IV: Recommendations

These recommendations are designed to prevent transmission of infectious agents among patients and healthcare personnel inpatients with suspected or proven SARS all settings where healthcare is delivered. As in other CDC/HICPAC guidelines, each recommendation is categorized on the basis of existing scientific data, theoretical rationale, applicability, and when possible, economic impact. The CDC/HICPAC system for categorizing recommendations is as follows:

Category IA Strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies.

Category IB Strongly recommended for implementation and supported by some experimental, clinical, or epidemiologic studies and a strong theoretical rationale.

Category IC Required for implementation, as mandated by federal and/or state regulation or standard.

Category II Suggested for implementation and supported by suggestive clinical or epidemiologic studies or a theoretical rationale.

No recommendation; unresolved issue. Practices for which insufficient evidence or no consensus regarding efficacy exists.

I. Administrative Responsibilities

Healthcare organization administrators should ensure the implementation of recommendations in this section.

I.A. Incorporate preventing transmission of infectious agents into the objectives of the organization’s patient and occupational safety programs.^{543-546, 561, 620, 626, 946} Category IB/IB

I.B. Make preventing transmission of infectious agents a priority for the healthcare organization. Provide administrative support, including fiscal and human resources for maintaining infection control programs.^{434, 548, 549, 559, 561, 566, 662, 552, 562-564, 946} Category IB/IB

I.C. Develop and implement processes to ensure oversight of infection control activities appropriate to the healthcare setting and assign responsibility for oversight of infection control activities to an individual or group within the healthcare organization that is knowledgeable about infection control.^{434, 549, 566} Category II

I.D. Develop and implement systems for early detection and management (e.g., use of appropriate infection control measures, including isolation precautions, PPE) of potentially infectious persons at initial points of patient encounter in outpatient settings (e.g., triage areas, emergency departments, outpatient clinics, physician offices) and at the time of admission to hospitals and long-term care facilities (LTCF).^{9, 122, 134, 253, 827} Category IB

I.E. Develop and implement policies and procedures to limit patient visitation by persons with signs or symptoms of a communicable infection. Screen visitors to high-risk patient care areas (e.g., oncology units, hematopoietic stem cell transplant [HSCT] units, intensive care units, other severely immunocompromised patients) for possible infection.^{43, 24, 41, 962, 963}Category IB

I.F. Identify performance indicators of the effectiveness of organization-specific measures to prevent transmission of infectious agents (Standard and Transmission-Based Precautions), establish processes to monitor adherence to those performance measures and provide feedback to staff members.^{704, 739, 705, 708, 666, 964, 667, 668, 555} Category IB

II. Education and Training

II.A. Provide job- or task-specific education and training on preventing transmission of infectious agents associated with healthcare during orientation to the healthcare facility; update information periodically during ongoing education programs. Target all healthcare personnel for education and training, including but not limited to medical, nursing, clinical technicians, laboratory staff; property service (housekeeping), laundry, maintenance and dietary workers; students, contract staff and volunteers. Document competency initially and repeatedly, as appropriate, for the specific staff positions. Develop a system to ensure that healthcare personnel employed by outside agencies meet these education and training requirements through programs offered by the agencies or by participation in the healthcare facility’s program designed for full-time personnel.^{126, 559, 561, 562, 655, 681-684, 686, 688, 689, 702, 893, 919, 965} Category IB

II.B. Provide instructional materials for patients and visitors on recommended hand hygiene and Respiratory Hygiene/Cough Etiquette practices and the application of Transmission-Based Precautions.^{9, 709, 710, 963} Category II

III. Surveillance

III.A. Monitor the incidence of epidemiologically-important organisms and targeted HAIs that have substantial impact on outcome and for which effective preventive interventions are available; use information collected through surveillance of high-risk populations, procedures, devices and highly transmissible infectious agents to detect transmission of infectious agents in the healthcare facility.^{566, 671, 672, 675, 687, 919, 967, 968, 673, 969, 970} Category IA

III.B. Apply the following epidemiologic principles of infection surveillance.^{671, 967, 673, 969, 663, 664} Category IB

• Use standardized definitions of infection
• Use laboratory-based data (when available)
• Collect epidemiologically-important variables (e.g., patient locations and/or clinical service in hospitals and other large multi-unit facilities, population-specific risk factors [e.g., low birth-weight neonates], underlying conditions that predispose to serious adverse outcomes)
• Analyze data to identify trends that may indicated increased rates of transmission
• Feedback information on trends in the incidence and prevalence of HAIs, probable risk factors, and prevention strategies and their impact to the appropriate healthcare providers, organization administrators, and as required by local and state health authorities

III.C. Develop and implement strategies to reduce risks for transmission and evaluate effectiveness.^{566, 673, 684, 970, 963, 971} Category IB

