1. Isolation Precaution Techniques
Maureen Spencer, M.Ed, BSN, RN, CIC, FAPIC
Infection Prevention Consultant

2. Categories of Precautions = Mode of Transmission
Modes of Transmission:
Direct contact with blood and bodily fluids (HIV, HBV)
Indirect contact with contaminated items and patient care equipment and the environment (MRSA, VRE, C.difficile)
Droplet nuclei (Influenza, Pertussis, Bacterial Meningitis, SARS)
Airborne route (TB, Chickenpox, Measles)
Vector (West Nile Virus, Malaria, Ebola Virus)

3. Surface Contamination (in hospitals) with MRSA, VRE, and C. Difficile
Blood Pressure Cuff:
VRE 14%
Windowsill:
C. Difficile 33%
Commode:
C. Difficile 41%
Overbed Table:
MRSA 40%
VRE 20%
Patient Gowns:
MRSA 51%
Bedrail:
MRSA 29%
VRE 28%
C. Difficile 19%
Floors:
MRSA 55%
C. Difficile 48%
Boyce J.M. et al.: Environmental contamination due to methicillin-resistant Staphylococcus aureus: Possible infection control implications. Infect Control Hosp Epidemiol 18: , Sep
Slaughter S., et al.: A comparison of the effect of universal use of gloves and gowns with that of glove use alone on acquisition of vancomycin-resistant enterococci in a medical intensive care unit. Ann Intern Med 125: , Sep 15, 1996.
Samore M.H., et al.: Clinical and molecular epidemiology of sporadic and clustered cases of nosocomial Clostridium difficile diarrhea. Am J Med 100:32-40, Jan
Bedsheets:
MRSA 53%
VRE 40%
Did you know that every time you get a new roommate, there is an increase of 3-10% that you will acquire an HAI.
Huang SS, Datta R, Platt R. Risk of acquiring antibiotic-resistant bacteria from prior room occupants. Arch Intern Med Oct 9;166(18):
Boyce J.M. et al.: Environmental contamination due to methicillin-resistant Staphylococcus aureus: Possible infection control implications. Infect Control Hosp Epidemiol 18: , Sep
Slaughter S., et al.: A comparison of the effect of universal use of gloves and gowns with that of glove use alone on acquisition of vancomycin-resistant enterococci in a medical intensive care unit. Ann Intern Med 125: , Sep 15, 1996.
Samore M.H., et al.: Clinical and molecular epidemiology of sporadic and clustered cases of nosocomial Clostridium difficile diarrhea. Am J Med 100:32-40, Jan

4. Organism Survival period 14- >300 days.1,5,10
Clostridium difficile
35- >200 days.2,7,8
Methicillin resistant Staphylococcus aureus (MRSA)
14- >300 days.1,5,10
Vancomycin-resistant enterococcus (VRE)
58- >200 days.2,3,4
Escherichia coli
> days.7,9
Acinetobacter
150- >300 days.7,11
Klebsiella
> days.6,7
Salmonella typhimurium
10 days- 4.2 years.7
Mycobacterium tuberculosis
120 days.7
Candida albicans
Most viruses from the respiratory tract (eg: corona, coxsackie, influenza, SARS, rhino virus)
Few days.7
Viruses from the gastrointestinal tract (eg: astrovirus, HAV, polio- or rota virus)
days.7
Blood-borne viruses (eg: HBV or HIV)
>7 days.5
1. Beard-Pegler et al J Med Microbiol. 26:251-5.
2. BIOQUELL trials, unpublished data.
3. Bonilla et al Infect Cont Hosp Epidemiol. 17:770-2
4. Boyce J Hosp Infect. 65:50-4.
5. Duckworth and Jordens J Med Microbiol. 32:
6. French et al ICAAC.
7. Kramer et al BMC Infect Dis. 6:130.
8. Otter and French J Clin Microbiol. 47:205-7.
9. Smith et al J Med. 27:
10. Wagenvoort et al J Hosp Infect. 45:231-4.
11. Wagenvoort and Joosten J Hosp Infect. 52:226-7. 4

