Infection Control and Barrier

Precautions
4.00 Contact Hours

Author: Dana Bartlett

Outcomes
The purpose of this course is to prepare healthcare professionals to adhere to scientifically
accepted principles and practices of infection control, understand modes and mechanisms of
transmission, understand the use of engineering and work practice controls, select and use
appropriate barrier protections, create and maintain a safe environment, and prevent and manage
infectious and communicable diseases.

Objectives
After completing this course, the learner will be able to:

1. Explain the transmission process of common diseases.

2. Identify when and how to use Standard Precautions, Airborne Precautions, Contact
Precautions, Droplet Precautions, and Neutropenic Precautions.
3. Identify when and how to perform hand washing, the use of PPE, safe injection practices,
Respiratory Hygiene/Cough Etiquette, and safe disposal of contaminated equipment and
materials.
4. Explain how to prevent the transmission of common diseases such as influenza.
5. Explain how to prevent the occurrence of common diseases and conditions like hospital-
acquired pneumonia.

New York Requirements for Adherence to Infection Control

Standards
Healthcare professionals should adhere to scientifically accepted standards for infection control to
prevent disease transmission amongst patients or between patients and healthcare professionals.
The healthcare professional also has a responsibility to monitor the infection control practices of
subordinates. The state of New York takes these responsibilities very seriously. New York rules and
regulations require healthcare professionals to participate in infection control and barrier
precautions education for at least four years. Evidence of completion of this training must be
submitted to the State Department of Health or the Education Department. Physicians with
hospital privileges will present the training documentation to the hospital instead of the
Department of Health training during the renewal process of hospital privileges (NYS, 2008). New
York professions required to obtain this education are dental hygienists, dentists, licensed
practical nurses, optometrists, physicians, physician assistants, podiatrists, registered
professional nurses and specialist assistants, medical students, medical residents, and physician
assistant students. Exemptions may be granted because the professional has completed equivalent
course work or because the nature of his or her practice does not require the use of infection
control techniques or barrier precautions (NYS, 2008). A written application for exemption from
completing this course work must be presented to the Department of Health for approval.

In New York, state rules and regulations define responsibility for compliance and consequences for
non-compliance with infection control practices. All licensed healthcare facilities are responsible
for monitoring and enforcing the proper use of infection control practices and Standard
Precautions. Failure to comply can result in citations, potential fines, and other disciplinary action
against the facility. Licensed healthcare professionals who fail to use appropriate infection control
techniques may be charged with professional misconduct and disciplinary action. Patient or
employee complaints about lax infection control practices in private offices will cause an
investigation by the Department of Health or Education. Substantiated lapses may result in
charges of professional misconduct against licensed healthcare professionals who were directly
involved, aware of the violations, or responsible for ensuring staff education and compliance.
Scientifically accepted infection control techniques include but are not limited to (NYSED, 2011):

Wear appropriate protective gloves when touching blood, saliva, other body fluids or
secretions, mucous membranes, non-intact skin, blood-soiled items or bodily fluid-soiled
items, contaminated surfaces, sterile body areas, and instrument cleaning decontamination
procedures.
Discarding used gloves following treatment of a patient and changing to new gloves if they
are torn or damaged during treatment of a patient; washing hands and donning new gloves
prior to performing services for another patient, and; washing hands and other skin surfaces
immediately if the hands are contaminated with blood or other body fluids.
Wear appropriate masks, gowns or aprons, and protective eyewear or chin-length plastic face
shields whenever splashing or spattering of blood or other body fluids is likely to occur.
Sterilizing equipment and devices that enter the patient’s vascular system or other normally
sterile body areas.
Sterilizing equipment and devices that touch intact mucous membranes but do not penetrate
the patient’s body or using high-level disinfection for equipment and devices which cannot
be sterilized prior to use for a patient.
Use appropriate agents, including but not limited to detergents, for cleaning all equipment
and devices prior to sterilization or disinfection.
Cleaning, by use of appropriate agents, including but not limited to detergents, equipment,
and devices which do not touch the patient or that only touch the intact skin of the patient.
Maintaining equipment and devices used for sterilization according to the manufacturer’s
instructions.
Adequately monitoring the performance of all personnel, licensed or unlicensed, for whom
the licensee is responsible regarding infection control techniques.
Placing disposable used syringes, needles, scalpel blades, and other sharp instruments in
appropriate puncture-resistant containers for disposal and; placing reusable needles, scalpel
blades, and other sharp instruments in appropriate puncture-resistant containers until they
can be appropriately cleaned and sterilized.
 Providing and maintaining appropriate ventilation devices to minimize the need for
emergency mouth-to-mouth resuscitation.
Refraining from direct patient care and handling patient care equipment when the healthcare
professional has exudative lesions or weeping dermatitis. The condition has not been
medically evaluated and determined to be safe or capable of being safely protected against
providing direct patient care or handling patient care equipment.
Placing all blood and body fluids specimens in well-constructed containers with secure lids
prevents leaking. Cleaning any spill of blood or other body fluid with an appropriate
detergent and appropriate chemical germicide.

Transmission of Infectious Pathogens

Definitions
A pathogen is a disease-producing microorganism.
Transmission is any mechanism by which a source or reservoir spreads a pathogen to a host.
Reservoir is any person, animal, plant, soil, substance, or any combination of which an
infectious agent normally lives and multiplies. The infectious agent depends on the reservoir
for survival, and the reservoir must provide a place where it can reproduce itself so that it can
be transmitted to a susceptible host.
Susceptibility is defined as the inability of a host to resist infection with a particular
pathogen.
The common vehicle is a contaminated material, product, or substance that serves as an
intermediate means by which an infectious agent is transported to two or more susceptible
hosts.
Colonization is when an organism is present without host interference or interaction, like
normal skin flora.
Host: An organism in which another organism can live and potentially multiply.
Infection is when there are invasion and multiplication by a microorganism. Infection may be
local or systemic; it may begin as local and become systemic, and; there may be no apparent
host response or clinical signs and symptoms caused by the infection or the host response.
Infectious disease is when the infected host declines wellness due to an infection.
Incubation period is between the beginning of an infection and the recognition of symptoms.
Latency is the time after primary infection during which the microorganism lives within the
host without producing clinical evidence.
Virulence is the degree of pathogenicity of a microorganism, i.e., how easily it can invade a
host and the severity of the disease it can cause.

Overview of Transmission
A chain of events is required for infection to occur. These events are a causative organism, a
reservoir for the organism. A means to exit the reservoir, a mode of transmission, a susceptible
host, and a mode of entry into the host. Causative organisms may be bacteria, rickettsiae, viruses,
protozoa, fungi, or parasites. The characteristics of causative organisms are:

Pathogenicity: The ability of a microorganism to cause disease.

 Virulence is the degree of pathogenicity of a microorganism, i.e., how easily it can invade a
host and the severity of the disease it can cause.
Invasiveness: The ability of a microorganism to enter into and move through tissue.
Infectious dose: The number of organisms needed to initiate an infection.
Organism specificity: Host preference of the infectious agent.
Antigen variations: The ability of an infectious organism to change its surface proteins to
escape host defenses.
Toxigenicity: The capacity to produce toxins
Resistance: The ability to develop resistance to antimicrobial agents

The organism and its reservoir are the sources of infection. The organism must have the means to
exit the reservoir. In an infected host, the organisms exit through the respiratory tract,
gastrointestinal tract, genitourinary tract, or drainage from a wound. A transmission route is
necessary to connect the source of infection to its new host. Routes of transmission are contact or
airborne.

Contact transmission
Direct contact: Person-to-person.
Indirect contact: Usually contact with a harmless inanimate object. The infected inanimate
object is called a fomite. Fomites can survive on objects and surfaces for a long time and be a
potential source of infection for weeks and months, e.g., fomites containing norovirus and
Clostridium difficile.
Droplet contact: Large particles from coughing, sneezing, or talking. Droplets move through
the air, but because of their size and the limited time they are airborne, they quickly settle on
environmental surfaces and are spread by contact, e.g., influenza, not by inhalation.

Airborne transmission
Droplet nuclei: Residue of evaporated droplets that remain suspended in the air. Pathogens
spread by airborne transmission include Mycobacterium tuberculosis and Varicella.
Dust: Particles in the air containing the infectious agents.

Organism Chart
The following table outlines the organism, mode of transmission and incubation period for most
common microorganisms and parasites.

Incubation
Disease/Condition Organism Mode of Transmission Period
 Incubation
Disease/Condition Organism Mode of Transmission Period

Acquired Human Sexual Median of 10

immunodeficiency immunodeficiency Percutaneous years (CDC,
syndrome (AIDS) virus Prenatal 2017)

Stage 1

HIV is passed from one

person to another. The
virus travels through the
bloodstream to many
different places in the
body.

Amebiasis Entamoeba Contaminated water 2-4 weeks

histolytica Contact with raw occasionally
vegetables longer (CDC,
Amebiasis - Life Cycle 2015)

Chancroid Haemophilus Sexual >4-7 days

ducreyi (Copeland &
Decker, 2016)

Chickenpox Varicella zoster Airborne 10-21 days

Photograph of Chicken (CDC, 2016)
Pox

Cholera Vibrio cholerae Ingestion of water A few hours-5

contaminated with days (CDC,
human waste 2014)

Creutzfeldt-Jacob Prion protein Unknown in most cases 12 months to

disease 30 years
(Manix et al.,
2015)

Cryptococcosis Cryptococcus Inhalation, tissue Unknown

neoformans inoculation,
Cryptococcus gatti gastrointestinal.
No person-to-person
spread (Maziarz &
Perfect, 2016)
 Incubation
Disease/Condition Organism Mode of Transmission Period

Cyptosporidiosis Cryptosporidium Ingestion of 2-10 days, an

species contaminated water average of 7
Direct contact with days (CDC,
carrier 2015b)

Cytomegalovirus Cytomegalovirus Transfusion Highly

(CMV) Transplant variable.

Sexual
Perinatal Newborn:3-12
Breast milk weeks after
Contact with mucous delivery (CDC,
membranes, saliva, or 2016b)
urine

Diarrheal diseases Campylobacter Ingestion of 24-72 hours

species contaminated food or (Kaakoush et
water al., 2015)

  Clostridium difficile Fecal-oral Variable, in

Efficient transfer by part related to
healthcare professionals the influence
to patients of antibiotics
(Curry, 2017)

  Salmonella species Ingestion of 12-72 hours

contaminated food or (CDC, 2016c)
drink

  Shigella species Ingestion of 1-2 days (CDC,

contaminated food or 2017b)
drink
Direct contact with
carrier

  Yersinia species Ingestion of 4-7 days (CDC,

contaminated food or 2016d)
drink
Direct contact with
carrier
Blood transfusion (Rare)
 Incubation
Disease/Condition Organism Mode of Transmission Period

Giardiasis Giardia lamblia Fecal-oral transmission 1-3 weeks

Ingestion of (CDC, 2015c)
contaminated water or
food
The risk of acquiring
Giardia infection from
your pet is small.
However, there are some
steps you can take to
lower your risk (CDC,
2015c)

Gonorrhea Neisseria Sexual contact 1-14 days

gonorrhoeae (CDC, 2016e)

Hand, foot, and Viruses of the Direct contact with nose Not known,
mouth disease Enterovirus genes and throat secretions, estimates vary
direct and with feces of infected widely (Koh et
persons al., 2016)

Foodborne Hepatitis A Ingestion of A: 2-6 weeks

hepatitis Hepatitis E contaminated food or (CDC, 2015d)

drink contaminated with

infected fecal material, E: 2-6 weeks
Direct contact with (CDC, 2015e)
carrier
Raw or uncooked meat,
contact with infected
feces

Bloodborne Hepatitis B Blood, seman, and other B: 6 weeks to 6

hepatitis Hepatitis C body fluids, and months (CDC,
Hepatitis D perinatally 2016f)

Blood, sexual contact, C: Acute

and perinatally infection, 6-7
Only occurs in people weeks (CDC,
infected with hepatitis B. 2016g)

Percutaneous D: Unclear
 Incubation
Disease/Condition Organism Mode of Transmission Period

Herpangina Coxsackie virus Direct contact with nose 4-14 days

and throat secretions and (Gompf &
with feces of infected Herpangia,
persons 2016)

Herpes simplex Human herpes Contact with mucous 2 days to 2

virus 1 and 2 membrane secretions weeks
during sexual activity (Jaishankar &
Shukla, 2016)

Histoplasmosis Histoplasma Inhalation of airborne 3-17 days

capsulatum spores (CDC, 2015d)

Hookworms Necator americanus Contact with soil 21-35 days

Ancyclostoma contaminated with feces (Brunet et al.,
deodenale Hookworm Life Cycle 2015)

Impetigo Staphylococcus Contact with carrier 4-10 days

aureus (most Photograph of Impetigo (Ostrovsky,
common), 2016)
Streptococcus
pyogenes

Influenza Influenza virus A, Droplet spread 1- 4 days (CDC,

B, or C 2016g)

Legionnaires’ Legionella Airborne from water 2-12 days,

disease pneumonphila source occasionally
longer (CDC,
2016h)

Listeriosis Listeria Perinatal Unclear,

monocytogenes Sexual probably 3-70
days
 Incubation
Disease/Condition Organism Mode of Transmission Period

Lyme disease Borrelia burgdorferi Tick bite 3-30 days

Blacklegged Tick Image (CDC, 2016i)
Relative sizes of several
ticks at different life
stages. In general, adult
ticks are approximately
the size of a sesame seed
and nymphal ticks are
approximately the size of
a poppy seed.
Tick Bite Image

Lymphogranuloma Chlamydia Sexual 3-30 days

venereum trachomatis (O’Byrne et al.,
2016)

Malaria Plasmodium vivax Bite from genus Anopheles 7-30 days

Plasmodium mosquito (CDC, 2015e)
malariae Malaria Life Cycle
Plasmodium
falciparum
Plasmodium ovale

Measles Measles virus Droplet spread and 7-14 days

Airborne (CDC, 2015f)
Measles image

Meningococcal Neisseria Contact with pharyngeal 1-14 days

meningitis or meningitidis secretions, perhaps (DynaMed
bacteremia airborne Plus, 2017)

Mononucleosis Epstein Barr virus Usually by contact with 4-6 weeks

oral and pharyngeal (CDC, 2016j)
secretions, also by blood
and semen during sexual
contact, and contact with
infected blood or organs.
 Incubation
Disease/Condition Organism Mode of Transmission Period

Mycobacterial Mycobacterium Variable: probably Variable

diseases (non- avium contact with soil, water,
tuberculosis) Mycobacterium or other environmental
Mycobacterium kansaii sources. Not
species Mycobacterium transmissible person-to-
fortuitum person
Mycobacterium
gordonae

Mycoplasma
Mycoplasma Droplet inhalation 1-4 weeks
pulmonary tract pneumonia (CDC, 2016k)
infections

Pediculosis Pediculus humanus Direct contact Approximately

capitus (head Head & Body Louse Image 2 weeks (CDC,
louse) 2015g)
Pediculus humanus
corporis (body
louse)

  Phthirus pubis Sexual Approximately

(crab louse) Crab Louse Image 2-3 weeks
(CDC, 2013)

Pinworm Enterobius Direct contact with egg- 1-2 months

vermicularis contaminated articles - (CDC, 2013b)
Usually fecal-oral
Pinworm - Life Cycle

Pneumocystis Pneumocystis Inhalation 4-8 weeks

pneumonia jiroveci Pneumocystis Pneumonia (Miller et al.,
Stages 2013)

Pneumococcal Streptococcus Droplet spread Probably 1-3

pneumonia pneumoniae days (CDC,
2015h)
 Incubation
Disease/Condition Organism Mode of Transmission Period

Rabies Rabies virus Direct contact of virus- weeks to

laden saliva of a rabid months (CDC,
animal into a bite or 2011b)
scratch. Transmission by
aerosol and organ
transplantation has been
reported.
The Infectious Path of the
Rabies Virus

Respiratory Respiratory Self-inoculation by 2/8 days

syncytial disease syncytial virus touching mouth or nose (Prasad, 2016)
after contact with
infectious respiratory
secretions

Ringworm Microsporum Direct and indirect 4-14 days

species contact with lesions (CDC, 2015i)
Trychophton Ringworm images
species
Epidermophyton
floccosum

Rocky Mountain Rickettsia rickettsii Tick bite 2-14 days

Spotted fever Rocky mountain image (CDC, 2010)

Rotavirus Rota virus Fecal, oral About 48 hours

gastroenteritis (CDC, 2016l)

Rubella Rubella virus Droplet spread 12-23 days

Direct contact (CDC, 2016m)

Scabies Sarcoptes scabiei Direct skin 1-4 days if

Scabies image  there was a
previous
exposure, 4-6
weeks for a
first-time
exposure
 Incubation
Disease/Condition Organism Mode of Transmission Period

Staphylococci Staphylococcus Direct contact with Variable (CDC,

aureus draining lesions 2016n)
Coagulase- Auto-infection from
negative: colonized nares
S.
epidermdidis
S.
haemolyticus

Streptococci Streptococcus Large respiratory droplets Variable, e.g.,

groups A with Direct contact with 2-5 days for
about 80 secretions group A strep
serologically Ingestion of pharyngitis
distinct types contaminated food (CDC, 2016n)

Syphilis Treponema Sexual 2-4 weeks

pallidum Syphilis Images (Stamm, 2016)

Tetanus Clostridium tetani Entry through broken 1 day to several

skin months,
usually 3 – 21
days (CDC,
2017b)

Trichinosis Trichinella spiralis Ingestion of insufficiently 1-2 days (CDC,

cooked food, especially 2012)
pork and beef

Tuberculosis Mycobacterium Airborne 2-10 weeks for

tuberculosis an immune
response,
weeks to years
for symptoms
to occur
(Jensen et al.,
2005)
 Incubation
Disease/Condition Organism Mode of Transmission Period

Typhoid fever Salmonella typhi Ingestion of Usually 8-14

contaminated food or days, the range
water is 3 days to 2
Typhoid images months (Van
Zuuren, 2017)

The host must be susceptible to the infection for infection to occur. Factors influencing
susceptibility are:

Number of organisms to which host is exposed and the duration of exposure

Age, genetic constitution of host, and general physical, mental, and emotional health and
nutritional status of the host
Status of hematopoietic systems; efficacy of reticuloendothelial system
Absent or abnormal immunoglobulins
The number of T lymphocytes and their ability to function

Pregnant healthcare professionals are not known to be at greater risk of contracting bloodborne
infections; however, during pregnancy, the infant is at risk of perinatal transmission.

The organism must have a portal of entry into the host for infection to occur. Portals of entry are
the mucous membranes, non-intact skin, respiratory tract, gastrointestinal tract, genitourinary
tracts, or a mechanism of introduction (percutaneous injury or invasive devices).

Antibiotic-Resistant Organisms
All microorganisms that can cause disease can develop resistance to antibiotics and other drugs
used to treat infections caused by these pathogens. Antibiotic-resistant organisms have become
an increasingly serious problem, and some of the more common ones are discussed.

Carbapenem-resistant enterobacteriaceae
Enterobacteriaceae are gram-negative bacilli that are commonly found in the gastrointestinal
tract. Common species of this family that cause infections include Enterobacter, Escherichia coli,
and Klebsiella. Carbapenem-resistant enterobacteriaceae (CRE) are resistant to treatment with the
carbapenem family of antibiotics (Doripenem, ertapenem, imipenem, and meropenem), the
antibiotics that have traditionally been used to treat pathogens that are resistant to broad-
spectrum antimicrobials. The CRE is spread through contact with infected surfaces (e.g., hands or
contaminated medical equipment). Infections with CRE are particularly dangerous: they can
spread rapidly, the mortality rate can exceed 40%, and antibiotics effective against multi-drug
resistant gram-negative bacilli are still being developed. CRE infections usually do not occur in
healthy people; they are more likely to occur in hospitalized patients who have a compromised
immune system, mechanically ventilated patients, or those who have received multiple
antibiotics. The incidence of CRE infections is increasing. Control and prevention of CRE
infections should focus on:
 1. identifying colonized patients
2. screening by taking a stool, rectal, and perirectal cultures and wound cultures when
appropriate
3. strict adherence to handwashing protocol
4. environmental cleaning
5. patient and staff cohorting
6. staff education, and
7. using contact precautions  (CDC, 2015l).

Drug Resistant Staphylococcus Aureus

Staphylococcus aureus is transmitted primarily via the hands of healthcare professionals and by
direct contact with contaminated equipment and surfaces. Transmission is very efficient, and S
aureus colonizes the skin and nares easily. Once colonized, the person faces the likelihood of
infection when invasive procedures are performed.

Methicillin and oxacillin-resistant S aureus (MRSA, ORSA) are common causes of nosocomial

infections in hospitals and extended care facilities. Methicillin- and oxacillin-resistant
colonization are rarely recognized, and MRSA colonization is quite common, so every patient must
be assumed to have been exposed to or colonized with MRSA/ORSA. In addition, MRSA often
contaminates medical equipment such as stethoscopes and environmental surfaces like computer
keyboards. Methicillin- and oxacillin-resistant S aureus can produce toxins and invade body
tissues. The only effective antibiotic for treating these infections is vancomycin. The Centers for
Disease Control and Prevention (CDC) recommends strict adherence to Standard Precautions,
correct and appropriate use of personal protective equipment PPE, appropriate handling of
medical devices and laundry, and Contact Precautions should be used if the facility has decided
that MRSA is of special clinical or epidemiological significance (CDC, 2016o)

Vancomycin intermediate S aureus (VISA) and vancomycin-resistant S aureus (VRSA) are classified

based on a lab test. The test result is called minimum inhibitory concentration (MIC), which
measures the minimum amount of antimicrobial agent that inhibits bacterial growth in a test
tube. Staph bacteria are classified as VISA if the MIC for vancomycin is 4-8µg/ml and classified as
VRSA if the vancomycin MIC is >16µg/ml (CDC, 2015j) These infections must be reported to the
CDC and the state department of health. Patients who are infected with VISA or VRSA should be in
a single room; Contact Precautions and Standard Precautions are required; staff education is
recommended; minimize the number of staff caring for the patient; and flag the chart to alert staff
of the situation (CDC, 2015j)

Vancomycin-Resistant Enterococcus (VRE)

Enterococcus is a gram-positive bacterium with the normal gastrointestinal tract and female
genital tract flora. It is a relatively weak pathogen, but it can produce significant infections if the
patient is infected with vancomycin-resistant enterococcus (VRE). Treatment options for these
infections are limited. People at risk for VRE infections include patients previously treated with
vancomycin, patients in intensive care, patients who are immunocompromised, patients who have
had abdominal or chest surgery, and patients with in-dwelling IV or urinary catheters (CDC,
2011b) Vancomycin-resistant enterococcus is transmitted primarily via the hands of healthcare
professionals and by direct contact with contaminated equipment and surfaces. There have been
many approaches used to control VRE in healthcare settings, and the methods used should be
tailored to the clinical setting, the specific patient/patients involved, and the epidemiological
characteristics of the situation. Contact precautions and Standard precautions should be used to
prevent transmission of VRE (CDC, 2011b)

Multidrug-Resistant Tuberculosis (MDR-TB)

The Mycobacterium tuberculosis bacteria cause tuberculosis (TB), one of the oldest recognized
infectious diseases. Multidrug-resistant tuberculosis is resistant to isoniazid, rifampin,
fluoroquinolones, and at least one of the three second-line injectable drugs used to treat TB. The
incidence of MDR-TB has increased in recent years due to poor compliance with prescribed drug
regimens, inappropriate/incorrect prescribing, patient risk factors, and characteristics of specific
TB strains. Infection control measures should include separating the infected patient/patients,
using Standard Precautions, Respiratory Hygiene/Cough Etiquette, minimal hospitalization time,
proper ventilation, and staff use of particulate respirators(CDC, 2007). Airborne Precautions are
required(CDC, 2007)

Drug-Resistant Streptococcus pneumoniae

Streptococcus pneumoniae is a commonly found pathogen in the upper respiratory tract. Infections
with this pathogen are a common cause of pneumonia, meningitis, sepsis, bacteremia, and otitis
media and a leading cause of morbidity and mortality (CDC, 2015d). The elderly and the very young
are the most susceptible. Transmission is from infected respiratory droplets, and it can be spread
by coughing, sneezing, close contact, or contact with infected droplets. Penicillin-resistant and
multidrug-resistant strains of this pathogen have emerged and are widespread in some
communities (Elshafie & Taj-Aldeen, 2016). A vaccine for the most common serotypes of S
pneumoniae is available but underutilized. Contact Precautions, Droplet Precautions, and
Respiratory hygiene/Cough Etiquette should be used when caring for patients infected with this
pathogen (CDC, 2007).

Drug-Resistant Acinetobacter
Acinetobacter is a bacterium usually found in the soil and water and on the skin of healthy people.
People susceptible to infections with drug-resistant Acinetobacter are usually
immunocompromised or have chronic lung disease or diabetes. Outbreaks of pneumonia, urinary
tract infections, wound infections, and blood infections from Acinetobacter occur in areas of
healthcare facilities where very sick patients are cared for, like intensive care units (Ainsworth et
al., 2017). People on ventilators, patients who have prolonged hospital stays, had an invasive
procedure (e.g., insertion of a central IV line), and open wounds are at greater risk (Ainsworth et
al., 2017). The morbidity and mortality rates associated with drug-
resistant Acinetobacter infections are very high, and outbreaks of these infections in healthcare
facilities are difficult to control (Lashinsky et al., 2017). Contact transmission is the primary
way Acinetobacter spreads, so Contact Precautions and Standard Precautions with special attention
to hand washing are integral parts of controlling and preventing these infections. Because of the
danger of these infections and the difficulty in containing outbreaks, patients who have an
infection with drug-resistant Acinetobacter may need to be isolated, or their placement in the
facility should be carefully considered.
Prevention of Exposure to Infectious Pathogens
Controls are incorporated into the healthcare work setting to avoid or reduce exposure to
potentially infectious materials. Healthcare-associated transmission is the transmission of
microorganisms that are likely to occur in a healthcare setting, and it can be reduced by using
engineered controls, safe injection practices, and safe work practices. Engineering controls are
equipment, devices, or instruments that remove or isolate a hazard. Safe injection practices are
equipment and practices that allow the performance of injections in an optimally safe manner for
patients, healthcare providers, and others that reduce exposure to injury or infection(CDC, 2007).
Work practice controls change practices and procedures to reduce or eliminate risks.

Standard Precautions
Standard Precautions are strategies for protecting healthcare professionals from the occupational
transmission of organisms; Standard Precautions also prevent patient-to-patient transmission
and staff-to-patient transmission. Standard Precautions assume that all pre-existing patient
infections cannot be identified. The primary underpinning of Standard Precautions is that all body
fluids and secretions should be considered potentially infectious, and barrier precautions should
be used routinely to protect from all sources of potential infection. Standard Precautions apply to
nonintact skin and mucous membranes, blood, and all body fluids, secretions, and excretions,
except sweat (And in certain circumstances, sweat can be considered infectious). In some cases,
e.g., with certain pathogens such as HIV, somebody fluids such as vomit are only considered a risk
for disease transmission if they contain visible blood. Additional precautions are based on highly
transmissible or epidemiologically important pathogens. Transmission-based precautions
(isolation) are Airborne, Droplet, and Contact Precautions.

Standard Precautions have six basic elements: Hand washing, the use of personal protective
equipment, safe and proper disposal of contaminated material and equipment, safe injection
practices, Respiratory Hygiene/Cough Etiquette practices, and the use of masks for insertion of
catheters or injections into spinal or epidural spaces via lumbar puncture. The new elements of
Standard Precautions that have been added since they were formulated were designed to focus on
patient protection. These elements are Respiratory Hygiene/Cough Etiquette, safe injection
practices, and the use of masks for insertion of catheters or injections into spinal or epidural
spaces via lumbar puncture(CDC, 2007).

