I.B.1. Assure that individuals with training in infection control are employed by or are available by contract to all healthcare facilities so that the infection control program is managed by one or more qualified individuals.^{552, 566, 316, 575, 947, 573, 576, 946} Category IB/IB

I.B.2. Include prevention of healthcare-associated infections (HAI) as one determinant of bedside nurse staffing levels and composition, especially in high-risk units.^{585-589, 590, 592, 593, 551, 594, 595, 418, 596, 597, 583} Category IB

I.B.3. Delegate authority to infection control personnel or their designees (e.g., patient care unit charge nurses) for making infection control decisions concerning patient placement and assignment of Transmission-Based Precautions.^{549, 434, 857, 946} Category IB

I.B.4. Involve infection control personnel in decisions on facility construction and design, determination of AIIR and Protective Environment capacity needs and environmental assessments.^{11, 13, 950, 951, 12} Category IB/IB

I.B.5. Involve infection control personnel in the selection and post-implementation evaluation of medical equipment and supplies and changes in practice that could affect the risk of HAI.^{952, 953} Category IB

I.B.6. Ensure availability of human and fiscal resources to provide clinical microbiology laboratory support, including a sufficient number of medical technologists trained in microbiology, appropriate to the healthcare setting, for monitoring transmission of microorganisms, planning and conducting epidemiologic investigations, and detecting emerging pathogens. Identify resources for performing surveillance cultures, rapid diagnostic testing for viral and other selected pathogens, preparation of antimicrobial susceptibility summary reports, trend analysis, and molecular typing of clustered isolates (performed either on-site or in a reference laboratory) and use these resources according to facility-specific epidemiologic needs, in consultation with clinical microbiologists.^{553, 609, 610, 612, 617, 954, 614, 603, 615, 616, 605, 599, 554, 598, 606, 607} Category IB

I.B.7. Provide human and fiscal resources to meet occupational health needs related to infection control (e.g., healthcare personnel immunization, post-exposure evaluation and care, evaluation and management of healthcare personnel with communicable infections.^{739, 12, 17, 879-881, 955, 134, 690} Category IB/IB

I.B.8. In all areas where healthcare is delivered, provide supplies and equipment necessary for the consistent observance of Standard Precautions, including hand hygiene products and personal protective equipment (e.g., gloves, gowns, face and eye protection).^{739, 559, 946} Category IB/IB

I.B.9. Develop and implement policies and procedures to ensure that reusable patient care equipment is cleaned and reprocessed appropriately before use on another patient.^{11, 956, 957, 958, 959, 836, 87, 11, 960, 961} Category IA/IB

II.A.1. Include in education and training programs, information concerning use of vaccines as an adjunctive infection control measure.^{17, 611, 690, 874} Category IB

II.A.2. Enhance education and training by applying principles of adult learning, using reading level and language appropriate material for the target audience, and using online educational tools available to the institution.^{658, 694, 695, 697, 698, 700, 966} Category IB

IV.A.1. During the delivery of healthcare, avoid unnecessary touching of surfaces in close proximity to the patient to prevent both contamination of clean hands from environmental surfaces and transmission of pathogens from contaminated hands to surfaces.^{72, 73, 739, 800, 975{CDC, 2001 #970} Category IB/IB

IV.A.2. When hands are visibly dirty, contaminated with proteinaceous material, or visibly soiled with blood or body fluids, wash hands with either a nonantimicrobial soap and water or an antimicrobial soap and water.⁵⁵⁹ Category IA

IV.A.3. If hands are not visibly soiled, or after removing visible material with nonantimicrobial soap and water, decontaminate hands in the clinical situations described in IV.A.3.a-f.. The preferred method of hand decontamination is with an alcohol-based hand rub.^{562, 978} Alternatively, hands may be washed with an antimicrobial soap and water. Frequent use of alcohol-based hand rub immediately following handwashing with nonantimicrobial soap may increase the frequency of dermatitis.⁵⁵⁹ Category IB

