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Infection prevention: Precautions for preventing transmission of infection

Infection prevention: Precautions for preventing transmission of infection
Author:
Deverick J Anderson, MD, MPH
Section Editor:
Anthony Harris, MD, MPH
Deputy Editor:
Keri K Hall, MD, MS
Literature review current through: Dec 2022. | This topic last updated: Dec 17, 2020.

INTRODUCTION — The risk of transmission of pathogens and subsequent infection in health care facilities is substantial. Pathogens may be transmitted from other patients, the hospital personnel, and/or the hospital environment. The risk is variable and depends on a patient's immune status, the local prevalence of various pathogens, and the infection control practices and antimicrobial stewardship utilized during hospitalization.

This topic will provide an overview of precautions devised to minimize risk for transmission of infection. Additional considerations in the setting of the COVID-19 pandemic are discussed separately. (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection".)

Issues related to the prevention of other specific infections, prophylaxis after exposure to bloodborne pathogens, and immunizations for health care workers are discussed in detail separately. (See related topics.)

STANDARD PRECAUTIONS — Standard precautions should be followed for the care of all patients (table 1) even when the presence of an infectious agent is not apparent or is thought to be minimal [1,2].

Standard precautions entail [1,3,4]:

Hand hygiene before and after contact with every patient, regardless of whether gloves are also used. (See 'Hand hygiene' below.)

Use of gloves, gowns, and eye protection in situations in which exposure to blood or body secretions is possible.

Use of respiratory hygiene/cough etiquette by patients or health care workers with cough or respiratory secretions; this includes covering the nose and mouth when coughing, disposing of used tissues promptly, and practicing hand hygiene after contact with respiratory secretions. Use of a mask and spatial separation of patients with respiratory symptoms in waiting areas is also warranted.

Safe injection practices and safe disposal of needles and sharp instruments in impervious containers. (See "Infection control in the outpatient setting", section on 'Safe injection practices'.)

Hand hygiene — Hand hygiene refers to hand washing with soap and water or the use of alcohol-based hand disinfection (table 2). Hand hygiene is the single most important measure to reduce transmission of microorganisms from one person to another or from one site to another on the same patient [5,6]. The primary challenge associated with hand hygiene efficacy is laxity of practice, not a paucity of good products [7-9].

The SAVE LIVES: Clean Your Hands initiative is part of a major global effort led by the World Health Organization (WHO); it includes "My Five Moments for Hand Hygiene," which define the key moments when health care workers should perform hand hygiene [10]:

Before touching a patient

Before clean/aseptic procedures

After body fluid exposure/risk

After touching a patient

After touching patient surroundings

Most hospitals and clinics emphasize hand hygiene at the time of room entry and exit and prior to any procedure.

Either soap and water or alcohol-based hand disinfection (AHD) may be used. In most circumstances, we favor AHD because it is more efficient than handwashing with soap and water. Handwashing with soap and water should be used in association with care of patients with known or suspected norovirus or Clostridioides difficile infection since alcohol does not kill C. difficile spores or norovirus. (See "Clostridioides difficile infection: Prevention and control", section on 'Hand hygiene' and "Norovirus", section on 'Prevention and control'.)

Health care worker compliance with hand hygiene is a longstanding challenge. Most studies have shown that hand hygiene compliance improves with monitoring and immediate feedback, although this approach is time and resource consuming [11-14]. Electronic- and video-based monitoring have been employed to monitor compliance, but such monitoring has not gained widespread use because of multiple barriers [9,11,15-17].

Soap and water — Hand hygiene with soap and water should be performed as summarized in the following table (table 2) [1,7,18].

Alcohol-based hand disinfection — AHD is an effective, inexpensive, and practical alternative to soap and water. AHD is faster and easier to perform than hand washing with soap and water; it should be performed at every room entry and exit and prior to any procedure. The use of AHD has been associated with improved hand hygiene compliance rates and reductions in nosocomial infections [19-21].

AHD products have rapid antimicrobial effects and are as effective as chlorhexidine against gram-positive and gram-negative organisms as well as viral pathogens including influenza [19,22]. AHD products do not have activity against norovirus or spore-forming bacteria, including C. difficile [20]. (See "Clostridioides difficile infection: Prevention and control", section on 'Hand hygiene'.)

