Routes of Transmission

Infection control and prevention depends on disrupting the transmission of pathogens from their source (the infected animal or human) to new hosts (animal or human) or locations.^7,12 Understanding routes of disease transmission and how it contributes to the spread of organisms allows for the identification of effective prevention and control measures not only for specific diseases, but also other pathogens transmitted by a similar route, including unanticipated infectious diseases.¹² The transmission of microorganisms can be divided into the following five main routes: direct contact, fomites, aerosol (airborne), oral (ingestion), and vector-borne. Some microorganisms can be transmitted by more than one route.

Zoonotic Transmission

It is important to remember many animal diseases are zoonotic and therefore pose a risk for the healthcare team as well as clients. The transfer of these agents can occur by the same five routes of transmission described above. Examples of zoonotic pathogens include Microsporum, Leptospira, Campylobacter, and Bartonella.

Hierarchy of Controls

The hierarchy of controls concept, often used to address measures taken to reduce workplace hazards, is useful when considering infection control strategies in veterinary settings.^7,13–17 Figure 1 shows a four-tier hierarchy pyramid that can be used to determine effective ICPB procedures such as changes in facility design, policies or procedures, and wearing protective clothing. The top tiers are generally considered more effective at minimizing hazards (e.g., pathogen exposure) than the lower tiers.^15,16 Often, a combination of control measures are needed to effectively reduce exposures.¹⁶

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Elimination of sources of pathogen exposure involves physically removing (or preventing) the hazard (i.e., pathogen) from entering the facility.^15,16 Although completely eliminating infected animals from a facility is unlikely to occur, measures can be taken to prevent patients from infecting the general population. While elimination controls are the most effective at reducing hazards, they are often the most difficult to implement.¹⁵

Engineering controls include measures designed into the facility to remove a hazard at its source or to improve compliance with infection control procedures.^4,7,15,16 These measures can be highly effective but generally have higher initial costs.^4,13–17

Administrative controls include protocols or changes to work practices, policies, or procedures to keep patients or staff separated from a known hazard as well as providing staff with information, training, and supervision for these measures. Administrative controls address the way people work and how animals move through the hospital (traffic flow) when an onsite infectious disease is known or suspected.^4,13–17

Personal protective equipment (PPE) includes the use of special clothing and equipment to protect staff and patients who may be exposed to known or suspected pathogens.^13,15,16 PPE places a barrier between staff and an exposure risk (e.g., infected animal, diagnostic specimens) and with appropriate use, helps prevent the spread of pathogens between animals and within the practice. The use of PPE is considered a relatively less effective means of controlling exposures because it relies on human factors such as staff compliance and appropriate education and training.^4,15 Although less effective, lower tiers (e.g., PPE) remain critical for effective infection control and should be used when indicated.

Table 1 provides examples of hierarchy of control measures that can be applied to disrupt pathogen transmission and provide infection control for a variety of microorganisms.

TABLE 1 Hierarchy of Control Measures Applied to Infection Control, Prevention, and Biosecurity Measures for the Disruption of Pathogen Transmission^{4,7, 13–17}

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Patient and Staff Flow

Attention to the movement of patients and staff into and through a practice can affect HAI risks.⁸ The ability to identify and manage infectious patients as early as possible (ideally before they enter the facility) will have the greatest success for reducing environmental contamination, direct and indirect patient contact, and within-hospital pathogen transmission.

Taking an appropriate history prior to patient arrival can prevent pathogen introduction. SOPs and staff training should address identifying high-risk patients when possible during appointment 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 examination. Practices should determine the best path based on their facility, with the intention of minimizing contact with the general patient population and staff. Animals suspected or confirmed to pose a high risk (Table 12) should be examined and housed in a dedicated isolation area. Because an isolation room may not always be available, facilities should develop an SOP for where and how such animals will be housed. Facilities’ procedures should be consistent with those used for isolation (i.e., housed physically and procedurally separate from other patients; Table 8). Complete discussion of facility design is beyond the scope of these guidelines.^4,19

TABLE 12 Pathogens of Greatest Infection Control Concern for a Small Animal Hospital⁶

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Some patients will be identified as potentially infectious during the appointment or while hospitalized. In such cases, staff should minimize owner and patient contact with other patients, staff, and surfaces (e.g., provide outpatient treatments and complete checkout process in the same exam room or designated infection control area). Staff should identify places where contact between infectious patients and other patients or where exposure to common areas may have occurred. These areas should be promptly cleaned and disinfected.

