Summary of Content: Infection Control Precautions for the Infectious Patient

Modes of transmission

Type of precautions

Healthcare workers donning of PPE

Healthcare workers doffing of PPE

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Non-emergency cases should be postponed until the patient is deemed to no longer be infectious. Precautions should be based on the mode of transmission of the specific microorganism.

Modes of transmission

Direct contact

• Physical contact with patient and body fluid, soil or vegetation.
• Droplet spread:
  • Large particles > 5 µm.
  • Short distance spread usually within one meter but can be further as has been demonstrated with smallpox and SARS viruses.
  • Airway instrumentation such as intubation, suctioning and extubation.
  • Sneezing, coughing, singing.

Indirect contact

• Airborne/aerosol spread:
  • Particles are less than 5 µm.
  • Remains suspended in air for prolonged periods.
  • Spread over large area and possibly further than physical barriers such as rooms or operating theatres.
    • Can be deposited on environmental surfaces. Depending on the type of surface, it can remain viable for a couple of hours or up to a couple of days.
  • Airway instrumentation such as intubation, suctioning and extubation.
• Vehicle spread:
  • Contaminated hands.
  • Inanimate objects such as laryngoscopes, pens, cell phones.
• Vector spread:
  • E.g. flies and mosquitoes.

Type of precautions

Standard precautions

• Keep to all the standard precautions discussed in this document.
• Healthcare workers should have documented immunity to hepatitis B virus.

Contact precautions

• Standard precautions as above.
• Adhere to hand hygiene standards.
• Isolation cubicle until no longer infectious.
• Use PPE including a gown.
• Remove PPE before leaving the immediate environment of the patient.
• Take care not to self-contaminate when removing PPE.
• Maintain contact precautions throughout the entire perioperative period.
• Appropriate environmental decontamination of the operating theatre at the end of the case.

Droplet precautions

• Standard precautions as above.
• Adhere to hand hygiene standards.
• Ideally, to be isolated. If isolation not available, keep patient at least one meter from any other patients.
• Educate patients on respiratory hygiene, e.g. coughing and sneezing etiquette.
• Patient to wear a standard face mask when outside the isolation area.
• Healthcare workers must use standard PPE.
• Maintain these precautions throughout the entire perioperative period.

Airborne precautions

• Standard precautions as above.
• Adhere to hand hygiene standards.
• Patient should be in an airborne isolation room.
• Patient should remain in the isolation room except for medical/ surgical procedures that require the patient to leave the room.
• Any non-emergency case should be postponed until the patient no longer needs respiratory isolation.
• Patient to wear a standard face mask when outside the isolation area.

Healthcare workers donning of PPE

• Remove jewellery and any other personal items.
• Empty pockets.
• Tie hair back and cover all hair.
• Perform hand hygiene and don disposable apron.
• Perform hand hygiene and change shoes or apply overshoes.
• Perform hand hygiene and don first pair of gloves.
• Hand hygiene and don an impermeable disposable gown or coverall.
  • Ensure that gown covers area from neck to knees, arms to the end of wrists and wrapped around the back.
  • Tie behind with a simple knot that can be easily untied.
• Perform hand hygiene and don respiratory protection.
  • Use N95 or higher mask/respirator.
  • Secure ties at middle of head and neck.
  • Fit flexible nose piece over the bridge of the nose.
  • Fit snuggly to face and chin.
  • Perform fit test: Mask collapses inward on inspiration and expands without a leak on exhalation.
• Hand hygiene and don goggles.
• Hand hygiene and don head cover, balaclava. Ensure that the sides of the goggles, the ears and nape of neck are covered. Ideally, the neck should be covered as well.
• Hand hygiene and don second pair of gloves. Extend to cover wrist. No skin should be exposed.
• Hand hygiene and don face shield.

Healthcare workers doffing of PPE

• Careful doffing is extremely important to prevent contamination.
• Perform hand hygiene on outer pair of gloves.
• Remove gown (Remember that the front of the gown and the arms are the most contaminated areas). Undo ties and carefully pull the gown down from neck and shoulders. Turn gown inside out.
• Outside gloves are removed with the gown as it reaches the wrist and hands.
• Carefully roll the gown with inside facing outwards into a bundle and discard.
• Perform hand hygiene on inner gloves using alcohol sanitiser.
• Remove face shield (remember that front is contaminated).
• Take off head covering – grasp from behind and carefully lift from the back of the head and into waste packet.
• Perform hand hygiene on inner gloves with alcohol sanitiser.
• Carefully remove goggles.
• Hand hygiene.
• Remove overshoes.
• Hand hygiene.
• Exit doffing area and then remove N95 mask/respirator.
• Hand hygiene.
• Remove inner pair of gloves.
• Maintain these precautions throughout the entire perioperative period.

Table V: Precautions for common pathogens

Pathogen	Level of precautions
HIV	Standard, post-exposure prophylaxis
Hepatitis (viral)	Standard precautions
Human Papilloma Virus (HPV)	Standard, droplet and airborne if plume from cauterisation of airway papillomas or genital warts are present
Mycobacterium tuberculosis	Standard and airborne precautions
Multidrug-resistant organisms Meticillin resistant Staphylococcus Aureus (MRSA) Vancomycin-resistant enterococci (VRE) Extended spectrum beta lactamase-producing organisms (ESBL)	Standard and contact precautions
Neisseria	Standard and droplet precautions
Clostridium difficile	Standard and contract precautions
Haemophilus influenza	Standard and droplet precautions
Influenza	Standard and airborne precautions
Coronaviruses	Standard, droplet and airborne precautions

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South African Society of Anaesthesiologists (SASA) Guidelines for Infection Control and Prevention in Anaesthesia in South Africa 2021