5. Patients as Source of Room Contamination Prior room occupancy increases risk
Study
Healthcare associated pathogen
Likelihood of patient acquiring HAI based on prior room occupancy (comparing a previously ‘positive’ room with a previously ‘negative’ room)
Martinez 20031
VRE – cultured within room
2.6x
Huang 20062
VRE – prior room occupant
1.6x
MRSA – prior room occupant
1.3x
Drees 20083
VRE – cultured within room
1.9x
2.2x
VRE – prior room occupant in previous two weeks
2.0x
Shaughnessy 20084
C. difficile – prior room occupant
2.4x
Nseir 20105
A. baumannii – prior room occupant
3.8x
P. aeruginosa – prior room occupant
2.1x
1. Martinez et al. Arch Intern Med 2003; 163:
2. Huang et al. Arch Intern Med 2006; 166:
3. Drees et al. Clin Infect Dis 2008; 46:
4. Shaughnessy. ICAAC/IDSA Abstract K-4194.
5. Nseir et al. Clin Microbiol Infect 2010 (in press).

6. Precautions are used for both colonized and infected patients
Colonization:
The complex process of new organisms becoming a part of the endogenous flora of an area of the body with no signs of active infection
Infection:
The presence of signs and symptoms of a host/pathogen response (fever, drainage, cough, purulence, inflammation, etc.)

7. Standard Precautions Applies to everyone Hand washing
Gloves, masks and gowns when deemed necessary to protect you
Cleaning patient care equipment between patient use
Environmental controls
Careful handling of linen
Appropriate patient placement

8. Precaution Materials *Precaution Gowns *Gloves *Masks *Private Room
*Precaution Cart or
Mounted Container
*Signage
*Dedicated Equipment
(stethoscope, sphgmanometer, commodes)
*Alcohol Hand Rub
*Red Bags for Infectious Waste Disposal

9. Additions to Standard Precautions
Safer injection practices
multiple outbreaks of infections attributed to unsafe injection practices
use a sterile single-use needle and syringe for each injection
use single-use medication vials whenever possible and avoid using multiple dose vials
avoid reinsertion of used needles in multiple dose vials or solutions
avoid use of single-use needles and syringes to administer intravenous medication to multiple patients
Special lumbar puncture procedures
Use a face mask during spinal procedures (e.g., lumbar punctures, myelogram, and spinal anesthesia)
mask prevents oral contamination during lumbar puncture procedures
Respiratory hygiene/cough etiquette
Respiratory hygiene and cough etiquette include covering the mouth and nose during coughing and sneezing with a tissue or offering a surgical mask to the coughing patient
discarding the mask or tissue appropriately
performing hand hygiene
posting signs in public areas in languages appropriate to the population served
educating healthcare staff, patients, and visitors

10. Transmission-Based Precautions
Contact
Special Contact (Clostridium difficile)
Droplet
Airborne

11. Contact Precautions
Used for diseases transmitted by contact with the patient or the patient’s environment
Diseases caused by organisms that have been demonstrated to cause heavy environmental contamination, such as vancomycin-resistant Enterococcus (VRE), methicillin-resistant Staphylococcus aureus (MRSA), or respiratory syncytial virus (RSV) in infants, children, and immunocompromised adults
Require gowns and gloves on room entry

12. Contact Precautions
Patient Placement: A single room is preferred; however, patients with the same disease or organism may share a room
Avoid placing immunocompromised patients or other patients who may have adverse outcomes from infection with a patient on Contact Precautions.
Personal Protective Equipment (PPE): Wear a gown and gloves on room entry. Change the gown and gloves between patients even if both patients share a room and both are on Contact Precautions.