Hand Hygiene

Hand hygiene, using soap and water or an alcohol-based hand sanitizer (AHS), is the responsibility of all individuals involved in healthcare. Generally considered the single most important way to prevent infections in healthcare, hand hygiene should be the subject of considerable attention to availability, encouragement, and compliance auditing.^21,24 Effective hand hygiene kills or removes microorganisms on the skin while maintaining skin integrity (i.e., prevents skin chapping and cracking). The objective is to reduce the number of microorganisms, particularly those that are part of the transient microflora of the skin, because these are easily shed and include the majority of opportunistic pathogens. In most circumstances, either method of hand hygiene (soap and water or AHS) is effective if performed appropriately and when indicated (Table 2). In the practice, hand hygiene should occur

• Immediately before and after patient contact, especially invasive procedures.

• Before and after contact with items in the patient’s environment.

• After exposure to patient bodily fluids (e.g., discharge, specimen handling).

• Before putting on gloves and especially after glove removal.

• After using the restroom.

• Before eating.

AHS is the preferred method when hands are not visibly soiled because these products have a superior ability to kill microorganisms on the skin, can quickly be applied, minimize skin damage, and are easily and inexpensively made available at any point of care.^24,25 AHS is not effective against bacterial spores (e.g., Clostridium spp.), Cryptosporidium spp., and nonenveloped viruses (e.g., parvovirus). When these pathogens are suspected, washing hands with soap and water is encouraged. Bar soaps should never be used in practices due to risks for microbial contamination and transfer to other personnel. Dispenser-provided liquid or foam soap should be used; if containers will be refilled, they must first be disinfected.

Cleaning and Disinfection

The environment and equipment in veterinary hospitals can serve as important routes of pathogen transmission to patients, owners, and staff.^26,27 Cleaning and disinfection aim to reduce key pathogens. However, when cleaning and disinfection are improperly performed, pathogens are likely to remain and can result in HAIs.^28–30 Cleaning and disinfection are two separate tasks. Cleaning involves the removal of visible organic matter (e.g., feces, urine, food, dirt) with soap or detergent, whereas disinfection involves the application of a chemical to kill the remaining microbes. Cleaning is essential because organic matter increases the environmental survival of many pathogens and decreases the effectiveness of many disinfectants. Surfaces that are porous (e.g., unsealed wood, concrete, grout) or with poor integrity (e.g., cracks) are difficult to effectively clean and disinfect and should be repaired or replaced.

Disinfection can only be maximally effective if it is preceded by cleaning. Some pathogens (e.g., clostridial spores) are highly resistant to disinfection; therefore, cleaning in these cases is particularly important to mechanically remove the organisms. Disinfectants should be selected based on pathogens of concern, compatibility with materials, and level of risk (Figures 3, 4; Table 11). For instance, a quaternary ammonium compound may be reasonable for routine disinfection in general animal areas, but a disinfectant with an extended spectrum (e.g., oxidizing agent that also kills nonenveloped viruses) would be indicated in an isolation or critical care area. To be effective and meet expected spectrum of activity, disinfectants must be applied at the correct dilution and for the designated contact time (allotted time required for disinfectant to remain wet on the surface to kill the pathogens of interest; this time is based on the product, concentration, and targeted pathogens, but is generally 5–10 min). If the disinfectant dries before the allotted time, it must be reapplied so that the surface remains wet throughout the contact time. Use of the proper disinfectant concentration is critical from a cost, effect, and safety standpoint. Because disinfectant products can have a range of efficacious concentrations depending on the specific pathogen, the concentration used for disinfecting is pathogen- and situation-dependent.

