Infectious Diseases Nursing Guide

Standard Precautions — ALL Patients, ALL the Time

Standard precautions assume that blood, body fluids, secretions, excretions (except sweat), broken skin, and mucous membranes may transmit infection regardless of diagnosis.

Element	When / How
Hand Hygiene	Before patient contact, before aseptic procedure, after body fluid exposure, after patient contact, after touching patient surroundings (WHO 5 Moments). Soap & water for C. difficile (spores).
Gloves	Contact with blood, body fluids, mucous membranes, non-intact skin, soiled equipment.
Apron / Gown	Risk of contamination to clothing / skin from body fluids or soiled linen.
Mask (surgical)	Risk of splash or spray to face/mouth; respiratory droplet procedures.
Eye Protection	Risk of blood/body fluid splash to eyes (goggles or face shield).
Safe Sharps Handling	No recapping, use sharps bins, engineered safety devices.
Environmental Cleaning	Regular disinfection of patient-care surfaces; terminal cleaning on discharge.
Respiratory Hygiene	Tissue + bin + hand hygiene; mask symptomatic patients in waiting areas.

Transmission-Based Precautions

Contact Precautions Organisms: MRSA, VRE, C. difficile, Norovirus, Scabies, MDR Gram-negatives (ESBL, CRE).
PPE: Gloves + long-sleeved gown. Single room or cohort. Dedicated equipment (stethoscope, BP cuff).

Droplet Precautions Organisms: Influenza, RSV, Mumps, Rubella, Pertussis, Group A Streptococcus (invasive), Meningococcal disease.
PPE: Surgical mask when within 1 metre. Single room preferred. Patient mask during transport.

Airborne Precautions Organisms: Active pulmonary/laryngeal TB, Measles, Varicella (chickenpox / disseminated zoster).
PPE: N95 / FFP3 respirator (fit-tested). Negative-pressure room, door kept closed. Limit patient transport.

Enhanced Contact + Droplet — MERS-CoV PPE (regular care): Surgical mask + gown + gloves + eye protection. Negative-pressure room.
PPE (aerosol-generating procedures — intubation, bronchoscopy, suctioning, BiPAP/CPAP, CPR): N95/FFP3 + full PPE.

Category	Examples	Room	PPE
Contact	MRSA, C.diff, VRE, norovirus	Single / cohort	Gloves + gown
Droplet	Flu, RSV, pertussis	Single preferred, curtain	Surgical mask ≤1 m
Airborne	TB, measles, varicella	Negative-pressure, closed	N95/FFP3
Enhanced (MERS)	MERS-CoV	Negative-pressure	Surgical mask → N95 for AGPs + full PPE

PPE Extended Use vs. Limited Reuse

Guidance applies during respiratory pathogen outbreaks (COVID-19, MERS-CoV) when PPE supply is constrained.

Extended use: Wearing the same N95 for multiple patients with the same respiratory infection without removing it between patients. Remove only when leaving the care area.
Limited reuse: Storing N95 in a breathable paper bag between uses by the same HCW. Do NOT store in plastic. Maximum 5 re-uses per mask or per manufacturer guidance.
Discard immediately if: visibly soiled, contaminated with blood/body fluids, breathing difficulty, damaged straps, or after AGP.
Never share N95 masks between healthcare workers.

CRITICAL — Mandatory Notification MERS-CoV is a notifiable disease in ALL GCC countries. Any suspected case MUST be reported immediately to the Ministry of Health (MOH). Do not delay isolation pending test results.

MERS-CoV Overview

Pathogen: Middle East Respiratory Syndrome Coronavirus (MERS-CoV) — betacoronavirus
Reservoir: Dromedary camels (primary animal host); Camelus dromedarius
Transmission: Zoonotic (camel-to-human) and nosocomial human-to-human (close contact, healthcare settings)
Case fatality rate: approximately 35% (highest for immunocompromised, diabetics, renal/lung disease)
Incubation period: 2–14 days (median 5 days)
GCC context: Saudi Arabia accounts for >80% of global cases; significant outbreaks in Saudi healthcare facilities. All GCC HCWs must maintain constant vigilance.

