Continuing Education Activity

Universal precautions are a foundational infection control practice introduced by the Centers for Disease Control and Prevention in 1985 to prevent transmission of bloodborne pathogens such as HIV and hepatitis B. These precautions require all blood and certain body fluids to be treated as potentially infectious, regardless of patient history or perceived risk.

Universal precautions apply to situations involving potential exposure to blood and certain body fluids, emphasizing the use of protective barriers, such as gloves, masks, gowns, and the safe handling of sharps and contaminated materials to prevent the transmission of bloodborne pathogens. Unlike body substance isolation or standard precautions, which evolved later to include a broader range of pathogens, universal precautions focus specifically on bloodborne exposures. Implementation requires administrative support, staff training, access to protective equipment, and adherence to established protocols.

The continued relevance of this approach underscores the need for consistent, system-wide practices that minimize occupational risk and protect both healthcare personnel and patients. Effective implementation depends on administrative support, staff education, readily accessible protective equipment, and strict adherence to established protocols.

This activity for healthcare professionals is designed to enhance learners' competence in appropriately implementing universal precautions. Participants deepen their understanding of exposure risks across expected, unexpected, and negligent scenarios. Improved proficiency enables clinicians to collaborate effectively within interprofessional teams, preventing the transmission of infections, managing incidents, and ensuring the safety of both healthcare personnel and patients.

Objectives:

• Differentiate universal precautions from other infection control strategies, such as standard precautions, by identifying their specific indications and limitations.
• Identify clinical scenarios requiring universal precautions.
• Implement universal precautions effectively across various clinical scenarios to prevent the transmission of bloodborne pathogens and protect both patients and healthcare personnel.
• Apply effective interprofessional team strategies to promote a culture of safety and address barriers to implementing universal precautions.

Introduction

Universal precautions were introduced by the Centers for Disease Control and Prevention (CDC) in 1985 in response to the HIV epidemic.[1][2][3][4] These guidelines establish a standardized approach to preventing the transmission of bloodborne pathogens through exposure to blood and other potentially infectious materials. According to the Occupational Safety and Health Administration (OSHA), other potentially infectious materials include the following:

• Human body fluids, such as semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva encountered in dental procedures, any body fluid visibly contaminated with blood, and any fluid in which differentiation is not possible
• Any unfixed human tissue or organ, excluding intact skin
• HIV-containing cell or tissue cultures, organ cultures, and HIV- or hepatitis B virus (HBV)-containing culture media or solutions; and blood, organs, or tissues from experimental animals infected with HIV or HBV.[5]

Universal precautions do not apply to substances such as sputum, feces, sweat, vomit, tears, urine, or nasal secretions unless they are visibly contaminated with blood, as these substances carry minimal to no risk for HIV or HBV transmission.

In 1987, a separate set of infection control guidelines known as body substance isolation was introduced by the CDC. This approach emphasized the avoidance of direct contact with all moist and potentially infectious body substances, regardless of whether visible blood was present. A major limitation of this approach was the recommendation to perform hand hygiene after glove removal only when hands were visibly soiled.

In 1996, the Guideline for Isolation Precautions in Hospitals was issued by the CDC through the Healthcare Infection Control Practices Advisory Committee (HICPAC), integrating the core elements of universal precautions and body substance isolation into what became known as standard precautions. In addition to standard precautions, the guideline introduced 3 categories of transmission-based precautions—airborne, droplet, and contact—which are intended for use in conjunction with standard precautions to prevent the spread of specific infectious agents.[6][7][8][9]

Function

Standard Precautions

Standard precautions apply to the care of all patients, regardless of known or suspected disease status. These measures are recommended whenever potential exposure occurs to blood; all body fluids, secretions, and excretions (excluding sweat), regardless of visible blood; nonintact skin; and mucous membranes. Core elements of standard precautions include hand hygiene and the use of personal protective equipment (PPE), with hand hygiene recognized as the most effective method for interrupting the transmission of diseases.[10][11][12][13][14]

PPE provides a physical barrier to prevent contamination of the skin, mucous membranes, respiratory tract, and clothing. Recommended components include gowns, gloves, masks, and either face shields or goggles, depending on the anticipated level and type of exposure.[15][16] The standard precautions listed below reflect common recommendations for healthcare personnel; however, the list is not exhaustive and should be adapted to the specific clinical context.

