Standard Precautions

A key element of Infection Control under

Critical Appraisal

Andreas F. Widmer, MD,MS,FIDSA,FSHEA

Core member patient safety WHO Geneva
Board member Society of Healthcare epidemiology of America
Treasurer of European Study for nosocomial Infections (ESGNI)
Chair Infection Control
University of Basel Hospitals & Clinics
Basel, Switzerland

Impact and History

Widmer AF 1
 Ten Great Public Health Achievements --
United States, 1900-1999
 Vaccination
 Motor-vehicle safety
 Safer workplaces
 Control of infectious diseases
 Decline in deaths from coronary heart disease and stroke
 Safer and healthier foods
 Healthier mothers and babies
 Family planning
 Fluoridation of drinking water
 Recognition of tobacco use as a health hazard

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4829a1.htm

Widmer AF 2
 Globally important
Infectious diseases
Frequently without
Effective or no treatment
Options
ISOLATION ONLY

www.prweb.com/releases/2005/3/prweb220610.htm

HISTORY OF GUIDELINES FOR ISOLATION

PRECAUTIONS IN HOSPITALS*
Year (Ref.) Document issued Comment
1970 Isolation Techniques for - Introduced seven isolation precaution categories with color-
National
Communicable Use in Hospitals, 1st ed. coded cards: Strict, Respiratory, Protective, Enteric, Wound
Disease and Skin, Discharge, and Blood
Center.
Isolation - No user decision-making required
Techniques for
Use in - Simplicity a strength; over isolation prescribed for some
Hospitals. 1st
ed. Infections
Washington,
DC: US
Government
Printing Office;.
PHS
publication no
2054.

1975 Isolation Techniques for - Same conceptual framework as 1st edition

HHS Use in Hospitals, 2nd ed.
publication no.
(CDC)
80-8314.

1983 CDC Guideline for Isolation - Provided two systems for isolation: category-specific and
Garner JS, Precautions in Hospitals diseases-pecific
Simmons BP.
HHS - Protective Isolation eliminated; Blood Precautions expanded
publication no. to include Body Fluids
(CDC) 83-8314.
Infect Control
- Categories included Strict, Contact, Respiratory, AFB,
1983;4:245- Enteric, Drainage/Secretion, Blood and Body Fluids
325. - Emphasized decision-making by users
CDC_08

Widmer AF 3
 HISTORY OF GUIDELINES FOR ISOLATION
PRECAUTIONS IN HOSPITALS*
Year (Ref.) Document issued Comment
1985-88 Universal - Developed in response to HIV/AIDS epidemic
MMWR Morb Precautions - Dictated application of Blood and Body Fluid precautions to all
Mortal Wkly
Rep 1988; patients, regardless of infection status
37(24):377-82, - Did not apply to feces, nasal secretions, sputum, sweat,
87-8.
Neal JG et al.
tears, urine, or vomitus unless contaminated by visible blood
J Long Term - Added personal protective equipment to protect HCWs from
Eff Med mucous membrane exposures
Implants
1998;8 - Handwashing recommended immediately after glove removal
(3-4):233-40. - Added specific recommendations for handling needles and
other sharp devices; concept became integral to OSHA’s
1991 rule on occupational exposure to blood-borne
pathogens in healthcare settings
1987 Body Substance - Emphasized avoiding contact with all moist and potentially
Lynch P et al. Isolation infectious body substances except sweat even if blood not
Ann Intern
Med 1987; present
107(2):243-6. - Shared some features with Universal Precautions
- Weak on infections transmitted by large droplets or by
contact with dry surfaces
- Did not emphasize need for special ventilation to contain
airborne infections
- Handwashing after glove removal not specified in the
absence of visible soiling
CDC_08

