VETERINARY PRACTICE GUIDELINES

2018 AAHA Infection Control, Prevention, and

Biosecurity Guidelines*
Jason W. Stull, VMD, MPVM, PhD, DACVPMy, Erin Bjorvik, BS, CVT, Joshua Bub, DVM, DABVP (C/F), Glenda
Dvorak, MS, DVM, MPH, DACVPM, Christine Petersen, DVM, PhD, Heather L. Troyer, DVM, DABVP (C/F), CVA,
CVPP

ABSTRACT
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A veterinary team’s best work can be undone by a breach in infection control, prevention, and biosecurity (ICPB). Such a breach, in
the practice or home-care setting, can lead to medical, social, and financial impacts on patients, clients, and staff, as well as damage
Journal of the American Animal Hospital Association 2018.54:297-326.

the reputation of the hospital. To mitigate these negative outcomes, the AAHA ICPB Guidelines Task Force believes that hospital
teams should improve upon their current efforts by limiting pathogen exposure from entering or being transmitted throughout the
hospital population and using surveillance methods to detect any new entry of a pathogen into the practice. To support these
recommendations, these practice-oriented guidelines include step-by-step instructions to upgrade ICPB efforts in any hospital,
including recommendations on the following: establishing an infection control practitioner to coordinate and implement the ICPB
program; developing evidence-based standard operating procedures related to tasks performed frequently by the veterinary team
(hand hygiene, cleaning and disinfection, phone triage, etc.); assessing the facility’s ICPB strengths and areas of improvement;
creating a staff education and training plan; cataloging client education material specific for use in the practice; implementing a
surveillance program; and maintaining a compliance evaluation program. Practices with few or no ICPB protocols should be
encouraged to take small steps. Creating visible evidence that these protocols are consistently implemented within the hospital
will invariably strengthen the loyalties of clients to the hospital as well as deepen the pride the staff have in their roles, both of which
are the basis of successful veterinary practice. (J Am Anim Hosp Assoc 2018; 54:297–326. DOI 10.5326/JAAHA-MS-6903)

AFFILIATIONS * These guidelines were prepared by a task force of experts convened

by AAHA. This document is intended as a guideline only, not an AAHA
From the Department of Veterinary Preventive Medicine, College of Veter-
standard of care. These guidelines and recommendations should not be
inary Medicine, Ohio State University, Columbus, Ohio, and Department of
construed as dictating an exclusive protocol, course of treatment, or
Health Management, Atlantic Veterinary College, the University of Prince
procedure. Variations in practice may be warranted based on the needs
Edward Island, Charlottetown, Prince Edward Island, Canada (J.W.S.); Vet-
of the individual patient, resources, and limitations unique to each indi-
erinary Specialty Center, Buffalo Grove, Illinois (E.B.); Mesa Veterinary Hos-
vidual practice setting. Evidence-based support for specific recommen-
pital, Golden, Colorado (J.B.); Center for Food Security and Public Health,
dations has been cited whenever possible and appropriate. Other
College of Veterinary Medicine, Iowa State University, Ames, Iowa (G.D.);
recommendations are based on practical clinical experience and a con-
Department of Epidemiology and Center for Emerging Infectious Diseases,
sensus of expert opinion. Further research is needed to document some
College of Public Health, University of Iowa, Iowa City, Iowa (C.P.); and
of these recommendations. Because each case is different, veterinar-
Oradell Animal Hospital, Paramus, New Jersey (H.L.T.).
ians must base their decisions on the best available scientific evidence
CONTRIBUTING REVIEWERS in conjunction with their own knowledge and experience.
J. Scott Weese, DVM, DVSc, DACVIM (Department of Pathobiology, On-
These guidelines were supported by a generous educational grant from
tario Veterinary College, University of Guelph, Guelph, Ontario, Canada);
Virox Animal Health. They were subjected to a formal peer-review process.
Jeff Bender, DVM, MS, DACVPM (Division of Environmental Sciences,
School of Public Health and College of Veterinary Medicine, University of AHS (alcohol-based hand sanitizer); HAI (hospital-acquired infections);
Minnesota, Minneapolis, Minnesota). ICP (infection control practitioner); ICPB (infection control, prevention,
and biosecurity); MDR (multidrug resistant); MRSP (methicillin-resistant
Correspondence: [email protected] (J.S.) Staphylococcus pseudintermedius); PPE (personal protective equip-
ment); SOP (standard operating procedure); SSI (surgical site infection)

† J. Stull was the chair of the Infection Control, Prevention, and Bio-
security Guidelines Task Force.

ª 2018 by American Animal Hospital Association JAAHA.ORG 297

 Introduction and Objectives to acknowledge that not all HAI will be prevented by following

Without effective infection control, prevention, and biosecurity ICPB SOPs; however, studies indicate 10–70% of all HAIs in

(ICPB) implemented in the veterinary primary care and referral human medicine are preventable by using practical infection
control measures, an estimate that is likely applicable to veteri-
settings, the clinician’s efforts at disease prevention and treatment
nary medicine.8 Even a 10% reduction in HAI would have large
are compromised and, in some cases, nullified. Thus, ICPB is at
impacts on patient health, owner cost, and owner and staff satis-
the heart of the veterinarian’s pledge to protect animal health and
faction.
welfare and public health, as well as the universal mandate among
Implementing the various protocols specified in these guide-
the healing professions to “first, do no harm.” Hospital-acquired
lines or provided as online resources may seem daunting at first.
infections (HAI), sometimes referred to as nosocomial infections,
However, most practices already effectively apply many infection
are an inherent risk in human and veterinary medicine, and
control procedures as an aspect of sound clinical practice. These
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breaches in ICPB can have direct and indirect financial, social,

guidelines will nevertheless help any primary care or referral
and environmental impacts on patients, clients, and staff. In a
practices to systematize and strengthen their existing ICPB
practical sense, any practitioner who doubts the value of ICPB
Journal of the American Animal Hospital Association 2018.54:297-326.

protocols and enlist the entire healthcare team in this essential

need only experience a client’s displeasure, an animal’s health
aspect of high-quality veterinary care. To that end, the guidelines
complications, or the consequences of an unflattering online re-
present a progression of interventions from most to least critical.
view when a pet contracts infectious enteritis or respiratory dis-
Therefore, veterinary practices can implement the recommen-
ease during boarding or hospitalization or requires postsurgical
dations of the ICPB task force incrementally without being
treatment due to an HAI.1 The fact is, our best work can be
overwhelmed by attempting an immediate, complete overhaul of
undone by an infection control breach in the practice or home-
ICPB protocols.
care setting. The AAHA Infection Control, Prevention, and
As ICPB principles become part of a practice’s culture, the
Biosecurity Guidelines are the first clinician-focused and practice-
healthcare team can more confidently admit and treat all patients,
oriented guidelines on this topic developed specifically for use in
including those with emerging or endemic infectious diseases,
companion animal medicine. As such, these guidelines comple-
while minimizing the risk of exposing other patients, staff,
ment the growing emphasis in human medicine on infection
and clients. An effective approach, strongly recommended by
control to prevent HAIs and exposure of patients and workers to the ICPB task force, is to appoint a practice “champion” who
infectious pathogens in the practice or laboratory and build off takes primary responsibility for implementing ICPB proto-
existing veterinary best practice and topic-focused documents.2–7 cols and ensuring staff compliance. This individual should fo-
The increasing involvement of drug-resistant pathogens such as cus on the two principal components of ICPB, which are to
methicillin-resistant staphylococci in HAIs has created addi- (1) limit pathogen introduction, exposure, transmission,
tional urgency for effective ICPB. Adding to the risk associated and infection within the hospital population; and (2) evaluate
with ICPB lapses is the potential for in-hospital exposure to the effectiveness of infection control practices at controlling
zoonotic diseases such as leptospirosis, rabies, salmonellosis, disease.9,10
campylobacteriosis, and infections with ecto- and endoparasites There are limited data and evidence-based studies that clearly
(e.g., fleas, ticks, and helminths). Taken together, these factors measure the added benefits of infection control practices in vet-
created a strong motivation to assemble a task force of experts to erinary practices.9,10 Nonetheless, the prevailing opinion within the
produce these ICPB guidelines. profession, supported by evidence from other healthcare fields, is
As many HAI likely occur unnoticed, solely relying upon the that veterinarians can more widely implement effective ICPB
awareness of outbreaks as a measure of effective ICPB practices protocols and conduct staff training on ICPB to protect patient,
results in a false sense of security and unnecessary patient and staff, and client health.6,9,11 To help fill this void, the guidelines
staff health risks. As such, effective ICPB is dependent on the represent the consensus recommendations of experts with exten-
development of and adherence to standardized processes and sive ICPB experience in veterinary medicine and public health.
protocols followed by self-audit and protocol adjustment. These Their recommendations reflect the latest scientific data, clinical
guidelines provide a conceptual roadmap and specific, practical expertise, and best practices for infection control. Thus, these
guidance on how to institute and evaluate ICPB standard operating guidelines address the growing public awareness of HAI, the
procedures (SOPs) that will safeguard patients, staff, and clients emergence of drug-resistant microbes and infections, and the ex-
from avoidable exposure to infectious pathogens. It is important pectation that veterinary medicine will match or exceed ICPB

298 JAAHA | 54:6 Nov/Dec 2018

 ICPB Guidelines

initiatives in human medicine. More specifically, the objectives (e.g., eyes, mouth), open wounds, or abraded skin. Direct in-
of the guidelines are to oculation can occur from bites or scratches. Examples include
· Help veterinary practice teams understand the importance of organisms such as rabies, Microsporum, Leptospira spp., and
ICPB and why it should be prioritized. staphylococci, including multidrug-resistant (MDR) species
· Help practice teams implement appropriate ICPB protocols that methicillin-resistant Staphylococcus aureus and Staphylococcus
enhance patient care and safety. pseudintermedius (MRSP). This is probably the most common
· Provide general concepts that guide effective ICPB (versus ex- and highest-risk route of pathogen transmission to patients
haustive information on all potential pathogens). and personnel.
· Provide specific surveillance strategies and protocols that will
allow practices to self-audit, assess, and adjust their SOPs for Fomite Transmission
infection control. Fomite transmission involves inanimate objects contaminated by an
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· Provide resources for motivating and training staff to under- infected individual that then come in contact with a susceptible
stand, implement, and comply with ICPB strategies. animal or human. Fomites can include a wide variety of objects such
·
Journal of the American Animal Hospital Association 2018.54:297-326.