13. Contact Precautions
MRSA, VRE, C.Difficile, Abscess, Draining Cellulitis, Herpes Zoster (vesicles), Impetigo, Staph aureus wound infections, Streptococcus wound infections, MDR-Acinetobacter, E.Coli, Klebsiella New: CRE, MERS-CoV, H7N9 Remember also for significant fecal incontinence - 2/3 of feces is pure organisms!

14. Contact Precautions Techniques
Gloves for EVERYONE entering the room – including physicians, visitors, family members

15. Contact Precautions Techniques
Inside the Room:
Covered linen hamper
Red lined trash container
Alcohol Hand Rub
Stethoscope and Blood Pressure Equipment
Disposable Thermometers
Red Bags for disposal of contaminated dressings and items used in patient care
SaniCloths– lid must be kept closed to prevent evaporation

16. MRSA contamination in precaution rooms
70% of rooms had environmental contamination when the patient was colonized or infected
42% of nurses’ gloves cultured were contaminated after touching environmental surfaces WITHOUT touching the patient!
Boyce,J et al. Infec Cont Hosp Epid 1977

17. Lab Coats, Stethoscopes, Otoscopes, Gloves, Gowns, Pagers, Cell Phones – contamination with Staph aureus, MRSA and VRE
Infect Control Hosp Epidemiol Sep;22(9): Contamination of gowns, gloves, and stethoscopes with vancomycin-resistant enterococci. Zachary KC, Bayne PS, Morrison VJ, Ford DS, Silver LC, Hooper DC. Infectious Disease Division Massachusetts General Hospital, Boston RESULTS: VRE were isolated from at least 1 examiner site (gloves, gowns, or stethoscope) in 33 (67%) of 49 cases. Gloves were contaminated in 63%, gowns in 37%, and stethoscopes in 31%.
J Hosp Infect Aug;48 Suppl A:S Stethoscopes and otoscopes--a potential vector of infection? Cohen HA, Amir J, Matalon A, Mayan R, Beni S, Barzilai A. RESULTS: All the stethoscopes and 90% of the otoscope handles were colonized by microorganisms. Staphylococci were isolated from 85.4% of the stethoscopes and 83.3% of the otoscopes, with 54.5% and 45.2% respectively being S. Aureus. Methicillin-resistant S. aureus were found in four each of the stethoscopes (7.3%) and otoscopes (9.5%)
Docs' Cell Phones May Spread Hospital Infections - screened 124 hospital personnel for the germ Acinetobacter baumannii percent of healthcare providers' cell phones were contaminated with the bug not only on phones but also on 24 percent of the hands of the people tested, who included 71 physicians and 53 nurses.
Infect Control Hosp Epidemiol May;23(5): Bacterial contamination of hospital pagers. Singh D, Kaur H, Gardner WG, Treen LB. Microorganisms were isolated from all pagers; 21% yielded Staphylococcus aureus, of which 14% were methicillin resistant. Cleaning with alcohol reduced the total colony count by an average of 94%.

18. Discontinuation of Precautions for MRSA
One negative PCR for MRSA
If using a culture - three negative surveillance cultures from nares obtained on separate days
Patient must be off mupirocin and antibiotic therapy for MRSA
One negative culture from original site of infection (urine, wound, g-tube, sputum, etc.)

19. SHEA – new isolation guidelines Jan 2018

20. Discontinuation of Precautions for VRE
Three negative surveillance cultures from rectal/stool specimen obtained on separate days
Patient must be off antibiotic therapy for VRE
One negative cultures from original site of infection (urine, wound, g-tube, sputum, etc.)