Hand hygiene: Handwashing with soap and water for 40 to 60 seconds is required when the hands are visibly soiled, after using the restroom, or when exposure to spore-forming organisms, such as Clostridioides difficile, is suspected. Clean hands should not be used to turn off the faucet to avoid recontamination. Alcohol-based hand rubs may be used in the absence of visible soiling or concerns related to spores. The solution should be applied generously to ensure full hand coverage and rubbed until completely dry.

Hand hygiene is indicated in the following situations:

• Before and after any direct patient contact, and between contacts with different patients, regardless of glove use
• Immediately after glove removal
• Before handling an invasive device
• After contact with blood, body fluids, secretions, excretions, nonintact skin, or contaminated items, even when gloves are worn
• While moving from a contaminated to a clean body site during patient care
• After contact with inanimate objects in the immediate vicinity of the patient

Routine and correct hand hygiene strengthens infection control efforts across the interprofessional team. The integration of these practices into the daily workflow maintains a safe clinical environment for both patients and healthcare personnel.

Gloves: Gloves must be worn when contact with blood, body fluids, secretions, excretions, mucous membranes, or nonintact skin is anticipated. Gloves should be changed after contact with potentially infectious material, even within the same patient encounter, to prevent cross-contamination. Gloves should be removed before touching environmental surfaces or handling cleaning equipment. Proper hand hygiene is essential before and after glove use, as gloves do not eliminate the risk of contamination.

Facial protection: A mask and eye protection or a face shield should be worn during procedures that may result in sprays or splashes of blood, body fluids, secretions, or excretions. Protective equipment should be positioned to fully cover the eyes, nose, and mouth to prevent mucosal exposure.

Gown: A gown should be worn during procedures with potential for spray or splash of blood, body fluids, secretions, or excretions. Proper donning and doffing techniques must be followed to prevent self-contamination.

Needles and other sharps: Used needles should not be broken, bent, or manually manipulated. Recapping is discouraged, but a one-handed scoop technique should be used if this measure is necessary. All used sharps must be discarded in designated puncture-resistant containers.

Transmission-Based Precautions

Transmission-based precautions provide additional protective measures for patients known or suspected to be infected with specific pathogens requiring more than Standard Precautions. These precautions are implemented based on the pathogen's mode of transmission to prevent the spread of health care–associated infections.

Airborne precautions: Airborne precautions are indicated for patients with known or suspected infections caused by pathogens transmitted through airborne droplet nuclei, defined as small-particle residues (≤5 µm) of evaporated droplets or dust particles capable of remaining suspended in the air for prolonged periods. Patients should be placed in a negative-pressure isolation room providing 6 to 12 air changes per hour. Cohorting may be considered for patients infected with the same pathogen and who do not have other concurrent infections. Room doors must remain closed at all times. When private rooms are unavailable and cohorting is not feasible, infection control personnel should be consulted before placement.

A respirator capable of filtering at least 95% of airborne particles—such as N95 respirators or powered air-purifying respirators equipped with high-efficiency particulate air filters—should be worn over the nose and mouth. A surgical mask should be placed on the patient when transport is necessary to minimize the dissemination of airborne particles.

Droplet precautions: Droplet precautions are indicated for patients with known or suspected infections caused by pathogens transmitted through respiratory droplets. These droplets, typically 5 µm or larger, are particles of respiratory secretions that remain suspended in the air for limited periods and are associated with transmission occurring within a distance of 3 to 6 feet (1-2 meters) from the source.

