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Isolation
• SecondPrecautions
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level
• Third level
•DR/ MARWA
Fourth levelSHABBAN ELSAYED
• Fifth level
Dr/Shimaa Ahmed Abdel Salam
Associate professors of medical microbiology,
Immunology, and Infection Control
 Transmission of infectious agents within a
healthcare setting requires three elements:

1. A source (or reservoir) of infectious agents

2. A susceptible host with a portal of entry receptive to

the agent

3. A mode of transmission for the agent

https://www.cdc.gov/hicpac/2007IP/2007isolationPrecautions.html
The occurrence of infection requires
all the following (Chain of infection):
• The goal of a successful infection control program
is to break the chain of infection by practicing
protocols which would prevent the infectious
agents moving from one host to another.
This is accomplished by two main categories of precautions
as follows:
I- Standard precautions: They are used for ALL PATIENTS, as
they are the primary strategy of preventing transmission of
microorganisms in health care facilities.
II- Transmission based isolation precautions:
• They are recommended to contain highly transmissible
microorganisms and is based on the mode of transmission
of the specific pathogens.
• They include contact, droplet and airborne isolation
precautions.
 Transmission Based Precautions
• Hand Hygiene
Contact Precautions • Gown
• Gloves

• Hand Hygiene
Droplet Precautions • Mask

Airborne Precautions • Hand Hygiene

• Negative pressure room
• N-95 Respirator mask
https://www.cdc.gov/hicpac/2007IP/2007isolationPrecautions.html
 I-Contact Precautions (CP)

• Contact Precautions apply to specified

patients known or suspected to be infected
or colonized with epidemiologically
important microorganisms that can be
transmitted by direct or indirect contact.
 Examples of disease transmitted by contact:
• Gastrointestinal, respiratory, skin, or wound infections or
colonization with multidrug resistant bacteria that have
been demonstrated to cause heavy environmental
contamination , such as vancomycin- resistant
Enterococci(VRE), methicillin – Staphylococcus aureus (MRSA)
• Enteric infections with a low infectious dose or prolonged
environmental survival, including:
➢ Clostridium difficile
➢ For diapered or incontinent patients: E.coliO157:H7, shigella,
hepatitis A, or rotavirus
➢Respiratory syncytial virus, parainfluenza virus in infants and
young children
Skin infections that are highly contagious
or that may occur on dry skin, including:

➢Diphtheria(cutaneous)
➢Herpes simplex virus(neonatal or mucocutaneous)
➢Impetigo
➢Major(non contained) abscesses, cellulitis
➢Pediculosis
➢Scabies
➢Staphylococcal frunculosis
➢Zoster
➢Viral/haemorrhagic conjunctivitis
➢Viral haemorrhagic infections (Ebola, Lassa, or Marburg)
Recommendations for contact precautions
include:

• Patient placement
• Hand hygiene & PPE (Gloves and Gowns)
• Patient transport
• Patient –care equipment
• Environmental measures
Patient placement

• In acute care hospitals, place patients who require

Contact Precautions in a single patient room when
available
• When single-patient rooms are in short supply, apply
the following principles for making decisions on
patient placement:
✓Prioritize patients with conditions that may facilitate
transmission (e.g., uncontained drainage, stool
incontinence) for single-patient room placement.
✓Place together in the same room (cohort) patients
who are infected or colonized with the same
pathogen and are suitable roommates
If it becomes necessary to place a patient who requires,
Contact Precautions in a room with a patient who is not
infected or colonized with the same infectious agent:
o Avoid placing patients on Contact Precautions in the same
room with patients who have conditions that may increase the
risk of adverse outcome from infection or that may facilitate
transmission (e.g., those who are immunocompromised, have
open wounds, or have anticipated prolonged lengths of stay).
o Ensure that patients are physically separated (i.e., >3 feet
apart) from each other.
o Draw the privacy curtain between beds to minimize
opportunities for direct contact.)
o Change protective attire and perform hand hygiene
between contact with patients in the same room, regardless of
whether one or both patients are on contact precautions.
Personal protective equipment
In addition to standard precautions
Gloves and Gowns
• Wear gloves whenever touching the patient’s intact
skin or surfaces and articles near to the patient (e.g.,
medical equipment, bed rails).
• Wear a gown whenever anticipating that clothing will
have direct contact with the patient or potentially
contaminated environmental surfaces or equipment
near to the patient.
• Don gloves & gown upon entry into the room or
cubicle.
• Remove gloves & gown before leaving the
patient’s room and wash hands immediately with
an antimicrobial agent or waterless antiseptic
agent.