Respiratory Hygiene/Cough Etiquette

Respiratory Hygiene/Cough Etiquette is a strategy to reduce the transmission of respiratory
infections at the first point of entry into a healthcare setting.

Signs educating patients and families about Respiratory Hygiene/Cough Etiquette protocol should
be posted at entry areas. The instructions are that persons with cough, congestion, rhinorrhea or
increased respiratory secretions should:

Cover the mouth and nose when coughing or sneezing.

Dispose of used tissues promptly.
Use a surgical mask if coughing and if tolerated.
Wash hands after contact with respiratory secretions.
 Separate at least three feet from persons with respiratory infections in common areas when
possible.

The effectiveness of Cough Etiquette techniques has been questioned, but it is still considered to
be a mandatory part of infection control, and its use among the lay public can be increased by
education (Choi & Kim, 2016

Healthcare personnel should observe Droplet Precautions (These will be discussed later in the
module) when caring for patients who have signs and symptoms of a respiratory infection and for
whom Respiratory Hygiene/Cough Etiquette is needed. Healthcare personnel with a respiratory
infection are advised to avoid direct patient contact, especially with high-risk patients. If this is
not possible, then a mask should be worn while providing patient care(CDC, 2007).

Safe Injection Practice

Needlestick and sharps injuries are a common occurrence in healthcare. The CDC estimates that
350,000 sharps injuries occur each year, and these injuries are a potential cause for transmission
of and infection with hepatitis B virus (HBV), hepatitis C virus (HCV), human immunodeficiency
virus (HIV), and more than 20 other pathogens  (CDC, 2015h). Infections with each of these
pathogens are potentially life-threatening, but they are also preventable. Literature reviews and
individual studies have shown that nurses are especially at risk for needle stick injuries compared
to other healthcare workers. However, housekeepers, physicians, laboratory staff, and other
people who work in healthcare suffer these injuries (Frickmann et al., 2016).

BD SafetyGlide™ Shielding Hypodermic Needle

Hypodermic Needle-Pro® 18G - 25G

One serious blood-borne infection can cost more than a million dollars for medications, follow-up
laboratory testing, clinical evaluation, lost wages, and disability payments, and the human costs
after exposure are immeasurable. Employees exposed to a dangerous pathogen such as HIV may
experience anger, depression, fear, anxiety, difficulty with sexual relations, difficulty sleeping,
problems concentrating, and doubts regarding their career choice. The emotional effect can be
long-lasting, even after a low-risk exposure that does not result in infection (Zhang & Yu, 2013).

Percutaneous injuries can be avoided by eliminating the unnecessary use of needles, using devices
with safety features, and promoting education and safe work practices for handling needles and
related systems. Since 1993, safety-engineered sharps devices have increased while conventional
sharps devices have decreased. Vigorous efforts to prevent needlestick and sharps injuries (e.g.,
the Needle Stick Prevention and Safety Act of 2000), increased awareness of and use of safe
injection practices, and improved equipment has helped decrease these injuries (Frickmann et al.,
2016).

Several sources have identified the desirable characteristics of needle and sharp safety devices.
These characteristics include the following (NIOSH, 2000):

The device is needleless.

The safety feature is an integral part of the device.
The device preferably works passively, i.e., it requires no activation by the user. If user
activation is necessary, the safety feature can be engaged with a single-handed technique
and allows the professional's hands to remain behind the exposed sharp.
The user can easily tell whether the safety feature is activated.
The safety feature cannot be deactivated and remains protective from initial use to disposal.
The device performs reliably.
The device is easy to use and practical.
The device is safe and effective for patient care.

Although these characteristics are desirable, some are not feasible, applicable, or available for
certain healthcare situations. For example, needles will always be necessary where alternatives for
skin penetration are not available. Also, a safety feature that requires activation by the user might
be preferable to one that is passive in some cases. Each device must be considered on its merit and
ultimately on its ability to reduce workplace injuries. The desirable characteristics listed here
should serve only as a guideline for device design and selection:

Needles should NEVER be recapped, bent, broken, or removed from contaminated syringes.
Recapping by hand is prohibited under the OSHA bloodborne pathogens standard [29 CFR
1910.1030] unless no alternative exists.
Sharps should be disposed into a puncture-proof container with a biohazard label designed
specifically for sharps disposal.
There is exposure to percutaneous injuries during procedures. There is an opportunity for
percutaneous exposure, particularly when poor visualization, blind suturing, the non-
dominant hand opposing or next to a sharp one, and exposure to bone spicules and metal
fragments.
Sharp equipment should be disassembled using forceps or other devices.
Suturing should always be done with a needle holder, forceps, or another tool.
Do not use fingers to hold tissue when suturing or cutting.
Never leave sharps on a work field. If used needles or other sharps are left in the work area or
are discarded in a sharps container that is not puncture resistant, a needle stick injury may
result. Injury may occur when a healthcare professional attempts to transfer blood or other
body fluids from a syringe to a specimen container (such as a vacuum tube) and misses the
target.
Safe injection practice in hospitals is well established. However, needle sticks and sharp injuries
continue to occur frequently; they are often not reported, and; failure to use safe injection
practices has led to several serious outbreaks of HBV and HCV infection  (Choi et al., 2017). Dolan
et al. write:

More than 50 outbreaks of viral and bacterial infections occurred in the United States during
1998-2014 because of these unsafe medical practices. These outbreaks resulted in the
transmission of hepatitis B virus (HBV), hepatitis C virus (HCV), and bacterial pathogens to
more than 700 patients. The unsafe practices used by HCP in these outbreaks can be
categorized as syringe reuse between patients during parenteral medication administration
to multiple patients, contamination of medication vials or intravenous (IV) bags after having
been accessed with a used syringe or needle, failure to follow basic injection safety practices
when preparing and administering parenteral medications to multiple patients, and
inappropriate use and maintenance of finger stick devices and glucometer equipment used
on multiple patients  (Dolan et al., 2016).

The following are examples of safe injection practices recommended by the CDC and other
professional organizations. These apply to the use of needles, cannulas that replace needles, and,
where applicable, intravenous delivery systems (CDC, 2011c).

Use an aseptic technique to avoid contamination of sterile injection equipment.

Do not administer medications from a syringe to multiple patients, even if the needle or
cannula on the syringe is changed.
Needles, cannula, and syringes are sterile, single-use items; they should not be reused
for another patient nor to access a medication or solution that might be used for a
subsequent patient.
Use fluid infusion and administration sets (i.e., intravenous bags, tubing, and connectors) for
one patient and dispose of them appropriately after use.
Consider a syringe or needle/cannula contaminated once used to enter or connect to a
patient's intravenous infusion bag or administration set.
Use needle-free systems when transferring solutions between containers.
Use single-dose vials for parenteral medications whenever possible.
Do not administer medications from single-dose vials or ampules to multiple patients
or combine leftover contents of single-dose vials for later use.
Always inspect vials prior to use and discard them if sterility has been compromised or
if there is visible particulate matter, discoloration, etc.
Remove syringes, needles, and cannulas from their packaging immediately before use.
If multi-dose vials must be used, both the needle or cannula and the syringe used to access
the multi-dose vial must be sterile.
Do not keep multi-dose vials in the immediate patient treatment area and store them
in accordance with the manufacturer's recommendations; discard them if sterility is
compromised or questionable.
Always use a new, sterile needle to access a multi-dose vial.
Do not combine the contents of multi-use vials.
Do not use bags or bottles of intravenous solution as a common supply source for multiple
patients.
Infection control practices for special lumbar puncture procedures:
 Wear a mask when placing a catheter or injecting material into the spinal canal or
subdural space, e.g., during myelograms, lumbar puncture, and spinal or epidural
anesthesia.
Employee safety
Adhere to federal and state requirements for protecting healthcare personnel from exposure
to bloodborne pathogens. Use PPE if there is or may be a risk of contact with blood or body
fluids during an injection procedure.
Hand hygiene should be performed prior to any use of injection equipment.
Injection equipment should be stored and used in clean areas, and there should not be non-
sterile contact with sterile devices.
Disinfect catheter hubs and IV injection ports with alcohol or an approved disinfectant before
inserting a needle. Use institutional policy for disinfecting catheter hubs and IV-line
injection ports prior to accessing them with a needle.
Always discard needles and sharps into the appropriate containers.

Handwashing
Handwashing is one of the most effective methods for preventing patient-to-patient, patient to
staff, and staff-to-patient transmission of microorganisms, and it is one of the foundations of
infection control (Scheithauer et al., 2017).

Hands should be washed, or alcohol-based rubs should be used:

1. before and after patient contact;

2. between patient contacts;
3. after gloves are removed;
4. after contact with blood, body fluids, secretions, mucous membranes, excretions, and
contaminated equipment;
5. after contact with inanimate objects and medical equipment near a patient;
6. after using the bathroom;
7. before eating; and
8. in certain situations, e.g., between tasks on the same patient to prevent cross-
contamination (CDC, 2017c).

Improved adherence to hand hygiene, i.e., hand washing or use of alcohol-based hand rubs, has
been shown to terminate outbreaks in healthcare facilities, reduce transmission of antimicrobial-
resistant organisms (e.g., MRSA), and reduce overall infection rates (WHO, 2009).

However, despite unequivocal evidence of the effectiveness of hand hygiene and mandatory hand
hygiene education, healthcare professionals’ compliance with hand hygiene protocols is often
very low, at times < 30% (Scheithauer et al., 2017). There are many reasons why healthcare
professionals are non-compliant with hand hygiene protocols, such as perceived lack of time,
perceived inconvenience, high workload, and poor staffing (Scheithauer et al.,
2017). Interventions for improving compliance with hand hygiene protocol can increase
compliance, and both the CDC and the World Health Organization (WHO) have published advice
and guidelines for improving hand hygiene compliance (Boyce & Pittet, 2002). As part of these
recommendations, the CDC is asking healthcare facilities to develop and implement a system for
measuring improvements in adherence to hand hygiene recommendations. Some of the suggested
performance indicators include periodic monitoring of hand hygiene adherence and providing
feedback to personnel regarding their performance, monitoring the volume of alcohol-based hand
rub used/1000 patient days, monitoring adherence to policies dealing with wearing artificial nails,
and focused assessment of the adequacy of healthcare personnel hand hygiene when outbreaks of
infection occur.

In addition to traditional handwashing with soap and water, the CDC recommends using alcohol-
based hand cleansers by healthcare personnel who perform patient care because they address
some of the obstacles that healthcare professionals face when taking care of patients and
frequently washing their hands (CDC, 2017c). Alcohol-based hand rubs are very effective, in most
cases as effective as soap and water. They significantly reduce the number of microorganisms on
the skin, are fast-acting, and cause less skin irritation than soap and water. When using an
alcohol-based hand rub, apply the product to the palm of one hand and rub your hands together,
covering all surfaces of the hands and fingers until the hands are dry, approximately 20 seconds
(CDC, 2017c). Note that the volume needed to reduce the number of bacteria on hands varies by
product, and using the appropriate volume for each specific product is crucial for effectiveness
(Wilkinson et al., 2016). Allergic contact dermatitis due to alcohol hand rubs are uncommon
(Bolon, 2016). However, with the increasing use of such products by healthcare personnel, likely,
true allergic reactions to these products will occasionally be encountered. Alcohol-based hand
rubs take less time than traditional hand washing, 20 seconds versus 40-80 seconds (Voss &
Widmer, 1997). In addition, hand rub dispensers can be mounted almost anywhere, unlike a sink
and a water tap.

Soap and water (not an alcohol-based hand rub) should be used when:

1. hands are visibly dirty/soiled;

2. after known exposure to C. difficile if the endemic rates are high or the healthcare facility is
experiencing an outbreak;
3. after known or suspected exposure to patients with infectious diarrhea during norovirus
outbreaks;
4. if exposure to Bacillus anthracis is suspected or proven, and; after using the bathroom and
before eating (CDC, 2017c). 

For all other situations, an alcohol-based hand rub can be used.

The use of hand hygiene does not eliminate the need for gloves. Gloves can significantly reduce
hand contamination, prevent cross-contamination, and protect patients and healthcare personnel
from infection (Hayden et al., 2008). However, improper use of gloves can greatly increase hand
contamination (Wilson, 2017). Gloves must be removed after patient contact and a new pair put on
for each new patient contact, and they should be replaced if they are torn, damaged, or grossly
soiled.

Healthcare personnel should avoid wearing artificial nails and keep natural nails less than one-
quarter of an inch long if they care for patients at high risk of acquiring infections, e.g., patients in
intensive care units or transplant units.

When evaluating hand hygiene products for potential use in healthcare facilities, administrators
or product selection committees should consider the relative efficacy of antiseptic agents against
various pathogens and the acceptability of hand hygiene products by personnel. Characteristics of
a product that can affect acceptance and, therefore, usage include its smell, consistency, color, and
the drying effect on hands.
Handwashing with soap and water remains a sensible strategy for hand hygiene in non-healthcare
settings, and the CDC and other experts recommend its use in these situations.

Respiratory Hygiene/Cough Etiquette

Respiratory Hygiene/Cough Etiquette should be used when patients, staff, or visitors have
signs/symptoms of a respiratory infection. This infection control technique includes:

1. covering the nose and mouth when coughing or sneezing;

2. using tissues to contain respiratory secretions and properly disposing of them;
3. washing hands after using a tissue;
4. offering a surgical mask to anyone who is coughing, and
5. turning the head and maintaining at least 3 feet of separation when coughing(CDC, 2007).

Personal Protective Equipment

Personal protective equipment (PPE) provides a physical barrier between the patient and the
healthcare professional. Personal protective equipment includes face shields, gloves, goggles,
gowns, hair covers, masks, respirators, and shoe covers. The appropriate use of PPE is an
important element of Standard Precautions. What PPE to use and when to use it depends on the
patient-provider interaction and transmission mode, e.g., blood-borne, airborne(CDC, 2007). In
most circumstances, this decision is based on the professional judgment of the healthcare
personnel.

Face shields, gowns, goggles, hair covers, masks, and shoe covers should be used if there is a risk
for splash contact from blood or other potentially infectious body fluids/secretions to the eyes,
mouth, mucous membranes, nose, or skin. Masks and respirators are used in certain situations to
protect healthcare personnel, patients, and the public.

Gloves should be used:

1. if contact is anticipated (or is possible) with blood, other potentially infectious body
fluids/secretions, or mucous membranes;
2. if there will be skin contact with patients who have or may have skin colonization with
certain pathogens such as MRSA; and
3. if there will be contact with contaminated or potentially contaminated medical equipment or
environmental surfaces(CDC, 2007) 

Double gloving is often used during surgical procedures, but there is no information about the
protective effectiveness of this technique during routine patient care, and in those situations,
single gloving is generally considered to be adequate(CDC, 2007) Latex, nitrile, and vinyl gloves
are available. Studies have shown that vinyl gloves are more likely to fail during patient care
situations, and latex gloves are superior in terms of bacterial passage if the glove is perforated
(Batdorf et al., 2016).

Proper use of gloves:

Change gloves when moving from patient to patient

Never wash or reuse gloves; they are single-use items
 Change gloves when the integrity of the glove has been compromised or if they are heavily
soiled
Change gloves after touching potentially contaminated medical equipment or environmental
surfaces
Handwashing should always be done after removing gloves. Gloves do not replace the need
for handwashing as the gloves may have a small, unnoticeable defect, they may become torn
during use, and hands can become contaminated when the gloves are removed.

Masks - often called surgical masks - are single-use items. Surgical masks can protect healthcare
workers, their use is part of Standard Precautions, Droplet Precautions, and Respiratory
Hygiene/Cough Etiquette (The last two will be explained later), and their use and the conditions for
which they should be used are mandated by the Occupational Health and Safety Administration
(OSHA) (OSHA, 199141991). Masks should be used:

To protect healthcare personnel from direct contact with blood, body fluids, and respiratory
secretions.
When performing a procedure that requires sterile technique to protect the patient from
exposure to infectious agents in the mouth or nose of the person/persons performing the
procedure, and if a patient is coughing, to limit the spread of droplets.
If the situation requires a mask, goggles, a face mask, or another type of eye and face
protection should be used.

Paper masks are not interchangeable with respirators, and they have limits (smith et al.,
2016). They are primarily intended to protect the patient and the public (in the situations
described above) and protect healthcare workers from direct contact with infectious
pathogens(CDC, 2007). Respirators (Discussed in the following section of the module) are used to
prevent the airborne transmission of selected and specific pathogens such as M. tuberculosis(CDC,
2007)

Standard Precautions and the OSHA Blood-borne pathogen standard dictate that face shields,
goggles, or other types of eye and face protection should be used if there is a risk for eye, mucous
membrane, or skin contact with blood or potentially infectious body fluids/secretions(CDC,
2007) These devices have been shown to protect healthcare workers against the transmission of
infectious pathogens(CDC, 2007) The choice of which type of protection to use, e.g., goggles
versus face shield, is determined by the clinical situation; there are no direct comparisons of one
type of eye/face protective device with others (Verbekk et al., 2016). Studies of their effectiveness
in preventing pathogens from contacting the users have produced mixed results (Roberge,
2016). and they should never be used as a substitute for respiratory protection devices (Lindsley et
al., 2014). Personal eyeglasses and contact lenses are not considered adequate protective
equipment and should not be used as a substitute for face shields, goggles, etc. (CDC, 2007)

Gowns are worn to prevent contamination of clothing and protect the healthcare professional’s
skin from blood and body fluid exposure. Impermeable gowns, leg coverings, boots, or shoe covers
provide additional protection when large quantities of blood or body fluids may be splashed. The
use of isolation gowns is part of Standard Precautions and Transmission Precautions, and their use
is mandated by the OSHA Bloodborne Pathogens standard(CDC, 2007). Isolation gowns are
intended “ to protect the HCW’s arms and exposed body areas and prevent contamination of
clothing with blood, body fluids, and other potentially infectious material(CDC, 2007)” Isolation
gowns (sometimes referred to as surgical gowns, procedures gowns, or protective gowns) are
disposable, single-use items made of materials that prevent movement of blood and other
potentially infectious body/fluids/secretions through the gown and onto the user’s skin (Kilinc,
2015).

Several types of gowns offer differing levels of performance; for example, a Level 1 gown is for
minimal risk situations such as basic patient care, standard isolations precautions, and a Level 3
gown is for moderate risk situations such as inserting an IV catheter while working in the ER (FDA,
2016). Isolation gowns should provide full coverage of the arms, the front of the torso, and from
the neck to the middle of the thighs, and they should always be used with gloves and other PPE if
needed (CDC, 2007). Evidence for the effectiveness of gowns for preventing transmission of
infectious material has been described as mixed (Kilinc, 2016). Laboratory jackets or coats are not
an acceptable substitute for an isolation gown (CDC, 2007).

The proper sequence for putting on PPE is:

1. Wash hands
2. Gown
3. Mask or respirator
4. Goggles/face shield
5. Gloves

The proper sequence for removing PPE is:

1. Gloves
2. Goggles/face shield
3. Gown
4. Mask
5. Wash hands

When removing PPE, it is important only to touch areas of the PPE that are not contaminated or
potentially contaminated, e.g., the front of the gown would be considered potentially
contaminated, and the ties in the back of the gown would not.

Transmission Based Precautions

Transmission Precautions and protective environment (PE) are terms used to describe protective
measures that need to be employed for specific groups of patients. These measures address the
three conditions needed for transmission of an infectious pathogen: a source, a susceptible host,
and a method of transmission. An older term for Transmission Precautions was isolation. Patients
requiring Transmission Precautions require a private room, and a negative pressure air handling
system that exhausts to the outside is required for Airborne Precautions. The movement of these
patients should be limited, and when transport outside the room is necessary, appropriate barriers
should be used. Masks should be used for patients who are on Airborne Precautions. Patients
infected with the same organism can share a room; this is called cohorting.

Airborne Precautions
Airborne Precautions are implemented for diseases transmitted by microorganisms carried by
airborne droplet nuclei. Droplet nuclei are tiny particle residues left when droplets evaporate, and
droplet nuclei remain suspended in the air, travel comparatively long distances, and can be widely
dispersed by air currents. Airborne Precautions are needed if the infectious pathogen is < 5
microns; the infectious particles are found in aerosol form, and; the infectious particles travel a
specific distance and remain airborne for a time that places those exposed at risk (FDA,
2016). Early identification and triage of suspected cases of airborne transmitted diseases should be
made, and possibly infectious patients should be separated from others and asked to wear a
surgical mask. Droplets, not aerosols, spread most respiratory illnesses, and the specific diseases
that require Airborne Precautions are listed below(CDC, 2007).

Diseases Requiring Airborne Precautions

Disease Precautions Period

Chickenpox Until lesions are crusted, and no new lesions appear

(varicella)

Herpes zoster Duration of illness

(disseminated)

Herpes zoster Duration of illness

(localized in
immunocompromised
patient)

Measles (rubeola) Duration of illness

Smallpox Duration of illness

Tuberculosis Depends upon clinical response; patient must be on effective therapy,

(pulmonary or be improving clinically (decreased cough and fever and improved
laryngeal, confirmed findings on chest radiograph), and have three consecutive negative
or suspected) sputum smears collected on different days, or TB must be ruled out.

Respirators are required to be worn by healthcare personnel if Airborne Precautions are in place or
during certain procedures such as endotracheal intubation in which aerosols are formed (CDC,
2007). A powered air-purifying respirator (PAPR) may be needed in some high-risk situations.

A surgical N95 respirator is recommended if Airborne Precautions are required (CDC, 2007). These
respirators will block at least 95% of infectious particles 3 microns or larger (OSHA, 1998). The N95
is a single-user, disposable item that must be tested effectively. Fit testing should be done when
first using an N95, and after the correct size and model have been chosen, the user should perform
a user seal check each time the N95 is used (CDC, 2007)

The N95 respirator is a disposable device (it cannot be cleaned or disinfected), but the N95 is
different from a simple surgical mask discarded after one use, as the N95 can be used more than
once. There are guidelines for what has been termed extended use and reuse of the N95 (CDC,
2014). These are somewhat lengthy and complex, and the reader can view them on the CDC
website by using the link provided below. Fortunately, most healthcare providers do not need to be
highly familiar with these guidelines or memorize them; the infection control department of each
healthcare facility will, if needed, provide case-by-case instructions for N95 basic use, extended
use, and reuse.

Airborne Precautions also require the use of an airborne infection isolation room (AIIR) that has
specially engineered airflow and ventilation systems, e.g., a specially ventilated room with at least
12 air changes per hour; negative air pressure relative to the hallway; and outside exhaust or
HEPA-filtered recirculation. The door to the room must be kept closed, and the negative air
pressure should be monitored.

When the patient in airborne precautions has to be moved or transported, the patient should wear
a surgical mask from the time he/she leaves the isolation room until she/he returns.

Droplet Precautions
Droplet Precautions are used for patients known or suspected of being infected with
microorganisms transmitted by droplets generated during coughing, sneezing, talking, or
performing procedures, e.g., the influenza virus. These droplets are larger than the aerosolized
infectious particles that require the use of Airborne Precautions, and they do not travel as far,
usually 6 feet or less (CDC, 2016p). The diseases that require the use of Droplet Precautions are
listed below (CDC, 2007)

Diseases Requiring Droplet Precautions: Disease and Precautionary Period

Disease Precautionary Period

Invasive Haemophilus Until 24 hours after initiation of effective therapy

influenzae type b disease,
including meningitis,
pneumonia, and sepsis

Invasive Neisseria meningitidis Until 24 hours after initiation of effective therapy

disease, including meningitis,
pneumonia, epiglottis, and
sepsis

Diphtheria (pharyngeal) Until antibiotic therapy has finished and two cultures taken
at least 24 hours apart are negative
Disease Precautionary Period

Mycoplasma pneumoniae Duration of illness

infection

Pneumonic plague Until five days after effective therapy has been started

Streptococcal pharyngitis, Until 24 hours after initiation of effective therapy

pneumonia, or scarlet fever in
infants and young children,
streptococcal pneumonia

Adenovirus infection in infants Duration of illness

and young children

Influenza For pandemic influenza, 5 days from onset of symptoms In a

healthcare setting, for 7 days after illness onset or until 24
hours after fever and respiratory symptoms have resolved,
whichever is longer

Mumps For 9 days after onset of swelling

Parvovirus B19 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.

Rubella (German measles) Until 7 days after onset of rash

Meningococcal disease, Until 24 hours after initiation of effective therapy.

including meningitis,
pneumonia, and sepsis

Rhinovirus Duration of illness

Severe acute respiratory Duration of the illness plus 10 days after resolution of the
syndrome (SARS) fever, if respiratory symptoms are absent or improving.
Airborne Precautions and Contact Precautions, as well

Streptococcal diseases, major Until 24 hours after initiation of effective therapy

burn

Viral hemorrhagic fevers Duration of illness

Pertussis Until five days after initiation of effective therapy

Droplet Precautions require a private room, but no special ventilation is necessary, and the door
may remain open. Masks should be worn if working within three feet of the patient. The patient
should be masked if transported, and she/he should observe Respiratory Hygiene/Cough Etiquette.

Contact Precautions
Contact Precautions are used for patients with known or suspected infections or colonized with
epidemiologically important microorganisms that can be transmitted by direct or indirect contact.

Diseases requiring the use of Contact Precaution are listed below (CDC, 2007).

Diseases Requiring Contact Precautions

Disease Precautionary Period

Infection or colonization Until off antibiotics and culture negative

with multidrug-resistant
bacteria

Clostridium difficile enteric Duration of illness

infection

Gastroenteritis/ multiple Duration of illness

different organisms, eg.,
E.coli, Shigella, in diapered
or incontinent patient

Hepatitis A, in diapered or Duration of illness

incontinent patient

Rotavirus infection, in Duration of illness

diapered or incontinent
patient

Respiratory syncytial virus Duration of illness

infection, in infants and
young children

Parainfluenza virus Duration of illness

infection, respiratory, in
infants or young children

Enteroviral infection, in Duration of illness

diapered or incontinent
patient

Scabies Until 24 hours after initiation of effective therapy

Disease Precautionary Period

Diphtheria (cutaneous) Until two cultures taken 24 hours apart are negative

Herpes simplex virus Until lesions are dry and crusted

infection (neonatal or
mucutaneous)

Impetigo Until 24 hours after initiation of effective therapy

Major abscesses, cellulitis, Until 24 hours after initiation of effective therapy

or decubiti, or wound
infections

Pediculosis (lice) Until 24 hours after initiation of effective therapy

Rubella, congenital Place infant on precautions during any admission until 1 year of
syndrome age, unless nasopharyngeal and urine culture are negative for
virus after age 3 months

Staphylococcal furunculosis Duration of illness

in infants and young
children

Acute viral (acute Duration of illness

hemorrhagic)
conjunctivitis

Viral hemorrhagic Duration of illness

infections (Ebola, Lassa,
Marburg)

Zoster (chickenpox, Until all lesions are crusted

disseminated zoster, or Requires airborne precautions

localized zoster in
immunodeficient patient)

Smallpox Duration of illness

Requires airborne precautions

Bronchiolitis Duration of illness

Human metapneumovirus Duration of illness

Monkeypox Until lesions are crusted. Airborne Precautions, as well

 Disease Precautionary Period

Parovirus B19 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. Droplet Precautions, as well

Pneumonia, adenovirus Duration of illness

Poliomyelitis Duration of illness

Respiratory infectious Duration of illness

disease, acute, infants and
young children

Ritter’s disease Duration of illness

(Staphylococcal scalded
skin syndrome)

Severe acute respiratory Duration of illness. Airborne Precautions and Droplet Precautions,
syndrome (SARS) as well

Tuberculosis/draining Until the patient is improved, the drainage has stopped, and there
lesion are three consecutive negative cultures of the drainage

If Contact Precautions are indicated, the patient should be in a private room. Standard Precautions
should be used, and a gown and gloves should be worn if contact with the patient or
environmental surfaces is likely to be contacted.

