New isolation guidelines coming later this year

CDC published draft will allow ICP input

Infection control professionals will have the opportunity to review and comment on controversial new patient isolation guidelines by the Centers for Disease Control and Prevention (CDC) later this year, a CDC advisor reports.

"We very much need those of you in the field who work with these kinds of guidelines every day to respond to those things in the guideline that you think are effective and those things that are problematic," said Marguerite Jackson, RN, PhD, CIC, FAAN, director of education, development, and research at University of California in San Diego Health Care. "This is particularly critical because we are transitioning this guideline to look at health care delivery across the continuum."

The guidelines will address infection control in other settings, including home care, ambulatory care, specialty care, freestanding sites, and long-term care. "We are looking to maintain flexibility as much as appropriate, particularly when there is conflicting evidence," said Jackson, who updated the status of the guidelines recently in San Antonio at the annual conference of the Association for Professionals in Infection Control and Epidemiology.

"By late summer or early fall, we anticipate publishing a revised draft in the Federal Register for public comments," said Jackson, an advisor to the CDC’s Healthcare Infection Control Practices Advisory Committee (HICPAC). "In the fall, we will revise again, that will be draft 8, with the public comments; and sometime in 2004, we hope early in the year, the guideline will be published in MMWR."

The new guidelines will replace the current patient isolation recommendations, which were published in 1996. The world of infectious diseases has continued to rapidly change in the ensuing years.

"Clearly, we have had to add SARS," she said. "We have had to add agents of bioterrorism because we started this work before 9/11. So we have been doing our very best to be responsive to the changes in the health care environment, which seem to be happening with greater and greater frequency. I’m sure we will have to put monkey pox in as well before we’re finished."

Antibiotic resistance emphasis

Draft versions of the guideline have sparked some debate over the issue of multidrug-resistant organisms (MDROs), and more specifically, whether patients should be actively screened for them to detect reservoirs of colonization and infection. The guidelines recommend that clinicians adhere to standard precautions (i.e., hand washing, glove use) under the assumption that any patient could be colonized or infected with an MDRO. While contact isolation measures continue to be recommended for hospitals, the final draft may emphasize that the use of standard precautions with all patients is a more practical measure in nonhospital settings.

"In other settings, assess the nature of the patient interaction or risk," Jackson said. "This is an area where we have had lots of debate, where there have been lots of comments from HICPAC. There are lots of opinions about this, and this is an area where we particularly need your input from the field."

The draft currently under discussion includes a section on a baseline approach to MDROs, and also includes intensified measures for settings that have recurrent problems or outbreaks. 

"[We] designate MDRO prevention and control as a organizational priority that requires administrative support, fiscal resources, human resources," she said. " If MDROs are an issue in your organization and you need support from this guideline to get the kind of resources that you need, we hope that this will be helpful to you. We believe that including MDRO education in the required curriculum of all health care worker training programs is quite important."

The guidelines stress the importance of judicious use of anti-microbial agents, including asking physicians to verify that anti-microbial agents used for treatment are active against the patient’s clinical isolates. "We are very strongly saying that the drug needs to work for the bug — that this is a responsibility that the organization has," Jackson said.

Staffing and patient safety link

HICPAC is currently considering adequate staffing as one of the "performance measures" for the guidelines. "There is a substantial body of evidence now that links inadequate staffing with poorer outcomes in patients, including several types of health care associated infections," she said.

HICPAC is emphasizing the importance of "administrative responsibilities," including incorporating infection control into the organization’s patient safety program. "This is to establish the link at the very beginning that infection prevention through the use of transmission precautions is part of patient safety," she said. "The second part of the administrative responsibilities is to make prevention and control and institutional priority and provide adequate administrative support and fiscal and human resources." The draft version currently bears the somewhat unwieldy title of The HICPAC Guideline to Prevent Transmission of Infectious Agents in Healthcare Settings.

"We have reduced the use of the term isolation precautions,’" Jackson said. "We haven’t eliminated it entirely, but we have reduced it, partly because of the psychological effect of the term "isolation" and partly because we want people to recognize that in many cases it’s not necessary to isolate the patient — you’re trying to isolate the organism that is causing the problem."

Another guiding principle is to provide recommendations that are epidemiologically sound and, whenever possible, evidence-based. The 1996 guidelines cited some 250 references in support of the recommendations. "We are now up to over 600 cited references, many of which do reflect studies and are not just case reports or anecdotes," she said.