• After PPE removal and hand hygiene, ensure that

hands don’t touch potentially contaminated
environmental surfaces or items in the patient’s
room to avoid transfer of microorganisms to other
patients or environments.
Patient transport

• Limit transport and movement of patients outside of

the room to medically-necessary purposes.
• When transport or movement in any healthcare
setting is necessary, ensure that infected or colonized
areas of the patient’s body are contained and
covered.
• Remove and dispose of contaminated PPE and
perform hand hygiene prior to transporting patients
on Contact Precautions.
• Don clean PPE to handle the patient at the transport
destination.
Patient-care equipment and
instruments/devices
• When possible, dedicate the use of noncritical
patient-care equipment to a single patient (or cohort
of patients infected or colonized with the pathogen
requiring precautions) to avoid sharing between
patients
• If common use of equipment for multiple patients is
unavoidable, clean and disinfect such equipment
before use on another patient
 Environmental measures

• Ensure that rooms of patients on Contact Precautions are

prioritized for frequent cleaning and disinfection (e.g., at
least daily) with a focus on frequently-touched surfaces
(e.g., bed rails, overbed table, bedside commode, lavatory
surfaces in patient bathrooms, doorknobs) and equipment
in the immediate vicinity of the patient.
• Environmental service workers should don gown and gloves
before room entry.
• Some viruses and spore-forming organisms (e.g.
Clostridium difficile, Norovirus) are resistant to traditional
disinfectants, and use of a 1:10- dilution of bleach solution
is recommended. Bleach is used as an adjunct to cleaning.
 II-Droplet Precautions

• Droplet precautions prevent transmission of diseases

caused by large respiratory droplets.
• Respiratory droplets are generated when an infected
person coughs, sneezes, or talks or during
procedures such as suctioning, endotracheal
intubation, cough induction by chest physiotherapy
and cardiopulmonary resuscitation.
✓Studies have shown that the nasal mucosa,
conjunctivae and less frequently the mouth, are
susceptible portals of entry for respiratory viruses.
✓Respiratory droplets carrying infectious pathogens
transmit infection when they travel directly from the
respiratory tract of the infectious individual to
susceptible mucosal surfaces of the recipient,
generally over short distances, necessitating facial
protection(<3 feet around the patient).
• Because droplets do not remain
suspended in the air, special air
handling and ventilation are not
required to prevent droplet
transmission.
Droplet precautions apply to any patient known or suspected
to be infected with epidemiologically important pathogens
that can be transmitted by infectious droplets :

➢Invasive Hemophilus influenzae type b disease

➢Neisseria meningitides disease
➢Diphtheria(pharyngeal)
➢Mycoplasma pneumonia
➢Pertussis
➢Pneumonic plaque
➢Streptococcal (group A) pharyngitis, pneumonia, or scarlet
fever in infants and young children
➢Viral (Adenovirus , influenza , Mumps , Rubella ,SARS-CoV)
In addition to standard precautions
Patient placement
• Place patients who require Droplet Precautions in a
single patient room when available
• When single-patient rooms are in short supply, apply
the following principles for making decisions on patient
placement:
✓Prioritize patients who have excessive cough and
sputum production for single-patient room placement.
✓Place together in the same room (cohort) patients who
are infected with the same pathogen and are suitable
roommates
• If it becomes necessary to place a patient who requires
Droplet Precautions in a room with a patient who does
not have the same infection:
o Avoid placing patients on Droplet Precautions in the same room
with patients who have conditions that may increase the risk of
adverse outcome from infection or that may facilitate
transmission (e.g., those who are immunocompromised, have
anticipated prolonged lengths of stay).
o Ensure that patients are physically separated (i.e., >3 feet apart)
from each other.
o Draw the privacy curtain between beds to minimize
opportunities for close contact. Change protective attire and
perform hand hygiene between contact with patients in the
same room, regardless of whether one or both patients are on
droplet precautions.
• Special air handling and ventilation are not
necessary.
• In ambulatory settings, place patients who require
Droplet Precautions in an examination room or
cubicle as soon as possible.
• Instruct patients to follow recommendations for
Respiratory Hygiene/Cough Etiquette.
• Mask the patient or have HCWs don surgical masks on
room entry.
Mask
• In addition to wearing a mask as outlined under Standard
Precautions, Don a mask upon entry into the patient room
or cubicle.
• Handle items contaminated with respiratory secretions (e.g.
tissues) with gloves.
• Change PPE between patients.
Patient transport
• Limit transport and movement of patients outside of the
room to medically-necessary purposes.
• If transport or movement is necessary, instruct patient to
wear a mask and follow Respiratory Hygiene/Cough
Etiquette
• No mask is required for persons transporting patients on
Droplet Precautions.
Environmental measures