HISTORY OF GUIDELINES FOR ISOLATION

PRECAUTIONS IN HOSPITALS*

Year (Ref.) Document issued Comment

1996 Guideline for Isolation - Prepared by the Healthcare Infection Control Practices
Garner JS. Precautions in Hospitals Advisory Committee (HICPAC)
ICHE 1996;17
(1):53-80 - Melded major features of Universal Precautions and Body
Substance Isolation into Standard Precautions to be used
with all patients at all times
- Included three transmission-based precaution categories:
airborne, droplet, and contact
- Listed clinical syndromes that should dictate use of empiric
isolation until an etiological diagnosis is established
2007 Guideline for Isolation Respiratory etiquette
Precautions in Hospitals More emphasis on environment in immunocompromised host
Emphasis of staffing and administrative responsabilities

CDC_08

Widmer AF 4
 Type of precautions Protection of

HCW Patients
• Standard +++ +++
• Contact + +++
• Droplet +++ +
• Airborne +++ ++

Modes of Transmission of Pathogens

 Airborne eg measles, Tbc

 Droplets eg Influenza

 Contact eg. methicillin-resistente S.aureus (MRSA), VRE

 Blood eg Hepatitis B und C

 Feco-oral eg Hepatitis A, Salmonella

 Nutrition eg Campylobacter

Widmer AF 5
 The Aerobiologic Pathway for the Transmission
of Communicable Respiratory Disease.

Roy CJ, Milton DK. N Engl J Med 2004;350:1710-1712.

Droplets

1m 3m

Widmer AF 6
 Tröpfchen (1m)CDC
- 2007 2008 -
1m (3 feet) 3m

2014 1m?

Detection of Bordetella pertussis and RSV RNA

in Samples from Patient Rooms
Bordetella pertussis RSV RNA

30%
19%

14%

Aintablian N. ICHE 1998,19;918-923 SHEA04

Widmer AF 7
 Spatial distribution of the average aerosol
concentrations of Influenza virus, measured over 20
minutes, in patient rooms.

The number of emitters

exceeding the low HID50
(defined as >90 RNA
copies) was 13 (50%) at
≤0.305 m, 11 (42%) at
0.914 m, and 9 (35%) at
1.829 m. The number of
emitters exceeding the
high HID50 (defined as
>1950 RNA
copies) was 3 (12%) at
≤0.305 m, 2 (8%) at 0.914
m, and 1 (4%) at 1.829 m.
The same emitter can
exceed the HID50
at >1 distance.

Bischoff W. J Infect Dis. 2013;

Total aerosol concentrations of influenza virus

emitted by individual subjects over 20 minutes.

«superspreader»

In the x-axis, patient age and influenza virus type

are shown in parentheses.
Abbreviations: HID50, 50% human infectious dose;
Infl., influenza; y/o, years old.

Bischoff et al J Infect Dis. 2013; Jan 30

Widmer AF 8
 Respiratory syncytial Virus (RSV)
transmission by aerosol, contact and environment

„Cuddler“ „Touchers“ „Sitters“

Contact contact Indirect Aerosol
2-4 h Surfaces contam. >2m . from bed
 touch nouse and eyes
Protection Gown Non Glove, Gown
Infection 5/7 4/10 0/14

Hall CB et al. J Pediatr 1981

HICPAC Guideline for Isolation 2007

Standard Precautions
Patient room Standard
Gloves Contact with blood, body fluids, mucous
membranes, secretions, excreta or broken skin
Hand hygiene Alcohol handrub; after glove removal; between
patients; handwashing if soiled (or spores a
concern)
Gown + mask + Before procedure likely to generate projections
googles or contact with blood, body fluids, secretions or
excreta
Respiratory Patient to cover mouth & nose when coughing;
hygiene/Cough wearing of mask; keep distance 1 m; hand
etiquette hygiene after touching secretions
Conditions All patients
www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf 18

Widmer AF 9
 HICPAC 2007 Guideline for Isolation
Precautions in Healthcare Settings

Two-tier approach:
 1. “Standard precautions to reduce to risk of
transmission of bloodborne pathogens ...and from
contact with moist body substances. Designed for the
care of all patients …”

