The recommendations in this guideline for Ebola Virus Disease have been
`superseded by CDC’s Infection Prevention and Control Recommendations for
`Hospitalized Patients with Known or Suspected Ebola Virus Disease in U.S.
`Hospitals.
`
`This information is in
`
`
`
`. Appendix A
`
` Click here for current information on how Ebola virus is transmitted.
`
`(cid:100)(cid:346)(cid:286)(cid:3)(cid:396)(cid:286)(cid:272)(cid:381)(cid:373)(cid:373)(cid:286)(cid:374)(cid:282)(cid:258)(cid:410)(cid:349)(cid:381)(cid:374)(cid:400)(cid:3)(cid:349)(cid:374)(cid:3)(cid:410)(cid:346)(cid:349)(cid:400)(cid:3)(cid:336)(cid:437)(cid:349)(cid:282)(cid:286)(cid:367)(cid:349)(cid:374)(cid:286)(cid:3)(cid:296)(cid:381)(cid:396)(cid:3)(cid:68)(cid:286)(cid:258)(cid:400)(cid:367)(cid:286)(cid:400)(cid:3)(cid:346)(cid:258)(cid:448)(cid:286)(cid:3)(cid:271)(cid:286)(cid:286)(cid:374)(cid:3)(cid:400)(cid:437)(cid:393)(cid:286)(cid:396)(cid:400)(cid:286)(cid:282)(cid:286)(cid:282)(cid:3)(cid:271)(cid:455)(cid:3)(cid:18)(cid:24)(cid:18)(cid:859)(cid:400)(cid:3)
`(cid:47)(cid:373)(cid:373)(cid:437)(cid:374)(cid:349)(cid:460)(cid:258)(cid:410)(cid:349)(cid:381)(cid:374)(cid:3)(cid:381)(cid:296)(cid:3)(cid:44)(cid:286)(cid:258)(cid:367)(cid:410)(cid:346)(cid:272)(cid:258)(cid:396)(cid:286)(cid:3)(cid:87)(cid:286)(cid:396)(cid:400)(cid:381)(cid:374)(cid:374)(cid:286)(cid:367)(cid:855)(cid:3)(cid:90)(cid:286)(cid:272)(cid:381)(cid:373)(cid:373)(cid:286)(cid:374)(cid:282)(cid:258)(cid:410)(cid:349)(cid:381)(cid:374)(cid:400)(cid:3)(cid:381)(cid:296)(cid:3)(cid:410)(cid:346)(cid:286)(cid:3)(cid:4)(cid:282)(cid:448)(cid:349)(cid:400)(cid:381)(cid:396)(cid:455)(cid:3)(cid:18)(cid:381)(cid:373)(cid:373)(cid:349)(cid:410)(cid:410)(cid:286)(cid:286)(cid:3)
`(cid:381)(cid:374)(cid:3)(cid:47)(cid:373)(cid:373)(cid:437)(cid:374)(cid:349)(cid:460)(cid:258)(cid:410)(cid:349)(cid:381)(cid:374)(cid:3)(cid:87)(cid:396)(cid:258)(cid:272)(cid:410)(cid:349)(cid:272)(cid:286)(cid:400)(cid:3)(cid:894)(cid:4)(cid:18)(cid:47)(cid:87)(cid:895)(cid:856)
`
`Medac Exhibit 2020
`Koios Pharmaceuticals v. Medac
`IPR2016-01370
`Page 00001
`
`

`

`2007 Guideline for Isolation Precautions:
`Preventing Transmission of Infectious
`Agents in Healthcare Settings
`
`Jane D. Siegel, MD; Emily Rhinehart, 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 Infectious Agents in Healthcare Settings
`http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf
`
`1
`
`
`
`
`
`
`
`
`
`
`
`Page 00002
`
`

`

`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 Medicine
`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
`(Executive Secretary)
`Centers for Disease Control and Prevention
`Atlanta, GA
`
`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
`
`Members
`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
`Associate 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
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`2
`
`Page 00003
`
`

`

`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 Minnesota
`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. Underwood, 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
`Liaison 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 National 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 CIC 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
`
`3
`
`Page 00004
`
`