III.D. When transmission of epidemiologically-important organisms continues despite implementation and documented adherence to infection prevention and control strategies, obtain consultation from persons knowledgeable in infection control and healthcare epidemiology to review the situation and recommend additional measures for control.^{566 247, 687} Category IB

III.E. Review periodically information on community or regional trends in the incidence and prevalence of epidemiologically-important organisms (e.g., influenza, RSV, pertussis, invasive group A streptococcal disease, MRSA, VRE) (including in other healthcare facilities) that may impact transmission of organisms within the facility.^{398, 687, 972, 973, 974} Category II

IV. Standard Precautions

Assume that every person is potentially infected or colonized with an organism that could be transmitted in the healthcare setting and apply the following infection control practices during the delivery of health care.

IV.A. Hand Hygiene

Perform hand hygiene ~ in the following clinical situations:

IV.A.4. Wash hands with non-antimicrobial soap and water or with antimicrobial soap and water if contact with spores (e.g., C. difficile or Bacillus anthracis) is likely to have occurred. The physical action of washing and rinsing hands under such circumstances is recommended because alcohols, chlorhexidine, iodophors, and other antiseptic agents have poor activity against spores.^{559, 956, 983} Category II

IV.A.5. Do not wear artificial fingernails or extenders if duties include direct contact with patients at high risk for infection and associated adverse outcomes (e.g., those in ICUs or operating rooms).^{30, 31, 559, 722-724} Category IA

IV.B. Personal protective equipment (PPE) (see Figure)

IV.B.1. Observe the following principles of use:

IV.B.2. Gloves

IV.B.3. Gowns

IV.B.4. Mouth, nose, eye protection

IV.B.5. During aerosol-generating procedures (e.g., bronchoscopy, suctioning of the respiratory tract [if not using in-line suction catheters], endotracheal intubation) in patients who are not suspected of being infected with an agent for which respiratory protection is otherwise recommended (e.g., M. tuberculosis, SARS or hemorrhagic fever viruses), wear one of the following: a face shield that fully covers the front and sides of the face, a mask with attached shield, or a mask and goggles (in addition to gloves and gown).^{95, 96, 113, 126, 93, 94, 134} Category IB

IV.C. Respiratory Hygiene/Cough Etiquette

IV.C.1. Educate healthcare personnel on the importance of source control measures to contain respiratory secretions to prevent droplet and fomite transmission of respiratory pathogens, especially during seasonal outbreaks of viral respiratory tract infections (e.g., influenza, RSV, adenovirus, parainfluenza virus) in communities.^{14, 24, 684, 10, 262} Category IB

IV.C.2. Implement the following measures to contain respiratory secretions in patients and accompanying individuals who have signs and symptoms of a respiratory infection, beginning at the point of initial encounter in a healthcare setting (e.g., triage, reception and waiting areas in emergency departments, outpatient clinics and physician offices).^{20, 24, 145, 902, 989}

IV.D. Patient Placement

IV.D.1. Include the potential for transmission of infectious agents in patient-placement decisions. Place patients who pose a risk for transmission to others (e.g., uncontained secretions, excretions or wound drainage; infants with suspected viral respiratory or gastrointestinal infections) in a single-patient room when available.^{24, 430, 435, 796, 797, 806, 990, 410, 793} Category IB

IV.D.2. Determine patient placement based on the following principles: Category II

• Route(s) of transmission of the known or suspected infectious agent
• Risk factors for transmission in the infected patient
• Risk factors for adverse outcomes resulting from an HAI in other patients in the area or room being considered for patient-placement
• Availability of single-patient rooms
• Patient options for room-sharing (e.g., cohorting patients with the same infection)

IV.E. Patient-care Equipment and Instruments/devices.⁹⁵⁶

IV.E.1. Establish policies and procedures for containing, transporting, and handling patient-care equipment and instruments/devices that may be contaminated with blood or body fluids.^{18, 739, 975} Category IB/IB

IV.E.2. Remove organic material from critical and semi-critical instrument/devices, using recommended cleaning agents before high level disinfection and sterilization to enable effective disinfection and sterilization processes.^{836, 991, 992} Category IA

IV.E.3. Wear PPE (e.g., gloves, gown), according to the level of anticipated contamination, when handling patient-care equipment and instruments/devices that is visibly soiled or may have been in contact with blood or body fluids.^{18, 739, 975} Category IB/IB

IV.F. Care of the Environment.¹¹

IV.F.1. Establish policies and procedures for routine and targeted cleaning of environmental surfaces as indicated by the level of patient contact and degree of soiling.¹¹ Category II