 2. “... transmission-based precautions are to be used in

addition to standard precautions to reduce the risk of
airborne, droplet and contact transmission”…
• Designed for patients known or suspected to be infected or
colonized with highly transmissible or pidemiologically important
pathogens …”
www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf

Standard Precautions

Principles

 Masks
 Gowns
 Gloves
 Special Situations
• Respiratory Etiquette

Widmer AF 10
 Masks to Prevent Droplet/Airborne
Transmission

Facemasks (Procedure or Surgical Masks)

CDC Recommendation 2011: Personal Protective Equipment

Wear a facemask:
 When there is potential contact with respiratory
secretions and sprays of blood or body fluids (as defined
in Standard Precautions and/or Droplet Precautions)
• May be used in combination with goggles or face shield to
protect the mouth, nose and eyes

 When placing a catheter or injecting material into the

spinal canal or subdural space (to protect patients from
exposure to infectious agents carried in the mouth or
nose of healthcare personnel)
• Wear a facemask to perform intrathecal chemotherapy
http://www.cdc.gov/HAI/settings/outpatient/basic-infection-control-prevention-plan-2011/standard-precautions.html

Widmer AF 11
 Masks
Europe vs US

Surgical Mask

GOAL: Protects Patient, NOT the Healthcare worker (HCW)

Respirators

GOAL: Protects HCW, NOT necessarily patient

Widmer AF 12
 Surgical Masks - Premarket
Notification [510(k)] Submissions
 8. Filtration Efficiency
 For surgical masks that are not NIOSH certified N95 Respirators, we recommend that you evaluate filter
efficiency performance and bacterial filtration efficiency. For surgical masks that are NIOSH certified N95
Respirators, you may submit your NIOSH certification number in lieu of this information.
 Particulate Filtration Efficiency
 We recommend that you conduct a particle challenge study using 0.1-Micron Polystyrene Latex Spheres.
This in vitro test challenges the mask with unneutralized 0.1-micron polystyrene latex spheres and
measures penetration. The use of latex spheres provides an appropriately rigorous test for evaluating a
submicron efficiency performance (ASTM F 1215-89 Standard Test Method for Determining the Initial
Efficiency of Flatsheet Filter Medium in an Airflow Using Latex Spheres.).
 Bacterial Filtration Efficiency
 Bacterial Filtration Efficiency (BFE) is a measure of the ability of the mask’s material to prevent the
passage of aerosolized bacteria. BFE is expressed in the percentage of a known quantity that does not
pass the mask material at a given aerosol flow rate. We recommend that you evaluate the BFE of your
device using one of the test methods or standards listed below.
 Bacterial Penetration (aerosol filtration) - Mil- M369454C, Military Specifications: Surgical Mask, disposable
(June 12, 1975).
 Modified Greene and Vesley Method: Method for evaluation of bacterial filtration efficiency of surgical
masks. J Bacteriol 83:663-667. (1962)..

ASTM F2101-01 Standard Test Method for Evaluating the Bacterial Filtration
Efficiency (BFE) of surgical masks using a Biological Aerosol of S. aureus

Fluid Resistance
Surgical Masks FDA Requirement
• ASTM F 1862: Standard Test Method for Resistance
of Surgical Mask to Penetration by Synthetic Blood

 According to ASTM F 1862, surgical masks are

tested on a pass/fail basis at three velocities
corresponding to the range of human blood
pressure (80, 120, 160 mm Hg).
 Fluid resistance may be claimed if the device
passes ASTM F1862 at any levels. Surgical
masks that show passing results at higher
velocities are more fluid resistant.

Widmer AF 13
 FDA Bacterial Filtration Efficiency
Surgical Masks FDA Requirement

Bacterial Filtration Efficiency (BFE) is a measure of the ability of the

mask’s material to prevent the passage of aerosolized bacteria. BFE is
expressed in the percentage of a known quantity that does not pass the
mask material at a given aerosol flow rate.
Accepted Methods to determine BFE of your device

• • Bacterial Penetration (aerosol filtration) - Mil- M369454C, Military

Specifications: Surgical Mask, disposable (June 12, 1975).