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ICPs should identify surfaces for cleaning and disinfection and establish a desired frequency that can be incorporated into a checklist (Table 13). In general, animal-contact surfaces should be cleaned and disinfected between patients. This includes exam rooms; floors where patients (e.g., large dogs) are examined/treated; and equipment such as thermometers, stethoscopes, bandage scissors, clippers handle and blades, otoscope handle and tips (if reused), monitoring equipment (e.g., Doppler cuffs, electrocardiogram leads), and endotracheal tubes. Surfaces such as lobby floors should be cleaned and disinfected on a regular basis, at least daily; when known-infectious animals have been in contact with the surface; or when surfaces are visibly soiled with feces, urine, or body fluids (Table 11). Nonanimal-contact surfaces should not be forgotten (e.g., light switches, door handles, computer keyboards/mice). Enhanced disinfection is important after contact with a suspected or confirmed infectious patient. Efforts will vary with the pathogen(s) suspected, including route of transmission, pathogenicity, persistence, and risk for the practice’s patient population. For an examination room, this would include careful attention to cleaning all patient-contact surfaces (including floors as indicated), followed by broad-spectrum disinfection (e.g., oxidizing agent) if more narrow-spectrum disinfectants are used routinely. Because many of the pathogens involved in veterinary HAIs can survive in the environment for an extended period, leaving an area closed for several days is unlikely to prove beneficial.³¹ Instead, as indicated by the level of risk, a second round of disinfection may be advisable. There is no evidence that appropriately chosen disinfectants should be routinely rotated to reduce the development of pathogen resistance.³² In all circumstances, protect involved staff by requiring the use of gloves and eye protection when splashes are likely (e.g., pouring or mixing disinfectants) and ensuring areas are well ventilated.

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

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PPE

PPE should be considered a last line of defense for hazards that cannot be overcome with other preventive measures. Nevertheless, given the inherent risk of exposure to pathogens in veterinary practices, the proper use of PPE is a critical component of an ICPB program. The purpose is to reduce the risk of contamination of clothing, reduce pathogen exposure to skin and mucous membranes of personnel, and reduce transmission of pathogens between patients by personnel. Common examples of PPE include lab coats, scrubs, gloves, gowns, eye protection, facemasks, and shoe covers. The type of PPE used will vary with procedure and suspicion for an infectious disease and its route of transmission (Table 14). Some form of PPE should be worn in all clinical situations, including any contact with animals and their environment, and should not be worn outside of the work environment. Lab coats and scrubs should be laundered at least daily or when contaminated (e.g., contact with an infectious patient). Gloves, gowns, and shoe covers should not be reused, even when attending to the same patient. Correct removal of PPE is critical to limit contamination of clothing and skin and mucous membranes (Table 4). Gloved hands should not be used to contact surfaces that will be touched by nongloved hands, with care taken to avoid contamination of personal items (e.g., telephones, pens). There is limited data on the effectiveness of footbaths and foot mats in infection control.^32,33 Careful use of other approaches (e.g., shoe covers) is reasonable and may have fewer concerns (e.g., maintenance of disinfectant, spills).

TABLE 14 Personal Protective Equipment and Clinical Indications²¹

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Disinfection of Physical Rehabilitation Equipment (Underwater Treadmill, Mats, Balls)

Physical rehabilitation equipment poses a unique challenge for infection control, as items for this use are frequently difficult to disinfect (e.g., foam construction, underwater treadmill with chemical-sensitive materials). Patients receiving physical rehabilitation are often at increased risk for shedding or acquiring HAI pathogens (e.g., older with concurrent disease or skin infections, patients with fecal or urinary incontinence, surgical complications including SSIs). Further, some pathogens may be frequently encountered in rehabilitation environments (e.g., MDR Pseudomonas spp.), yet such environments are often overlooked as a source of HAIs.^35,36 Infection control, prevention, and biosecurity for a physical rehabilitation unit should focus on screening of patients, restricting or adjusting use based on risk (e.g., confirmed/suspected infectious disease, recent history of diarrhea), regular cleaning and disinfection of all equipment surfaces, monitoring and adjusting water chemistry for water devices (e.g., appropriate chlorine levels will provide adequate disinfection for healthy patients), and educating the entire practice team for proper technique and the use of PPE. SOPs unique to this environment (e.g., fecal accidents in water devices) should be developed.³⁷

Animals Fed a Raw Meat Diet

Raw meat diets have grown in popularity.³⁸ Pets fed raw foods are a unique source of HAI-associated pathogens in the hospital environment because they may shed organisms (often asymptomatically) that can cause illness in humans or other pets.^39–41 Education of the client is of utmost importance with this population of patients because risk avoidance starts in the home environment with adequate cooking of raw ingredients before the patient reaches the hospital. Patients fed raw meat products within the past 30 days likely pose the greatest risk and may warrant enhanced precautions such as use of PPE with or without isolation. Proper handling of feces and surfaces contaminated by patients fed raw animal diets (e.g., PPE, prompt cleaning and disinfection) is critical.