Patients should be placed in private rooms whenever possible. Cohorting may be permitted if both patients have the same active infection and no other concurrent infections. When neither private rooms nor cohorting is feasible, the infected patient should be positioned at least 3 feet away from others. Doors may remain open, and special air handling is not required. A surgical mask should be worn when within 6 feet of the patient. If the patient must be transported, a surgical mask should be placed to minimize the risk of droplet spread.

Contact precautions: Contact Precautions are used for patients with known or suspected infections or colonization involving pathogens transmitted through direct or indirect contact. Indirect contact refers to the transmission of infection through contaminated surfaces or objects in the patient's environment. Patients should be placed in private rooms whenever possible. Cohorting may be considered for patients with the same active infection and no other concurrent infections. When neither private rooms nor cohorting is feasible, placement decisions should be guided by the epidemiology of the organism and characteristics of the patient population, in consultation with infection control personnel.

Gloves and gowns should be donned before entering the patient's room and removed before exiting. Hand hygiene must be performed immediately afterward. Care should be taken to avoid touching potentially contaminated surfaces during exit.[17][18][19]

Contact precautions must be maintained during patient transport. Whenever possible, dedicated equipment should remain in the patient's room. If shared use is necessary, all equipment must be properly cleaned and disinfected before use on another patient.

Issues of Concern

Airborne precautions should be implemented for the following infections and conditions for at least the minimum duration indicated:

• Aspergillosis: If associated with massive soft tissue infection requiring copious drainage and repeated irrigations
• COVID-19: Requires both airborne and droplet precautions
• Herpes zoster: For the duration of illness, if disseminated or in immunocompromised patients
• Measles: For 4 days after rash onset in immunocompetent hosts; for the duration of illness in immunocompromised individuals
• Monkeypox: Until the diagnosis is confirmed and smallpox has been excluded
• Severe acute respiratory syndrome: For the duration of illness plus 10 days after fever and respiratory symptoms have resolved or improved
• Smallpox: For the duration of illness
• Pulmonary or laryngeal tuberculosis: Until clinical improvement with effective therapy and 3 consecutive negative sputum smears
• Extrapulmonary tuberculosis with draining lesions: Until clinical improvement and cessation of drainage or 3 consecutive negative cultures
• Varicella zoster: Until all lesions have crusted and dried

Droplet precautions should be implemented for the following infections and conditions for the duration listed: 

• Adenovirus pneumonia: For the duration of illness
• COVID-19: Requires both droplet and airborne precautions
• Pharyngeal diphtheria: Until completion of antibiotics and 2 negative cultures taken 24 hours apart
• Haemophilus influenzae type b causing epiglottitis or meningitis: Until 24 hours after initiating effective therapy
• Influenza during a pandemic: For the duration of illness
• Neisseria meningitidis causing meningitis, sepsis, or pneumonia: Until 24 hours after initiating effective therapy
• Mumps: For 5 days after symptom onset
• Mycoplasma pneumoniae: For the duration of illness
• Parvovirus B19 (acute or chronic disease in an immunocompromised host): For 7 days in acute infection; for the duration of hospitalization in chronic cases
• Pertussis: For 5 days after initiating therapy
• Yersinia pestis during a pneumonic plague: For 48 hours after effective treatment begins
• Group A Streptococcus causing pneumonia, pharyngitis, scarlet fever, or serious invasive disease: Until 24 hours after initiating effective therapy
• Rhinovirus: For the duration of illness
• Rubella: Until 7 days after rash onset
• Severe acute respiratory syndrome: For the duration of illness plus 10 days after resolution or improvement of fever and respiratory symptoms
• Ebola, Marburg, Crimean-Congo, and Lassa fever viruses (viral hemorrhagic fevers): For the duration of illness [20]

Contact precautions should be implemented for the following infections and conditions for the duration listed:

• Extensive abscess with drainage: For the duration of illness until drainage ceases
• Adenovirus: For the duration of illness
• Burkholderia cepacia in patients with cystic fibrosis: For the duration of illness
• Bronchiolitis: For the duration of illness
• C difficile infection: For the duration of illness
• Congenital rubella: Until 1 year of age, or until urine and nasopharyngeal cultures are consistently negative after 3 months of age
• Viral conjunctivitis: For the duration of illness
• Cutaneous diphtheria: Until completion of antibiotics and 2 negative cultures taken 24 hours apart
• Furunculosis caused by Staphylococcus aureus: For the duration of illness
• Rotavirus: For the duration of illness
• Hepatitis A in incontinent patients: For the duration of hospitalization in children younger than 3, 2 weeks after onset in those aged 3 to 14, and 1 week after onset in those older than 14
• Neonatal, disseminated, severe, or mucocutaneous herpes simplex: Until lesions crust and dry
• Disseminated herpes zoster: For the duration of illness
• Human metapneumovirus: For the duration of illness
• Impetigo: Until 24 hours after initiating effective therapy
• Head lice: Until 24 hours after initiating effective therapy
• Monkeypox: Until all lesions have crusted
• Multidrug-resistant organism infection or colonization: While ongoing transmission risk is evident, or open wounds cannot be covered
• Parainfluenza virus: For the duration of illness
• Poliomyelitis: For the duration of illness
• Large, infected pressure ulcers: For the duration of illness
• Respiratory syncytial virus: For the duration of illness in infants, young children, and immunocompromised adults
• Staphylococcal scalded skin syndrome (Ritter disease): For the duration of illness
• Scabies: Until 24 hours after initiating effective treatment
• Severe acute respiratory syndrome: For the duration of illness plus 10 days after resolution or improvement of fever and respiratory symptoms
• Smallpox: For the duration of illness
• Major S aureus skin infection: For the duration of illness
• Major Group A Streptococcus skin infection: Until 24 hours after initiating effective therapy
• Extrapulmonary tuberculosis with draining lesions: Until clinical improvement and cessation of drainage or 3 consecutive negative cultures
• Vaccinia: Until lesions crust and dry
• Varicella-zoster: Until all lesions have crusted and dried
• Viral hemorrhagic fevers, such as Ebola, Marburg, Crimean-Congo, and Lassa: For the duration of illness
• Major wound infections: For the duration of illness

Strict adherence to appropriate transmission-based precautions is essential for preventing health care–associated infections. Consistent implementation of these measures protects both patients and healthcare personnel from avoidable exposure.

Clinical Significance

Occupational exposure to blood and other potentially infectious materials has prompted multiple regulatory agencies to establish guidelines and mandates concerning universal precautions. The effective implementation of standard precautions plays a crucial role in limiting the transmission of infectious diseases.[21][22] Healthcare personnel must actively anticipate potential exposure scenarios for each patient encounter. For instance, treating a trauma patient with arterial bleeding necessitates the use of gloves, a gown, and a mask with a face shield. Some pathogens require a combination of transmission-based precautions. For example, disseminated herpes zoster necessitates the simultaneous use of standard, contact, and airborne precautions.

Other Issues

Proper Donning and Removal of Personal Protective Equipment

The proper sequence for donning PPE, as recommended by the CDC, begins with the gown, followed by the mask or respirator, then goggles or a face shield, and finally gloves. This order ensures maximal protection and reduces the risk of contamination during patient contact.

Removing PPE safely requires careful attention to surfaces that are now considered contaminated. Gloves should be removed first by grasping the outside of one glove at the palm and peeling it away. The removed glove should be held in the gloved hand while sliding the fingers of the ungloved hand under the remaining glove and peeling it off over the first. Goggles or a face shield should be lifted from behind the head without touching the front. The gown should be untied and pulled away from the neck and shoulders, turned inside out, and removed by handling only the inner surface. The mask or respirator should be removed by reaching behind the head, first releasing the bottom ties, then the top ties, and lifting it away from the face without touching the front.

Alternatively, gloves and gown may be removed together by grasping the gown at the front and pulling it away from the body, rolling it into a bundle while simultaneously removing the gloves, ensuring the contaminated surfaces remain enclosed. Hand hygiene must be performed after PPE removal and at any point during the process if contamination is suspected. If the patient must be transported outside the room, PPE should remain in place until direct contact with the patient has concluded.