• • Modified Greene and Vesley Method: Method for evaluation of bacterial

filtration efficiency of surgical masks. J Bacteriol 83:663-667. (1962).

• • ASTM F2101-01 Standard Test Method for Evaluating the Bacterial Filtration
Efficiency (BFE) of surgical masks using a Biological Aerosol of Staphylococcus
aureus.

Masks in the US

 Two mask types are available for use in healthcare settings:

1. „surgical masks“ cleared by the FDA and required to have fluid-
resistant properties
2. „procedure or isolation masks“

 No studies have been published that compare mask types to determine

whether one mask type provides better protection than another.

 Since procedure/isolation masks are not regulated by the FDA,

there may be more variability in quality and performance than with
surgical masks.
Masks come in various shapes (e.g., molded and non-molded), sizes,
filtration efficiency, and method of attachment (e.g., ties, elastic, ear loops).

 Healthcare facilities may find that different types of masks are needed to
meet individual healthcare personnel needs.

Widmer AF 14
 The Surgical Mask EN 14683 Typ II
MASK BFE Delta-P Splash-
Resistant (R)
1810 F ≥ 98% < 29,4 Pa No
1810 G ≥ 98% < 29,4 Pa No
1816 / 1826 ≥ 99% < 24,5 Pa No
1818 / 1818FS ≥ 98% = 19,6 Pa No
1819 ≥ 99,3 ≤ 17,6 Pa Yes
1838 ≥ 98% = 19,6 Pa No
Delta-P determines the resistance of the surgical facemask to air flowing
through the mask. Pressure drop also relates to the breathability and comfort of
the surgical mask.
In general, a lower Delta-P translates to increased breathability.

Widmer AF 15
 Protective measures reported by
infected vs non-infected staff

NC=not calculatable. *Two-tailed. †Odds ratio of staff with specific protection not getting infected. ‡”Yes” and “most of the time” were grouped
together. §Total cases 254 by forward stepwise (Waldesian) logistic regression using 0·05 as entry probability and 0·10 as removal probability.
Forward and backward stepwise regression result in same model with mask in the model (p=0·011). ¶Comparing proportion of infected over non-
infected staff, with those without mask (11 infected and 72 non-infected).

Seto WH et al, Lancet 2003;361:1519-20

Surgical_Masks_05

Widmer AF 16
 Respirators
CDC Recommendation 2011: Personal Protective Equipment

 If available, wear N95-or higher respirators for

potential exposure to infectious agents
transmitted via the airborne route (e.g.,
tuberculosis).

 All healthcare personnel that use N95-or higher

respirator are fit tested at least annually and
according to OSHA requirements

http://www.cdc.gov/HAI/settings/outpatient/basic-infection-control-prevention-plan-2011/standard-precautions.html

PPE N95 vs FFP 2 or FFP3

Classification of gas filters
Class Effective against Total inward Protection
leakage Factor
FFP1 Course dust 22% 4

FFP2 Course dust, troublesome and

harmful fine dust, welding smoke, 8% 10
glass fibers, lead dust and smoke, oil
hazes and harmful aerosols
FFP3 Carcinogenic particles, radio-active
particles, bacteria, viruses, 2% 50
proteolytic enzymes, spores

N95 US Norm 95% filtration capacity ?

?

Widmer AF 17
 What is difference between

Fit or Seal Check and Fit Test?

Results of user seal checks (Fit Check)

in three masks

Type of mask n= Fit-test pass User seal check User seal check User seal check
rate (%) correct (%) incorrectly failed mask incorrectly passed
mask mask

1860s (N95) 84 69% 75% 40% failure 19% passes

9210 (N95) 93 55% 71% 24% failure 31% passes
8233 (N100) 91 70% 73% 45% failure 18% passes

Derrick JL. J.Hosp.Infect. 59 (2):152-155, 2005.