Clinical Features & Progression

Phase	Features
Early	Fever (>38°C), cough (dry), myalgia, fatigue, headache
Moderate	Dyspnoea, worsening cough, GI symptoms (diarrhoea, nausea, vomiting) — seen in ~30%
Severe	Hypoxic respiratory failure, ARDS, multi-organ dysfunction
Complications	Acute renal failure (common — often requiring CRRT), septic shock, secondary infections

High-Risk Patient Groups Elderly, diabetes mellitus, chronic renal disease, chronic lung disease, cancer, immunosuppressed. Fatality rate significantly higher in these groups.

Screening Criteria

Screen for MERS-CoV if the patient has ALL THREE:

Fever (≥38°C) or history of fever in last 10 days
Respiratory symptoms (cough, dyspnoea, sore throat, rhinorrhoea)
Epidemiological link — one or more of:
- Direct contact with confirmed MERS-CoV patient
- Healthcare worker in MERS-CoV care area
- Exposure to dromedary camels or camel products
- Residence or travel to Arabian Peninsula within 14 days

Even with one epidemiological risk factor + compatible symptoms — escalate to senior and initiate isolation pending review.

PPE Protocol for MERS-CoV

Regular Patient Care (non-AGP) Surgical mask + Long-sleeved gown + Gloves + Eye protection (goggles/face shield). Negative-pressure room, door closed. Dedicated equipment.

Aerosol-Generating Procedures (AGPs) N95/FFP3 respirator (fit-tested) + Long-sleeved gown + Gloves + Eye protection + Head cover.
AGPs include: Endotracheal intubation, extubation, CPR, bronchoscopy, suctioning (open), nebulisation, non-invasive ventilation (BiPAP/CPAP), high-flow nasal oxygen (HFNO), specimen collection (nasopharyngeal swabs in some protocols).

Visitor Restrictions

No visitors unless essential (end-of-life). Strictly limited, with full PPE.
All visitors must be logged for contact tracing purposes.

Treatment — Supportive

Oxygen therapy: Titrate to SpO₂ ≥94% (≥90% in COPD). Early escalation to HFNO or NIV in ARDS
IV Fluids: Careful fluid management (ARDS risk — avoid fluid overload)
Vasopressors: Noradrenaline for septic shock (ICU setting)
CRRT / haemodialysis: Acute kidney injury common; early nephrology input
Experimental antivirals: Remdesivir, interferons (IFN-α2b) used in some protocols — no definitive evidence for MERS; discuss with infectious diseases team
Corticosteroids: Not routinely recommended (may prolong viral shedding); use only for ARDS per institutional protocol

Camel Exposure Warning

Public Health Advisory — GCC Context Advise patients and public: avoid direct contact with dromedary camels (especially sick camels). Do NOT consume raw camel milk or raw camel urine. Health claims about camel urine circulate widely in some GCC communities — this practice poses serious infection risk including MERS-CoV. Pasteurised camel milk is considered lower risk.

Outbreak Management

Immediate: Isolate case, notify MOH, identify and list all contacts (HCWs and patients)
Contact tracing: All contacts within 1 metre for ≥10 minutes without PPE, or any unprotected AGP exposure — 14-day monitoring
Ring isolation: Symptomatic contacts placed under enhanced precautions immediately
Ward closure: If cluster identified — stop new admissions, declare ward closed, enhance environmental decontamination
HCW surveillance: Daily symptom checks for all exposed staff; furlough if symptomatic
Communication: Brief all staff, update IPC team, hospital management, and MOH regularly

Tuberculosis (TB)

High-Risk Groups in GCC South Asian and Sub-Saharan African expatriate workers are the highest-risk population in GCC countries. TB screening is part of expatriate visa medical requirements in many GCC states.

