Download Standard Precautions

Updates on
Isolation Precautions
by
by
Tariq Ahmed Madani, MBBS, FRCP(Canada)
Professor of Internal Medicine & Infectious Diseases
Chairman, Infection Control Committee
Department of Medicine, Faculty of Medicine,
King Abdulaziz University,
University Jeddah,
Jeddah Saudi Arabia
KAUH 05.01.09
Updates on
Isolation Precautions
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Chain of infection
New Isolation Categories
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Standard Precautions
Transmission-Based Precautions
Empiric
E
i i (syndromic)
(
d
i ) isolation
i l ti
Examples
A new proposal for Isolation Precautions
Chain of Infection
Organism
Source
Mode of
T
Transmission
i i
Host
Chain of Infection
Organism
Source
Mode of
Transmission
Host
Mode of Transmission
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Contact
C
t t
Droplet
Airborne
Common Vehicle
Vector borne
New Isolation Precautions, 1996
“Standard”
and
“T
“Transmission-Based
i i B dP
Precautions”
ti ”
Standard Precautions
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Consider all patients and their bodily fluids
(except sweat) to be potentially infectious.
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Use appropriate barrier precautions when
there is a risk of exposure to blood, body
fluids secretions
fluids,
secretions, excretions
excretions, mucous
membranes and non-intact skin.
Standard Precautions
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Hand hygiene
Gloves
Masks
Eye protection
Gowns
Standard Precautions
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Used needles and sharps should be disposed
of safely (in puncture proof sharp boxes)
Needles should NOT be recapped
All health care workers should receive the
HBV vaccine
Standard Precautions
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Patients with known or suspected infections
are NOT to have their medical records
labeled as "infectious".
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Specimens of patients with known or
suspected infections are NOT to be labeled
as "infectious"
infectious . All specimens are to be
treated in the same safe manner.
Hand Hygiene
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Hand hygiene is the single most important
practice to reduce the transmission of
infectious agents in healthcare settings
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The term “hand hygiene” includes:
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handwashing with either plain or antisepticcontaining soap and water
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use of alcohol-based products (gels, rinses,
foams) containing an emollient that do not
require the use of water
Hand Hygiene
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In the absence of visible soiling
g of hands,
approved alcohol-based products for hand
disinfection are preferred over handwashing
with water and antimicrobial or plain soap
because of their superior microbiocidal
activity,
y reduced drying
y g of the skin, and
convenience
When to wash hands
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Before and immediately after patient contact
(examination feeding
(examination,
feeding, bathing
bathing, carrying out
aseptic and/or invasive procedures …etc).
Between different procedures on the same patient.
After contact with mucous membranes, blood and
body fluids, secretions and excretions.
After removing gloves.
After touching objects or surfaces contaminated
with blood or body fluids.
Before preparing or serving food.
Handwashing
Healthcare Infection Control Practices Advisory
Committee (HICPAC) former recommendations
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Plain soap and water was recommended for routine
handwashing
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Antimicrobial soaps (e.g.: chlorhexidine) was
recommended for
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Patients under contact precautions
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During instances of epidemic or hyperendemic spread of
infections
Handwashing
HICPAC/SHEA/APIC/IDSA Hand Hygiene Task
Force latest recommendations (MMWR
October 25, 2002)
Alcohol based hand rub or handwashing with water and
antimicrobial soap should be used for routine hand
h i
hygiene
as wellll as ffor patients
ti t under
d contact
t t
precautions
Waterless Hand Hygiene
Antiseptic Waterless
Hand Gel
Hand Hygiene
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In observational studies of opportunities for
handwashing in health care workers in USA
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The overall compliance was 40% (range 5 - 81%)
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Compliance was highest among nurses and
gp
physicians,
y
, in intensive care units,,
lowest among
and when required intensity of care was greater
Boyce JM, et al. MMWR Recomm Rep 2002;51(RR-16):1-45
Handwashing study in Riyadh
Medical Complex-General Hospital
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312 handwashing opportunities for 230
Health Care Workers in five medical (88
beds) and five surgical (117 beds) wards
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110 nurses
76
6 residents
es de ts
23 medical students
11 interns
10 consultants
Basurrah and Madani, Scand J Infect Dis, 2006;38(8):620-4.