Multidrug-Resistant Organisms

MDR organisms (e.g., MRSP, methicillin-resistant S aureus, extended spectrum b-lactamase-producing Enterobacteriaceae such as E coli, enterococci, Salmonella spp., Acinetobacter spp., Pseudomonas spp.) have become increasingly problematic in veterinary medicine. These organisms can be passed directly or indirectly between patients, the environment, and staff, resulting in infections that are challenging to treat.⁶ Close attention to hand hygiene, early identification of patients infected or colonized with these organisms, prompt removal of feces, environmental cleaning and disinfection, proper PPE, surveillance, antimicrobial stewardship, and education of clients and the practice team are the keys to minimizing HAIs by these bacteria.^6,42

Surgery

Surgical site infections are an inherent risk in veterinary medicine and are complicated by the emergence of MDR organisms and the evolution of more invasive procedures and increasing frequency of immunocompromised patients.⁴³ Examples of risk factors for SSIs are the length and invasiveness of the procedure, perioperative hypotension, the presence of MDR organisms on the patient or environment, a “clean” versus “dirty” procedure, and the presence of an implant.⁴³ In a recent study of veterinary SSIs, the majority of infections were caused by MRSP, an organism that is not controlled solely by most patient pre- or postsurgical protocols or perioperative prophylaxis with beta-lactam antimicrobials (e.g., cephalosporins).⁴³ HAIs in surgery can be controlled or prevented through attention to environmental cleaning and disinfection, patient preparation, proper surgical technique, simplified surgical suite design, PPE of surgeons and staff, the use of proper hand preparation techniques, appropriate (drug, dose, frequency) perioperative antimicrobial prophylaxis, and meticulous postoperative wound managment.^6,44 Because of enhanced antibacterial efficacy, rapid action, fewer side effects (e.g., do not cause skin abrasion), lower potential for resistance development, and time savings (generally 3 min rub time), presurgical hand rubbing using alcohol-based formulations is now encouraged over traditional scrubs.⁴⁵

Dentistry

The primary HAI considerations for a veterinary dentistry unit are the heightened risk of aerosolization of infectious particles; contamination of equipment such as wet tables, endotracheal tubes, and drills; and staff education on environmental cleaning and disinfection and PPE.⁴⁶ Aerosols (defined as particles <50 μ that have the potential to remain airborne and penetrate the airways and lower lung passages of humans) can transmit pathogens, saliva, blood, and bacteria-laden debris.⁴⁶ As pathogens frequently reside in the oral cavity of companion animals and aerosolization of pathogens is possible, zoonotic transmission during veterinary dentistry is a concern.^7,47 Pathogens of recent interest and relevance to veterinary dentistry, such as Pasteurella multocida and Staphylococcus spp., emphasize the importance of proper ICPB practices. Irrigating the oral cavity with a 0.12% chlorhexidine solution before dental scaling has been recommended by some to decrease bacterial aerosolization.^48,49 Dental procedures should be performed in a designated location distant from other procedures, patient housing, and staff so as not to potentiate HAIs via aerosolization. Proper face protection (e.g., goggles/face shield and face mask), gowns, and gloves should be used, and surfaces cleaned and disinfected between patients.⁷

Resuscitation

Considerations for ICPB for cardiopulmonary resuscitation procedures are similar to what are proposed for dentistry. Aerosolization and exposure to direct contact with pathogens are similar risk factors for HAIs and zoonotic transmission to the practice team. Environmental cleaning, separate areas for resuscitation (if possible) to avoid cross-contamination, and the use of PPE during resuscitation are critical, and can be easily overlooked during an emergency.⁷ The acute nature of resuscitation emphasizes the need for regular (e.g., quarterly) “practice runs” in order to prepare the veterinary practice team to properly incorporate hand hygiene, PPE, and cleaning and disinfection into resuscitation procedures.

Immunocompromised Patients

Immunocompromised patients include those receiving chemotherapy or other immunosuppressive agents and those with immune-altering comorbidities (e.g., cancer, asplenia), as well as very young and geriatric patients. Proper identification of these individuals is important so that individualized procedures can be developed for each patient. When possible, the use of higher-risk procedures should be avoided (e.g., in-dwelling urinary catheters); when used, additional attention should be placed on protocols that reduce HAI (e.g., Tables 6, 7). In addition, hand hygiene and proper PPE should be strictly enforced.⁷

Obstetrics

Zoonotic risks of exposure to Brucella canis, C burnetii, and other infectious pathogens result from contact with birthing fluids of parturient animals, stillborn fetuses, and infected neonates.⁷ Proper PPE includes gloves, waterproof gowns, and facial protection. In some circumstances, respiratory tract protection is necessary (e.g., when handling aborted fetuses likely to be infected with C burnetii).⁷ It is helpful to know in advance what pathogens are common in a geographic area in order to take appropriate infection control precautions.