Diagnosis

Sputum AFB smear × 3: 3 consecutive early-morning samples; send for microscopy and culture (culture is gold standard)
Chest X-ray: Upper lobe cavitation, fibronodular shadows, bilateral infiltrates
Mantoux test (TST): ≥10 mm induration positive in immunocompetent (≥5 mm in HIV/immunosuppressed)
QuantiFERON-Gold (IGRA): Preferred in BCG-vaccinated individuals; not affected by BCG
Nucleic Acid Amplification Test (NAAT / GeneXpert MTB/RIF): Rapid detection + rifampicin resistance within 2 hours

Treatment — Active TB (RHEZ Regimen)

Phase	Duration	Drugs
Intensive	2 months	Rifampicin + Hisoniazid + Etambutol + ZPyrazinamide (RHEZ)
Continuation	4 months	Rifampicin + Isoniazid (RH)

Latent TB Infection (LTBI)

IGRA positive + normal chest X-ray + no symptoms = LTBI
Treatment: Isoniazid (INH) 6 months OR Rifampicin 4 months
Liver function monitoring during treatment (especially with rifampicin)

Isolation Criteria

Airborne precautions until 3 consecutive negative sputum AFB smears (on 3 different days)
Negative-pressure room, N95 for all entering HCWs
Clinical improvement + AFB negative = can step down precautions

Hepatitis B

Hepatitis B is endemic in the Middle East. Healthcare workers are at occupational risk via needlestick and blood exposure.

Serology Interpretation

HBsAg	HBsAb	HBcAb	Interpretation
Negative	Negative	Negative	Susceptible — vaccinate
Negative	Positive	Negative	Immune due to vaccination
Negative	Positive	Positive	Immune due to past infection
Positive	Negative	Positive	Active infection (acute or chronic)
Negative	Negative	Positive	Resolved/occult — may need NAAT

HCW Vaccination

3-dose schedule: 0, 1, 6 months (recombinant vaccine)
Check HBsAb titre 4–8 weeks after 3rd dose. Target: ≥10 mIU/mL (protective)
Non-responders: repeat 3-dose course; if still non-immune — HBsAg test (carrier?); advise strict barrier precautions

COVID-19

GCC protocols (evolved): Droplet + contact precautions for stable patients; airborne precautions (N95) for AGPs
Isolation: Single room; if not available, cohort with confirmed cases
Testing: NAAT (PCR) from nasopharyngeal/oropharyngeal swab; rapid antigen for screening
Long COVID: Fatigue, brain fog, dyspnoea, post-exertional malaise >12 weeks; multidisciplinary management; common among recovered HCWs in GCC
Vaccination: Mandatory or strongly recommended for HCWs across GCC; booster doses per current national schedules

Dengue Fever

Dengue is not endemic in GCC but imported cases are common — especially among expatriate workers returning from South/Southeast Asia, East Africa, or the Indian Subcontinent.

Diagnosis

Days 1–5: NS1 antigen (high sensitivity in early disease)
Day 5+: IgM/IgG serology (ELISA)
FBC: thrombocytopaenia (platelets <100 × 10⁹/L), leucopaenia, rising haematocrit

Dengue Warning Signs — Urgent Escalation

Abdominal pain or tenderness
Persistent vomiting
Clinical fluid accumulation (ascites, pleural effusion)
Mucosal bleeding
Lethargy or restlessness
Liver enlargement >2 cm
Rapid clinical deterioration or haematocrit rise with rapid platelet drop

Treatment: Supportive — oral rehydration, paracetamol (avoid NSAIDs and aspirin), IV fluids if unable to maintain oral intake. Platelet transfusion only for severe bleeding or pre-procedure.

Malaria

Malaria is not endemic in most GCC countries but imported cases are seen regularly — particularly P. vivax and P. falciparum from South Asia and Sub-Saharan Africa.