Provide practical information that can be adapted as client ed- as exam tables, cages, kennels, medical equipment, environmental
ucation materials. surfaces, and clothing. Disease examples include canine parvovirus
Conversely, the purpose of the guidelines is not to focus on and feline calicivirus infections.
hospital design or the judicious use of antimicrobial agents, two
ancillary topics that are more appropriately reviewed in other Aerosol (Airborne) Transmission
forums and publications. When the ICPB objectives listed above Aerosol transmission encompasses the transfer of pathogens via
are met, it will inherently advance the quality of care provided by very small particles or droplet nuclei. Aerosol particles may be
your practice. When clients see visible evidence that ICPB pro- inhaled by a susceptible host or deposited onto mucous mem-
tocols are consistently implemented by your healthcare team branes or environmental surfaces. This can occur from breathing,
(e.g., barrier precautions, take-home postsurgical instructions, coughing, sneezing, or vocalization of an infected individual,
posted ICPB protocols), it will invariably strengthen the mutual but also during certain medical procedures (e.g., suctioning,
loyalties of the veterinarian-client-patient relationship that is bronchoscopy, dentistry, inhalation anesthesia). Very small par-
the basis of successful veterinary practice. ticles may remain suspended in the air for extended periods
and be disseminated by air currents in a room or through a fa-
Principles of Infection Control, Prevention, cility. However, most pathogens pertinent to companion ani-
and Biosecurity mal veterinary medicine do not survive in the environment for
Routes of Transmission extended periods or do not travel great distances due to size and
Infection control and prevention depends on disrupting the trans- as a result require close proximity or contact for disease trans-
mission of pathogens from their source (the infected animal or mission. Examples of common aerosolized pathogens include
7,12
human) to new hosts (animal or human) or locations. Under- Bordetella bronchiseptica, canine influenza, and canine distemper
standing routes of disease transmission and how it contributes virus.
to the spread of organisms allows for the identification of effective
prevention and control measures not only for specific diseases, Oral (Ingestion) Transmission
but also other pathogens transmitted by a similar route, including The ingestion of pathogenic organisms can occur from contami-
12
unanticipated infectious diseases. The transmission of microor- nated food or water as well as by licking or chewing on contam-
ganisms can be divided into the following five main routes: direct inated objects or surfaces. Environmental contamination is most
contact, fomites, aerosol (airborne), oral (ingestion), and vector- commonly due to exudates, feces, urine, or saliva. Examples of
borne. Some microorganisms can be transmitted by more than one diseases acquired via oral transmission include feline panleukopenia
route. and infections caused by Campylobacter, Salmonella, Escherichia coli,
and Leptospira.
Direct Contact Transmission
Direct contact transmission occurs through direct body contact Vector-Borne Transmission
with the tissues or fluids of an infected individual. Physical transfer Vectors are living organisms that can transfer pathogenic mi-
and entry of microorganisms occurs through mucous membranes croorganisms to other animals or locations and include

JAAHA.ORG 299
 arthropod vectors (e.g., mosquitoes, fleas, ticks) and rodents or
other vermin. Vector-borne transmission can be an important
route of transmission in climates where these pests exist year-
round and may be brought into the practice by an infested pa-
tient. Examples of vector-borne diseases include heartworm
disease, Bartonella infection, Lyme disease (borreliosis), and
plague.

Zoonotic Transmission
It is important to remember many animal diseases are zoonotic
and therefore pose a risk for the healthcare team as well as
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clients. The transfer of these agents can occur by the same five FIGURE 1 An inverted pyramid depicting tiers of the hierarchy of
routes of transmission described above. Examples of zoonotic control methods used in determining effective infection control proce-
Journal of the American Animal Hospital Association 2018.54:297-326.

pathogens include Microsporum, Leptospira, Campylobacter, and dures to disrupt pathogen spread. The top tiers (e.g., physical barriers)
Bartonella. are generally more effective at reducing pathogen exposure (elimina-
tion) than the lower tiers (procedural barriers; e.g., PPE). Not all tiers
Hierarchy of Controls will be applicable to a given situation. Although less effective, lower tiers
The hierarchy of controls concept, often used to address measures (e.g., PPE) remain critical for effective infection control. PPE, personal
taken to reduce workplace hazards, is useful when considering in- protective equipment. Adapted from CDC NIOSH Hierarchy of Con-
fection control strategies in veterinary settings.7,13–17 Figure 1 shows trols, available at: https://www.cdc.gov/niosh/topics/hierarchy/default.
a four-tier hierarchy pyramid that can be used to determine ef- html.15
fective ICPB procedures such as changes in facility design, poli-
cies or procedures, and wearing protective clothing. The top
tiers are generally considered more effective at minimizing haz- may be exposed to known or suspected pathogens.13,15,16 PPE
ards (e.g., pathogen exposure) than the lower tiers.15,16 Often, a places a barrier between staff and an exposure risk (e.g., infected
combination of control measures are needed to effectively reduce animal, diagnostic specimens) and with appropriate use, helps
exposures.16 prevent the spread of pathogens between animals and within the
Elimination of sources of pathogen exposure involves physi- practice. The use of PPE is considered a relatively less effective
cally removing (or preventing) the hazard (i.e., pathogen) from means of controlling exposures because it relies on human factors
entering the facility. 15,16
Although completely eliminating infected such as staff compliance and appropriate education and train-
animals from a facility is unlikely to occur, measures can be taken to ing.4,15 Although less effective, lower tiers (e.g., PPE) remain
prevent patients from infecting the general population. While critical for effective infection control and should be used when
elimination controls are the most effective at reducing hazards, they indicated.
are often the most difficult to implement. 15 Table 1 provides examples of hierarchy of control measures
Engineering controls include measures designed into the fa- that can be applied to disrupt pathogen transmission and provide
cility to remove a hazard at its source or to improve compliance infection control for a variety of microorganisms.
with infection control procedures.4,7,15,16 These measures can be
highly effective but generally have higher initial costs.4,13–17 Implementing an Infection Control,
Administrative controls include protocols or changes to work Prevention, and Biosecurity Program
practices, policies, or procedures to keep patients or staff separated Every veterinary practice should have a documented ICPB program.
from a known hazard as well as providing staff with information, At a minimum, this should be a collection of agreed-upon basic
training, and supervision for these measures. Administrative con- infection control practices and accompanying SOPs, growing into
trols address the way people work and how animals move through a formal manual incorporating specific staff education and
the hospital (traffic flow) when an onsite infectious disease is known training, client education, surveillance, and compliance pro-
or suspected.4,13–17 grams. The pros-pect of developing or refining an existing in-
Personal protective equipment (PPE) includes the use of fection control program may seem daunting to veterinary staff.
special clothing and equipment to protect staff and patients who Most staff have not received formal training in this area, and the

300 JAAHA | 54:6 Nov/Dec 2018

 Journal of the American Animal Hospital Association 2018.54:297-326.
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TABLE 1
13–17
Hierarchy of Control Measures Applied to Infection Control, Prevention, and Biosecurity Measures for the Disruption of Pathogen Transmission4,7,

Hierarchy of Measures for All Additional Measures for Additional Measures

Control Tier Transmission Routes Aerosol Transmission for Vector-Borne Transmission

Elimination Early identification of infectious cases (e.g., phone triage) Implement pest management
to prevent exposures within the main hospital areas (extermination) for the practice
Engineering · Establish a dedicated isolation room (preferably with a Isolation room with separate ventilation
direct to outside or alternate entrance in a lower-traffic area) (negative-pressure ventilation possibly
· Place dedicated equipment within the isolation room an additional benefit)
· Place hand hygiene and cleaning and disinfection resources
near exam rooms to improve compliance
· Install (or use) nonporous materials for work surfaces and
floors for more effective disinfection
Administrative · Develop and implement infection control policies Remove vectors
and procedures (written infection control plan) from infested patients
· Provide staff training on infection control protocols:
isolation, infectious disease outbreaks, use of PPE,
disinfection procedures, proper animal handling
and restraint
· Limit staff access to patients with suspected or
known infectious diseases
· Place signs to deter unauthorized persons from entering
isolation areas
· Limit and control infectious patient transport throughout
the hospital to essential purposes only
· Require hand hygiene between patients
· Provide rabies pre-exposure vaccination for staff
· Establish effective waste management and soiled laundry protocols
· Implement proper disinfection protocols for equipment, work areas, and traffic areas
PPE · Use gloves and gowns when in contact with infected animals, Use gloves, gowns, masks, and Use gloves when performing
their bodily fluids, or contaminated surfaces/equipment or bedding eye protection as appropriate vector removal or extermination tasks
· Use higher levels of protection (e.g., masks, eye protection) when performing for the pathogen
necropsies, dental procedures, obstetrics, or other procedures for which there is a
splash or aerosol hazard depending on the target pathogen

PPE, personal protective equipment.

JAAHA.ORG
ICPB Guidelines

301
 value of providing the required resources (e.g., time, finances) protocols for key areas of a practice’s ICPB program in-
may be questioned. However, the process of instituting a pro- clude
gram need not be an “all or none” approach. Importantly, a · Hand hygiene (Table 2).
significant percentage of HAIs in veterinary practices can likely · Cleaning and disinfection (Table 3).
be prevented with proper compliance to basic, practical infec- · Sequence for putting on and removing PPE (Table 4).
tion control practices that a hospital can build over time.18 An · Identifying high-risk patients; questions to ask when mak-
incremental approach to program development and refinement ing appointments (Table 5).
can be done in a step-by-step process that is practical, eco- · Placing and maintaining IV and urinary catheters (Tables
nomical, and effective. Ordered steps to develop an ICPB program 6, 7).
are as follows: · Entering and exiting isolation or dedicated areas for high-
1. Assign a staff member to oversee and champion the devel- risk patients (Table 8).
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opment of and implementation of the ICPB program. Com- · Necropsy procedures (Table 9).
monly referred to as the infection control practitioner · Checklists of key tasks are known to improve compli-
Journal of the American Animal Hospital Association 2018.54:297-326.

(ICP) or infection preventionist, this individual serves a ance throughout the practice workplace, including in-
critical role in infection control (1) program develop- fection control and the reduction of HAIs.22 Checklists
ment, maintenance, compliance, and evaluation; (2) staff are encouraged for cleaning and disinfection, surgery
training development and documentation; (3) protocol (pre- and postoperative), and any commonly performed
compliance evaluation; and (4) receipt of actionable in- duty that benefits from a reminder and communication
fection control concerns, including suspected HAIs. Time system.
commitments will vary with attributes of the practice 3. Perform an initial assessment of the facility to identify
(e.g., size, caseload, existing SOPs) but in most cases strengths and areas for improvement. To best prioritize re-
can be accomplished by an existing practice technician sources, ICPs should identify ICPB strengths and weakness
or veterinarian who has an interest, but not necessarily of the practice. Tools have been developed to assist with this
specific training, in infection control. The factors most process (Table 10). Regardless of the tool used, it is most
critical to success are an interest in the topic, motivation important that all key areas of a program are examined
to make improvements, and support (e.g., enthusiasm, (e.g., hand hygiene, cleaning and disinfection, identification
financial resources and incentives, time) of practice of procedures used to treat and house high-risk patients, PPE)
leaders. Existing resources are available in the human and the continuum of effective risk mitigation is included
and veterinary fields that provide an engaged practice (e.g., presence of written protocols, staff knowledge of and
member with the guidance, skills, and tools to be compliance with protocols). A properly performed assess-
4,5,7,8,18–21
successful. Because staff acceptance, support, ment will indicate areas of the facility on which to focus
and respect for established protocols are critical to a pro- most immediate attention. The ICP should then begin to
gram’s success, the ICP should keep staff engaged (e.g., develop and refine an infection control manual containing
regular program updates, surveillance findings, eval- protocols for identified areas.
uations; seek and respond to infection control-related 4. Develop a staff education and training plan. All personnel,
feedback; involve staff in SOP development and re- including temporary lay personnel, kennel staff, veterinar-
view). Additional resources can be found at aaha.org/ ians, technicians, receptionists, students, and volunteers,
biosecurity. should receive education and training about infection con-
2. Identify and develop protocols and checklists. Protocols trol. Training should occur during orientation and at least
serve as the main resource for guidance of many compo- annually. Training should be tailored to individual job duties,
nents of an ICPB program and should be compiled within but in all cases emphasize health risks and existing protocols
an infection control manual. To be effective, protocols to reduce patient, staff, and client infection-related hazards.
must consist of agreed-upon steps that will be taken by A checklist of required readings, meetings with key staff, and
all practice members. Existing protocols developed as electronic resources to review should be provided and comple-
general guidance or for a specific practice are an excellent tion documented. An assessment (examination) to document
4,7
starting point for ICPs. Protocols should be customized staff knowledge and comprehension should be performed
for the given needs and resources of the practice. Sample after trainings.

