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Infection Control and Barrier Precautions - 4 Contact

Hours
(New York Provider ID# IC 145, as Mandated by Chapter 786 of the New York Laws of
1992)
 
Authors: Dana Bartlett (RN, BSN, MA, MA, CSPI)

Course Outline
 Outcomes
 Objectives
 New York Requirements for Adherence to Infection Control Standards
 Transmission of Infectious Pathogens
o Definitions
o Overview of Transmission
o Contact transmission
o Airborne transmission
o Organism Chart
 Antibiotic-Resistant Organisms
o Carbapenem-resistant enterobacteriaceae
o Drug Resistant Staphylococcus Aureus
 o Vancomycin-Resistant Enterococcus (VRE)
o Multidrug-Resistant Tuberculosis (MDR-TB)
o Drug-Resistant Streptococcus pneumoniae
o Drug-Resistant Acinetobacter
 Prevention of Exposure to Infectious Pathogens
o Standard Precautions
o Respiratory Hygiene/Cough Etiquette
o Safe Injection Practice
o Handwashing
o Respiratory Hygiene/Cough Etiquette
o Personal Protective Equipment
o Transmission Based Precautions
o Airborne Precautions
o Droplet Precautions
o Contact Precautions
o Neutropenic Precautions
o Immunization
o Immunization for Healthcare Personnel
 Development and Maintenance of a Safe Environment
o Definitions
 Infection Control: Basic Strategies
o Staff Education: Basics
o Cleaning, Disinfection, and Sterilization
o Reuse of Single-Use Medical Devices
o Microbial Contamination of Disinfectants
o Engineering and Environmental Controls
o Disinfection in Ambulatory Care, Home Care, and the Home
 Selected Issues in Infection Control: Common Diseases/Conditions
o Hospital-Acquired Pneumonia
 o Primary Prevention and Control of Healthcare Associated Legionnaires
Disease
o Prevention and Control of Healthcare Associated Pertussis
o Prevention and Control of Healthcare-Associated Pulmonary Aspergillosis
o Prevention and Control of Healthcare-Associated Adenovirus, Parainfluenza
Virus, and Respiratory Syncytial Virus Infections
o Prevention and Control of Healthcare-Associated Influenza
o Infectious and Communicable Disease Control among Healthcare
Professionals
 Sepsis Awareness and education
o Epidemiology of Sepsis; The Scope of the Problem
o The New York State Sepsis Improvement Initiative, Rory’s Law, and the New
York State Infection Control Training Requirements
o Signs and Symptoms of Sepsis: Early Identification for Early Treatment
o Common Sources of Sepsis
o Public Education
 Conclusion
 References
 Management of Equipment and Surfaces in Dentistry

Outcomes

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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

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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

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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

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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.

Disease/Condition Organism Mode of Transmission

Acquired immunodeficiency  Human immunodeficiency virus  Sexual

syndrome (AIDS)
 Percutaneous

 Prenatal

Stage 1

 HIV is passed from one person to another. Th

the bloodstream to many different p

Amebiasis  Entamoeba histolytica  Contaminated water

 Contact with raw vegetab

 Amebiasis - Life Cycle

Chancroid  Haemophilus ducreyi  Sexual

Chickenpox  Varicella zoster  Airborne

 Photograph of Chicken P

Cholera  Vibrio cholerae  Ingestion of water

 contaminated with human

Creutzfeldt-Jacob disease  Prion protein  Unknown in most case

Cryptococcosis  Cryptococcus neoformans  Inhalation, tissue inoculation, gast

 Cryptococcus gatti  No person-to-person spread (Maziarz

Cyptosporidiosis  Cryptosporidium species  Ingestion of contaminated

 Disease/Condition Organism Mode of Transmission

 Direct contact with carri

Cytomegalovirus (CMV)  Cytomegalovirus  Transfusion

 Transplant

 Sexual

 Perinatal

 Breast milk

 Contact with mucous membranes, s

Diarrheal diseases  Campylobacter species  Ingestion of contaminated food

 Clostridium difficile  Fecal-oral

 Efficient transfer by healthcare profess

 Salmonella species  Ingestion of contaminated food

 Shigella species  Ingestion of contaminated food

 Direct contact with carri

 Yersinia species  Ingestion of contaminated food

 Direct contact with carri

 Blood transfusion (Rare

Giardiasis  Giardia lamblia  Fecal-oral transmission

 Ingestion of contaminated wate

 The risk of acquiring Giardia infection fro

However, there are some steps you can t
(CDC, 2015c)
 Disease/Condition Organism Mode of Transmission

Gonorrhea  Neisseria gonorrhoeae  Sexual contact

Hand, foot, and mouth disease  Viruses of the Enterovirus genes direct  Direct contact with nose and throat secretio
infected persons