Burn Care

Although burn victims are relatively uncommon in veterinary medicine, they present special challenges because the patients in these cases are immunocompromised and have wounds that require invasive techniques. Burns trigger a cascade of necrotic changes in tissue that are directly related to the cause of the injury and temperature of exposure.⁵⁰ Precautions for HAIs depend on the depth and severity of burn-resulting thermal injury.⁵⁰ Infection control, prevention, and biosecurity related to burns focus on wound control and exposure of patient and veterinary practice team members to potential MDR pathogens as well as other HAIs. As appropriate, isolation and wound management including cleaning of the burn site, use of only sterile equipment, and careful attention to hand hygiene with proper PPE are critical for protecting these patients.

Necropsy

Necropsy presents several infection risks for veterinary personnel including personal injury while performing the procedure, exposure to zoonotic pathogens originating from the animal, and environmental contamination with pathogens.⁷ Eye protection, respiratory protection, and cut-proof gloves are necessary PPE for necropsy procedures (Table 9).⁷ Necropsies should be performed in a location distant from the general hospitalized population and staff. However, if this is not possible, adherence to PPE, removing organic debris, and postprocedural cleaning and disinfection will help minimize HAI risks.

Heating, Ventilation, and Air Conditioning

Consideration of proper heating, ventilation, and air conditioning is critical for practice infection control. Appropriate ventilation is particularly important for reducing airborne diseases, excessive moisture and dust, and chemical fumes from disinfection products that make patients and staff susceptible to infection as a result of damaging their airways. Ventilation should not cause movement of air from areas with known infected patients to other areas of the practice. Spaces where infected patients are held should be vented to the outside. The number of air exchanges per hour (the rate at which the complete volume of air inside a building or room is replaced with fresh outside air) is critical for good ventilation. Recommendations vary between 5 and 8 air exchanges per hour. Whenever possible, three levels of air filtration are recommended in a practice: (1) a wire mesh to remove hair and large matter from the air; (2) a finer (less porous) filter placed within the air ducts to remove dust and other particulate matter; and (3) a high-efficiency particulate air filter to remove viral particles and very fine particulate matter. High-efficiency particulate air filters are expensive, and appropriate replacement of these filters may not be affordable for all practices. Regardless of type, filters must be cleaned or changed frequently to prevent infectious buildup and hair-clogged vents. Ventilation systems need to be inspected regularly and updated as needed.

Rodent and Insect Vectors

Some important veterinary pathogens can be transmitted by wild rodents or insect vectors (e.g., fleas, ticks, mosquitoes, flies). Pest management practices include examination of patients upon arrival for ectoparasites; immediate treatment of patients with fleas, ticks, or mites; and appropriate housing (e.g., isolation) until resolution. Dry pet food and garbage should be stored in metal or thick plastic containers with pest-proof lids. Prompt disposal of food waste and other materials (e.g., feces) that may attract rodents or insects is critical. Sealing potential pest points-of-entry, including maintenance of intact window screens, is important. Elimination of potential rodent nesting and mosquito breeding sites around the practice (e.g., brush, debris, empty food bowls, clogged gutters) prevents onsite pest reproduction. Consultation with a pest control expert is recommended if a particular infestation is present, or for additional guidance and information.

Spills and Waste

Veterinary biomedical waste is a potential source of zoonotic and nonzoonotic pathogens. In the United States, biomedical waste is defined and regulated at both state and municipal levels.⁵¹ Veterinary medical waste includes sharps, tissues (anatomic waste), highly contaminated materials, and deceased animals.

It is beyond the scope of these guidelines to describe spill clean-up and veterinary biomedical waste management in detail. However, basic guidelines are summarized here. Used sharps are considered biomedical waste and should be disposed of in accordance with regulations from municipal and state authorities. Use approved, puncture-resistant sharps disposal containers to remove, store, and dispose of needles and other items capable of causing punctures. Ensure such containers are readily available and used everywhere sharps are handled to prevent sharps injuries to staff and clients. Nonanatomical waste saturated with blood, such as blood-soaked lap sponges and gauze, or materials used to clean up a spill of blood or infectious secretions, are also disposed of as biomedical waste. Liquid waste such as drained thoracic fluid, abdominal fluid, irrigated solutions, excretions, and secretions may usually be poured carefully down a toilet or drain connected to a sanitary sewer or septic tank. Local, state, and federal regulations may dictate maximum volume of blood or body fluids permitted to be poured into the sanitary sewer. If the fluid is likely to splash or spray during disposal, appropriate PPE should be worn. Waste should be contained in a leak-proof container or bag discarded with the waste (plastic garbage bag). Urine and feces are not biomedical waste, nor is disposable equipment that has come in contact with an infectious animal (e.g., examination gloves, gowns, bandage materials not saturated with blood).

