dermatomycosis, tinea) S
Ritter's disease (staphylococcal scalded skin syndrome) S
Rocky Mountain spotted fever S
Roseola infantum (exanthem subitum) S
Rotavirus infection (see gastroenteritis)
Fv
Rubella (German measles; also see congenital rubella) D
Salmonellosis (see gastroenteritis)
Scabies C U(24 hrs)
Scalded skin syndrome, staphylococcal (Ritter's disease) S
Schistosomiasis (bilharziasis) S
Shigellosis (see gastroenteritis)
Sporotrichosis S
Spirillum minus disease (rat-bite fever) S
Staphylococcal disease (S aureus)
Skin, wound, or burn
Major a C DI
Minor or limited b S
Sj
Enterocolitis
Multidrug-resistant (see multidrug-resistant organisms)
Pneumonia S
Scalded skin syndrome S
Toxic shock syndrome S
Streptobacillus moniliformis disease (rat-bite fever) S
Streptococcal disease (group A streptococcus)
Skin, wound, or burn
Major a C U(24 hrs)
Minor or limited b S
Endometritis (puerperal sepsis) S
Pharyngitis in infants and young children D U(24 hrs)
Pneumonia in infants and young children D U(24 hrs)
Scarlet fever in infants and young children D U(24 hrs)
Streptococcal disease (group B streptococcus), neonatal S
Streptococcal disease (not group A or B) unless covered elsewhere S
Multidrug-resistant (see multidrug-resistant organisms)
Strongyloidiasis S
Syphilis
Skin and mucous membrane, including congenital, primary, secondary S
Latent (tertiary) and seropositivity without lesions S
Tapeworm disease
Hymenolepis nana S
Taenia solium (pork) S
Other S
Tetanus S
Tinea (fungus infection dermatophytosis, dermatomycosis, ringworm) S
Toxoplasmosis S
Toxic shock syndrome (staphylococcal disease) S
Trachoma, acute S
15

16. Type and Duration of Precautions Needed for Selected Infections and Conditions
Precautions
*
Duration†
Infection/Condition Type
Trench mouth (Vincent's angina) S
Trichinosis S
Trichomoniasis S
Trichuriasis (whipworm disease) S
Tuberculosis
Extrapulmonary, draining lesion (including scrofula) S
Extrapulmonary, meningitis o S
Fw
Pulmonary, confirmed or suspected or laryngeal disease A
Skin-test positive with no evidence of current pulmonary disease S
Tularemia
Draining lesion S
Pulmonary S
Typhoid (Salmonella typhi) fever (see gastroenteritis)
Typhus, endemic and epidemic S
Urinary tract infection (including pyelonephritis), with or without urinary catheter S
Fe
Varicella (chickenpox) A,C
Vibrio parahaemolyticus (see gastroenteritis)
Vincent's angina (trench mouth) S
Viral diseases
Respiratory (if not covered elsewhere)
Adults S
Infants and young children (see respiratory infectious disease, acute)
Fs
Whooping cough (pertussis) D
Wound infections
Major a C DI
Minor or limited b S
Yersinia enterocolitica gastroenteritis (see gastroenteritis)
Zoster (varicella-zoster)
DI m
Localized in immunocompromised patient, disseminated A,C
Sm
Localized in normal patient
Zygomycosis (phycomycosis, mucormycosis) S
16

17. Isolation Precaution Guidelines for Hospitals
Abbreviations:
* Type of Precautions: A, Airborne; C, Contact; D, Droplet; S, Standard; when A, C, and D are specified, also use S.