• Daily cleaning and frequent disinfection of the high

touch surfaces is recommended.
• Environmental services workers should don a surgical
mask before room entry.
 III-Airborne Precautions

• They are used to prevent transmission of infectious organisms

that remain suspended in the air and travel great distances.
• Airborne transmission occurs by dissemination of either
airborne droplet nuclei or small particles in the respirable size
range containing infectious agents that remain infective over
time and distance (e.g., spores of Aspergillus spp, and
Mycobacterium tuberculosis).
• Microorganisms carried in this manner may be dispersed over
long distances by air currents and may be inhaled by
susceptible individuals who have not had face-to-face contact
with (or been in the same room with) the infectious individual.
• Other infectious agents to which this applies include rubeola
virus (measles), and varicella-zoster virus (chickenpox). In
addition, published data suggest the possibility that variola
virus (smallpox) may be transmitted over long distances
through the air under unusual circumstances.
Transmission from the environment:
Some airborne infectious agents are derived from the
environment and do not usually involve person-to
person transmission. For example, anthrax spores,
spores of environmental fungi (e.g., Aspergillus
spp.),Legionella.
New Classification for airborne transmission :

▪ Obligate: (e.g., tuberculosis);

▪ Preferential: (e.g. measles, varicella);
▪ Opportunistic (Influenza, SARS,COVID-19)
▪ Transmission from the environment [anthrax
spores, Spores of environmental fungi (e.g.,
Aspergillus spp.),]. No person to person
transmission
Patient placement

Place patients who require Airborne Precautions in

an AIIR that has been constructed in accordance
with current guidelines.
▪ Provide at least six (existing facility) or 12 (new
construction/renovation) air changes per hour.
▪ Direct exhaust of air to the outside or air is
directed through HEPA filters.
▪ Keep the AIIR door closed when not required
for entry and exit.
When an AIIR is not available:

➢Transfer the patient to a facility that has an available

AIIR.
➢An air –conditioned single room with an exhaust or a
well -ventilated room is an adequate options for
health care facilities without negative pressure room.
➢If an air- conditioned single room is not available, a
suction fan can be placed in the room to direct airflow
towards an outside window and the door should be
kept always closed.
In the event of an outbreak or exposure
involving large numbers of patients who require
Airborne Precautions:
➢Place together (cohort) patients who are presumed to
have the same infection( based on clinical
presentation and diagnosis when known) in areas of
the facility that are away from other patients,
especially patients who are at increased risk for
infection (e.g., immunocompromised patients).
➢Use temporary portable solutions (e.g., exhaust fan)
to create a negative pressure environment in the
converted area of the facility.
➢Discharge air directly to the outside, away from
people and air intakes, or direct all the air through
HEPA filters before it is introduced to other air spaces
In ambulatory settings:

➢Develop systems (e.g., triage) to identify patients

with known or suspected infections that require
Airborne Precautions upon entry into ambulatory
settings
➢Place the patient in an AIIR as soon as possible.
➢If an AIIR is not available, place a surgical mask on the
patient and place him/her in an examination room.
➢Once the patient leaves, the room should remain
vacant for the appropriate time, generally one hour,
to allow for a full exchange of air
Personnel restrictions

Restrict susceptible healthcare personnel from entering

the rooms of patients known or suspected to have
measles (rubeola), varicella (chickenpox), disseminated
zoster, or smallpox if other immune healthcare
personnel are available.
Respiratory protection

Wear a fit-tested NIOSH-approved N95 or higher-level

respirator for respiratory protection when entering the
room or home of a patient with known or suspected
Infectious pulmonary tuberculosis
Seal check
Patient transport