IV.F.2. Clean and disinfect surfaces that are likely to be contaminated with pathogens, including those that are in close proximity to the patient (e.g., bed rails, over bed tables) and frequently-touched surfaces in the patient care environment (e.g., door knobs, surfaces in and surrounding toilets in patients’ rooms) on a more frequent schedule compared to that for other surfaces (e.g., horizontal surfaces in waiting rooms).^{11, 73, 740, 746, 993, 994, 72, 800, 835, 995} Category IB

IV.F.3. Use EPA-registered disinfectants that have microbiocidal (i.e., killing) activity against the pathogens most likely to contaminate the patient-care environment. Use in accordance with manufacturer’s instructions.^{842-844, 956, 996} Category IB/IB

IV.F.4. In facilities that provide health care to pediatric patients or have waiting areas with child play toys (e.g., obstetric/gynecology offices and clinics), establish policies and procedures for cleaning and disinfecting toys at regular intervals.^{379, 80} Category IB

IV.F.5. Include multi-use electronic equipment in policies and procedures for preventing contamination and for cleaning and disinfection, especially those items that are used by patients, those used during delivery of patient care, and mobile devices that are moved in and out of patient rooms frequently (e.g., daily).^{850, 851, 852, 997} Category IB

IV.G. Textiles and Laundry

IV.G.1. Handle used textiles and fabrics with minimum agitation to avoid contamination of air, surfaces and persons.^{739, 998, 999} Category IB/IB

IV.G.2. If laundry chutes are used, ensure that they are properly designed, maintained, and used in a manner to minimize dispersion of aerosols from contaminated laundry.^{11, 13, 1000, 1001} Category IB/IB

IV.H. Safe Injection Practices

The following recommendations apply to the use of needles, cannulas that replace needles, and, where applicable, intravenous delivery systems.⁴⁵⁴

IV.H.1. Use aseptic technique to avoid contamination of sterile injection equipment.^{1002, 1003} Category IA

IV.H.2. Do not administer medications from a syringe to multiple patients, even if the needle or cannula on the syringe is changed. Needles, cannulae and syringes are sterile, single-use items; they should not be reused for another patient nor to access a medication or solution that might be used for a subsequent patient.^{453, 919, 1004, 1005} Category IA

IV.H.3. Use fluid infusion and administration sets (i.e., intravenous bags, tubing and connectors) for one patient only and dispose appropriately after use. Consider a syringe or needle/cannula contaminated once it has been used to enter or connect to a patient’s intravenous infusion bag or administration set.⁴⁵³ Category IB

IV.H.4. Use single-dose vials for parenteral medications whenever possible.⁴⁵³ Category IA

IV.H.5. Do not administer medications from single-dose vials or ampules to multiple patients or combine leftover contents for later use.^{369, 453, 1005} Category IA

IV.H.6. If multidose vials must be used, both the needle or cannula and syringe used to access the multidose vial must be sterile.^{453, 1002} Category IA

IV.H.7. Do not keep multidose vials in the immediate patient treatment area and store in accordance with the manufacturer’s recommendations; discard if sterility is compromised or questionable.^{453, 1003} Category IA

IV.H.8. Do not use bags or bottles of intravenous solution as a common source of supply for multiple patients.^{453, 1006} Category IB

IV.I. Infection control practices for special lumbar puncture procedures

Wear a surgical mask when placing a catheter or injecting material into the spinal canal or subdural space (i.e., during myelograms, lumbar puncture and spinal or epidural anesthesia).^{906, 907-909, 910, 911, 912-914, 918, 1007} Category IBosure to bloodborne pathogens.⁷³⁹ Category IB

IV.J. Worker safety

Adhere to federal and state requirements for protection of healthcare personnel from exposure to bloodborne pathogens.⁷³⁹ Category IB

V. Transmission-Based Precautions

V.A. General Principles

V.A.1. In addition to Standard Precautions, use Transmission-Based Precautions for patients with documented or suspected infection or colonization with highly transmissible or epidemiologically-important pathogens for which additional precautions are needed to prevent transmission (see Appendix A).^{24, 93, 126, 141, 306, 806, 1008} Category IA

V.A.2. Extend duration of Transmission-Based Precautions, (e.g., Droplet, Contact) for immunosuppressed patients with viral infections due to prolonged shedding of viral agents that may be transmitted to others.^{928, 931-933, 1009-1011} Category IA 

V.B. Contact Precautions

V.B.1. Use Contact Precautions as recommended in Appendix A for patients with known or suspected infections or evidence of syndromes that represent an increased risk for contact transmission. For specific recommendations for use of Contact Precautions for colonization or infection with MDROs, go to Management of Multidrug-Resistant Organisms in Healthcare Settings 2006.⁸⁷⁰

