After completing this course, the learner will be able to:
Healthcare professionals have an obligation to 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 this very seriously. In fact New York rules and regulations require healthcare professionals to participate in infection control and barrier precautions education at least every 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 in lieu of the Department of Health during the process of renewal of hospital privileges (NY, 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 (NY, 2008). A written application for exemption from completion of 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 proper use of infections control practices and standard precaution. Failure to comply can result in a citation, 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 and/or Education. Substantiated lapses may result in charges of professional misconduct against licensed healthcare professionals who were directly involved, who were aware of the violations, or who were responsible for ensuring staff education and compliance (NY, 2008). Scientifically accepted infection control techniques include but are not limited to (NY, 1992, p D):
A chain of events is required for infection to occur. These events are a causative organism, 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:
The organism and its reservoir are the source of infection. The organism must have a means to exit the reservoir. In an infected host the organisms exits through the respiratory tract, gastrointestinal tract, genitourinary tract, or drainage from a wound. A route of transmission is necessary to connect the source of infection to its new host. Routes of transmission are contact or airborne.
The following table outlines the organism, mode of transmission and incubation period for most common microorganisms and parasites (Kennamer, 2007).
|Disease/Condition||Organism||Mode of Transmission||Incubation Period|
|Acquired immunodeficiency syndrome (AIDS)||Human immunodeficiency virus||Sexual
|Prenatal Median of 10 years|
|Amebiasis||Entamoeba histolytica||Contaminated water
Contact with raw vegetables
|Chancroid||Haemophilus ducreyi||Sexual||3-5 days|
|Chickenpox||Varicella zoster||Airborne||14 days|
|Cholera||Vivrio cholera||Ingestion of water contaminated with human waste||A few hours-5days|
|Creutzfeldt-Jacob disease||Prion proteinaceous||Unknown in most cases||15 months to 30 years|
|Cryptococcosis||Cryptococcus neoformans||Probably by inhalation
No person-to-person spread
|Cyptosporidiosis||Cryptosporidium species||Ingestion of contaminated water
Direct contact with carrier
|Probably 1-2 days|
Contact with mucus membranes
|Highly variable: 3-8 weeks after transmission
Newborn: 3-12 weeks after delivery
|Diarrheal diseases||Campylobacter species||Ingestion of contaminated food||3-5 days|
Efficient transfer by healthcare
professionals to patients
|Variable, in part related to the influence of antibiotics|
|Salmonella species||Ingestion of contaminated food or drink||12-36 hours|
|Shigella species||Ingestion of contaminated food or drink
Direct contact with carrier
|Yersinia species||Ingestion of contaminated food or drink
Direct contact with carrier
|Giardiasis||Giardia lamblia||Fecal-oral transmission
Ingestion of contaminated water or food
|Gonorrhea||Neisseria gonorrhea||Sexual||2-7 days|
|Hand, foot, and mouth disease||Coxsackie virus||Direct contact with nose and throat secretions, and with feces of infected persons||3-5 days|
|Foodborne hepatitis||Hepatitis A
|Ingestion of contaminated food or drink
Direct contact with carrier
|A: 15-50 days
|Bloodborne hepatitis||Hepatitis B
|B: 45-160 days
C: 6-9 months
|Herpangina||Coxsackie virus||Direct contact with nose and throat secretions, and with feces of infected persons||3-5 days|
|Herpes simplex||Human herpesvirus 1 and 2||Contact with mucous membrane secretions||2-12 days|
|Histoplasmosis||Histoplasma capsulatum||Inhalation of airborne spores||5-18 days|
|Contact with soil contaminated with feces||A few week to many months|
|Impetigo||Staphylococcus aureus||Contact with carrier||4-10 days|
|Influenza||Influenza virus A, B, or C||Droplet spread||27-72 hours|
|Legionnaires’ disease||Legionella pneumonphila||Airborne from water source||2-10 days|
|Unclear, probably 3-70 days|
|Lyme disease||Borrelia burgdorferi||Tick bite||14-23 days|
|Lymphogranuloma venereum||Chlamydia inguinale||Sexual||Weeks to years|
|Bite from Anopheles mosquito||12-30 days|
|Measles||Measles virus||Droplet spread||8-13 days|
|Meningococcal meningitis or bacteremia||Neisseria meningitidis||Contact with pharyngeal secretions, perhaps airborne||2-10 days|
|Mononucleosis||Epstein Barr virus||Contact with pharyngeal secretions||4-6 weeks|
|Mycobacterial diseases (non-tuberculosis) Mycobacterium species||Mycobacterium avium
Other Mycobacterium species
|Variable: probably contact with soil, water, or other environmental sources. Not transmissible person-to-person||Variable|
|Mycoplasma pneumonia||Droplet inhalation||14-21 days|
|Pediculosis||Pediculus humanus capitus (head louse)
Pediculus humanus corporis (body louse)
|Direct contact||1-2 weeks|
|Phthirus pubis (crab louse)||Sexual||1-2 weeks|
|Pinworm||Enterobius vermicularis||Direct contact with egg-contaminated articles||4-6 week life cycle