Handwashing study in Riyadh
Medical Complex-General Hospital
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Females : 56%
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Nationality
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Saudi : 51.3%
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Phillipine: 25.7%
25 7%
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India: 16.5%
Sink – bed ratio: 1 : 6-7
Basurrah and Madani, Scand J Infect Dis, 2006;38(8):620-4.
Handwashing study in Riyadh
Medical Complex-General Hospital
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Overall frequency of handwashing
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23.7% after patient contact
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6 7% before patient contact
6.7%
Basurrah and Madani, Scand J Infect Dis, 2006;38(8):620-4.
Handwashing study in Riyadh
Medical Complex-General Hospital
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Frequency of handwashing by profession
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Medical students: 70.0%
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Interns: 69.2%
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Nurses: 18.8%
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Residents: 12.5%
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Consultants: 9.1%
Basurrah and Madani, Scand J Infect Dis, 2006;38(8):620-4.
Handwashing study in Riyadh
Medical Complex-General Hospital
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Duration of handwashing by profession
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Medical students :6.1 seconds
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Interns: 5.4 seconds
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Nurses: 4.1 seconds
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Residents: 3.1 seconds
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Consultants: 3.0 seconds
Basurrah and Madani, Scand J Infect Dis, 2006;38(8):620-4.
Handwashing study in Riyadh
Medical Complex-General Hospital
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F
Frequency
off hanwashing
h
hi by
b tasks
t k
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After wound care: 52.4%
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After inserting peripheral iv lines: 40.0%
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Aft examining
After
i i patients:
ti t 31.6%
31 6%
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After emptying of urine bags: 21.4%
Basurrah and Madani, Scand J Infect Dis, 2006;38(8):620-4.
Handwashing study in Riyadh
Medical Complex-General Hospital
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Frequency of wearing gloves when
indicated: 75.5%
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Frequency of handwashing after removing
gloves: 48.8%
Basurrah and Madani, Scand J Infect Dis, 2006;38(8):620-4.
Gloves for Barrier Precautions
Disposable Gloves
6.00 SR
5.00 SR
Fluidshield Mask & a SplashGuard Visor
Gowns and other protective
apparel (eg. aprons)
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Indications
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if contact with blood and body fluid is likely
For patients under Contact Precautions
Gowns and other protective
apparel (eg. aprons)
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The practice of routine gowning upon
entrance into an intensive care or other
high-risk area does not prevent colonization
or infection of p
patients. Therefore,, CDC
recommendations for this practice have
been rescinded
Transmission-Based Precautions
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Three categories of Transmission-based
Transmission based
precautions:
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Contact Precautions
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Droplet Precautions
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Airborne Precautions
Transmission-Based Precautions
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More than
M
th one category
t
may be
b used
d for
f
diseases that have multiple routes of
transmission (e.g., SARS, chickenpox)
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When used either singularly or in
combination, they are always to be used in
addition to Standard Precautions
Contact Transmission
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Contact
C
t t transmission
t
i i (direct
(di t and
d indirect)
i di t)
is the most important and frequent mode
of transmission of nosocomial infections.
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Includes exposure to blood, other body
fluids, secretions, excretions (except
sweat), non-intact skin, and mucous
membrane covered by Standard
Precautions.
Contact Transmission
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Examples of organisms spread by contact:
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Multi-drug-resistant organisms in the
gastrointestinal tract, sputum, or wounds
(MRSA, MDR Gram -ve, VRE)
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Clostridium difficile
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Herpes simplex virus (mucocutaneous)
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Scabies
Contact Transmission
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Examples of direct contact transmission in
healthcare settings include:
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blood directly enters a caregiver’s body
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scabies
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herpetic whitlow
Contact Transmission
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Examples of indirect contact transmission:
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Hands
H
d off h
healthcare
lth
personnell ttouch
h an iinfected
f t d
or colonized body site on one patient or a
contaminated inanimate object, and then
subsequently touch another patient without
performing hand hygiene between patient
contacts.
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Shared toys become a vehicle for transmitting
respiratory viruses (e.g., RSV or pathogenic
bacteria) to pediatric patients.