302 JAAHA | 54:6 Nov/Dec 2018

 ICPB Guidelines

TABLE 2
Protocol for Hand Hygiene Using Soap and Water or Alcohol-Based Hand Sanitizer21

Hand Wash (Soap and Water) Hand Rub (AHS)

Turn on water —
Wet hands —
Dispense appropriate amount of product directly onto hands Dispense appropriate amount of product directly onto hands
(e.g., 1–2 pumps from dispenser) (e.g., 1–2 pumps from dispenser)
Apply product to all surfaces of hands; min. 15 s contact time Apply product to all surfaces of hands; min. 15 s contact time
Palms Palms
Back of hands Back of hands
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Between fingers Between fingers

Finger tips Finger tips
Thumb and thumb web Thumb and thumb web
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6 Wrists 6 Wrists
Rinse all surfaces of hands with water —
Dry hands thoroughly with single-use towel Rub hands until dry
Turn water off, using drying towel to avoid direct contact —
with faucet handles (unless automatic faucet present)
Discard towel —
TOTAL TIME: w30–60 s TOTAL TIME: w20–30 s

AHS, alcohol-based hand sanitizer

5. Identify a staff member to collect client education materials materials that assist clients in understanding infectious and
specific for use in your practice. Efforts should be made to zoonotic disease risks and the basic steps they can take to
identify, catalog, and make readily available appropriate protect themselves, household members, and their animals.

TABLE 3
Example of an Environmental Cleaning and Disinfection Protocol (Adapted)20
· Have all material safety data sheets or product safety data sheets for cleaning and disinfection materials available. Follow instructions for proper mixing, disposal, and
PPE (e.g., gloves, eye protection). As able, ensure the area is well ventilated.
· Exam rooms and cages should be cleaned and disinfected immediately following use. Place signage at the room entry that it should not be used until cleaning and
disinfection is completed.
· Asshould
applicable, remove all bedding and organic material (e.g., feces, feed, hair, linens, bandage, or other materials) and dispose in designated waste bin. Gloves
be worn during this procedure.
· “Dry”-clean surfaces (e.g., sweeping, wiping with disposable microfiber cloth) to remove loose organic material.
· “Wet”-clean surfaces with warm water and detergent. Scrubbing surfaces is often necessary to remove feces or bodily fluids, biofilms, and stubborn organic debris,
especially in animal housing areas.
· Rinse with clean water. For all rinsing and product application procedures, care must be exercised to avoid overspray. High-pressure washing should be avoided.
Higher pressures can help remove stubborn organic debris but may also force debris and organisms into crevices or porous materials, from which they can later
emerge. Additionally, high-pressure washing causes aerosolization and overspray, which may spread organisms widely, even into previously uncontaminated areas.
· Allow the area to dry or manually do so. If excess water remains, subsequently applied disinfectants may be diluted to the point of inefficacy.
· Apply disinfectant solution at the indicated concentration and ensure the appropriate contact time (allotted time required for disinfectant to remain wet on the surface
to kill the pathogens of interest; time is based on the product, concentration, and targeted pathogens but generally 5–10 min). Rinse thoroughly with clean water; this
is especially important for disinfectants that leave a residue or for surfaces vulnerable to damage from the disinfectant. Always follow the disinfectant label (Figure 2)
for appropriate use, concentration, and contact time (see Figures 3, 4; Table 11 for choosing a disinfectant).
· Allow the treated area to dry as much as possible before reintroducing animals or reusing the area.
· Inconsidered
known contaminated or high-risk areas, a second application of a disinfectant with wide spectrum (e.g., accelerated hydrogen peroxide product) should be
as a final decontamination step. Ensure appropriate contact time, rinse with clean water, and allow the treated area to dry, as stated above.

PPE, personal protective equipment.

JAAHA.ORG 303
 TABLE 4
Sequence for Donning and Doffing of Personal Protective Equipment21

Donning PPE (Putting on) Doffing PPE (Taking off)

1. Perform hand hygiene 1. Remove shoe covers (if applicable)

2. Put on shoe covers (if applicable) 2. Remove gown and gloves together*
3. Put on gown 3. Perform hand hygiene
4. Put on mask/respirator (if applicable) 4. Remove eye protection (if applicable)
5. Put on eye protection (if applicable) 5. Remove mask/respirator (if applicable)
6. Put on gloves 6. Perform hand hygiene
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* If gloves are removed first, hands must only touch uncontaminated surfaces of the gown, typically behind the neck (ties) and at the back of the shoulders. The gown is
then peeled down off the body and arms, balling or rolling in the contaminated surfaces (front and sleeves). This is difficult to do, however, without contaminating the
hands. The preferred method for doffing a disposable gown and gloves is, therefore, to break the ties at the neck by pulling on the upper front portion of the gown with the
hands still gloved, balling or rolling in the contaminated surfaces, and pulling the gloves off inside-out as the hands are withdrawn from the gown’s sleeves. The gown and
Journal of the American Animal Hospital Association 2018.54:297-326.

gloves can then be placed in a disposal receptacle together.

PPE, personal protective equipment.

Several sources provide client-appropriate materials on these weakness, and provides a warning to allow for an early re-
topics, such as Worms and Germs blog’s pet resources sponse to a concern, reducing patient and staff illness, ex-
(wormsandgermsblog.com), the CDC’s Healthy Pets Healthy penses, and time. Many forms of surveillance are easy,
People (http://www.cdc.gov/healthypets/index.html), the Center inexpensive, and can be readily incorporated into day-to-
for Food Security and Public Health (http://www.cfsph.iastate. day veterinary practice. Some form of surveillance (either
edu), and aaha.org/biosecurity. passive or active) should be used by all veterinary facilities.
6. Develop and implement a surveillance program. Surveillance, Passive surveillance involves using data that are already avail-
the routine collection of information with defined responses, able (e.g., client-paid bacterial culture and susceptibility re-
is critical for effective infection control. It provides feedback sults, identified surgical site infections [SSIs]) to determine
to determine if a practice’s infection control practices are clinically relevant elements such as disease rates, antimicro-
effective at controlling disease, helps to identify areas of bial susceptibility patterns, and trends and identify changes

TABLE 5
Identifying High-Risk Patients: Questions to Ask When Making Appointments5*
· Age of the patient.
· Vaccination history.
· Recent history:
Has the pet been to a boarding kennel, dog park, day care facility, animal shelter, or other similar venue in the past month?
Traveled to another area or country?
Are other pets in the household ill?
· Acute vomiting?
· Acute diarrhea (defined as three or more loose stools during the past 24 hr) or episodes of bloody diarrhea?
· Acute coughing?
· Acute sneezing?
· Fever (if known)?
If the patient is acutely coughing, sneezing, vomiting, or having diarrhea, 6 a fever, the pet should not enter the reception area. Evaluate such animals before entry into the
building or immediately transport them to a dedicated examination or isolation room depending on practice policy.
If the hospital records indicate that the pet has a multidrug-resistant infection, the pet should not enter the reception area.
* Patients fitting these criteria should not enter the reception area. Meet owners outside and escort them in via a separate entrance or use a carrier or gurney to transport
the pet through the reception area if necessary. Use alternative waiting/examination locations or use of barrier precautions based on the initial risk assessment. Clean and
disinfect any waiting or examination locations occupied before using those areas again for other animals.

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TABLE 6
Placement and Maintenance of Peripheral Intravenous Catheters to Prevent Infection5
1. Clip hair from the proposed site of catheter insertion.
2. Perform hand hygiene and put on clean examination gloves.
3. Use gauze sponges, sterile saline, and chlorhexidine scrub diluted with sterile saline to between 0.5 and 2% chlorhexidine.
4. Perform hand hygiene and put on sterile or clean gloves to insert the catheter. Do not reuse a catheter after a failed attempt.
5. Attach a catheter cap, T set, or suitable extension set to the catheter, and flush the catheter with sterile saline solution. Carefully secure the catheter with tape and
cover it with sterile bandage materials. Povidone iodine ointment may be applied at the site of entry into the skin.
6. Examine the catheter site at least two times daily. Observe for pain and evaluate for evidence of swelling or thrombophlebitis. If the bandage is not clean and dry,
replace the bandage. If there is any evidence of thrombophlebitis and the catheter is still necessary, replace the catheter in a different site.
7. When IV lines are disconnected (e.g., to take a dog for a walk), the sites of connection should be cleaned with isopropyl alcohol single-use wipes and capped with
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injection caps. Do not reuse injection caps.

8. IV tubing used for fluid administration should be changed every 72 hr. The IV tubing used for TPN administration should be changed every time a new bag of TPN is
placed, or every 24 hr, whichever is more frequent.
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TPN, total parenteral nutrition.