Potentially infectious, contaminated materials may pose a risk to practice personnel, patients, and waste disposal personnel. Precautions should be taken to minimize contamination of the practice environment and the risk to people and animals from potentially infectious waste. These include double-bagging of materials from isolation areas. If the inside of a waste container becomes contaminated, the container should be thoroughly cleaned and disinfected after emptying. All waste from an isolation room should be treated as potentially infectious; trash from these areas should be removed by appropriately gloved and gowned personnel. Contaminated articles should be either discarded or taken for additional cleaning and disinfection. Rural practices, where biomedical waste disposal services may not be available, may be able to make arrangements with a local human hospital or other medical facility to have waste disposed of with human hospital waste.

Laundry

Single-use, disposable items are ideal for infection control, but their disposal produces tremendous waste and an environmental burden. Laundering reusable bedding, gowns, scrubs, towels, and other items is therefore an important component of infectious disease control. Linens and professional garb can serve as fomites, transporting pathogens within the practice and outside the practice into the community. Microbe populations on soiled laundry are significantly reduced by dilution and further by the mechanical action of washing. Hot air drying further eliminates microorganisms. As transport to individuals’ homes or other facilities increases ICPB risks, professional garb (e.g., scrubs, lab coats) should be washed onsite or by a specialized commercial laundry facility equipped to clean medical laundry. Practices should have appropriate laundry facilities or laundry services to accommodate cleaning of these items daily or more frequently if necessary. To reduce contamination with infectious organisms and health risks to staff, appropriate PPE (i.e., gloves and dedicated laboratory coat) should be worn by those performing laundry duties. Linens with gross contamination should be assessed to determine if they can be effectively cleaned. If not, they should be properly discarded. Otherwise, gross organic material should be removed prior to washing.

Additional precautions should be taken for laundry from isolation rooms and infected animals. These items should be washed and processed separately from other practice laundry while wearing appropriate PPE to prevent spread of microbes. Items from infected animals should be presoaked in diluted bleach (9 parts water:1 part household bleach) for 10 min to disinfect prior to machine washing. Isolation-room laundry should be washed in hot water with bleach, per manufacturer’s instructions. After bleaching and washing, laundry should be completely dried in a separate load from any other laundry and returned to isolation.

Appropriate Antimicrobial Stewardship

The concept of antimicrobial stewardship, or the judicious use of antimicrobials, including when not to use these agents, has emerged in the last decade as a necessary approach across health professions to prevent adverse events and selection for drug-resistant infectious pathogens. The misuse of antimicrobials in human and veterinary healthcare is one of the key factors leading to the current epidemic of antimicrobial resistance. More information on the overall concept of antimicrobial stewardship and how it is applied in veterinary practice as advised by the American Veterinary Medical Association can be found at avma.org/KB/Resources/Reports/Pages/Antimicrobial-Stewardship-in-Companion-Animal-Practice.aspx. Previously created American Association of Feline Practitioners-AAHA guidelines discuss the judicial therapeutic use of antimicrobials (aaha.org/public_documents/professional/guidelines/aafp_aaha_antimicrobialguidelines.pdf). Information on more longstanding antimicrobial stewardship practices in human hospitals and long-term care facilities in the United States, referenced in the American Veterinary Medical Association document, can be found at cdc.gov/getsmart/healthcare/implementation/core-elements.html.

Personnel Vaccination

Although not always financially viable for all hospitals or staff within a hospital, personnel vaccination is an important component of occupational health and safety. Decisions regarding vaccination of staff should consider the risk of exposure, the severity of disease, whether the disease is treatable, the transmissibility of disease, and the quality and safety of the vaccine. It is recommended that all veterinary personnel who might have contact with animals should be vaccinated against rabies, except in areas that have been formally declared rabies-free (e.g., Hawaii).⁷ This includes lay staff that might have periodic animal contact, such as receptionists. Rabies vaccines for humans are generally considered safe and highly effective. For additional information on human rabies vaccination, see the CDC rabies website (cdc.gov/rabies/exposure/preexposure.html).