Some facilities may implement special isolation for VRE. This isolation is an exaggerated form of
contact precautions requiring gowns and gloves anytime the room is entered, even if you do not
anticipate patient contact (Isenman et al., 2016). The rationale is that VRE survives in the
environment for a long time, and contact with any surface may lead to transmission.

Neutropenic Precautions
Neutropenic precautions (also called protective isolation or reverse isolation) are implemented to
protect immunocompromised patients. Guidelines for neutropenic precautions have been
published (Mofenson et al., 2009). However, these are specific for certain clinical situations, and
there is no standard universally accepted protocol that dictates how, when, and for whom
neutropenic precautions should be used (Lequilliec et al., 2017). There are conditions and
treatments, e.g., hematopoietic stem cell transplant, patients receiving chemotherapy, and
patients who have suffered a serious burn (A more detailed list is provided below), in which a
patient is particularly at risk for infection. In these cases, special precautions should be taken, and
in their 2007 Guideline for Isolation Precautions, the CDC does mention the need for and use of a
PE for immunocompromised patients. Some of the conditions of the PE include a private, well-
sealed room with positive air pressure, HEPA filtered air, frequent air changes, and minimizing the
amount of time the patient is outside the room (OSHA, 1991). The exact methods used for
neutropenic precautions vary depending on the reason for the precautions and the degree of the
patient’s immunosuppression and level of risk.

Conditions/Diseases that may require neutropenic precautions:

Acquired immunodeficiency syndrome

Agranulocytosis
Burns
Chemotherapy
Hematopoietic stem cell transplantation
Immunosuppressive therapy

Immunization
Immunization is one method to reduce the transmission of communicable diseases. The following
are recommendations for immunization based on age and exposure risk. Specifics and schedules
for high-risk populations and catch-up immunizations are available from the CDC.

Immunization schedules for adults are available from the CDC.

Recommended immunization schedule for children and adolescents aged 18 years or younger,
United States 2017.

Immunization Chart

Immunization Schedule 0-18 Years

1 2 4 6 9 12 15 18 19-23 2-3 4-6 7-10 11-12 13-15 1
Vaccine Birth
mo mos mos mos mos mos mos mos mos yrs yrs yrs yrs yrs y
Hepatitis 1st 2nd 2nd 3rd 3rd 3rd 3rd 3rd
               
B1(HepB) dose dose dose dose dose dose dose dose
Rotavirus(RV)
RV-1 (2-dose 1st 2nd
                           
series); RV-5 dose dose
(3-dose series)
Diphtheria,
tetanus, &
1st 2nd 3rd 4th 4th 5th
acellular                    
dose dose dose dose dose dose
pertussis
(DTaP: <7 yrs)
Tetanus,
diphtheria,
tetanus, &
                          (Tdap)   
acellular
pertussis
(Tdap: > 7 yrs)
Haemophilus 3rd or 3rd or
1st 2nd 3rd
influenzae       4th 4th                
dose dose dose
type b (Hib) dose dose
 1 2 4 6 9 12 15 18 19-23 2-3 4-6 7-10 11-12 13-15 1
Vaccine Birth
mo mos mos mos mos mos mos mos mos yrs yrs yrs yrs yrs y
Pneumococcal
1st 2nd 3rd 4th 4th
conjugate                      
dose dose dose dose dose
(PCV13)
Pneumococcal
polysaccharide                                
(PPSV23)
Inactivated
poliovirus 1st 2nd 3rd 3rd 3rd 3rd 3rd 4th
               
(IPV) dose dose dose dose dose dose dose dose
(<18years)
p.a. p.a. p.a. p.a.
p.a. p.a. p.a. p.a. p.a. p.a. p.a. p
Influenza (IIV; vacc. vacc. vacc. vacc.
vacc. vacc. vacc. vacc. vacc. vacc. vacc. v
LAIV) 2 doses         (IIV (IIV (IIV (IIV
(IIV (IIV (IIV (IIV (IIV (IIV (IIV or (
for some or or or or
only)only)only) only) only) only) LAIV) L
LAIV) LAIV) LAIV) LAIV)
Measles,
1st 1st 2nd
Mumps,                          
dose dose dose
Rubella (MMR)
Varicella 1st 1st 2nd
                         
(VAR) dose dose dose
2 2 2 2
Hepatitis A
            dose dose dose dose            
(HepA)
seriesseriesseriesseries
Human
papillomavirus
(HPV2: 3 dose
                             
females only; series
HPV4: males
and females)
Meningococcal
(Hib-MenCY > 1st
                            b
6 wks; MCV4- dose
< 9mos;

Range of Range of Range of Range of recommended ages

recommended recommended recommended during which catch-up is Not routinely
ages for all ages for catch-up ages for certain encouraged and for certain recommended
children immunization high-risk groups high-risk groups

Immunization for Healthcare Personnel

These recommendations for the immunization of healthcare personnel are from the Advisory
Committee on Immunization Practices and the CDC (ACIP, 2011).
Hepatitis B - Three doses of hepatitis B vaccine, the second given 1 month after the first, the third
at approximately 5 months after the second.

Influenza - Two influenza vaccines are available, live attenuated influenza vaccine (LAIV), which is
given intranasally, and trivalent inactivated influenza vaccine (TIV), which is given as an
intramuscular injection. Live attenuated influenza vaccine is licensed for use in healthy
nonpregnant persons aged 2--49 years. The TIV can be given to anyone ≥6 months of age. Live
attenuated influenza vaccine can be used for healthcare personnel except for anyone caring for
patients who are severely immunocompromised and require a PE. If the healthcare worker has a
pre-existing condition that confers a high risk for influenza complications, is pregnant, or is ≥50
years of age, that person should not receive LAIV; use TIV.

Meningococcal – A 2-dose meningococcal vaccine series is recommended for 1) healthcare

personnel who have asplenia or persistent complement component deficiencies; 2) healthcare
personnel traveling to countries in which meningococcal disease is hyperendemic or epidemic and
who have asplenia or persistent complement component deficiencies; these people should receive
a 2-dose vaccine series. Other healthcare personnel traveling to high-risk areas should be given a
single dose of meningococcal conjugate vaccine quadrivalent (MCV4) before travel if they have
never received it or received it >5 years previously. Clinical microbiologists and research
microbiologists who might be exposed routinely to isolates of N. meningitides should receive a
single dose of MCV4 and a booster dose every 5 years if they remain at increased risk. Health-care
personnel aged >55 years who have any of the above risk factors for meningococcal disease should
be vaccinated with MPSV4, i.e., meningococcal quadrivalent polysaccharide vaccine.

MMR – Vaccination with mumps, measles, and rubella (MMR) vaccine, two doses, 4 weeks apart if
the healthcare worker was born later than 1957 or if there is no serologic evidence of immunity.

Poliomyelitis - Vaccination against poliovirus is recommended for healthcare personnel who have
a high risk of exposure, laboratory personnel who work with the virus, clinicians who have close
contact with patients who might be excreting wild polioviruses, and healthcare personnel who are
traveling to an area where the virus is endemic. Unvaccinated individuals should be given 3 doses
of the polio vaccine, dose 2 to be given 4-8 weeks after the first, and dose 3 at 6-12 months after
the second dose. Previously vaccinated individuals can receive a booster dose.

Tetanus, diphtheria, pertussis – Tdap once if never vaccinated, and a Td booster every 10 years.

Typhoid - Microbiologists and anyone who frequently works with S typhi should be vaccinated,
and booster vaccinations given as indicated.

Varicella – Healthcare personnel who have no evidence of immunity to varicella should be given 2
doses of varicella vaccine, 4-8 weeks apart.

Development and Maintenance of a Safe Environment

Although the environment is a reservoir for various microorganisms, it is rarely implicated in
disease transmission except in the immunocompromised population. Applying infection-control
strategies and engineering controls effectively prevents opportunistic, environmentally-related
infections in immunocompromised populations (Wingard, 2016).

Definitions(Rutala & Weber, 2008)

 Contamination is the presence of microorganisms on inanimate objects or substances
Decontamination is the process of removing disease-producing microorganisms and
rendering the object safe for handling
Cleaning is the removal of visible blood, soil, and other debris, usually by soap and water or
an enzyme cleaner and water
Disinfection is the process that results in the elimination of many or all pathogenic
microorganisms on inanimate objects, except for bacterial endospores
High-level disinfection kills bacteria, mycobacteria (TB), fungi, viruses, and some bacterial
spores
Intermediate-level disinfection kills bacteria, mycobacteria, most fungi, and most viruses. It
does not kill resistant bacterial spores
Low-level disinfection kills most bacteria, some fungi, and some viruses. It will not kill
bacterial spores and is less active against some gram-negative rods like Pseudomonas and
mycobacteria
Sterilization is a process that eliminates or destroys all forms of microbial life

Infection Control: Basic Strategies

Infection control strategies include:

1. education of the staff;

2. policies and procedures for cleaning, disinfection, and sterilization; and;
3. engineering and environmental controls.

General principles of engineering and environmental controls will be discussed; more information
will be provided as specific clinical situations are covered.

Staff Education: Basics

Basic education has been briefly discussed in previous sections of the module, and its application
to other parts of the infection control process will be covered below. Both the CDC and OSHA
recommend that the healthcare facility/employer must inform the staff of potential risks for
exposure to infectious materials and provide them with the education and equipment they need to
prevent contamination of medical equipment and the environment; to protect themselves against
contamination and infection, and to protect patients against contamination and infections.

Cleaning, Disinfection, and Sterilization

Cleaning, disinfection, and sterilization are essential for infection control and maintaining a safe
environment. These processes can be used singly or in combination. They are done using different
tools and techniques, producing different results. In simple terms, sterilization is intended to kill
all microorganisms, disinfection will kill/remove the majority of microorganisms, and cleaning
will physically remove surface contamination and debris.

General Principles of Cleaning, Disinfection, and Sterilization (Rutala & Weber, 2008).

In general, reusable medical devices or patient-care equipment that enters normally sterile
tissue or the vascular system or through which blood flows are considered critical items, and
they should be sterilized before each use. Sterilization means using a physical or chemical
 procedure to destroy all microbial life, including highly resistant bacterial endospores. The
major sterilizing agents used in hospitals are a) moist heat by steam autoclaving, b) ethylene
oxide gas, and c) dry heat. However, various chemical germicides (sterilants) have been used
to reprocess reusable heat-sensitive medical devices and appear effective when used
appropriately, e.g., according to the manufacturer's instructions. These chemicals are rarely
used for sterilization but appear effective for high-level disinfection of medical devices that
contact mucous membranes during use (e.g., flexible fiberoptic endoscopes).
Heat stable, reusable medical devices that enter the bloodstream or normally sterile tissue
should always be reprocessed using heat-based sterilization methods (e.g., steam autoclave
or dry heat oven).
Laparoscopic or arthroscopic telescopes (optic portions of the endoscopic set) should be
subjected to a sterilization procedure before each use; if this is not feasible, they should
receive high-level disinfection. Heat stable accessories to the endoscopic set like trocars and
operative instruments should be sterilized by heat-based methods (e.g., steam autoclave or
dry heat oven).
Reusable devices or items that touch mucous membranes should, at a minimum, receive
high-level disinfection between patients. These devices include reusable, flexible
endoscopes, endotracheal tubes, anesthesia breathing circuits, and respiratory therapy
equipment.
Medical devices that require sterilization or disinfection must be thoroughly cleaned to
reduce organic material or bioburden before being exposed to the germicide, and the
germicide and the device manufacturer's instructions should be closely followed.
Except in rare and special instances, items that do not ordinarily touch the patient or touch
only intact skin are not involved in disease transmission and generally do not necessitate
disinfection between uses on different patients. These items include crutches, bed boards,
blood pressure cuffs, and other medical accessories. Consequently, depending on the
particular equipment or item, washing with a detergent or using a low-level disinfectant may
be sufficient when decontamination is needed. If noncritical items are grossly soiled with
blood or other body fluids, a higher level of disinfection is required.

Cleaning and Disinfecting

Cleaning removes visible and surface contamination from an object and can be completed
mechanically or with cleaners. Cleaning can also help disinfect, but the two processes are not the
same, and cleaning is not intended to kill bacteria or other microorganisms. Disinfection is the
process of destroying pathogenic organisms; disinfection cannot and does not destroy all
organisms.

The following information is from the CDC Guideline for Sterilization and Disinfection in
Healthcare facilities (Rutala & Weber, 2008).

Remove visible organic residue (e.g., residue of blood and tissue) and inorganic salts with
cleaning. Use cleaning agents that are capable of removing visible organic and inorganic
residues.
Clean medical devices as soon as practical after use (e.g., at the point of use) because soiled
materials become dried onto the instruments. The instrument's dried or baked materials
make the removal process more difficult and the disinfection or sterilization process less
effective or ineffective.
 Perform manual cleaning (i.e., friction) or mechanical cleaning (e.g., with ultrasonic
cleaners, washer-disinfector, washer-sterilizers).
If using an automatic washer/disinfector, ensure that the unit is used in accordance with the
manufacturer’s recommendations.
Detergents or enzymatic cleaners should be compatible with the metals and other materials
used in medical instruments.
Ensure that the rinse step is adequate for removing cleaning residues to levels that will not
interfere with subsequent disinfection/sterilization processes.
Discard or repair equipment that no longer functions as intended or cannot be properly
cleaned, disinfected, or sterilized.
The rinse step should be adequate for removing cleaning residues to levels that will not
interfere with subsequent disinfection/sterilization processes.
Inspect equipment surfaces for breaks in integrity that would interfere with cleaning or
disinfection/sterilization.
Meticulously clean patient-care items with water and detergent or water and enzymatic
cleaners before high-level disinfection or sterilization procedures.

Cleaning and Disinfecting Environmental Surfaces in Healthcare Facilities (Rutala & Weber, 2008).

Cleaning and disinfecting environmental surfaces and patient rooms have been shown to
decrease the incidence of hospital-acquired infections and to reduce environmental
contamination with potentially dangerous microorganisms such as C difficile, MRSA, and
VRE (Rutala, 2016).
Clean housekeeping surfaces (e.g., floors, tabletops) regularly, when spills occur, and when
these surfaces are visibly soiled.
Disinfect or clean environmental surfaces regularly (e.g., daily, three times per week) and
when surfaces are visibly soiled.
Follow manufacturers’ instructions for proper disinfecting or detergent products, such as
recommended use-dilution, material compatibility, storage, shelf-life, and safe use and
disposal.
Clean walls, blinds, and window curtains in patient-care areas when these surfaces are
visibly contaminated or soiled.
Prepare disinfecting or detergent solutions as needed and replace these with fresh solutions
frequently (e.g., replace floor mopping solution every three patient rooms, and change no
less often than at 60-minute intervals or according to the facility’s policy).
Decontaminate mop heads and clean cloths regularly to prevent contamination.
Use a one-step process and an EPA-registered hospital disinfectant designed for
housekeeping purposes in patient care areas where
uncertainty exists about the nature of the soil on the surfaces (e.g., blood or body fluid
contamination versus routine dust or dirt), or
uncertainty exists about the presence of multidrug-resistant organisms on such
surfaces
Detergent and water are adequate for cleaning surfaces in non-patient care areas.
Do not use high-level disinfectants/liquid chemical sterilants to disinfect non-critical
surfaces.
Wet-dust horizontal surfaces regularly, e.g., three times per week, using clean cloths
moistened with an EPA-registered hospital disinfectant or detergent. Use the disinfectant or
detergent as per the manufacturer’s recommendations.
According to the label’s safety precautions and use directions, disinfect noncritical surfaces
with an EPA-registered hospital disinfectant. Most EPA-registered hospital disinfectants
have a label contact time of 10 minutes. However, many scientific studies have demonstrated
the efficacy of hospital disinfectants against pathogens with a contact time of at least 1
minute.
The user must follow all applicable label instructions on EPA-registered products by law. If
the user selects exposure conditions that differ from those on the EPA-registered product
label, the user assumes liability for any injuries resulting from off-label use and is potentially
subject to enforcement action.
Do not use disinfectants to clean infant bassinets and incubators while these items are
occupied. If disinfectants are used for the terminal cleaning of infant bassinets and
incubators, thoroughly rinse the surfaces of these items with water and dry them before they
are reused.
Promptly clean and decontaminate spills of blood and other potentially infectious materials.
Discard blood-contaminated items in compliance with federal regulations.
Implement the following procedures for site decontamination of blood spills or other
potentially infectious materials (OPIM). Use protective gloves and other PPE when sharps are
involved. Use forceps to pick up sharps and discard these items in a puncture-resistant
container appropriate for this task.
Disinfect areas contaminated with blood spills using an EPA-registered tuberculocidal agent,
a registered germicide on the EPA Lists D and E, i.e., products with specific label claims for
HIV or HBV or freshly diluted hypochlorite solution.
If sodium hypochlorite solutions are selected, use a 1:100 dilution (e.g., 1:100 dilution of a
5.25-6.15% sodium hypochlorite provides 525-615 ppm available chlorine) to decontaminate
nonporous surfaces after a small spill (e.g., <10 mL) of either blood or OPIM.
If a spill involves large amounts (e.g., >10 mL) of blood or OPIM, or involves a culture spill in
the laboratory, use a 1:10 dilution for the first application of hypochlorite solution before
cleaning in order to reduce the risk of infection during the cleaning process in the event of a
sharp injury (Rutala & Weber, 2008).
Follow this decontamination process with terminal disinfection, using a 1:100 dilution of
sodium hypochlorite.
If the spill contains large amounts of blood or body fluids, clean the visible matter with
disposable absorbent material and discard the contaminated materials in appropriate,
labeled containment.
Use gloves and PPE that is appropriate for the task.
In units with high rates of endemic Clostridium difficile infection or an outbreak setting, use
dilute solutions of 5.25%–6.15% sodium hypochlorite for routine environmental disinfection
(Rutala & Weber, 2008). Currently, no products are EPA-registered specifically for
inactivating C. difficile spores.
If chlorine solution is not prepared fresh daily, it can be stored at room temperature for up to
30 days in a capped, opaque plastic bottle with a 50% reduction in chlorine concentration
after 30 days of storage (e.g., 1000 ppm chlorine [approximately a 1:50 dilution] at day 0
decreases to 500 ppm chlorine by day 30).
An EPA-registered sodium hypochlorite product is preferred, but generic versions of sodium
hypochlorite solutions (e.g., household chlorine bleach) that can be used in such products are
 not available.

Indications for Sterilization, High-Level Disinfection, and Low-Level Disinfection

Before using each patient, sterilize critical medical and surgical devices and instruments that
normally enter sterile tissue or the vascular system or a sterile body fluid flow (e.g., blood) (Rutala,
2016). Provide, at a minimum, high-level disinfection for semi-critical patient-care equipment
(e.g., gastrointestinal endoscopes, endotracheal tubes, anesthesia breathing circuits, and
respiratory therapy equipment) that touches either mucous membranes or nonintact skin (Rutala
& Weber, 2008).

Perform low-level disinfection for noncritical patient-care surfaces (e.g., bedrails, over-the-bed
table) and equipment (e.g., blood pressure cuff) that touch intact skin (Rutala, 2016).

Selection and Use of Low-Level Disinfectants for Non-critical Patient-Care Devices (Rutala & Weber,
2008).

Intact skin is an effective barrier against most microorganisms. Because non-critical patient
care devices like a sphygmomanometer cuff will only contact intact skin, these items do not
need to be sterilized or extensively disinfected (Rutala, 2016). There is no documentation of
infectious disease transmission from a non-critical patient care device/patient care
equipment (Rutala, 2016). However, these devices and equipment can contaminate the hands
of healthcare personnel and subsequently cause person-to-person contamination so
cleaning these items is important.
Process non-critical patient-care devices using a disinfectant and the concentration of
germicide.
Disinfect non-critical medical devices (e.g., blood pressure cuff) with an EPA-registered
hospital disinfectant using the label’s safety precautions and use directions. Most EPA-
registered hospital disinfectants have a label contact time of 10 minutes. However, multiple
scientific studies have demonstrated the efficacy of hospital disinfectants against pathogens
with a contact time of at least 1 minute. By law, all applicable label instructions on EPA-
registered products must be followed. If the user selects exposure conditions that differ from
those on the EPA-registered product label, the user assumes liability for any injuries
resulting from off-label use and is potentially subject to enforcement action.
Ensure that, at a minimum, noncritical patient-care devices are disinfected when visibly
soiled and regularly (such as after use on each patient or once daily or once weekly).
If dedicated, disposable devices are not available, disinfect noncritical patient-care
equipment after using it on a patient who is on contact precautions before using this
equipment on another patient.

Disinfectant Fogging
Do not perform disinfectant fogging for routine purposes in patient-care areas.

The manufacturer should be contacted for questions about disinfectants. A source of information
about low level or intermediate level disinfectants is the Antimicrobial Program Branch,
Environmental Protection Agency (EPA), Selected EPA-Registered Disinfectants (EPA) (703) 308-
6411, online link.

High-Level Disinfection of Endoscopes

Endoscopes are fragile, expensive, difficult to clean, much used, and susceptible to contamination
(Rutala & Weber, 2008). There are millions of endoscopic procedures done each year, and
iatrogenic infections caused by contamination of endoscopes are rare (Rutala & Weber,
2008). However, endoscopes have been linked to more infectious outbreaks than any other
reusable medical device, and failure to properly clean and disinfect endoscopes is a primary reason
these outbreaks happen (Rutala & Weber, 2008). In addition, studies have shown that even
cleaned, and processed endoscopes are often contaminated (Neves et al., 2016).

The recommendations for the disinfection and sterilization of endoscopes listed below are from
the CDC (Rutala & Weber, 2008). The American Society for Gastrointestinal Endoscopy has also
published guidelines for cleaning endoscopes, multi- medical societies, and the Society of
Gastroenterology Nurses guidelines for this procedure (ASGE, 2011). Test each flexible endoscope
for leaks as part of each reprocessing cycle to detect damaged endoscopes. Remove any instrument
that fails the leak test from clinical use and repair this instrument.

Immediately after use, meticulously clean the endoscope with an enzymatic cleaner
compatible with the endoscope. Cleaning is necessary before both automated and manual
disinfection.
Disconnect and disassemble endoscopic components (e.g., suction valves) as completely as
possible and completely immerse all components in the enzymatic cleaner. Steam sterilizes
these components if they are heat stable.
Flush and brush all accessible channels to remove all organic (e.g., blood, tissue) and other
residues. Clean the external surfaces and accessories of the devices by using a soft cloth or
sponge, or brushes. Continue brushing until no debris appears on the brush.
Use cleaning brushes appropriate for the size of the endoscope channel or port (e.g., bristles
should contact surfaces). Cleaning items (e.g., brushes, cloth) should be disposable; or, if
they are not disposable, they should be thoroughly cleaned and either high-level disinfected
or sterilized after each use.
Discard enzymatic cleaners or detergents after each use. They are not microbicidal and,
therefore, will not retard microbial growth.
Process endoscopes (e.g., arthroscopes, cystoscopes, and laparoscopes) that pass through
normally sterile tissues using a sterilization procedure before each use; if this is not feasible,
provide at least high-level disinfection. A sterile water rinse should follow high-level
disinfection of arthroscopes, laparoscopes, and cystoscopes.
Phase-out endoscopes are critical items (e.g., arthroscopes, laparoscopes) but cannot be
steam sterilized. Replace these endoscopes with steam sterilizable instruments when
feasible.
Mechanically clean reusable accessories inserted into endoscopes (e.g., biopsy forceps or
other cutting instruments) that break the mucosal barrier (e.g., ultrasonically clean biopsy
forceps) and then sterilize these items between each use.
Use ultrasonic cleaning of reusable endoscopic accessories to remove soil and organic
material from hard-to-clean areas.
Process endoscopes and accessories that contact mucous membranes as semi-critical items
and use at least high-level disinfection after use on each patient.
Use an FDA-cleared sterilant or high-level disinfectant for sterilization or high-level
disinfection.
After cleaning, use formulations containing glutaraldehyde, glutaraldehyde with
phenol/phenate, ortho-phthalaldehyde, hydrogen peroxide, and peracetic acid to achieve
high-level disinfection, followed by rinsing and drying.
Extend exposure times beyond the minimum effective time for disinfecting semi-critical
patient-care equipment cautiously and conservatively because extended exposure to a high-
level disinfectant is more likely to damage delicate and intricate instruments such as flexible
endoscopes. The exposure times vary among the Food and Drug Administration (FDA)-
cleared high-level disinfectants.
Federal regulations are to follow the FDA-cleared label claim for high-level disinfectants.
Based on three-tier testing, the FDA-cleared labels for high-level disinfection with >2%
glutaraldehyde at 25°C range from 20-90 minutes, depending upon the product, based on
three-tier testing, including AOAC sporicidal tests, simulated use testing with mycobacterial
and in-use testing.
Several scientific studies and professional organizations support the efficacy of >2%
glutaraldehyde for 20 minutes at 20ºC; that efficacy assumes adequate cleaning prior to
disinfection, whereas the FDA-cleared label claim incorporates an added margin of safety to
accommodate possible lapses in cleaning practices. Facilities that have chosen to apply the
20 minutes duration at 20ºC have done so based on the multi-society Guideline for
Reprocessing Flexible Gastrointestinal Endoscopes.
When using FDA-cleared high-level disinfectants, use manufacturers’ recommended
exposure conditions. Certain products may require a shorter exposure time (e.g., 0.55%
ortho-phthalaldehyde for 12 minutes at 20°C, 7.35% hydrogen peroxide plus 0.23% peracetic
acid for 15 minutes at 20°C) than glutaraldehyde at room temperature because of their rapid
inactivation of mycobacteria or reduced exposure time because of increased mycobactericidal
activity at elevated temperature (e.g., 2.5% glutaraldehyde at 5 minutes at 35°C).
Select a disinfectant or chemical sterilant that is compatible with the device that is being
reprocessed. Avoid reprocessing chemicals on an endoscope if the endoscope manufacturer
warns against using these chemicals because of functional damage, with or without cosmetic
damage.
Completely immerse the endoscope in the high-level disinfectant and ensure all channels
are perfused. As soon as feasible, phase out non-immersible endoscopes.
After high-level disinfection, rinse endoscopes and flush channels with sterile water, filtered
water, or tap water to prevent adverse effects from retained disinfectant, e.g., disinfectant-
induced colitis. Follow this water rinse with a rinse with 70% - 90% ethyl or isopropyl
alcohol.
After flushing all channels with alcohol, purge the channels using forced air to reduce the
likelihood of contamination of the endoscope by waterborne pathogens and facilitate drying.
Hang endoscopes in a vertical position to facilitate drying.
Store endoscopes in a manner that will protect them from damage or contamination.
Sterilize or high-level disinfect both the water bottle used to provide intraprocedural flush
solution and its connecting tube at least once daily. After sterilizing or high-level
disinfection of the water bottle, fill it with sterile water.
Maintain a log for each procedure in which an endoscope has been used and record the
following: patient’s name and medical record number, the type of procedure and the date,
the name of the endoscopic, the system used to reprocess the endoscope (if more than one
system could be used in the reprocessing area), and the serial number or other identifiers of
the endoscope that was used.
Design facilities where endoscopes are used and disinfected to provide a safe environment
for healthcare professionals and patients. Use air-exchange equipment (e.g., the ventilation
system, out-exhaust ducts) to minimize exposure of all persons to potentially toxic vapors
(e.g., glutaraldehyde vapor). Do not exceed the allowable limits of the vapor concentration of
the chemical sterilant or high-level disinfectant; these limits are set by the American
Conference of Governmental Industrial Hygienists (ACGIH) and OSHA.
Routinely test the liquid sterilant/high-level disinfectant to ensure minimal effective
concentration of the active ingredient. Check the solution each day of use (or more
frequently) using the appropriate chemical indicator (e.g., glutaraldehyde chemical indicator
to test minimal effective concentration of glutaraldehyde) and document the results of this
testing. Discard the solution if the chemical indicator shows the concentration is less than
the minimum effective concentration. Do not use the liquid sterilant/high-level disinfectant
beyond the reuse life recommended by the manufacturer (e.g., 14 days for ortho-
phthalaldehyde).
Personnel assigned to reprocess endoscopes should be given device-specific reprocessing
instructions to ensure proper cleaning and high-level disinfection or sterilization.
Competency testing in these procedures should be done regularly.
Educate all personnel who use disinfectants and sterilants about the possible biological,
chemical, and environmental hazards of performing procedures that require these products.
The appropriate PPE should be provided to the staff who clean and disinfect endoscopes.
If using an automated endoscope reprocessor (AER), place the endoscope in the reprocessor,
and attach all channel connectors according to the AER manufacturer’s instructions to
ensure exposure of all internal surfaces to the high-level disinfectant/chemical sterilant.
If using an AER, ensure the endoscope can be effectively reprocessed in the AER. Also, ensure
any required manual cleaning/disinfecting steps are performed (e.g., elevator wire channel of
duodenoscopes might not be adequately disinfected by most AERs).
Review the FDA advisories and the scientific literature for reports of deficiencies that can
lead to infection because design flaws and improper operation and practices have
compromised the effectiveness of AERs.
Develop protocols to ensure that users can readily identify an endoscope that has been
properly processed and is ready for patient use.
Do not use the carrying case designed to transport clean and reprocessed endoscopes outside
of the healthcare environment, store an endoscope, or transport the instrument within the
healthcare environment.
For quality assurance purposes, no recommendation is made about routinely performing
microbiologic testing of either endoscope or rinse water.
If environmental microbiologic testing is conducted, use standard microbiologic techniques.
If a cluster of endoscopy-related infections occurs, investigate potential transmission routes
(e.g., person-to-person, common source) and reservoirs.
Report outbreaks of endoscope-related infections to persons responsible for institutional
infection control, risk management, and the FDA. Notify the local and the state health
departments, CDC, and the manufacturer(s).
According to the recommendations in this guideline, no recommendation is made regarding
reprocessing an endoscope immediately before use if that endoscope has been processed
 after use.
Compare the reprocessing instructions provided by both the endoscope’s and the AER’s
manufacturer’s instructions and resolve any conflicting recommendations.