TABLE 7
Placement and Maintenance of Indwelling Urethral Catheters5
For all site cleansing, wear examination gloves and use sterile gauze sponges to cleanse, alternating between an appropriate dilute skin antiseptic (e.g., chlorhexidine
scrub diluted with sterile saline to 0.5–2% chlorhexidine, 1:200 povidone iodine/sterile saline) and sterile saline.
Dogs
· Clip hair on prepuce and surrounding ventral abdomen. Shorten nearby long hair.
· Cleanse the area, using at least three scrubs with each solution.
Males
· Flush the prepuce three to five times with 2–12 mL of dilute skin antiseptic (volume depends on size of dog) using a sterile syringe.
· Assistant wearing clean examination gloves should exteriorize the penis. Cleanse of any gross exudates, then cleanse the entire area, using at least three wipes with
each solution. Flush with 2–5 mL dilute skin antiseptic.
Females
· Cleanse vulva and perivulvar area, using at least three scrubs with each solution.
· Flush the vaginal vault three to five times with 0.5–12 mL dilute skin antiseptic (volume depends on size of animal) using a sterile syringe.
All
· Place a sterile fenestrated drape over the work area.
· Perform hand hygiene and put on sterile gloves.
· Test the bulbs of Foley catheters before placement.
· Coat the distal catheter with sterile lubricating jelly from a single-use packet and place the catheter using sterile technique.
· Immediately connect a sterile closed collection system.
· Anchor the catheter to prevent displacement and place an Elizabethan collar on the animal.
Daily maintenance of indwelling catheters
Perform hand hygiene and put on sterile gloves. Clean at the junction of the patient and the external portion of the catheter every 24 hr with sterile gauze sponges,
alternating between dilute skin antiseptic solution and sterile saline (greater than or equal to three scrubs with each solution).
Managing the closed collection system
· Doantimicrobials
not administer prophylactic antimicrobials; these increase the risk of hospital-acquired resistant infections and have not been shown to prevent infection. Give
only for documented infection.
· Position collection bags lower than the animal to allow urine to flow by gravity. Prevent retrograde flow of urine from the collection bag back into the patient because
this may cause iatrogenic urinary tract infection with resistant organisms. The collection system clamp should be closed when the patient is moved or walked and
immediately reopened once the collection bag is again lower than the patient. Check patency of the tubing hourly.
· Culturing the urine (via cystocentesis) at the time of catheter removal is only indicated if there is evidence of cystitis. Urine culture results drawn from indwelling
catheters (not recommended) should be interpreted with caution. Do not culture the tip of a removed catheter.

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Sample Protocol for Entering and Exiting an Isolation (or Similarly Dedicated) Area5
Entering and exiting isolation rooms
1. Before entering the isolation area, remove practice outerwear (e.g., laboratory coat) and any equipment (e.g., stethoscope, scissors, thermometer, watch, cell phone)
and leave outside the isolation unit/anteroom.
2. Gather any necessary supplies and medications before putting on PPE.
3. Wash hands or use alcohol hand rub, and then put on booties, gown, and gloves before entering the isolation room (see Table 4 for proper procedures).
4. Attend to the patient in isolation as needed. DO NOT bring treatment sheets, pens, or electronic devices such as laptops, cell phones, or tablets into the isolation
room.
5. Clean and disinfect any equipment used while caring for the patient.
6. Before leaving the isolation room, remove PPE (see Table 4; remove booties last as stepping out of the isolation room and avoid touching the outer surface of the
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boots). Clean and disinfect nondisposable PPE (e.g., eye protection). Place used disposable PPE in the trash container lined with a biohazard bag in the isolation
room. DO NOT SAVE DISPOSABLE PPE FOR REUSE. Avoid contact with external portions of the door when exiting the isolation room.
7. Wash hands with soap and water, and then disinfect any surfaces (e.g., doorknobs) that may have accidentally been contaminated when the room was exited. Make
Journal of the American Animal Hospital Association 2018.54:297-326.

any needed chart entries. Wash hands again before leaving the anteroom (as applicable).

PPE, personal protective equipment.

that may indicate an important infection control problem environmental cleaning is fluorescent tagging. This process
(e.g., increase in SSI rate). Routine recording of animals with involves applying marks only visible under ultraviolet light
specific diagnoses (e.g., SSIs, MDR organisms) or syndromes (so staff are not aware marks have been placed) that are easily
(e.g., vomiting, diarrhea, coughing) is another simple method removed with routine cleaning and monitoring surfaces for
of collecting information that can help in the prevention presence of marks after cleaning was to occur (e.g., 24 hr after
and early detection of outbreaks. The key to passive surveil- mark placement).23 Regularly marking and collecting this
lance is to centralize available data, with the ICP compiling information provides insight into cleaning deficiencies (e.g.,
and evaluating data and reporting results on a regular basis. locations or objects often missed), allowing for targeted ad-
Many electronic medical record systems can be set to track justment to cleaning and disinfection protocols or staff train-
and report on certain diagnostic codes that the ICP has ing. Culturing environmental surfaces or diagnostic samples
designated for surveillance. Active surveillance involves gath- from animals is another example of active surveillance, but
ering data specifically for infection control purposes. An in- due to expense would generally be reserved for an outbreak
expensive, highly effective example of active surveillance for investigation.

TABLE 9
Procedures for Performing a Necropsy Appointments5*

Necropsies are high-risk procedures because of potential contact with infectious body fluids, aerosols, and contaminated sharps. Nonessential persons should
not be present.

· Personnel involved in or present at necropsies should wear:

B
Protective outerwear (e.g., designated lab coat, designated scrubs)
B
Disposable gloves
B
Protective eye glasses/goggles or a full-face shield
B
Cut-proof gloves (machine washable) when opening the body cavities of larger animals, for heavy cutting, and when working on cases of high occupational risk (e.g.,
rabies suspect)
B
Additional precautions for respiratory protection (including environmental controls and face masks) should be employed if power equipment is used
· In-hospital necropsies should not be conducted on any animal suspected of being infected with a pathogen requiring biosafety precautions above level 2 (e.g.
Chlamydophila psittaci, Coxiella burnetii, Francisella tularensis, rabies virus). Instead, the entire body (or head for rabies testing as required by the testing facility)
should be submitted to an approved diagnostic laboratory.
· Ensure all requirements for shipment of biological samples are met (available from the laboratory in question).

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TABLE 10
Sample Infection Control Audit Tool4

Fully Partly Not Not

Audit Areas and Items Implemented Implemented Implemented Applicable Comments

Designated practice areas available

Isolation area

Diagnostic specimen handling area

Staff “break” area

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Protective equipment available

Gloves
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Household rubber, reusable

Latex, nitrile or other, disposable

Masks

Surgical

N95 masks, including fit testing

Gowns

Lab coats

Foot covers/booties

Eye protection (e.g., goggles)

Written policies for dress code

No/limited jewelry (rings or bracelets)

for staff with animal contact

No artificial nails or nail enhancements

(e.g., nail polish) for staff
with direct patient care

Hand hygiene

AHS stations available

Signage for AHS with instructions

Hand washing stations available

Signage for hand washing with instructions

Staff trained on how and when to use hand hygiene

Before and after patient contact

Before aseptic procedures

Before putting on and after taking off gloves

After contact with body fluids or

mucous membranes

After contact with contaminated equipment or surfaces

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 TABLE 10 (Continued )
Fully Partly Not Not
Audit Areas and Items Implemented Implemented Implemented Applicable Comments

After personal body functions (i.e., sneezing, coughing,

going to the bathroom)

Before eating

Cleaning and disinfecting procedures

Written protocols and procedures for cleaning and disinfection developed and
followed

Safety Data Sheets for disinfectant products available

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Appropriate detergents available

Appropriate disinfectant products available for patient-contact surfaces

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Approved and appropriate disinfectant products available for

equipment and instruments

Disinfection and sterilization of medical devices

Proper technique used (i.e., product concentration, contact time,

equipment properly cleaned before sterilized)

Manufacturer’s instructions followed

Laundry

Laundry performed on site or by a commercial service

Laundry dried at high temperatures (65–708C)

Infectious laundry presoaked in bleach solution

(9 parts water:1 part household bleach)

Soiled laundry transported in a clean manner

Clean laundry segregated from soiled laundry

Hand hygiene available in laundry area

Education provided regarding protective practices

Sharps handling

Approved puncture-resistant, labeled containers used

Containers not more than 3/4 filled

Containers accessible in all required areas

Sharps disposed immediately after use

Waste segregation

Clear guidelines regarding waste that is:

Biohazardous

Nonbiohazardous

Vector control

Rodent control apparent

Food debris and clutter eliminated

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TABLE 10 (Continued )
Fully Partly Not Not
Audit Areas and Items Implemented Implemented Implemented Applicable Comments

Points of entry for rodents sealed

No standing water outside practice

Windows screened

Documentation of staff immunization (may not be provided

by employer, but useful to document)

Rabies
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Tetanus

Examination rooms
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Hand washing sinks with soap available in all rooms

Only essential supplies present

Policies enforced for cleaning exam rooms between patients

and at the end of the day

Protocol ensuring rooms immediately cleaned/disinfected as needed

(e.g., used for an infectious case)

Enhanced cleaning/disinfection protocol in place for cleaning rooms where

an infectious case may have been

Written procedures for handling potential exposure of staff to zoonotic

pathogens

Separate refrigerators used for food, vaccines and medications,

and diagnostic specimens

Protocol development and staff training

Documented annual staff training and updating on

infection prevention and control measures

Documented annual staff training on use of PPE

Infection control program

ICP designated in the practice to oversee the infection control program

Surveillance in place

Infection control and prevention issues (e.g., SSIs, MDR organisms) reported to ICP

All new staff trained and provided with a copy of the infection control protocols

Periodic assessment of all staff’s knowledge of related SOPs

Periodic assessment of staff’s compliance with related SOPs

A list of reportable diseases readily available in the practice

Contact numbers for the appropriate veterinary and public

health groups (e.g., for disease reporting) readily available
in the practice

Autoclave

Quality control sterility indicators included in each autoclaved pack

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 TABLE 10 (Continued )
Fully Partly Not Not
Audit Areas and Items Implemented Implemented Implemented Applicable Comments

Biological indicators periodically used to ensure adequate sterilization,

and results are recorded in a log

Isolation areas

Dedicated isolation area for animals with infectious diseases

available and clearly marked

Dedicated equipment and PPE available and remain

in the isolation area
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Signage available and appropriate

Footbaths or footmats available

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Miscellaneous

Policy not to feed patients raw meat

Printed materials for clients on zoonotic diseases available

Written policy on admitting animals from shelters

List of syndromes of potentially infectious diseases (i.e., acute

diarrhea, acute upper respiratory tract infection) provided
to receptionists

Policy with list of potential HAIs (e.g., SSIs) requiring reporting

to hospital ICP

Animal bite policy

Training requirements for volunteers

Staff (including receptionists) trained to triage and identify potentially infectious

patients when making appointments, and contact a veterinarian to determine
whether additional infection control practices are required prior to the animal
entering the practice

AHS, alcohol-based hand sanitizer; HAI, hospital-acquired infection; ICP, infection control practitioner; MDR, multidrug resistant; PPE, personal protective equipment; SOP,
standard operating procedure; SSI, surgical site infection.

