AMERICAN ACADEMY OF PEDIATRICS Committee on Infectious Diseases and Committee on Hospital Care

The Revised CDC Guidelines for Isolation Precautions in Hospitals: Implications for Pediatrics

ABSTRACT. The Hospital Infection Control Practices timal performance of an expanded set of universal Advisory Committee of the US Centers for Disease Con- precautions, now called standard precautions, for the trol and Prevention and the National Center for Infec- care of all patients regardless of their diagnosis or tious Diseases have issued new isolation guidelines that presumed infection status, and pathogen and syn- replace earlier recommendations. Modifications of these drome-based precautions, termed transmission- guidelines for the care of hospitalized infants and chil- based precautions, for the care of patients who are dren should be considered specifically as they relate to glove use for routine diaper changing, private room iso- infected or colonized with pathogens spread through lation, and common use areas such as playrooms and airborne, droplet, or contact routes. schoolrooms. These new guidelines replace those pro- vided in the 1994 Red Book and have been incorporated STANDARD PRECAUTIONS into the 1997 Red Book. Standard precautions now apply to nonintact skin, mucous membranes, blood, all body fluids, secre- ABBREVIATION. CDC, Centers for Disease Control and Preven- tions, and excretions except sweat, regardless of tion. whether or not they contain visible blood. These general methods of infection prevention are indi- hese new isolation guidelines developed by the cated for all patients and are designed to reduce the Hospital Infection Control Practices Advisory risk of transmission of microorganisms from both Committee of the US Centers for Disease Con- recognized and unrecognized sources of infection in T hospitals. trol and Prevention (CDC) and the National Center for Infectious Diseases are specifically recommended for use in the care of hospitalized adults and chil- TRANSMISSION-BASED PRECAUTIONS dren.1 Settings such as schools and child care centers Transmission-based precautions are designed for are similar to hospital environments in which chil- patients documented or suspected to be infected or dren share common space but differ in that the in- colonized with pathogens that require additional volved children are, for the most part, healthy. These precautions beyond the standard precautions neces- recommendations, therefore, should not be applied sary to interrupt transmission. These precautions ap- to those settings. These new guidelines are simpler ply to airborne, droplet, and contact transmissions. and rely on very consistent strategies to prevent the The precautions may be combined for diseases that spread of infection to uninfected hospitalized pa- have multiple routes of transmission. Whether singly tients. These new recommendations specifically state or in combination, they are always to be used in that “No guideline can address all of the needs of the addition to standard precautions. more than 6000 US hospitals, which range in size from five beds to more than 1500 beds and serve very Contact Transmission different patient populations. Hospitals are encour- Contact transmission, the most important and fre- aged to review the recommendations and to modify quent mode of transmission of nosocomial infec- them according to what is possible, practical, and tions, is divided into two subgroups: direct-contact 1 Therefore, with these new recommen- prudent . . . ” transmission and indirect-contact transmission. dations as a guide, each institution must create its Direct-contact transmission involves a direct body own specific isolation policies. These isolation poli- surface-to-body surface contact and physical transfer cies, supplemented by hospital policies and proce- of microorganisms between a susceptible host and an dures for other aspects of infection and environmen- infected or colonized person, such as occurs when a tal control and occupational health, coupled with person turns a patient, gives a patient a bath, or common sense, will serve to create reasonable poli- performs other patient-care activities that require di- cies for each unique medical center. rect personal contact. Direct-contact transmission These new guidelines rely on the routine and op- also can occur between two patients, with one serv- ing as the source of the infectious microorganisms and the other as a susceptible host. The recommendations in this statement do not indicate an exclusive course Indirect-contact transmission involves contact of a of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. susceptible host with a contaminated intermediate PEDIATRICS (ISSN 0031 4005). Copyright © 1998 by the American Acad- object, usually inanimate, such as contaminated in- emy of Pediatrics. struments, needles, dressings, or contaminated http://www.pediatrics.org/cgi/content/full/101/3/Downloaded from www.aappublications.org/newse13 by guestPEDIATRICS on October 2, Vol. 2021 101 No. 3 March 1998 1of4 TABLE 1. Transmission-Based Precautions for Hospitalized Patients* Standard Precautions Use standard precautions for the care of all patients Airborne Precautions In addition to standard precautions, use airborne precautions for patients known or suspected to have serious illnesses transmitted by airborne droplet nuclei. Examples of such illnesses include: Measles Varicella (including disseminated zoster)† Tuberculosis‡ Droplet Precautions In addition to standard precautions, use droplet precautions for patients known or suspected to have serious illnesses transmitted by large particle droplets. Examples of such illnesses include: Invasive Haemophilus influenzae type b disease, including meningitis, pneumonia, epiglottitis, and sepsis Invasive Neisseria meningitidis disease, including meningitis, pneumonia, and sepsis Other serious bacterial respiratory infections spread by droplet transmission, including: Diphtheria (pharyngeal) Mycoplasma pneumonia Pertussis Pneumonic plague Streptococcal pharyngitis, pneumonia, or scarlet fever in infants and young children Serious viral infections spread by droplet transmission, including those caused by: Adenovirus* Influenza Mumps Parvovirus B19 Rubella Contact Precautions In addition to standard precautions, use contact precautions for patients known or suspected to have serious illnesses easily transmitted by direct patient contact or by contact with items in the patient’s environment. Examples of such illnesses include: Gastrointestinal, respiratory, skin, or wound infections or colonization with multidrug-resistant bacteria judged by the infection control program, based on current state, regional, or national recommendations, to be of special clinical and epidemiologic significance Enteric infections with a low infectious dose or prolonged environmental survival, including those caused by: Clostridium difficile For diapered or incontinent patients: enterohemorrhagic Escherichia coli 0157:H7, Shigella, hepatitis A, or rotavirus Respiratory syncytial virus, parainfluenza virus, or enteroviral infections in infants and young children Skin infections that are highly contagious or that may occur on dry skin, including: Diphtheria (cutaneous) Herpes simplex virus (neonatal or mucocutaneous) Impetigo Major (noncontained) abscesses, cellulitis, or decubiti Pediculosis Scabies Staphylococcal furunculosis in infants and young children Zoster (disseminated or in the immunocompromised host)* Viral/hemorrhagic conjunctivitis Viral hemorrhagic infections (Ebola, Lassa, or Marburg) * Reprinted from Garner JS and the Hospital Infection Control Practices Advisory Committee.1 † Certain infections require more than one type of precaution. ‡ See Centers for Disease Control and Prevention.2 hands that are not washed and gloves that are not transmission; that is, droplet transmission must not changed between patients. be confused with airborne transmission.

