The Healthcare Infection Control Practices Advisory Committee (HICPAC) is a federal advisory committee chartered in 1991 to provide advice and guidance to the Centers for Disease Control and Prevention (CDC) and the Secretary of the Department of Health and Human Services (HHS) regarding the practice of infection control and strategies for surveillance, prevention, and control of healthcare-associated infections, antimicrobial resistance and related events in United States healthcare settings. CDC has been developing recommendations for healthcare infection control to prevent infections in patients and healthcare personnel since the 1970’s. These recommendations continue to evolve over time as evidence bases are built and serve as a foundation for healthcare safety across settings, a basis for quality improvement efforts, and part of the process that identifies important research gaps. Guideline development methods have since moved beyond expert opinion alone and incorporated systematic approaches to evidence analysis. A number of core practices are recommended by CDC and considered standards of care and/or accepted practices (e.g., aseptic technique, hand hygiene before patient contact) to prevent infection in healthcare settings. These widely agreed upon practices are elements of care that are not expected to change based on additional research, either because of an overwhelming preponderance of evidence (e.g., hand hygiene requirements), or in some cases due to ethical concerns (e.g., randomizing patients to procedures performed by trained versus untrained personnel). Therefore, these accepted practices are categorized as strong recommendations, even when high-quality randomized controlled trials are not available to support them. In an effort to streamline and systematize the process for updating existing guidelines without recreating the analytic process for each of these accepted/core practices, in March 2013, CDC charged HICPAC to review existing CDC guidelines and identify all recommendations that warrant inclusion as core practices. A HICPAC workgroup was formed that was led by HICPAC members and contained representatives from the following stakeholder organizations: America’s Essential Hospitals, the Association for Professionals in Infection Control and Epidemiology (APIC), the Council of State and Territorial Epidemiologists (CSTE), the Public Health Agency of Canada (PHAC), the Society for Healthcare Epidemiology of America (SHEA), and the Society of Hospital Medicine (SHM). The Workgroup provided updates and obtained HICPAC input at the June 2013, November 2013, April 2014, and July 2014 public meetings. HICPAC voted to finalize the recommendations at the July 2014 meeting. Additional information about HICPAC is available on this website.
Adherence to infection prevention and control practices is essential to providing safe and high-quality patient care across all settings where healthcare is delivered. Substantial attention has been focused in recent years on improving infection prevention practices within acute care hospitals to optimize patient safety; many of these practices also need to be applied across multiple aspects of patient care. In addition, changes in healthcare during the past decade, driven at least in part by efforts to contain costs, have resulted in an increasing proportion and range of healthcare services being delivered outside of the acute care setting. 1,2 These ambulatory and community-based healthcare encounters also can lead to infectious complications that can be prevented using those same infection prevention and control practices.
This document concisely describes a core set of infection prevention and control practices that are required in all healthcare settings, regardless of the type of healthcare provided. The practices were selected from among existing CDC recommendations and are the subset that HICPAC and its Core Practices Working Group determined were fundamental standards of care that are not expected to change based on emerging evidence or to be regularly altered by changes in technology or practices, and are applicable across the continuum of healthcare settings. This document also is intended to improve consistency of language, reduce redundancy across guidelines, and provide a convenient reference wherein these recommendations are maintained. A review of existing CDC guidelines demonstrated many examples of similar recommendations in multiple guidelines with variability in language. The recommendations outlined in this document are intended to serve as a standard reference and reduce the need to repeatedly evaluate practices that are considered basic and accepted as standards of medical care. Readers are urged to consult the full text of CDC guidelines (see references) for additional background and rationale related to the core practice recommendations captured here.
The core practices in this document should be implemented in all settings where healthcare is delivered. These venues include both inpatient settings (e.g., acute, long-term care, rehabilitation, behavioral health) and outpatient settings (e.g., physician and nurse practitioner offices, clinics, urgent care, ambulatory surgical centers, imaging centers, dialysis centers, physical therapy and rehabilitation centers, alternative medicine clinics). In addition, these practices apply to healthcare delivered in settings other than traditional healthcare facilities, such as homes, pharmacies, and health fairs.
Healthcare personnel (HCP) referred to in this document include all persons, paid and unpaid, in the healthcare setting having direct patient contact and/or potential for exposure to patients and/or to infectious materials (e.g., body substances, used medical supplies and equipment, soiled environmental surfaces). This also includes persons not directly involved in patient care (e.g., clerical staff, environmental services, volunteers) who could be exposed to infectious material in a healthcare setting.