7. Establish and maintain a compliance evaluation program. audit process is encouraged to provide additional perspectives
Although the development of an effective ICPB program and further buy-in by practice staff.
is a primary goal, only with regular compliance self-
auditing can a practice ensure that their practices align with General Procedures for a Veterinary
their protocols, goals are being met, and continued im- Infection Control, Prevention, and
provement occurs, resulting in lowering HAIs and worker Biosecurity Program
safety risks. A comprehensive audit can build from the As the foundation for infection control practices, patient and staff
previously mentioned initial assessment using the same flow, hand hygiene, cleaning and disinfection, and PPE should be
audit tool. The audit should include inspection of the phys- addressed in all practice ICPB programs.
ical environment, review of workplace ICPB practices,
and assessment of workers’ knowledge and application of Patient and Staff Flow
infection control principles. Regular audits (at least annually) by Attention to the movement of patients and staff into and through a
the ICP will allow for the establishment of benchmarks, identify practice can affect HAI risks.8 The ability to identify and manage
and prioritize needs, and identify resources and timelines to infectious patients as early as possible (ideally before they enter the
meet benchmarks. Incorporating other team members in the facility) will have the greatest success for reducing environmental

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TABLE 11
Properties of Disinfectants Recommended for Routine Disinfection of Environmental Surfaces and Equipment34

Active Agent Product Examples Contact Time, min Advantages Disadvantages Comments

Hypochlorite Bleach; 1:10–1:50 dilution of 1–5 - Broad spectrum effective - Corrosive for some surfaces. - Good for various environmental
household bleach against most resistant - Poor stability when exposed to surfaces.
organisms (nonenveloped light. - Efficacy decreases with
viruses, bacterial spores, - Poorly active in the presence increasing pH, decreasing
dermatophytes). of organic debris (e.g., dirt, temperature, presence of
- Readily available. feces). ammonia and nitrogen.
- Cost-effective. - Can discolor fabrics. - Reserve high concentration
(1:10) for specific
circumstances with resistant
microorganisms.
21:32–1:50 more commonly
used.
- Never mix with other
chemicals.
- Change diluted solutions daily.
- Do not store in clear
containers.
Potassium peroxymonosulfate Virkon, Trifectant 10 - Broad spectrum, with activity - Corrosive, especially with - Commonly used routine
(oxidizing agent) against nonenveloped viruses metal surfaces. disinfectant.
and bacterial spores. Masks should be worn when - Care must be taken when
- Active in the presence of mixing powdered solutions handling concentrated
moderate organic debris. product.
- Consider rinsing metal and
concrete surfaces after
required contact time.
Accelerated hydrogen peroxide Rescue, Prevail 1–10 - Broad spectrum, with activity - More expensive than other - Excellent choice for
(oxidizing agent) against nonenveloped viruses, options. environmental disinfection.
bacterial spores, and
dermatophytes.
- Good activity in moderate
organic debris.
- Low toxicity.
- Biodegradable.
- Does not appear to be
corrosive, unlike other
oxidizing agents.
Quaternary ammonium Various 10–30 - Low cost. - Limited impact on - Common environmental
compounds - Low toxicity. nonenveloped viruses, disinfectant, but spectrum may
- Stable under storage. bacterial spores, be inadequate for some
- Good against Gram-negative, dermatophytes. situations.
many Gram-positive bacteria, - Inhibited by organic debris.
and enveloped viruses.

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 TABLE 12
Isolating an Infectious Patient
Pathogens of Greatest Infection Control Concern for a Small
As an example, before a dog suspected of parvovirus arrives at a Animal Hospital6
practice, staff should consider
· Adenovirus (canine)
· Mode of transmission for the suspected pathogen (in this · Bordetella bronchiseptica
case most likely to be spread by fecal, direct, or fomite · Calicivirus (feline)
transmission). · Chlamydophila (feline)
· Individuals with anticipated patient contact should wear · Distemper virus (canine)
appropriate PPE (i.e., gowns, gloves). · Herpesvirus (feline)
· Carrying the patient or use a gurney with a disposable · Influenza viruses (canine, novel)
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cover through a separate entrance directly into the exam · Leptospira interrogans
or isolation room. · Microsporum canis
· Use of a similar transport procedure for patient’s admis- · Parainfluenza virus (canine)
Journal of the American Animal Hospital Association 2018.54:297-326.

sion to isolation or during practice discharge. · Parvoviruses (canine, feline)

· Use of a disinfectant that is effective against parvovirus. · Respiratory coronavirus (canine)
· Salmonella spp.
contamination, direct and indirect patient contact, and within-
· Multidrug-resistant organisms
B
Acinetobacter spp.
hospital pathogen transmission. B
Escherichia coli
Taking an appropriate history prior to patient arrival can pre- B
Enterococcus spp.
vent pathogen introduction. SOPs and staff training should address B
Staphylococcus spp.
identifying high-risk patients when possible during appointment B
Pseudomonas spp.
scheduling (Table 5). When an infectious disease is suspected prior to
the appointment, the client should be instructed to call upon arrival
and use a designated path to an appropriate, dedicated area for ex-
amination. Practices should determine the best path based on their Generally considered the single most important way to prevent infections

facility, with the intention of minimizing contact with the general in healthcare, hand hygiene should be the subject of considerable at-

patient population and staff. Animals suspected or confirmed to pose tention to availability, encouragement, and compliance auditing.21,24
a high risk (Table 12) should be examined and housed in a dedicated Effective hand hygiene kills or removes microorganisms on the skin
isolation area. Because an isolation room may not always be available, while maintaining skin integrity (i.e., prevents skin chapping and
facilities should develop an SOP for where and how such animals will cracking). The objective is to reduce the number of microorganisms,
be housed. Facilities’ procedures should be consistent with those used particularly those that are part of the transient microflora of the skin,
for isolation (i.e., housed physically and procedurally separate from because these are easily shed and include the majority of opportunistic
other patients; Table 8). Complete discussion of facility design is pathogens. In most circumstances, either method of hand hygiene (soap
beyond the scope of these guidelines.4,19 and water or AHS) is effective if performed appropriately and when
Some patients will be identified as potentially infectious during indicated (Table 2). In the practice, hand hygiene should occur
the appointment or while hospitalized. In such cases, staff should · Immediately before and after patient contact, especially inva-
minimize owner and patient contact with other patients, staff, and sive procedures.
surfaces (e.g., provide outpatient treatments and complete checkout · Before and after contact with items in the patient’s environ-
process in the same exam room or designated infection control area). ment.
Staff should identify places where contact between infectious patients · After exposure to patient bodily fluids (e.g., discharge, speci-
and other patients or where exposure to common areas may have men handling).
occurred. These areas should be promptly cleaned and disinfected. · Before putting on gloves and especially after glove removal.
· After using the restroom.
Hand Hygiene · Before eating.
Hand hygiene, using soap and water or an alcohol-based hand sanitizer AHS is the preferred method when hands are not visibly soiled
(AHS), is the responsibility of all individuals involved in healthcare. because these products have a superior ability to kill microorganisms

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TABLE 13
Recommended Cleaning and Disinfection Frequency for Common Environmental Surfaces in Veterinary Practices4

Surface or Object Procedures Special Considerations

Horizontal surfaces with low 1. Clean regularly with detergent (e.g., biweekly) Electrostatic wipes (can be used to remove loose fur and dust)
patient contact (e.g., front 2. Clean and disinfect promptly if visibly soiled with feces, urine, or body fluids
desk, records area)
Horizontal surfaces with high 1. Clean and disinfect between all patients.
patient contact (e.g., exam Surface should be cleaned of visible debris, and
tables, scale, kennels) then a disinfectant should be applied. Adequate contact time should
be ensured, as per label directions.
2. Provide enhanced disinfection after contact with high-risk patients (e.g., diarrheic).
Higher-level disinfection (i.e., oxidizing agent) should be used if lower-level disinfectants
are used routinely
Vertical surfaces (e.g., walls, 1. Clean regularly with a detergent (e.g., monthly)
doors, windows including 2. Clean and disinfect if visibly soiled with feces, urine, or body fluids
blinds/curtains)
Hard floors (e.g., 1. Clean and disinfect daily
tile, sealed cement) 2. Clean and disinfect after potentially infectious patients
3. Clean and disinfect if visibly soiled with feces, urine, or body fluids
Carpets and upholstery 1. Vacuum regularly (e.g., weekly)* Cleaning is especially important for these surfaces as they are
2. Shampoo or steam clean if necessary to remove visible dirt and debris difficult or impossible to disinfect

* Do not vacuum if there may have been contact with an animal shedding an infectious pathogen (i.e., ringworm), unless the vacuum is equipped with a high-efficiency particulate air (HEPA) filter.

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314
TABLE 14
Personal Protective Equipment and Clinical Indications21

Contact Precaution Description Applicable Conditions and Scenarios Comments

JAAHA |
Sterile gloves Impermeable, sterile, single-use latex, nitrile, or vinyl Sterile gloves should be used when the primary Not a substitute for hand hygiene. Due to the risk of pre-
gloves of appropriate size for individuals risk is transmission of microbes to (rather than existing defects, puncture, or tears during use and
from) a particular body site or item (e.g., potential contamination of the hands when removing
surgery, examination of “clean” wounds (and of sterile gloves when putting on), hand hygiene
[surgical incisions, handling sterile before and after glove use remains as important as
equipment]). before and after patient contact when gloves are not
used
Single-use gowns or dedicated Single-use disposable gowns, reusable cloth gowns, or Any scenario in which there is increased risk of Disposable gowns and laboratory coats are typically
laboratory coats laboratory coats that are laundered after each hand or clothing contamination with a larger permeable to liquids, especially with prolonged or
applicable patient contact or procedure. Clothing worn number of microbes or any number of highly heavy contact; therefore, additional precautions may

54:6 Nov/Dec 2018

underneath must be completely covered from the virulent, resistant, or transmissible microbes, be required to prevent microbial strike-through
wrists and waist to the collar at a minimum, depending for example:
on the size and type of patient. Use of coveralls is also · Any animal with potential respiratory tract
an option for animals requiring extensive handling, infection, diarrhea, skin infection, fever of
especially on the floor. unknown origin
· Oral manipulation or procedures (e.g.,
dentistry)
· Exposure to potentially infectious fluids or
discharge (e.g., obstetric procedures,
necropsy, handling of clinical samples or
soiled linens and other items)
Face mask Single-use disposable surgical mask along with eye Any scenario in which there is a significant splash shield may be more appropriate for individuals
protection or reusable full-face shield consisting of a risk or risk of droplet transmission, for
· Awithfaceheavy facial hair that is not adequately covered
stiff clear plastic sheet that covers the face from instance: by a mask.
forehead to chin. Each face shield should be dedicated · Dental procedures · Does not protect against airborne pathogens—this
to a single person but should be discarded or fully · Wound lavage requires a properly fitted respirator (N95 or higher)
reprocessed (i.e., cleaned and disinfected) if it · Potentially zoonotic respiratory disease with
becomes visibly contaminated or comes in contact productive coughing or sneezing
with a contaminated surface (including used glove), · Necropsy (especially if any potential risk of
and between patients. rabies)
Eye protection Typically, reusable plastic goggles that wrap around the Poorly fitted eye protection can cause visibility issues
sides of the face or include side-protectors or a full- from fogging or slipping.
face shield Regular eyeglasses are not a substitute because they
do not fully protect the eyes, particularly from the
lateral aspect
Shoe covers or dedicated footwear Single-use disposable cloth or plastic boots that fit over Any scenario in which there is suspected to be Disposable plastic shoe covers can create a slipping
regular footwear or reusable slip-on footwear that is significant contamination of the floor with a hazard if they do not have treads.
easily cleaned and disinfected (e.g., rubber boots) high-risk substance, for example: Not commonly needed in small animal practices;
· Dog with leptospirosis housed on the floor however, contamination of the floor must always be
· Infectious vomiting or diarrhea, particularly carefully considered because of the high degree of
in large dogs housed on the floor contact of patients and staff with the floor.
· Management of large open wounds if floor
could become contaminated with discharge
or lavage fluid
 ICPB Guidelines
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Journal of the American Animal Hospital Association 2018.54:297-326.