Diagnosis

Blood film (thick and thin): gold standard — identifies species and parasite density
Rapid Diagnostic Test (RDT): HRP-2 antigen for P. falciparum; pLDH for all species
PCR: Confirmatory, especially for low-density parasitaemia

Treatment

P. falciparum (uncomplicated): Artemether-Lumefantrine (AL) — Artemisinin-based Combination Therapy (ACT)
P. vivax / P. ovale: Chloroquine (if sensitive) + Primaquine for radical cure (check G6PD before primaquine — haemolysis risk)
Severe malaria: IV Artesunate (first-line); exchange transfusion considered if >10% parasitaemia

G6PD Deficiency Primaquine causes haemolysis in G6PD-deficient patients. G6PD deficiency is common in GCC and South Asian populations. Always test before prescribing primaquine.

Brucellosis

GCC Epidemiology Brucella melitensis from goats and sheep is the most common cause in GCC. Consumption of unpasteurised goat/sheep cheese and milk is a frequent exposure — a common rural and traditional practice across the region.

Clinical Features

Undulant (relapsing) fever, drenching night sweats
Arthralgia / arthritis (sacroiliitis characteristic)
Myalgia, fatigue, hepatosplenomegaly
Complications: spondylitis (vertebral osteomyelitis), neurobrucellosis, endocarditis

Diagnosis

Blood culture (sensitivity ~50–70%); Bone marrow culture more sensitive
Serology: Standard Agglutination Test (SAT / Wright's), Rose Bengal test (screening), ELISA

Treatment

Doxycycline 100 mg BD + Rifampicin 600–900 mg OD × 6 weeks (standard; high relapse rate if shorter)
Alternative: Doxycycline + Gentamicin (first 2 weeks) + Doxycycline alone to complete 6 weeks
Neurobrucellosis / endocarditis: triple therapy + prolonged duration; specialist input

GCC Context — High AMR Burden GCC countries historically had high antibiotic usage — both in healthcare and community settings. This has driven elevated rates of MRSA, ESBL-producing Enterobacterales, and CRE in regional hospitals. Antimicrobial stewardship is a national priority across all GCC states.

Key MDR Organisms in GCC

MRSA — Methicillin-Resistant Staphylococcus aureus

Mechanism: mecA gene — altered penicillin-binding protein (PBP2a); resistant to all beta-lactams
Treatment: Vancomycin (IV, therapeutic drug monitoring — trough AUC/MIC) or Teicoplanin; Linezolid for SSTI/LRTI
Precautions: Contact precautions; single room or cohort; decolonisation (mupirocin nasal ointment + chlorhexidine body wash × 5 days for carriers)
Screening sites: Nose, groin, axilla, wounds, catheter sites

ESBL-Producing Enterobacterales

Extended-Spectrum Beta-Lactamase producers — E. coli, Klebsiella pneumoniae, Proteus mirabilis
Resistant to all penicillins, cephalosporins, and aztreonam
Common sites: UTI (catheter-associated), bloodstream infection (BSI), wound infections
Treatment: Carbapenem (Meropenem / Imipenem) for severe infections; Fosfomycin / nitrofurantoin for uncomplicated lower UTI (review sensitivities)
Precautions: Contact precautions; standard hand hygiene critical (spread via hands)

CRE / CPE — Carbapenem-Resistant Enterobacterales

Resistance to carbapenems (last-resort antibiotics) — OXA-48, NDM, KPC, VIM carbapenemases
Clinical impact: Very limited treatment options; associated with high mortality
Treatment (last resort): Colistin ± Tigecycline ± Fosfomycin; new agents (Ceftazidime-Avibactam for KPC/OXA-48, Meropenem-Vaborbactam for KPC)
Precautions: Strict contact precautions; negative-pressure room if available; enhanced environmental decontamination; patient cohorting
Screening: Rectal swab for carbapenemase PCR on admission from high-risk settings