CDC healthcare infection control guidelines 3-19 were reviewed, and recommendations included in more than one guideline were grouped into core infection prevention practice domains (e.g., education and training of HCP on infection prevention, injection and medication safety). Additional CDC materials aimed at providing general infection prevention guidance outside of the acute care setting 20-22 were also reviewed. HICPAC formed a workgroup led by HICPAC members and including representatives of professional organizations (see Contributors for full list). The workgroup reviewed and discussed all of the practices, further refined the selection and description of the core practices, and presented drafts to HICPAC at public meetings in June 2013, November 2013, April 2014, and July 2014 to inform HICPAC’s final recommendations. The recommendations (see Table) were approved by the full Committee in July 2014.
Adherence to basic infection prevention and control practices are essential, not only in acute care hospitals but also in settings with limited infection prevention infrastructure. The frequency of infectious outbreaks stemming from errors in infection control across settings (e.g., reuse of syringes between patients leading to transmission of viral hepatitis 23-25 ) underscores the critical importance of adherence to these core infection prevention practices wherever healthcare is provided. Recommendations highlighted in this document represent minimum expectations, and healthcare personnel and facilities will need to supplement them according to their settings, procedures performed, and patient populations.
Readers should consult the full texts of CDC healthcare infection control guidelines for background, rationale, and related infection prevention recommendations for more comprehensive information. We encourage professional associations and societies and the research community to develop tools to facilitate implementation and maintenance of these core infection prevention practices across the continuum of healthcare.
1. Leadership Support
References and resources: 1-12
2. Education and Training of Healthcare Personnel on Infection Prevention
References and resources: 1-4, 6-8, 10-13
3. Patient, Family and Caregiver Education
References and resources: 2-5, 7-8, 10-11
4. Performance Monitoring and Feedback
References and resources: 1-14
Use Standard Precautions to care for all patients in all settings. Standard Precautions include:
5a. Hand hygiene
5b. Environmental cleaning and disinfection
5c. Injection and medication safety
5d. Risk assessment with use of appropriate personal protective equipment (e.g., gloves, gowns, face masks) based on activities being performed
5e. Minimizing Potential Exposures (e.g. respiratory hygiene and cough etiquette)
5f. Reprocessing of reusable medical equipment between each patient and when soiled
5a. Hand Hygiene
References and resources: 3, 7, 11
Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Hand rubs are generally less irritating to hands and are effective in the absence of a sink.
Refer to “CDC Guideline for Hand Hygiene in Health-Care Settings” or “Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, 2007” for additional details.
5b. Environmental Cleaning and Disinfection
References and resources: 4, 7, 10, 11, 13, 21
When information from manufacturers is limited regarding selection and use of agents for specific microorganisms, environmental surfaces or equipment, facility policies regarding cleaning and disinfecting should be guided by the best available evidence and careful consideration of the risks and benefits of the available options.
Refer to “CDC Guidelines for Environmental Infection Control in Health-Care Facilities” and “CDC Guideline for Disinfection and Sterilization in Healthcare Facilities” for details
5c. Injection and Medication Safety
References and resources: 11, 17-20
5d. Risk Assessment with Appropriate Use of Personal Protective Equipment
References and resources: 7, 11, 20
PPE, e.g., gloves, gowns, face masks, respirators, goggles and face shields, can be effective barriers to transmission of infections but are secondary to the more effective measures such as administrative and engineering controls.
Refer to “Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, 2007” as well as Occupational Safety and Health Administration (OSHA) requirements for details
5e. Minimizing Potential Exposures
References and resources: 1, 7, 11, 16
5f. Reprocessing of Reusable Medical Equipment
References and resources: 2-4, 7-8, 11-13
Manufacturer’s instructions for reprocessing reusable medical equipment should be readily available and used to establish clear operating procedures and training content for the facility. Instructions should be posted at the site where equipment reprocessing is performed. Reprocessing personnel should have training in the reprocessing steps and the correct use of PPE necessary for the task. Competencies of those personnel should be documented initially upon assignment of their duties, whenever new equipment is introduced, and periodically (e.g., annually). Additional details about reprocessing essentials for facilities can be found in HICPAC’s recommendations Essential Elements of a Reprocessing Program for Flexible Endoscopes [PDF – 217 KB].
Refer to “CDC Guideline for Disinfection and Sterilization in Healthcare Facilities” for details.
6. Transmission-Based Precautions
References and resources: 7, 11
Implementation of Transmission-Based Precautions may differ depending on the patient care settings (e.g., inpatient, outpatient, long-term care), the facility design characteristics, and the type of patient interaction, and should be adapted to the specific healthcare setting.
Refer to “Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, 2007” for details.
7. Temporary invasive Medical Devices for Clinical Management
References and resources: 8, 1
Early and prompt removal of invasive devices should be part of the plan of care and included in regular assessment. Healthcare personnel should be knowledgeable regarding risks of the device and infection prevention interventions associated with the individual device, and should advocate for the patient by working toward removal of the device as soon as possible.