Often months of infection before recognition
|Pneumocystis pneumonia||Pneumocystis carinii||Unknown
Not transmitted person-to-person
|Infants 1-2 months
|Pneumococcal pneumonia||Streptococcus pneumoniae||Droplet spread||Probably 1-3 days|
|Rabies||Rabies virus||Direct contact of virus-laden saliva of a rabid animal into a bite or scratch||2-8 weeks|
|Respiratory syncytial disease||Respiratory syncytial virus||Self inoculation by touching mouth or nose after contact with infectious respiratory secretions||3-7 days|
|Direct and indirect contact with lesions||4-10 days|
|Rocky Mountain Spotted fever||Rickettsia ricketsii||Tick bite||3-14 days|
|Rotavirus gastroenteritis||Rota virus||Fecal, oral||About 48 hours|
|Rubella||Rubella virus||Droplet spread
|Scabies||Sarcoptes scabiei||Direct skin||contact 2-6 weeks|
|Direct contact with draining lesions
Auto-infection from colonized nares
|Variable, usually 4-10 days|
pyogenes groups A with about 80 serologically distinct types
|Large respiratory droplets
Direct contact with secretions
Ingestion of contaminated food
|Syphilis||Treponema pallidum||Sexual||2-6 weeks|
|Tetanus||Clostridium tetani||Puncture wound||4-21 days|
|Trichinosis||Trichinella spiralis||Ingestion of insufficiently cooked food, especially pork and beef||10-14 days|
|Tuberculosis||Mycobacterium tuberculosis||Airborne||4-12 weeks|
|Typhoid fever||Salmonella typhi||Ingestion of contaminated food or water||3 days to 3 months|
The host must be susceptible to the infection for infection to occur. Factors influencing susceptibility are:
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).
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 are spread through contact with infected surfaces (e.g., hands or contaminated medical equipment), and infections with CRE are particularly dangerous: they can spread rapidly, the mortality rate can exceed 40%, and antibiotics that are effective against multi-drug resistant gram-negative bacilli are still being developed. CRE infections usually don’t occur in healthy people; they are more likely to occur in hospitalized patients who have a compromised immune system, patients who are mechanically ventilated, 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 stool, rectal, and peri-rectal cultures, and wound cultures when appropriate; 3) strict adherence to handwashing protocol, and;4) using contact precautions. (CDC, March 5, 2013; Morbidity and Mortality Weekly, March 9, 2013).
Staphylococcus aureus is transmissted primarily via the hands of healthcare professional and by direct contact with contaminated equipment and surfaces. Transmission is very efficient and Staphylococcus 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 Staphylococcus aureus (MRSA, ORSA) are a common nosocomial infection in hospitals and extended care facilities. MRSA/ORSA colonization is rarely recognized, so every patient must be assumed to have been exposed to MRSA/ORSA. MRSA/ORSA can produce toxins and invade body tissues. The only effective antibiotic is vancomycin. Contact precautions are not recommended by the Centers for Disease Control and Prevention (CDC), but the CDC does note that contact precautions should be used if the facility has decided that MRSA is of special clinical or epidemiological significance (CDC, August, 9, 2010).
Vancomycin Intermediate Staphylococcus aureus (VISA) and Vancomycin Resistant Staphylococcus aureus (VRSA) are classified based on a lab test. The result of the test is called minimum inhibitory concentration (MIC), which is the measure of 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, August 6, 2012). This infection must be reported to the CDC and the state department of health. Contact precautions are required.
Enterococcus is a gram-positive bacterium that is normal flora of the gastrointestinal tract and female genital tract. It is a relatively weak pathogen, but it is capable of producing significant infections and treatment options 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, May 10, 2011). VRE is transmitted primary via the hands of healthcare professionals and direct contact with contaminated equipment and surfaces. Contact precautions are required. Some facilities are requiring a special isolation where a gown and glove are worn even if contact with the patient is not expected. This is not recommended by CDC (CDC, May 10, 2011).
TB is caused by the bacteria, mycobacterium tuberculosis. It is one of the oldest recognized infectious diseases. MDR-TB is resistant to isoniazid, rifampin, the fluoroqunilones, 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 or incomplete therapy regimen. Airborne precautions are required (CDC, June 28, 2012).
Streptococcus pneumoniae is a leading cause of morbidity and mortality in the United States. It is a pathogen that is commonly found in the upper respiratory tract. Infections are community-acquired and manifested in meningitis, bacteremia, pneumonia, and otitis media. 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 have begun to emerge and are widespread in some communities (Jenkins, et al, 2012). A vaccine for the most common serotypes of S. pneumoniae is available, but underutilized. Droplet precautions and cough etiquette should be used.
