All hospitalized patients should be handled with standard precautions, as outlined by the CDC Health Care Infection Control Practices Advisory Committee. These guidelines recognize that not only blood but also other body fluids pose a risk of carrying pathogens and that all patients should be treated in a consistent manner to decrease the risk of transmission of these pathogens between patients and HCWs. Standard precautions are based on the following basic assumptions:
Hand hygiene is the most important infection-control practice—the basis of all precautions including standard precautions.
Barrier techniques help to avoid contact with any body fluid or mucosal surface to decrease transmission of pathogens and include Gloves, gowns, mask, and eye protection or face shield as appropriate for patient contact.
Standard precautions for pediatrics are summarized in Table 5–3.
Table 5–3. Recommendations for Standard Precautions* ||Download (.pdf)
Table 5–3. Recommendations for Standard Precautions*
Hand hygiene: Before and after each and every patient contact, or after touching blood, body fluids, secretions, excretions or contaminated items, and after removing gloves
Barriers: Personal protective equipment for special situations
Gloves: Put on before touching blood, body fluids, secretions, excretions or contaminated items, and/or touching a mucosal membrane or nonintact skin
Gown: Before doing a procedure or patient care activity when contact of clothing or exposed skin with blood/body fluids, secretions and excretions is anticipated
Mask: Before procedure or patient care likely to cause splashes or sprays of blood, body fluids, secretions, excretions or contaminated items
Eye protection/Face mask: Before a procedure or patient care activity that may cause splashes that could contaminate the eyes or face
Patient Resuscitations: Mouth-to-mouth resuscitation should be avoided; use resuscitation bags and these should be readily available for emergency situations
Used linens and hospital garments should be treated as contaminated and possible sources of infection. They should be transported and processed in a manner that prevents contamination of the clothing, skin, or mucous membranes of HCWs or housekeeping staff
When handling needles and other sharps: Do not recap, bend, or break a sharp; whenever possible, use needle-free safety devices; place sharps in a puncture-resistant container when finished using. If recapping of a needle is necessary, use the single-hand technique only
More specialized precautions are used to prevent the spread of specific microorganisms when standard precautions are not sufficient. The types of transmission-based precautions are airborne, droplet, and contact precautions (Table 5–4).
Table 5–4. Transmission-Based Precautions in the Hospital* ||Download (.pdf)
Table 5–4. Transmission-Based Precautions in the Hospital*
Airborne: Single-patient room with negative air pressure and filtered air and 6–12 air changes per hour
Respirators: N95 mask or Powered Purified Air Respirator (does not require fit testing)
Single patient room
Masks: Surgical mask put on entry into room
Airborne precautions are employed for infectious agents spread primarily by the droplet route, such as Mycobacterium tuberculosis, varicella zoster virus, and the measles virus. These organisms are carried on small-particle droplets or dust in the air, remaining suspended for long periods of time, and are subject to spread based on airflow. They can be spread over long distances, and require special ventilation and air handling. Patients should be given a private room with negative air pressure ventilation system that exhausts air externally or filter it through a high-efficiency particulate (HEPA) filter prior to recirculation. If a private room is not possible, patients with the same infectious agent should be cohorted. HCWs susceptible to infection with measles or varicella virus should not care for these patients. If susceptible workers must care for these children, a mask should be worn when in the room. Workers with immunity to measles or varicella do not require masks. N-95 masks, or other sealed respirators should be used in the care of patients with suspected or known cavitary pulmonary tuberculosis. HCWs require “fit” testing, to be sure that the mask selected is properly fit and will be protective, prior to using in the care of patients.
Droplet precautions are used for organisms with transmission by aerosols from activities such as talking or sneezing. Aerosols deposited on the mucous membranes of another individual transmit infection. These larger droplets spread only over a more limited range of less than 3 ft, compared to airborne organisms. Since these microorganisms are contained in large droplets, they are not readily spread by air currents and therefore do not require negative pressure rooms with high-efficiency particulate filters or outside exhausts. In general, patients with an organism spread by droplet transmission should be given a private room. If a private room is not available, cohorting patients with the same infection is acceptable. If neither of these solutions is possible, then infected patients must be separated from their roommates by a distance of at least 3 ft. HCWs entering the room should wear masks to prevent infection when in close contact with the patient, within 3 ft. Masks should be removed and left in the room or anteroom, with hand hygiene after removing the mask. Organisms that require droplet precautions include adenovirus, diphtheria (pharyngeal), invasive Haemophilus type b, Influenza, mumps, Neisseria meningiditis, parvovirus prior to rash, pertussis, rubella, streptococcal respiratory infections, and the SARS virus.
Contact precaution is used to prevent both direct and indirect contact transmission. Direct contact transmission occurs when microorganisms are transferred from a patient to a HCW or another patient directly by direct contact (e.g., patient to hand of HCW). In contrast, indirect contact transmission occurs when the spread is via an intermediate object, such as when a HCW touches contaminated linens or bed surfaces and his hands become contaminated. Hand hygiene and barrier methods are particularly important in preventing the spread of these organisms. Patients should be given a private room, or cohorted with other patients with the same infection, and gloves should be worn at all times. If a HCW is likely to have contact with a patient's clothing or with surfaces in the patient's room, gowns should be worn and removed with gloves prior to leaving the room (or in an anteroom) and then hand hygiene. Organisms requiring this isolation include C. difficile, conjunctivitis, enteroviruses, Escherichia coli O157:H7, hepatitis A, herpes simplex virus: neonatal and cutaneous herpes zoster shingles, parainfluenza virus, RSV, rotavirus, scabies, Shigella, and Staphylococcus aureus draining wounds.
When the etiology of the infection is unknown, the transmission precautions can be used empirically and can be used in combination. For example, infants who are clinically diagnosed with bronchiolitis should be placed in both droplet and contact precautions if and until their specific pathogen is known. Similarly, pediatric patients with a diarrheal illness that is likely to be infectious should be placed in contact precautions.
Children placed in transmission-based precautions should not be allowed to leave their rooms for visits to the cafeteria or play rooms. Gloves are not required for routine diaper changes unless the child is in contact isolation. A full listing of organisms with isolation recommendations and incubation periods is available at the CDC Web site: www.cdc.gov/ncidod/dhqp/gl_isolation.