The technique for hand hygiene is summarized in the following table (table 2). The United States Centers for Disease Control and Prevention (CDC) endorses a three-step method for AHD (apply sanitizer and rub both palms together, cover all surfaces, and rub until dry) [18], whereas the WHO endorses a six-step method (apply sanitizer and specifically rub six different aspects of the hands and fingers) [23]. In a randomized trial comparing these two methods among 120 doctors and nurses at an acute care hospital, those assigned to the six-step method had a greater reduction in the bacterial count of their hands but took approximately 8 seconds longer to complete hand hygiene and had lower compliance (65 versus 100 percent) [24]. Hospital transmission or infection rates were not measured. We continue to favor the three-step CDC AHD method because it is practical and the difference in the bacterial count reduction is of uncertain clinical significance.

Prohibiting artificial nails — Health care workers with direct patient contact should have fingernails that are short, clean, and free from false nails and nail polish [7,25-27]. There is an increase in periungual colonization with a variety of pathogens when fingernails are long and when artificial fingernails are worn [7,28,29]. Artificial fingernails and inadequately cleaned native fingernails have been epidemiologically linked to outbreaks of infection in intensive care unit patients, neonates, and patients undergoing surgery [30-32].

Gloves — Gloves should be worn by health care workers in situations in which exposure to blood or body secretions is possible; they provide a protective barrier for the health care worker as well as the patient [3]. Nonsterile examination gloves are typically used.

Gloves are also a component of contact precautions; in such circumstances, they reduce the likelihood of health care worker colonization with microorganisms from a patient who is colonized or infected with pathogenic organisms. (See 'Isolation precautions' below.)

Wearing gloves does not replace the need for hand hygiene. Gloves may have unapparent tears, and hands predictably become contaminated during glove removal [33-36].

Gloves should be changed between patient encounters; in some cases, it may be necessary to change heavily contaminated gloves while caring for a single patient to prevent cross-contamination of body sites or contamination of medical equipment.

Masks — Masks should be worn by health care workers caring for patients in the following categories [37]:

Patients with respiratory secretions, to protect health care workers from patients' infectious material (such as droplets containing blood or body fluids).

Patients undergoing sterile procedures (including central line insertion, invasive spinal procedures), to protect patients from respiratory droplets generated by health care personnel performing the procedure.

In addition, masks should be worn by patients with respiratory secretions who are coughing if they leave their hospital rooms, to limit spread of infectious secretions to other patients and to health care workers.

Masks should not be confused with particulate respirators that are used to prevent transmission by airborne droplet nuclei of infectious agents such as Mycobacterium tuberculosis. (See "Tuberculosis transmission and control in health care settings", section on 'Use of masks'.)

ISOLATION PRECAUTIONS — Isolation precautions used to interrupt or reduce the risk of transmission of pathogens are summarized in the following table (table 1) and in a table prepared by the United States Centers for Disease Control and Prevention (CDC) [1]. Guidance regarding the duration of precautions for common pathogens is summarized in the table (table 3).

Three isolation categories reflect the major modes of pathogen transmission in nosocomial settings: contact, droplet, and airborne spread [3]. The rooms of patients requiring precautions should be clearly marked with signs containing instructions regarding the type of precautions that must be observed. Ample supplies should be readily available outside the patient room to facilitate adherence, and hospital policies should be enforced [38].

Types

Contact precautions — Contact precautions are used for the care of patients with selected multidrug-resistant bacteria and various enteric and viral pathogens as summarized in the table (table 1). Patients who require contact precautions should be in a private room or in a cohort with other patients who have the same indication for contact precautions [3]. Health care workers should perform hand hygiene and wear gloves upon room entry, even if no direct patient contact is anticipated. Gowns should be worn even if direct contact with the patient or infective material is not anticipated [39]. Upon room exit, gowns and gloves should be removed and hand hygiene should be performed immediately since hands predictably become contaminated during glove removal [36].

Medical equipment should be dedicated to a single patient when possible in order to avoid transfer of pathogens via fomites. Equipment that is not dedicated to a single patient must be cleaned and disinfected before reuse [38]. (See "Infection prevention: General principles", section on 'Medical equipment: Disinfection and sterilization'.)