Enhancing Healthcare Team Outcomes

Preventing the transmission of infectious diseases is a fundamental responsibility shared by all healthcare professionals, including nurse practitioners. In 1996, the Guideline for Isolation Precautions in Hospitals was issued by the CDC through the HICPAC, integrating the core elements of universal precautions and body substance isolation into a unified approach now referred to as standard precautions. This guideline also introduced 3 categories of transmission-based precautions—airborne, droplet, and contact—which must always be applied in conjunction with standard precautions.

Interprofessional teams within each institution are tasked with overseeing the implementation and adherence to these infection control measures. Randomized audits should be conducted to assess compliance, and personnel found to be in violation must receive appropriate corrective action, including remedial education in infection prevention.[23][24][25]

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References

1.

The Lancet Hiv Progress in elimination of vertical HIV transmission. Lancet HIV. 2025 Jul;12(7):e463. [PubMed: 40579050]

2.

Yasin J, Fisseha R, Mekonnen F, Yirdaw K. Occupational exposure to blood and body fluids and associated factors among health care workers at the University of Gondar Hospital, Northwest Ethiopia. Environ Health Prev Med. 2019 Mar 09;24(1):18. [PMC free article: PMC6408855] [PubMed: 30851726]

3.

Larson C, Oronsky B, Varner G, Caroen S, Burbano E, Insel E, Hedjran F, Carter CA, Reid TR. A practical guide to the handling and administration of personalized transcriptionally attenuated oncolytic adenoviruses (PTAVs). Oncoimmunology. 2018;7(9):e1478648. [PMC free article: PMC6140583] [PubMed: 30228948]

4.

Brooks C, Ballinger C, Nutbeam D, Mander C, Adams J. Nursing and allied health professionals' views about using health literacy screening tools and a universal precautions approach to communication with older adults: a qualitative study. Disabil Rehabil. 2020 Jun;42(13):1819-1825. [PubMed: 30669896]

5.

Stedman M, Kitching S, Whyte MB, Heald A. Protective Measures Taken in Residential Care Homes in England During the COVID-19 Pandemic. An Assessment of the Change in Mortality Rates Before and During the COVID-19 Pandemic Years. Infect Dis Ther. 2025 Aug;14(8):1649-1665. [PMC free article: PMC12339804] [PubMed: 40571829]

6.

King KC, Strony R. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): May 1, 2023. Needlestick. [PubMed: 29630199]

7.

Centers for Disease Control and Prevention. Ebola Virus Disease. Resources and Guidance from the CDC. Insight. 2015 Winter;40(1):11-8. [PubMed: 26364436]

8.

Goodman MS, Griffey RT, Carpenter CR, Blanchard M, Kaphingst KA. Do Subjective Measures Improve the Ability to Identify Limited Health Literacy in a Clinical Setting? J Am Board Fam Med. 2015 Sep-Oct;28(5):584-94. [PMC free article: PMC4987705] [PubMed: 26355130]

9.

Rezaei F, Ghorbannejad M, Najarkolaie FM, Kordian A, Salamat FZ, Riseh FN, Esmi A. Knowledge and Performance of Nurses in Observing Standard Precautions: A Narrative Review. J Pharm Bioallied Sci. 2025 May;17(Suppl 1):S197-S200. [PMC free article: PMC12156668] [PubMed: 40511130]

10.

Ndu AC, Arinze-Onyia SU. Standard precaution knowledge and adherence: Do Doctors differ from Medical Laboratory Scientists? Malawi Med J. 2017 Dec;29(4):294-300. [PMC free article: PMC6019545] [PubMed: 29963283]

11.

Banach DB, Bearman G, Barnden M, Hanrahan JA, Leekha S, Morgan DJ, Murthy R, Munoz-Price LS, Sullivan KV, Popovich KJ, Wiemken TL. Duration of Contact Precautions for Acute-Care Settings. Infect Control Hosp Epidemiol. 2018 Feb;39(2):127-144. [PubMed: 29321078]

12.