Widmer AF 18
 The effectiveness of training and taste
testing when using respirator masks

Staff member Previously Ties Nose Pointed down Pass/fail

trained

Nurse yes yes yes yes Pass

Nurse No yes No No Fail
Nurse yes No yes yes Pass
Doctor No No yes No Fail
Doctor yes yes yes No Pass
Doctor No yes yes No Fail
Physiotherapist No No yes No Pass
Physiotherapist No No yes No Fail
Student nurse No No yes yes Fail
Student nurse yes No yes yes Fail
Student nurse No No yes No Fail

L. Kelly and K. Clark. J.Hosp.Infect. 58 (3):240-241, 2004. 7/12 fail

Comparison filtering face piece (FFP) Masks (Respirators)

EN 149 (EUROPE) and NIOSH (USA)
and surgical Masks EN 14683 (EUROPE)
• Type Filter capacity for Maximal acceptable
NaCl- leakage

• FFP 1 80 % 22% 1
• FFP 2 94 % 8% 1
• FFP 3 99 % 2% 1

• NIOSH N95 95 % N for Not resistant to oil, 10% 2

• NIOSH N99 99 % R for Resistant to oil 10% 2
• NIOSH N100 99,97 % P for oil Proof 10% 2

• MNS (S. aureus) [95] NA

[Staphylococcus aureus]

FFP = Filtering facepiece, NIOSH = National Institute for Occupational Safety & Health
1) Fr FFP-Masken mit NaCl-Aerosol gemäss EN 149 festgelegt
2) NIOSH-N-Masken abgeleitet aus dem von NIOSH angegebenen Assigned Protection Factor (APF) von 10.
Dieser setzt einen bestandenen qualitativen oder quantitativen Fit-Test nach OSHA voraus

Widmer AF 19
 Gloves

Gloves
CDC Recommendation 2011: Personal Protective Equipment

 Wear gloves when there is potential contact with blood

(e.g., during phlebotomy), body fluids, mucous
membranes, nonintact skin or contaminated equipment.
 Wear gloves that fit appropriately (select gloves
according to hand size)
 Do not wear the same pair of gloves for the care of more
than one patient
 Do not wash gloves for the purpose of reuse
 Perform hand hygiene before and immediately after
removing gloves

http://www.cdc.gov/HAI/settings/outpatient/basic-infection-control-prevention-plan-2011/standard-precautions.html

Widmer AF 20
 Gloves
Surgical vs Examination

AQL - Punctures & Colonization

Leakage Test
EN 355-1

Widmer AF 21
 Air Fill check

Accepted Quality Level (AQL)

AQLfor holes http://www.ansellhealthcare.com/america/latamer/quality/page9.htm

- surgical gloves 1.5

- examination gloves 2.5
Table: Risk of no holes in a box with 100 glove

No. of AQL 0.065 AQL 1.5 AQL 2.5

Defects

0 93.7% 22.1% 8.0%

1 6.1% 33.6% 20.4%
2 0.2% 25.3% 25.9%
3 12.6% 21.7%
4 4.6% 13.5%
5 1.4% 6.6%
6+ 0.4% 3.9%

Widmer AF 22
 Isolation Gowns

Gowns

Requirements for Isolation Gown

 Section 1910.1030(d)(3)(i) of Occupational Safety and

Health Administration’s (OSHA) Bloodborne pathogens
standard reads,
‘‘Personal protective equipment will be considered
‘appropriate’ only if it does not permit blood or other
potentially infectious materials to pass through under
normal conditions of use..’

 The Association for the Advancement of Medical

Instrumentation (AAMI) states that ‘‘[gowns [and] other
protective apparel must provide an effective barrier
against the transmission of microorganisms..’’
 Liquid repellency is a necessary component of this
protection.