FIGURE 2 Understanding the information on a disinfectant product label is essential for effective disease organism removal and the safety of
those handling the product. Always read the product label before use. It is a violation of federal law to use a product in a manner inconsistent with its
labeling. From the Center for Food Security and Public Health, available at: http://www.cfsph.iastate.edu/Disinfection/Assets/dis-
infectant_product_label.pdf.

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FIGURE 3 Spectrum of selected disinfectants.

on the skin, can quickly be applied, minimize skin damage, and are and disinfection are two separate tasks. Cleaning involves the re-
24,25
easily and inexpensively made available at any point of care. AHS moval of visible organic matter (e.g., feces, urine, food, dirt) with
is not effective against bacterial spores (e.g., Clostridium spp.), soap or detergent, whereas disinfection involves the application of a
Cryptosporidium spp., and nonenveloped viruses (e.g., parvovirus). chemical to kill the remaining microbes. Cleaning is essential be-
When these pathogens are suspected, washing hands with soap and cause organic matter increases the environmental survival of many
water is encouraged. Bar soaps should never be used in practices due pathogens and decreases the effectiveness of many disinfectants.
to risks for microbial contamination and transfer to other person- Surfaces that are porous (e.g., unsealed wood, concrete, grout) or
nel. Dispenser-provided liquid or foam soap should be used; if with poor integrity (e.g., cracks) are difficult to effectively clean and
containers will be refilled, they must first be disinfected. disinfect and should be repaired or replaced.
Disinfection can only be maximally effective if it is preceded by
Cleaning and Disinfection cleaning. Some pathogens (e.g., clostridial spores) are highly resistant
The environment and equipment in veterinary hospitals can serve as to disinfection; therefore, cleaning in these cases is particularly
important routes of pathogen transmission to patients, owners, and important to mechanically remove the organisms. Disinfectants
staff.26,27 Cleaning and disinfection aim to reduce key pathogens. should be selected based on pathogens of concern, compatibility with
However, when cleaning and disinfection are improperly performed, materials, and level of risk (Figures 3, 4; Table 11). For instance, a
pathogens are likely to remain and can result in HAIs.28–30 Cleaning quaternary ammonium compound may be reasonable for routine

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 ICPB Guidelines
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Journal of the American Animal Hospital Association 2018.54:297-326.

FIGURE 4 Characteristics of selected disinfectants.

disinfection in general animal areas, but a disinfectant with an ex- and disinfected between patients. This includes exam rooms; floors
tended spectrum (e.g., oxidizing agent that also kills nonenveloped where patients (e.g., large dogs) are examined/treated; and equip-
viruses) would be indicated in an isolation or critical care area. To be ment such as thermometers, stethoscopes, bandage scissors, clippers
effective and meet expected spectrum of activity, disinfectants must be handle and blades, otoscope handle and tips (if reused), monitoring
applied at the correct dilution and for the designated contact time equipment (e.g., Doppler cuffs, electrocardiogram leads), and en-
(allotted time required for disinfectant to remain wet on the surface to dotracheal tubes. Surfaces such as lobby floors should be cleaned
kill the pathogens of interest; this time is based on the product, con- and disinfected on a regular basis, at least daily; when known-
centration, and targeted pathogens, but is generally 5–10 min). If the infectious animals have been in contact with the surface; or when
disinfectant dries before the allotted time, it must be reapplied so that surfaces are visibly soiled with feces, urine, or body fluids (Table 11).
the surface remains wet throughout the contact time. Use of the proper Nonanimal-contact surfaces should not be forgotten (e.g., light
disinfectant concentration is critical from a cost, effect, and safety switches, door handles, computer keyboards/mice). Enhanced disin-
standpoint. Because disinfectant products can have a range of effica- fection is important after contact with a suspected or confirmed in-
cious concentrations depending on the specific pathogen, the con- fectious patient. Efforts will vary with the pathogen(s) suspected,
centration used for disinfecting is pathogen- and situation-dependent. including route of transmission, pathogenicity, persistence, and risk
ICPs should identify surfaces for cleaning and disinfection and for the practice’s patient population. For an examination room, this
establish a desired frequency that can be incorporated into a checklist would include careful attention to cleaning all patient-contact sur-
(Table 13). In general, animal-contact surfaces should be cleaned faces (including floors as indicated), followed by broad-spectrum

JAAHA.ORG 317
 disinfection (e.g., oxidizing agent) if more narrow-spectrum disinfec- pathogens (e.g., older with concurrent disease or skin infections,
tants are used routinely. Because many of the pathogens involved in patients with fecal or urinary incontinence, surgical complications
veterinary HAIs can survive in the environment for an extended pe- including SSIs). Further, some pathogens may be frequently en-
riod, leaving an area closed for several days is unlikely to prove ben- countered in rehabilitation environments (e.g., MDR Pseudomonas
31
eficial. Instead, as indicated by the level of risk, a second round of spp.), yet such environments are often overlooked as a source of
disinfection may be advisable. There is no evidence that appropriately HAIs.35,36 Infection control, prevention, and biosecurity for a physical
chosen disinfectants should be routinely rotated to reduce the devel- rehabilitation unit should focus on screening of patients, restricting
opment of pathogen resistance.32 In all circumstances, protect involved or adjusting use based on risk (e.g., confirmed/suspected infectious
staff by requiring the use of gloves and eye protection when splashes are disease, recent history of diarrhea), regular cleaning and disinfection
likely (e.g., pouring or mixing disinfectants) and ensuring areas are of all equipment surfaces, monitoring and adjusting water chemistry
well ventilated. for water devices (e.g., appropriate chlorine levels will provide ad-
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equate disinfection for healthy patients), and educating the entire

PPE practice team for proper technique and the use of PPE. SOPs unique
Journal of the American Animal Hospital Association 2018.54:297-326.

PPE should be considered a last line of defense for hazards that to this environment (e.g., fecal accidents in water devices) should
cannot be overcome with other preventive measures. Nevertheless, be developed.37
given the inherent risk of exposure to pathogens in veterinary
practices, the proper use of PPE is a critical component of an ICPB Animals Fed a Raw Meat Diet
program. The purpose is to reduce the risk of contamination of Raw meat diets have grown in popularity.38 Pets fed raw foods are a
clothing, reduce pathogen exposure to skin and mucous membranes unique source of HAI-associated pathogens in the hospital envi-
of personnel, and reduce transmission of pathogens between patients ronment because they may shed organisms (often asymptomati-
by personnel. Common examples of PPE include lab coats, scrubs, cally) that can cause illness in humans or other pets.39–41
gloves, gowns, eye protection, facemasks, and shoe covers. The type Education of the client is of utmost importance with this pop-
of PPE used will vary with procedure and suspicion for an infectious ulation of patients because risk avoidance starts in the home en-
disease and its route of transmission (Table 14). Some form of PPE vironment with adequate cooking of raw ingredients before the
should be worn in all clinical situations, including any contact with patient reaches the hospital. Patients fed raw meat products within
animals and their environment, and should not be worn outside of the past 30 days likely pose the greatest risk and may warrant
the work environment. Lab coats and scrubs should be laundered at enhanced precautions such as use of PPE with or without isola-
least daily or when contaminated (e.g., contact with an infectious tion. Proper handling of feces and surfaces contaminated by pa-
patient). Gloves, gowns, and shoe covers should not be reused, even tients fed raw animal diets (e.g., PPE, prompt cleaning and
when attending to the same patient. Correct removal of PPE is disinfection) is critical.
critical to limit contamination of clothing and skin and mucous
membranes (Table 4). Gloved hands should not be used to contact Multidrug-Resistant Organisms
surfaces that will be touched by nongloved hands, with care taken to MDR organisms (e.g., MRSP, methicillin-resistant S aureus, extended
avoid contamination of personal items (e.g., telephones, pens). spectrum b-lactamase-producing Enterobacteriaceae such as E coli,
There is limited data on the effectiveness of footbaths and foot mats enterococci, Salmonella spp., Acinetobacter spp., Pseudomonas spp.)
32,33
in infection control. Careful use of other approaches (e.g., shoe have become increasingly problematic in veterinary medicine. These
covers) is reasonable and may have fewer concerns (e.g., mainte- organisms can be passed directly or indirectly between patients, the
nance of disinfectant, spills). environment, and staff, resulting in infections that are challenging to
treat.6 Close attention to hand hygiene, early identification of patients
Areas for Special Consideration infected or colonized with these organisms, prompt removal of feces,
Disinfection of Physical Rehabilitation Equipment environmental cleaning and disinfection, proper PPE, surveillance,
(Underwater Treadmill, Mats, Balls) antimicrobial stewardship, and education of clients and the practice
Physical rehabilitation equipment poses a unique challenge for team are the keys to minimizing HAIs by these bacteria.6,42
infection control, as items for this use are frequently difficult
to disinfect (e.g., foam construction, underwater treadmill with Surgery
chemical-sensitive materials). Patients receiving physical rehabili- Surgical site infections are an inherent risk in veterinary medicine
tation are often at increased risk for shedding or acquiring HAI and are complicated by the emergence of MDR organisms and the

318 JAAHA | 54:6 Nov/Dec 2018

 ICPB Guidelines

evolution of more invasive procedures and increasing frequency of and exposure to direct contact with pathogens are similar risk factors
immunocompromised patients.43 Examples of risk factors for SSIs for HAIs and zoonotic transmission to the practice team. Envi-
are the length and invasiveness of the procedure, perioperative hy- ronmental cleaning, separate areas for resuscitation (if possible) to
potension, the presence of MDR organisms on the patient or en- avoid cross-contamination, and the use of PPE during resuscitation
vironment, a “clean” versus “dirty” procedure, and the presence of are critical, and can be easily overlooked during an emergency.7 The
43
an implant. In a recent study of veterinary SSIs, the majority of acute nature of resuscitation emphasizes the need for regular (e.g.,
infections were caused by MRSP, an organism that is not controlled quarterly) “practice runs” in order to prepare the veterinary practice
solely by most patient pre- or postsurgical protocols or perioperative team to properly incorporate hand hygiene, PPE, and cleaning and
43
prophylaxis with beta-lactam antimicrobials (e.g., cephalosporins). disinfection into resuscitation procedures.
HAIs in surgery can be controlled or prevented through attention
to environmental cleaning and disinfection, patient preparation, Immunocompromised Patients
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proper surgical technique, simplified surgical suite design, PPE of Immunocompromised patients include those receiving chemotherapy
surgeons and staff, the use of proper hand preparation techniques, or other immunosuppressive agents and those with immune-altering
Journal of the American Animal Hospital Association 2018.54:297-326.