`

`
`
`
`
`
`
`
`
`TABLE OF CONTENTS
`
`Executive Summary ……………………………………………………………………………….7
`
`Abbreviations………………………………………………………………………………………11
`Part I: Review of the Scientific Data Regarding Transmission of Infectious Agents in
`Healthcare Settings................................................................................................................ 12
`I.A. Evolution of the 2007 document ........................................................................................ 12
`I.B. Rationale for Standard and Transmission-Based Precautions in healthcare settings ........ 14
`I.B.1. Source of infectious agents....................................................................................... 14
`I.B.2. Susceptible hosts ...................................................................................................... 14
`I.B.3. Modes of transmission ............................................................................................. 15
`I.B.3.a. Contact transmission..................................................................................... 15
`I.B.3.a.i. Direct contact transmission ............................................................ 16
`I.B.3.a.ii. Indirect contact transmission ......................................................... 16
`I.B.3.b. Droplet transmission .................................................................................... 17
`I.B.3.c. Airborne transmission................................................................................... 18
`I.B.3.d. Emerging issues and controversies concerning bioaerosols and airborne
`transmission of infectious agents...............................................19
`I.B.3.d.i. Transmission from patients…………………………...19
`I.B.3.d.ii. Transmission from the environment…………………20
`I.B.3.e. Other sources of infection ..............................…………………………………20
`I.C. Infectious agents of special infection control interest for healthcare settings..................... 20
`I.C.1. Epidemiologically important organisms………………………………….21
`I.C.1.a. Clostridium difficile ........................................................................................ 21
`I.C.1.b. Multidrug-resistant organisms(MDROs)…………………………………..…22
`I.C.2. Agents of bioterrorism............................................................................................... 23
`I.C.3. Prions ...................................................................................................................... 24
`I.C.4. Severe acute respiratory syndrome (SARS) ............................................................. 26
`I.C.5. Monkeypox ............................................................................................................... 28
`I.C.6. Noroviruses………………………………………………………………………………28
`I.C.7. Hemorrhagic fever viruses……………………………………………………………..29
`I.D. Transmission risks associated with specific types of healthcare settings .......................... 31
`I.D.1. Hospitals .................................................................................................................. 31
`I.D.1.a. Intensive care units ...................................................................................... 31
`I.D.1.b. Burn units..................................................................................................... 32
`I.D.1.c. Pediatrics ..................................................................................................... 33
`I.D.2. Non-acute care settings…………............................................................................. 34
`I.D.2.a. Long term care ............................................................................................ 34
`I.D.2.b. Ambulatory care settings ............................................................................. 35
`I.D.2.c. Home care ................................................................................................... 36
`I.D.2.d. Other sites of healthcare delivery ............................................................... 37
`I.E. Transmission risks associated with special patient populations....................................... 38
`I.E.1. Immunocompromised patients ................................................................................. 38
`I.E.2. Cystic fibrosis patients ............................................................................................. 39
`
`4
`
`Page 00005
`
`

`

`I.F. New therapies with potential transmissible infectious agents........................................... 39
`I.F.1. Gene therapy ........................................................................................................... 39
`I.F.2. Infections Transmitted through Blood, Organs and Tissues................................ .... 40
`I.F.3. Xenotransplantation and tissue allografts ................................................................ 40
`
`Part II. Fundamental Elements to Prevent Transmission of Infectious Agents in
`Healthcare Settings................................................................................................................ 41
`II.A. Healthcare system components that influence the effectiveness of
`precautions to prevent transmission .............................................................................. 41
`II.A.1. Administrative measures……………………………………………..…41
`II.A.1.a. Scope of Work and Staffing Needs for Infection Control Professionals
`(ICP)…………………..………………………………………………….……..42
`II.A.1.a.i. Infection Control Liaison Nurse……..………………..43
`II.A.1.b. Bedside nurse staffing……………………….……………………43
`II.A.1.c. Clinical microbiology laboratory support…..….………………. ..43
`II.A.2. Institutional safety culture and organizational characteristics………45
`II.A.3. Adherence of healthcare personnel to recommended guidelines….45
`II.B. Surveillance for healthcare-associated infections (HAIs)………………..…46
`II.C. Education of healthcare workers, patients, and families ................................................. 47
`II.D. Hand hygiene.................................................................................................................. 49
`II.E. Personal protective equipment for healthcare personnel ................................................ 49
`II.E.1. Gloves................................................................................................................... 50
`II.E.2. Isolation gowns ..................................................................................................... 51
`II.E.3. Face protection: masks, goggles, face shields………………………52
`II.E.3.a. Masks…………………………………………………………..52
`II.E.3.b. Goggles, face shields…………………………………………52
`II.E.4. Respiratory protection ........................................................................................... 53
`II.F. Safe work practices to prevent HCW exposure to bloodborne pathogens .................... 55
`II.F.1. Prevention of needlesticks and other sharps-related injuries ................................ 55
`II.F.2. Prevention of mucous membrane contact ............................................................. 56
`II.F.2.a. Precautions during aerosol-generating procedures………56
`II.G. Patient placement .......................................................................................................... 56
`II.G.1. Hospitals and long-term care settings .................................................................. 56
`II.G.2. Ambulatory care settings ...................................................................................... 58
`II.G.3. Home care ............................................................................................................ 59
`II.H. Transport of patients ...................................................................................................... 59
`II.I. Environmental measures................................................................................................. 60
`II.J. Patient care equipment, instruments/devices ................................................................. 61
`II.K. Textiles and laundry ....................................................................................................... 61
`II.L. Solid waste……………………………………………………………………62
`II.M. Dishware and eating utensils......................................................................................... 62
`II.N. Adjunctive measures ..................................................................................................... 63
`II.N.1. Chemoprophylaxis ................................................................................................ 63
`II.N.2. Immunoprophylaxis............................................................................................... 63
`
`5
`
`
`
`
`
`
`
`
`
`Page 00006
`
`

