Contact Precautions, Discontinuing
Last revised: February 20, 2009
Reviewer: see note at end of this document.
Discontinuing Contact Precautions is a nursing order.
Nursing staff can discontinue contact precautions after discussing with infection control when patients meet the criteria in this infection control procedure, or when the Infection Control Medical Director or his designee recommends discontinuation.
Physicians requesting exceptions to this policy should contact Infection Control before removing patients from isolation.
HMC does not retest for C. Difficile for purposes of discontinuing isolation.
Oral swab: a swab taken to culture oral flora. Specimens can be taken from posterior pharynx, or endotracheal tube suction. Avoid sampling saliva, the tongue or bucchal area which will give a low yield for the desired pathogens.
Page Infection Control 663-8872 for Assistance.
A. Determining if Contact Precautions can be discontinued.
- Methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-intermediate and vancomycin-resistant S. aureus (VISA and VRSA, respectively)
Review of patients with MRSA in 2008 demonstrated that only 7% of patients actually cleared their colonization, consistent with the literature as well as the fact that 1 out of 3 individuals is colonized with S. aureus. In addition, there is not good evidence to support routine decolonization within the hospital setting. Therefore, as consistent with CDC recommendations, patients colonized or infected with MRSA will NOT be routinely decolonized and will NOT be cleared from contact precautions during their hospitalization.
Patients colonized or infected with VISA or VRSA will NOT be cleared from contact precautions during their hospitalization.
- Clostridium difficile
Patients in Contact Precautions for C. difficile may have precautions discontinued when:
- They have been treated with metronidazole or oral vancomycin for seven days and their symptoms of C. difficile associated disease (CDAD) have resolved. This generally means no diarrhea and no abdominal pain. However, note that severe CDAD can sometime interrupt bowel motility and stop diarrhea. If the elevated WBC persists without other explanation, check with the physicians to verify if the symptoms of CDAD have resolved.
- Note that the patient may need to have metronidazole or vancomycin continued per the physician’s orders beyond seven days. Patients can still be taken off Contact Precautions after seven days if CDAD symptoms have resolved.
- Re-culturing or retesting for C. difficile antigens or toxins is strongly discouraged for purposes of discontinuing isolation and patients may remain colonized after treatment. The important point is whether their symptoms, particularly diarrhea, have resolved.
- Patients with a colostomy or ileostomy should remain in precautions.
- Call infection control 744-9560 or page 663-8872, if there are questions about clearing patients.
- Clearance of patients with highly resistant Gram-negative bacteria such as:
- Carbapenem-resistant Acinetobacter,
- Extended Spectrum Beta-Lactamase (ESBL) producing bacteria
These patients can be removed from Contact Precautions when they have been off antibiotics with activity against these organisms for 72 hours (shown below by organism) and have two negative cultures from the sites specified by organism below
Acinetrobacter: Previously positive site(s) if available*
ESBL: Previously positive site(s) if available*
*Notes: If the original positive culture site was CSF, blood, or a healed surgical site or wound do not do an invasive procedure to reculture. Instead, substitute a rectal swab, oral swab or stool specimen for the previously positive site. If the patient has a colostomy or ileostomy, collect the stool sample from this site.
Do not interrupt the course of antibiotics just to get the patient cleared from contact isolation.
Antibiotics for carbapenem-resistant Acinetobacter and ESBL-producing Gram negative bacteria
- Clearance of patients with vancomycin resistant Enterrococcus. (VRE)
- The patient should be cultured when they have been off antibiotics with activity against VRE for at least 72 hours. Do not interrupt the course of antibiotics just to get the patient cleared from contact isolation.
- Antibiotics with activity against VRE may include:
- Daptomycin (Cubicin)
- Linezolid (Zyvox)
- Nitrofurantoin (urine only)
- Quinupristin + Dalfopristin (Synercid)
- Culture the site that was originally positive, plus a rectal swab. This is repeated on two different days, at least 24 hours apart.
Note: If the original site was CSF, blood or a healed surgical site, a rectal swab alone can be submitted.
Enterococcus normally inhabits the intestines so one swab should always be a rectal or stool specimen.
For questions or management of unusual situations call Infection Control 744-9560 or page 663-8872.
- For other organisms, refer to Table A. The table explains the criteria for discontinuation for different infections or conditions, and the type and duration of precautions recommended for selected infections and conditions from CDC Guidelines.
B. Discontinuing contact precautions. If the criteria for discontinuing precautions are met:
- Contact Infection Control 744-9560 or pager 663-8872 to review.
- If infection Control agrees with discontinuation of contact precautions, contact patient placement at 744-3932.
- Notify Environmental Services to have the room terminally cleaned.
- Patients who have been in Contact Precautions with C. difficile should have their rooms terminally cleaned with a chlorine containing solution. (As of 7/07 product in use is Bru-Clean tablet which contains sodium dichloroisocyanurate. One tablet in one gallon of water at room temp prepared daily makes a solution of 973 PPM or the equivalent of 1:50 water : bleach solution.)
- Nursing should remove all linen from the room and discard single-use supplies. (For this reason it is important to minimize the supplies taken into the room.)
- Nursing staff should clean and disinfect re-usable patient equipment and remove it from the room, unless it is to be stored in the room.
- All equipment should be cleaned with soap and water or a detergent to remove all visible dirt, grease and body fluids. When visibly clean, a disinfectant should be wiped onto the surface and allowed to air dry.
- Equipment that is cleaned on the floors should be cleaned before it is taken out of the Contact Precautions room. Removing the equipment before housekeeping cleans makes it easier for them to clean the room.
Table A: Type And Duration Of Isolation Precautions For Selected Infections And Conditions (196k pdf*)
Infection Control Surveillance and Clearance Culture Request (need link to this or copy for website)
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