Disinfection Strategies for Other Semi-Critical Devices

Other medical devices aside from endoscopes that contact mucous membranes and are considered
to be semi-critical include (but are not limited to) rectal and vaginal probes, flexible cystoscopes,
tonometers, and ultrasound probes used for various procedures. The risk of contracting an
infectious disease from one of these devices is very small but not impossible, and contamination
with microorganisms such as cytomegalovirus, human papillomavirus, hepatitis C, herpes
simplex, Klebsiella, and Pseudomonas have been found on these devices. Even after cleaning and
disinfection (Leroy, 2013).

Disinfection strategies vary widely for these semi-critical items devices, and the FDA requests the
manufacturers to provide at least one validated cleaning and disinfection/sterilization protocol in
the labeling for their devices. The CDC guidelines are listed below; disinfection and sterilization
with different forms of hydrogen peroxide or ultraviolet light are also being evaluated for
sterilizing these devices.

Even if probe covers have been used, clean and high-level disinfect semi-critical devices
such as rectal probes, vaginal probes, and cryosurgical probes with a product that is not toxic
to staff, patients, probes, and retrieved germ cells (if applicable). Use a high-level
disinfectant at the FDA-cleared exposure time.
When probe covers are available, use a probe cover or a condom to reduce the level of
microbial contamination. Do not use a lower category of disinfection or cease to follow the
appropriate disinfectant recommendations when using probe covers because these sheaths
and condoms can fail.
After high-level disinfection, rinse all items. Use sterile water, filtered water, or tap water
followed by an alcohol rinse for semi-critical equipment that will have contact with mucous
membranes of the upper respiratory tract, e.g., the nose, pharynx, and esophagus.
There is no recommendation to use sterile or filtered water rather than tap water for rinsing
semi-critical equipment that contacts the mucous membranes of the rectum (e.g., rectal
probes, anoscope) or vagina (e.g., vaginal probes).
Wipe clean tonometer tips and disinfect them by immersing them for 5-10 minutes in either
5000 ppm chlorine or 70% ethyl alcohol. None of these listed disinfectant products are FDA-
cleared high-level disinfectants.

Sterilization (Rutala & Weber, 2008).

Steam is the preferred method for sterilizing critical medical and surgical instruments that are not
damaged by heat, steam, pressure, or moisture.

Cool steam or heat-sterilized items before they are handled or used in the operative setting.
Follow the sterilization times, temperatures, and other operating parameters (e.g., gas
concentration, humidity) recommended by the manufacturer(s) of the instruments, the
sterilizer, and the container or wrap used, consistent with guidelines published by
government agencies and professional organizations.
Use low-temperature sterilization technologies (e.g., EtO, hydrogen peroxide gas plasma) for
reprocessing critical patient-care equipment that is heat or moisture sensitive.
 Completely aerate surgical and medical items that have been sterilized in the EtO sterilizer
(e.g., polyvinyl chloride tubing requires 12 hours at 50oC, 8 hours at 60oC) before using these
items in inpatient care.
Sterilization using the peracetic acid immersion system can sterilize heat-sensitive
immersible medical and surgical items.
The peracetic acid immersion process must be sterilized, for critical items must be used
immediately.
Dry-heat sterilization at 340oF for 60 minutes can be used to sterilize items like powders and
oils that can sustain high temperatures.
Comply with the sterilizer manufacturer’s instructions regarding the sterilizer cycle
parameters.
Because narrow-lumen devices provide a challenge to all low-temperature sterilization
technologies and direct contact is necessary for the sterilant to be effective, ensure that the
sterilant has direct contact with contaminated surfaces (e.g., scopes processed in peracetic
acid must be connected to channel irrigators).

Packaging (Rutala & Weber, 2008).

Packaging materials must be compatible with the sterilization process and have received FDA
510[k] clearance.
Packaging must be strong enough to resist punctures and tears and to provide a barrier to
microorganisms and moisture.

Monitoring of Sterilizers (Rutala & Weber, 2008).

Use mechanical, chemical, and biological monitors to ensure the effectiveness of the
sterilization process.
Monitor each load with mechanical (e.g., time, temperature, pressure) and chemical (internal
and external) indicators. An external indicator is not needed if the internal chemical
indicator is visible.
If the mechanical or chemical indicators suggest inadequate processing, do not use processed
items.
Use biologic indicators to monitor the effectiveness of sterilizers at least weekly with an
FDA-cleared commercial challenge preparation for spores (e.g., a Geobacillus
stearothermophilus for steam) intended specifically for the type and cycle parameters of the
sterilizer.
After a single positive biologic indicator is used with a method other than steam sterilization,
treat as nonsterile all items that have been processed in that sterilizer, dating from the
sterilization cycle having the last negative biologic indicator to the next cycle showing
satisfactory biologic indicator results. These nonsterile items should be retrieved if possible
and reprocessed.
After a positive biologic indicator with steam sterilization, objects other than implantable
objects do not need to be recalled because of a single positive spore test unless the sterilizer
or the sterilization procedure is defective as determined by maintenance personnel or
inappropriate cycle settings. If additional spore tests remain positive, consider the items
nonsterile and recall and reprocess the items.
Use biologic indicators for every load containing implantable and quarantine items,
whenever possible, until the biologic indicator is negative.
 Indicator tapes provide a seal for sterilization packs and an immediate
identification of processed items. Dispensers are available in all sizes

Internal CI's should be used within each pouch or package, tray, or container.
Class 5 integrators should be used in conjunction with physical monitoring and
biological indicator testing for verifying the efficacy of a sterilization system. (See
AAMI ST79:2006)

Load Configuration (Rutala & Weber, 2008).

Place items correctly and loosely into the basket, shelf, tray, or cart of the sterilizer. This will
ensure that the penetration of the sterilant is not impeded.

Storage of Sterile Items (Rutala & Weber, 2008).

The sterile storage area should be well ventilated and protect against dust, moisture, insects,
and temperature and humidity extremes.
Store sterile items so the packaging is not compromised (e.g., punctured, bent).
The shelf life of a packaged sterile item depends on the quality of the wrapper, the storage
conditions, the conditions during transport, the amount of handling, and other events like
moisture that compromise the integrity of the package. If event-related storage of sterile
items is used, then packaged sterile items can be used indefinitely unless the packaging is
compromised.
Evaluate packages for loss of integrity before use; look to see if they are torn, wet, or
punctured. The pack can be used unless the integrity of the packaging is compromised.
If the integrity of the packaging is compromised, repack and reprocess the pack before use.
If time-related storage of sterile items is used, label the pack at the time of sterilization with
an expiration date. Once this date expires, reprocess the pack.

Quality Control (Rutala & Weber, 2008).

To ensure they understand the importance of reprocessing these instruments, provide

comprehensive and intensive training for all staff assigned to reprocess semi-critical and
critical medical/surgical instruments.
Compare the reprocessing instructions (e.g., for the appropriate use of endoscope
connectors, the capping/non-capping of specific lumens) provided by the instrument
manufacturer and the sterilizer manufacturer and resolve any conflicting recommendations
by communicating with both manufacturers.
Conduct infection control rounds periodically (e.g., annually) in high-risk reprocessing areas
(e.g., the gastroenterology clinic, central processing); ensure reprocessing instructions are
current and accurate and are correctly implemented. Document all deviations from policy. All
stakeholders should identify what corrective actions will be implemented.
The quality control program for sterilized items should include the following: a sterilizer
maintenance contract with records of service; a system of process monitoring; air-removal
 testing for pre-vacuum steam sterilizers; visual inspection of packaging materials, and;
traceability of load contents.
Record the type of sterilizer and cycle used; the load identification number; the load
contents; the exposure parameters (e.g., time and temperature); and the operator’s name or
initials. And; the results of mechanical, chemical, and biological monitoring.
Retain sterilization records (mechanical, chemical, and biological) for a time that complies
with standards, statutes of limitations, and state and federal regulations.
Prepare and package items to be sterilized so that sterility can be achieved and maintained to
the point of use. Consult the Association for the Advancement of Medical Instrumentation or
the manufacturers of surgical instruments, sterilizers, and container systems for guidelines
for the density of wrapped packages.
Periodically review sterilization policies and procedures.
Preventive maintenance on sterilizers should be done by qualified personnel guided by the
manufacturer’s instructions.

Flash Sterilization

Flash sterilization (immediate-use steam sterilization, IUSS) was traditionally used for items
needed immediately, but a traditionally sterilized one was unavailable. Flash sterilization involves
placing items in a gravity displacement sterilizer for 3 minutes at 27-28 pounds of pressure and a
temperature of 132°C. It is an effective technique, but it has limitations, and it should only be used
when necessary, not for convenience or to compensate for poor planning. Concerns have been
raised by the CDC, the Association of Perioperative Registered Nurses (AORN), and others that
flash sterilization has become overused and can cause adverse events  (Smart et al., 2012). The
CDC and the Joint Commission have guidelines for the proper use of immediate use steam
sterilization, and these guidelines are supported by the AORN (Graybill-D’Frcole, 2013).

These guidelines for flash sterilization are from the CDC (Rutala & Weber, 2008).

Do not flash sterilize implanted surgical devices unless doing so is unavoidable.

If flash sterilization is needed for an implantable device, recordkeeping is essential: the load
identification, the patient’s name, and the biological indicator result must be carefully
documented.
Do not use flash sterilization for convenience, avoid purchasing additional instrument sets,
or save time.
When using flash sterilization, make sure the following parameters are met: 1) clean the item
before placing it in the sterilizing container (a container that is FDA approved for use with
flash sterilization) or tray; 2) prevent exogenous contamination of the item during transport
from the sterilizer to the patient, and; 3) monitor sterilizer function with mechanical,
chemical, and biologic monitors.
Do not use packaging materials and containers in flash sterilization cycles unless the
sterilizer and the packaging material/container are designed for this use.
When necessary, use flash sterilization for patient-care items that will be used immediately,
e.g., to reprocess an inadvertently dropped instrument.
When necessary, use flash sterilization for processing patient-care items that cannot be
packaged, sterilized, and stored before use.

The Joint Commission recommendations for immediate use of steam sterilization (TJC, 2017):
 Review the equipment manufacturer’s instructions to determine if IUSS is appropriate for a
device or instrument.
Circumstances in which IUSS is an appropriate technique are:
when a specific instrument is needed for an emergency procedure;
when a non-replaceable instrument has been contaminated but needs to be used
immediately, and;
when an item was dropped on the floor but is needed immediately
The use of IUSS does not mean that the proper cleaning and transport steps can be omitted.
Items suitable for IUSS must be processed in approved/validated containers suitable for IUSS.
IUSS should not be used for mere convenience or due to limited instruments or equipment
for the number of cases/procedures performed.
Evaluate the IUSS process in all locations where it is being performed.

Reuse of Single-Use Medical Devices

Adhere to the FDA enforcement document for single-use devices reprocessed by the hospital. FDA
requires hospitals to use the same standards by which it regulates the original equipment
manufacturer (FDA, 2015).

Exceptional circumstances that require non-critical items to be either dedicated to one patient or
patient cohort or subjected to low-level disinfection between patient uses are those involving
(Fedorowicz, 2017):

Patients infected or colonized with VRE other drug-resistant microorganisms judged by the
infection control program, based on the current state, regional, or national
recommendations, to be of special or clinical or epidemiologic significance 

or

Patients infected with highly virulent microorganisms, e.g., viruses causing hemorrhagic
fever such as Ebola or Lassa.

Microbial Contamination of Disinfectants

Disinfectants can be a source of microbial contamination, and hospital-acquired infections caused
by contaminated disinfectants have been documented (Ko et al., 2015). These measures should be
used to reduce the occurrence of contaminated disinfectants (Rutala & Weber, 2008):

Prepare the disinfectant correctly to achieve the manufacturer’s recommended use-dilution.

Prevent extrinsic contamination of germicides, e.g., container contamination or surface
contamination of the healthcare environment where the germicides are prepared or used.
The instructions on the disinfectant labels in terms of shelf life, storage, dilution, proper use,
disposal, and material compatibility must be followed.
The user is responsible for any harm caused by off-label use.

Disinfection in Ambulatory Care, Home Care, and the

Home(Rutala & Weber, 2008)
The home environment should be as safe as hospitals or ambulatory care. Epidemics should not be
a problem, and cross-infection should be rare. The healthcare provider is responsible for
providing the responsible family member information about infection-control procedures to
follow in the home, including hand hygiene, proper cleaning and disinfection of equipment, and
safe storage of cleaned and disinfected devices.

The products recommended for home disinfection of reusable objects are bleach, alcohol, and
hydrogen peroxide.
The Associations for Professionals in Infection Control and Epidemiology (APIC)
recommends that reusable objects (e.g., tracheostomy tubes) that touch mucous membranes
be disinfected by immersion in 70% isopropyl alcohol for 5 minutes or in 3% hydrogen
peroxide for 30 minutes. Additionally, a 1:50 dilution of 5.25%–6.15% sodium hypochlorite
(household bleach) for 5 minutes should be effective.
Non-critical items like blood pressure cuffs and crutches can be cleaned with a detergent.
Blood spills should be handled according to OSHA regulations. In general, sterilization of
critical items is not practical in homes but could be accomplished by chemical sterilants or
boiling.
Single-use disposable items can be used or reusable items sterilized in a hospital.
Some environmental groups advocate environmentally safe products as alternatives to
commercial germicides in the home-care setting. These alternatives (e.g., ammonia, baking
soda, vinegar, borate-based products, and liquid detergents) are not registered with the EPA
as disinfectants or germicides, and they should not be used for disinfecting are ineffective
against S. aureus. Borate-based products, baking soda, and detergents also are ineffective
against Salmonella typhi and E coli; however, undiluted vinegar and ammonia are effective
against S typhi and E coli. Common commercial disinfectants designed for home use also are
effective against selected antibiotic-resistant bacteria.
Public concerns have been raised that the use of antimicrobials in the home can promote the
development of antibiotic-resistant bacteria. This issue is unresolved and needs to be
considered further through scientific and clinical investigations.
The public health benefits of using disinfectants in the home are unknown. However, some
facts are known: many sites in the home kitchen and bathroom are microbially
contaminated, hypochlorites markedly reduce bacteria, and good hand and food hygiene
standards can help reduce infections in the home. In addition, laboratory studies indicate
that many commercially prepared household disinfectants are effective against common
pathogens and can interrupt surface-to-human transmission of pathogens. The “targeted
hygiene concept” means identifying situations and areas like the bathroom and food
preparation areas where risk exists for transmission of pathogens may be a reasonable way to
identify when disinfection might be appropriate.

Engineering and Environmental Controls

Construction activities in or near healthcare facilities increase disease risks for airborne and
waterborne diseases, and infections caused by construction activity have been well documented
(Pokala et al., 2014). The increasing age of healthcare facilities generates the ongoing need for
repair and remediation work that can introduce or increase contamination of the air and water in
patient-care environments. The CDC has further recommendations for construction activity in
healthcare facilities that should be reviewed (Sehulster & Chinn, 2003).
The purpose of heating, ventilation, and air conditioning (HVAC) systems in healthcare facilities is
to a) maintain the indoor air temperature and humidity at comfortable levels; b) control odors; c)
remove contaminated air; d) facilitate air-handling requirements to protect from airborne,
healthcare-related pathogens; e) direct airflow; f) manage outside air; g) provide reliable
filtration, and; h) minimize the risk of transmission of airborne pathogens (Sehulster & Chinn,
2003). Decreased performance of healthcare facility HVAC systems, filter inefficiencies, improper
installation, and poor maintenance can contribute to the spread of healthcare-related airborne
infections. The CDC has further recommendations for HVAC systems in healthcare facilities that
should be reviewed (Sehulster & Chinn, 2003).

Management of Equipment and Surfaces in Dentistry(CDC,

2016m)
Dentists and dental office personnel are exposed to blood, body fluids, and aerosols, and the
exposure can be by direct contact, indirect contact, or inhalation. Transmission of infectious
agents from staff to patient or patient to staff is rare in dental settings, but it has occurred (CDC,
2016m). The mode of transmission in these cases has not always been established, but poor
compliance with infection control practices has been reported and is the likely cause (CDC,
2016m).

Infection control in dental settings is identical to infection control in other healthcare settings,
and the basic principles outlined here should be observed (Rutala & Weber, 2008).

Administrative measures: A written infection control and infection prevention policy must be in
place. Important aspects include having at least one person responsible for
coordinating/overseeing the policy and a plan for handling exposures.

Infection control and infection prevention training: Training/education in infection control and

infection prevention must complete during the hiring period; annually, when employees are
learning or performing new procedures; and according to local, state, and federal regulations.

Dental personnel safety: This would include (but is not limited to) proper immunizations, OSHA-
approved training in the OSHA Bloodborne Pathogens standard, knowing the proper post-
exposure protocol, and rules/policies for dental personnel and patients who have a potentially
infectious illness. This last point includes specific recommendations regarding the influenza virus
(Sebastiani et al., 2017).

Encourage all dental personnel to get seasonal influenza and 2009 H1N1 vaccinations.
If a patient has an influenza-like illness, schedule non-urgent visits until the illness has
resolved and the patient is afebrile.
Evaluate patients for the presence of influenza-like illness at check-in time and provide a
face mask and tissues if needed.
Use Respiratory Hygiene/Cough Etiquette for symptomatic patients and reschedule non-
urgent care. Separate ill patients whenever possible.
Urgent dental treatment can be done without an airborne infection isolation room as the
transmission of 2009 H1N1 influenza is not thought to occur over longer distances, e.g., from
one patient care area to another.
If it is known or suspected that the patient has an influenza-like illness, use a treatment
room with a closed door. If this is not possible, place the (potentially) infectious patient as
 far as possible from other patients.
Wear recommended PPE before entering the treatment room.
Dental personnel should wear an N95 respirator before entering the room and providing
treatment if a patient has suspected or confirmed 2009 H1N1 influenza.
Minimize the potential for sprays and splatters.

Program evaluation: There must be a policy to evaluate the infection control and infection
prevention program.

Hand hygiene: Training in hand hygiene must be provided, and hand hygiene supplies must be
available.

PPE: Training in the proper use of PPE should be provided, and PPE supplies must be available.

Respiratory Hygiene/Cough Etiquette: Training in Respiratory Hygiene/Cough Etiquette must be

provided, and supplies needed to observe this infection control technique must be available.

Sharps safety and Safe Injection Practices: Personnel must be trained in sharps safety and Safe
Injection Practices, and they must be provided the equipment needed to practice these infection
control techniques.

Sterilization and disinfection: Policies and procedures for sterilization and disinfection must be
in place and easily accessed, dental staff must be trained in these policies and procedures, and the
appropriate equipment necessary for sterilization and disinfection must be available. Dental
equipment, like medical equipment, should be divided into critical, semi-critic, and non-critical,
and these classifications should be used as a guideline for choosing sterilization and disinfection
techniques. Specific recommendations for dental setting sterilization and disinfection include
(CDC, 2016m):

The instrument processing area must be divided into separate areas for cleaning, packaging,
sterilization, and storage, and there are specific recommendations for each, e.g., the storage
area must be dry, dust-proof, well ventilated, and equipment must be stored at least 8 inches
from the floor, 18 inches from the ceiling, and 2 inches from the walls.
Cleaning should always be done before disinfection or sterilization.
Cleaning, disinfection, and sterilization should only be done by dental personnel who have
been specifically trained for these tasks. Cleaning, disinfection, and sterilizing of dental
equipment should be done according to manufacturers’ recommendations and recommended
infection control/prevention policies.
Sterilization monitoring for both proper procedures and effectiveness should be done
routinely. The effectiveness of sterilization can be done using biological, chemical, and
mechanical monitoring.
The four accepted methods of sterilization of dental equipment are autoclaving, unsaturated
chemical vapor pressure sterilization (chemiclave), dry heat sterilization (dryclave), and
ethylene oxide sterilization.
Dental instruments that penetrate soft tissue or bone (e.g., extraction forceps, scalpel
blades, bone chisels, periodontal scalers, and surgical burrs) are critical and should be
sterilized after each use or discarded. In addition, after each use, sterilize dental instruments
that are not intended to penetrate oral soft tissue or bone (e.g., amalgam condensers, air-
water syringes), but that might contact oral tissues and are heat-tolerant although classified
 as semi-critical. Clean and, at a minimum, high-level disinfect heat-sensitive semi-critical
items.
Non-critical clinical contact surfaces, such as uncovered operatory surfaces (e.g.,
countertops, switches, light handles), should be barrier-protected or disinfected between
patients with an intermediate-disinfectant (i.e., EPA-registered hospital disinfectant with a
tuberculocidal claim) or low-level disinfectant (i.e., EPA-registered hospital disinfectant
with HIV and hepatitis B claim).
Barrier protective coverings can be used for non-critical clinical contact surfaces that are
frequently touched with gloved hands during the delivery of patient care, that are likely to
become contaminated with blood or body substances, or that are difficult to clean. Change
these coverings when visibly soiled, when they become damaged, and routinely, e.g.,
between patients. Disinfect protected surfaces at the end of the day or if visibly soiled.
Non-critical surfaces are surfaces that might frequently be touched with gloved hands during
patient care or become contaminated with blood or other potentially infectious material.
These surfaces can subsequently contact instruments, hands, gloves, or devices and could be
a source of caregiver-object-patient pathogen transmission. These surfaces should be
disinfected between patient contacts with an intermediate disinfectant or a low-level
disinfectant. Barrier protection can also be used on these surfaces, and the coverings can be
changed between patients.
Medical waste, including tissues, extracted teeth, dental amalgams, and other materials,
should be considered infectious and handled and disposed of properly.

Environmental infection control and prevention (CDC, 2016m): Surfaces that are likely to be
contaminated and patients or staff may have contact should be regularly cleaned or cleaned as
needed using the proper disinfectant. Ordinary surfaces (e.g., walls) can be cleaned with soap and
water; high-level disinfectants are not recommended for these surfaces as they can be corrosive
and damaging. Spills of contaminated/potentially contaminated material should be correctly and
promptly cleaned, and PPE should be used as needed during the cleanup.

Dental unit water quality: Water lines used for dental procedures can develop biofilm and growth
of bacteria (CDC, 2016m). Most of the microorganisms typically found in dental unit waterlines
have limited pathogenic potential, but Legionella species, Pseudomonas aeruginosa, and non-
tuberculous Mycobacterium have been found in these water systems. Dental units must have a
water filtration system that allows for ≤ 500 colony-forming units (CFU) per mL of heterotrophic
water bacteria. (Note: A heterotrophic organism requires carbon and nitrogen for its metabolic
activity). If dental equipment is permanently attached to air and water lines, waterproof barriers
must be used and changed after each use. Other equipment that uses water must be properly used,
e.g., a patient should not close her/his lips tightly around a saliva ejector as this may reverse the
flow, causing material from a previous patient to aspirate.

Selected Issues in Infection Control: Common

Diseases/Conditions
Hospital-Acquired Pneumonia
Hospital-acquired pneumonia is a significant cause of morbidity and mortality. This section will
discuss risk factors for hospital-acquired pneumonia and methods/techniques for preventing
hospital-acquired pneumonia (which is sometimes referred to as healthcare-associated
pneumonia) in mechanically ventilated patients and those who are not.

Risk Factors

The most important risk factor for hospital-acquired pneumonia is mechanical ventilation. Other
risk factors include (File, 2016).:

Age > 55 years

Anemia
Aspiration
Chest or upper abdominal surgery
Chronic lung disease
Chronic renal failure
Depressed consciousness
Frequent ventilator circuit changes
Increased gastric pH, e.g., from therapeutic use of H2 blockers or proton pump inhibitors
Intracranial pressure monitoring
Malnutrition
Medications, e.g., glucocorticoids, muscle relaxers, opioids
Multiple central venous catheter placements
Multiple surgeries
Multiple trauma
Paralysis
Prolonged intubation, re-intubation

Preventing Hospital-Acquired Pneumonia

For mechanically ventilated patients, measures that can prevent hospital-acquired pneumonia
include avoiding intubation when possible, elevating the head of the bed, oral hygiene with an
antiseptic, maintaining physical conditioning, minimizing the use of sedation, minimizing
pooling of secretions above the endotracheal tube, proper maintenance of ventilator circuit, and
staff education (File, 2016).

There has been comparatively little research on preventing hospital-acquired pneumonia in non-
ventilated patients. However, proper positioning, early identification and treatment of dysphagia,
good oral hygiene, an antiseptic mouth rinse, and conscientious use of Standard Precautions and
infection control techniques may be helpful (Passaro et al., 2016).

The CDC and the American Thoracic Society recommendations for preventing hospital-acquired
pneumonia (Tablan et al., 2003). The Institute for Healthcare Improvement recommendations is
included (IHI, 2012).