Foodborne hepatitis  Hepatitis A  Ingestion of contaminated food or drink cont

fecal material, Direct contact w
 Hepatitis E
 Raw or uncooked meat, contact with

Bloodborne hepatitis  Hepatitis B  Blood, seman, and other body fluids,

 Hepatitis C  Blood, sexual contact, and per

 Hepatitis D  Only occurs in people infected with hepat

Herpangina  Coxsackie virus  Direct contact with nose and throat secreti
infected persons

Herpes simplex  Human herpes virus 1 and 2  Contact with mucous membrane secretions

Histoplasmosis  Histoplasma capsulatum  Inhalation of airborne spo

Hookworms  Necator americanus  Contact with soil contaminated

 Ancyclostoma deodenale  Hookworm Life Cycle

Impetigo  Staphylococcus aureus (most  Contact with carrier

common), Streptococcus pyogenes
 Photograph of Impetig

Influenza  Influenza virus A, B, or C  Droplet spread

Legionnaires’ disease  Legionella pneumonphila  Airborne from water sou

Listeriosis  Listeria monocytogenes  Perinatal

 Disease/Condition Organism Mode of Transmission

 Sexual

Lyme disease  Borrelia burgdorferi  Tick bite

 Blacklegged Tick Imag

 Relative sizes of several ticks at different li

adult ticks are approximately the size o
nymphal ticks are approximately the s

 Tick Bite Image

Lymphogranuloma venereum  Chlamydia trachomatis  Sexual

Malaria  Plasmodium vivax  Bite from genus Anopheles m

 Plasmodium malariae  Malaria Life Cycle

 Plasmodium falciparum

 Plasmodium ovale

Measles  Measles virus  Droplet spread and Airbo

 Measles image

Meningococcal meningitis or  Neisseria meningitidis  Contact with pharyngeal secretions, p

bacteremia

Mononucleosis  Epstein Barr virus  Usually by contact with oral and pharynge
blood and semen during sexual contac
infected blood or orga

Mycobacterial diseases (non-  Mycobacterium avium  Variable: probably contact with soil, water, o
tuberculosis) Mycobacterium sources. Not transmissible pers
species
 Mycobacterium kansaii

 Mycobacterium fortuitum

 Mycobacterium gordonae

Mycoplasma  Mycoplasma pneumonia  Droplet inhalation

 Disease/Condition Organism Mode of Transmission

pulmonary tract infections

Pediculosis  Pediculus humanus capitus (head louse)  Direct contact

 Pediculus humanus corporis (body louse)  Head & Body Louse Ima

 Phthirus pubis (crab louse)  Sexual

 Crab Louse Image

Pinworm  Enterobius vermicularis  Direct contact with egg-contaminated articl

 Pinworm - Life Cycle

Pneumocystis pneumonia  Pneumocystis jiroveci  Inhalation

 Pneumocystis Pneumonia S

Pneumococcal pneumonia  Streptococcus pneumoniae  Droplet spread

Rabies  Rabies virus  Direct contact of virus-laden saliva of a rabi

scratch. Transmission by aerosol and org
been reported.

 The Infectious Path of the Rab

Respiratory syncytial disease  Respiratory syncytial virus  Self-inoculation by touching mouth or no

infectious respiratory sec

Ringworm  Microsporum species  Direct and indirect contact wit

 Trychophton species  Ringworm images

 Epidermophyton floccosum

Rocky Mountain Spotted  Rickettsia rickettsii  Tick bite

fever
 Rocky mountain image
 Disease/Condition Organism Mode of Transmission

Rotavirus gastroenteritis  Rota virus  Fecal, oral

Rubella  Rubella virus  Droplet spread

 Direct contact

Scabies  Sarcoptes scabiei  Direct skin

 Scabies image

Staphylococci  Staphylococcus aureus  Direct contact with draining

 Coagulase-negative:  Auto-infection from colonize

o S. epidermdidis

o S. haemolyticus

Streptococci  Streptococcus groups A with about 80  Large respiratory drople

serologically distinct types
 Direct contact with secret

 Ingestion of contaminated

Syphilis  Treponema pallidum  Sexual

 Syphilis Images

Tetanus  Clostridium tetani  Entry through broken sk

Trichinosis  Trichinella spiralis  Ingestion of insufficiently cooked food, esp

Tuberculosis  Mycobacterium tuberculosis  Airborne

Typhoid fever  Salmonella typhi  Ingestion of contaminated food

 Typhoid images
 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

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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

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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.

o Do not administer medications from a syringe to multiple patients, even if

the needle or cannula on the syringe is changed.

o 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.

o Consider a syringe or needle/cannula contaminated once used to enter or

connect to a patient's intravenous infusion bag or administration set.

o Use needle-free systems when transferring solutions between containers.

