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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-
dren should be considered specifically as they relate to
based precautions, for the care of patients who are
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-
cated for all patients and are designed to reduce the
T
hese new isolation guidelines developed by 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
trol and Prevention (CDC) and the National Center hospitals.
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
prudent . . . ”1 Therefore, with these new recommen- 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
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2021 101 No. 3 March 1998 1 of 4TABLE 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 mm 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
2 of 4 REVISED CDC GUIDELINES FOR
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3, 2021TABLE 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.
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Downloaded from www.aappublications.org/news by guest on April 3, 2021 3 of 4ticularly 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
Jon S. Abramson, MD
mon-use areas such as playrooms and schoolrooms. 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
Canadian Paediatric Society
negative pressure ventilation is indicated. The guide- 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
Society of Pediatric Nurses
tial virus) who can be separated by cohorts. 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
4 of 4 REVISED CDC GUIDELINES FOR
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3, 2021The 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 April 3, 2021The 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
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/101/3/e13
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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