AIIR Rooms Are Full: Suspected TB and C. difficile in the Same ED
You are the emergency department nurse. At 14:00 you receive a 47-year-old man with a 3-week history of fever, drenching night sweats, an 8-kg weight loss, and a productive cough with streaks of blood. Chest x-ray shows right upper lobe cavitation; sputum for AFB smear and nucleic acid amplification testing has been sent. All six airborne infection isolation rooms (AIIR) are occupied. He is placed in a semi-private bay, but the other bed is empty. In the adjacent bay is a 79-year-old woman with six watery stools today and a positive C. difficile toxin. Ten minutes ago, before airborne precautions were started, a respiratory therapist gave the man a nebulized bronchodilator in the open bay, and a nurse entered without an N95 respirator to adjust his nasal cannula.
1. State the precautions each patient requires and what you do about the room assignments right now.
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Suspected pulmonary TB → Airborne precautions. AIIR (negative pressure, door closed), fit-tested N95 or PAPR for everyone entering, and a surgical mask on the patient whenever transport is unavoidable.
- The current semi-private bay is not acceptable even with an empty second bed, because the door cannot be closed and the room is not negatively pressurized.
- Immediate actions: move him to a private room with the door closed, patient masked, and put a note on the door; notify infection prevention and the house supervisor to expedite an AIIR; if he needs any aerosol-generating procedure, he gets first priority for the next AIIR.
- Do not "solve" the problem by cohorting him with another patient - a TB suspect is never cohorted.
C. difficile → Contact precautions. Private room preferred; cohort only with another confirmed C. difficile patient. Gown and gloves on entry, dedicated thermometer and stethoscope, and soap and water handwashing - alcohol does not kill spores. Cleaning requires a sporicidal (bleach-based) agent.
The nebulized bronchodilator was an aerosol-generating procedure performed with no airborne precautions - that single event, not the coughing, defines the exposure.
2. The nurse who entered without an N95 asks what she should do. Outline the post-exposure steps and what determines whether she receives treatment.
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Steps:
- Report immediately to employee health/infection control and file the exposure report the same shift. Document the time, duration, distance, whether the patient was masked, and PPE worn.
- Baseline testing: IGRA (or two-step TST) unless she has a documented prior positive result.
- Symptom surveillance for the incubation window - fever, cough, night sweats, weight loss, hemoptysis - with instructions to report any of these immediately.
- Review her fit-test record and whether the respirator she eventually uses seals properly.
What determines treatment: a single exposure to a TB suspect does not trigger preventive medication. Treatment of latent TB infection is considered only if she converts (a new positive IGRA/TST with no prior positive), and active TB disease is treated if symptoms or imaging develop. Whoever orders this must know her prior results - a known positive baseline changes the whole algorithm.
The same steps apply to the respiratory therapist who performed the nebulizer treatment; the nurse should not be the only person reported.
3. The provider asks when airborne precautions can be discontinued and how the specimens should be collected and transported. What do you say?
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Specimens: collect at least three sputum specimens for AFB smear and culture, ideally early-morning induced specimens on separate days; at least one should go for nucleic acid amplification testing, which gives a result in hours rather than weeks. Label them as a suspected-TB biohazard so the lab can protect staff.
Transport: patient wears a surgical mask, staff wear an N95, the receiving department is notified in advance, and he is not left in a hallway or waiting area.
Discontinuation: airborne precautions stay in place until there are three negative AFB smears (and ideally no cavitary disease on imaging and clinical improvement) - a negative NAAT alone or one negative smear is not sufficient, and a single negative test in a cavitary case is a classic trap. Removal requires a provider order after these criteria are met.
Judgment point: the C. difficile contact precautions are independent and are not lifted by the TB results. Contact precautions continue until diarrhea resolves and, per policy, a stool test is negative.