Acinetobacter is bacteria usually found in the soil, water, and on the skin of healthy people. Susceptible people are immunocompromised, have chronic lung disease, or diabetes. Outbreaks of pneumonia, urinary tract infections, wound infections, and blood infections from Acinetobacter occur in healthcare facilities where very sick patients are housed, like intensive care units. People on ventilators, patients who have prolonged hospital stays, and patients who have open wounds are at greater risk (CDC November 24, 2010). The morbidity and mortality rates associated with drug-resistant Acinetobacter infections are very high, and outbreaks of these infections in healthcare facilities are very difficult to control (Kuo, et al, 2012). Contact transmission is the primary way that Acinetobacter is spread, so standard precautions with special attention to handwashing are sufficient. 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 (APIC, 2010).
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 is likely to occur in a healthcare setting that 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 (CDC, 2008). Work practice controls change practices and procedures to reduce or eliminate risks.
Standard precautions are strategies for protecting healthcare professionals from occupational transmission of organisms. The premise is that all pre-existing patient infections cannot be identified; therefore, barrier precautions should be used routinely to protect from all sources of potential infection. Standard precautions apply to nonintact skin and mucous membranes, blood, all body fluids, secretions, and excretions, except sweat, regardless of whether or not they contain visible blood. Additional precautions are based on highly transmissible or epidemiologically important pathogens. Transmission Based Precautions (isolation) are airborne, droplet, and contact.
New elements of standard precautions have been added 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 is a strategy to reduce transmission of respiratory infections at the first point of entry into a healthcare setting. Signs educating patients and families should be posted at entry areas. The instructions are that persons with cough, congestion, rhinorrhea, or increased respiratory secretions should (CDC, 2007):
Healthcare personnel should observe Droplet Precautions when caring for patients with signs and symptoms of a respiratory infection. Healthcare personnel who have 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).
Needlestick and sharps injuries are major occupational hazards for nurses (Cho, et al, 2012). Nurses sustain a large proportion of the needlestick and sharps injuries sustained by healthcare professionals, but laboratory staff, physicians, housekeepers, and other healthcare professionals are also injured (Himmelreich, et al, 2012). Some of these injuries expose professionals to bloodborne pathogens that can cause infection. The most important of these pathogens are hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV). Infections with each of these pathogens are potentially life threatening and preventable.
One serious bloodborne infection can cost more than a million dollars for medications, follow up laboratory testing, clinical evaluation, lost wages, and disability payments. The human costs after an exposure are immeasurable. Employees 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 in a low risk exposure that does not result in infection (Zhang, et al, 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, the use of safety-engineered sharps devices has increased while the use of conventional sharps devices has decreased. Vigorous efforts to prevent needlestick and sharps injuries (e.g., the Needlestick Prevention and Safety Act of 2000) and increased awareness have helped to decrease the number of these injuries: several authors noted that needlestick injuries have decreased 38% in recent years (Phillips, et al, 2012; Trossman, 2012). A number of sources have identified the desirable characteristics of safety devices. These characteristics include the following (NIOSH, 1999):
Although each of these characteristics is 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 own 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.
There is exposure to percutaneous injuries during procedures where there is opportunity for percutaneous exposure, especially where there is poor visualization, blind suturing, non-dominant hand opposing or next to a sharp, 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 other 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 needlestick 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, outbreaks of HBV and HCV amongst patients were traced back to ambulatory care facilities, which identified the need to define and reinforce safe injection practices in outpatient care setting. The reuse of needles, multidose vials, and work areas containing both sterile and contaminated injection supplies contributed to the problem. There was a lack of understanding of aseptic technique, a lack of oversight, and failure to follow up on infection control breeches (Kuehn, 2012).. The following are safe injection practices recommended by CDC (CDC, April 1, 2011) that apply to the use of needles, cannulas that replace needles and, where applicable, intravenous delivery systems.
Handwashing is the most important measure to reduce the transmission of microorganisms. Hands should be washed or alcohol-based rubs should be used between patient contacts and after gloves are removed. Hands should be washed after contact with blood, body fluids, secretions, excretions, and contaminated equipment. It may be necessary to wash hands between tasks on the same patient to prevent cross-contamination of different body sites. CDC and Prevention Guideline for Hand Hygiene in Healthcare Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force (Morbidity and Mortality Weekly Report, October 25, 2002; WHO, 2009)
The appropriate use of personal protective equipment (PPE) is an important element of standard precautions. Gloves provide a protective barrier between the patient and the healthcare professional and prevent gross contamination of the hands. Gloves do not replace the need for handwashing because the gloves may have small defects, may be torn during use, and hands may become contaminated during glove removal.
Masks, goggles, or face shields should be used to protect the mucous membranes of the eyes, nose, and mouth during situations where there is a likelihood of splashes or sprays. A surgical mask is worn by healthcare professionals to provide protection against large-particle droplets during close patient contact. When tuberculosis is known or suspected, healthcare professionals should wear an N95 respirator, a high-efficiency particulate air (HEPA) filter respirator or a powered air-purifying respirator (PAPR).