Droplet Transmission Airborne Transmission Droplet transmission, theoretically, is a form of con- Airborne transmission occurs by dissemination of tact transmission. However, the mechanism of trans- either airborne droplet nuclei (small-particle residue fer of the pathogen to the host is quite distinct from [5 ␮m or smaller] of evaporated droplets containing either direct- or indirect-contact transmission. There- microorganisms that remain suspended in the air for fore, droplet transmission is considered a separate long periods) or dust particles containing the infec- route of transmission in this guideline. Droplets are tious agent. Microorganisms carried in this manner generated from the source person primarily during can be dispersed widely by air currents, and may be coughing, sneezing, and talking, and during the per- inhaled by a susceptible host within the same room formance of certain procedures such as suctioning or over a longer distance from the source patient, and bronchoscopy. Transmission occurs when drop- depending on environmental factors; therefore, lets containing microorganisms generated from the special air handling and ventilation are required to infected person are propelled a short distance prevent airborne transmission. Microorganisms through the air and deposited on the host’s conjunc- transmitted by airborne transmission include Myco- tivae, nasal mucosa, or mouth. Because droplets do bacterium tuberculosis and the measles and varicella not remain suspended in the air, special air handling viruses. and ventilation are not required to prevent droplet These new guidelines provide summary tables for

2of4 REVISED CDC GUIDELINESDownloaded from FOR www.aappublications.org/news ISOLATION PRECAUTIONS by guest on IN October HOSPITALS 2, 2021 TABLE 2. Clinical Syndromes or Conditions Warranting Additional Empiric Precautions to Prevent Transmission of Epidemiolog- ically Important Pathogens Pending Confirmation of Diagnosis* Clinical Syndrome or Condition† Potential Pathogens‡ Empiric Precautions Diarrhea Acute diarrhea with a likely infectious cause in an Enteric pathogens§ Contact incontinent or diapered patient Diarrhea in an adult with a history of recent Clostridium difficile Contact antibiotic use

