Infection control and isolation precautions: a nursing reference guide

Healthcare-associated infections (HAIs) affect roughly 1 in 38 hospitalized patients in the United States on any given day, based on the CDC Emerging Infections Program point-prevalence survey of 218 acute care hospitals conducted in 2023 and published in 2026. That works out to an estimated 518,000 HAIs in US acute care hospitals in a single year, and it represents real progress: the same survey found patients in 2023 were about 27% less likely to have an HAI than in 2015, when the figure was 1 in 31. Nurses are the primary line of defense: you implement precautions, enforce hand hygiene, don and doff PPE correctly, and educate patients and families every shift. Infection control knowledge is not optional background information – it is an active clinical skill tested on NCLEX, evaluated by Joint Commission, and directly tied to patient survival.

This reference covers every tier of the CDC precaution hierarchy: standard precautions that apply to all patients, and the three categories of transmission-based precautions used when standard precautions alone are insufficient. It includes PPE selection tables, the hand hygiene algorithm, the critical C. diff and norovirus exception to alcohol-based hand rub, and focused NCLEX tips on the most-tested confusions. Use alongside the MRSA nursing reference, C. diff nursing reference, and tuberculosis nursing reference for disease-specific detail.

Types of isolation precautions at a glance

Standard precautions: the foundation of infection control

Standard precautions are the baseline tier of CDC infection control guidance, established by the Healthcare Infection Control Practices Advisory Committee (HICPAC). They apply to every patient, every encounter, regardless of diagnosis or perceived infection risk. This is the single most important concept in infection control nursing – standard precautions are not triggered by a positive test result. They are the default.

Standard precautions treat blood, all body fluids (except sweat), non-intact skin, and mucous membranes as potentially infectious for bloodborne pathogens and other microorganisms. The OSHA Bloodborne Pathogens Standard (29 CFR 1910.1030) provides the regulatory framework governing exposure risk to HIV, hepatitis B, and hepatitis C.

Bloodborne infections need Standard Precautions only. CDC Appendix A lists Standard Precautions, with no added transmission-based tier, for HIV and for hepatitis B (acute or chronic), C, D and G. Bleeding or wound drainage is handled through the task-based gloves, gown and face protection of Standard Precautions. Hemodialysis units are the exception for hepatitis B: CDC dialysis recommendations call for HBsAg-positive patients to be dialyzed in a separate room on dedicated machines, equipment and supplies, by staff who are not caring for susceptible patients at the same time. Patients with hepatitis C or HIV do not need isolation or dedicated machines.

Components of standard precautions

Hand hygiene is the single most effective infection control intervention. See the dedicated section below for full detail on timing and product selection.

Personal protective equipment (PPE): Selection is task-based. Gloves are worn whenever contact with blood, body fluids, mucous membranes, or non-intact skin is anticipated. Gowns are worn when clothing or skin contamination with blood or body fluids is likely (wound irrigation, suctioning, surgical procedures). Masks and eye protection (face shield or goggles) are worn when splash or spray of blood or body fluids to the face is possible.

Respiratory hygiene and cough etiquette: Covers the mouth and nose when coughing or sneezing, uses tissues followed by hand hygiene, and offers masks to symptomatic patients in waiting areas. This element of standard precautions was added after the 2003 SARS epidemic.

Safe injection practices: Use a sterile, single-use needle and syringe for each injection. Never recap needles using two hands. Dispose of sharps immediately in a puncture-resistant sharps container. Never use single-dose vials for multiple patients.

Environmental cleaning: High-touch surfaces (bedrails, call lights, IV pumps, doorknobs) require routine cleaning and disinfection between patients and during patient stays. Products must be EPA-registered disinfectants with labeled activity against the target organism.

Sharps safety: Activate safety devices after use. Use needleless IV systems where available. Report all sharps injuries immediately per institutional protocol. Occupational post-exposure prophylaxis (PEP) for HIV should start as soon as possible, up to 72 hours after exposure; if PEP is being considered later than 72 hours after a high-risk exposure, consult an HIV expert (2025 US Public Health Service occupational guideline). Hepatitis C has no PEP; exposed staff get baseline and follow-up testing instead.

Patient placement: When a patient’s hygiene or behavior increases transmission risk (e.g., uncontained secretions, inability to follow respiratory hygiene), private room placement is preferred even under standard precautions alone.

Transmission-based precautions

Transmission-based precautions are layered on top of standard precautions when a patient is known or suspected to have an infection that requires additional protective measures. The three categories – contact, droplet, and airborne – correspond to the routes by which specific pathogens spread.