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 more protection when large quantities of blood or body fluids may be splashed. Gowns are also worn as a part of some transmission based precautions. Mouthpieces, resuscitation bags, or other ventilation devices should be used instead of mouth-to-mouth resuscitation.
Transmission based precautions and protective environment (PE) are terms used to describe protective measures that need to be employed for specific groups of patients. An older term for this was isolation. Patients requiring transmission based precautions require a private room. A negative pressure air handling system that exhausts to the outside is required for airborne precautions. Movement of these patients should be limited. When transport 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 are implemented for diseases that are transmitted by microorganisms in airborne droplet nuclei. Droplet nuclei are tiny particle residues left when droplets evaporate. Droplet nuclei remain suspended in the air and can be widely dispersed by air currents. Early identification and triage of suspected cases of airborne transmitted diseases should be done and possibly infectious patients should be separated from others and asked to wear a surgical mask.
|Chickenpox (varicella)||Until lesions are crusted and no new lesions appear|
|Herpes zoster (disseminated)||Duration of illness|
|Herpes zoster (localized in immunocompromised patient)||Duration of illness|
|Measles (rubeola)||Duration of illness|
|Smallpox||Duration of illness|
|Tuberculosis (pulmonary or laryngeal, confirmed or suspected)||Depends upon clinical response; patient must be on effective therapy, be improving clinically (decreased cough and fever and improved findings on chest radiograph), and have three consecutive negative sputum smears collected on different days, or TB must be ruled out.|
Airborne precautions require a specially ventilated room with at least 6 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. The negative air pressure should be monitored. An N-95 mask or a PAPR is used in airborne precautions.
When the patient in airborne precautions has to be moved or transported, the patient should wear a surgical mask from the time he leaves the isolation room, until he returns.
Droplet precautions are used for patients known or suspected to be infected with microorganisms transmitted by droplets generated during coughing, sneezing, talking, or performance of procedures.
|Invasive Haemophilus influenzae type b disease, including meningitis, pneumonia, and sepsis||Until 24 hours after initiation of effective therapy|
|Invasive Neisseria meningitidis disease, including meningitis, pneumonia, epiglottis, and sepsis||Until 24 hours after initiation of effective therapy|
|Diphtheria (pharyngeal)||Until off antibiotics and two cultures taken at least 24 hours apart are negative|
|Mycoplasma pneumoniae infection||Duration of illness|
|Pertussis||Until five days after initiation of effective therapy|
|Pneumonic plague||Until 72 hours after initiation of effective therapy|
|Streptococcal pharyngitis, pneumonia, or scarlet fever in infants and young children||Until 24 hours after initiation of effective therapy|
|Adenovirus infection in infants and young children||Duration of illness|
|Influenza||Duration of illness|
|Mumps||For 9 days after onset of swelling|
|Parvovirus B19||Maintain precautions for duration of hospitalization when chronic disease occurs in an immunodeficient patient. For patients with transient aplastic crisis or red-cell crisis, maintain precautions for 7 days.|
|Rubella (German measles)||Until 7 days after onset of rash|
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.
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.
|Infection or colonization with multidrug-resistant bacteria||Until off antibiotics and culture negative|
|Clostridium difficile enteric infection||Duration of illness|
|Escherichia coli disease, in diapered or incontinent patient||Duration of illness|
|Shigellosis, in diapered or incontinent patient||Duration of illness|
|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, in diapered or incontinent patient||Duration of illness|
|Enteroviral infection, in diapered or incontinent patient||Duration of illness|
|Scabies||Until 24 hours after initiation of effective therapy|
|Diphtheria (cutaneous)||Duration of illness|
|Herpes simplex virus infection (neonatal or mucutaneous)||Duration of illness|
|Impetigo||Until 24 hours after initiation of effective therapy|
|Major abscesses, cellulitis, or decubiti||Until 24 hours after initiation of effective therapy|
|Pediculosis (lice)||Until 24 hours after initiation of effective therapy|
|Rubella, congenital syndrome||Place infant on precautions during any admission until 1 year of age, unless nasopharyngeal and urine culture are negative for virus after age 3 months|
|Staphylococcal furunculosis in infants and young children||Duration of illness|
|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 immunodeficient patient)||Until all lesions are crusted
Requires airborne precautions
|Smallpox||Duration of illness|
The patient should be in a private room. Standard precautions should be used, and a gown should be worn if there is likely to be contact with the patient or environmental surfaces.
Some facilities may be implementing special isolation for VRE. This is an exaggerated form of contact precautions requiring the use of gowns and gloves anytime the room is entered, even if you do not anticipate patient contact. The rational is that VRE survives in the environment for a long time and contact with any surface may lead to transmission. This isolation is not recommended by CDC.