The association between contact precautions and adverse events (such as diminished frequency and intensity of contact with health care workers, increased likelihood of medication errors, pressure sores, falls, depression and anxiety, and delays in hospital admission and discharge) is uncertain [40]. One randomized trial evaluating the impact of contact precautions on the incidence of adverse patient events noted a trend to fewer adverse events among patients on contact isolation precautions [39]. Other reports describe observational (and mostly retrospective) data and lack statistical power [41-46].

Health care worker compliance with contact isolation precautions is a challenging problem [47]. It is uncertain whether universal decolonization can achieve the same effect as contact isolation for selected pathogens. The strongest data evaluating this issue come from studies performed in intensive care units; this is discussed further separately. (See "Infections and antimicrobial resistance in the intensive care unit: Epidemiology and prevention", section on 'Decolonization/patient bathing'.)

Droplet precautions — Droplets are particles of respiratory secretions ≥5 microns. Droplets remain suspended in the air for limited periods. Transmission is associated with exposure within three to six feet (one to two meters) of the source [1].

Droplet precautions are used for the care of patients with suspected or confirmed infections with Neisseria meningitidis, Bordetella pertussis, influenza, adenovirus, Haemophilus influenzae type b, Mycoplasma pneumoniae, rubella, and other pathogens spread by droplets (table 1). Specific precautions for patients with coronavirus disease 2019 (COVID-19) are presented elsewhere. (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection".)

Many hospitals favor simplifying the approach to isolation precautions for viral respiratory pathogens by placing all patients with suspected viral illness on both contact and droplet precautions.

Respiratory syncytial virus (RSV) may be transmitted by the droplet route but is primarily spread by direct contact with infectious respiratory secretions [48]. Therefore, the most important intervention for prevention of RSV transmission in health care settings is adherence to contact precautions (plus standard precautions) [1,49,50]. The CDC does not recommend droplet precautions for RSV [1]; however, droplet precautions are warranted if the infecting agent is not known, if the patient may be coinfected with other pathogens that require droplet precautions, and/or if there is a chance of exposure to aerosols of infectious respiratory secretions.

Health care workers caring for patients on droplet precautions should wear a surgical mask when they are within six feet of patients [1]. No special air handling systems or higher level respirator masks are required for the care of patients with known or suspected infection due to organisms capable of droplet transmission. The doors of rooms used to house these patients may remain open (in contrast with airborne precautions).

Airborne precautions — Airborne droplet nuclei are particles of respiratory secretions <5 microns. Droplet nuclei can remain suspended in the air for extended periods and thus can be a source of inhalational exposure for susceptible individuals.

Patients on airborne isolation precautions should be placed in a private room with negative air pressure that has a minimum of 6 to 12 air changes per hour. Doors to the isolation rooms must remain closed, and all individuals who enter must wear a respirator with a filtering capacity of 95 percent that allows a tight seal over the nose and mouth. (See "Tuberculosis transmission and control in health care settings", section on 'Airborne infection isolation'.)

Airborne precautions are warranted for the care of all patients with suspected or confirmed tuberculosis, measles, varicella, and smallpox.

In the setting of herpes zoster, airborne and contact precautions are warranted for all patients with disseminated zoster and for immunocompromised patients with localized zoster. Immunocompetent patients with localized zoster that can be contained/covered may be managed with standard precautions. Susceptible health care workers should not provide direct care to these patients if immune caregivers are available [51]. (See "Prevention and control of varicella-zoster virus in hospitals".)

Airborne and contact precautions are also required for patients with severe acute respiratory syndrome (SARS) and COVID-19 who are undergoing aerosol-generating procedures (eg, endotracheal intubation) [52-54]. Some guideline panels also recommend airborne precautions for those undergoing routine care [55]. Although these pathogens are transmitted predominantly by droplet spread (and probably direct contact), airborne transmission may also occur, especially during aerosol-generating procedures. More detailed discussions of infection control precautions for patients with SARS and COVID-19 are discussed elsewhere. (See "Severe acute respiratory syndrome (SARS)", section on 'Infection control' and "COVID-19: Infection prevention for persons with SARS-CoV-2 infection".)

Patients in respiratory isolation who require transport outside their isolation rooms for medical procedures should wear surgical masks that cover the mouth and nose during transport. Procedures for these patients should be scheduled at times when they can be performed rapidly and when occupation of waiting areas is minimal [56].