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.1.a. Wear PPE, as described in IV.B.2-4,when the nature of the anticipated patient interaction indicates that contact with blood or body fluids may occur.^{739, 780, 896} Category IB/IB

IV.B.1.b. Prevent contamination of clothing and skin during the process of removing PPE (see Figure). Category II

IV.B.1.c. Before leaving the patient’s room or cubicle, remove and discard PPE.^{18, 739} Category IB/IB

IV.B.2.a. Wear gloves when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, nonintact skin, or potentially contaminated intact skin (e.g., of a patient incontinent of stool or urine) could occur.^{18, 728, 739, 741, 780, 985} Category IB/IB

IV.B.2.b. Wear gloves with fit and durability appropriate to the task.^{559, 731, 732, 739, 986, 987} Category IB

IV.B.2.c. Remove gloves after contact with a patient and/or the surrounding environment (including medical equipment) using proper technique to prevent hand contamination (see Figure). Do not wear the same pair of gloves for the care of more than one patient. Do not wash gloves for the purpose of reuse since this practice has been associated with transmission of pathogens.^{559, 728, 741-743, 988} Category IB

IV.B.2.d. Change gloves during patient care if the hands will move from a contaminated body-site (e.g., perineal area) to a clean body-site (e.g., face). Category II

IV.B.3.a. Wear a gown, that is appropriate to the task, to protect skin and prevent soiling or contamination of clothing during procedures and patient-care activities when contact with blood, body fluids, secretions, or excretions is anticipated.^{739, 780, 896} Category IB/IC

IV.B.3.b. Do not reuse gowns, even for repeated contacts with the same patient. Category II

IV.B.3.c. Routine donning of gowns upon entrance into a high risk unit (e.g., ICU, NICU, HSCT unit) is not indicated.^{365, 747-750} Category IB

IV.B.4.a. Use PPE to protect the mucous membranes of the eyes, nose and mouth during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions and excretions. Select masks, goggles, face shields, and combinations of each according to the need anticipated by the task performed.^{113, 739, 780, 896} Category IB/IB

IV.C.2.a. Post signs at entrances and in strategic places (e.g., elevators, cafeterias) within ambulatory and inpatient settings with instructions to patients and other persons with symptoms of a respiratory infection to cover their mouths/noses when coughing or sneezing, use and dispose of tissues, and perform hand hygiene after hands have been in contact with respiratory secretions. Category II

IV.C.2.b. Provide tissues and no-touch receptacles (e.g.,foot-pedal-operated lid or open, plastic-lined waste basket) for disposal of tissues.²⁰ Category II

IV.C.2.c. Provide resources and instructions for performing hand hygiene in or near waiting areas in ambulatory and inpatient settings; provide conveniently-located dispensers of alcohol-based hand rubs and, where sinks are available, supplies for handwashing.^{559, 903} Category IB

IV.C.2.d. During periods of increased prevalence of respiratory infections in the community (e.g., as indicated by increased school absenteeism, increased number of patients seeking care for a respiratory infection), offer masks to coughing patients and other symptomatic persons (e.g., persons who accompany ill patients) upon entry into the facility or medical office.^{126, 899, 898} and encourage them to maintain special separation, ideally a distance of at least 3 feet, from others in common waiting areas.^{23, 103, 111, 114, 20, 134} Category IB

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

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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

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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

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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 IB

IV.J. Worker safety

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

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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 

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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

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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.2.a. In acute care hospitals and long-term care settings, place patients who require Airborne Precautions in an AIIR that has been constructed in accordance with current guidelines.^11-13 Category IA/IB

V.D.2.b. When an AIIR is not available, transfer the patient to a facility that has an available AIIR.¹² Category II

V.D.2.c. In the event of an outbreak or exposure involving large numbers of patients who require Airborne Precautions:

• Consult infection control professionals before patient placement to determine the safety of alternative room that do not meet engineering requirements for an AIIR.
• Place together (cohort) patients who are presumed to have the same infection( based on clinical presentation and diagnosis when known) in areas of the facility that are away from other patients, especially patients who are at increased risk for infection (e.g., immunocompromised patients).
• Use temporary portable solutions (e.g., exhaust fan) to create a negative pressure environment in the converted area of the facility. Discharge air directly to the outside,away from people and air intakes, or direct all the air through HEPA filters before it is introduced to other air spaces.¹² Category II

