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Page 1 of 206 Accessable version : https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings Last update: July 2019 Jane D. Siegel, MD; Emily Rhi nehart, RN MPH CIC; Marguerite Jackson, PhD; Linda Chiarello, RN MS; the Healthcare Infection Control Practices Advisory Committee Acknowledgement: The authors and HICPAC gratefully acknowledge Dr. Larry Strausbaugh for his many contributions and valued guidance in the preparation of this guideline. Suggested citation: Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee, 2007 Guideline for Isolation Precautions: Preventing Transmission of Infe ctious Agents in Healthcare Settings https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html

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Guideline for Isolation Pr ecautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007) Last update: July 2019 Page 2 of 206 Healthcare Infection Control Practices Advisory Committee (HICPAC): Chair Patrick J. Brennan, MD Professor of Medicine Division of Infectious Diseases University of Pennsylvania Medical School Executive Secretary Michael Bell, MD Division of Healthcare Quality Promotion National Center for Infectious Diseases Centers for Disease Control and Prevention Member s BRINSKO, Vicki L., RN, BA Infection Control Coordinator Vanderbilt University Medical Center DELLINGER, E. Patchen., MD Professor of Surgery University of Washington School of Medicine ENGEL, Jeffrey, MD Head General Communicable Disease Control Branch North Carolina State Epidemiologist GORDON, Steven M., MD Chairman, Department of Infections Diseases Hospital Epidemiologist Cleveland Clinic Foundation Department of Infectious Disease HARRELL, Lizzie J., PhD, D(ABMM) Research Professor of Molecular Genetics, Microbiology and Pathology Assoc iate Director, Clinical Microbiology Duke University Medical Center O™BOYLE, Carol, PhD, RN Assistant Professor, School of Nursing University of Minnesota PEGUES, David Alexander, MD Division of Infectious Diseases David Geffen School of Medicine at UCLA PERROTTA, Dennis M. PhD., CIC Adjunct Associate Professor of Epidemiology University of Texas School of Public Health Texas A&M University School of Rural Public Health PITT, Harriett M., MS, CIC, RN Director, Epidemiology Long Beach Memorial Medical Center RAMSEY, Keith M., MD Professor of Medicine Medical Director of Infection Control The Brody School of Medicine at East Carolina University SINGH, Nalini, MD, MPH Professor of Pediatrics Epidemiology and International Health The George Washington University Children™s National Medical Center STEVENSON, Kurt Brown, MD, MPH Division of Infectious Diseases Department of Internal Medicine The Ohio State University Medical Center SMITH, Philip W., MD Chief, Section of Infectious Diseases Department of Internal Me dicine University of Nebraska Medical Center HICPAC membership (past) Robert A. Weinstein, MD (Chair) Cook County Hospital Chicago, IL Jane D. Siegel, MD (Co -Chair) University of Texas Southwestern Medical Center Dallas, TX Michele L. Pearson, MD (Executi ve Secretary) Centers for Disease Control and Prevention Atlanta, GA

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Guideline for Isolation Pr ecautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007) Last update: July 2019 Page 3 of 206 Raymond Y.W. Chinn, MD Sharp Memorial Hospital San Diego, CA Alfred DeMaria, Jr, MD Massachusetts Department of Public Health Jamaica Plain, MA James T. Lee, MD, PhD University of Mi nnesota Minneapolis, MN William A. Rutala, PhD, MPH University of North Carolina Health Care System Chapel Hill, NC William E. Scheckler, MD University of Wisconsin Madison, WI Beth H. Stover, RN Kosair Children™s Hospital Louisville, KY Marjorie A. Underw ood, RN, BSN CIC Mt. Diablo Medical Center Concord, CA HICPAC Liaisons William B. Baine, MD Liaison to Agency for Healthcare Quality Research Joan Blanchard, RN, MSN, CNOR Liaison to Association of periOperative Registered Nurses Patrick J. Brennan, MD Lia ison to Board of Scientific Counselors Nancy Bjerke, RN, MPH, CIC Liaison to Association of Professionals in Infection Prevention and Control Jeffrey P. Engel, MD Liaison to Advisory Committee on Elimination of Tuberculosis David Henderson, MD Liaison to N ational Institutes of Health Lorine J. Jay MPH, RN, CPHQ Liaison to Healthcare Resources Services Administration Stephen F. Jencks, MD, MPH Liaison to Center for Medicare and Medicaid Services Sheila A. Murphey, MD Liaison to Food and Drug Administration Mark Russi, MD, MPH Liaison to American College of Occupational and Environmental Medicine Rachel L. Stricof, MPH Liaison to Advisory Committee on Elimination of Tuberculosis Michael L. Tapper, MD Liaison to Society for Healthcare Epidemiology of America Robert A. Wise, MD Liaison to Joint Commission on the Accreditation of Healthcare Organizations Authors™ Associations Jane D. Siegel, MD Professor of Pediatrics Department of Pediatrics University of Texas Southwestern Medical Center Emily Rhinehart RN MPH C IC CPHQ Vice President AIG Consultants, Inc. Marguerite Jackson, RN PhD CIC Director, Administrative Unit, National Tuberculosis Curriculum Consortium, Department of Medicine University of California San Diego Linda Chiarello, RN MS Division of Healthcare Quality Promotion National Center for Infectious Diseases, CDC