Meningitis Neisseria meningitidis Droplet

Rash or exanthems, generalized, etiology unknown Petechial/ecchymotic with fever Neisseria meningitidis Droplet Vesicular Varicella Airborne and contact Maculopapular with coryza and fever Rubeola (measles) Airborne

Respiratory infections Cough/fever/upper lobe pulmonary infiltrate in an Mycobacterium tuberculosis Airborne HIV-negative patient or a patient at low risk for HIV infection Cough/fever/pulmonary infiltrate in any lung Mycobacterium tuberculosis Airborne location in an HIV-infected patient or a patient at high risk for HIV infection Paroxysmal or severe persistent cough during Bordetella pertussis Droplet periods of pertussis activity Respiratory infections, particularly bronchiolitis and Respiratory syncytial or parainfluenza virus Contact croup, in infants and young children

Risk of multidrug-resistant microorganisms History of infection or colonization with multidrug- Resistant bacteria Contact resistant organisms࿣ Skin, wound, or urinary tract infection in a patient Resistant bacteria Contact with a recent hospital or nursing home stay in a facility where multidrug-resistant organisms are prevalent

Skin or wound infection Abscess or draining wound that cannot be covered Staphylococcus aureus, group A streptococcus Contact * Infection control professionals are encouraged to modify or adapt this table according to local conditions. To ensure that appropriate empiric precautions are implemented always, hospitals must have systems in place to evaluate patients routinely according to these criteria as part of their preadmission and admission care. (Reprinted with permission from Garner JS and the Hospital Infection Control Practices Advisory Committee.1) † Patients with the syndromes or conditions listed herein may present with atypical signs or symptoms (eg, neonates and adults with pertussis may not have paroxysmal or severe cough). The clinician’s index of suspicion should be guided by the prevalence of specific conditions in the community, as well as clinical judgment. ‡ The organisms listed are not intended to represent the complete, or even most likely, diagnoses, but rather possible etiologic agents that require additional precautions beyond standard precautions until they can be ruled out. § These pathogens include enterohemorrhagic Escherichia coli 0157:H7, Shigella, hepatitis A, and rotavirus. ࿣ Resistant bacteria judged by the infection control program, based on current state, regional, or national recommendations, to be of special clinical or epidemiological significance. different settings. A synopsis of the precautions and cautions needed when the specific infection or con- patients requiring these precautions is presented in dition is known. Table 1. Table 2 describes empiric precautions for clinical syndromes pending confirmation of diagno- PEDIATRIC CONSIDERATIONS sis. Table 3 outlines the specific procedures indicated These guidelines are intended to be not only epi- for each type of precaution. Footnotes document the demiologically sound but also simple and readily acceptable changes for children. Appendix A in the implemented for the care of both adults and children. guidelines, which is not reproduced here, is the spe- Practically, however, unique requirements of pediatric cific recommendation on type and duration of pre- care necessitate modifications of these guidelines, par-

TABLE 3. Recommendations for Transmission-Based Precautions for Hospitalized Patients Category of Hand Washing for Single Room Masks Gowns Gloves Precautions Patient Contact Airborne Yes Yes, with negative-pressure Yes No No ventilation Droplet Yes Yes* Yes, for those close to No No patient Contact Yes Yes* No Yes Yes * Preferred but not required for crib-confined patients. Cohorting of children infected with the same pathogen is acceptable.