Contact Transmission
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Examples of indirect contact transmission:
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Patient-care
P
ti t
d i
devices
((e.g., electronic
l t i
thermometers, glucose monitoring devices)
contaminated with blood or body fluids shared
between patients without cleaning and disinfecting
between patients.
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Instruments that are inadequately cleaned
between patients (e.g., endoscopes or surgical
instruments) or that have manufacturing defects
that interfere with the effectiveness of
reprocessing
Contact Precautions
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Private room preferred; cohorting allowed if
necessary
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The door of the room may remain open
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Gloves:
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upon entering room
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change gloves after contact with contaminated secretions
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should be removed before leaving the room
Gown:
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if clothing may come into contact with the patient or
environmental surfaces
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should be removed before leaving the room
Contact Precautions
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Wash hands with antimicrobial soap before
leaving the patient’s
patient s room
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Minimize risk of environmental contamination
during patient transport (e.g. patient can be
placed in a gown)
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Patient’s care devices (e.g., thermometer, BP
cuffs, stethoscopes) should be dedicated to use
for a single patient if possible, otherwise, they
should be rigorously cleansed and disinfected
before use for other patients
Droplet Transmission
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Respiratory droplets are large particles
(>5 micron) expelled during
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coughing
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sneezing
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talking
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during procedures such as suctioning and
bronchoscopy
Droplets travel < 1.5 meter from the source
patient
Droplet Transmission
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Because of their "large" size (> 5 microns),
droplets do not remain suspended in the air
and are therefore not spread by air currents
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In order for transmission to take place, there
must be a relatively close proximity between
the infected person and the host
Droplet Transmission
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Major organisms spread as respiratory droplets:
z Neisseria meningitidis
z Haemophilus influenzae type b (invasive)
z Streptococcus pyogenes (group A streptococcus)
z Mycoplasma pneumoniae
z Bordetella pertussis
z Influenza virus
z Adenovirus
z Rhinovirus
Rhi
i
z Rubella virus
z Mumps
z SARS-associated coronavirus
z Multi-drug resistant organisms in the respiratory tract
Droplet Precautions
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Private room preferred; cohorting allowed if
necessary
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Special air handling and ventilation are unnecessary
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The door of the room may remain open
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Wear a mask when within 1 meter of the patient
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Mask the patient during transport
Airborne Transmission
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Airborne spread depends upon aerosolization of
VPDOO SDUWLFOHV ”5 micron) of the infectious agent that
VPDOOSDUWLFOHV”5
can then travel over long distances through the air
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Most common nosocomial pathogens transmitted by
this route:
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Mycobacterium tuberculosis
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V i ll
Varicella-zoster
t virus
i
(Chickenpox)
(Chi k
)
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Measles
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Smallpox
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? SARS
Airborne Precautions
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Place the patient in a negative pressure room
with at least 6-12 air exchanges per hour
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Room exhaust must be be appropriately
discharged outdoors or passed through a
HEPA (high-efficiency particulate aerator)