A note on the 5-micron cutoff. The droplet-versus-airborne distinction used throughout this reference, and throughout the 2007 CDC HICPAC isolation guideline, rests on a 5-micron particle-size threshold. In April 2024 the WHO, together with the CDC, ECDC and other agencies, published updated terminology that abandons this dichotomy: infectious respiratory particles are now understood to exist on a continuous size spectrum with no single valid cutoff, grouped under the umbrella term “transmission through the air.” US isolation practice, hospital policy, and NCLEX questions still run on the 2007 contact/droplet/airborne categories, so learn them as written here. Expect the underlying language to shift as guidelines are revised.

Contact precautions

Contact precautions are used when the pathogen spreads through direct contact with the patient or indirect contact with contaminated surfaces and equipment. They are the most commonly used transmission-based precaution in hospital settings.

Indications for contact precautions:

PPE required: Gown and gloves on room entry – before touching the patient or any surface in the room (2007 guideline V.B.3, Category IB). Remove the gown and perform hand hygiene before leaving the patient-care environment. Gloves are changed after contact with infectious material and before touching clean surfaces within the room.

Room setup: Single-patient room is preferred. When single rooms are unavailable, cohorting (grouping patients with the same organism) is acceptable. Signage must be posted outside the door.

Dedicated equipment: Use disposable noncritical equipment (such as blood pressure cuffs) or keep stethoscope, cuff, and thermometer dedicated to the patient. If common use is unavoidable, clean and disinfect the item before it is used on another patient (V.B.5.b, Category IB).

Room cleaning: Rooms of patients on contact precautions are prioritized for frequent cleaning and disinfection, at least daily, focused on high-touch surfaces such as bed rails, the overbed table, the bedside commode, bathroom surfaces, and doorknobs (V.B.6, Category IB). Use an EPA-registered disinfectant with label activity against the target organism; C. diff needs a sporicidal product.

Patient transport: Limit transport to medically essential movement. When the patient must leave the room, cover wounds and lesions. Remove and discard contaminated PPE and perform hand hygiene before transport, then put on clean PPE to handle the patient at the destination (V.B.4). Notify the receiving department in advance so they can prepare. The patient should perform hand hygiene before leaving the room.

Nursing homes: CDC uses Enhanced Barrier Precautions (EBP) for residents with MDRO infection or colonization, wounds, or indwelling devices such as central lines, urinary catheters, feeding tubes and tracheostomies. EBP means gown and gloves during high-contact care (dressing, bathing, transfers, hygiene, linen and brief changes, device care, wound care) without restricting the resident to the room. Contact Precautions are used instead when an MDRO resident has acute diarrhea, draining wounds or uncontained secretions, during an outbreak investigation, or for Appendix A conditions such as C. diff, norovirus and scabies.

Discontinuing precautions: Criteria vary by pathogen and institution. For MRSA, the 2006 CDC HICPAC MDRO guideline calls discontinuation an unresolved issue and suggests it is reasonable to stop precautions when three or more surveillance cultures are repeatedly negative over a week or two in a patient who has not received antimicrobial therapy for several weeks, especially with no draining wound or profuse respiratory secretions. The SHEA/IDSA/APIC 2022 MRSA update still calls the duration unresolved and points to the 2018 SHEA expert guidance (Banach), which advises a written facility policy, notes that 1–3 negative cultures are often used in patients off anti-MRSA therapy, and says the best sampling site, including the role of extra-nasal sites, is unclear. That guidance keeps contact precautions for ESBL or CRE carriers for the index stay and asks for at least 6 months since the last positive culture plus 2 or more negative rectal swabs a week apart before stopping; carbapenemase-producing CRE may warrant indefinite precautions. Follow your institution’s protocol rather than a single remembered number. For C. diff, CDC Appendix A lists contact precautions for the duration of illness; IDSA/SHEA 2017 suggests continuing them for at least 48 hours after diarrhea resolves, and until discharge if CDI rates stay high despite standard measures (both weak recommendations, low-quality evidence). The general 2007 rule (V.B.7) is to discontinue contact precautions once signs and symptoms resolve or according to the pathogen-specific Appendix A entry.

Droplet precautions

Droplet precautions apply to pathogens that spread via respiratory droplets larger than 5 microns generated during coughing, sneezing, talking, or procedures such as suctioning. These droplets travel short distances and do not remain suspended in the air the way aerosols do. The CDC 2007 isolation guideline notes that the risk zone was historically defined as 3 feet or less around the patient, but smallpox experiments and SARS investigations found droplets reaching people 6 feet or more away, so 3 feet is an example of “a short distance” and should not be the sole trigger for masking.

Indications for droplet precautions:

PPE required: The healthcare worker puts on a surgical mask on entry to the patient’s room (CDC 2007 isolation guideline, recommendation V.C.3.a). Older teaching used a 3-foot rule, and the guideline replaced it with room entry. Eye protection is added when splash or spray is anticipated. A gown is added when direct contact with the patient is expected.