appropriate (drug, dose, frequency) perioperative antimicrobial comorbidities (e.g., cancer, asplenia), as well as very young and
prophylaxis, and meticulous postoperative wound managment.6,44 geriatric patients. Proper identification of these individuals is im-
Because of enhanced antibacterial efficacy, rapid action, fewer side portant so that individualized procedures can be developed for each
effects (e.g., do not cause skin abrasion), lower potential for re- patient. When possible, the use of higher-risk procedures should be
sistance development, and time savings (generally 3 min rub avoided (e.g., in-dwelling urinary catheters); when used, additional
time), presurgical hand rubbing using alcohol-based formulations attention should be placed on protocols that reduce HAI (e.g., Tables
is now encouraged over traditional scrubs.45 6, 7). In addition, hand hygiene and proper PPE should be strictly
enforced.7
Dentistry
The primary HAI considerations for a veterinary dentistry unit are Obstetrics
the heightened risk of aerosolization of infectious particles; con- Zoonotic risks of exposure to Brucella canis, C burnetii, and other
tamination of equipment such as wet tables, endotracheal tubes, infectious pathogens result from contact with birthing fluids of
and drills; and staff education on environmental cleaning and parturient animals, stillborn fetuses, and infected neonates.7 Proper
disinfection and PPE.46 Aerosols (defined as particles ,50 m that PPE includes gloves, waterproof gowns, and facial protection. In
have the potential to remain airborne and penetrate the airways some circumstances, respiratory tract protection is necessary (e.g.,
and lower lung passages of humans) can transmit pathogens, sa- when handling aborted fetuses likely to be infected with C burne-
liva, blood, and bacteria-laden debris.46 As pathogens frequently tii).7 It is helpful to know in advance what pathogens are common
reside in the oral cavity of companion animals and aerosolization in a geographic area in order to take appropriate infection control
of pathogens is possible, zoonotic transmission during veterinary precautions.
7,47
dentistry is a concern. Pathogens of recent interest and rele-
vance to veterinary dentistry, such as Pasteurella multocida and Burn Care
Staphylococcus spp., emphasize the importance of proper ICPB Although burn victims are relatively uncommon in veterinary medicine,
practices. Irrigating the oral cavity with a 0.12% chlorhexidine they present special challenges because the patients in these cases are
solution before dental scaling has been recommended by some to immunocompromised and have wounds that require invasive tech-
48,49
decrease bacterial aerosolization. Dental procedures should be niques. Burns trigger a cascade of necrotic changes in tissue that are
performed in a designated location distant from other procedures, directly related to the cause of the injury and temperature of exposure.50
patient housing, and staff so as not to potentiate HAIs via aero- Precautions for HAIs depend on the depth and severity of burn-
solization. Proper face protection (e.g., goggles/face shield and resulting thermal injury.50 Infection control, prevention, and bio-
face mask), gowns, and gloves should be used, and surfaces security related to burns focus on wound control and exposure of
cleaned and disinfected between patients.7 patient and veterinary practice team members to potential MDR
pathogens as well as other HAIs. As appropriate, isolation and wound
Resuscitation management including cleaning of the burn site, use of only
Considerations for ICPB for cardiopulmonary resuscitation proce- sterile equipment, and careful attention to hand hygiene with
dures are similar to what are proposed for dentistry. Aerosolization proper PPE are critical for protecting these patients.

JAAHA.ORG 319
 Necropsy critical. Sealing potential pest points-of-entry, including mainte-
Necropsy presents several infection risks for veterinary personnel nance of intact window screens, is important. Elimination of po-
including personal injury while performing the procedure, exposure tential rodent nesting and mosquito breeding sites around the
to zoonotic pathogens originating from the animal, and environ- practice (e.g., brush, debris, empty food bowls, clogged gutters)
7
mental contamination with pathogens. Eye protection, respiratory prevents onsite pest reproduction. Consultation with a pest control
protection, and cut-proof gloves are necessary PPE for necropsy expert is recommended if a particular infestation is present, or for
7
procedures (Table 9). Necropsies should be performed in a location additional guidance and information.
distant from the general hospitalized population and staff. However,
if this is not possible, adherence to PPE, removing organic debris, Spills and Waste
and postprocedural cleaning and disinfection will help minimize Veterinary biomedical waste is a potential source of zoonotic and
HAI risks. nonzoonotic pathogens. In the United States, biomedical waste is
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defined and regulated at both state and municipal levels.51 Veterinary

Environmental Procedures medical waste includes sharps, tissues (anatomic waste), highly
Journal of the American Animal Hospital Association 2018.54:297-326.

Heating, Ventilation, and Air Conditioning contaminated materials, and deceased animals.
Consideration of proper heating, ventilation, and air conditioning is It is beyond the scope of these guidelines to describe spill clean-
critical for practice infection control. Appropriate ventilation is up and veterinary biomedical waste management in detail. However,
particularly important for reducing airborne diseases, excessive basic guidelines are summarized here. Used sharps are considered
moisture and dust, and chemical fumes from disinfection products biomedical waste and should be disposed of in accordance with
that make patients and staff susceptible to infection as a result of regulations from municipal and state authorities. Use approved,
damaging their airways. Ventilation should not cause movement of puncture-resistant sharps disposal containers to remove, store, and
air from areas with known infected patients to other areas of the dispose of needles and other items capable of causing punctures.
practice. Spaces where infected patients are held should be vented to Ensure such containers are readily available and used everywhere
the outside. The number of air exchanges per hour (the rate at which sharps are handled to prevent sharps injuries to staff and clients.
the complete volume of air inside a building or room is replaced with Nonanatomical waste saturated with blood, such as blood-soaked lap
fresh outside air) is critical for good ventilation. Recommendations sponges and gauze, or materials used to clean up a spill of blood or
vary between 5 and 8 air exchanges per hour. Whenever possible, infectious secretions, are also disposed of as biomedical waste.
three levels of air filtration are recommended in a practice: (1) a wire Liquid waste such as drained thoracic fluid, abdominal fluid, ir-
mesh to remove hair and large matter from the air; (2) a finer (less rigated solutions, excretions, and secretions may usually be poured
porous) filter placed within the air ducts to remove dust and other carefully down a toilet or drain connected to a sanitary sewer or
particulate matter; and (3) a high-efficiency particulate air filter septic tank. Local, state, and federal regulations may dictate
to remove viral particles and very fine particulate matter. High- maximum volume of blood or body fluids permitted to be poured
efficiency particulate air filters are expensive, and appropriate into the sanitary sewer. If the fluid is likely to splash or spray during
replacement of these filters may not be affordable for all prac- disposal, appropriate PPE should be worn. Waste should be con-
tices. Regardless of type, filters must be cleaned or changed tained in a leak-proof container or bag discarded with the waste
frequently to prevent infectious buildup and hair-clogged vents. (plastic garbage bag). Urine and feces are not biomedical waste, nor
Ventilation systems need to be inspected regularly and updated is disposable equipment that has come in contact with an infectious
as needed. animal (e.g., examination gloves, gowns, bandage materials not
saturated with blood).
Rodent and Insect Vectors Potentially infectious, contaminated materials may pose a risk to
Some important veterinary pathogens can be transmitted by wild practice personnel, patients, and waste disposal personnel. Precau-
rodents or insect vectors (e.g., fleas, ticks, mosquitoes, flies). Pest tions should be taken to minimize contamination of the practice
management practices include examination of patients upon arrival environment and the risk to people and animals from potentially
for ectoparasites; immediate treatment of patients with fleas, ticks, or infectious waste. These include double-bagging of materials from
mites; and appropriate housing (e.g., isolation) until resolution. Dry isolation areas. If the inside of a waste container becomes con-
pet food and garbage should be stored in metal or thick plastic taminated, the container should be thoroughly cleaned and dis-
containers with pest-proof lids. Prompt disposal of food waste and infected after emptying. All waste from an isolation room should be
other materials (e.g., feces) that may attract rodents or insects is treated as potentially infectious; trash from these areas should be

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 ICPB Guidelines

removed by appropriately gloved and gowned personnel. Contam- healthcare is one of the key factors leading to the current epidemic of
inated articles should be either discarded or taken for additional antimicrobial resistance. More information on the overall concept of
cleaning and disinfection. Rural practices, where biomedical waste antimicrobial stewardship and how it is applied in veterinary practice
disposal services may not be available, may be able to make ar- as advised by the American Veterinary Medical Association can
rangements with a local human hospital or other medical facility to be found at avma.org/KB/Resources/Reports/Pages/Antimicrobial-
have waste disposed of with human hospital waste. Stewardship-in-Companion-Animal-Practice.aspx. Previously cre-
ated American Association of Feline Practitioners-AAHA guidelines
Laundry discuss the judicial therapeutic use of antimicrobials (aaha.org/
Single-use, disposable items are ideal for infection control, but their public_documents/professional/guidelines/aafp_aaha_antimicro-
disposal produces tremendous waste and an environmental burden. bialguidelines.pdf). Information on more longstanding antimicro-
Laundering reusable bedding, gowns, scrubs, towels, and other items bial stewardship practices in human hospitals and long-term care
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is therefore an important component of infectious disease control. facilities in the United States, referenced in the American Veterinary
Linens and professional garb can serve as fomites, transporting Medical Association document, can be found at cdc.gov/getsmart/
Journal of the American Animal Hospital Association 2018.54:297-326.

pathogens within the practice and outside the practice into the healthcare/implementation/core-elements.html.
community. Microbe populations on soiled laundry are significantly
reduced by dilution and further by the mechanical action of washing. Personnel Vaccination
Hot air drying further eliminates microorganisms. As transport to Although not always financially viable for all hospitals or staff
individuals’ homes or other facilities increases ICPB risks, pro- within a hospital, personnel vaccination is an important compo-
fessional garb (e.g., scrubs, lab coats) should be washed onsite or nent of occupational health and safety. Decisions regarding vac-
by a specialized commercial laundry facility equipped to clean cination of staff should consider the risk of exposure, the severity of
medical laundry. Practices should have appropriate laundry fa- disease, whether the disease is treatable, the transmissibility of
cilities or laundry services to accommodate cleaning of these disease, and the quality and safety of the vaccine. It is recommended
items daily or more frequently if necessary. To reduce contami- that all veterinary personnel who might have contact with animals
nation with infectious organisms and health risks to staff, ap- should be vaccinated against rabies, except in areas that have been
propriate PPE (i.e., gloves and dedicated laboratory coat) should formally declared rabies-free (e.g., Hawaii).7 This includes lay staff
be worn by those performing laundry duties. Linens with gross that might have periodic animal contact, such as receptionists.
contamination should be assessed to determine if they can be Rabies vaccines for humans are generally considered safe and
effectively cleaned. If not, they should be properly discarded. highly effective. For additional information on human rabies
Otherwise, gross organic material should be removed prior to vaccination, see the CDC rabies website (cdc.gov/rabies/exposure/
washing. preexposure.html).
Additional precautions should be taken for laundry from iso- Other vaccinations including tetanus and annual influenza may
lation rooms and infected animals. These items should be washed be appropriate depending on the practice setting and other exposure
and processed separately from other practice laundry while wearing risks. Additional information is available.7
appropriate PPE to prevent spread of microbes. Items from infected
animals should be presoaked in diluted bleach (9 parts water:1 part Education, Training, and Compliance
household bleach) for 10 min to disinfect prior to machine washing. Education and training of the practice team is an integral part to any
Isolation-room laundry should be washed in hot water with bleach, successful ICPB program. Numerous studies have demonstrated
per manufacturer’s instructions. After bleaching and washing, decreases in HAIs after some form of educational or training pro-
laundry should be completely dried in a separate load from any gram was completed.52–55 A comprehensive training program should
other laundry and returned to isolation. include education on basic principles of ICPB, departmental specific
protocols, strategies to develop critical and independent thinking to
Appropriate Antimicrobial Stewardship help team members in unexpected patient care situations, and an
The concept of antimicrobial stewardship, or the judicious use of evaluation of staff compliance through surveillance, testing, and
antimicrobials, including when not to use these agents, has emerged auditing.56
in the last decade as a necessary approach across health professions to The effectiveness of an ICPB program is dependent on not only
prevent adverse events and selection for drug-resistant infectious appropriate training of the practice team, but on the extent to which
pathogens. The misuse of antimicrobials in human and veterinary infection control protocols are accepted by the practice team as