filter before recirculation within the hospital
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The door of the room should be kept closed
Airborne Precautions
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A certified respirator (Particulate Masks e
e.g.:
g:
N95) must be worn when entering the room of a
patient with diagnosed or suspected TB
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Susceptible individuals should not enter the room
of patients with confirmed or suspected measles
or chickenpox
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Transport of the patient should be minimized; the
patient should be masked if transport within the
hospital is unavoidable
N95 Particulate Masks
Type and Duration of Precautions Needed
for Selected Infections and Conditions
Infection/ Condition
Precautions Duration
Abscess,
Draining, major
Draining, minor
C
S
AIDS
S
DI
Type and Duration of Precautions Needed for
Selected Infections and Conditions
Infection/Condition
Adenovirus infection
Precautions Duration
D&C
Amoebiasis
S
Anthrax (pulmonary or
cutaneous)
S
DI
Type and Duration of Precautions Needed
for Selected Infections and Conditions
Infection/Condition
Chickenpox
Precautions
Duration
A&C
Until all lesions
are crusted
Dengue
S
Epiglottitis, due to
Haemophilus
influenzae
D
Until 24h after
starting
therapy
Type and Duration of Precautions Needed
for Selected Infections and Conditions
Infection/Condition
ect o /Co d t o
Gastroenteritis:
Campylobacter, Vibrio
E. coli, Giardia lamblia
Rotavirus, Salmonella
Shigella, Viral, Yersinia
Clostridium difficile
Precautions
ecaut o s
Duration
u at o
S
(Apply Contact
precautions for
diapered or
incontinent pts for
duration of illness)
C
DI
Type and Duration of Precautions Needed
for Selected Infections and Conditions
Infection
Precautions
Duration
German measles
(rubella)
D
Until 7 days after
onset of rash
M
Measles
l ((rubeola)
b l )
A
DI
Influenza
D
DI
Type and Duration of Precautions Needed
for Selected Infections and Conditions
Infection
Hepatitis (viral)
Hepatitis A
B, C, D, E
Precautions
Duration
S
(Apply Contact - <3 y: for duration of stay
precautions for - 3-14 y: until 2 wk after
onset of illness
diapered or
co
e pts)
p s) - O
Others:
e s until
u
1 wk a
after
e
incontinent
onset of illness
S
Type and Duration of Precautions Needed
for Selected Infections and Conditions
Infection/Condition
Meningitis:
Aseptic
Fungal
Haemophilus influenzae
y g
Listeria monocytogenes
Neisseria meningitidis
Pneumococcal
TB
Other bacteria
Precautions
S
S
D
S
D
S
S
S
Duration
Until 24h after starting therapy
Until 24h after starting therapy
Type and Duration of Precautions Needed
for Selected Infections and Conditions
Infection
ect o
Tuberculosis
Extrapulmonary
Pulmonary or
laryngeal
Precautions
ecaut o s
Duration
u at o
S
A
Discontinue precautions only
when TB patient is on effective
therapy, is improving clinically,
and has 3 consecutive –ve
sputum smears collected on
different days.
TRANSMISSION-BASED PRECAUTIONS
CONTACT DROPLET AIRBORNE 1. HANDS MUST BE WASHED BEFORE & AFTER PATIENT CONTACT
2. GLOVES
NO
YES
3. GOWN
NO
YES
REGULAR
NO
YES
REGULAR
4. MASK
WATERPROOF
N95 (AIRBORNE)
5. DOOR MUST BE KEPT CLOSED
NO
YES
COMMENTS: ……………………………………………………………………..
Please do not indicate patient diagnosis
NOTE THE ABOVE ARE IMPLEMENTED IN ADDITION TO STANDARD PRECAUTIONS
Syndromic or empiric application of
Expanded Precautions
Condition
Potential pathogen Empiric
precautions
Meningitis
Neisseria meningitidis
Droplet for first 24 hrs
of antimicrobial
therapy
Enteroviruses
Contact for infants and
children
Neisseria meningitidis
Droplet for first 24 hrs
of antimicrobial
therapy
Petechial/ecchymotic
rash with fever
Syndromic or empiric application of
Expanded Precautions
Condition
Potential pathogen Empiric
p
precautions
Generalized vesicular
rash
Varicella, smallpox, or
vaccinia virus
Airborne Infection
Isolation plus Contact;
Contact if vaccinia
Generalized
maculopapular
generalized rash with
cough, coryza and
fever
Rubeola (measles)
virus
Airborne Infection
Isolation
Syndromic or empiric application of
Expanded Precautions
Condition
Potential
pathogen
Empiric precautions
Cough/fever/upper lobe
pulmonary infiltrate in an
HIV negative patient or a
patient at low risk for HIV
infection
TB
Airborne Infection
Isolation;
add Contact plus eye
protection if there is
history of exposure to
SARS
SARS
Cough/fever/pulmonary
TB
infiltrate in any lung
location in an HIV-infected
patient or a patient at high
risk for HIV infection
Airborne Infection
Isolation
Syndromic or empiric application of
Expanded Precautions
Condition
Potential
pathogen
Empiric precautions
Respiratory infections,
particularly bronchiolitis
and pneumonia in infants
and young children
RSV,
parainfluenza,
adenovirus,
influenza virus
Contact plus Droplet;
Droplet may be
discontinued when
adenovirus and influenza
have been ruled out
Acute diarrhea with a
lik l infectious