Spatial considerations: The patient should be placed in a single room when available. The door may remain open – negative pressure is not required for droplet precautions. If a single room is not available, keep patients more than 3 feet apart and draw the privacy curtain between beds (recommendation V.C.2.a.iv). A mask should be placed on the patient during transport.

Airborne precautions

Airborne precautions are required when pathogens are transmitted via droplet nuclei – particles of 5 microns or smaller that can remain suspended in the air for extended periods and travel significant distances on air currents. Standard surgical masks are not protective against airborne pathogens.

Indications for airborne precautions:

Room requirements: In acute care and long-term care, patients on airborne precautions go in an airborne infection isolation room (AIIR) (Siegel V.D.2.a). Key specifications per CDC:

• Negative air pressure relative to the corridor (air flows into the room, not out)
• At least 12 air changes per hour for new construction or renovation; a minimum of 6 is accepted for older existing rooms (CDC 2005 TB guideline; CDC measles guidance)
• Pressure differential of at least 0.01 inch of water gauge relative to the corridor, checked with smoke tubes or another visual check before occupancy and daily while the room is occupied
• After the patient leaves, keep the room empty long enough to clear the air: 35 minutes for 99.9% removal at 12 ACH and 69 minutes at 6 ACH (CDC 2005, Table 1). CDC measles guidance allows up to 2 hours
• Dedicated exhaust to the outdoors or HEPA filtration of recirculated air
• Door kept closed except when needed for entry and exit (Siegel V.D.2.a.iv)
• If no AIIR is available, transfer the patient to a facility that has one (V.D.2.b); in an outbreak with many airborne patients, infection control may approve cohorting with temporary negative-pressure solutions (V.D.2.c)

PPE required: A fit-tested N95 respirator (or higher – PAPR or elastomeric half-face respirator). Standard surgical masks do not filter particles to the required level. Healthcare workers must be fit-tested for the specific N95 model and size they use, before first use and at least annually (OSHA 29 CFR 1910.134), and must perform a user seal check every time they put it on. For measles, CDC asks every HCW to wear an N95 or higher on room entry even with presumptive evidence of immunity. For varicella, CDC makes no recommendation on respiratory protection for immune HCWs, so follow facility policy (most require an N95). For both, HCWs without evidence of immunity should not enter the room if immune caregivers are available.

Patient transport: Limit transport to medically necessary purposes. The patient wears a surgical mask if possible, and varicella, smallpox or draining TB skin lesions are covered; staff transporting a masked patient with covered lesions do not need a mask or respirator (Siegel V.D.5). The destination department must be notified in advance. Procedures on airborne-precaution patients should be performed in the AIIR or, if the patient must leave, in a room with equivalent ventilation.

PPE selection guide

Hand hygiene

Hand hygiene is the most evidence-based, highest-impact infection control intervention available to nurses. The WHO “Five Moments of Hand Hygiene” framework, adopted by the CDC and Joint Commission, defines the five critical junctures:

1. Before touching a patient
2. Before a clean or aseptic procedure (e.g., inserting an IV, drawing blood cultures, accessing a central line)
3. After exposure risk – after contact with blood, body fluids, mucous membranes, or non-intact skin
4. After touching a patient
5. After touching patient surroundings – even if you did not touch the patient directly

Alcohol-based hand rub vs. soap and water

Alcohol-based hand rub (ABHR) – ethanol or isopropanol-based gel or foam – is the preferred hand hygiene method in most clinical situations. It is faster than soap and water, causes less skin irritation with repeated use, and achieves greater log reduction against most healthcare pathogens within 15–30 seconds of correct technique.

However, ABHR does NOT kill spores. This is the most clinically important exception in infection control:

• C. difficile: Produces heat- and alcohol-resistant endospores. ABHR does not eliminate C. diff spores. Soap and water is the preferred method after C. diff care – the mechanical friction of lathering and rinsing physically removes spores from the hands. Gloves and gowns are the primary protection: IDSA/SHEA 2017 accepts either method in routine settings and prefers soap and water during outbreaks, in hyperendemic settings, and after contact with feces, and CDC’s healthcare guidance encourages soap and water during C. diff outbreaks. Many facilities require it for every C. diff room, and it is the NCLEX answer.
• Norovirus: Has an alcohol-resistant non-enveloped capsid. ABHR is significantly less effective; soap and water is preferred, especially after direct patient contact or contact with contaminated surfaces.

When to use soap and water:

• After caring for a patient on C. diff contact precautions (preferred; expected during outbreaks and after fecal contact, and required by many facility policies)
• After caring for a patient with known or suspected norovirus
• When hands are visibly soiled or contaminated with blood or body fluids
• Before eating, after using the restroom

Correct ABHR technique: apply enough product to cover all surfaces of both hands, rub together for 20–30 seconds until hands are dry. Do not wipe off – allow to air dry completely.