Neutropenic precautions (reverse isolation) are implemented to protect immunocompromised patients.
|CONDITION OR TREATMENT||PRECAUTIONARY PERIOD|
|Acquired immunodeficiency syndrome||Until white blood cell count reaches 1,000/µl or more or according to facility guidelines|
|Burns, extensive noninfected||Until skin surface heals substantially|
|Dermatitis, noninfected vesicular, bullous, or eczematous disease (when severe and extensive)||Until skin surface heals substantially|
|Immunosuppressive therapy||Until patient’s immunity is adequate|
|Lymphomas and leukemia, especially late stages of Hodgkin’s disease or acute leukemia||Until clinical improvement is substantial|
Neutropenic precautions require a private room with positive air pressure. Other precautions may range from standard precautions and limitation of traffic to extensive precautions using gloves, gowns, and masks. This varies depending on the reason for the precautions and the degree of the patient’s immunosuppression.
|Vaccine||Birth||1 mo||2 mos||4 mos||6 mos||9 mos||12 mos||15 mos||18 mos||19-23 mos||2-3 yrs||4-6 yrs||7-10 yrs||11-12 yrs||13-15 yrs||16-18 yrs|
|Hepatitis B1(HepB)||1st dose||2nd dose||2nd dose||3rd dose||3rd dose||3rd dose||3rd dose||3rd dose|
|Rotavirus(RV) RV-1 (2-dose series); RV-5 (3-dose series)||1st dose||2nd dose|
|Diphtheria, tetanus, & acellular pertussis (DTaP: <7 yrs)||1st dose||2nd dose||3rd dose||4th dose||4th dose||5th dose|
|Tetanus, diphtheria, tetanus, & acellular pertussis (Tdap: > 7 yrs)||(Tdap)|
|Haemophilus influenzae type b (Hib)||1st dose||2nd dose||3rd dose||3rd or 4th dose||3rd or 4th dose|
|Pneumococcal conjugate (PCV13)||1st dose||2nd dose||3rd dose||4th dose||4th dose|
|Pneumococcal polysaccharide (PPSV23)|
|Inactivated poliovirus (IPV) (<18years)||1st dose||2nd dose||3rd dose||3rd dose||3rd dose||3rd dose||3rd dose||4th dose|
|Influenza (IIV; LAIV) 2 doses for some||p.a. vacc. (IIV only)||p.a. vacc. (IIV only)||p.a. vacc. (IIV only)||p.a. vacc. (IIV only)||p.a. vacc. (IIV only)||p.a. vacc. (IIV only)||p.a. vacc. (IIV or LAIV)||p.a. vacc. (IIV or LAIV)||p.a. vacc. (IIV or LAIV)||p.a. vacc. (IIV or LAIV)||p.a. vacc. (IIV or LAIV)||p.a. vacc. (IIV or LAIV)|
|Measles, Mumps, Rubella (MMR)||1st dose||1st dose||2nd dose|
|Varicella (VAR)||1st dose||1st dose||2nd dose|
|Hepatitis A (HepA)||2 dose series||2 dose series||2 dose series||2 dose series|
|Human papillomavirus (HPV2: females only; HPV4: males and females)||3 dose series|
|Meningococcal (Hib-MenCY > 6 wks; MCV4-< 9mos;||1st dose||booster|
|Range of recommended ages for all children||Range of recommended ages for catch-up immunization||Range of recommended ages for certain high-risk groups||Range of recommended ages during which catch-up is encouraged and for certain high-risk groups||Not routinely recommended|
|Hepatitis B||HepB (3 doses)|
|Influenza||TIV or LAIV annually|
|MMR||MMR if born 1957 or later if no serologic evidence of immunity or prior vacciniation|
|Varicella||varicella vaccine (3 doses) if no serologic evidence of immunity|
|Tetanus, Diphtheria, Pertussis||Tdap one time if younger than 65, Td every 10 years|
|Meningococcal||1 dose to microbiologist who are routinely exposed to N. meningitidis|
Although the environment is a reservoir for a variety of microorganisms, it is rarely implicated in disease transmission except in the immunocompromised population. Consistently applied infection-control strategies and engineering controls are effective in preventing opportunistic, environmentally-related infections in immunocompromised populations (CDC, June 6, 2003).
The following discussion of environmental recommendations is a synopsis of the most recent CDC recommendations (CDC, 2008).
(OSHA, 29 CFR 1910.1030; OSHA, CFR 1910.132: OSHA, CFR 1910.134)
Endoscopes are fragile, expensive, difficult to clean, much used, and susceptible to contamination (Hervé, et al, 2013). There are millions of endoscopic procedures done each year, but iatrogenic infections caused by contamination of endoscopes are rare (ASGE, 2011). The recommendations for the disinfection and sterilization of endoscopes listed below are from the CDC (CDC, 2008). The American Society of Gastrointestinal Endoscopy has also published guidelines for cleaning endoscopes (ASGE, 2011).