21. SHEA – new isolation guideline Jan 2018

22. Special Contact Precautions
For Clostridium difficile
Alcohol hand rub will not kill spores
Hand washing imperative to remove spores
Discontinued precautions at discharge if possible
If not – keep patient in room alone
disinfect with bleach
EVS use rapid room disinfector at discharge

23. Special Contact Precautions
Meticulous environmental cleaning and use of products with a C. difficile inactivation label claim (such as bleach)
Strict hand hygiene
Good laundry practices are recommended to decrease transmission of C. difficile
Commodes should have a commode liner

24. SHEA – new isolation guideline Jan 2018

25. Discontinuation of Precautions for Clostridium Difficile
No policy requiring surveillance cultures for C.difficile
Maintain precautions until discharge (if possible)
Up to 70 percent of patients may have skin contamination with C. difficile 6 days after the resolution of diarrhea and 40 percent may have skin contamination up to 9 days after the resolution of diarrhea

26. Hands and Gloved Hands as Sources for Spread
The imprint of a health care worker's gloved hand after examining a patient infected with Clostridium difficile.
The larger yellow colonies outlining the fingers are clusters of Clostridium difficile
The patient had showered an hour before the 
specimen was collected.
Clinical Infectious Diseases, February 2008

28. New Technology for Environmental Disinfection
Movable UV-C robots for
terminal cleaning (Steriliz)
Permanent fixture white light disinfection (Indigo Clean)
Disinfecting Ceiling Light Units
(Vitashield)
Movable air treatment system with HEPA filer and UV (Aerobiotix)
Copper surfaces (EOScu)
Spencer M, et al: A model for choosing an automated ultraviolet-C disinfection system and building a case for the C-suite: Two case reports. AJIC 2016

29. Droplet Precautions
Prevent transmission of diseases caused by large respiratory droplets that are generated by coughing, sneezing, or talking
H3N2 flu season is transmitted by even talking – ineffective vaccine this year as well

30. Droplet Precautions Influenza Meningitis - Hemophilus Meningococcemia
Mumps
Pertussis
Rubella
Sudden Acute Respiratory Syndrome (SARS)

31. Droplet Precautions
Private Room (does not have to be a negative pressure room)
Masks for all entering the room

33. Airborne Precautions Pulmonary Tuberculosis Sputum AFB Positive
Chickenpox
Disseminated Herpes Zoster
Measles
Avian Flu
NEW: MERS-CoV, H7N9

34. Airborne Precautions Negative Pressure Isolation Room N95 Respirator
Door must be kept closed
When transporting patient – place a surgical mask on during transport

35. Environmental Disinfection
Quaternary disinfectant used in all Contact Precaution rooms to clean bed, bedside equipment and environmental surfaces (ex 456, Virex, HBQuat)
Sani Cloths are used for low level disinfection – they are bactericidal, virucidal, tuberculocidal
Bleach Sani Cloths for C difficile and bathrooms
Hyrdrogen peroxide sani cloths

36. Patient Transport
Limit patient transport outside the room to medically necessary purposes
Inform the receiving department of the Isolation Precautions status of the patient
Cover or contain potentially infectious body fluids before transport
The transporter should discard contaminated PPE before transport
Don clean PPE to handle the patient at the destination

37. Ambulatory Settings and Long-term Care Settings
Place patients on Contact Precautions in examination rooms as soon as possible
In long-term care settings, patient placement should be handled on a case-by-case basis
Each facility should make decisions on the basis of infection risks to other patients in the facility

38. Environmental Measures
Clean daily with a focus on high touch areas, patient bathrooms, and areas close to the patient
EVS workers should don gown and gloves before room entry to clean the patient’s room
Processes for room disinfection should be audited, especially in outbreak scenarios, to ensure compliance

39. Hand Hygiene

40. DIRECT TRANSMISSION FROM HANDS MOST COMMON WAY DISEASE IS TRANSMITTED

41. Most Important Control Measure
HAND HYGIENE in the operating room
Wash hands several times a shift – especially if you have had gloves on for more than 20 minutes – organisms multiply every 20 minutes
Communication between organisms to pass resistance factors

42. Most Important Control Measure
HAND HYGIENE
Wash hands several times a shift – especially if you have had gloves on for more than 20 minutes – organisms multiply every 20 minutes

43. Use Alcohol Based Hand Rub “FOAM in FOAM out”

44. Hand Cultures – before and after

48. THE END M.R.S.A.
“ MAKE RESISTANCE STAY AWAY”