Other vaccinations including tetanus and annual influenza may be appropriate depending on the practice setting and other exposure risks. Additional information is available.⁷

Education, Training, and Compliance

Education and training of the practice team is an integral part to any successful ICPB program. Numerous studies have demonstrated decreases in HAIs after some form of educational or training program was completed.^52–55 A comprehensive training program should include education on basic principles of ICPB, departmental specific protocols, strategies to develop critical and independent thinking to help team members in unexpected patient care situations, and an evaluation of staff compliance through surveillance, testing, and auditing.⁵⁶

The effectiveness of an ICPB program is dependent on not only appropriate training of the practice team, but on the extent to which infection control protocols are accepted by the practice team as necessary and useful.^57,58 Therefore, it is critical that prior to starting the formal education program, the practice team is committed to and passionate about infection control. One strategy to accomplish this is a hospital-wide meeting (or a small-group meeting if training new employees) in which the ICP discusses recent hospital or local disease outbreaks, documented increases in HAIs, or presents current ICPB deficiencies at the practice (e.g., observations of hand hygiene compliance, environmental cleaning deficiencies identified with fluorescent tagging; see the “Implementing an Infection Control Program” section). The ICP should use data uncovered during an assessment/audit of the practice facility to guide this discussion (Table 10).

The formal education program should begin with training all practice team members on the basic principles of ICPB. Topics to cover include modes of transmission of pathogens (discussed earlier in these guidelines), common pathogens that may be encountered in the practice setting, and a demonstration of appropriate hand hygiene and PPE use. Cleaning and disinfection protocols should be covered at this time as well. This training can take the form of an in-person meeting, required reading/online training, or both, depending on the practice setting.

After teaching basic ICPB principles, focused education on departmental-specific protocols and situations should be covered. This is best accomplished by integrating infection control education into routine training on daily duties for the position, supplemented with handouts and checklists covering specific protocols. For example, during phone training for receptionists, there should be discussion of recognizing cases that may present an infection control concern, phone scripts to identify high-risk patients, demonstrating appointment scheduling for a suspected infectious patient, and learning arrival instructions for patients with infectious disease. The team member being trained should be given written material to reference and shown where to easily access any scripts or checklists within the practice.

However, even the most extensive training cannot prepare practice team members for all the possible infection control scenarios they might encounter. Although having protocols for the most common situations is helpful, practice team members must also develop a level of critical and independent thinking about infection control so that they can make sound clinical decisions when encountering a more complex or unexpected situation. Simulations of these situations has been theorized to improve outcomes in the human medical field.^58,59 Although the resources of a typical veterinary practice do not allow for the often-extensive simulated training that occurs in human hospitals, simulating infection control scenarios in the practice setting can be an invaluable tool. The ICP’s creativity is a key factor in the infection control component of the training program, and this type of training can be accomplished without excessive time or expense. The use of fluorescent tagging or simulated patients (stuffed animals or staff pets) can be helpful in staging a mock infection outbreak. Infection control drills can be staged during downtime in the practice. Receptionists can receive a call from a mock client that challenges their history-taking and decision-making process.

A method for evaluating compliance with the practice’s training program is needed to ensure the training has been successful, and a formal performance feedback program can also further improve outcomes.⁵³ Written testing of basic ICPB knowledge and departmental-specific protocols should be performed at the end of each training period and periodically thereafter to assess retention of knowledge. Routine surveillance data should be used to monitor for any breaches or noncompliance with the ICPB program. Regular reporting of this data can provide feedback to staff members. Simulated, real-world scenarios can also be useful in assessing the practice team’s knowledge of infection control and can be used to monitor compliance with the program. These tools for evaluating and assessing compliance should be applied in a positive, nonpunitive way to help motivate staff to consistently and effectively implement the practice’s program and appreciate the importance of each person’s actions in HAI prevention and overall ICPB success.

Client Education

Although veterinary staff work to prevent the spread of pathogens and disease within their facilities, it is imperative that clients are also sufficiently educated regarding the key role they have in ICPB in the community and their home environment. Educating clients on the importance of regular visits to their veterinarian and appropriate preventive measures, such as vaccination, endo- and ectoparasite control, and good overall health of their pets, is the best way to prevent the spread of disease.