Other repeat-use invasive medical devices such as vaginal and rectal ultrasound transducers can be a source of contamination and disease transmission with pathogens such as human papilloma virus, CMV, HIV, and gram-negative pathogens (Leroy, 2013). Contamination of these instruments is not common, but although the rate of patients infected by the use of one of these types of devices is low (3.1% in one study) it is not negligible or acceptable (Leroy, 2013). The CDC guidelines are listed below; disinfection and sterilization with different forms of hydrogen peroxide or ultra violet light are also being evaluated for sterilizing these types of devices.
Disinfectants can be a source of microbial contamination. A 2007 review of the literature found 7 outbreaks involving 622 patients who had developed a hospital-acquired infection caused by contaminated disinfectants (Vonberg, et al, 2007).
Flash sterilization (immediate-use sterilization) was traditionally used for items that were needed immediately but were not available. 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 AORN and others that flash sterilization has become overused (Smart, et al, 2012), and it should not be used as a routine method of sterilization. The guidelines below are from the CDC (CDC, 2008).
Medical equipment should come with manufacturer instructions on how to provide care and maintenance. The instructions should include a) the equipments’ compatibility with chemical germicides, b) whether the equipment is water-resistant or can be safely immersed for cleaning, and c) how the equipment should be decontaminated if servicing is required (CDC, 2008). If manufacturers’ instructions are not available for non-critical medical equipment, like stethoscopes and blood pressure cuffs, they usually only require cleansing followed by low- to intermediate-level disinfection, depending on the nature and degree of contamination (CDC, 2008).
Cleaning disinfecting and sterilizing patient care items should be done in a central location to control the quality. If disinfecting and sterilizing is done in outside the central processing location, the same level of efficiency and safety should be maintained (CDC, 2008).
The following principles about sterilization or disinfection of patient-care equipment are put forth by CDC (CDC, 2008).
Exceptional circumstances that require noncritical items to be either dedicated to one patient or patient cohort or subjected to low-level disinfection between patient uses are those involving:
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) hotline (703) 308-0127 or email: firstname.lastname@example.org. A source of information about high level disinfectants if the Food and Drug Administration (FDA) regional office or the FDA Center for Devices and Radiological Health at (301) 443-4690 (CDC, December 21, 2012).
Construction activities in or near healthcare facilities cause increase disease risks for airborne and waterborne disease Berger, et al, 2011). The increasing age of healthcare facilities is generating ongoing need for repair and remediation work that can introduce or increase contamination of the air and water in patient-care environments (CDC, June 6, 2003). The CDC has further recommendations for constructions that should be reviewed if applicable (CDC, June 6, 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 provide protection from airborne healthcare–related pathogens; and e) minimize the risk for transmission of airborne pathogens (CDC, June 6, 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 that should be reviewed if applicable (CDC, June 6, 2003).
The following are risk factors for healthcare-associated bacterial pneumonia (Kollef, 2011).
|Factors that enhance colonization of the oropharynx and/or stomach by microorganisms||Administration of antimicrobial agents
Admission to the ICU
Presence of underlying chronic lung disease
|Conditions favoring aspiration into the respiratory tract or reflux from the gastrointestinal tract||Initial or repeat endotracheal intubation
Insertion of nasogastric tube
Surgical procedures involving the head, neck, thorax, or upper abdomen
Immobilization due to trauma or illness
|Conditions requiring prolonged use of mechanical ventilatory support with potential exposure to contaminated respiratory devices and/or contact with contaminated or colonized hands|
|Host factors||Extremes of age
Severe underlying conditions
Recommendations for the prevention of healthcare associated pneumonia typically focus on: 1) educating staff of the risks; 2) preventing cross-infection; 3) increasing the host’s defenses; 4) optimizing nutrition while reducing the risk of aspiration; 5) reducing colonization, and; 6) correcting/minimizing co-morbid conditions (Morrow, 2009). The following are the CDC and the American Thoracic Society recommendations for the prevention of healthcare associated pneumonia (CDC, 2003; American Thoracic Society, 2005). Recommendations from the Institute for Health Improvement are included, as well (Institute for Health Improvement, 2012).
Special attention in dental facilities is required. Back flow prevention devices are required to prevent cross contamination when using cuspidors, high speed hand piece and air or water syringes. Back-siphonage devices are required to prevent contamination of the public water. This is regulated by the health authority or plumbing code enforcement agencies in the community (CDC, October, 2008).
Safety and health issues can best be addressed in the setting of a comprehensive prevention program that considers all aspects of the work environment and that has employee involvement as well as management commitment. Implementing the use of 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.
Employers are required to establish exposure control plans that include post-exposure follow up for their employees and to 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. HBIG, hepatitis B 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 (OSHA, 2011).
The following are recommendation by the Centers for Disease Control (CDC, July 2003) for immediate activity after exposure.
Provide immediate care to the exposure site.