MDR-TB

Rifampicin-resistant (RR-TB) or Rifampicin + Isoniazid resistant (MDR-TB)
Diagnosis: GeneXpert MTB/RIF detects rifampicin resistance rapidly; confirm with DST (drug susceptibility testing)
Treatment: Bedaquiline-based regimen (BPaL or BPaLM) — 18–24 months
Isolation: Strict airborne precautions; specialist TB centre referral required in GCC

Organism	Key Resistance	Preferred Treatment	Precautions
MRSA	All beta-lactams	Vancomycin / Teicoplanin	Contact
VRE	Vancomycin, beta-lactams	Linezolid / Daptomycin	Contact
ESBL Enterobacterales	Penicillins, cephalosporins	Carbapenem (severe)	Contact
CRE / CPE	Carbapenems	Colistin / CAZ-AVI	Strict contact
MDR-TB	Rifampicin ± Isoniazid	Bedaquiline-based, 18–24 mo	Airborne

Active Surveillance Cultures (ASC)

Screen on admission (before or at admission) in high-risk patients:

Transfer from ICU (any hospital, especially overseas)
Prior history of MDR organism
Admission from a healthcare facility in the last 12 months
Previous admission to a high-prevalence country (South Asia, Middle East, Southern Europe, USA)
Immunocompromised, haematology/oncology patients

Screening Sites

MRSA: Nose (anterior nares), axillae, groin, wounds, catheter sites
ESBL / CRE: Rectal swab (highest yield); wound, urine if catheterised
VRE: Rectal swab

Antimicrobial Stewardship — Nursing Role

Allergy history accuracy: Differentiate true penicillin allergy (anaphylaxis) from intolerance (GI upset). Inaccurate allergy labels drive suboptimal antibiotic choice. Document precise reaction and timing.
Culture before antibiotics: Ensure blood cultures × 2, urine, wound swabs collected BEFORE first antibiotic dose wherever possible
IV to oral (IV-to-PO) switch: Assess daily from day 3 — apyrexial, tolerating oral intake, clinical improvement, no SSTI/endocarditis/meningitis = usually eligible for oral switch
Culture review: Review microbiology results daily; notify prescriber if sensitivities allow de-escalation to narrower-spectrum antibiotic
Duration: Challenge inappropriate long courses; most uncomplicated infections need ≤5–7 days
Vancomycin monitoring: AUC/MIC-guided dosing; trough levels; renal function monitoring

Outbreak Response Protocol

Identify cluster (≥2 related cases by time, place, organism)
Notify IPC team and microbiologist immediately
Place all affected patients on contact precautions
Patient cohorting — dedicated nursing staff if possible
Enhanced environmental decontamination (chlorhexidine or bleach-based products; hydrogen peroxide vapour for terminal clean)
Stop ward admissions if outbreak declared
Point prevalence screening of all ward patients
HCW hand hygiene audit and education
Incident report and Root Cause Analysis (RCA)

HCW Vaccination Schedule — GCC

Vaccine	Schedule	Notes
Hepatitis B	3 doses: 0, 1, 6 months	Check HBsAb 4–8 weeks post-series; repeat if non-immune
Influenza	Annual (seasonal)	Mandatory in most GCC healthcare facilities
MMR	2 doses if non-immune	Check serology or document prior vaccination; MMR contraindicated in pregnancy
Varicella	2 doses if non-immune	Check history and serology; HCWs without immunity are high-risk
COVID-19	Per national schedule	Booster doses per MOH guidance; mandatory in most GCC HCW settings
TB Screening	Baseline Mantoux or QuantiFERON; annual or post-exposure	IGRA preferred in BCG-vaccinated HCWs (common in GCC workforce)

Needlestick / Blood & Body Fluid Exposure

Act Immediately — Time is Critical HIV PEP must be started within 2 hours of exposure for maximum efficacy (up to 72 hours, but earlier = better). HBV immunoglobulin within 24–48 hours.