 Use single-dose vials for parenteral medications whenever possible.

o Do not administer medications from single-dose vials or ampules to

multiple patients or combine leftover contents of single-dose vials for later
use.

o 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.

o 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.

o Always use a new, sterile needle to access a multi-dose vial.

o 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:

o 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 (varicella) Until lesions are crusted, and no new lesions ap

Herpes zoster (disseminated) Duration of illness

Herpes zoster (localized in Duration of illness

immunocompromised patient)

Measles (rubeola) Duration of illness

 Smallpox Duration of illness

Tuberculosis (pulmonary or laryngeal, Depends upon clinical response; patient must be on effective therapy, be improving clinically (decreased
confirmed or suspected) and have three consecutive negative sputum smears collected on different

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 P

Invasive Haemophilus influenzae type b disease, including meningitis, Until 24 hours after initiation o
pneumonia, and sepsis

Invasive Neisseria meningitidis disease, including meningitis, pneumonia, Until 24 hours after initiation o
epiglottis, and sepsis

Diphtheria (pharyngeal) Until antibiotic therapy has finished and two cultures

Mycoplasma pneumoniae infection Duration of illn

Pneumonic plague Until five days after effective the

Streptococcal pharyngitis, pneumonia, or scarlet fever in infants and young Until 24 hours after initiation o
children, streptococcal pneumonia

Adenovirus infection in infants and young children Duration of illn

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

and respiratory symptoms have resol

Mumps For 9 days after onset o

Parvovirus B19 Maintain precautions for duration of hospitalization when chronic disea
transient aplastic crisis or red-cell crisis, m

Rubella (German measles) Until 7 days after ons

Meningococcal disease, including meningitis, pneumonia, and sepsis Until 24 hours after initiation o

Rhinovirus Duration of illn

Severe acute respiratory syndrome (SARS) Duration of the illness plus 10 days after resolution of the fever, if respira
and Contact Precautio

Streptococcal diseases, major burn Until 24 hours after initiation o

Viral hemorrhagic fevers Duration of illn

Pertussis Until five days after initiation o

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 Perio

Infection or colonization with multidrug-resistant bacteria Until off antibiotics and cultur

Clostridium difficile enteric infection Duration of illness

Gastroenteritis/ multiple different organisms, eg., E.coli, Shigella, in Duration of illness

diapered or incontinent patient

Hepatitis A, in diapered or incontinent patient Duration of illness

Rotavirus infection, in diapered or incontinent patient Duration of illness

Respiratory syncytial virus infection, in infants and young children Duration of illness

Parainfluenza virus infection, respiratory, in infants or young Duration of illness

children

Enteroviral infection, in diapered or incontinent patient Duration of illness

Scabies Until 24 hours after initiation of eff

Diphtheria (cutaneous) Until two cultures taken 24 hours ap

Herpes simplex virus infection (neonatal or mucutaneous) Until lesions are dry and c

Impetigo Until 24 hours after initiation of eff

Major abscesses, cellulitis, or decubiti, or wound infections Until 24 hours after initiation of eff

Pediculosis (lice) Until 24 hours after initiation of eff

Rubella, congenital syndrome Place infant on precautions during any admission until 1 year of age, unless nasop
months

Staphylococcal furunculosis in infants and young children Duration of illness

 Diseases Requiring Contact Precautions

Disease Precautionary Perio

Acute viral (acute hemorrhagic) conjunctivitis Duration of illness

Viral hemorrhagic infections (Ebola, Lassa, Marburg) Duration of illness

Zoster (chickenpox, disseminated zoster, or localized zoster in Until all lesions are crus
immunodeficient patient) Requires airborne precau

Smallpox Duration of illness

Requires airborne precau

Bronchiolitis Duration of illness

Human metapneumovirus Duration of illness

Monkeypox Until lesions are crusted. Airborne Pre

Parovirus B19 Maintain precautions for duration of hospitalization when chronic disease occur
aplastic crisis or red-cell crisis, maintain precautions for

Pneumonia, adenovirus Duration of illness

Poliomyelitis Duration of illness

Respiratory infectious disease, acute, infants and young children Duration of illness

Ritter’s disease (Staphylococcal scalded skin syndrome) Duration of illness

Severe acute respiratory syndrome (SARS) Duration of illness. Airborne Precautions and D

Tuberculosis/draining lesion Until the patient is improved, the drainage has stopped, and there are t