† Duration of precautions: CN, until off antibiotics and culture-negative; DI, duration of illness (with wound lesions, DI means
until they stop draining); U, until time specified in hours (hrs) after initiation of effective therapy; F, see footnote.
a
No dressing or dressing does not contain drainage adequately.
b
Dressing covers and contains drainage adequately.
c
Also see syndromes or conditions listed in Table 2.
d
Install screens in windows and doors in endemic areas.
e
Maintain precautions until all lesions are crusted. The average incubation period for varicella is 10 to 16 days, with a range of
10 to 21 days. After exposure, use varicella zoster immune globulin (VZIG) when appropriate, and discharge susceptible patients
if possible. Place exposed susceptible patients on Airborne Precautions beginning 10 days after exposure and continuing until 21
days after last exposure (up to 28 days if VZIG has been given). Susceptible persons should not enter the room of patients on
precautions if other immune caregivers are available.
f
Place infant on precautions during any admission until 1 year of age, unless nasopharyngeal and urine cultures are negative for
virus after age 3 months.
g
Additional special precautions are necessary for handling and decontamination of blood, body fluids and tissues, and
contaminated items from patients with confirmed or suspected disease. See latest College of American Pathologists (Northfield,
Illinois) guidelines or other references.
h
Until two cultures taken at least 24 hours apart are negative.
i
Call state health department and CDC for specific advice about management of a suspected case. During the 1995 Ebola
outbreak in Zaire, interim recommendations were published.(97) Pending a comprehensive review of the epidemiologic data
from the outbreak and evaluation of the interim recommendations, the 1988 guidelines for management of patients with
suspected viral hemorrhagic infections (16) will be reviewed and updated if indicated.
j
Use Contact Precautions for diapered or incontinent children <6 years of age for duration of illness.
k
Maintain precautions in infants and children <3 years of age for duration of hospitalization; in children 3 to 14 years of age,
until 2 weeks after onset of symptoms; and in others, until 1 week after onset of symptoms.
l
For infants delivered vaginally or by C-section and if mother has active infection and membranes have been ruptured for more
than 4 to 6 hours.
m
Persons susceptible to varicella are also at risk for developing varicella when exposed to patients with herpes zoster lesions;
therefore, susceptibles should not enter the room if other immune caregivers are available.
n
The quot;Guideline for Prevention of Nosocomial Pneumoniaquot; (95,96) recommends surveillance, vaccination, antiviral agents, and
use of private rooms with negative air pressure as much as feasible for patients for whom influenza is suspected or diagnosed.
Many hospitals encounter logistic difficulties and physical plant limitations when admitting multiple patients with suspected
influenza during community outbreaks. If sufficient private rooms are unavailable, consider cohorting patients or, at the very
least, avoid room sharing with high-risk patients. See “Guideline for Prevention of Nosocomial Pneumonia” (95,96) for
additional prevention and control strategies.
o
Patient should be examined for evidence of current (active) pulmonary tuberculosis. If evidence exists, additional precautions
are necessary (see tuberculosis).
p
Resistant bacteria judged by the infection control program, based on current state, regional, or national recommendations, to be
of special clinical and epidemiologic significance.
q
For 9 days after onset of swelling.
r
Maintain precautions for duration of hospitalization when chronic disease occurs in an immunodeficient patient. For patients
with transient aplastic crisis or red-cell crisis, maintain precautions for 7 days.
s
Maintain precautions until 5 days after patient is placed on effective therapy.
t
Avoid cohorting or placement in the same room with a CF patient who is not infected or colonized with B cepacia. Persons with
CF who visit or provide care and are not infected or colonized with B cepacia may elect to wear a mask when within 3 ft of a
colonized or infected patient.
u
Avoid placement in the same room with an immunocompromised patient.
v
Until 7 days after onset of rash.
w
Discontinue precautions only when TB patient is on effective therapy, is improving clinically, and has three consecutive
negative sputum smears collected on different days, or TB is ruled out. Also see CDC “Guidelines for Preventing the
Transmission of Tuberculosis in Health-Care Facilities.”(23)
REFERENCES
Garner JS and The Hospital Infection Control Practices Advisory
Committee (HICPAC). 1996. Guideline for isolation precautions in
hospitals. Infect Control Hosp Epidemiol 17(1): 53–80, and Am J Infect
Control 24(1): 24–52.
17