V.D.2.d. In ambulatory settings:

• V.D.2.d.i. Develop systems (e.g., triage, signage) to identify patients with known or suspected infections that require Airborne Precautions upon entry into ambulatory settings.^{9, 12, 34, 127, 134} Category IA
• V.D.2.d.ii. Place the patient in an AIIR as soon as possible. If an AIIR is not available, place a surgical mask on the patient and place him/her in an examination room. Once the patient leaves, the room should remain vacant for the appropriate time, generally one hour, to allow for a full exchange of air.^{11, 12, 122} Category IB/IB
• V.D.2.d.iii. Instruct patients with a known or suspected airborne infection to wear a surgical mask and observe Respiratory Hygiene/Cough Etiquette. Once in an AIIR, the mask may be removed; the mask should remain on if the patient is not in an AIIR.^{12, 107, 145, 899} Category IB/IB

V.D.4.a. Wear a fit-tested NIOSH-approved N95 or higher level respirator for respiratory protection when entering the room or home of a patient when the following diseases are suspected or confirmed:

V.D.4.b. ~ Suspected measles, chickenpox or disseminated zoster.
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.
No recommendation is made regarding the type of personal protective equipment (i.e., surgical mask or respiratory protection with a N95 or higher respirator) to be worn by susceptible healthcare personnel who must have contact with patients with known or suspected measles, chickenpox or disseminated herpes zoster. Unresolved issue

V.D.5.a. In acute care hospitals and long-term care and other residential settings, limit transport and movement of patients outside of the room to medically-necessary purposes. Category II

V.D.5.b. If transport or movement outside an AIIR is necessary, instruct patients to wear a surgical mask, if possible, and observe Respiratory Hygiene/Cough Etiquette.¹² Category II

V.D.5.c. For patients with skin lesions associated with varicella or smallpox or draining skin lesions caused by M. tuberculosis, cover the affected areas to prevent aerosolization or contact with the infectious agent in skin lesions.^{108, 1025, 1026, 1029-1031} Category IB

V.D.5.d. Healthcare personnel transporting patients who are on Airborne Precautions do not need to wear a mask or respirator during transport if the patient is wearing a mask and infectious skin lesions are covered. Category II

VI.C.1. Environmental controls

VI.C.2. Lower dust levels by using smooth, nonporous surfaces and finishes that can be scrubbed, rather than textured material (e.g., upholstery). Wet dust horizontal surfaces whenever dust detected and routinely clean crevices and sprinkler heads where dust may accumulate.^{940, 941} Category II

VI.C.3. Avoid carpeting in hallways and patient rooms in areas.⁹⁴¹ Category IB

VI.C.4. Prohibit dried and fresh flowers and potted plants.^942-944 Category II

VI.E.1.a. No recommendation for fit-testing of patients who are using respirators. Unresolved issue

VI.E.1.a. No recommendation for use of particulate respirators when leaving the Protective Environment in the absence of construction. Unresolved issue

VI.F.1. Use Standard Precautions as recommended for all patient interactions. Category IA

VI.F.2. Implement Droplet and Contact Precautions as recommended for diseases listed in Appendix A. Transmission-Based precautions for viral infections may need to be prolonged because of the patient’s immunocompromised state and prolonged shedding of viruses.^{930, 1010, 928, 932, 1011} Category IB

VI.F.3. Barrier precautions, (e.g., masks, gowns, gloves) are not required for healthcare personnel in the absence of suspected or confirmed infection in the patient or if they are not indicated according to Standard Precautions.¹⁵ Category II

VI.F.4. Implement Airborne Precautions for patients who require a Protective Environment room and who also have an airborne infectious disease (e.g., pulmonary or laryngeal tuberculosis, acute varicella-zoster). Category IA