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

19
Bi 2 4 6 12 15 - 7- 11- 13- 16-
Vaccin 1 9 18 2-3 4-6
rt m m m m m 23 10 12 15 18
e mo mos mos yrs yrs
h os os os os os m yrs yrs yrs yrs
os

Hepatit 1st 2nd 2 3r 3rd 3r 3r 3rd

is do dos n d dose d d dose
B1(Hep se e d do do do
Immunization Schedule 0-18 Years

19
Bi 2 4 6 12 15 - 7- 11- 13- 16-
Vaccin 1 9 18 2-3 4-6
rt m m m m m 23 10 12 15 18
e mo mos mos yrs yrs
h os os os os os m yrs yrs yrs yrs
os

d
B) os se se se
e

Rotavir
us(RV) 2
1s
RV-1 n
t
(2-dose d
d
series); d
os
RV-5 os
e
(3-dose e
series)

Diphth
eria,
tetanus, 2
1s
& n 3r 4t
t 5th
acellula d d h 4th
d dos
r d do do dose
os e
pertussi os se se
e
s e
(DTaP:
<7 yrs)

Tetanu
s,
diphthe
ria,
tetanus,
& (Tda
acellula p)
r
pertussi
s
(Tdap:
> 7 yrs)

3r 3r
Haemo 2
1s d d
philus n 3r
t or or
influen d d
d 4t 4t
zae d do
os h h
type b os se
e do do
(Hib) e
se se

Pneum 2
1s
ococcal n 3r 4t 4t
t
conjuga d d h h
d
te d do do do
os
(PCV13 os se se se
e
) e
Immunization Schedule 0-18 Years

19
Bi 2 4 6 12 15 - 7- 11- 13- 16-
Vaccin 1 9 18 2-3 4-6
rt m m m m m 23 10 12 15 18
e mo mos mos yrs yrs
h os os os os os m yrs yrs yrs yrs
os

Pneum
ococcal
polysac
charide
(PPSV2
3)

Inactiv
2
ated 1s
n 3r 3r 3r
poliovir t 4th
d d 3rd d d 3rd
us d dos
d do dose do do dose
(IPV) os e
os se se se
(<18yea e
e
rs)

p. p.a
p.a p.a p.a p.a. p.a. p.a. p.a.
a. .
Influen p.a. . . p.a. . vac vac vac p.a. vac
va vac
za (IIV; vacc va va vacc va c. c. c. vacc. c.
cc c.
LAIV) . cc. cc. . cc. (II (II (II (IIV (II
. (II
2 doses (IIV (II (II (IIV (II V V V or V
(II V
for only V V only V or or or LAI or
V or
some ) on on ) on LA LA LA V) LA
on LA
ly) ly) ly) IV) IV) IV) IV)
ly) IV)

Measles
, 2n
1st 1st
Mumps d
do do
, dos
se se
Rubella e
(MMR)

2n
Varicell 1st 1st
d
a do do
dos
(VAR) se se
e

2 2 2
2
Hepatit do do do
dose
is A se se se
serie
(HepA) ser ser ser
s
ies ies ies

Human 3
papillo dose
maviru serie
s s
(HPV2:
females
only;
HPV4:
 Immunization Schedule 0-18 Years

19
Bi 2 4 6 12 15 - 7- 11- 13- 16-
Vaccin 1 9 18 2-3 4-6
rt m m m m m 23 10 12 15 18
e mo mos mos yrs yrs
h os os os os os m yrs yrs yrs yrs
os

males
and
females
)

Mening
ococcal
(Hib-
MenCY 1st boo
>6 dose ster
wks;
MCV4-
< 9mos;

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

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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
 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

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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

o uncertainty exists about the nature of the soil on the surfaces (e.g., blood
or body fluid contamination versus routine dust or dirt), or

o 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 identificati

Internal CI's should be used within each pouch or package, tray, or container. Clas
monitoring and biological indicator testing for verifying the efficacy of

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:

o when a specific instrument is needed for an emergency procedure;

o when a non-replaceable instrument has been contaminated but needs to

be used immediately, and;

o 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.

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).

Disinfection in Ambulatory Care, Home Care, and the Home

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.

Selected Issues in Infection Control: Common Diseases/Conditions

 Return to Menu

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 H O. 2

 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:

o contact the local or state health department or the CDC if the disease is
reportable in the state or if assistance is needed;

o conduct an epidemiologic investigation by retrospectively reviewing of

microbiologic, serologic, and postmortem data to identify previous cases,
and

o 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:

o 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;

o 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

o 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:

o 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

o 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

o women in their third trimester of pregnancy and infants;

o 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;

o 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

o 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

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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 

o 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

o 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

 Return to Menu

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.

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 Management of Equipment and Surfaces in Dentistry

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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.

Select one of the following methods to complete this course.

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