No scientific evidence shows that using antiseptics or squeezing the wound will reduce the risk of transmission of a bloodborne pathogen. Using a caustic agent such as bleach is not recommended.
Report the exposure to the government agency responsible for managing exposures. Reporting is necessary because PEP treatment may be recommended.
Determine risk associated with exposure by:
Evaluate exposure source.
Evaluate the exposed person.
Comprehensive exposure prevention strategies have played a significant role in decreasing the probable risk of infection from bloodborne pathogens. The risks of exposure with appropriate precautions are low, but they are real. Understanding how an exposure occurs and the risks of exposure is imperative for both the occupational health clinician and the healthcare professional. After an occupational exposure to a bloodborne pathogen, the risk of infection depends on a number of factors including:
HBV: The number of occupational infections decreased by 95% after the HBV vaccine became available in 1982 (CDC, July 2003). Healthcare professionals who have received hepatitis B vaccine and have developed immunity to the virus are at virtually no risk for infection. The risk of HBV infection is primarily related to the degree of contact with blood in the workplace and also to the hepatitis B e antigen (HBeAg) status of the source person. Individuals who are both hepatitis B surface antigen (HBsAg) positive and HBeAg positive have more virus in their blood and are more likely to transmit HBV. Amongst healthcare professionals who are susceptible, the risk of infection after one percutaneous exposure is 6%-30% (CDC, July 2003).
Although percutaneous injuries are among the most efficient modes of HBV transmission, these exposures probably account for only a minority of HBV infections among healthcare professionals. In several investigations of nosocomial hepatitis B outbreaks, most infected healthcare professionals could not recall an overt percutaneous injury, although in some studies, up to one third of the infected recalled caring for a patient who was HBsAg-positive. Additionally, HBV has been demonstrated to survive in dried blood at room temperature on environmental surfaces for approximately 4 days (CDC, October 22, 2012).
HBV infections that occur in healthcare professionals with no history of non-occupational exposure or occupational percutaneous injury might have resulted from direct or indirect blood or body fluid exposures that inoculated HBV into cutaneous scratches, abrasions, burns, other lesions, or on mucosal surfaces (CDC, June 29, 2001). HBsAg is also found in several other body fluids, including breast milk, bile, cerebrospinal fluid, feces, nasopharyngeal washings, saliva, semen, sweat, and synovial fluid. However, most body fluids are not efficient vehicles of transmission because they contain low quantities of infectious HBV, despite the presence of HBsAg (CDC, June 29, 2001).
HCV is not transmitted efficiently through occupational exposures to blood. Transmission has been reported rarely, but more than half the reported cases had other risk factors (Pearlman, 2004). The risk for HCV infection after a needlestick or sharps exposure to HCV-positive blood is approximately 1.8% (range: 0%–10%) (CDC, Nov., 2008; Tomkins, et al, 2012). Transmission rarely occurs from mucous membrane exposures to blood, and no transmission in healthcare professionals has been documented from intact or non-intact skin exposures to blood.
HIV: The average risk of HIV transmission after a percutaneous exposure to HIV-infected blood has been estimated to be approximately 0.3% (Gilman, 2012). The risk after a mucous membrane exposure is approximately 0.09% (Gilman, 2012). Although episodes of HIV transmission after non-intact skin exposure have been documented, the average risk for transmission by this route has not been precisely quantified but is estimated to be less than the risk for mucous membrane exposures. The risk for transmission after exposure to fluids or tissues other than HIV-infected blood also has not been quantified but is probably considerably lower than for blood exposures (Gilman, 2012).
By calling 1-888-448-4911 from anywhere in the United States 24 hours a day, 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 needlestick injuries and other serious occupational exposures to blood borne microorganisms that lead to such serious infections or diseases as HIV or hepatitis.
HBV: Recommendations for HBV post-exposure management include initiation of the hepatitis B vaccine series to any susceptible, unvaccinated person who sustains an occupational blood or body fluid exposure, regardless of the source person’s hepatitis B status. Postexposure Prophylaxis (PEP) with hepatitis B immune globulin (HBIG) and/or hepatitis B vaccine series should be considered for occupational exposures after evaluation of the hepatitis B surface antigen status of the source and the vaccination and vaccine response status of the exposed person (Mathieu, 2012).
Women who are pregnant or breastfeeding can be vaccinated against HBV infection and/or get HBIG. Pregnant women who are 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.
Post-exposure treatment should begin as soon as possible after exposure, preferably within 24 hours, and no later than 7 days. Hepatitis B immune globulin (HBIG) is effective in preventing HBV infection after an exposure. The decision to begin treatment is based on several factors, such as (DHHS, 2003):
HCV: There is no vaccine against hepatitis C and no treatment after an exposure that will prevent infection. Immune globulin and antiviral agents like, Interferon, with or without ribavirin, are not recommended for PEP of hepatitis C.