Widmer AF 23
 Recognized Consensus Standards by FDA
•AAMI/ANSI PB70:2003/(R)2009
Liquid barrier performance and classification of protective apparel and drapes
intended for use in health care facilities

•ASTM F2407-06
Standard Specification for Surgical Gowns Intended for Use in Healthcare
Facilities

•ASTM F1671-07
Standard Test Method for Resistance of Materials Used in Protective Clothing to
Penetration by Blood-Borne Pathogens Using Phi-X174 Bacteriophage
Penetration as a Test System

•ASTM F1670-08
Standard Test Method for Resistance of Materials Used in Protective Clothing to
Penetration by Synthetic Blood

•AAMI/ANSI ST65:2008
Processing of reusable surgical textiles for use in health care facilities
http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpcd/classification.cfm?ID=4911
Andreas F. Widmer, MD,MS
ECCMID 2012

Widmer AF 24
 Classification of Gowns / Drapes in the US
Level 1 Gowns and Drapes
Describes surgical gowns, other protective apparel, surgical drapes and drape accessories that demonstrate the ability
to resist liquid penetration in a laboratory test,
AATCC 42 (Water resistance: Impact penetration test).
Level 2 Gowns and Drapes
Describes surgical gowns, other protective apparel, surgical drapes and drape accessories that demonstrate the ability
to resist liquid penetration in two laboratory tests, AATCC 42 (Water resistance: Impact penetration test) andAATCC
127 (Water resistance: Hydrostatic pressure test).
Level 3 Gowns and Drapes
Describes surgical gowns, other protective apparel, surgical drapes and drape accessories that demonstrate the ability
to resist liquid penetration in two laboratory tests, AATCC 42 (Water resistance: Impact penetration test) and AATCC
127 (Water resistance: Hydrostatic pressure test). For Level 3, the test criterion for AATCC 127 performance is set at a
higher value than for Level 2.
Level 4 Gowns
Describes surgical gowns and protective apparel that demonstrate the
ability to resist liquid and viral penetration in a laboratory test, ASTM
F1671 (Standard test method for resistance of materials used in
protective clothing to penetration by blood-borne pathogens using
Phi-X174 bacteriophage penetration as a test system).
Level 4 Drapes
Describes surgical drapes and drape accessories that demonstrate the ability to resist liquid penetration in a laboratory
test, ASTM F1670 (Standard test method for resistance of materials used in protective clothing to penetration by
synthetic blood).

Quality of Gowns: Classification

Widmer AF 25
 Quality of Gowns: Test procedures

Gowns
CDC Recommendation 2011: Personal Protective Equipment

 Wear a gown to protect skin and clothing during

procedures or activities where contact with blood
or body fluids is anticipated.
 Do not wear the same gown for the care of more
than one patient
 Remove gown and perform hand hygiene before
leaving the patient’s environment (e.g., exam
room)

http://www.cdc.gov/HAI/settings/outpatient/basic-infection-control-prevention-plan-2011/standard-precautions.html

Widmer AF 26
 Goggles, Face Shields
CDC Recommendation 2011: Personal Protective Equipment

 Wear eye protection for potential splash or spray

of blood, respiratory secretions, or other body
fluids.
 Personal eyeglasses and contact lenses are
not considered adequate eye protection
 May use goggles with facemasks, or face shield
alone, to protect the mouth, nose and eyes

http://www.cdc.gov/HAI/settings/outpatient/basic-infection-control-prevention-plan-2011/standard-precautions.html

Clinical approach

Widmer AF 27
 Respiratory Hygiene and Cough Etiquette

 All persons with signs and symptoms of a

respiratory infection (including facility staff) are
instructed to:
• Cover the mouth and nose with a tissue when
coughing or sneezing;
• Dispose of the used tissue in the nearest waste
receptacle
• Perform hand hygiene after contact with respiratory
secretions and contaminated objects/materials

http://www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm

Respiratory Hygiene/Cough Etiquette

With signs and symptoms of a respiratory infection.

