Should two unrelated individuals with cystic fibrosis (CF) avoid close contact, defined as being within 6 feet of each other?

Infection Control Distance Requirements for Cystic Fibrosis Patients

Yes, it is true that two unrelated individuals with cystic fibrosis should maintain a distance of at least 6 feet (approximately 2 meters) from each other, though the original recommendation was 3 feet and evidence suggests even greater distances may be necessary.

The Evidence-Based Recommendation

The American Thoracic Society/European Respiratory Society guidelines explicitly state that people with CF should maintain a distance of at least 3 feet from all others with CF when in outpatient clinic settings, given the potential risk of cross-infection with antibiotic-resistant bacteria 1. However, the Cystic Fibrosis Foundation has since strengthened these recommendations to minimize person-to-person transmission of infectious agents by segregating patients from each other 2.

Why This Distance Matters

The rationale for maintaining distance between CF patients is based on documented person-to-person transmission of dangerous respiratory pathogens:

• Pseudomonas aeruginosa transmission has been well-documented between individuals with CF who are cared for at the same center 2
• Mycobacterium abscessus complex shows frequent transmission between CF patients despite conventional infection control measures, confirmed by whole-genome sequencing studies 1, 3
• The Wisconsin Randomized Controlled Trial demonstrated that children with CF who were not isolated from other CF patients acquired P. aeruginosa at a median age of 1.0 years, compared to 5.6 years for those who were isolated 2

The 6-Foot Distance May Not Be Sufficient

Research evidence suggests that even the commonly recommended distances may be inadequate:

• A 2010 study examining 336 samples from 42 CF patients found that transmission of P. aeruginosa beyond 1 meter (approximately 3 feet) is possible during both talking and coughing, with a probability of 1.7% 4
• This finding challenges the universal recommendation of maintaining only 1 meter distance and supports the need for greater separation 4

Practical Implementation

In Healthcare Settings

• The Cystic Fibrosis Foundation recommends implementation of standard infection prevention and control guidelines in healthcare settings where there is high likelihood of close contact between multiple people with CF 2
• Local infection control policies may preclude participation of people with CF in standard group-based pulmonary rehabilitation programs 1

During Exercise and Rehabilitation

• When CF patients participate in exercise programs, they should exercise at stations a few feet apart from other participants to avoid cross-contamination with bacterial pathogens that may be antibiotic-resistant 1
• Patients and staff members must pay close attention to hygiene techniques during any shared activities 1

Additional Protective Measures

Distance alone is not sufficient—comprehensive infection control requires multiple strategies:

• Standard hand hygiene and cough etiquette should be practiced with all contacts 2
• CF patients should be educated to contain their secretions even if culture results are unavailable or negative 5
• Neither antibiotic therapy nor mask-wearing alone adequately prevents cross-infection between CF patients 2
• Environmental reservoirs including nebulizers, medical equipment, sinks, and toilets should be decontaminated as they can harbor P. aeruginosa 2

Critical Caveat

The evidence quality supporting these distance recommendations is low to very low 6, 7. Most studies are observational, retrospective, or "before-after" designs rather than randomized controlled trials 8. However, undertaking high-quality randomized controlled trials in this area is ethically difficult given the potential harm from allowing close contact 6, 7. Despite the low quality of evidence, the abundance of observational data consistently suggests that segregation is beneficial in reducing pathogen spread 7.

Bottom Line for Clinical Practice

The 6-foot distance recommendation represents a conservative approach to minimize cross-infection risk between CF patients, particularly for transmission of P. aeruginosa and M. abscessus complex 1, 2, 3. This distance should be maintained in all settings where CF patients might encounter each other, including clinics, hospitals, and community events 1, 2.