Staff education: Staff knowledge of the risks of hospital-acquired pneumonia and their knowledge
of and compliance with prevention techniques are critical for reducing the incidence and severity
of this disease.

Conduct surveillance in ICU patients: Do not routinely perform surveillance cultures of patients,
equipment, or devices

Sterilization and Disinfection:

Thoroughly clean all equipment. When possible, use steam sterilization or high-level
disinfection by wet heat pasteurization.
Use sterile water for rinsing reusable semi-critical respiratory equipment after chemical
disinfection. If this is not feasible, rinse with filtered water.
Adhere to provisions in the FDA’s enforcement document for single-use devices that third
parties reprocess.
Do not routinely sterilize or disinfect the internal machinery of mechanical ventilators.
Do not routinely change the breathing circuit humidifiers based on the duration of use. Clean
only when visibly soiled or malfunctioning.
Breathing-circuit tubing condensate: Periodically drain and discard any condensate. Make
sure the condensate does not drain toward the patient. Wear gloves during the procedure or
handling of condensate. After the procedure, wash your hands with soap and water or an
alcohol-based hand rub.
No recommendation can be made for placing a filter or trap at the distal end of the
expiratory-phase tubing to collect condensate.
Use sterile water to fill bubbling humidifiers.
No recommendation can be made for the preferential use of a close, continuous-feed
humidification system.
Ventilator breathing circuits with heat moisture exchange (HME): No recommendation can
be made for the preferential use of either HMEs or heated humidifiers to prevent pneumonia
in mechanically assisted ventilation patients. Change an HME in use on a patient when it
malfunctions mechanically or becomes visibly soiled. Do not routinely change an HME that is
in use on a patient more frequently than every 48 hours. Do not routinely change the
breathing circuit attached to an HME while it is in use on a patient.
Oxygen humidifiers: Follow manufacturers' instructions for the use of oxygen humidifiers.
Change the humidifier-tubing (including nasal prongs or masks) when it malfunctions or
becomes visibly contaminated.
Small-volume medication nebulizers and in-line and hand-held nebulizers: Between
treatments on the same patient, clean, disinfect; rinse with sterile water (if rinsing is
needed), and dry small-volume in-line or hand-held medication nebulizers. Use only sterile
fluid for nebulization, and dispense the fluid into the nebulizer aseptically. Whenever
possible, use aerosolized medications in single-dose vials. If multi-dose medication vials are
used, follow manufacturers’ instructions for handling, storing, and dispensing the
medications.
Mist-tents: Between uses on different patients, replace mist tents and their nebulizers,
reservoirs, and tubing with those that have been sterilized or had high-level disinfection. No
recommendation can be made about the frequency of routinely changing mist-tent
nebulizers, reservoirs, and tubing while in use on one patient. Mist-tent nebulizers,
reservoirs, and tubing used on the same patient should receive daily low-level disinfection
(e.g., 2% acetic acid) or pasteurization followed by air-drying.
Other devices: Between uses on different patients, sterilize or subject to high-level
disinfection portable respirometers and ventilator thermometers; reusable hand-powered
resuscitation bags; no recommendation can be made about the frequency of changing
hydrophobic filters placed on the connection port of resuscitation bags.
Anesthesia machines and breathing systems or patient circuits: Do not routinely sterilize or
disinfect the internal machinery of anesthesia equipment. Between uses on different
 patients, clean the reusable components of the breathing system or patient circuit and then
sterilize or subject them to high-level liquid chemical disinfection or pasteurization in
accordance with the device manufacturers’ instructions for their reprocessing. No
recommendation can be made about the frequency of routinely cleaning and disinfecting
unidirectional valves and carbon dioxide absorber chambers.
Follow published guidelines and manufacturers' instructions about in-use maintenance,
cleaning, and disinfection or sterilization of other components or attachments of anesthesia
equipment's breathing system or patient circuit. No recommendation can be made for
placing a bacterial filter in the breathing system or patient circuit of anesthesia equipment.
Pulmonary-function testing equipment: Do not routinely sterilize or disinfect the internal
machinery of pulmonary-function testing machines between uses on different patients.
Change the mouthpiece of a peak flow meter or the mouthpiece and filter of a spirometer
between uses on different patients.
Room-air humidifiers and faucet aerators: Do not use large-volume room-air humidifiers
that create aerosols unless they can be sterilized or subjected to high-level disinfection daily
and filled only with sterile water.
No recommendation can be made about the removal of faucet aerators from areas for
immunocompetent patients.
If Legionella spp. are detected in the water of a transplant unit and until Legionella spp. are
no longer detected by culture, remove faucet aerators in the unit.

Tracheostomy Care and Suctioning

Good tracheostomy care reduces morbidity and reduces decannulation time (Mitchell et al., 2013).
Principles of good tracheostomy care include:

All supplies to replace a tracheostomy tube should be at the bedside or within easy reach.
Humidification should be used if the patient is mechanically ventilated or has thick
secretions.
Perform tracheostomy under aseptic conditions.
When changing a tracheostomy tube, wear a gown and use the aseptic technique.
No recommendation can be made for the daily application of topical antimicrobial agent(s) at
the tracheostoma.
Perform cuff pressure checks as needed.
Cuffs should be deflated when the patient no longer needs mechanical ventilation.

Suctioning of respiratory tract secretions: Suctioning is an essential part of care for certain
mechanically ventilated patients who have a tracheostomy, but it places them at risk for infection
and hospital-acquired pneumonia. The following advice and recommendations can help prevent
these complications.

No recommendation can be made for the preferential use of either the multiuse closed-
system suction catheter or the single-use open system suction catheter to prevent
pneumonia (Hamishekar et al., 2014).
Sterile gloves do not have to be worn (Li Bassi, 2017).
No recommendation can be made about the frequency of routinely changing the in-line
suction catheter of a closed-suction system in use on one patient.
If the open-system suction is employed, use a sterile single-use catheter.
 Use only sterile fluid to remove secretions from the suction catheter if the catheter is to be
used for re-entry into the patient's lower respiratory tract. Routine use of saline is not
recommended (Leddy & Wilkinson, 2015).

Modifying Host Risk for Infection and Hospital-Acquired Pneumonia: Vaccination

Vaccination is an important part of protecting patients against hospital-acquired pneumonia and

pneumonia. Patients at risk who should be given pneumococcal vaccination include (Kobayashi et
al., 2015):

All infants and children age 2 to 59 months.

Children 60 to 71 months with underlying medical conditions, including immunocompetent
children with chronic heart disease (particularly cyanotic congenital heart disease and heart
failure), children who have cerebrospinal fluid leaks, chronic lung disease, asthma (if there is
a need for high-dose corticosteroids), cochlear implants, or diabetes.
Children with functional or anatomic asplenia, including sickle cell disease or other
hemoglobinopathies, children who have congenital or acquired asplenia, or splenic
dysfunction.
Children with immunocompromising conditions including chronic renal failure, congenital
immunodeficiency (includes B or T cell deficiency, complement deficiencies, and phagocytic
disorders; excludes chronic granulomatous disease), generalized malignancies, HIV infection,
Hodgkin’s disease, nephrotic syndrome, leukemia, lymphoma, solid organ transplant, or
other diseases requiring immunosuppressive drugs.
Children ≥6 years, adolescents ≤18 years, and adults ≥19 years.
Person who have these underlying medical conditions: Anatomic asplenia, including sickle
cell disease or other hemoglobinopathies, congenital or acquired asplenia;
immunocompetent persons with cerebrospinal fluid leaks or cochlear implants;
immunocompromising conditions including congenital or acquired immunodeficiency (this
includes B or T cell deficiency, complement deficiencies and phagocytic disorders, excludes
chronic granulomatous disease); HIV infection, chronic renal failure, nephrotic syndrome,
leukemia, lymphoma, Hodgkin’s disease; generalized malignancies; solid organ transplant;
multiple myeloma; or other diseases requiring immunosuppressive drugs (including long
term systemic corticosteroids and radiation therapy).
All adults ≥65 years.

No recommendation can be made for the routine administration of preparations of granulocyte

colony-stimulating factor (GCSF) medications or intravenous gamma globulin for prophylaxis
against healthcare-associated pneumonia.

No recommendation can be made for the routine administration of glutamine to prevent

healthcare-associated pneumonia (Kaya et al., 2017).

Preventing Aspiration

Aspiration is a significant risk factor for hospital-acquired pneumonia and pneumonia. Measures
that can prevent and decrease the risk for aspiration include (File, 2016).:

As soon as the clinical indications for their use are resolved, remove devices such as
endotracheal, tracheostomy, or enteral tubes from patients.
 Limit sedating or paralytic agents as these drugs can depress cough and other host-
protective mechanisms.
Maintain endotracheal tube cuff pressure at 20-30 cm H2O.
Condensation in the ventilator circuit can become contaminated. Care should be taken to
prevent condensation from reaching the lower airway or the nebulizer chamber.
If possible, use non-invasive ventilation (NIV); this will reduce endotracheal intubation's
need for and duration.
If possible and not medically contraindicated, use noninvasive positive-pressure ventilation
delivered continuously by face or nose mask in preference to endotracheal intubation in
patients with respiratory failure and who do not need immediate intubation.
If possible and not medically contraindicated, use NIV during the weaning process. This NIV
can shorten the duration of endotracheal intubation.
As much as possible, avoid repeat endotracheal intubation in patients who have received
mechanically assisted ventilation.
Unless contraindicated by the patient’s condition, perform orotracheal rather than
nasotracheal intubation.
If feasible, use an endotracheal tube with a dorsal lumen above the endotracheal cuff to allow
drainage (by continuous or intermittent suctioning) of tracheal secretions that accumulate in
the subglottic area.
Before deflating the cuff of an endotracheal tube in preparation for extubation, tube removal,
or before moving the tube, clear secretions from above the cuff and ensure that secretions
are cleared above the tube cuff

Prevention of aspiration associated with enteral feeding (CCN, 2016).:

Maintain the head of the bed at 30-45° unless contraindicated.

Routinely verify appropriate feeding tube placement, e.g., every four hours. Auscultating for
air, checking the pH of the aspirate, and inserting the open end of a tube into water are not
reliable methods of confirming tube placement; capnography is preferred. Radiographic
confirmation is the gold standard.
Routinely assess the patient’s tolerance for enteral feedings, e.g., every four hours.
Gastric residual volume (GRV) does not correlate with aspiration or pneumonia incidences.
Withholding feeding if the GRV is < 500 mL is contraindicated unless the patient has signs of
feeding intolerance.
Prokinetic medications such as metoclopramide should be used if possible.
If the patient is at high-risk for aspiration or if he/she is intolerant to bolus delivery of
enteral nutrition, deliver enteral nutrition by continuous infusion.
Use sedatives sparingly.
Consider a swallowing evaluation before oral feedings are started for recently extubated
patients who had been intubated for more than 2 days.
No recommendation can be made for using small-bore tubes for enteral feeding.
Feedings can be delivered in the stomach, the jejunum, or the duodenum. The selection of
the delivery site should be made on a case-by-case basis; if the patient has a high risk for
aspiration, a site lower than the stomach is preferred.

Prevention or Modulation of Oropharyngeal Colonization

Bacteria are present in the oral cavity. Both normal flora and bacteria are transmitted to the
patient during hospitalization. Aerobic and facultatively anaerobic gram-negative bacilli
frequently colonize the oral cavities in hospitalized or immunocompromised patients. These
pathogens are a significant cause of hospital-acquired pneumonia.

Mechanically ventilated patients increase oral biofilm, xerostomia, colonization of the oral cavity
by pathogens, and no ability to self-clean, all of which increase the risk for ventilator-associated
pneumonia (Ory et al., 2017).

Oropharyngeal cleaning and decontamination with an antiseptic agent can help reduce the
number of these pathogens and reduce the incidence of hospital-acquired pneumonia and
ventilator-acquired pneumonia (Tang et al., 2017).

Chlorhexidine is the most commonly used and studied oral antiseptic to prevent oral
decolonization and hospital-acquired pneumonia. However, it is unclear which antiseptic agent is
the most effective, and the optimal oral hygiene protocol has not been determined (Ory et al.,
2017).

Develop and implement a comprehensive oral-hygiene program (that might include the use of an
antiseptic agent) for patients in acute-care settings or residents in long-term care facilities who
are at high risk of developing healthcare-associated pneumonia

No recommendation can be made for the routine use of oral chlorhexidine rinse to prevent
healthcare-associated pneumonia in all postoperative or critically ill patients or other patients at
high risk for pneumonia (Kusahara et al., 2012).

Using an oral chlorhexidine gluconate (0.12%) rinse during the perioperative period in adult
patients who had cardiovascular surgery was shown to reduce the incidence of ventilator-
associated pneumonia (Nicolosi et al., 2014).

Prevention of Gastric Colonization

Mechanical ventilation for > 48 hours is considered a risk factor for stress ulcers and
gastrointestinal bleeding, and stress ulcer prophylaxis is recommended for these patients
(Nicolosi et al., 2014).

Oral proton pump inhibitors, oral or IV, are the drug of choice (Weinhouse, 2015). Antacids,
histamine-2 receptor blockers, and sucralfate can also be used (Nicolosi et al., 2014). Evidence
comparing the proton pump inhibitor, antacids, histamine-2 receptor blockers, and sucralfate in
efficacy and safety favors the proton pump inhibitors, but studies are few and limited in scope.

There is evidence that stress ulcer prophylaxis decreases the incidence of stress ulcers and
bleeding but increases the risk for nosocomial pneumonia (Weinhouse, 2015). However, experts
feel that this risk is preferable to the development of stress ulcers and bleeding and that the
studies that have associated stress ulcer prophylaxis with nosocomial pneumonia had
methodologic flaws and were poorly controlled for co-morbidities (Weinhouse, 2015).

Enteral nutrition may have a protective effect against stress ulcers. However, unless it is
contraindicated, patients receiving enteral nutrition and needing stress ulcer prophylaxis should
be treated with a proton pump inhibitor or another protective drug (Weinhouse, 2015).

Prevention of postoperative pneumonia

Patients who are at risk for developing postoperative pneumonia include (Pfeifer & Smetana,
2017):

Age > 50
Chronic corticosteroid use
Chronic obstructive pulmonary disease
Comorbid disease (ASA class ≥2)
Congestive heart failure
Consumption of >2 alcoholic drinks per day within two weeks
Functional dependence
History of stroke
Impaired sensorium
Obstructive sleep apnea
Preoperative anemia or transfusion
Preoperative hypoxemia
Preoperative sepsis
Preoperative transfusion of >4 units of packed red blood cells
Pulmonary hypertension
Smoking
Respiratory infection within the past month
Weight loss of >10% within six months

Interventions for preventing postoperative pneumonia include Kazaure et al., 2014):

Staff education about their involvement in preventing post-operative pneumonia

Coughing and deep breathing exercises
Twice daily oral hygiene with chlorhexidine
Pain control
Ambulation as tolerated
If applicable, head of the bed elevation to at least 30°
Documentation of interventions and scheduled assessment of their effectiveness
Chest physiotherapy is not routinely recommended for all postoperative patients at high risk
for pneumonia (Passaro et al., 2016)

Other prophylactic procedures for prevention of hospital-acquired pneumonia/pneumonia

Antimicrobials are not recommended for preventing pneumonia in critically ill patients or in
patients who are mechanically ventilated (Li Bassi et al., 2017).

Selective decontamination of the digestive tract with antiseptics or antibiotics applied to the
oropharynx has been shown to reduce the incidence of ventilator-associated pneumonia and
hospital-associated pneumonia (File, 2016).

There is insufficient evidence to recommend glucocorticoids, pro-biotics, or silver-coated

endotracheal tubes as effective prophylactic measures (File, 2016).

Routine turning of the patient or automatically turning beds is not routinely recommended
(Passaro et al., 2016).
Primary Prevention and Control of Healthcare Associated
Legionnaires Disease
Warm, stagnant water between 50°-122°F allows for the multiplication of Legionella pneumophila,
and the organism grows in structures such as evaporative coolers, faucets, misters, showers, water
heaters, and whirlpool baths (OSHA, 2017).

Legionella pneumophilia is aspirated, or the aerosolized bacteria is inhaled into the lungs. One case
of person-to-person transmission has been reported, but Legionnaires’ disease is not generally
considered a contagious disease (OSHA, 2017). Standard Precautions are considered to be sufficient
infection control technique when caring for a patient who has Legionnaires’ disease (CDC, 2007)

Factors that increase the risk of developing Legionnaires’ disease include (OSHA, 2017):

Age ≥ 50 years
Chronic lung disease
Chronic illnesses such as diabetes, hepatic failure, or renal failure
Cigarette smoking (Current or past)
Compromised immune system
Exposure to hot tubs
Glucocorticoid treatment
Heavy drinking
Systemic malignancy
Travel outside the home (Staying in hotels)

Testing for Legionnaires’ disease should be done if (CDC, 2017l):

The patient has failed outpatient antibiotic treatment for community-acquired pneumonia.
The patient has severe pneumonia, particularly if she/he requires intensive care.
The patient is immunocompromised and has pneumonia.
He/she has traveled away from their home within 10 days before the onset of illness.
The patient has pneumonia, and there is a Legionnaires’ disease outbreak.
The patient is at risk for Legionnaires’ disease with healthcare-associated pneumonia
(pneumonia with onset > 48 hours after admission).
The patient is > 50 years of age.

The Legionella bacteria grow in water systems, and there are multiple national, state, and local
guidelines for detecting, controlling, and preventing Legionnaire’s disease in these systems (Parr
et al., 2015). However, it is interesting that some authors feel that routine water testing is not
helpful and that efforts should focus on control and prevention (Whiley, 2016). National guidelines
for the control and prevention of Legionnaire’s disease in healthcare facilities are available from
the CDC, and some aspects of those guidelines are presented below (Tablan et al., 2003).

Clinical laboratory testing: Periodically review the availability and clinicians’ use of laboratory
diagnostic tests for Legionnaires disease. If clinicians do not routinely use the tests on patients
diagnosed with or suspected pneumonia, implement measures to enhance clinicians’ use of the
tests.

Water cultures: No recommendation can be made about routinely culturing water systems
for Legionella spp. in healthcare facilities that do not have patient-care areas (i.e., transplant
units) for persons at high risk for Legionella infection

Transplant units: In facilities with hematopoietic stem-cell- or solid organ transplantation

programs, periodic culturing for Legionellae in water samples from the transplant unit(s) can be
performed as part of a comprehensive strategy to prevent Legionnaires disease in transplant
recipients

No recommendation can be made about the optimal methods (i.e., frequency, number of sites) for
environmental surveillance cultures in transplant units.

Maintain a high index of suspicion for Legionellosis in transplant patients with healthcare-
associated pneumonia even when environmental surveillance cultures do not yield Legionellae.

If Legionella spp. is detected in the water of a transplant unit and until Legionella spp. is no longer

detected by culture, remove faucet aerators in areas for severely immunocompromised patients.

Transplant units/positive cultures: If Legionellae are detected in the potable water supply of a

transplant unit, and until Legionellae are no longer detected by culture:

Decontaminate the water supply.

Restrict severely immunocompromised patients from taking showers.
Use water that is not contaminated with Legionella spp. for patients’ sponge baths.
Provide hematopoietic stem cell patients with sterile water for tooth brushing or drinking,
and use sterile water for flushing nasogastric tubes.
Do not use water from faucets with Legionella-contaminated water in patients’ rooms to
avoid creating infectious aerosols.
If Legionella spp. is detected in the water of a transplant unit and until Legionella spp. is no
longer detected by culture, remove faucet aerators in areas for severely
immunocompromised patients.

Healthcare facilities that do not house or treat severely immunocompromised patients (e.g.,
hematopoietic stem cell transplant or solid-organ transplant recipients):

If a case of laboratory-confirmed health-care-associated Legionnaires disease is identified,

or when two or more cases of laboratory-confirmed, possible health-care-associated
Legionnaires' disease occur within 6 months of each other:
contact the local or state health department or the CDC if the disease is reportable in
the state or if assistance is needed;
conduct an epidemiologic investigation by retrospectively reviewing of microbiologic,
serologic, and postmortem data to identify previous cases, and
begin intensive prospective surveillance for additional cases of health-care-associated
Legionnaires disease
If there is no evidence of continued nosocomial transmissions, continue the intensive
prospective surveillance for cases for >2 months after the surveillance is begun.
If evidence of continued transmission exists:
conduct an environmental investigation to determine the source(s) of Legionella spp. by
collecting water samples from potential sources of aerosolized water and saving and
subtyping isolates  Legionella spp. Obtained from patients and the environment;
if a source is not identified, continue surveillance for new cases for >2 months and,
depending on the scope of the outbreak, decide to either defer decontamination
 pending identification of the source(s) of Legionella spp. or proceed with
decontamination of the hospital's water distribution system, with special attention to
the specific hospital areas involved in the outbreak; and
if a source of infection is identified, promptly decontaminate the source

Engineering/construction concerns:

When a new building is constructed, place cooling towers in such a way that the tower drift is
directed away from the facility's air intake system and design the cooling towers such that
the volume of aerosol drift is minimized

For cooling towers, install drift eliminators, regularly use an effective biocide, maintain the tower
according to manufacturers' recommendations, and keep adequate maintenance records.

Where practical and allowed by state law, maintain potable water at the outlet at >51ºC (>124ºF) or
<20ºC (<68ºF), especially in facilities housing organ-transplant recipients or other patients at
high- risk.

If water is maintained at >51ºC, use thermostatic mixing valves to prevent scalding.

No recommendation can be made about water treatment with chlorine dioxide, heavy metal ions,
ozone, or ultraviolet light. Hospitals served by municipalities with monochloramine-treated water
have had success in controlling Legionellae.

Prevention and Control of Healthcare Associated Pertussis

Staff education

Review of Disease Transmission, the Required Precautions, and Infection Control Techniques

Pertussis is transmitted by infected respiratory secretions that become airborne when someone
coughs or sneezes. It is typically a mild, self-limiting disease but serious complications are
possible. The incidence of pertussis has declined for many years, but more and more cases are
being reported each year, and given the fact that effective vaccination is available, this is a very
unfortunate and preventable public health development.

Pertussis is a reportable disease, and the local or state health department should be notified about
all confirmed and suspected cases of pertussis. Conduct active surveillance for cases of pertussis
until 42 days after the onset of the last pertussis case.

Notify persons who have had close contact with a case of pertussis in the healthcare setting to be
monitored for symptoms of pertussis or administered appropriate chemoprophylaxis. Close
contact is considered to be (Tablan et al., 2003):

Living in the same household.

Face-to-face contact with a symptomatic patient in the catarrhal or paroxysmal period of the
illness.
Sharing a confined space nearby for a prolonged time (e.g., >1 hour) with a symptomatic
patient.
Face-to-face exposure within 3 feet of a symptomatic patient.
Direct contact with a symptomatic patient's respiratory, oral, or nasal secretions.

Preventing Pertussis Transmission/Vaccination

Droplet Precautions, Respiratory Hygiene/Cough Etiquette, and Standard Precautions should be
used when caring for patients with pertussis(CDC, 2007). Droplet Precautions should be used for
up to 5 days after initiation of effective therapy(CDC, 2007).

Wear a surgical mask when within three feet of a patient with confirmed or suspected pertussis,
when performing procedures or patient-care activities that are likely to generate sprays of
respiratory secretions, or when entering the room of a patient with confirmed or suspected
pertussis (Tablan et al., 2003).

A single room is preferable, but courting is an option if needed (CDC, 2007)

Patients with confirmed pertussis should be in a private room, or if known not to have any other
respiratory infection, in a room with other patients (s) with pertussis until after the first 5 days of
a full course of antimicrobial treatment or 21 days after the onset of cough if unable to take
antimicrobial treatment for pertussis (Tablan et al., 2003).

Limit the movement and transport with diagnosed or suspected pertussis to essential purposes
only. If a patient is transported out of the room, ensure that precautions are maintained.

Restrict symptomatic pertussis-infected healthcare professionals from work during the first 5
days after beginning antimicrobial prophylaxis (Tablan et al., 2003).

For symptomatic healthcare personnel, do diagnostic laboratory tests if they have

signs/symptoms that are suggestive of pertussis (i.e., unexplained cough illness of > 1-week
duration, paroxysmal cough) (Tablan et al., 2003).

The following are the current recommendations for pertussis vaccination (Tablan et al., 2003):

Infants and children should receive 5 doses of DTaP, usually administered at 2, 4, and 6
months, 15 through 18 months, and 4 through 6 years of age. DT can be used for infants and
children who should not receive acellular pertussis-containing vaccines.
Adolescents 11-18 years should receive a single dose of Tdap, preferably at 11 to 12 years of
age.
Pregnant women should receive a single dose of Tdap every pregnancy, preferably at 27
through 36 weeks gestation. Tdap is recommended only in the immediate postpartum period
before discharge from the hospital or birthing center for new mothers who have never
received Tdap before or whose vaccination status is unknown.
Adults 19 years or older who have never received a dose of Tdap should get one as soon as
feasible to protect themselves and infants. Boostrix (GlaxoSmithKline) should be used for
adults 65 years and older; however, either vaccine product administered to someone 65 years
or older provides protection and may be considered valid. Providers should not miss an
opportunity to vaccinate persons aged 65 years and older with Tdap, especially if they have
close contact with infants.
Adults should receive a single dose of Td every 10 years.
A single dose of Tdap is recommended for healthcare personnel who have not previously
received Tdap, regardless of the time since their most recent Td vaccination. Priority should
be given to vaccinating those who have direct contact with babies younger than 12 months.
No recommendation can be made for routinely vaccinating adults, including healthcare
professionals, with the acellular pertussis vaccine at regular intervals (e.g., every 10 years).
In LTCFs for children and children with prolonged stay in acute-care facilities, follow the
recommendations of the ACIP for vaccinating children according to their chronologic age.

During an institutional outbreak of pertussis, accelerate scheduled vaccinations to infants and

children aged <7 years who have not completed their primary vaccinations, as follows:

Infants aged <2 months who are receiving their initial vaccination: Administer the first dose
of the DTaP vaccine as early as age 6 weeks and the second and third doses at a minimum of
4-week intervals between doses. Give the fourth dose on or after age 1 year and >6 months
after the third dose
Other children aged <7 years: Administer DTaP vaccine to all patients who are aged <7 years
and are not up-to-date with their pertussis vaccinations, as follows:
Administer a fourth dose of DTaP vaccine if the child has had 3 doses of DTaP or
diphtheria, tetanus, and pertussis (DTP) vaccine, is >12 months old, and >6 months
have passed since the third dose of DTaP or DTP vaccine; administer the fifth dose of
DTaP vaccine if the child has had four doses of DTaP or DTP vaccine, is aged 4-6 years,
and received the fourth vaccine dose before the fourth birthday
No recommendation can be made for administering additional dose(s) of pertussis
vaccine to children who have a history of well-documented pertussis disease (i.e.,
pertussis illness with either a B. pertussis-positive culture or epidemiologic linkage to a
culture-positive case)

Post-Exposure Prophylaxis

Post-exposure antimicrobial prophylaxis (PEP) aims to protect at-risk individuals from death and
serious complications from pertussis (CDC 2015h). The CDC’s recommendations for PEP for
pertussis are (CDC 2015h):

Give PEP to all household contacts of a pertussis case. Antimicrobial prophylaxis given to
asymptomatic household contacts within 21 days of onset of a cough in the index patient can
prevent symptomatic infection.
Providing PEP to persons within 21 days of exposure to an infectious pertussis case-patient if
they are at high risk of severe illness or if they will have close contact with a person at high
risk of severe illness. People who fit the latter criteria are
women in their third trimester of pregnancy and infants;
anyone who has a pre-existing health condition that a pertussis infection may
exacerbate, e.g., asthma that requires medical treatment or someone who is
immunocompromised;
contacts whom themselves have close contact with infants < 12 months, pregnant
women, or individuals with pre-existing health conditions at risk of severe illness or
complications; and
all contacts in high-risk settings that include infants aged <12 months or women in the
third trimester of pregnancy, e.g., neonatal intensive care units, childcare settings, and
maternity wards

Post-exposure prophylaxis should be offered to close contacts and to healthcare workers who have
had prolonged exposure to respiratory secretions (CDC, 2007)

Symptomatic healthcare personnel who have pertussis or are highly suspected of having pertussis
should be given chemoprophylaxis (Tablan et al., 2003). Restrict symptomatic pertussis-infected
healthcare professionals from work during the first 5 days after beginning antimicrobial
prophylaxis (Tablan et al., 2003).

