A 65-year-old man with dementia is transferred to the hospital from an assisted living facility due to low-grade fever and altered mental status. The patient was discharged 6 weeks ago following treatment for community-acquired pneumonia. Temperature is 37.2 C (99 F), blood pressure is 104/80 mm Hg, pulse is 94/min, and respirations are 14/min. On physical examination, the patient is alert and oriented to self only. The lungs are clear bilaterally with equal breath sounds. The patient winces and appears uncomfortable upon palpation of the suprapubic region and costovertebral angle. Blood cultures are negative. After the patient is admitted, urine cultures from samples obtained at admission show extended-spectrum beta-lactamase–producing Klebsiella pneumoniae. The hospital has recently experienced multiple outbreaks associated with this organism. Which of the following isolation precautions is required for this patient?
Infection control: isolation precautions | ||
Type | Pathogen* | Key requirements |
Airborne |
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Contact |
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Droplet |
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Standard |
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*Precaution is started immediately when infection with pathogen is suspected. COVID-19 = coronavirus disease 2019; ESBL = extended-spectrum beta-lactamase; MRSA = methicillin-resistant Staphylococcus aureus; RSV = respiratory syncytial virus; VRE = vancomycin-resistant Enterococcus; VZV = varicella-zoster virus. | ||
Extended-spectrum beta-lactamase (ESBL) is an enzyme that confers bacterial resistance to most beta-lactam antibiotics (eg, penicillins, cephalosporins). ESBL-producing bacteria (eg, Enterobacteriaceae species, Klebsiella) are an important cause of potentially serious infections and outbreaks in health care settings (as seen in this hospital); community spread is also a growing concern. This patient with ESBL-producing Klebsiella pneumoniae infection has several risk factors for infection, including health care exposure (eg, assisted living facility, recent hospitalization) and antibiotic use (treatment for pneumonia).
ESBL-producing organisms colonize the gastrointestinal tract and environmental surfaces (eg, sinks, catheters). Therefore, contact precautions for colonized or infected patients are required to minimize transmission, especially in settings experiencing a higher-than-average infection rate or an outbreak. Contact precautions require use of gowns and gloves when interacting with the patient; single-use equipment (eg, stethoscope) is preferred. Precautions should be followed for the duration of the patient's hospital stay (Choice D).
(Choices A and E) Droplet precautions (eg, for influenza virus) include use of a surgical mask when in close proximity to the patient (eg, 1-2 m) to prevent transmission of infectious respiratory droplets that are suspended in air for limited periods and distances. Airborne precautions (eg, for tuberculosis) include use of a certified N95 respirator in the patient's room (regardless of distance from the patient) and negative pressure room ventilation (which requires that the door always remain closed) to prevent transmission of microscopic (eg, <5 microns) respiratory particles that remain suspended in air for longer periods and distances. ESBL-producing organisms spread primarily through surface contact, not respiratory droplets, so these interventions are not required.
(Choice B) Outside the intensive care unit setting, decolonization of drug-resistant bacteria (eg, with chlorhexidine rinses) is not currently recommended to reduce transmission risk.
Educational objective:
Hospitalized patients who have infections caused by multidrug-resistant gram-negative organisms (eg, extended-spectrum beta-lactamase–producing Klebsiella pneumoniae) require contact precautions for the duration of their hospital stays. Contact precautions include use of gowns and gloves when interacting with the patient and single-use equipment (eg, stethoscope).