JAAHA.ORG 321
 necessary and useful.57,58 Therefore, it is critical that prior to starting the training program, and this type of training can be accomplished
the formal education program, the practice team is committed to without excessive time or expense. The use of fluorescent tagging or
and passionate about infection control. One strategy to accomplish simulated patients (stuffed animals or staff pets) can be helpful in
this is a hospital-wide meeting (or a small-group meeting if training staging a mock infection outbreak. Infection control drills can be
new employees) in which the ICP discusses recent hospital or local staged during downtime in the practice. Receptionists can receive a
disease outbreaks, documented increases in HAIs, or presents cur- call from a mock client that challenges their history-taking and
rent ICPB deficiencies at the practice (e.g., observations of hand decision-making process.
hygiene compliance, environmental cleaning deficiencies identified A method for evaluating compliance with the practice’s training
with fluorescent tagging; see the “Implementing an Infection Con- program is needed to ensure the training has been successful, and
trol Program” section). The ICP should use data uncovered during a formal performance feedback program can also further im-
an assessment/audit of the practice facility to guide this discussion prove outcomes.53 Written testing of basic ICPB knowledge and
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(Table 10). departmental-specific protocols should be performed at the end of

The formal education program should begin with training all each training period and periodically thereafter to assess retention of
Journal of the American Animal Hospital Association 2018.54:297-326.

practice team members on the basic principles of ICPB. Topics to knowledge. Routine surveillance data should be used to monitor for
cover include modes of transmission of pathogens (discussed earlier any breaches or noncompliance with the ICPB program. Regular
in these guidelines), common pathogens that may be encountered in reporting of this data can provide feedback to staff members.
the practice setting, and a demonstration of appropriate hand hy- Simulated, real-world scenarios can also be useful in assessing the
giene and PPE use. Cleaning and disinfection protocols should be practice team’s knowledge of infection control and can be used to
covered at this time as well. This training can take the form of an in- monitor compliance with the program. These tools for evaluating
person meeting, required reading/online training, or both, depending and assessing compliance should be applied in a positive, nonpu-
on the practice setting. nitive way to help motivate staff to consistently and effectively im-
After teaching basic ICPB principles, focused education on plement the practice’s program and appreciate the importance of
departmental-specific protocols and situations should be covered. each person’s actions in HAI prevention and overall ICPB success.
This is best accomplished by integrating infection control education
into routine training on daily duties for the position, supplemented Client Education
with handouts and checklists covering specific protocols. For ex- Although veterinary staff work to prevent the spread of pathogens
ample, during phone training for receptionists, there should be and disease within their facilities, it is imperative that clients are also
discussion of recognizing cases that may present an infection control sufficiently educated regarding the key role they have in ICPB in the
concern, phone scripts to identify high-risk patients, demonstrating community and their home environment. Educating clients on the
appointment scheduling for a suspected infectious patient, and importance of regular visits to their veterinarian and appropriate
learning arrival instructions for patients with infectious disease. The preventive measures, such as vaccination, endo- and ectoparasite
team member being trained should be given written material to control, and good overall health of their pets, is the best way to
reference and shown where to easily access any scripts or checklists prevent the spread of disease.
within the practice. In addition to general infectious disease education, clients
However, even the most extensive training cannot prepare should be informed on zoonotic risks relevant to their pets, them-
practice team members for all the possible infection control scenarios selves, and family members. Key pathogens to highlight for clients
they might encounter. Although having protocols for the most include but are not limited to common endoparasites (e.g., hook-
common situations is helpful, practice team members must also worms, roundworms, tapeworms), dermatophytosis, toxoplasmosis,
develop a level of critical and independent thinking about infection geographically relevant ectoparasite-transmitted diseases, rabies,
control so that they can make sound clinical decisions when en- Salmonella, and Campylobacter spp.60 Some diseases, although not
countering a more complex or unexpected situation. Simulations of transmitted directly from the pet to humans, still demand appro-
these situations has been theorized to improve outcomes in the priate control methods such as avoiding exposure to vector-borne
human medical field.58,59 Although the resources of a typical vet- diseases via shared contact with the pet or its environment. For
erinary practice do not allow for the often-extensive simulated example, fleas are easily transferred between animals and humans.
training that occurs in human hospitals, simulating infection con- Environmental or on-animal infestations, particularly in homes
trol scenarios in the practice setting can be an invaluable tool. The with young children, carry a risk of zoonosis for flea-borne diseases,
ICP’s creativity is a key factor in the infection control component of such as Bartonella infection. Although there is not a direct zoonotic

322 JAAHA | 54:6 Nov/Dec 2018

 ICPB Guidelines

risk from ticks attached to a pet, they should be disposed of carefully organ transplantation, or treatment for autoimmune diseases; or
when removed, and owners of these pets should take caution of have other conditions for which their physician has indicated that
similar risks to themselves and others in the household due to en- they are at an increased risk for infections should take greater
countering ticks in the same environments as their pet.61 caution.62 Immunocompromised clients should be advised of
It is possible to reduce the spread of zoonotic diseases with modifiable behaviors that reduce their risk for pet-associated in-
appropriate preventive care including routine veterinary visits for fections, with particular emphasis on always performing hand hy-
annual exams, vaccinations, overall health assessment, as well as flea giene after pet contact, discouraging pets from face-licking, and not
and tick control as indicated by their area. Fecal exams for detection having contact with pet feces (i.e., ideally have an immunocompe-
of intestinal parasites should be performed as indicated by the patient tent household member perform this duty). Regular cleaning and
age, geographical location, and parasite exposure risk. disinfection of cages, food areas, bedding, and toys should be per-
Further owner considerations in preventing zoonotic diseases formed by an immunocompetent individual who observes strict
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include the practice of good personal hygiene, particularly hand hand hygiene. Immunocompromised people should avoid contact
hygiene after handling pets; handling pet food and treats, especially with amphibians, reptiles, rodents, exotic animals, strays, young
Journal of the American Animal Hospital Association 2018.54:297-326.

when it includes an uncooked meat product; and always before animals, and any animal suspected to be infectious (e.g., with acute
eating. Litter boxes, pet dishes, pet beds, and toys should be kept vomiting, diarrhea, skin disease), as well as items that have been in
clean. Cat litter boxes should be cleaned regularly (daily if higher- contact with these animals.
risk persons are in the household). In the case of households with A key to infection control success in the household and com-
dogs, cleaning up pet feces should be done regularly (e.g., at least munity is client compliance with risk reduction strategies. This
weekly) to reduce environmental contamination with pathogens. requires active involvement and cooperation of the clinical team and
Feces should be disposed of in a waste receptacle, not in recyclable the client. Clients should be provided with handouts in addition to
waste or compost. Additional pet “messes” (vomitus, stool, and face-to-face counseling on prevalent local infectious diseases of
urine) should be cleaned up, disposed of accordingly, and surfaces importance. Pet owners can also be directed to online resources such
disinfected. Hands should be thoroughly washed afterward; gloves as the Companion Animal Parasite Council (capcvet.org/capc-
can be used to provide an extra level of protection. Pets should recommendations), the CDC’s Healthy Pets Healthy People (cdc.
be fed a high-quality diet, avoiding raw or undercooked diets. gov/healthypets), Worms and Germs Blog’s resources for pets
Hunting for food sources, including garbage or table scraps, (wormsandgermsblog.com), the DVM360’s handout on parasites
should also be discouraged. Additional pet behaviors that can pose (veterinarybusiness.dvm360.com/forms-parasitology-handouts), and
increased zoonotic disease risks and should be discouraged are aaha.org/biosecurity.
drinking from the toilet, eating feces (own or of other animals),
and drinking standing water. Summary
Pets should not be permitted to have contact with wild animals. Without effective ICPB practices implemented in the primary care
Owners of pets likely to have contact with wild animals (e.g., pre- and referral settings, the clinician’s efforts at disease prevention
dominately outdoor, hunting) should be informed of these increased and treatment are compromised and, in some cases, nullified.
risks and, when possible, preventive measures taken to reduce pet and Because many pathogens in the hospital environment have
owner health risks (e.g., endo- or ectoparasite prevention, rabies zoonotic potential, barriers to human exposure to animal
vaccination, preventing consumption of wildlife). Potentially con- pathogens in a clinical setting also serve to safeguard public
taminated environments or situations in which exposure risks are health. Taken together, the consequences of ICPB have profound
unknown, including interactions with animals with unknown vac- implications for clinical practice and should be of high priority.
cination or parasite status, should be avoided. Additional suggestions Stated another way, the veterinarian’s best efforts can be negated
for prevention of infection include regular pet grooming and bathing, if faulty ICPB results in exposure of the staff or patient to in-
maintaining short nails to prevent scratches, and spaying and fectious pathogens.
neutering to prevent roaming, which can increase risk of disease The methodology of ICPB is largely procedural, meaning that it
exposure and transmission.60 is based on protocols and SOPs that apply to the entire healthcare
Immunocompromised people have an increased risk of ac- team. To adapt to changing circumstances at the local level, including
quiring zoonotic diseases, including those transmitted by pets. Those staff turnover, these processes should be regularly revisited, followed
individuals who are ,5 or .65 yr of age; pregnant; diabetic; have by revision as needed, with refresher trainings for the entire
HIV-infection; are undergoing immunosuppressive chemotherapy, healthcare team. Patient and staff flow, hand hygiene, cleaning and

JAAHA.ORG 323
 disinfection, and PPE serve as the foundation for ICPB practices and as well as indirect financial, social, and environmental positive
should be addressed in all practice programs. impacts.
Effective ICPB is based on control methods that form a hier-
archy of effectiveness. Prevention (elimination) of microbial con- The AAHA Infection Control, Prevention, and Biosecurity task
tamination by removal or denying access to general patient areas of force gratefully acknowledges the contribution of Mark Dana of
the premises by high-risk patients (i.e., those considered likely to be Kanara Consulting Group, LLC in preparation of the guidelines.
infectious) is the most effective method of ICPB control, followed in
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