Correct soap and water technique: wet hands, apply soap, lather and scrub for at least 20 seconds covering all surfaces including fingertips and between fingers, rinse thoroughly, dry with a single-use towel, use the towel to turn off the faucet.

NCLEX tips and common confusions

Infection control consistently appears on NCLEX-RN and NCLEX-PN. The following areas produce the most wrong answers.

The TB vs. droplet confusion

Tuberculosis requires airborne precautions – not droplet. This is the most common wrong answer on NCLEX isolation questions. TB (Mycobacterium tuberculosis) is transmitted via droplet nuclei that are small enough to remain suspended in air and travel beyond 6 feet. A surgical mask does not provide protection. An N95 fit-tested respirator is required. The patient requires an AIIR with negative pressure.

Meningitis caused by Neisseria meningitidis requires droplet precautions (surgical mask), not airborne. Students frequently confuse these two because both are serious infections – but the transmission routes are completely different.

The C. diff ABHR exception

NCLEX frequently tests this: alcohol-based hand rub does not kill C. diff spores. When the question stem describes a patient with C. diff or contact precautions for C. diff, the correct hand hygiene answer is soap and water. The same applies to norovirus, though C. diff appears more frequently.

Standard precautions are always active

Standard precautions apply to all patients, including those with no known infection. NCLEX questions sometimes ask about a patient with no listed diagnosis – the correct answer still includes standard precautions. Transmission-based precautions are added on top, not instead.

Varicella requires two precaution types

Active varicella (chickenpox) and disseminated herpes zoster require both airborne AND contact precautions. Students often select only airborne (because the virus is airborne-transmitted) and miss the contact component for skin lesions. Both types must be in place simultaneously.

PPE donning and doffing order

NCLEX tests the correct sequence. Donning order: gown first, then mask/respirator, then eye protection, then gloves. Doffing order (most contaminated items removed first): gloves first, then eye protection, then gown, then mask/respirator. Hand hygiene is performed after removing gloves and again after all PPE is removed.

When to discontinue airborne precautions for TB

CDC Appendix A and the CDC 2005 TB guideline separate suspected from confirmed TB:

• Suspected TB: precautions can stop when infectious TB is considered unlikely AND either another diagnosis explains the illness OR three sputum AFB smears are negative. The three specimens are collected 8–24 hours apart, with at least one early-morning specimen.
• Confirmed TB: Appendix A says to stop only when the patient is improving clinically on effective therapy and has 3 consecutive AFB-negative sputum smears collected on separate days. The CDC 2005 TB guideline sets a fuller hospital rule for patients whose culture and susceptibility results are not yet known: 3 consecutive negative smears collected 8–24 hours apart (one early morning), at least 2 weeks of standard multidrug therapy, and clinical improvement. Most hospital policies follow the 2005 rule.

Negative smears alone are not automatically sufficient – clinical judgment is required. A single negative smear is not enough to discontinue precautions.

References

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2. Chea N, Li R, Eure T, et al. Health Care–Associated Infections in U.S. Hospitals, 2023 versus 2015. N Engl J Med. 2026;395(3):255–266. doi:10.1056/NEJMoa2510881

3. World Health Organization. WHO Guidelines on Hand Hygiene in Health Care. Geneva: WHO; 2009.

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8. Rutala WA, Weber DJ, Healthcare Infection Control Practices Advisory Committee. Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008. Atlanta, GA: CDC; 2008.

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12. Septimus EJ, Schweizer ML. Decolonization in prevention of health care-associated infections. Clin Microbiol Rev. 2016;29(2):201–222. doi:10.1128/CMR.00049-15

13. Weber DJ, Anderson D, Rutala WA. The role of the surface environment in healthcare-associated infections. Curr Opin Infect Dis. 2013;26(4):338–344. doi:10.1097/QCO.0b013e3283630f04

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Related references

For disease-specific infection control detail, see the dedicated reference pages on this site:

• MRSA nursing reference – contact precaution management, vancomycin monitoring, decolonization
• C. diff nursing reference – severity classification, IDSA treatment guidelines, the soap-and-water rule
• Tuberculosis nursing reference – RIPE regimen, DOT, AFB smear interpretation, airborne isolation management
• COVID-19 nursing reference – PPE guidance, aerosol-generating procedure definitions, current precaution tiers
• Influenza nursing reference – droplet precaution timing, antiviral therapy, chemoprophylaxis
• Sepsis nursing reference – HAI as a leading cause of sepsis, source control, 1-hour bundle
• Wound assessment guide – systematic assessment of wounds requiring contact precautions
• Vital signs by age – fever thresholds that trigger infection workup across age groups