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Guideline for Isolation Pr ecautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007) Last update: July 2019 Page 4 of 206 TABLE OF CONTENTS Updates . 7 Executive Summary . 8 Parts I – III: Review of the Scientific Data Regarding Transmission of Infectious Agents in Healthcare Settings 9 Tables, Appendices, and Other Information 10 Appendix A: Type and Duration of Precautions Recommended for Selected Infections and Conditions . 10 Pre – Publication of the Guideline on Preventing Transmission of MDROs .. 11 Summary .. 11 Part I: Review o f Scientific Data Regarding Transmission of Infectious Agents in Healthcare Settings . 13 I.A. Evolution of the 2007 Document .. 13 Chang es or clarifications in terminology. .. 14 Scope. .. 14 I.B. Rationale for Standard and Transmission -Based Precautions in healthcare setti ngs 15 I.B.1. Sources of infectious agents. 15 I.B.2. Susceptible hosts. .. 15 I.B.3. Modes of transmission. .. 16 I.B.3.a. Contact transmission. . 16 I.B.3.a.i. Direct contact transmission. .. 16 I.B.3.a.ii. Indirect contact transmission. . 17 I.B.3.b. Droplet transmission. . 18 I.B.3. c. Airborne transmission. .. 19 I.B.3.d. Emerging issues concerning airborne transmission of infectious agents. .. 20 I.B.3.d.i. Transmiss ion from patients. .. 20 I.B.3.d.ii. Transmission from the environment. .. 21 I.B.3.e. Other sources of infection. . 21 I.C. Infectious Agents of Special Infection Control Interest for Healthcare Settings 21 I.C.1. Epidemiologically important organisms. 22 I.C.1.a. C. difficile. . 22 I.C.1. b. Multidrug -resistant organisms (MDROs). .. 23 I.C.2. Agents of bioterrorism. 24 I.C.2.a. Pre -event administration of smallpox (vaccinia) vaccine to healthcare personnel. . 25 I.C.3. Prion s. .. 25 I.C.4. Severe Acute Respiratory Syndrome (SARS). 27 I.C.5. Monkeypox. .. 29 I.C.6. Noroviruses. .. 30 I.C.7. Hemorrhagic fever viruses (HFV). .. 31 I.D. Transmission Risks Associated with Specific Types of Healthcare Settings 32 I.D.1. Hospitals. 33 I.D.1.a. Intensive care units. 33 I.D.1.b. Burn units. 33 I.D.1.c. Pediatrics. . 34 I.D.2. Non -acute healthcare settings. .. 35 I.D.2.a. Long -term care. . 35 I.D.2.b. Ambulatory care. . 37