likely
i f ti
cause in
i
an incontinent or
diapered patient
Enteric pathogens Standard plus Contact
( di t i and
(pediatrics
d adult)
d lt)
Abscess or draining
wound that cannot be
covered
Staphylococcus
aureus, group A
streptococcus
Contact
Latest Proposal for Isolation
Precautions, 2004-2005
“Standard”
and
“Expanded Precautions”
Latest Proposal for Isolation
Precautions 2004-2005
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Ch
Changes
or clarifications
l ifi ti
in
i terminology
t
i l
z
“Nosocomial infection” has been replaced by
“Healthcare-associated infection” (HAI)
z
“Transmission-based Precautions” has been
p
by
y “Expanded
p
Precautions”
replaced
z
“Airborne Precautions” has been replaced with
“Airborne Infection Isolation”
Latest Proposal for Isolation
Precautions 2004-2005
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Respiratory Hygiene/Cough Etiquette
added to Standard Precautions
A new category of isolation precautions
“Protective Environment” is added to the
Expanded Precautions
Latest Proposal for Isolation
Precautions 2004-2005
z
a new emphasis on the importance of
administrative involvement in development
and support of infection control programs
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a unified infection control approach to
MDROs replacing prior pathogen-specific
recommendations (e.g., VRE, VISA)
Standard Precautions
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Respiratory Hygiene/Cough Etiquette
z
prevent transmission of respiratory infections at
the first point of contact within a healthcare setting
(e.g., reception and triage areas in ER and OPD)
Standard Precautions
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Elements of Respiratory Hygiene/Cough
Etiquette:
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education of healthcare facility staff, patients,
and visitors
z
posted signs in language appropriate to the
population served with instructions to patients
and accompanying family members or friends
Standard Precautions
z
Elements of Respiratory Hygiene/Cough
Etiquette
z
source control measures e.g.:
z
covering the mouth/nose with a tissue when
coughing or sneezing and disposing of used tissues
z
using surgical masks on the coughing person when
tolerated and appropriate
Standard Precautions
z
Elements of Respiratory Hygiene/Cough
Etiquette
z
hand hygiene after contact with respiratory
secretions
z
spatial separation
separation, ideall
ideally >1 meter,
meter of persons
with respiratory infections in common waiting
areas when possible
Expanded Precautions
(Transmission-Based Precautions)
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Expanded Precautions, 4 categories
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Contact Precautions
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Droplet Precautions
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Airborne Infection Isolation
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Protective Environment
Protective Environment
z
meant to prevent the patient from acquiring
fungal infections from the environment
z
designed for allogeneic hematopoietic stem
cell transplant (HSCT) patients to minimize
fungal spore counts in the air
z
no published reports support the benefit of
placing solid organ transplants or other
immunocompromised patients in a PE
Protective Environment
z
The need for such controls has been
demonstrated in
z
studies of outbreaks of aspergillosis
associated with construction
z
molecular typing
yp g studies that have found
identical strains of Aspergillus terreus in
patients with hematologic malignancies
and in potted plants in the vicinity of the
patients
Protective Environment
z
Improving
p
g air quality
q
y for HSCT patients
p
z
HEPA filtration of incoming air
z
directed room air flow
z
positive room air pressure relative to the
corridor (Pressure differential of >2.5 Pa [0.01”
water gauge])
z
well-sealed rooms (including sealed walls,
floors, ceilings, windows, electrical outlets) to
prevent infiltration of air from the outside
Protective Environment
z
Improving air quality for HSCT patients
z
ventilation to provide >12 air changes per hour
z
strategies to lower dust, e.g.,
z
z
scrubbable surfaces rather than carpet and
upholstery
z
routinely
i l cleaning
l
i crevices
i
and
d sprinkler
i kl heads
h d
prohibiting dried and fresh flowers and potted
plants and fresh flowers in the rooms of HSCT
patient.
Protective Environment
z
The desired
Th
d i d quality
lit off air
i may be
b achieved
hi
d
without the inconvenience or expense of
laminar airflow
z
To prevent inhalation of respirable particles
in the presence of construction, placement
off an N95 respirator
i t on the
th patient
ti t is
i
advised when patients leave the PE for
diagnostic studies or treatments elsewhere
in the facility
OLD
NEW
Standard Precautions for all
Isolation when indicated
+ TBP when indicated
Thank You