Precaution duration — Timing for discontinuation of contact, droplet, and/or airborne precautions varies by organism and is based on expert guidance [57]. Guidance for discontinuation of precautions for several common organisms is provided in the table (table 3).

In addition, these issues are discussed further separately:

(See "Methicillin-resistant Staphylococcus aureus (MRSA) in adults: Prevention and control", section on 'Contact precautions'.)

(See "Vancomycin-resistant enterococci: Epidemiology, prevention, and control", section on 'Infection control'.)

(See "Clostridioides difficile infection: Prevention and control", section on 'Infection control'.)

(See "Infection control measures for prevention of seasonal influenza", section on 'Isolation precautions'.)

(See "Prevention and control of varicella-zoster virus in hospitals".)

OTHER CLINICAL INFECTION CONTROL ISSUES

Patient bathing — In intensive care units (ICUs), patient bathing with chlorhexidine gluconate (an antiseptic agent with broad-spectrum activity against many organisms) reduces the rate of hospital-acquired bloodstream infections and the risk of colonization acquisition with drug-resistant organisms. This issue is discussed further separately. (See "Infections and antimicrobial resistance in the intensive care unit: Epidemiology and prevention", section on 'Decolonization/patient bathing'.)

For hospitalized patients in general medical and surgical units (eg, outside of the ICU), thus far, there are insufficient data to support routine use of patient bathing with chlorhexidine gluconate [58-60]. In a cluster-randomized trial including more than 330,000 patients in 53 hospitals in the United States over a 21-month intervention period, no difference in the rate of hospital-acquired infection was observed among patients in units randomized to receive universal chlorhexidine bathing plus mupirocin for methicillin-resistant S. aureus (MRSA) carriers compared with patients in units who received standard care [60]. However, in post-hoc analysis of decolonized patients with medical devices (including central venous catheters, accessed ports, midline catheters, and lumbar drains), reductions in rates of MRSA and vancomycin-resistant enterococci (VRE) infection and all-cause bacteremia were observed (37 and 31 percent, respectively). Patients with medical devices constituted 10 percent of the standard care population studied but were responsible for 37 percent of positive MRSA and VRE cultures and 56 percent of all-cause bloodstream infections. Further prospective study regarding benefit of decolonization for patients with medical devices is needed.

Single-patient rooms — Separating infected patients from non-infected patients to prevent transmission is a core concept in infection prevention that is utilized in outpatient and inpatient settings throughout the world. In inpatient settings, patients with highly contagious or devastating infections such as tuberculosis, measles, Ebola, and pertussis are routinely isolated from other patients and placed in single-patient rooms. Occupation of individual patient rooms may also decrease the rate of colonization and infection with hospital-acquired organisms.

In an analysis of rates of colonization and infection with multidrug-resistant organisms in a hospital transitioning from multi-bed to new individual patient rooms, single-patient rooms were associated with decreased rates of VRE and MRSA colonization and VRE infection [61]. However, there was no decrease in rates of C. difficile or MRSA infection. Effective use of contact precautions may obviate the benefit of single-patient rooms for some organisms. In a trial conducted in the medical and surgical wards of 16 Dutch hospitals, use of contact precautions in multiple-bed rooms compared with contact precautions in single-bed rooms resulted in similar rates of transmission of extended-spectrum beta-lactamase-producing Enterobacteriaceae (7 versus 4 percent, respectively), although the trial was underpowered to detect small differences [62]. Rates of transmission were higher in multi-patient rooms during the time period before contact precautions were instituted, which suggests a benefit of contact precautions.

Attire for health care personnel — Several studies have demonstrated that clothing and paraphernalia of health care personnel (including white coats, nursing uniforms, ties, stethoscopes, badges, and mobile phones) can become contaminated with pathogens (such as S. aureus, vancomycin-resistant enterococci, C. difficile, and gram-negative bacilli) during the course of patient care [27,63-70]. For example, stethoscopes are routinely contaminated by complex microbial communities, including important potentially pathogenic organisms such as S. aureus, Pseudomonas, and Acinetobacter spp [71]. The areas of attire with the heaviest colonization are those most frequently touched by hands.