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Guideline for Isolation Pr ecautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007) Last update: July 2019 Page 5 of 206 I.D.2.c. Home care. .. 38 I.D.2.d. Other sites of healthcare delivery. . 39 I.E. Transmission Risks Associated with Special Patient Populations . 39 I.E.1. Immunocompromised patients. . 40 I.E.2. Cystic fibrosis patients. 40 I.F. New Therapies Associated wit h Potentially Transmissible Infectious Agents 41 I.F.1. Gene therapy. .. 41 I.F.2. Infections transmitted through blood, organs and oth er tissues. . 41 I.F.3. Xenotransplantation. 41 Part II: Fundamental Elements Needed to Prevent Transmission of Infectious Agents in Healthcare Settings .. 43 II.A. Healthcare System Components that Influence the Effectiveness of Precautions to Prevent Transmission 43 II.A.1. Administrative measures. . 43 II.A.1.a.Scope of work and staffing needs for infection control professionals. 43 II.A.1.a.i. In fection control nurse liaison. 45 II.A.1.b. Bedside nurse staffing. . 45 II.A.1.c. Clinical microbiology laboratory support. .. 45 II.A.2. Institutional safety culture and organizational characteristics. 46 II.A.3. Adherence of healthcare personnel to recommended guide lines. . 47 II.B. Surveillance for Healthcare -Associated Infections (HAIs) .. 48 II.C. Education of HCWs, Patients, and Families 49 II.D. Hand Hygiene 50 II.E. Personal Protective Equipment (PPE) for Healthcare Personnel . 51 II.E.1. Gloves. 51 II.E.2. Isolation gowns. . 52 II.E.3. Face protection: masks, goggles, face shields. .. 53 II.E.3.a. Masks. 53 II.E.3.b. Goggles, face shields. 54 II.E.4. Respiratory prot ection. .. 55 II.F. Safe Work Practices to Prevent HCW Exposure to Bloodborne Pathogens 57 II.F.1. Prevention of needlesticks and other sharps -related injuries. .. 57 II.F.2. Prevention of mucous membrane contact. . 57 II.F.2.a. Precautions during aerosol -generating proce dures. . 57 II.G. Patient Placement .. 58 II.G.1. Hospitals and long -term care settings. .. 58 II.G.2. Ambulatory settings. .. 60 II.G.3. Home care. .. 61 II.H. Transport of Patients 61 II.I. Environmental Measures .. 61 II.J. Patient Care Equipment and Instruments/Devices . 62 II.K. Textil es and Laundry .. 63 II.L. Solid Waste . 64 II.M. Dishware and Eating Utensils . 64

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Guideline for Isolation Pr ecautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007) Last update: July 2019 Page 6 of 206 II.N. Adjunctive Measures . 64 II.N.1. Chemoprophylaxis. .. 65 II.N.2. Immunoprophylaxis. .. 65 II.N. 3. Management of visitors. . 66 II.N.3.a. Visitors as sources of infection. .. 66 II.N.3.b. Use of barrier precautions by visitors. . 67 Part III: Precautions to Prevent Transmission of Infectious Agents .. 68 III.A. Standard Precautions .. 68 III.A.1. New elements of standard precautions. . 69 III.A.1.a. Respiratory hygiene/cough etiquette. 69 III.A.1.b. Safe injection practices. . 70 III.A.1.c. Infection Control Practices for Special Lumbar Puncture Procedures. .. 71 III.B. Transmission -Based Precautions 71 III.B.1. Contact precautions. . 72 III.B.2. Droplet precautions. .. 72 III.B.3. Airborne precautions. 73 III.C. Syndromic and Empiric Applications of Transmission -Based Precautions 73 III.D. Discontinuation of Transmission -Based Precautions .. 74 III.E. Application of Transmission -Based Precautions in Ambulatory and Home Care Settings 75 III.F. Protective Environment .. 75 Part IV: Recommendations .. 76 Appendix A: .. 96 Type and Duration of Precautions Recommended for Selected Infections and Conditions 1 .. 96 Table 1. History of Guidelines for Isolati on Precautions in Hospitals* 117 Table 2. Clinical Syndromes or Conditions Warranting Empiric Transmission -Based Precautions in Addition to Standard Precautions. 118 Table 3. Infection Control Considerations for High -Priority (CDC Category A) Diseases that May Result from Bioterrorist Attacks or are Considered to be Bioterrorist Threats . 120 Table 4. Recommendations for Application of Standard Precautions for the Care of All Patients in All Healthcare Settings .. 124 Table 5. Components of a Protective Environment .. 125 I. Patients: allogeneic hematopoeitic stem cell transplant (HSCT) only .. 125 II. Standard and Expanded Precautions 125 III. Engineering .. 125 IV. Surfaces . 126 V. Other . 126 Figure. Example of Safe Donning and Removal of Personal Protective Equipment (PPE) . 127 Glossary 129 Ref erences .. 136