Refer to “CDC Guidelines for Environmental Infection Control in Health-Care Facilities” and “CDC Guideline for Disinfection and Sterilization in Healthcare Facilities” for details.
8. Occupational Health
References and resources: 1, 7, 16, 20
It is the professional responsibility of all healthcare organizations and individual personnel to ensure adherence to federal, state and local requirements concerning immunizations; work policies that support safety of healthcare personnel; timely reporting of illness by employees to employers when that illness may represent a risk to patients and other healthcare personnel; and notification to public health authorities when the illness has public health implications or is required to be reported.
Refer to OSHA’s website for specific details on healthcare standards: Occupational Safety and Health Administration – Infectious Diseases.
Healthcare Infection Control Practices Advisory Committee. Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings–Recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) 2017.
Ruth M. Carrico, PhD, RN, CIC, HICPAC Member (Workgroup Chair); Gina Pugliese, RN, MS, HICPAC Member (Workgroup Co-Chair); Deborah S. Yokoe, MD, MPH, HICPAC Member (Workgroup Co-Chair); Loretta L. Fauerbach, MS, CIC; Susan Courage, Public Health Agency of Canada; Kathleen Dunn, BScN, MN, RN, Public Health Agency of Canada; Neil O. Fishman, MD, HICPAC; Silvia Munoz-Price, MD, PhD, America’s Essential Hospitals; Michael Anne Preas, RN CIC, Association of Professionals of Infection Control and Epidemiology, Inc. (APIC); Mark E. Rupp, MD, Society for Healthcare Epidemiology of America (SHEA); Sanjay Saint, MD, MPH, Society of Hospital Medicine (SHM); and Rachel Stricof, MPH, Council of State and Territorial Epidemiologists (CSTE).
Neil O. Fishman, MD, University of Pennsylvania Health System; Hilary M. Babcock, MD, MPH, Washington University School of Medicine; Ruth M. Carrico, PhD, RN, CIC, University of Louisville School of Medicine; Sheri Chernetsky Tejedor, MD, Emory University School of Medicine; Daniel J. Diekema, MD, University of Iowa Carver College of Medicine; Mary K. Hayden, MD, Rush University Medical Center; Susan Huang, MD, MPH; University of California Irvine School of Medicine; W. Charles Huskins, MD, MSc, Mayo Clinic College of Medicine; Lynn Janssen, MS, CIC, CPHQ, California Department of Public Health; Gina Pugliese, RN, MS, Premier Healthcare Alliance; Selwyn O. Rogers Jr., MD, MPH, FACS, The University of Texas Medical Branch; Tom Talbot, MD, MPH, Vanderbilt University Medical Center; Michael L. Tapper, MD, Lenox Hill Hospital; and Deborah S. Yokoe, MD, MPH, Brigham & Women’s Hospital.
William B. Baine, MD, Agency for Healthcare Research and Quality (AHRQ); David Henderson, MD, National Institutes of Health (NIH); Elizabeth Claverie-Williams, MS, U.S. Food and Drug Administration (FDA); Daniel Schwartz, MD, MBA, Center for Medicare and Medicaid Services (CMS); and Gary A. Roselle, MD, Department of Veterans Affairs (VA); Rebecca Wilson, MPH, CHES, Health Resources and Services Administration (HRSA).
Kathleen Dunn, BScN, MN, RN, Public Health Agency of Canada; Janet Franck, RN, MBA, CIC, DNV Healthcare, Inc.; Diana Gaviria, MD, MPH, National Association of County and City Health Officials (NACCHO); Michael D. Howell, MD, MPH, Society of Critical Care Medicine (SCCM); Marion Kainer, MD, MPH, Council of State and Territorial Epidemiologists (CSTE); Emily Lutterloh, MD, MPH, Association of State and Territorial Health Officials (ASTHO); Michael Anne Preas, RN CIC, Association of Professionals of Infection Control and Epidemiology, Inc. (APIC); Mark E. Rupp, MD, Society for Healthcare Epidemiology of America (SHEA); Sanjay Saint, MD, MPH, Society of Hospital Medicine (SHM); Robert G. Sawyer, MD, FACS, FIDSA, FCCM, Surgical Infection Society (SIS); Margaret VanAmringe, MHS, The Joint Commission; and Amber Wood, MSN, RN, CNOR, CIC, CPN, Association of periOperative Registered Nurses (AORN).
Melissa Schaefer, MD; Joseph Perz, DrPH; Michael Bell, MD; Erin Stone, MA; and Jeffrey Hageman, MHS, the Division of Healthcare Quality Promotion (DHQP), the Centers for Disease Control and Prevention.