V.B.2. Patient placement

V.B.3. Use of personal protective equipment

V.B.4. Patient transport

V.B.5. Patient-care equipment and instruments/devices

V.B.6. Environmental measures
Ensure that rooms of patients on Contact Precautions are prioritized for frequent cleaning and disinfection (e.g., at least daily) with a focus on frequently-touched surfaces (e.g., bed rails, overbed table, bedside commode, lavatory surfaces in patient bathrooms, doorknobs) and equipment in the immediate vicinity of the patient.^{11, 24, 88, 746, 837} Category IB

V.B.7. Discontinue Contact Precautions after signs and symptoms of the infection have resolved or according to pathogen-specific recommendations in Appendix A. Category IB

V.C. Droplet Precautions

V.C.1. Use Droplet Precautions as recommended in Appendix A for patients known or suspected to be infected with pathogens transmitted by respiratory droplets (i.e., large-particle droplets >5µ in size) that are generated by a patient who is coughing, sneezing or talking.^{14, 23, Steinberg, 1969 #1708, 41, 95, 103, 111, 112, 755, 756, 989, 1017} Category IB

V.C.2. Patient placement

V.C.3. Use of personal protective equipment

V.C.4. Patient transport

V.D. Airborne Precautions

V.D.1. Use Airborne Precautions as recommended in Appendix A for patients known or suspected to be infected with infectious agents transmitted person-to-person by the airborne route (e.g., M tuberculosis,¹² measles,^{34, 122, 1020} chickenpox,^{123, 773, 1021} disseminated herpes zoster.¹⁰²² Category IA/IB

V.D.2. Patient placement

V.D.3. Personnel restrictions
Restrict susceptible healthcare personnel from entering the rooms of patients known or suspected to have measles (rubeola), varicella (chickenpox), disseminated zoster, or smallpox if other immune healthcare personnel are available.^{17, 775} Category IB

V.D.4. Use of PPE

No recommendation is made regarding the use of PPE by healthcare personnel who are presumed to be immune to measles (rubeola) or varicella-zoster based on history of disease, vaccine, or serologic testing when caring for an individual with known or suspected measles, chickenpox or disseminated zoster, due to difficulties in establishing definite immunity.^{1027, 1028} Unresolved issue

V.D.4.c. ~ Suspected measles, chickenpox or disseminated zoster.

V.D.5. Patient transport

V.D.6. Exposure management

Immunize or provide the appropriate immune globulin to susceptible persons as soon as possible following unprotected contact (i.e., exposed) to a patient with measles, varicella or smallpox: Category IA

• Administer measles vaccine to exposed susceptible persons within 72 hours after the exposure or administer immune globulin within six days of the exposure event for high-risk persons in whom vaccine is contraindicated.^{17, 1032-1035}
•  Varicella Exposure Management Update [May 2019]: Administer varicella vaccine to exposed susceptible persons within 120 hours after the exposure or administer varicella immune globulin (varicella zoster immune globulin or alternative product), when available, within 96 hours for high-risk persons in whom vaccine is contraindicated (e.g., immunocompromised patients, pregnant women, newborns whose mother’s varicella onset was <5 days before or within 48 hours after delivery^{888, 1035-1037}).
• Administer smallpox vaccine to exposed susceptible persons within 4 days after exposure.^{108, 1038-1040}

V.D.7. Discontinue Airborne Precautions according to pathogen-specific recommendations in Appendix A. Category IB

V.D.8. Consult CDC’s “Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005.”¹² and the “Guideline for Environmental Infection Control in Health-Care Facilities.”¹¹ for additional guidance on environment strategies for preventing transmission of tuberculosis in healthcare settings. The environmental recommendations in these guidelines may be applied to patients with other infections that require Airborne Precautions.

VI. Protective Environment (Table 4)

VI.A. Place allogeneic hematopoietic stem cell transplant (HSCT) patients in a Protective Environment as described in the “Guideline to Prevent Opportunistic Infections in HSCT Patients,” ¹⁵ the “Guideline for Environmental Infection Control in Health-Care Facilities,”¹¹ and the “Guidelines for Preventing Health-Care-Associated Pneumonia, 2003”¹⁴ to reduce exposure to environmental fungi (e.g., Aspergillus sp).^{157, 158} Category IB

VI.B. No recommendation for placing patients with other medical conditions that are associated with increased risk for environmental fungal infections (e.g., aspergillosis) in a Protective Environment.¹¹ Unresolved issue

VI.C. For patients who require a Protective Environment, implement the following (see Table 5).^{11, 15}

VI.D. Minimize the length of time that patients who require a Protective Environment are outside their rooms for diagnostic procedures and other activities.^{11, 158, 945} Category IB

VI.E. During periods of construction, to prevent inhalation of respirable particles that could contain infectious spores, provide respiratory protection (e.g., N95 respirator) to patients who are medically fit to tolerate a respirator when they are required to leave the Protective Environment.^{945, 158} Category II

VI.F. Use of Standard and Transmission-Based Precautions in a Protective Environment.