• Limit transport and movement of patients outside of the

room to medically-necessary purposes.
• If transport or movement outside an AIIR is necessary,
instruct patients to wear a surgical mask, if possible, and
observe Respiratory Hygiene/Cough Etiquette.
• For patients with skin lesions associated with varicella or
smallpox or draining skin lesions caused by M.
tuberculosis, cover the affected areas to prevent
aerosolization or contact with the infectious agent in skin
lesions.
• Healthcare personnel transporting patients who are on
Airborne Precautions do not need to wear a mask or
respirator during transport if the patient is wearing a mask
and infectious skin lesions are covered.
 Environmental measures
• Routine cleaning and disinfection of the high touch
surfaces is recommended.
• Environmental services workers should don the N-95
respirator on room entry.
• After the patient has left the examination room or the
patient room, the room should remain unoccupied
for enough time to allow for complete air exchange
to occur.
 Discontinuation of transmission -based
precautions
• Transmission-Based Precautions remain in effect for limited
periods of time (i.e., while the risk for transmission of the
infectious agent persists or for the duration of the illness
• For most infectious diseases, this duration reflects known
patterns of persistence and shedding of infectious agents
associated with the natural history of the infectious process and
its treatment.
• For some diseases (e.g., pharyngeal or cutaneous diphtheria,
RSV), Transmission-Based Precautions remain in effect until
culture or antigen-detection test results document eradication
of the pathogen, and, for RSV, symptomatic disease is resolved.
• In immunocompromised patients, viral shedding can persist for
prolonged periods of time (many weeks to months) and
transmission to others may occur during that time; therefore,
the duration of contact and/or droplet precautions may be
prolonged for many weeks.
 Syndromic and empiric application of
transmission -based precautions

While it’s not possible to identify prospectively all

patients needing transmission -based precautions,
certain clinical syndromes and conditions carry a
sufficiently high risk to warrant their use empirically
while confirmatory tests are pending.
Ex. Diarrhea in an adult with a history of recent
antibiotic use( contact isolation as potential pathogen
is clostridium difficile )
Bacteria Meningitis (Droplet Precautions for first 24
hrs of antimicrobial therapy)
 Protective Environment(PE)

Protective environment includes engineering and

design interventions that decrease the risk of exposure
to environmental fungi for severely
immunocompromised allogeneic hematopoietic stem
cell transplant(HSCT) patients during their highest risk
phase, usually the first 100 days post transplant, or
longer in the presence of graft-versus-host disease.
Components of PE:

I. Patients: allogeneic hematopoeitic stem cell

transplant (HSCT) only
• Maintain in PE room except for required diagnostic or
therapeutic procedures that cannot be performed in
the room, e.g. radiology, operating room
• Respiratory protection e.g., N95 respirator, for the
patient when leaving PE during periods of
construction
II. Standard and Expanded Precautions

• Hand hygiene observed before and after patient

contact
• Use of gown, gloves, mask by HCWs and visitors
according to Standard Precautions and as indicated
for suspected or proven infections for which
Transmission-Based Precautions are recommended
III. Engineering

• Filtered incoming air using Central or point-of-use HEPA

(99.97% efficiency) filters
• Well-sealed rooms (including sealed walls, floors, ceilings,
windows, electrical outlets) to prevent flow of air from the
outside.
• Ventilation to maintain >12 air changes per hour.
• Directed room airflow with the air supply on one side of
the room that moves air across the patient bed and out
through an exhaust on the opposite side of the room.
Positive room air pressure in relation to the corridor
• Self-closing door on all room exits
• For patients who require both a PE and Airborne
Infection Isolation, positive air pressure is maintained in
the patient room with relation to the anteroom. Air in
the anteroom is filtered with a HEPA filtration unit.
If an anteroom is not available, place patient in an AIIR
and use portable HEPA unit to filter the air inside the
patient room for fungal spores.
IV.Surfaces

• Daily wet-dusting of horizontal surfaces using cloths

moistened with EPA-registered hospital
disinfectant/detergent
• Avoid dusting methods that disperse dust
• No carpeting in patient rooms or hallways
• Lower dust levels by using smooth, nonporous
surfaces and finishes that can be scrubbed, rather
than textured material.
V.Other

• No flowers (fresh or dried) or potted plants in PE

rooms or areas
• Use vacuum cleaner equipped with HEPA filters
when vacuum cleaning is necessary
 How to apply transmission- based isolation
precautions in protective environment???
• Droplet and Contact Precautions: implement as recommended.
▪ Immunocompromised patients may experience prolonged
shedding of organisms and may need precautions for longer
than anticipated.
▪ Airborne Precautions: could be implemented in the Protected
Environment if an anteroom is present. Positive air pressure is
maintained in the patient room with relation to the anteroom. Air in
the anteroom is filtered with a HEPA filtration unit.
▪ If an anteroom is not available, place the patient in an AIIR not on
the Protected Environment and use a portable HEPA unit to filter the
air inside the patient room for fungal spores.
➢ Private room
Negative air pressure in relation to the corridor
Criteria of isolation room

▪ Optimal number according to

guidelines
Must be separated from other patients
▪ Signs are placed
▪ A single room with an en suite toilet
and a basin for hand washing
▪ Special air handling and ventilation
when indicated
▪ Minimize number of staff and visitors