In addition to general infectious disease education, clients should be informed on zoonotic risks relevant to their pets, themselves, and family members. Key pathogens to highlight for clients include but are not limited to common endoparasites (e.g., hookworms, roundworms, tapeworms), dermatophytosis, toxoplasmosis, geographically relevant ectoparasite-transmitted diseases, rabies, Salmonella, and Campylobacter spp.⁶⁰ Some diseases, although not transmitted directly from the pet to humans, still demand appropriate control methods such as avoiding exposure to vector-borne diseases via shared contact with the pet or its environment. For example, fleas are easily transferred between animals and humans. Environmental or on-animal infestations, particularly in homes with young children, carry a risk of zoonosis for flea-borne diseases, such as Bartonella infection. Although there is not a direct zoonotic risk from ticks attached to a pet, they should be disposed of carefully when removed, and owners of these pets should take caution of similar risks to themselves and others in the household due to encountering ticks in the same environments as their pet.⁶¹

It is possible to reduce the spread of zoonotic diseases with appropriate preventive care including routine veterinary visits for annual exams, vaccinations, overall health assessment, as well as flea and tick control as indicated by their area. Fecal exams for detection of intestinal parasites should be performed as indicated by the patient age, geographical location, and parasite exposure risk.

Further owner considerations in preventing zoonotic diseases include the practice of good personal hygiene, particularly hand hygiene after handling pets; handling pet food and treats, especially when it includes an uncooked meat product; and always before eating. Litter boxes, pet dishes, pet beds, and toys should be kept clean. Cat litter boxes should be cleaned regularly (daily if higher-risk persons are in the household). In the case of households with dogs, cleaning up pet feces should be done regularly (e.g., at least weekly) to reduce environmental contamination with pathogens. Feces should be disposed of in a waste receptacle, not in recyclable waste or compost. Additional pet “messes” (vomitus, stool, and urine) should be cleaned up, disposed of accordingly, and surfaces disinfected. Hands should be thoroughly washed afterward; gloves can be used to provide an extra level of protection. Pets should be fed a high-quality diet, avoiding raw or undercooked diets. Hunting for food sources, including garbage or table scraps, should also be discouraged. Additional pet behaviors that can pose increased zoonotic disease risks and should be discouraged are drinking from the toilet, eating feces (own or of other animals), and drinking standing water.

Pets should not be permitted to have contact with wild animals. Owners of pets likely to have contact with wild animals (e.g., predominately outdoor, hunting) should be informed of these increased risks and, when possible, preventive measures taken to reduce pet and owner health risks (e.g., endo- or ectoparasite prevention, rabies vaccination, preventing consumption of wildlife). Potentially contaminated environments or situations in which exposure risks are unknown, including interactions with animals with unknown vaccination or parasite status, should be avoided. Additional suggestions for prevention of infection include regular pet grooming and bathing, maintaining short nails to prevent scratches, and spaying and neutering to prevent roaming, which can increase risk of disease exposure and transmission.⁶⁰

Immunocompromised people have an increased risk of acquiring zoonotic diseases, including those transmitted by pets. Those individuals who are <5 or >65 yr of age; pregnant; diabetic; have HIV-infection; are undergoing immunosuppressive chemotherapy, organ transplantation, or treatment for autoimmune diseases; or have other conditions for which their physician has indicated that they are at an increased risk for infections should take greater caution.⁶² Immunocompromised clients should be advised of modifiable behaviors that reduce their risk for pet-associated infections, with particular emphasis on always performing hand hygiene after pet contact, discouraging pets from face-licking, and not having contact with pet feces (i.e., ideally have an immunocompetent household member perform this duty). Regular cleaning and disinfection of cages, food areas, bedding, and toys should be performed by an immunocompetent individual who observes strict hand hygiene. Immunocompromised people should avoid contact with amphibians, reptiles, rodents, exotic animals, strays, young animals, and any animal suspected to be infectious (e.g., with acute vomiting, diarrhea, skin disease), as well as items that have been in contact with these animals.

A key to infection control success in the household and community is client compliance with risk reduction strategies. This requires active involvement and cooperation of the clinical team and the client. Clients should be provided with handouts in addition to face-to-face counseling on prevalent local infectious diseases of importance. Pet owners can also be directed to online resources such as the Companion Animal Parasite Council (capcvet.org/capc-recommendations), the CDC’s Healthy Pets Healthy People (cdc.gov/healthypets), Worms and Germs Blog’s resources for pets (wormsandgermsblog.com), the DVM360’s handout on parasites (veterinarybusiness.dvm360.com/forms-parasitology-handouts), and aaha.org/biosecurity.