 Cover your mouth and nose with a tissue when coughing or sneezing;
 Use in the nearest waste receptacle to dispose of the tissue after use;
 Perform hand hygiene (e.g., hand washing with non-antimicrobial soap
and water, alcohol-based hand rub, or antiseptic handwash) after having
contact with respiratory secretions and contaminated objects/materials.
 Healthcare facilities should ensure the availability of materials for
adhering to Respiratory Hygiene/Cough Etiquette in waiting areas for
patients and visitors.
 Provide tissues and no-touch receptacles for used tissue disposal.
 Provide conveniently located dispensers of alcohol-based hand rub;
where sinks are available, ensure that supplies for hand washing (i.e.,
soap, disposable towels) are consistently available.

http://www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm

Widmer AF 28
 HICPAC Guideline for Isolation
Contact Precautions

Patient room Private (or cohorting)

Gloves Before entering room
Hand hygiene Alcohol handrub after glove removal
Gown Before entering room if contact with
patient or items in room
Mask Standard
Other Limit patient transport; dedicate
precautions equipment to single patient; disinfect
room surfaces daily

www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf
58

Widmer AF 29
 Conditions Warranting
Contact Precautions
 Colonization with multi-resistant bacteria (MDROs)
 Major abcess, cellulitis or bedsore
 Clostridium difficile infection
 Acute diarrhea in an incontinent patient
 RSV infection, croup or bronchiolitis in young infants
 isseminated herpes simplex skin lesions
 Scabies norwegica
 HightRisk of MDROs: transfer from endemic healthcare
facility

www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf
59

HICPAC Guideline for Isolation

Droplet Precautions

Patient room Private

Gloves Standard
Hand hygiene Standard
Gown Standard
Face mask Before entering room
Other Limit patient transport; patient to follow
precautions cough etiquette

www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf 60

Widmer AF 30
 Multiple Modes of transmission of human
respiratory viruses
Primary mode(s) of respiratory
Virus Family
transmission
Contact, possibly droplet spray and/or
Adenoviruses Adenoviridae
aerosol (limited data) [2, 3 and 4]
Contact, droplet spray and/or aerosol
Influenza viruses Orthomyxoviridae
(conflicting data) [5•, 6, 7•, 8 and 9••]
Parainfluenza
Paramyxoviridae Uncertain (limited data) [10, 11 and 12]
viruses (HPIV)
Metapneumovirus Paramyxoviridae Uncertain (limited data) [2]
Respiratory
Direct and indirect contact [7• and 13], possibly
syncytial virus Paramyxoviridae
droplet spray [14]
(RSV)
Contact, droplet spray and/or aerosol
Rhinoviruses Picornaviridae
(conflicting data) [7• and 15]
Droplet spray and aerosol [2, 4 and 16],
SARS coronavirus Coronaviridae
possibly contact [17
Pica N Current Opinion in Virology, Volume 2, Issue 1, 2012, 90 - 95

Physical interventions to interrupt or

reduce the spread of respiratory viruses

Jefferson T. Cochrane Database Syst Rev. 2011 Jul 6;

Widmer AF 31
 Physical interventions to interrupt or
reduce the spread of respiratory viruses N=

1225
7 Allinterventions

1482
9 Nose wash

8 Use of eye protection 369

6 Wearing gowns 1460

5 Wearing gloves
1836

4 Wearing N95 respirator

817
3 Wearing mask
3216
2 Frequent handwashing

1 Thorough disinfection of 2825

living quarter
0
0.1 990
0.2
0.3
0.4
0.5
0.6

Jefferson T. Cochrane Database Syst Rev. 2011 Jul 6;

Respiratory virus inactivation rates (Ki)

log reduction/hr

Boone S A , and Gerba C P Appl. Environ. Microbiol. 2007;73:1687-1696

Widmer AF 32
 Contact Precautions: how long?