Downloaded from www.aappublications.org/newshttp://www.pediatrics.org/cgi/content/full/101/3/ by guest on October 2, 2021 e13 3of4 ticularly concerning 1) use of gloves for routine diaper Committee on Infectious Diseases, 1996 to 1997 changing, 2) private rooms and cohorting, and 3) com- Neal A. Halsey, MD, Chair mon-use areas such as playrooms and schoolrooms. Jon S. Abramson, MD P. Joan Chesney, MD Margaret C. Fisher, MD Diaper Changing Michael A. Gerber, MD When dealing with infants and preschool-age chil- Donald S. Gromisch, MD dren who require routine diaper changing, the use of Steve Kohl, MD gloves is not mandatory. The routine use of gloves, S. Michael Marcy, MD however, for diaper changing in hospitalized children Dennis L. Murray, MD could minimize the potential transmission of coloniz- Gary D. Overturf, MD ing microbes (eg, cytomegalovirus, Clostridium difficile, Richard J. Whitley, MD and Citrobacter freundii) to another patient who might Ram Yogev, MD become infected. While exceptions to routine glove use Ex-Officio in units such as the normal newborn nursery or outpa- Georges Peter, MD tient surgical suites are acceptable, the lack of a uniform Consultant policy for glove use may be confusing and actually Leigh G. Donowitz, MD impede implementation of recommended and consis- Liaison Representatives tent infection control practices. Robert Breiman, MD National Vaccine Program Office Private Rooms and Cohorting M. Carolyn Hardegree, MD The CDC guidelines recommend private rooms for Food and Drug Administration all patients requiring isolation precautions (airborne, Richard F. Jacobs, MD droplet, or contact). For any patient with an infection American Thoracic Society requiring airborne precautions, a single room with Noni E. MacDonald, MD negative pressure ventilation is indicated. The guide- Canadian Paediatric Society Walter A. Orenstein, MD lines also recommend that patients who do not con- Centers for Disease Control and Prevention trol body excretions should be in single rooms. How- N. Regina Rabinovich, MD ever, because the majority of young pediatric National Institutes of Health patients are incontinent, by definition, this recom- Ben Schwartz, MD mendation is inappropriate for routine care of unin- Centers for Disease Control and Prevention fected children. Even with infection in settings such Committee on Hospital Care, 1996 to 1997 as nurseries, intensive care units, and infant wards, James E. Shira, MD, Chair single room isolation for droplet and contact precau- Jess Diamond, MD tions, although preferred, is not mandatory because Mary E. O’Connor, MD these infants are confined to cribs or incubators. John M. Packard, Jr, MD However, for young children who are not confined Marleta Reynolds, MD to their cribs or incubators who require droplet or Henry A. Schaeffer, MD contact precautions, single rooms are indicated be- Curt M. Steinhart, MD cause young children are unable to limit the spread Liaison Representatives of their secretions and excretions. The exception to C. Stamey English, MD the need for a single room is for children infected American Academy of Family Physicians with the same pathogen (such as respiratory syncy- Mary T. Perkins, RN, DNSC tial virus) who can be separated by cohorts. Society of Pediatric Nurses Rob Maruca American Hospital Association Common Use Areas (Hospital Schoolrooms, Playrooms, Jerriann M. Wilson Etc) Association for the Care of Children’s Health Hospital playrooms and schoolrooms are unique Eugene Wiener, MD to the field of pediatrics. Any child being treated National Association of Children’s Hospital and with isolation precautions should be excluded from Related Institutes these general use areas. Paul R. VanOstenberg, DDS, MS Joint Commission on Accreditation of Healthcare RECOMMENDATIONS Organizations In general, the revised CDC guidelines are en- AAP Section Liaison dorsed for the care of hospitalized infants and chil- Theodore Striker, MD dren. Section on Anesthesiology Modification of these guidelines for the care of Consultant hospitalized infants and children should be consid- Russell C. Raphaely, MD ered specifically as they relate to glove use for rou- tine diaper changing, private room isolation, and REFERENCES common use areas such as playrooms and school- 1. Garner JS and the Hospital Infection Control Practices Advisory Com- rooms. mittee. Guideline for isolation precautions in hospitals. Infect Control Hosp Epidemiol. 1996;17:53–80 These new guidelines replace those provided in 2. Centers for Disease Control and Prevention. Guidelines for preventing the 1994 Red Book and have been incorporated into the transmission of Mycobacterium tuberculosis in health-care facilities, the 1997 Red Book. 1994. MMWR. 1994;43:1–132

4of4 REVISED CDC GUIDELINESDownloaded from FOR www.aappublications.org/news ISOLATION PRECAUTIONS by guest on IN October HOSPITALS 2, 2021 The Revised CDC Guidelines for Isolation Precautions in Hospitals: Implications for Pediatrics Committee on Infectious Diseases and Committee on Hospital Care Pediatrics 1998;101;e13 DOI: 10.1542/peds.101.3.e13

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Downloaded from www.aappublications.org/news by guest on October 2, 2021 The Revised CDC Guidelines for Isolation Precautions in Hospitals: Implications for Pediatrics Committee on Infectious Diseases and Committee on Hospital Care Pediatrics 1998;101;e13 DOI: 10.1542/peds.101.3.e13

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Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 1998 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

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