`

`
`
`II.N.3. Management of visitors………………………………………………64
`II.N.3.a. Visitors as sources of infection…………………………….64
`II.N.3.b. Use of barrier precautions by visitors……………………..65
` Part III. HICPAC Precautions to Prevent Transmission of Infectious Agents ................... 66
`III.A. Standard Precautions ................................................................................................... 66
`III.A.1.New Standard Precautions for patients……………………………………………67
`III.A.1.a. Respiratory Hygiene/Cough Etiquette ........................................................... 67
`III.A.1.b. Safe Injection Practices………………………………………………………. 68
`III.A.1.c. Infection Control Practices for Special Lumbar Puncture Procedures……69
`III.B. Transmission-Based Precautions ................................................................................. 69
`III.B.1. Contact Precautions............................................................................................. 70
`III.B.2. Droplet Precautions ............................................................................................. 70
`III.B.3. Airborne Infection Isolation Precautions............................................................... 71
`III.C. Syndromic or empiric application of Transmission-Based Precautions......................... 71
`III.D. Discontinuation of precautions...................................................................................... 72
`III.E. Application of Transmission-Based Precautions in ambulatory and home care
`settings ..................................................................................................................................... 72
`III.F. Protective environment (PE) ......................................................................................... 73
`
`Part IV: Recommendations.................................................................................................... 74
`
`Appendix A.Type and duration of precautions needed for selected infections and
`conditions ............................................................................................................ 93
`
`Tables
`Table 1. Recent history of guidelines for prevention of healthcare-associated infections......
`Table 2. Clinical syndromes or conditions warranting additional empiric transmission-
`based precautions pending confirmation of diagnosis………………………….........
`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 ..
`Table 4. Recommendations for application of Standard Precautions for the care of all
`patients in all healthcare settings...........................................................................
`Table 5. Components of a Protective Environment .............................................................
`
`Figure Sequence for donning and removing PPE ................................................................
`
`Glossary………………………………….………………………………………........................…
`
`References............................................................................................................................
`
`6
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`Page 00007
`
`

`

`EXECUTIVE SUMMARY
`
`The Guideline for Isolation Precautions: Preventing 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 primarily 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 infection 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 “nosocomial infections“ is replaced by “healthcare•
`associated infections” (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 reaffirmation 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, including 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 strong 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 immunocompromised 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
`
`7
`
`
`
`
`
`Page 00008
`
`

`

`emphasis and recommendations for administrative involvement in the
`development and support of infection control programs.
`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 transmission 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, healthcare 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 referred 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 transmission 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 “epidemiologically important
`organisms” 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 hold 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 these 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 practices 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
`administrators. 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
`demonstrates 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
`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
`
`8
`
`
`
`
`
`
`
`
`
`Page 00009
`
`

`

`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 indicated 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 contaminated 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, Appendices, 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 recommendations 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 figure 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 Selected 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 recommended 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.
`
`Pre- Publication of the Guideline on Preventing 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 (Siegel JD, Rhinehart E,
`Jackson M, Chiarello L and HICPAC. Management of Multidrug-Resistant Organisms in
`Healthcare Settings 2006 www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf), 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 individual healthcare settings. A rationale and
`
`9
`
`
`
`
`
`
`
`
`
`
`
`Page 00010
`
`

`

`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, information 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,
`environmental 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 MDRO
`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 guideline is to improve the
`safety of the nation’s healthcare delivery system by reducing the rates of HAIs.
`
`10
`
`
`
`
`
`Page 00011
`
`

`

`Abbreviations Used in the Guideline
`
`Airborne infection isolation room
`AIIR
`Centers for Disease Control and Prevention
`CDC
`Cystic fibrosis
`CF
`Creutzfeld-Jakob Disease
`CJD
`CLSI
` Clinical Laboratory Standards Institute
`Extended spectrum beta-lactamases
`ESBL
`Food and Drug Administration
`FDA
`Healthcare-associated infections
`HAI
`Hepatitis B virus
`HBV
`Hepatitis C virus
`HCV
`High efficiency particulate air [filtration]
`HEPA
`Healthcare Infection Control Practices Advisory Committee
`HICPAC
`Human immunodeficiency virus
`HIV
`Healthcare worker
`HCW
`Hematopoetic stem-cell transplant
`HSCT
` Intensive care unit LTCF
`ICU
`Long-term care facility
`
`Multidrug-resistant organism
`MDRO
`MDR