IG is not effective for postexposure prophylaxis of HCV. Antiviral agents (e.g., interferon) are not recommended to prevent HCV infection. The mechanisms of the effect of interferon in treating HCV are not understood, and an established infection might need to be present for interferon to be effective.
Limited data indicate that antiviral therapy might be beneficial when started early in the course of HCV infection, but no guidelines exist for administration of therapy during the acute phase of infection. When HCV infection is identified early, the individual should be referred for medical management to a specialist in this area.
HIV: There is no vaccine against HIV. PEP is not recommended for all occupational exposures to HIV because most exposures do not lead to HIV infection and because the drugs used to prevent infection may have serious side effects. Based on the level of risk of HIV transmission of the exposure, a two or more drug PEP may be recommended. A three or more drug regimen may be recommended for an exposure of high risk transmission, but potential toxicity many prevent completion of the regimen, making the regimen ineffective (Gilman, 2012; Mathieu, 2012). The PEP regimen should be started immediately. The optimal duration of PEP is not known.
The majority of HIV exposures warrant a two drug regime using two nucleoside reverse transcriptase inhibitors (NRTIs), or one NRTI and one nucleotide reverse transcriptase inhibitors (NtRTIs). Because of the complexity determining PEP, consultation should be sought. The following are resources for consultation (Panlilio, et.al, 2005, pg 10):
All of the antiviral drugs for HIV 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 PEP have included kidney stones, hepatitis, and suppressed blood cell production. Interaction with other medicines can cause serious side effects.
Pregnancy should not rule out the use of post-exposure treatment when it is warranted. However, what is known and not known regarding the potential benefits and risks associated with the use of antiviral drugs in order to make an informed decision about treatment. The effect of antiretroviral drugs on developing fetus may be teratogenic (Gilman, 2012).
If the source individual cannot be identified or tested, decisions regarding follow-up should be based on the exposure risk and whether the source is likely to be a person who is infected with a bloodborne pathogen. Follow-up testing should be available to all professionals who are concerned about possible infection through occupational exposure.
HBV: If the HBV vaccine is given, a follow up test in 1-2 months will determine the response to the vaccine. Other routine follow-up after post-exposure treatment is not recommended, because the prevention is highly effective. Symptoms suggesting hepatitis should be reported (CDC, August 16, 2012).
|Postexposure follow-up of healthcare, emergency medical and public safety professionals for HCV virus (CDC, Nov., 2008):|
|For the source||Perform baseline testing for anti-HCV|
|For the person exposed to an HCV-positive source||Perform baseline and follow-up testing, including baseline testing for anti-HCV and ALT activity
Follow-up testing for anti-HCV (e.g., at 4–6 months) and ALT activity. If earlier diagnosis of HCV infection is desired, testing for HCV RNA may be performed at 4–6 weeks
|Supplemental anti-HCV testing to confirm all anti-HCV results reported as positive by enzyme immunoassay|
“CDC's recommendations for prevention and control of HCV infection specify that persons should not be excluded from work, school, play, child care, or other settings on the basis of their HCV infection status. There is no evidence of HCV transmission from food handlers, teachers, or other service providers in the absence of blood-to-blood contact” (CDC, 2008).
HIV: Follow up counseling, postexposure testing, and medical evaluation should be done regardless of whether PEP was used (Gilman, 2012). Perform HIV-antibody testing by enzyme immunoassay should be monitored at baseline, six weeks, 12 weeks, and six months. If the exposed person becomes infected with HCV, HIV testing should be done for 12 months (Gilman, 2012). People on PEP should be monitored closely for toxicity.
HBV: If the exposed healthcare professional receives post-exposure treatment, it is unlikely that infection and exposure to others will occur. No precautions are recommended (DHHS, 2003).
HCV: Because the risk of becoming infected and passing the infection on to others after an exposure to HCV is low, no precautions are recommended.
HIV: 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 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.
Healthcare professionals have an obligation to adhere to scientifically accepted standards for infection control and responsibility to monitor the infection control practices of subordinates. The correct incorporation of work practice controls and engineering controls help to avoid or reduce exposure to potentially infectious materials and hazards. Compliance with environmental infection control measures will decrease the risk of healthcare related infections among patients, especially the immunocompromised and healthcare professionals (Sehulster et al., 2004).
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Zhang, M.X., Yu, Y. (2013). A study of the psychological effects of sharps injuries on healthcare workers in China. American Journal of Infection Control, 41(2), 186-187.
This course is applicable for the following professions:
Advanced Registered Nurse Practitioner (ARNP), Certified Nursing Assistant (CNA), Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), Dietetic Technicians, Registered (DTR), Dietitian/Nutritionalist (RDN), Home Health Aid (HHA), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Midwife (MW), Registered Nurse (RN), Respiratory Therapist (RT)
CPD: Practice Effectively, CPD: Preserve Safety, Infection Control/Disease, Medical Surgical, New York Requirements