What contact precautions should be in place for patients with suspected mycobacterial infections?

Contact Precautions for Patients with Suspected Mycobacterial Infections

For patients with suspected mycobacterial infections, standard precautions plus airborne precautions should be implemented, including isolation in a negative pressure room, use of N95 respirators by healthcare workers, and patient education on respiratory hygiene. 1

Types of Precautions Required

Airborne Precautions

• Place patient in a negative pressure isolation room with air exhausted directly outside 1
• Ensure room has at least 12 air changes per hour 1
• Keep doors closed except when entering or leaving the room
• Healthcare workers must wear N95 respirators or higher-level respiratory protection when entering the room 1
• Limit patient transport outside the room to medically essential purposes 1
• If transport is necessary, place a surgical mask on the patient 1

Standard Precautions

• Hand hygiene before and after all patient contact 1
• Use of gloves, gowns, and eye protection based on anticipated exposure 1
• Safe handling and disposal of sharps and contaminated materials
• Proper cleaning and disinfection of equipment and environment

Special Considerations by Mycobacterial Type

For M. tuberculosis

• Maintain airborne precautions until patient has:
  • Received effective therapy for at least 2-3 weeks
  • Demonstrated clinical improvement
  • Has three consecutive negative sputum smears collected on different days 1
• Enhanced ventilation or air-disinfection techniques (HEPA filters or UV germicidal lamps) may be appropriate in waiting areas 1

For Non-tuberculous Mycobacteria (e.g., M. abscessus)

• Standard precautions are generally sufficient 2
• Additional droplet precautions during cough-inducing procedures 2
• Airborne isolation rooms designed for tuberculosis are generally unnecessary and waste resources 2

Setting-Specific Considerations

Hospital Inpatient Settings

• Implement contact isolation precautions for patients with multidrug-resistant organisms 1
• Ensure proper signage to alert staff and visitors about required precautions 1
• Limit visitors and provide them with appropriate protective equipment 1

Outpatient Settings

• Instruct patients with pulmonary symptoms to cover their mouths and noses when coughing or sneezing 1
• Minimize time spent in common waiting areas 1
• Train front-desk personnel to identify patients with symptoms suggestive of tuberculosis 1

Emergency Medical Services

• When transporting patients with suspected TB:
  • Place a surgical mask on the patient 1
  • EMS personnel should wear respiratory protection 1
  • Keep vehicle windows open if possible 1
  • Set heating and air conditioning on non-recirculating cycle 1

Home Healthcare Settings

• For home visits to patients with suspected TB:
  • Instruct patients to cover coughs and sneezes 1
  • Wear appropriate respiratory protection when entering the home 1
  • Perform cough-inducing procedures in well-ventilated areas away from household members 1
  • Consider temporary relocation of immunocompromised persons or young children living in the home 1

Implementation Challenges and Solutions

Compliance Challenges

• Compliance with all components of contact precautions is often low (28.9%) 3
• Compliance decreases as the proportion of isolated patients increases 3
• When more than 40% of patients require isolation, this represents a tipping point for noncompliance 3

Solutions

• Provide clear, unambiguous guidelines that align with national standards 4
• Ensure adequate training on infection control procedures and proper use of PPE 4
• Maintain sufficient supplies of appropriate PPE 4
• Engage management support and foster a culture of safety 4
• Include all staff (including cleaning staff, porters, and support staff) in training and implementation 4

Equipment Disinfection

• For bronchoscopes used on patients with mycobacterial infections:
  • Thorough cleaning with detergent is the most important initial stage 1
  • For M. tuberculosis, immersion in 2% glutaraldehyde for 20 minutes is recommended 1
  • For atypical mycobacteria, longer immersion times of 60 minutes are recommended 1
  • Patients with suspected tuberculosis should undergo bronchoscopy at the end of the list 1

By implementing these comprehensive precautions, healthcare facilities can effectively reduce the risk of mycobacterial transmission while providing appropriate care to affected patients.