Prevention and Control of Healthcare-Associated

Pulmonary Aspergillosis
Staff Education

Review the process of disease transmission and infection control techniques.

Surveillance (Tablan et al., 2003)

Maintain a high index of suspicion for healthcare-associated pulmonary aspergillosis in severely

immunocompromised patients. Establish a surveillance system for cases of healthcare-associated
pulmonary aspergillosis. Promptly inform infection-control personnel Aspergillus sp. is isolated
from cultures of specimens from the patient’s respiratory tract. Periodically review the hospital's
microbiologic, histopathologic, and postmortem data.

Do not perform routine, periodic cultures of the nasopharynx of asymptomatic patients at high
risk for aspergillosis.

Do not perform routine, periodic cultures of equipment or devices used for respiratory therapy,
pulmonary function testing, or delivery of inhalation anesthesia in the hematopoietic stem cell
transplant unit or of dust in rooms of hematopoietic stem cell transplant recipients.

No recommendation can be made about routine microbiologic air sampling before, during, or after
facility construction or renovation, or before or during occupancy of areas housing
immunocompromised patients.

Prevention of Transmission of Aspergillus Spores

Aspergillus is a fungus, and Aspergillus spores are very common in the environment. Aspergillus is

not a contagious disease, and aspergillosis is primarily a disease contracted by people who have a
compromised immune system or chronic lung disease. Standard Precautions are considered
sufficient when caring for a patient who has an infection with Aspergillus (CDC, 2007). Use Contact
Precautions and Airborne Precautions if there is a massive soft tissue infection with copious
drainage and repeated irrigations are needed (CDC, 2007)

There are numerous methods of preventing the transmission of Aspergillus. The following
recommendations are from the CDC and the Infectious Disease Society of America (Passaro et al.,
2016):

Allogeneic hematopoietic stem cell transplant patients should be placed in a protective

environment (PE); details about PEs are provided later in this section.
Highly immunosuppressed patients should be cared for in a HEPA-filtered ward.
If a PE is not possible, the patient should be in a private room. There should be no connection
to construction sites, and plants or cut flowers should not be allowed in the room.
Educate high-risk patients about infection prevention measures. Discharge planning should
include recommendations for the patient to reduce mold exposure, e.g., avoiding working
with mulch, gardening, and construction or renovation activities.
 Leukemia and transplant centers should perform regular surveillance for cases of invasive
mold infection. If there is an increase over baseline or mold infections in patients who are
not high-risk, a quick search for the source should be done.
Use proper dusting methods for patient-care areas designated for severely
immunocompromised
Wet-dust horizontal surfaces daily using cloth that has been moistened with an EPA-
registered hospital disinfectant
Avoid dusting methods that disperse dust, e.g., feather dusting
Keep vacuums in good repair and equip them with HEPA filters for use in areas with patients
at high risk
Do not use carpeting in hallways and rooms occupied by severely immunocompromised
patients
Avoid using upholstered furniture or furnishings in rooms occupied by severely
immunocompromised patients
Minimize the length of time immunocompromised patients in PEs are outside their rooms
for diagnostic procedures and other activities
Instruct severely immunocompromised patients to wear a high-efficiency respiratory-
protection device (e.g., an N95 respirator) when they leave the PE during periods when
construction, renovation, or other dust-generating activities are ongoing in and around the
healthcare facility
No recommendation can be made about the specific type of respiratory-protection device
(e.g., surgical mask, N95 respirator) for use by a severely immunocompromised patient who
leaves the PE during no construction, renovation, or other dust-generating activity in
progress in or around the healthcare facility
Systematically review and coordinate infection-control strategies with personnel in charge
of the facility’s engineering, maintenance, central supply and distribution, and catering
services
Develop a water-damage response plan for immediate execution when water leaks, spills,
and moisture accumulation occur to prevent fungal growth in the involved areas
Do not use laminar airflow (LAF) routinely in PE
During construction, demolition, or renovation activities, construct impermeable barriers
between patient-care and construction areas to prevent dust from entering the patient-care
areas
Direct pedestrian traffic from construction areas away from patient-care areas to limit the
opening and closing of doors or other barriers that might cause dust dispersion,
contaminated air entry, or dust tracking into patient-care areas.

Construction is a well-known and well-documented risk factor for the development of

aspergillosis (Abdul et al., 2010). construction activity is a serious threat to immunocompromised
patients, and preventive measures during construction are essential. When constructing
specialized-care units with a PE for hematopoietic stem cell transplant, the patient rooms must be
designed to minimize the accumulation of fungal spores:

HEPA filtration of the incoming air is recommended

there must be directed room airflow,
there must be positive air pressure in the patient's room in relation to the corridor,
 the room must be well-sealed, and 5) there should be >12 air changes per hour (Passaro et al.,
2016)

Other recommendations include (Abdul et al., 2010):

Install and maintain HEPA and other filtration systems as needed.

Use targeted air sampling prior to commissioning a new ward or air-handling systems.
Conduct an infection control risk assessment and conduct a review of the mechanical air
filtration and supply to high-risk areas prior to the arrival of patients.
Reduce patients’ exposure to dust, stagnant water, and damp areas as much as possible.
Consider targeted environmental sampling during any hospital construction.

Chemoprophylaxis

Patients with prolonged neutropenia and at high risk for invasive aspergillosis should be given
prophylactic treatment with antifungal drugs: posaconazole, voriconazole, or micafungin
(Patterson et al., 2016).

Prevention and Control of Healthcare-Associated

Adenovirus, Parainfluenza Virus, and Respiratory Syncytial
Virus Infections
Adenovirus, parainfluenza virus, and respiratory syncytial virus (RSV) are common causes of self-
limited respiratory infections in infants and children, and they can also cause diarrhea
keratoconjunctivitis, and pneumonia. Infections with these viruses are typically less severe in
adolescents and adults than in infants and children (Dolin, 2015). However, patients who are
elderly, immunocompromised, with cardiopulmonary disease, or hematopoietic stem cell
transplants and solid-organ transplant recipients may develop severe illnesses when infected. The
respiratory syncytial virus is a very common nosocomial pathogen that can infect up to 50% of
patients and staff (Dolin, 2015). 

Transmission

Adenovirus is transmitted by inhaling short-range aerosols and droplets, inoculating the

virus into the conjunctival sac, direct contact with infected fomites, and possibly the fecal-
oral route (Dolin, 2015).
Infected respiratory secretions transmit the parainfluenza virus via person-to-person
contact, large droplets, or contact with infected fomites that carry respiratory secretions
(Dolin, 2015).
Respiratory syncytial virus is transmitted by coarse aerosols produced by coughing or
sneezing. It is also transmitted by contact with contaminated fingers or fomites and self-
inoculation of conjunctival sacs and nares (Dolin, 2015).

Surveillance (Tablan et al., 2003)

Healthcare personnel should be promptly notified of an increase in the activity of

adenovirus, parainfluenza virus, or RSV in the community. In addition, there should be
mechanisms by which the appropriate healthcare personnel can promptly inform the local
and state health departments of any increase in the activity of these viruses in their facility.
 In acute-care facilities, during periods of increased prevalence of symptoms of viral
respiratory illness in the community or the healthcare facility, or influenza and RSV season
(December-March), use rapid diagnostic techniques as indicated in patients who are
admitted to the healthcare facility with respiratory illness and who are at high risk for
serious complications from viral respiratory infections, e.g., pediatric patients or patients
who have chronic cardiac or pulmonary diseases or who are immunocompromised.
No recommendation can be made for routinely conducting surveillance cultures for RSV or
other respiratory viruses.
In LTCFs, establish the mechanism(s) for continuing surveillance to allow rapid
identification of a potential outbreak in the facility.

Prevention of Transmission and Infection Control

Adenovirus: Use Standard Precautions, and use Contact and Droplet Precautions for the
duration of the illness (CDC, 2007). Use Contact Precautions for diapered or incontinent
persons for the duration of illness or to control institutional outbreaks (CDC, 2007).
Parainfluenza virus: Use Standard Precautions, and use Contact and Droplet Precautions for
the duration of the illness (CDC, 2007). The parainfluenza virus can remain infectious in
airborne droplets for approximately 1 hour and on environmental surfaces for several hours
(CDC, 2017n).
RSV: Use Standard Precautions, and for infants, young children, and patients who are
immunocompromised, use Contact and Droplet Precautions for the duration of the illness
(CDC, 2007). Wear a mask according to the guidelines of Standard Precautions when caring
for patients who are immunocompromised (CDC, 2007).
Place a patient with diagnosed RSV, parainfluenza, adenovirus, or other viral respiratory tract
infection in a private room when possible or in a room with other patients with the same
infection and no other infection (Passaro et al., 2016).
No adenovirus vaccine is available to the general public, there is no vaccine for parainfluenza
virus, and there is no vaccine for RSV (CDC, 2017n). Palivizumab is a monoclonal antibody,
and the American Academy of Pediatrics recommends that it be given to high-risk infants
and young children likely to benefit from immunoprophylaxis based on factors such as
gestational age and underlying medical conditions RSV seasonality (AAP, 2014).
Promptly perform rapid diagnostic laboratory tests on patients admitted with or who have
symptoms of RSV infection after admission to the healthcare facility to facilitate early
downgrading of infection-control precautions to the minimum required for each patient’s
specific viral infection.
Promptly perform rapid diagnostic laboratory tests on patients who are admitted with or who
have symptoms of parainfluenza or adenovirus infection after admission to the healthcare
facility to facilitate early downgrading of infection-control precautions to the minimum
required for each patient’s specific viral infection and early initiation of treatment when
indicated (Tablan et al., 2003).
Limit patient movement or transport in acute-care facilities to essential purposes.
For a patient with diagnosed or suspected adenovirus, RSV, or parainfluenza virus infection,
ensure that precautions are maintained to minimize the risk of transmission of the virus to
other patients and contamination of environmental surfaces or equipment by ensuring that
the patient does not touch other persons’ hands or environmental surfaces with hands that
have been contaminated with his/her respiratory secretions (Tablan et al., 2003).
 Healthcare personnel who have signs and symptoms of an acute upper respiratory tract
infection should not care for infants and other patients at high risk for complications from
viral respiratory tract infections.
When feasible, perform rapid diagnostic testing on healthcare personnel with respiratory
tract infection symptoms, especially those who provide care to patients at high risk. Limit
visitors and do not allow persons with respiratory infection symptoms to visit pediatric
patients, patients who have chronic cardiac or pulmonary disease, or immunocompromised
patients (Tablan et al., 2003).
Perform rapid screening diagnostic tests for the particular virus known or suspected to be
causing the outbreak on patients admitted with viral respiratory illness symptoms. Promptly
cohort the patients (according to their specific infections) as soon as the results of the
screening tests are available. In the interim, when possible, admit patients with symptoms of
viral respiratory infections to private rooms (Tablan et al., 2003).
During an outbreak of healthcare-associated RSV infection, cohort personnel, is as practical
(e.g., restrict personnel who care for infected patients from giving care to uninfected
patients).
No recommendation can be made for routinely cohorting personnel during an outbreak of
healthcare-associated adenovirus or parainfluenza virus infection (Tablan et al., 2003).

Prevention and Control of Healthcare-Associated Influenza

Staff Education

Staff knowledge and infection control techniques to prevent influenza transmission are very
important (Eibach et al., 2013). However, there is ample evidence that nurses' knowledge of and,
perhaps more importantly, compliance with these techniques is less than ideal (Eibach et al.,
2013). The CDC includes staff education in its recommendations for preventing seasonal influenza
in healthcare settings, and staff education on this topic can make a positive difference (Smith et
al., 2016).

Surveillance

Healthcare facilities should have mechanisms in place to that healthcare personnel can be
promptly notified about increased influenza activity in the community or if there is an in-house
influenza outbreak (CDC, 2016p). There should be a staff member who is specifically assigned to
communicating with public health officials and the health care personnel.

Ensure that laboratory tests are made available to clinicians for prompt diagnosis of influenza.

Vaccination

Vaccination is one of the most effective methods for preventing influenza transmission (Pless et
al., 2017).

In acute-care settings (including acute-care hospitals, emergency rooms, and walk-in clinics) or
ongoing-care facilities (including physicians’ offices, public health clinics, employee health
clinics, hemodialysis centers, hospital specialty-care clinics, outpatient rehabilitation programs,
or mobile clinics), offer influenza vaccine to inpatients and outpatients at high-risk for
complications from influenza, beginning in September and throughout the influenza season.
Groups at high risk for influenza-related complications include (CDC, 2016p):

Children aged 6 through 59 months.

All persons aged ≥50 years.
Adults and children who have chronic pulmonary (including asthma) or cardiovascular
(except isolated hypertension), renal, hepatic, neurologic, hematologic, or metabolic
disorders (including diabetes mellitus).
People who are immunosuppressed by disease, by medications, or by both.
Women who are or will be pregnant during the influenza season.
Children and adolescents (aged 6 months–to 18 years) who are receiving long-term aspirin
therapy might be at risk of experiencing Reye syndrome after influenza virus infection.
Residents of nursing homes and LTCFs.
American Indians/Alaska Natives.
Persons who are extremely obese (BMI ≥40).

Influenza vaccination is also recommended (CDC, 2016p).

Healthcare personnel who have patient contact, healthcare profession students, and anyone
who has regular contact with nursing home or LTCF residents.
Household contacts (including children) and caregivers of children aged ≤59 months and
adults aged ≥50 years, particularly those who have contact with children aged <6 months.
Household contacts (including children) and caregivers of persons with medical conditions
put them at high risk for severe complications from influenza.

Vaccination should be offered before influenza activity in the community begins. If possible,
healthcare personnel should be offered vaccination by October. Children aged 6 months through 8
years who require 2 doses should be given the first dose as soon as possible after the vaccine
becomes available and the second dose ≥4 weeks later (Grohskopf et al., 2016).

In LCTFs, establish an SOP for timely administration of the inactivated influenza vaccine to high-
risk persons (Tablan et al., 2003).

Obtain consent for influenza vaccination (if required by local or state law) from every
resident (or his/her guardian) when the resident is admitted to the facility or any time
afterward before the next influenza season.
Routinely vaccinate all residents unless medically contraindicated. If a resident is admitted
during the winter months after completing the facility’s vaccination program, offer the
vaccine at their admission (Tablan et al., 2003).

In other settings where healthcare is given (e.g., home healthcare agencies), vaccinate patients for
whom vaccination is indicated and refer the patient’s household members and caregivers for
vaccination (Tablan et al., 2003).

Preventing Person-to-Person Transmission

Preventing person-to-person transmission of influenza involves educating the public and the
staff, identifying members of the public and patients who are likely to have influenza, and
observing the proper infection control techniques (CDC, 2016p). For the public and patients (CDC,
2016p).:
 Patients and people visiting a healthcare facility should be instructed to inform healthcare
personnel upon arrival if they have any signs/symptoms of a respiratory illness. In addition,
they should be instructed on the need for and proper procedures for handwashing,
Respiratory Hygiene/Cough Etiquette, and other appropriate infection control measures.
If there is an increase in influenza activity in the community, minimize elective visits to
healthcare facilities.
Visual alerts should be at the entrance and in strategic places to provide patients and
healthcare personnel with Respiratory Hygiene/Cough Etiquette, especially during periods
when the influenza virus is circulating in the community. These alerts should cover: How to
use tissues to cover the nose and mouth, where to dispose of contaminated items, how and
where to hand wash, and how and when to use a facemask.
Encourage persons with symptoms of respiratory infections to sit as far away from others as
possible. During periods of increased community influenza activity, consider setting up
triage stations that facilitate rapid screening of patients for symptoms of influenza and
separation from other patients.
Place patients with suspected or confirmed influenza in a private room or area. If this is not
possible, consult with infection control and consider cohorting.

For healthcare personnel (CDC, 2016p).:

Healthcare personnel who have a fever and respiratory symptoms should not report to work.
If they are at work, they should stop doing patient care, put on a facemask, and promptly
notify the supervisor and infection control personnel/occupational health before leaving
work.
Healthcare personnel should not return to work for at least 24 hours after they no longer
have a fever and without using fever-reducing medicines.
They should be considered for temporary reassignment or exclusion from work for 7 days
from symptom onset or until the resolution of signs and symptoms, whichever is longer if
returning to care for patients in a PE such as hematopoietic stem cell transplant patients.
Healthcare personnel who develop signs/symptoms of an acute respiratory illness but are
afebrile should be considered for evaluation by occupational health to determine the
appropriateness of contact with patients. Influenza antiviral treatment should be considered
in these cases. These same workers can be allowed to continue or return to work unless
assigned to care for patients requiring a PE, or they should be considered for temporary
reassignment or considered for exclusion from work for 7 days from symptom onset or until
the resolution of all non-cough symptoms, whichever is longer.
Employee health services should track absences related to influenza, review job tasks to
ensure that personnel at high risk for exposure to those with suspected or confirmed
influenza are given priority for vaccination, ensure that employees have prompt access to
medical consultation, and, if necessary, early treatment, and promptly identify individuals
with possible influenza.

Infection control techniques are vitally important in preventing person-to-person transmission of

influenza. In order to prevent the spread/transmission of influenza, healthcare personnel should
strictly adhere to Standard Precautions, handwashing protocol, Respiratory Hygiene/Cough
Etiquette, Droplet Precautions, and the proper use of PPE (CDC, 2016p). Don a face mask when
entering the room. Droplet precautions should be used if the patient has suspected or confirmed
influenza for 7 days after illness onset or until 24 hours after the resolution of fever and
respiratory symptoms, whichever is longer, while a patient is in a healthcare facility (CDC, 2016p).
If a patient under Droplet Precautions requires movement or transport outside of the room, have
the patient wear a face mask; use Respiratory Hygiene/Cough Etiquette; and hand hygiene. Be sure
that the personnel caring for/receiving these patients know the clinical situation (CDC, 2016p).

Use caution when performing aerosol-generating procedures

Precautions for aerosol-generating procedures include performing these procedures only if they
are medically necessary and cannot be postponed, limiting the number of personnel present,
performing the procedures in an airborne infection isolation room if feasible, and room doors
should be kept closed except when entering or leaving the room, and entry and exit should be
minimized; healthcare personnel should wear respiratory protection equivalent to a fitted N95
filtering facepiece respirator or equivalent N95 respirator and perform surface cleaning after the
procedures (CDC, 2016p).

Perform environmental infection control

Environmental infection control includes cleaning and disinfection and engineering controls, e.g.,
air filtration systems and physical barriers (CDC, 2016p).

Control of Influenza Outbreaks – Vaccination and Chemoprophylaxis

Determine the outbreak strain. Vaccinate unvaccinated patients and healthcare personnel.

Early antiviral treatment is recognized as a safe and effective therapy that can shorten the
duration of the illness and prevent complications (CDC, 2017o). Chemoprophylaxis should be
given as soon as possible, and it is not advisable to wait for laboratory confirmation (CDC, 2017o).

At-risk patients who should receive prophylactic antiviral therapy include (CDC, 2017o):

Adults ≥65 years of age

American Indians/Alaska Natives
Children < 2 years of age
Patients who have a chronic cardiac disease (except for hypertension alone); chronic
pulmonary disease; hematologic; hepatic or renal disorders; metabolic disorders including
diabetes mellitus; neurologic/neurodevelopmental disorders, including disorders of the
brain, spinal cord, peripheral nerve, and muscle, such as cerebral palsy, epilepsy seizure
disorders, stroke, intellectual disability, moderate to severe developmental delay, muscular
dystrophy, or spinal cord injury delay, muscular dystrophy, or spinal cord injury
Patients who are immunosuppressed by way of disease, medical conditions, or drugs
Patients who are morbidly obese, with BMI >40
Residents of LTCFs, nursing homes
Women who are pregnant or postpartum (within 2 weeks after delivery)

Antiviral treatment is also recommended as early as possible for any patient with confirmed or
suspected influenza who is hospitalized, a patient who has a severe, complicated, or progressive
illness, or a high risk for complications from influenza. (CDC, 2017o). The available antivirals are
amantadine, oseltamivir, peramivir, rimantadine, and zanamivir, and depending on the drug, oral,
inhaled, and IV forms are available. The specific drug that should be used depends on the patient's
age, the clinical setting, and the strain of influenza (CDC, 2016p). The CDC has published
guidelines that can help clinicians make the proper choice of antivirals: Influenza (Flu). Influenza
Antiviral Medications: Summary for Clinician, March 8, 2017; these can be viewed using these
links: the second link pertains to LTCFs.

Influenza Antiviral Medications: Summary for Clinicians (CDC, 2017o)

Interim Guidance for Influenza Outbreak Management in Long-Term Care and Post-Acute
Care Facilities (CDC, 2017p)

Infectious and Communicable Disease Control among

Healthcare Professionals
Definitions

Infectious disease is a clinically manifest disease of a man or animal resulting from an

infection.
A communicable disease is an illness due to a specific infectious agent which arises through
transmission of that agent from an infected person, animal, or inanimate reservoir to a
susceptible host.
As applied to infection control, occupational health strategies are activities intended to
assess, prevent, and control infections and communicable diseases in healthcare
professionals.

Safety and health issues can best be addressed in a comprehensive prevention program that
considers all aspects of the work environment and has employee involvement and management
commitment. Implementing improved engineering controls is one component of such a
comprehensive program. Prevention strategy factors that must be addressed include
implementation of needleless systems if possible, modification of hazardous work practices,
administrative changes to address needle hazards in the environment (e.g., prompt removal of
filled sharps disposal boxes), safety education and awareness, feedback on safety improvements,
and action taken on continuing problems.

Occupational Exposure to Infectious Pathogens: Hepatitis B, Hepatitis C, HIV

Healthcare personnel who perform patient care are at risk for exposure to potentially dangerous
pathogens, and the most common of these are hepatitis B (HBV), hepatitis C (HCV), and HIV.
Fortunately, the transmission of one of these highly virulent microorganisms from patient to
provider and the development of infection are rare occurrences. However, occupational exposures
to pathogens such as HBV, HCV, and HIV are a common everyday experience in healthcare
facilities and during patient care, and nurses and other healthcare professionals must understand
the risks of exposure and how to protect themselves.

Hepatitis B, HCV, and HIV are (in the healthcare setting) primarily transmitted by exposure to
contaminated blood, and this can occur by a percutaneous injury, i.e., a needle stick or a sharps
exposure, or by contact with a mucous membrane or non-intact skin. The risk that a healthcare
professional will acquire HBV, HCV, or HIV and develop an infection because of an occupational
exposure depends on these factors (Weber et al., 2015):

Prevalence of the infectious pathogen in the general population and the patient population.
Frequency of exposures to these pathogens.
Nature of the exposure and efficiency of transmission for that exposure: percutaneous,
mucosal, non-intact skin, or intact skin, a deep puncture versus a splash exposure, the
 amount of blood involved, the bore of the needle if there was a needle stick injury.
The viruses present in the contaminated fluid and the titer of the virus (i.e., the viral load) in
that fluid.
Availability and efficacy of pre-and post-exposure prophylaxis.
The underlying health and immune system function of the exposed person.

Blood is the most important HBV, HCV, and HIV transmission source to healthcare professionals.
Other body fluids, such as cerebrospinal fluid, synovial fluid, pericardial fluid, pleural fluid,
peritoneal fluid, and amniotic fluid are considered potentially infectious (Weber et al., 2015).
Semen and vaginal secretions can be a source of sexual transmission of these viruses, but there are
no documented cases of transmission of HBV, HCV, or HIV in the occupational setting from
exposure to semen or vaginal secretions (Fauci & Lane, 2017). Other body fluids, e.g., feces, gastric
secretions, nasal secretions, saliva, sputum, sweat, tears, and urine, may contain low amounts of
HBV, HCV, and HIV, but unless these fluids are visibly contaminated with blood, they are not
considered infectious (Weber et al., 2015).

Occupational exposure to HBV, HCV, or HIV is defined by Weber et al. as “contact with potentially
infectious blood, tissue, or body fluids in a manner that allows for possible transmission of HIV
and therefore requires consideration of post-exposure prophylaxis (PEP).” Exposure then would
include needle stick or sharps injuries, puncture wounds, mucosal contact, or non-intact skin
exposure, i.e., abraded skin.

Risk of Occupational Transmission/ Infection of HBV, HCV, and HIV

In descending order, the risk of transmission and development of infection after an occupational
exposure is HBV, HIV, and HCV.

Hepatitis B is highly infectious. The risk for transmission depends on the HBV surface antigen and
HBV e antigen status of the source (and the previously mentioned factors), and this risk has been
estimated to be 18%-62% (Weber et al., 2015). The risk of developing hepatitis from occupational
exposure to HBV has been estimated to be 1%-31% (Weber et al., 2015).

Hepatitis C is less infectious than HBV. The CDC has estimated that the risk for seroconversion
after occupational exposure to HCV is 1.8%, ranging from 0-7% (USPHS, 2001). However, Egro et
al. (2017) noted that the data used by the CDC to develop these numbers were from old sources,
some of it was from non-US medical centers where universal precautions are not used as they
should be, and that only needle stick injuries were assessed  (Egro et al., 2017). These authors
examined 1361 exposures over 13 years (mucous membrane exposures and percutaneous
exposures) and found a seroconversion rate of 0.1%; the two cases of seroconversion happened
after percutaneous exposure  (Egro et al., 2017).