Thus far, no studies have demonstrated an association between contamination of clothing and transmission of pathogens to patients, and no studies have demonstrated any clinical impact associated with minimizing attire contamination or utilizing a "bare below the elbow" policy [72-75]. We agree with the suggestions by the Society for Healthcare Epidemiology of America to reduce the possible but unproven risk of pathogen transmission through attire [76]:

Health care personnel should be provided with sufficient white coats to allow for frequent cleaning.

Attire should be laundered daily in hot water, preferably with bleach.

Shared equipment (such as stethoscopes) or other personal items (such as pagers and cell phones) that come into direct contact with the patient or environment should be disinfected. (See "Infection prevention: General principles", section on 'Medical equipment: Disinfection and sterilization'.)

When possible, a "bare below the elbows" policy may be reasonable (eg, use of short sleeves, no wristwatch or jewelry, no ties).

Immunocompromised patients — Special interventions are warranted for patients undergoing hematopoietic cell transplantation to minimize exposure to invasive fungal infections such as aspergillosis. These include high-efficiency particulate air filtration of incoming air, positive room air pressure relative to corridors, directed room air flow, ventilation systems that provide at least 12 air changes per hour, dust control measures, and the prohibition of flowers and potted plants in patient rooms. (See "Overview of infections following hematopoietic cell transplantation".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Infection control".)

SUMMARY AND RECOMMENDATIONS

The goal of infection control is to prevent and reduce rates of nosocomial infection. Types of precautions for preventing transmission of infection include standard precautions and isolation precautions. (See 'Introduction' above.)

Standard precautions should be followed for the care of all patients; refer to the following table (table 1) and the table prepared by the United States Centers for Disease Control and Prevention. They include hand hygiene before and after every patient contact, use of gloves, gowns, and eye protection (for situations in which exposure to body fluids is possible), use of respiratory hygiene/cough etiquette, and safe disposal of sharp instruments in impervious containers. (See 'Standard precautions' above.)

Hand hygiene refers to hand washing with soap and water or the use of alcohol-based hand disinfection (AHD) (table 2). Hand hygiene is the single most important measure to reduce transmission of microorganisms from one person to another or from one site to another on the same patient. Wearing gloves does not replace the need for hand hygiene. (See 'Hand hygiene' above and 'Gloves' above.)

Either soap and water or AHD may be used in most circumstances; we favor AHD because it is more efficient than handwashing with soap and water. Hand washing with soap and water should be used in association with care of patients with known or suspected Clostridioides difficile infection or norovirus. (See 'Hand hygiene' above.)

Three isolation categories reflect the major modes of pathogen transmission in nosocomial settings: contact, droplet, and airborne spread. The types of precaution(s) warranted for care of patients with known or suspected pathogens are summarized in the following table (table 1). (See 'Isolation precautions' above.)

Contact precautions – Health care workers should perform hand hygiene and wear gloves upon room entry, even if no direct patient contact is anticipated. Gowns should be worn if there is likely to be direct contact with the patient or any infective material. (See 'Contact precautions' above.)

Droplet precautions – Health care workers should wear a mask when within six feet of patients on droplet precautions. No special air handling systems or higher level respirator masks are required, and the door may remain open. (See 'Droplet precautions' above.)

Airborne precautions – Patients requiring airborne isolation precautions should be placed in an airborne infection isolation room, which should be a private room with negative air pressure and a minimum of 6 to 12 air changes per hour. The door must remain closed, and all individuals who enter must wear a respirator with a filtering capacity of 95 percent that allows a tight seal over the nose and mouth. (See 'Airborne precautions' above.)

Guidance for discontinuation of precautions for several common organisms is provided in the table (table 3). (See 'Precaution duration' above.)

For hospitalized patients in general medical and surgical units (eg, outside of the intensive care unit), thus far, there are insufficient data to support routine use of bathing with chlorhexidine gluconate. Issues related to patient bathing in intensive care units are discussed further separately. (See 'Patient bathing' above and "Infections and antimicrobial resistance in the intensive care unit: Epidemiology and prevention", section on 'Decolonization/patient bathing'.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Daniel Sexton, MD, and N Deborah Friedman, MPH, MBBS, FRACP, MD, who contributed to an earlier version of this topic review.

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