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Guideline for Isolation Pr ecautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007) Last update: July 2019 Page 8 of 206 Executive Summary The Guideline for Isolation Precautions: Prevent ing Transmission of Infectious Agents in Healthcare Settings 2007 updates and expands the 1996 Guideline for Isolation Precautions in Hospitals . The following developments led to revision of the 1996 guideline: 1. The transition of healthcare delivery from pr imarily acute care hospitals to other healthcare settings (e.g., home care, ambulatory care, free -standing specialty care sites, long -term care) created a need for recommendations that can be applied in all healthcare settings using common principles of in fection control practice, yet can be modified to reflect setting -specific needs. Accordingly, the revised guideline addresses the spectrum of healthcare delivery settings. Furthermore, the term finosocomial infectionsfl is replaced by fihealthcare -associated infectionsfl (HAIs) to reflect the changing patterns in healthcare delivery and difficulty in determining the geographic site of exposure to an infectious agent and/or acquisition of infection. 2. The emergence of new pathogens (e.g., SARS -CoV associated with the severe acute respiratory syndrome [SARS], Avian influenza in humans), renewed concern for evolving known pathogens (e.g., C. difficile, noroviruses, community -associated MRSA [CA -MRSA]), development of new therapies (e.g., gene therapy), and increasing concern for the threat of bioweapons attacks, established a need to address a broader scope of issues than in previous isolation guidelines. 3. The successful experience with Standard Precautions, first recommended in the 1996 guideline, has led to a reaffir mation of this approach as the foundation for preventing transmission of infectious agents in all healthcare settings. New additions to the recommendations for Standard Precautions are Respiratory Hygiene/Cough Etiquette and safe injection practices, inclu ding the use of a mask when performing certain high -risk, prolonged procedures involving spinal canal punctures (e.g., myelography, epidural anesthesia). The need for a recommendation for Respiratory Hygiene/Cough Etiquette grew out of observations during the SARS outbreaks where failure to implement simple source control measures with patients, visitors, and healthcare personnel with respiratory symptoms may have contributed to SARS coronavirus (SARS -CoV) transmission. The recommended practices have a stro ng evidence base. The continued occurrence of outbreaks of hepatitis B and hepatitis C viruses in ambulatory settings indicated a need to re -iterate safe injection practice recommendations as part of Standard Precautions. The addition of a mask for certain spinal injections grew from recent evidence of an associated risk for developing meningitis caused by respiratory flora. 4. The accumulated evidence that environmental controls decrease the risk of life -threatening fungal infections in the most severely immu nocompromised patients (allogeneic hematopoietic stem -cell transplant patients) led to the update on the components of the Protective Environment (PE). 5. Evidence that organizational characteristics (e.g., nurse staffing levels and composition, establishment of a safety culture) influence healthcare personnel adherence to recommended infection control practices, and therefore are important factors in preventing transmission of infectious agents, led to a new emphasis and recommendations for administrative inv olvement in the development and support of infection control programs.

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Guideline for Isolation Pr ecautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007) Last update: July 2019 Page 9 of 206 6. Continued increase in the incidence of HAIs caused by multidrug -resistant organisms (MDROs) in all healthcare settings and the expanded body of knowledge concerning prevention of transm ission of MDROs created a need for more specific recommendations for surveillance and control of these pathogens that would be practical and effective in various types of healthcare settings. This document is intended for use by infection control staff, he althcare epidemiologists, healthcare administrators, nurses, other healthcare providers, and persons responsible for developing, implementing, and evaluating infection control programs for healthcare settings across the continuum of care. The reader is ref erred to other guidelines and websites for more detailed information and for recommendations concerning specialized infection control problems. Parts I – III: Review of the Scientific Data Regarding Transmission of Infectious Agents in Healthcare Settings Part I reviews the relevant scientific literature that supports the recommended prevention and control practices. As with the 1996 guideline, the modes and factors that influence transmission risks are described in detail. New to the section on transmissi on are discussions of bioaerosols and of how droplet and airborne transmission may contribute to infection transmission. This became a concern during the SARS outbreaks of 2003, when transmission associated with aerosol -generating procedures was observed. Also new is a definition of fiepidemiologically important organismsfl that was developed to assist in the identification of clusters of infections that require investigation (i.e. multidrug -resistant organisms, C. difficile) . Several other pathogens that hol d special infection control interest (i.e., norovirus, SARS, Category A bioterrorist agents, prions, monkeypox, and the hemorrhagic fever viruses) also are discussed to present new information and infection control lessons learned from experience with thes e agents. This section of the guideline also presents information on infection risks associated with specific healthcare settings and patient populations. Part II updates information on the basic principles of hand hygiene, barrier precautions, safe work p ractices and isolation practices that were included in previous guidelines. However, new to this guideline, is important information on healthcare system components that influence transmission risks, including those under the influence of healthcare admini strators. An important administrative priority that is described is the need for appropriate infection control staffing to meet the ever -expanding role of infection control professionals in the modern, complex healthcare system. Evidence presented also dem onstrates another administrative concern, the importance of nurse staffing levels, including numbers of appropriately trained nurses in ICUs for preventing HAIs. The role of the clinical microbiology laboratory in supporting infection control is described to emphasize the need for this service in healthcare facilites. Other factors that influence transmission risks are discussed i.e., healthcare worker adherence to recommended infection control practices, organizational safety culture or climate, education and training.