Transmission of HIV from a patient to a healthcare professional is uncommon. The risk of

seroconversion has been estimated to be 0.3% for percutaneous exposure and 0.09% per mucous
membrane exposure. However, as with risk estimations for HCV, these estimates have been
criticized as possibly being too high and based on conditions that do not reflect current exposure
circumstances and the availability and effectiveness of post-exposure prophylaxis  (Nwaiwu et al.,
2017). Fortunately, confirmed cases of occupational transmission of HIV and subsequent HIV
infection are rare, with 58 cases reported to the CDC between 1985 and 2013 (Bartlet & Weber,
2015).
Post-Exposure Care

Any possible or potential occupational exposure to HBV, HCV, or HIV should be reported to
the appropriate in-house person or department (e.g., supervisor, employee health)
immediately or as soon as possible. Do not decide that exposure is/is not a risk for
transmission of HBV, HCV, or HIV. This decision is the responsibility of the
person/department that evaluates risks and prescribes treatment. In several investigations
of nosocomial HBV outbreaks, most infected healthcare professionals could not recall an
overt percutaneous injury, although in some studies, up to one-third of the infected persons
recalled caring for a patient who was hepatitis B surface antigen-positive, and HBV and HCV
can survive on environmental surfaces for seven days and 16 hours, respectively (Weber et
al., 2015). Treatment of exposures should focus on wound care, evaluation of the risk, and
post-exposure drug prophylaxis.
Wound care: The basics of wound care are the same for exposure to HBV, HCV, or HIV (Weber
et al., 2015). Wash the wound with soap and water, or flush the area with water. Antiseptics
do have virucidal action, and they may be helpful but do not delay basic wound care if an
antiseptic is not close at hand (Weber et al., 2015).
Evaluate the risk: This involves determining the circumstances of the exposure (e.g., time of
exposure, how the exposure occurred) and determining the HBV, HCV, and HIV status of a
patient who was the source of the exposure. Rapid HIV testing should be done on the source
patient unless it is known that she/he is infected with HIV. The source patient should be
tested for the presence of HBV unless it is known that he/she is infected with HBV or the
healthcare professional has completed the three-dose hepatitis vaccine series. Testing for
HCV status should always be done unless it is known that the source has an HCV infection
(Weber et al., 2015). The health care professional should also be tested for HBV, HCV, and
HIV, tetanus vaccination status should be determined, and medical history, including a
medication profile, should be obtained. For an HBV exposure, if the source patient was
hepatitis B surface antigen-positive or if the source patient’s HBV status could not be
determined, the healthcare professional should be tested six months after the exposure
(Weber et al., 2015). For HCV exposure, testing should be done every two months for six
months (Weber et al., 2015). Testing for HIV should be done immediately after the exposure,
and if a fourth-generation HIV assay test is done (preferred), retesting should be done six
weeks and four months after the exposure (Bartlet & Weber, 2015). Post-exposure drug
prophylaxis, HBV exposure: The need for post-exposure drug prophylaxis after exposure to
HBV depends on the HBV status of the source patient and the immunization status of the
healthcare professional (Weber et al., 2015). There are a variety of possible circumstances,
e.g., the source patient has an HBV infection, but the exposed person is a vaccine non-
responder (the anti-HBs remain <10 mIU/mL after receiving the three-dose hepatitis B
vaccine series on two separate occasions); the source patient is positive, but the healthcare
professional has responded to hepatitis B vaccination, or she/he has serologic evidence of a
past HBV infection. The specific details of all the possible situations regarding when and for
whom post-exposure drug prophylaxis should be used after an HBV exposure will not be
covered here; they can be viewed at the Post-Exposure Prophylaxis Hotline website.
However, key points to remember are: if the source patient is positive or her/his HBV status
cannot be determined, administer the first dose of the hepatitis B vaccine series and one dose
of hepatitis B immune globulin; and if hepatitis immune globulin is needed it is preferable
that it be given within 24 hours of exposure but this time limit can be extended to seven days
 (Weber et al., 2015). Women who are pregnant or breastfeeding can be vaccinated against
HBV infection or receive hepatitis B immune globulin. Pregnant women exposed to blood
should be vaccinated against HBV infection because infection during pregnancy can cause
severe illness in the mother and a chronic infection in the newborn. The vaccine does not
harm the fetus. During the follow-up period, anyone who has been exposed should not
donate blood, organs, semen, or tissues (Weber et al., 2015).
Post-exposure drug prophylaxis, HCV exposure: Currently, no medications are approved for
post-exposure prophylaxis after exposure to HCV. The drug protocols with second-
generation protease inhibitors used to treat an HCV infection are not recommended for post-
exposure prophylaxis (CDC, 2017o).
Post-exposure drug prophylaxis, HIV exposure: Post-exposure drug prophylaxis for HIV
exposure is effective. It should be started as soon as possible, preferably within one-two
hours after the exposure, and initiation of therapy should not be delayed while waiting for
HIV test results (Bartlet & Weber, 2015). In certain situations, e g., a high-risk exposure, drug
therapy can be started up to a week after an HIV exposure  (Egro et al., 2017). Details about
drug regimens can be viewed on the Post-Exposure Prophylaxis Hotline website. The
antiviral drugs used to prevent HIV infection after exposure have been associated with side
effects. The most common side effects include nausea, vomiting, diarrhea, tiredness, or
headache. The few serious side effects that have been reported in healthcare professionals
using combination HIV post-exposure prophylaxis have included kidney stones, hepatitis,
and suppressed blood cell production. Interaction with other medicines can cause serious
side effects. Pregnant women should be given HIV post-exposure prophylaxis (Bartlet &
Weber, 2015). These drug regimens may cause a slight increase in the rate of pre-term
delivery and impaired fetal growth, but the evidence for these effects is conflicting  (Hughes
& Henderson, 2016). During the follow-up period, especially the first 6-12 weeks, when most
infected persons are expected to show signs of infection, the exposed person should follow
recommendations for preventing transmission of HIV. These include not donating blood,
semen, or organs and not having unprotected sexual intercourse. If the healthcare
professional chooses to have sexual intercourse, using a condom consistently and correctly
may reduce the risk of HIV transmission. In addition, women should consider not
breastfeeding infants during the follow-up period to prevent exposing their infants to HIV in
breast milk. During the follow-up period, anyone who has been exposed should not donate
blood, organs, semen, or tissues (Weber et al., 2015).

By calling 1-888-448-4911 from anywhere in the United States from 9:00 am to 9:00 pm, seven
days a week, clinicians can gain access to the National Clinicians' Post-Exposure Prophylaxis
Hotline (PEPline). The PEPline has trained physicians prepared to give clinicians information,
counseling, and treatment recommendations for professionals who have needle stick injuries and
other serious occupational exposures to bloodborne microorganisms that lead to such serious
infections or diseases as HIV or hepatitis.

Other helpful resources are:

HIV Antiretroviral Pregnancy Registry. Address: Research Park, 1011 Ashes Drive, Wilmington, NC
28405. Telephone: 800-258-4263; fax: 800-800-1052. Email: registry@nc.crl.com.

FDA (for reporting unusual or severe toxicity to antiretroviral agents) here. Address: U.S. Food and
Drug Administration, 10903 New Hampshire Avenue Silver Spring, MD 20993. Telephone: 800-
332-1088.

U.S. Department of Health and Human Services. AIDS Info. Address: AIDSinfo, P.O. Box 4780,
Rockville, MD 20849-6303. Telephone: 1-800-4448-0440; fax, 1-302-315-2818; TTY, 1-888-480-
3739. Email: ContactUs@aidsinfo.nih.gov

Employers must establish exposure control plans that include post-exposure follow-up for their
employees and comply with incident reporting requirements mandated by the 1992 OSHA
bloodborne pathogen standard. Access to clinicians who can provide post-exposure care should be
available during all working hours, including nights and weekends. Hepatitis B immune globulin,
HBV vaccine, and antiretroviral agents for HIV post-exposure prophylaxis (PEP) should be
available for timely administration, either by providing access on-site or by creating linkages with
other facilities or providers to make them available off-site.

Pre-exposure prophylaxis

Healthcare professionals should be well-versed in using Standard Precautions and use them
conscientiously. Anyone who may be exposed to blood or body fluids should be offered hepatitis B
vaccination at no charge. There are no vaccines for the prevention of HCV or HIV infection.

Sepsis Awareness and education

Sepsis is a potentially fatal condition of organ dysfunction that is primarily caused by a
dysfunctional inflammatory response to an infection  (Neviere, 2018). Sepsis can be usefully
viewed as a continuum, and the definitions and conditions associated with sepsis have evolved.
Sepsis is now defined as life-threatening organ dysfunction caused by a dysregulated host
response to infection; septic shock is a subset of sepsis characterized by circulatory cellular and
metabolic dysfunction associated with high mortality risk (Rhodes et al., 2017). The definition of
septic shock is consistent with the basic definition of shock: a condition of cellular and tissue
hypoxia caused by reduced oxygen delivery, increased oxygen consumption, or inadequate
utilization of delivered oxygen. Regardless of its origin, shock essentially represents a mismatch
between the tissues' demand and supply of oxygen. 

The clinical view of sepsis has changed over time, and terms such as systemic inflammatory
response syndrome (SIRS), early sepsis, severe sepsis, and septicemia are no longer included in
the definition of sepsis.

The pathogenesis of sepsis is very complex, and a full discussion of the process will not be
included here. In brief, sepsis begins with an infection, and infection is defined as an invasion and
multiplication of microorganisms; it is important to remember that infection is not synonymous
with harm or damage. It simply indicates the presence of a microorganism. The normal response
to infection is to destroy or contain the microorganisms through the immune response, e.g., the
activity of macrophages and by the activation and production of inflammatory mediators that
direct and control the immune response. In sepsis, however, the inflammatory response is both
exaggerated and generalized, and healthy tissue and organs - and not only those of the initial
location of the infection - become damaged and dysfunctional (Neviere, n.d.). 

The diagnosis of sepsis depends on the presence of a pathogen, a clear source/site of infection, and
septic shock, a clinical picture of organ dysfunction. Patients who have sepsis typically present
with signs and symptoms that are consistent with the source of the infection (e.g., cough,
hypoxia, and respiratory distress with a pulmonary infection); fever, hypotension, and
tachycardia, and; evidence of hypoperfusion such as mental status changes, cyanosis, and
decreased urinary output  (Neviere, 2018). The mortality rate of sepsis depends on many factors
like age, medical co-morbidities, and if sepsis progresses to septic shock, but it has been
estimated to be 10%-52%  (Neviere, 2018). 

Epidemiology of Sepsis; The Scope of the Problem

Sepsis is a very serious public health problem. It has been estimated that globally there are 30
million cases of sepsis each year, and sepsis is responsible for 6 million deaths every year, and the
problem of sepsis is no less serious in the United States. Rhee et al. performed a retrospective
review of adult patients admitted to 409 hospitals from 2009-to 2014 (Rhee et al., 2017). The
authors located 173,690 cases; this was an incidence of 6% of all hospitalizations, 15% of these
patients died while in the hospital, and sepsis was present in 35% of all hospitalizations that ended
in death (Rhee et al., 2017). Sepsis is a potentially deadly condition, but some evidence suggests
that the severity of sepsis has been increasing in recent years, with the proportion of patients with
sepsis who developed severe organ dysfunction increasing from 26% to 44%. (Envier, 2018) In New
York State, sepsis affects 50,000 people each year, and the mortality rate is ~ 30% (NYSDH, 2017). 

The New York State Sepsis Improvement Initiative, Rory’s

Law, and the New York State Infection Control Training
Requirements
The New York State Sepsis Improvement Initiative and Rory’s Law

In 2014, New York state began to require every hospital in the state that provides care for patients
who have sepsis to develop and implement evidence-based protocols and to provide the
Department of Health with clinical information that could be used to evaluate the hospital’s
performance and to determine the risk-adjusted mortality of patients treated for sepsis at each
hospital. These requirements were initiated in response to the death of 12-year-old Rory
Staunton. Staunton developed sepsis after suffering an abrasion, and despite being hospitalized,
he died five days after the injury. The opinion is that Staunton’s case was mismanaged and that
although he had clear clinical and laboratory indications of sepsis, the diagnosis was not made. His
parents began a movement for public awareness of sepsis and change in-hospital care of sepsis,
eventually culminating in the passage of the informally known regulations as Rory’s Law.

Each hospital in New York that provides care for patients with sepsis must abide by and follow
Sections 405.2 and 405.4 of the New York State Codes, Rules, and Regulations (NYSDH,
2017). Sections 405.2 and 405.4 are outlined below in a (very slightly) abbreviated form, and italics
have been added where it was deemed important; the full texts can be accessed by using this link.

405.2 
Hospitals shall have evidence-based protocols for the early recognition and treatment
of patients with severe sepsis and septic shock based on generally accepted standards of
care as required by section 405.4(a) of this Part.
405.4
The medical staff shall adopt, implement, periodically update and submit to the
department evidence-based protocols for the early recognition and treatment of
patients with severe sepsis and septic shock (“sepsis protocols”) that are based on
generally accepted standards of care. Sepsis protocols must include components specific to
 the identification, care, and treatment of adults and children and identify where and when
components will differ for adults and children. These protocols must include the following
components:
(i) a process for the screening and early recognition of patients with sepsis, severe
sepsis, and septic shock;
(ii) a process to identify and document individuals appropriate for treatment
through severe sepsis and septic shock protocols, including explicit criteria
defining those patients who should be excluded from the protocols, such as
patients with certain clinical conditions or who have elected palliative care;
(iii) guidelines for hemodynamic support with explicit physiologic and biomarker
treatment goals, methodology for invasive or non-invasive hemodynamic
monitoring, and timeframe goals;
(iv) for infants and children, guidelines for fluid resuscitation with explicit
timeframes for vascular access and fluid delivery consistent with current,
evidence-based guidelines for severe sepsis and septic shock with defined
therapeutic goals for children;
(v) a procedure for identification of the infectious source and delivery of early
antibiotics with timeframe goals; and
(vi) criteria for use, where appropriate, of an invasive protocol and the use of
vasoactive agents.

The medical staff shall ensure that staff with direct patient care responsibilities and, as
appropriate, staff with indirect patient care responsibilities, including, but not limited to
laboratory and pharmacy staff, are periodically trained to implement sepsis protocols required
pursuant to paragraph (4) of this subdivision. The medical staff shall ensure updated training
when the hospital initiates substantive changes to the protocols.

Hospitals shall submit the required sepsis protocols according to paragraph (4) of this subdivision
to the department for review no later than September 3, 2013. Hospitals must implement these
protocols after receiving a letter from the department indicating that the proposed protocols have
been reviewed and determined to be consistent with the criteria established in this Part. Hospitals
must update protocols based on newly emerging evidence-based standards. Unless the
department identifies hospital-specific performance concerns, protocols are to be resubmitted at
the department's request, not more frequently than once every two years.

The medical staff shall be responsible for collecting, using, and reporting quality measures related
to recognizing and treating severe sepsis for internal quality improvement and hospital reporting
to the department. Such measures shall include, but not be limited to, data enough to evaluate
each hospital’s adherence rate to its sepsis protocols, including adherence to timeframes and
implementation of all protocol components for adults and children.

Hospitals shall submit data specified by the department to permit the department to develop risk-
adjusted severe sepsis and septic shock mortality rates in consultation with appropriate national,
hospital, and expert stakeholders. Such data shall be reported annually or more frequently at the
department's request and shall be subject to audit at the department's discretion.

Definitions:

For this section, the following terms shall have the following meanings:
Sepsis shall mean a proven or suspected infection accompanied by a systemic inflammatory
response;

Severe sepsis shall mean sepsis plus at least one sign of hypoperfusion or organ dysfunction; for
pediatrics, severe sepsis shall mean sepsis plus one of the following: cardiovascular organ
dysfunction or acute respiratory distress syndrome (ARDS) or two or more organ dysfunctions. For
adults, septic shock shall mean severe sepsis with persistent hypotension or cardiovascular organ
dysfunction despite adequate IV fluid resuscitation; for pediatrics, septic shock shall mean severe
sepsis and cardiovascular dysfunction despite adequate IV fluid resuscitation.

Infection Control Training Requirements 

Sepsis is caused by infection, and New York state has infection control education outlined in New
York State Law 6505-B and Section 239 of the New York State Public Health Law. 

New York State Law 6505-B mandates infection control education for dental hygienists, dentists,
licensed practical nurses, optometrists, podiatrists, and registered nurses practicing in the state
(NYSDH, 2017).

Section 239 of the New York State Public Health Law states, part:  

(a) Every physician, physician assistant, and specialist assistant practicing in the state shall,
on or before July first, nineteen hundred ninety-four, and every four years after that,
complete coursework or training appropriate to the professional's practice, approved by the
department regarding infection control and barrier precautions, including engineering and
work practice controls, per regulatory standards promulgated by the department in
consultation with the department of education, to prevent the transmission of HIV, HBV or
HCV in the course of professional practice. Such coursework or training must also be
completed by every medical student, medical resident, and physician assistant student in the
state as part of the orientation programs conducted by medical schools, medical residency
programs, and physician assistant programs.
(b) Every physician, physician assistant, specialist assistant, medical student, medical
resident, and physician assistant student must provide to the department documentation
demonstrating the completion of and competence in the coursework or training required
under subdivision (a) of this section, provided, however, that physicians subject to the
provisions of paragraph (f) of subdivision one of section twenty-eight hundred five-k of this
chapter shall not be required to provide such documentation to the department.

Implementation of these measures has been beneficial. The New York State Report on Sepsis Care
Improvement Initiative: Hospital Quality Performance (2017) reported that hospitals had
improved the rates of initiation of sepsis protocols and performing the early treatment protocols,
and mortality rates have improved. The adult mortality rate decreased to 25.4% from 30.2%; the
pediatric mortality rate fluctuated, from 6.8% in quarter two of 2014 to 5.3% in quarter one of 2015,
to a low of 6.5% in quarter three of 2015 (NYSDH, 2017). 

Signs and Symptoms of Sepsis: Early Identification for

Early Treatment
Coordinated efforts to improve sepsis detection and treatment positively impact patient survival,
and performance improvement programs like the New York state program improve compliance
with sepsis care guidelines and decrease patient mortality (Rhodes et al., 2017). 

Early identification and thus early treatment of sepsis is critically important; this point is
repeatedly stressed in the medical literature. A recent (2017) article that used data collected from
2014 – 2016 and reported to the New York State Department of Health reinforced this as early
initiation of the three-hour bundle and antibiotic therapy decreased the mortality rate (Seymour
et al., 2017). Many therapies for treating sepsis, particularly antibiotic therapy and fluid
resuscitation, are recommended to be given within the first few hours of treatment, and late
administration increases the risk for mortality  (Neviere, 2018). Early identification of sepsis
involves;

1. knowing the risk factors for sepsis and;

2. knowing the signs and symptoms of sepsis. 

Risk Factors for Sepsis  (Neviere, 2018).: 

Age > 60 years

Alcohol abuse
Chronic renal failure
Community-acquired infection
COPD
Diabetes
HIV infection
Immune system deficiency
In-dwelling urinary catheter
IV drug use
Male gender
Malignancy
No immunization
Prior history of sepsis
Smoking

Signs and Symptoms 

The signs and symptoms of sepsis are essentially the same for adults and children (Neviere,
2018). Common signs and symptoms include, but are not limited to: 

Clinical and diagnostic/laboratory findings consistent with the source of infection

Fever
Hypotension
Leukocytosis
Tachycardia
Altered mental status, acute kidney injury, and other signs of organ dysfunction, if septic
shock is present
Some clinicians recommend using the Sequential Organ Failure Assessment (SOFA) scoring
system (Gotur, 2018). The SOFA scale measures blood pressure, the Glasgow coma score,
serum bilirubin, serum creatinine, platelet count, and PaO2/FiO2. Each of these is given a
score of 0 – 4 based on the result/measurement, the scores are added, and the total score is
used to identify which patients have a high risk for mortality (Kelley, 2018).
Common Sources of Sepsis
Gram-negative and gram-positive bacteria and fungal infections can cause sepsis, but the
causative microorganism is not identified (Neviere, 2018). Respiratory tract infections and
abdominal infections are the most common causes of sepsis, followed by soft tissue infections and
urinary tract infections (Kalil, 2018).

Public Education
Sepsis often begins outside the hospital, but public awareness of sepsis is very low (Jabaley et al.,
2018). Early recognition and early treatment are critically important, so educating patients,
families, caregivers, and the public about sepsis is important. 

The lay public will often not have the technical background to understand the complexities of
sepsis, but that is not a hindrance to providing them with accurate information that is simple to
use and has practical benefits. Any basic educational program about sepsis should include sections
on the seriousness of sepsis, causes of sepsis, signs, and symptoms, what to do if you suspect
someone has sepsis, and sepsis prevention. The following information provides a framework for
such a program.  

The Problem of Sepsis

Sepsis affects millions of people in the US every year, from infants to the elderly and seemingly
healthy adults, and the risk of death from sepsis is very high. People most at risk are the elderly,
people who have a chronic infection or are immunocompromised, people who have a chronic
medical condition, or anyone who has recently had an invasive procedure. However, it is
important to remember that sepsis can happen to anyone. 

Causes of Sepsis

Sepsis is caused by an infection, an invasion of the body by bacteria; the infection can occur in the
skin, the urinary bladder, the lungs, or other areas.

Signs and Symptoms

Sepsis is characterized by a very high fever or a very low fever, a rapid heart rate, and a general
sense of not feeling well, and these happen in the context of an infection.

The Sepsis Alliance uses the mnemonic TIME as an educational device to teach people about the
signs and symptoms of sepsis (Sepsis Alliance, 2018).

T = Temperature, high or low

I – Infection
M = Mental decline, the change in mental status that occurs with the decreased perfusion
that occurs with severe sepsis
E = Extremely ill

What to Do if You Suspect Someone has Sepsis

Seek medical attention immediately; do not wait. If someone has sepsis, nothing can be done at
home to improve the situation, and delaying treatment is dangerous. 

Preventing Sepsis
 Make sure that vaccinations are up-to-date
Practice good wound care
If you have an infection, follow the self-care instructions you have been given by your health
care provider, especially for the use of antibiotics
Practice good handwashing
If you live with someone who is immune-compromised or immune-compromised, get advice
and guidance from your healthcare provider about how to prevent infections and sepsis

Conclusion
Healthcare professionals must adhere to scientifically accepted standards for infection control and
the responsibility to monitor subordinates' infection control practices. The correct incorporation
of work practice controls and engineering controls helps avoid or reduce exposure to potentially
infectious materials and hazards. Compliance with environmental infection control measures will
decrease healthcare-related infections among patients, especially the immunocompromised, and
among healthcare professionals.