First Aid

Wash wound with soap and water for ≥2 minutes (do NOT suck or squeeze)
If mucous membrane (eye, mouth): irrigate with copious water or normal saline
Report immediately to supervisor / occupational health

Risk Assessment

Source patient: HIV status (VL), HBV (HBsAg), HCV status
Type of exposure: percutaneous (highest risk), mucous membrane, intact skin (lowest risk)
Volume: hollow needle (high volume = higher risk), solid needle lower

Post-Exposure Management

Pathogen	Action	Timing
HIV	PEP (Tenofovir + Emtricitabine + Raltegravir or Dolutegravir) × 28 days if source HIV+ or unknown high-risk	Start within 2 hours; up to 72h
HBV	HBIG (if non-immune) + Hepatitis B vaccine dose	HBIG within 24–48h
HCV	No PEP available; monitor HCV RNA at 6 weeks; treat if seroconversion (DAA — highly curative)	—

Follow-Up Testing

Baseline: HIV Ab/Ag, HBsAg, HBsAb, HCV Ab, LFTs
6 weeks: HIV Ag/Ab, LFTs (if on PEP)
3 months: HIV Ab, HCV Ab
6 months: HIV Ab, HCV Ab, HBsAg (if source HBsAg+)

Respiratory Fit Testing

N95 / FFP3 fit testing is mandatory for all HCWs who may enter airborne precaution areas (TB, MERS-CoV, measles, varicella)
Qualitative fit test (saccharin/Bitrex) or quantitative test (PortaCount)
Retest if: significant weight change (>10%), facial surgery or injury, new model of respirator
Annual renewal recommended
HCWs who fail fit testing (beards, facial structure) must not enter airborne precaution rooms
Perform seal check every time before donning N95

GCC Infection Control Resources

Saudi Arabia (MOH): IPAC — Infection Prevention and Control Manual (MOH Saudi Arabia); available via MOH portal
Dubai / UAE: DHA Infection Control Standards (Dubai Health Authority)
Qatar: QCHP IPC Guidelines (Qatar Council for Healthcare Practitioners)
Bahrain / Kuwait / Oman: National MOH IPC policies aligned with WHO IPC core components
WHO IPC: WHO Infection Prevention and Control Guidelines (WHO.int) — global reference standard
CDC: 2007 CDC/HICPAC Isolation Precautions Guideline — widely referenced across GCC facilities

Standard Precautions — ALL Patients, ALL the Time

Transmission-Based Precautions

PPE Donning & Doffing — Interactive Checklist

PPE Extended Use vs. Limited Reuse

MERS-CoV Overview

Clinical Features & Progression

Screening Criteria

PPE Protocol for MERS-CoV

Visitor Restrictions

Treatment — Supportive

Camel Exposure Warning

Outbreak Management

Tuberculosis (TB)

Diagnosis

Treatment — Active TB (RHEZ Regimen)

Latent TB Infection (LTBI)

Isolation Criteria

Hepatitis B

Serology Interpretation

HCW Vaccination

COVID-19

Dengue Fever

Diagnosis

Dengue Warning Signs — Urgent Escalation

Malaria

Diagnosis

Treatment

Brucellosis

Clinical Features

Diagnosis

Treatment

Key MDR Organisms in GCC

MRSA — Methicillin-Resistant Staphylococcus aureus

ESBL-Producing Enterobacterales

CRE / CPE — Carbapenem-Resistant Enterobacterales

MDR-TB

Active Surveillance Cultures (ASC)

Screening Sites

Antimicrobial Stewardship — Nursing Role

Outbreak Response Protocol

HCW Vaccination Schedule — GCC

Needlestick / Blood & Body Fluid Exposure

First Aid

Risk Assessment

Post-Exposure Management

Follow-Up Testing

Respiratory Fit Testing

GCC Infection Control Resources

Self-Assessment Quiz — 10 MCQs