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Guideline for Isolation Pr ecautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007) Last update: July 2019 Page 10 of 206 Discussed for the first time in an isolation guideline is surveillance of healthcare -associated infections. The information presented will be useful to new infection control professionals as well as persons involved in designing or responding to state programs for public reporting of HAI rates. Part III describes each of the categories of precautions developed by the Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Centers for Disease Control and Prevention (CDC) and provides guidance for their application in various healthcare settings. The categories of Transmission -Based Precautions are unchanged from those in the 1996 guideline: Contact, Droplet, and Airborne. One important change is the recommendation to don the i ndicated personal protective equipment (gowns, gloves, mask) upon entry into the patient™s room for patients who are on Contact and/or Droplet Precautions since the nature of the interaction with the patient cannot be predicted with certainty and contamina ted environmental surfaces are important sources for transmission of pathogens. In addition, the Protective Environment (PE) for allogeneic hematopoietic stem cell transplant patients, described in previous guidelines, has been updated. Tables, Appendice s, and Other Information There are several tables that summarize important information: 1. a summary of the evolution of this document; 2. guidance on using empiric isolation precautions according to a clinical syndrome; 3. a summary of infection control recomme ndations for category A agents of bioterrorism; 4. components of Standard Precautions and recommendations for their application; 5. components of the Protective Environment; and 6. a glossary of definitions used in this guideline. New in this guideline is a fig ure that shows a recommended sequence for donning and removing personal protective equipment used for isolation precautions to optimize safety and prevent self -contamination during removal. Appendix A: Type and Duration of Precautions Recommended for Sel ected Infections and Conditions Appendix A consists of an updated alphabetical list of most infectious agents and clinical conditions for which isolation precautions are recommended. A preamble to the Appendix provides a rationale for recommending the use of one or more Transmission -Based Precautions, in addition to Standard Precautions, based on a review of the literature and evidence demonstrating a real or potential risk for person -to-person transmission in healthcare settings.The type and duration of re commended precautions are presented with additional comments concerning the use of adjunctive measures or other relevant considerations to prevent transmission of the specific agent. Relevant citations are included.

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Guideline for Isolation Pr ecautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007) Last update: July 2019 Page 11 of 206 Pre – Publication of the Guideline on Pre venting Transmission of MDROs New to this guideline is a comprehensive review and detailed recommendations for prevention of transmission of MDROs. This portion of the guideline was published electronically in October 2006 and updated in November, 2006 (Si egel JD, Rhinehart E, Jackson M, Chiarello L and HICPAC. Management of Multidrug -Resistant Organisms in Healthcare Settings (2006) (https://www.cdc.gov/infectioncontrol/guidelines/mdro/ accessed May 2016 )), and is considered a part of the Guideline for Isolation Precautions. This section provides a detailed review of the complex topic of MDRO control in healthcare settings and is intended to provide a context for evaluation of MDRO at in dividual healthcare settings. A rationale and institutional requirements for developing an effective MDRO control program are summarized. Although the focus of this guideline is on measures to prevent transmission of MDROs in healthcare settings, informati on concerning the judicious use of antimicrobial agents is presented since such practices are intricately related to the size of the reservoir of MDROs which in turn influences transmission (e.g., colonization pressure). There are two tables that summarize recommended prevention and control practices using the following seven categories of interventions to control MDROs: administrative measures, education of healthcare personnel, judicious antimicrobial use, surveillance, infection control precautions, envi ronmental measures, and decolonization. Recommendations for each category apply to and are adapted for the various healthcare settings. With the increasing incidence and prevalence of MDROs, all healthcare facilities must prioritize effective control of MD RO transmission. Facilities should identify prevalent MDROs at the facility, implement control measures, assess the effectiveness of control programs, and demonstrate decreasing MDRO rates. A set of intensified MDRO prevention interventions is presented to be added 1. if the incidence of transmission of a target MDRO is NOT decreasing despite implementation of basic MDRO infection control measures, and 2. when the first case(s) of an epidemiologically important MDRO is identified within a healthcare facility. Summary This updated guideline responds to changes in healthcare delivery and addresses new concerns about transmission of infectious agents to patients and healthcare workers in the United States and infection control. The primary objective of the guidel ine is to improve the safety of the nation™s healthcare delivery system by reducing the rates of HAIs.

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