TYPE AND DURATION OF PRECAUTIONS RECOMMEN-

DED FOR SELECTED INFECTIONS AND CONDITIONS1

CDC_08
07_CDC_Isolation_Guidelines

Widmer AF 33
 CLINICAL SYNDROMES OR CONDITIONS WARRANTING EMPIRIC
TRANSMISSION-BASED PRECAUTIONS IN ADDITION TO STAN-
DARD PRECAUTIONS PENDING CONFIRMATION OF DIAGNOSIS*

Clinical Syndrome or Potential Pathogens‡ Empiric Precautions (Always includes Standard

Condition† Precautions)
Vesicular Varicella-zoster, herpes Airborne plus Contact Precautions;
simplex, variola (small-
pox), vaccinia
viruses Contact Precautions only if herpes simplex,
localized zoster in an immunocompetent host or
Vaccinia virus
vaccinia viruses most likely

Maculopapular with cough, Rubeola (measles) Airborne Precautions

coryza and fever virus
RESPIRATORY INFECTIONS
Cough/fever/upper lobe M. tuberculosis, Airborne Precautions plus Contact precautions
pulmonary infiltrate in an Respiratory viruses, S.
HIV-negative patient or a pneu-moniae, S.
patient at low risk for aureus (MSSA or
human immunodeficiency MRSA)
virus (HIV) infection

CDC_08
07_CDC_Isolation_Guidelines

CLINICAL SYNDROMES OR CONDITIONS WARRANTING EMPIRIC

TRANSMISSION-BASED PRECAUTIONS IN ADDITION TO STAN-
DARD PRECAUTIONS PENDING CONFIRMATION OF DIAGNOSIS*

Clinical Syndrome or Potential Empiric Precautions (Always includes Standard Precautions)

Condition†
Cough/fever/pulmonary
infiltrate in any lung
location in an HIV-infec-
ted patient or a patient at
high risk for HIV infection
Cough/fever/pulmonary
infiltrate in any lung
location in a patient with
a history of recent travel
(10-21 days) to countries
with active outbreaks of
SARS, avian influenza
Pathogens‡
M. tuberculosis, Airborne Precautions plus Contact Precautions
Respiratory Use eye/face protection if aerosol-generating procedure
viruses, S. pneu- performed or contact with respiratory secretions anticipated.
moniae, S. aureus If tuberculosis is unlikely and there are no AIIRs and/or
(MSSA or MRSA) respirators available, use Droplet Precautions instead of
Airborne Precautions
Tuberculosis more likely in HIV-infected individual than in
HIV negative individual
M. tuberculosis, Airborne plus Contact Precautions plus eye protection.
severe acute If SARS and tuberculosis unlikely, use Droplet Precautions
respiratory instead of Airborne Precautions.
syndrome virus
(SARS-CoV),
avian influenza

CDC_08

Widmer AF 34
 Not covered, but important
standard precaution

Handhygiene Technique
old 6 steps / new 3

/
http://www.who.int/patientsafety/en

Chair: Didier Pittet

WHO_Update_Juni_07
Widmer AF.
Surgical Hand Hygiene in:
WHO Guideline for Hand Hygiene 2009
Widmer AF. Infect Control Hosp Epidemiol 2004
Widmer AF. Infect Control Hosp Epidemiol 2007
Widmer AF. J Hosp Infect 2009
Tschudin S & Widmer AF. Crit Care Med 2010
Tschudin S & Widmer AF. ICHE 2010
Widmer AF. J Hosp Infect 2013
Widmer AF. WHO guideline 2014

Widmer AF 35
 Compliance with standard
precautions in patients in Isolation

Survey Results of Practices of

contact Isolation in 11 sites

Contact isolation precautions definition in this

study: the use of gloves and gown only

Widmer AF 36
 Impact of burden of isolation on contact
isolation precautions (CIP) compliance

Widmer AF 37
 CONCLUSIONS

 Standard precautions are ill defined in terms of

technical requirements
• US- vs –Europe – vs Asia – other regulatory agency
 Hand hygiene likely most important
• covered by Andreas Voss
 Compliance remains unresolved issue
 Clinical applications by Christina
Vandenbroucke

Widmer AF 38