COMMITTEE ON INFECTIOUS DISEASES. Recommendations for Prevention and Control of Influenza in Children, 2017 - 2018. Pediatrics. 2017 Oct;140(4) [PubMed: 28870977]

13.

COMMITTEE ON INFECTIOUS DISEASES. Recommendations for Prevention and Control of Influenza in Children, 2016-2017. Pediatrics. 2016 Oct;138(4) [PubMed: 27600320]

14.

Chen R, Du Y, Zhang J, Wang L, Cheng H, Wu L, Yu T, Chen Q, Wang G. Investigation on hand hygiene in anaesthesiology departments in China. J Hosp Infect. 2025 Sep;163:42-50. [PubMed: 40571257]

15.

Abbas MA, Abdullahi AA, Murtala HA, Yusuf AL, Mukhtar RA, Salihu HM. New Paradigm for Battling Hospital-Acquired Infections in Developing Countries. Int J MCH AIDS. 2025;14:e008. [PMC free article: PMC12180738] [PubMed: 40547272]

16.

Meunier O, Eckenfelder D, Bertaux AC, Hanssen C, Fersing T, Burger S, Santasouk J, North S. [Risk perception and confidence assessment of healthcare professionals' barrier measures in the Covid-19 era]. Soins. 2022 Jan-Feb;67(862):17-24. [PubMed: 35148850]

17.

With strengthened guidelines for health care workers, the CDC ups its game against the deadly Ebola virus. ED Manag. 2014 Dec;26(12):133-6. [PubMed: 25522493]

18.

Hinkin J, Gammon J, Cutter J. Review of personal protection equipment used in practice. Br J Community Nurs. 2008 Jan;13(1):14-9. [PubMed: 18399366]

19.

Schrank GM, O'Hara LM, Pineles L, Popescu S, Brown JP, Magder L, Harris AD. A survey of healthcare workers on the acceptance and value of personal protective equipment for patient care. Infect Control Hosp Epidemiol. 2024 Oct 23;:1-5. [PubMed: 39440514]

20.

Moriceau G, Gagneux-Brunon A, Gagnaire J, Mariat C, Lucht F, Berthelot P, Botelho-Nevers E. Preventing healthcare-associated infections: Residents and attending physicians need better training in advanced isolation precautions. Med Mal Infect. 2016 Feb;46(1):14-9. [PubMed: 26654322]

21.

Porto JS, Marziale MH. Reasons and consequences of low adherence to standard precautions by the nursing team. Rev Gaucha Enferm. 2016 Jun;37(2):e57395. [PubMed: 27253597]

22.

Ritchie L, McIntyre J. Standardising infection control precautions. Nurs Times. 2015 Sep 16-22;111(38):17-20. [PubMed: 26513984]

23.

What is the bloodborne pathogens standard? HDA Now. 2013 Winter;:20. [PubMed: 23556281]

24.

Peponis T, Cropano MC, Larentzakis A, van der Wilden MG, Mejaddam YA, Sideris CA, Michailidou M, Fikry K, Bramos A, Janjua S, Chang Y, King DR. Trauma team utilization of universal precautions: if you see something, say something. Eur J Trauma Emerg Surg. 2017 Feb;43(1):145-150. [PubMed: 27084540]

25.

Aprile A, Morlino G, Mosconi C, Guarente L, Messina A, Carestia M, De Filippis P, Pica F, Maurici M, Palombi L. Survey of Hand Hygiene, High-Touch Device Use, and Proper Habits of Health Care Workers for Infection Risk Prevention: Protocol for a Cross-Sectional Study. JMIR Res Protoc. 2025 Apr 29;14:e60450. [PMC free article: PMC12076024] [PubMed: 40300165]

Disclosure: Nancy Kopitnik declares no relevant financial relationships with ineligible companies.

Disclosure: Chadi Kahwaji declares no relevant financial relationships with ineligible companies.