References
Abdul Salam ZH, Karlin RB, Ling ML, Yang KS. The impact of portable high-efficiency
particulate air filters on the incidence of invasive aspergillosis in a large acute tertiary-care
hospital. Am J Infect Control. 2010;38(4):e1-e7. doi: 10.1016/j.ajic.2009.09.014.
American Academy of Pediatrics Committee on Infectious Diseases; American Academy of
Pediatrics Bronchiolitis Guidelines Committee. Updated guidance for palivizumab
prophylaxis among infants and young children at increased risk of hospitalization for
respiratory syncytial virus infection. Pediatrics. 2014;134(2):415-420. doi: 10.1542/peds.2014-
1665.
Advisory Committee on Immunization Practices; Centers for Disease Control and Prevention
(CDC). Immunization of health-care personnel: recommendations of the Advisory
Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2011 Nov 25;60(RR-7):1-
45. PIMD: 22108587.
Ainsworth S, Ketter PM, Yu JJ, et al. Vaccination with a live attenuated Acinetobacter
baumannii deficient in thioredoxin provides protection against systemic Acinetobacter
infection. Vaccine. 2017;35(26):3387-3394. doi:10.1016/j.vaccine.2017.05.017. Epub 2017 May
15.
ASGE Quality Assurance in Endoscopy Committee, Petersen BT, Chennat J, et al. Multisociety
guidelines on reprocessing flexible gastrointestinal endoscopes: 2011. Gastrointest Endosc.
2011;73(6):1075-1084. doi:10.1016/j.gie.2011.03.1183.
Bardorf MH, Jäger B, Boeckmans E, Kramer A, Assadian O. Influence of material properties on
gloves' bacterial barrier efficacy in the presence of microperforation. Am J Infect Control.
2016;44(12):1645-1649. doi:10.1016/j.ajic.2016.03.070.
Bartlett JG, Weber DJ. Management of healthcare personnel exposed to HIV. UpToDate. May
20, 2015. (Visit Source). Accessed July 1, 2017.
Bolon MK. Hand hygiene: An update. Infect Dis Clin North Am. 2016;30(3):591-607. doi:
10.1016/j.idc.2016.04.007.
Boyce JM, Pittet D; Healthcare Infection Control Practices Advisory Committee;
HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Guideline for Hand Hygiene in Health-
Care Settings. The Healthcare Infection Control Practices Advisory Committee and the
HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force are recommendations. Society for
Healthcare Epidemiology of America/Association for Professionals in Infection
Control/Infectious Diseases Society of America. MMWR Recomm Rep. 2002 Oct 25;51(RR-
16):1-45, quiz CE1-4. PIMD: 12418624.
Brunet J, Lemoine JP, Lefebvre N, et al. Bloody diarrhea associated with hookworm infection
in traveler returning to France from Myanmar. Emerg Infect Dis. 2015;21(10):1878-1879. doi:
10.3201/eid2110.150695.
CDC: HIV/AIDS. April 10, 2017. (Visit Source). April 10. Accessed May 19, 2017.
CDC.  Parasites – Amebiasis – Entamoeba histolytica infection. July 20, 2015. (Visit Source).
Accessed May 19, 2017.
CDC. Chickenpox (Varicella). June 13, 2016. (Visit Source). Accessed May 19, 2017.
CDC.  Cholera - Vibrio cholerae infection. October 27, 2014. (Visit Source). Accessed May 19,
2017.
CDC.   Parasites - Cryptosporidium (also known as "Crypto"). February 20, 2015b.(Visit
Source). Accessed May 21, 2017.
CDC.  Cytomegalovirus (CMV) and Congenital CMV Infection. June 17, 2016b. (Visit Source).
Accessed May 21, 2017.
CDC.  Salmonella. (Visit Source). August 25, 2016c. Accessed May 21, 2017.
CDC. Shigella – Shigellosis. (Visit Source). March 31, 2017b. Accessed May 21, 2017.
CDC.  Yersinia enterocolitica (Yersiniosis). (Visit Source). May 25, 2016d. Accessed May 21,
2017.
CDC.  Parasites – Giardia. (Visit Source). July 21, 2015c. Accessed May 21, 2017.
CDC.  Gonorrhea. (Visit Source). October 28, 2016e. Accessed May 21, 2017.
CDC.  Viral hepatitis. (Visit Source). August 27, 2015d. Accessed May 21, 2017.
CDC.  Viral hepatitis. (Visit Source). August 28, 2015e. Accessed May 21, 2017.
CDC.  Viral hepatitis. (Visit Source). May 23, 2016f. Accessed May 21, 2017.
CDC.  Viral hepatitis. (Visit Source). October 17, 2016g. Accessed May 21, 2017.
CDC.  Fungal diseases. November 21, 2015d. (Visit Source). Accessed May 21, 2017.
CDC.  Parasites – Hookworm. January 10, 2013. (Visit Source). Accessed May 21, 2017.
CDC.  Influenza (Flu). (Visit Source). May 25, 2016g. Accessed May 21, 2017.
CDC.  Legionella (Legionnaires’ Disease and Pontiac Fever). July 18, 2016h. (Visit Source).
Accessed May 21, 2017.
CDC.  Lyme Disease. October 26, 2016i. (Visit Source). Accessed May 21, 2017.
CDC.  Malaria. October 7, 2015e. (Visit Source). Accessed May 21, 2017.
CDC.  Measles. February 17, 2015f. (Visit Source). Accessed May 21, 2017.
CDC. Epstein-Barr Virus and Infectious Mononucleosis. September 14, 2016j. (Visit Source).
Accessed May 21, 2017. 42. CDC.
CDC Mycoplasma Pneumoniae. March 15, 2016k. (Visit Source).  Accessed May 21, 2017.
CDC.  Parasites – Lice _ Head Lice. September 1, 2015g. (Visit Source). Accessed May 24, 2017.
CDC. Parasites: Lice. Frequently Asked Questions. September 24, 2013 (Visit Source).
 Accessed May 24, 2017.
CDC.  Parasites - Enterobiasis (also known as Pinworm Infection). January 10, 2013b. (Visit
Source). Accessed May 21, 2017.
CDC.  Pneumococcal Disease. June 10, 2015h. (Visit Source). Accessed May 21, 2017.
CDC. Rabies. April 22, 2011b. (Visit Source). Accessed May 22, 2017.
CDC.  Fungal Diseases. December 6, 2015i. (Visit Source). Accessed May 22, 2017.
CDC.  Rocky Mountain Spotted Fever (RMSF). September 5, 2010. (Visit Source). Accessed May
22, 2017.
CDC.  Rotavirus. August 12, 2016l. (Visit Source). Accessed May 22, 2017.
CDC.  Rubella (German Measles, Three-Day Measles). March 31, 2016m. (Visit Source).
 Accessed May 22, 2017.
CDC.  Group A Streptococcal (GAS) Disease. September 16, 2016n. (Visit Source). Accessed
May 22, 2017.
CDC.  Tetanus. January 10, 2017b. (Visit Source). Accessed May 22, 2017.
CDC. Parasites - Trichinellosis (Also Known as Trichinosis). August 8, 2012. (Visit Source).
Accessed May 22, 2017.
CDC. Facility Guidance for Control of Carbapenem-resistant Enterobacteriaceae (CRE).
November 2015j Update – CRE Toolkit. April 18, 2017. (Visit Source).  Accessed May 22, 2017.
CDC.  Methicillin-Resistant Staphylococcus Aureus (MRSA).  March 24, 2016o. (Visit Source).
Accessed May 22, 2017.
CDC.  Investigation and Control of Vancomycin-Resistant Staphylococcus aureus: 2015j
Update. April 2015. (Visit Source).  Accessed May 22, 2017.
CDC.  Vancomycin-Resistant Enterococci (VRE) in Healthcare Settings. May 10, 2011b. (Visit
Source). Accessed May 21, 2017.
CDC.  Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in
Healthcare Settings. 2007. (Visit Source).  Accessed May 22, 2017.
CDC.  Pneumococcal Disease. Drug Resistance. June 10, 2015d. (Visit Source). Accessed May
22, 2017.
CDC.  Safe Injection Practices to Prevent Transmission of Infections to Patients. April 1,
2011c. (Visit Source). Accessed May 22, 2017.
CDC.  Sharps Safety for Healthcare Settings. February 11, 2015h. (Visit Source). Accessed May
24, 2017.
CDC. Hand Hygiene in Healthcare Settings. March 24, 2017. (Visit Source). Accessed May 29,
2017.
CDC. Pandemic Planning. Recommended Guidance for Extended Use and Limited Reuse of
N95 Filtering Facepiece Respirators in Healthcare Settings. March 13, 2014. (Visit Source).
Accessed June 2, 2017.
CDC.  Prevention Strategies for Seasonal Influenza In Healthcare Settings. October 5, 2016p.
(Visit Source). Accessed June 2, 2017.
CDC Centers for Disease Control and Prevention. Division of Oral Health. Summary of
Infection Prevention Practices in Dental Settings: Basic Expectations for Safe Care, Atlanta,
GA: Centers for Disease Control and Prevention, US Dept of Health and Human Services;
October 2016m. (Visit Source). Accessed June 14, 2017.
CDC. Legionella (Legionnaires' Disease and Pontiac Fever), Diagnosis, Treatment, and
Prevention. June 1, 2017l. (Visit Source). Accessed June 18, 2107.
CDC. Pertussis (Whooping Cough). Post-exposure Antimicrobial Prophylaxis. September 8,
2015h. (Visit Source). Accessed June 19, 2017.
CDC. Human Parainfluenza Viruses. Clinical overview. August 8, 2015. (Visit Source).
Accessed June 21, 2017n.
CDC. Influenza (Flu). Prevention Strategies for Seasonal Influenza in Healthcare Settings.
October 5, 2016p. (Visit Source) Accessed June 21, 2017.
CDC. Influenza (Flu). Influenza Antiviral Medications: Summary for Clinicians. March 8,
2017o. (Visit Source). Accessed June 21, 2017.
CDC. Interim Guidance for Influenza Outbreak Management in Long-Term Care Facilities.
March 28, 2017p. (Visit Source). Accessed June 21, 2017.
Choi JS, Kim KM. Predictors of respiratory hygiene/cough etiquette in a large community in
Korea: A descriptive study. Am J Infect Control. 2016;44(11): e271-e273. doi:
10.1016/j.ajic.2016.04.226.
Choi LY, Torres R, Syed S, et al. Sharps and needle stick injuries among medical students,
surgical residents, faculty, and operating room staff at a single academic institution. J Surg
Educ. 2017;74(1):131-136. doi: 10.1016/j.jsurg.2016.06.003.
Copeland NK, Decker CF. Other sexually transmitted diseases chancroid and donovanosis. Dis
Mon. 2016;62(8):306-313. doi: 10.1016/j.disamonth.2016.03.016.
Critical Care Nurse. [No authors listed]. Prevention of aspiration in adults. Crit Care Nurse.
2016;36(1):e20-e4. doi: 10.4037/ccn2016831.
Curry SR. Clostridium difficile. Clin Lab Med. 2017;37(92):341-369. doi:
10.1016/j.cll.2017.01.007.
Dolan SA, Arias KM, Felizardo G, et al. APIC position paper: Safe injection, infusion, and
medication vial practices in health care. Am J Infect Control. 2016;44(7):750-757. doi:
10.1016/j.ajic.2016.02.033.
Dolin R. Common viral respiratory infections. In: Kasper D, Fauci A, Hauser S, Long D,
Jameson JL, Loscalzo J, eds. Harrison’s Principles of Internal Medicine, 19th ed. New York,
NY: McGraw-Hill, 2015. Online edition, accessed June 21, 2017, from www.UCHC.edu.
DynaMed Plus. Meningococcal disease. DynaMed Plus, May 17, 2017. (Visit Source).
Accessed May 21, 2017.
Eibach D, Casalegno JS, Bouscambert M, et al. Routes of transmission during a nosocomial
influenza A(H3N2) outbreak among geriatric patients and healthcare workers. J Hosp Infect.
2014;86(3):188-193. doi: 10.1016/j.jhin.2013.11.009.
Elshafie S, Taj-Aldeen SJ. Emerging resistant serotypes of invasive Streptococcus
pneumoniae. Infect Drug Resist. 2016;29(9):153-160. doi: 10.2147/IDR.S102410.
Fauci AS, Lane HC. Human immunodeficiency virus disease: AIDS and related disorders. In:
Kasper D, Fauci A, Hauser S, Longo D, Jameson JL, Loscalzo J, eds. Harrison's Principles of
Internal Medicine, 19e. New York, NY: McGraw-Hill Education; 2015. Online edition, Accessed
June 23, 2017, www.UCHC.edu.
Fedorowicz Z. Ebola virus disease. DynaMed Plus. February 22, 2017. (Visit Source). Accessed
June 17, 2017.
Egro FM, Nwaiwu CA, Smith S, Harper JD, Spiess AM. Seroconversion rates among health care
workers exposed to hepatitis C virus-contaminated body fluids: The University of Pittsburgh
13-year experience. Am J Infect Control. 2017 Apr 24. pii: S0196-6553(17)30209-2. doi:
10.1016/j. ajic2017.03.011. [Epub ahead of print]
File TM. Risk factors and prevention of hospital-acquired and ventilator-associated
pneumonia in adults. UpToDate. September 27, 2016. (Visit Source). Accessed June 17, 2017.
Food and Drug Administration. Medical Gowns. May 10, 2016. (Visit Source). Accessed June 1,
2017.
Food and Drug Administration. Masks and N95 Respirators. June 26, 2016. (Visit Source).
Accessed June 2, 2017.
Food and Drug Administration. Reprocessing Medical Devices in Health Care Settings:
Validation Methods and Labeling Guidance for Industry and Food and Drug Administration
Staff. March 17, 2015. (Visit Source). Accessed June 17, 2017.
Frickmann H, Schmeja W, Reisinger E, et al. Risk reduction of needle stick injuries due to
continuous shift from unsafe to safe instruments at a German university hospital. Eur J
Microbiol Immunol (Bp). 2016;6(3):227-237. eCollection 2016 Sep 29.
DOI:10.1556/1886.2016.00025.
Gompf SG. Herpangina. eMedcine. August 15, 2016. (Visit Source). Accessed May 21, 2017.
Gotur, DB. Sepsis in a Panorama: What the Cardiovascular Physician Should Know.
2018;14(2):89-100. doi:  10.14797/mdcj-14-2-89.
Graybill-D'Ercole P. Implementing AORN recommended practices for sterilization. AORN J.
2013;97(5):521-533. doi: 10.1016/j.aorn.2013.03.002.
Grohskopf LA, Sokolow LZ, Broder KR, et al. Prevention and control of seasonal influenza
with vaccines. MMWR Recomm Rep. 2016;65(5):1-54. doi: 10.15585/ mmwr.rr6505a1.
Hamishekar H, Shadvar K, Taghizadeh M. Ventilator-associated pneumonia in patients
admitted to intensive care units, using open or closed endotracheal suctioning. Anesth Pain
Med. 2014;4(5): e21649. doi: 10.5812/aapm.21649.
Hayden MK, Blom DW, Lyle EA, Moore CG, Weinstein RA. Risk of hand or glove
contamination after contact with patients colonized with vancomycin-resistant enterococcus
or the colonized patients' environment. Infect Control Hosp Epidemiol. 2008;29(2):149-154.
doi: 10.1086/524331.
Hughes HY, Henderson DK. Post-exposure prophylaxis after hepatitis C occupational
exposure in the interferon-free era. Curr Opin Infect Dis. 2016;29(4):373-380. doi:
10.1097/QCO.0000000000000281.
Institute for Healthcare Improvement. How-To Guide: Prevent Ventilator-Associated
Pneumonia.2012. www.ihi.org.
Isenman H, Michaels J, Fisher D. Global variances in infection control practices for
vancomycin resistant Enterococcus - results of an electronic survey. Antimicrob Resist Infect
Control. 2016 Nov 3;5:41. eCollection 2016. DOI:10.1186/s13756-016-0140-5.
Jabaley, C.S., Blum, J.M., Groff, R.F., O'Reilly-Shah, V.N. (2018). Global trends in the
awareness of sepsis: insights from search engine data between 2012 and 2017. Critical Care,
Jan 17;22(1):7. doi: 10.1186/s13054-017-1914-8.
Jaishankar D, Shukla D. Genital herpes: Insights into sexually transmitted infectious disease.
Microb Cell. 2016;3(9):438-450. doi: 10.15698/mic2016.09.528.
Jensen PA, Lambert LA, Iademarco MF, Ridzon R; CDC. Guidelines for preventing the
transmission of Mycobacterium tuberculosis in health-care settings, 2005. MMWR Recomm
Rep. 2005;54(RR-17):1-141.PIMD: 16382216.
Kaakoush NO, Castaño-Rodríguez N, Mitchell HM, Man SM. Global epidemiology of
Campylobacter infection. Clin Microbiol Rev .2015;28(3),687-720. doi: 10.1128/CMR.00006-
15.
Kalil, A. (2018). Septic shock. eMedicine. Accessed August 28, 2018 (Visit Source).
Kaya H, Turan Y, Tunali Y, et al. Effects of oral care with glutamine in preventing ventilator-
associated pneumonia in neurosurgical intensive care unit patients. Appl Nurs Res. 2017;
33:10-14. doi: 10.1016/j.apnr.2016.10.006.
Kazaure HS, Martin M, Yoon JK, Wren SM. Long-term results of a postoperative pneumonia
prevention program for the inpatient surgical ward. JAMA Surg. 2014;149(9):914-918. doi:
10.1001/jamasurg.2014.1216.
Kelley, M.A. (2018). Predictive scoring systems in the intensive care unit. UpToDate. Accessed
August 28, 2018, from (Visit Source).
Kilinc FS. A review of isolation gowns in healthcare: Fabric and gown properties. J Eng Fiber
Fabr. 2015;10(3):180-190. PIMD: 26989351.
Kilinc Balci FS. Isolation gowns in health care settings: Laboratory studies, regulations and
standards, and potential gown selection and use barriers. Am J Infect Control.
2016;44(1):104-111. doi: 10.1016/j.ajic.2015.07.042.132.Seto WH. Airborne transmission and
precautions: facts and myths. J Hosp Infect. 2015;89(4):225-228. doi:
10.1016/j.jhin.2014.11.005.
Kobayashi M, Bennett NM, Gierke R, et al. Intervals between PCV13 and PPSV23
vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP).
MMWR Morb Mortal Wkly Rep. 2015;64(34):944-947.
Ko S, An HS, Bang JH, Park SW. An outbreak of Burkholderia cepacia complex
pseudobacteremia associated with intrinsically contaminated commercial 0.5% chlorhexidine
solution. Am J Infect Control. 2015;43(3):266-268. doi:10.1016/j.ajic.2014.11.010.
Koh WM, Bogich T, Siegel K, et al. The epidemiology of hand, foot and mouth disease in Asia:
A systematic review and analysis.  Pediatr Infect Dis J. 2016;35(10), e285-e300. doi:
10.1097/INF.0000000000001242.
Kusahara DM, Peterlini MA, Pedreira ML Oral care with 0.12% chlorhexidine for
the prevention of ventilator-associated pneumonia in children: randomized, controlled and
double-blind trial. Int J Nurs Stud. 2012;49(11):1354-1363. doi:10.1016/j.ijnurstu.2012.06.005.
Lashinsky JN, Henig O, Pogue JM, Kaye KS. Minocycline for the treatment of multidrug and
extensively drug-resistant A. baumannii: A review. Infect Dis Ther. 2017 Mar 29. doi:
10.1007/s40121-017-0153-2. [Epub ahead of print]
Leddy R, Wilkinson JM. Endotracheal suctioning practices of nurses and respiratory
therapists: How well do they align with clinical practice guidelines? Can J Respir Ther.
2015;51(3):60-64. PIMD: 26283870.
Lequilliec N, Raymond R, Vanjak D. Practices of infectious control management during
neutropenia: A survey from 149 French hospitals. J Mycol Med. 2017 Mar 14. pii: S1156-
5233(17)30018-5. doi: 10.1016/j.mycmed.2017.02.006. [Epub ahead of print]
Leroy S. Infectious risk of endovaginal and transrectal ultrasonography: systematic review
and meta-analysis. J Hosp Infect. 2013;83(2):99-106. doi: 10.1016/j.jhin.2012.07.014.
Li Bassi G. Airway secretions and suctioning. In: Tobin MJ, ed. Principles and Practice of
Mechanical Ventilation.New York, NY: McGraw-Hill; 2013. Accessed June 17, 2017, from
www.UCHC.edu.
Li Bassi G, Senussi T, Aguilera Xiol E. Prevention of ventilator-associated pneumonia. Curr
Opin Infect Dis. 2017;30(2):214-220. doi: 10.1097/QCO.0000000000000358.
Lindsley WG, Noti JD, Blachere FM, Szalajda JV, Beezhold DH. Efficacy of face shields against
cough aerosol droplets from a cough simulator. J Occup Environ Hyg. 2014;11(8):509-518. doi:
10.1080/15459624.2013.877591.
Macinga DR, Shumaker DJ, Werner HP, et al. The relative influences of product volume,
delivery format and alcohol concentration on dry-time and efficacy of alcohol-based hand
rubs. BMC Infect Dis. 2014 Sep 20; 14:511. doi: 10.1186/1471-2334-14-511.
Manix M, Kalakoti P, Henry M, et al. Creutzfeldt-Jakob disease: updated diagnostic criteria,
treatment algorithm, and the utility of brain biopsy. Neurosurg Focus. 2015 Nov;39(5): E2.
doi: 10.3171/2015.8.FOCUS15328.
Maziarz EK, Perfect JR. Cryptococcosis. Infect Dis Clin North Am. 2016;30(1),179-206. doi:
10.1016/j.idc.2015.10.006.
Mitchell RB, Hussey HM, Setzen G, et al. Clinical consensus statement – Tracheostomy
care. Otolaryngol Head Neck Surg. 2013;148(1):6-20. doi: 10.1177/0194599812460376.
Miller RF, Huang L, Walzer PD. Pneumocystis pneumonia is associated with the human
immunodeficiency virus. Clin Chest Med. 2013;34(2):229-241. doi: 10.1016/j.ccm.2013.02.001.
Mofenson LM, Brady MT, Danner SP, et al. Guidelines for the Prevention and Treatment of
Opportunistic Infections among HIV-exposed and HIV-infected children: recommendations
from CDC, the National Institutes of Health, the HIV Medicine Association of the Infectious
Diseases Society of America, the Pediatric Infectious Diseases Society, and the American
Academy of Pediatrics. MMWR Recomm Rep. 2009 Sep 4;58(RR-11):1-166.  PIMD: 19730409.
Neves MS, da Silva MG, Ventura GM, et al. Effectiveness of current disinfection procedures
against biofilm on contaminated GI endoscopes. Gastrointest Endosc. 2016;83(5):944-953.
doi: 10.1016/j.gie.2015.09.016.
Neviere, R. Sepsis syndrome in adults: Epidemiology, definitions, clinical presentation,
diagnosis, and prognosis. UpTo Date. (Visit Source) Updated June 12, 2018, Accessed August
29, 2018.
Neviere, R. Pathophysiology of sepsis. UpToDate. (Visit Source).
New York State (2008). Department of Health. Healthcare Provider Infection Control
Training. (Visit Source) Accessed May 19, 2017.
New York State Education Department. Rules of the Board of Regents. Part 29,
Unprofessional Conduct (October 5, 2011). Section 29.2(a) 13. (Visit Source). Accessed May 19,
2017.
New York State Department of Health. (2017). New York State Report on Sepsis Care
Improvement Initiative: Hospital Quality Performance. Revised June 2017. Accessed August
29, 2018, from (Visit Source).
New York State. New York State Education Law. Sec. 6505-B Course Work or Training in
Infection Control Practices  Accessed August 28, 2018, from (Visit Source).
Nicolosi LN, del Carmen Rubio M, Martinez CD, González NN, Cruz ME. Effect of oral hygiene
and 0.12% chlorhexidine gluconate oral rinse in preventing ventilator-associated pneumonia
after cardiovascular surgery. Respir Care. 2014;59(4):504-509. doi: 10.4187/respcare.02666.
NIOSH.  Alert: Preventing needle stick injuries in healthcare settings. DSSH NIOSH
publication 2000 -1999. (Visit Source) Accessed May 25, 2017.
Nwaiwu CA, Egro FM, Smith S, Harper JD, Spiess AM. Seroconversion rate among health care
workers exposed to HIV-contaminated body fluids: The University of Pittsburgh 13-year
experience. Am J Infect Control. 2017 Apr 24. pii: S0196-6553(17)30234-1. doi:
10.1016/j.ajic.2017.03.012. [Epub ahead of print]
O'Byrne P, MacPherson P, DeLaplante S, Metz G, Bourgault A.  Approach to
lymphogranuloma venereum. Can Fam Physician. 2016;62(7):554-558. PIMD: 27412206.
Occupational Safety and Health Administration, 29 CFR. Standard 1910.1030 – Bloodborne
Pathogens. December 6, 1991. (Visit Source). Accessed June 1, 2017.
Occupational Safety and Health Administration. Fit Testing Procedures (Mandatory). 1910.134
App A. April 23, 1998. (Visit Source). Accessed June 2, 2017.
Ory J, Raybaud E, Chabanne R, et al. Comparative study of 2 oral care protocols in intensive
care units. Am J Infect Control. 2017;45(3):245-250. doi: 10.1016/j.ajic.2016.09.006.
OSHA. Legionnaire’s Disease. Frequently Asked Questions. (Visit Source).  Accessed June 18,
2017.
Ostrovsky DA. Impetigo. DynaMed Plus, June 15, 2016. (Visit Source). Accessed May 21, 2017.
Parr A., Whitney E.A., Berkelman R.L. Legionellosis on the rise: A review of guidelines for
prevention in the United States. J Public Health Manag Pract. 2015;21(5): E17-26. doi:
10.1097/PHH.0000000000000123.
Pássaro L, Harbarth S, Landelle C. Prevention of hospital-acquired pneumonia in non-
ventilated adult patients: a narrative review. Antimicrob Resist Infect Control. 2016 Nov
14;5:43. eCollection 2016. DOI:10.1186/s13756-016-0150-3.
Patterson TF, Thompson GR 3rd, Denning DW, et al. Practice Guidelines for the Diagnosis and
Management of Aspergillosis: 2016 Update by the Infectious Diseases Society of America.
Clin Infect Dis. 2016;63(4):e1-e60. doi: 10.1093/cid/ciw326.
Pfeifer K, Smetana GW. Perioperative pulmonary risk assessment and management. In:
McKean SC, Ross JJ, Dressler DD, Scheurer, eds. Principles and Practice of Hospital Medicine,
2nd ed. New York, NY: McGraw-Hill Education; 2017. Accessed June 18, 2017, from
www.UCHC.edu.
Pless A, McLennan SR, Nicca D, Shaw DM, Elger BS. Reasons why nurses decline influenza
vaccination: a qualitative study. BMC Nurs. 2017 Apr 28;16:20. doi: 10.1186/s12912-017-0215-
5. eCollection 2017.
Pokala HR, Leonard D, Cox J, Metcalf P, McClay J, Siegel J, Winick N. Association of hospital
construction with the development of healthcare associated environmental mold infections
(HAEMI) in pediatric patients with leukemia. Pediatr Blood Cancer. 2014;61(2):276-280. doi:
10.1002/pbc.24685.
Prasad, P.  Respiratory syncytial virus in adults. DynaMed Plus. July 26, 2016. (Visit
Source). Accessed May 22, 2017.
Rhee, C., Dantes, R., Epstein, L., et al. (2017). Incidence and trends of sepsis in US hospitals
using clinical vs. claims data, 2009-2014. JAMA, 318(13):1241-1249.
Rhodes, A., Evans, L., Alhazzani, W., et al. Surviving Sepsis Campaign: International
Guidelines for Management of Sepsis and Septic Shock. Intensive Care Med. 2017;43(3):304-
377.doi: 10.1007/s00134-017-4683-6.
Roberge RJ. Face shields for infection control: A review. J Occup Environ Hyg. 2016;13(4):235-
242. doi: 10.1080/15459624.2015.1095302.
Rutala WA, Weber DJ, and the Healthcare Infection Control Practices Advisory Committee
(HICPAC). Guideline for Sterilization and Disinfection in Healthcare Facilities, 2008.
November 2008. (Visit Source).  Accessed June 5, 2017.
Rutala WA, Weber DJ. Disinfection and sterilization in health care facilities: An overview and
current issues. Infect Dis Clin North Am. 2016;30(3):609-637. doi: 10.1016/j.idc.2016.04.002.
Scheithauer S, Batzer B, Dangel M, Passweg J, Widmer A. Workload even affects hand hygiene
in a highly trained and well-staffed setting: a prospective 365/7/24 observational study. J
Hosp Infect. 2017 Feb 20. pii: S0195-6701(17)30110-X. doi: 10.1016/j.jhin.2017.02.013. [Epub
ahead of print]
Sebastiani FR, Dym H, Kirpalani T. Infection control in the dental office. Dent Clin North Am.
2017;61(2):435-457. doi: 10.1016/j.cden.2016.12.008.
Sehulster L, Chinn RY; CDC; HICPAC. Guidelines for environmental infection control in
health-care facilities. Recommendations of CDC and the Healthcare Infection Control
Practices Advisory Committee (HICPAC). MMWR Recomm Rep. 2003 Jun 6;52(RR-10):1-42.
PIMD: 12836624.
Sepsis Alliance. Accessed August 28, 2018, from Sepsis Alliance (Visit Source).
Seymour, C.W., Gesten, F., Prescott. H., et al.: (2017). Time to treatment and mortality during
mandated emergency care for sepsis. New England Journal of Medicine,376(23): 2235–2244.
Smart JD, Belkoff SM, Mears SC. The effectiveness of a program to reduce the rate of flash
sterilization. J Arthroplasty. 2012;27(7):1267-1270. doi: 10.1016/j.arth.2011.10.028.
Smith JD, MacDougall CC, Johnstone J, Copes RA, Schwartz B, Garber GE. Effectiveness of N95
respirators versus surgical masks in protecting health care workers from acute respiratory
infection: a systematic review and meta-analysis. CMAJ. 2016;188(8):567-574. doi:
10.1503/cmaj.150835.
Smith S, Sim J, Halcomb E. Nurses' knowledge, attitudes and practices regarding influenza
vaccination: an integrative review. J Clin Nurs. 2016;25(19-20):2730-2744. doi:
10.1111/jocn.13243.
Stamm LV. Syphilis: Re-emergence of an old foe. Microb Cell. 2016;3(9):363-370. doi:
10.15698/mic2016.09.523.
Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R; CDC; Healthcare Infection Control
Practices Advisory Committee. Guidelines for preventing health-care--associated
pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices
Advisory Committee. MMWR Recomm Rep. 2004;53(RR-3):1-36.
Tang HJ, Chao CM, Leung PO, Lai CC. An observational study to compare oral hygiene care
with chlorhexidine gluconate gel versus mouthwash to prevent ventilator-associated
pneumonia.
Infect Control Hosp Epidemiol. 2017;38(5):631-632. doi: 10.1017/ice.2017.24.
The Joint Commission. Instrument Reprocessing - Immediate Use Steam Sterilization (IUSS).
May 12, 2017. (Visit Source). Accessed June 17, 2017.
U.S. Public Health Service. Updated U.S. Public Health Service Guidelines for the
Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for
Post-exposure Prophylaxis. MMWR Recomm Rep. 2001;50(RR-11):1-52.  PIMD: 11442229.
Van Zuuren, EJ. Enteric fever (Typhoid and paratyphoid). DynaMed Plus, March 31, 2017.
(Visit Source). Accessed May 23, 2017.
Verbeek JH, Ijaz S, Mischke C, et al. Personal protective equipment for preventing highly
infectious diseases due to exposure to contaminated body fluids in healthcare staff. Cochrane
Database Syst Rev. 2016 Apr 19;4:CD011621. doi: 10.1002/14651858.CD011621.pub2.
Voss A, Widmer AF. No time for handwashing!? Handwashing versus alcoholic rub: can we
afford 100% compliance? Infect Control Hosp Epidemiol. 1997;18(3):205-208. PIMD: 9095051.
Weber DJ, Rutala WA, Eron J. Prevention of hepatitis B virus and hepatitis C virus among
healthcare providers. UpToDate. April 6, 2015. (Visit Source). Accessed June 22, 2017.
Weinhouse GL. Stress ulcer prophylaxis in the intensive care unit. UpToDate. August 25,
2015. (Visit Source). Accessed June 18, 2017.
Whiley H. Legionella risk management and control in potable water systems: Argument for
the abolishment of routine testing. Int J Environ Res Public Health. 2016 Dec 24;14(1). pii:
E12. doi: 10.3390/ijerph14010012.
Wilkinson MA, Ormandy K, Bradley CR, Fraise AP, Hines J. Dose considerations for alcohol-
based hand rubs. J Hosp Infect. 2017;95(2):175-182. doi: 10.1016/j.jhin.2016.12.023.
 Wilson J, Bak A, Loveday HP. Applying human factors and ergonomics to the misuse of
nonsterile clinical gloves in acute care. Am J Infect Control. 2017 Mar 29. pii: S0196-
6553(17)30140-2. doi: 10.1016/j.ajic.2017.02.019. [Epub ahead of print]
Wingard JR. Prevention of infections in hematopoietic cell transplant recipients. UpToDate.
December 1, 2016. (Visit Source). Accessed July 5, 2017.
World Health Organization (WHO). WHO Guidelines om Hand Hygiene in Healthcare. 2009.
(Visit Source). Accessed May 27, 2017.
Ying Q, Qun L, Qinzhong L, Mingliang C, Hong C, Ni Z. Investigation and control of a
suspected nosocomial outbreak of pan-drug resistant Acinetobacter baumannii in an
intensive care unit. Open Med (Wars). 2016;11(1):587-592. doi: 10.1515/med-2016-0096.
Zhang MX, Yu Y. A study of the psychological effects of sharps injuries on healthcare workers
in China. Am J Infec Control. 2013;41(2):186-187. DOI: 10.1016/j.ajic.2012.02.023.