flowchart TD
A([Patient admission]) --> B
B{"🟠 DECISION POINT<br/>MRSA screening criteria ?<br/>Prior carrier · recent hosp. · stay >6w<br/>ICU · roommate · geriatric · onco · dialysis · pre-op"}
B -- No --> C(["🟢 NURSE<br/>Standard care<br/>No isolation required"])
B -- Yes --> D
D["🟢 NURSE<br/>Order triple swab<br/>Nose + throat + perineum/rectum<br/>Send to laboratory"]
D --> E["🟡 LABORATORY<br/>Pool 3 swabs<br/>Microbiological analysis<br/>Result published on Cliniweb"]
E --> F{"🟠 RESULT ?"}
F -- Negative --> G{"🟠 Stay > 6 weeks ?"}
G -- No --> C
G -- Yes --> H["🟢 NURSE<br/>Repeat screening every 6 weeks<br/>Schedule in H++"]
H --> D
F -- Positive --> I["🟡 LABORATORY / CLINIWEB<br/>Automatic MRSA flag added<br/>to patient record on Cliniweb"]
I --> J
J["🔴 MRSA CONFIRMED — ALERT<br/>Single room mandatory<br/>C3 sign on door"]
J --> K["🟢 NURSE<br/>Encode isolation in H++<br/>Select C3 under specific care<br/>Tick and validate each measure"]
K --> L{"🟠 Respiratory MRSA infection<br/>or aerosol-generating procedure ?<br/>Intubation · tracheotomy · bronchoscopy"}
L -- No --> M["🟢 NURSE<br/>Contact precautions C3<br/>Gloves + disposable gown + SHA"]
L -- Yes --> N["🟢 NURSE<br/>Contact + Droplet precautions DC1<br/>Gloves + gown + surgical mask + SHA<br/>Update isolation to DC1 in H++"]
M --> O["🟢 NURSE<br/>Inform patient<br/>Isolation brochure provided<br/>Movement restricted to urgent cases only"]
N --> O
O --> P{"🟠 IODINE ALLERGY ?"}
P -- No --> Q["🟢 NURSE<br/>Iso-Betadine protocol 5 days<br/>Nose: gel 3x/day · Body: Uniwash<br/>Throat: mouthwash 3x/day<br/>Wounds: saline + Iso-Betadine"]
P -- Yes --> R["🟢 NURSE<br/>Alternative protocol 5 days<br/>Nose: Bactroban / Affusine<br/>Body: Dermanios scrub 4%<br/>Throat: Corsodyl 3x/day"]
Q --> S["🟢 NURSE<br/>Daily during decolonisation<br/>Clean clothes + linen changed 1x/day<br/>New washcloth + hand towel daily"]
R --> S
S --> T["🟢 NURSE<br/>Control swabs 48h after end of decolonisation<br/>3 swabs · 3 different days · all sites"]
T --> U["🟡 LABORATORY<br/>Analysis of control swabs<br/>Result published on Cliniweb"]
U --> V{"🟠 3 consecutive<br/>negative results ?"}
V -- No --> W{"🟠 2nd decolonisation<br/>attempt already done ?"}
W -- No --> X["🟢 NURSE<br/>Restart decolonisation protocol"]
X --> T
W -- Yes --> Y["🟣 INFECTION CONTROL TEAM ☎ 19744/19765/19658<br/>Chlorhexidine gloves protocol<br/>Mandatory contact with HH team"]
Y --> Z{"🟠 Controls<br/>still positive ?"}
Z -- Yes --> AA["🟣 INFECTION CONTROL TEAM<br/>Patient classified as chronic carrier<br/>Maintain isolation<br/>Reassess with HH team"]
Z -- No --> V
V -- Yes --> AB["🔵 PHYSICIAN<br/>Lift isolation order<br/>MRSA flag updated on Cliniweb<br/>Team notified"]
AB --> AC["🟢 NURSE<br/>Clear room · dispose non-disinfectable materials<br/>Disinfect isolation kit<br/>Sterilise dedicated equipment"]
AC --> AD["🟢 HOUSEKEEPING<br/>Full terminal cleaning<br/>Bed · furniture · sanitaries · floor · TV<br/>Wash curtains"]
AD --> AE{"🟠 Roommate exposed > 12h ?"}
AE -- No --> AF([End — room available])
AE -- Yes --> AG["🟢 NURSE<br/>Order screening swab for roommate<br/>Single room while awaiting results<br/>Standard precautions"]
AG --> AH["🟡 LABORATORY<br/>Analysis of roommate swab<br/>Result on Cliniweb"]
AH --> AI{"🟠 Roommate result ?"}
AI -- Negative --> AJ["🟢 NURSE<br/>Unblock room<br/>Standard precautions"]
AI -- Positive --> AK["🔴 ROOMMATE ISOLATION<br/>Single room<br/>Contact precautions C3"]
AJ --> AF
AK --> AF
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WorkflowPCI
1 MRSA
1.1 Workflow Description
The MRSA (Methicillin-Resistant Staphylococcus Aureus) workflow at Clinique Saint-Jean covers the full patient pathway from admission screening through to end of isolation, and is organised around four interconnected processes: screening, isolation precautions, decolonisation, and room clearance.
Screening is triggered at admission for any patient meeting at least one risk criterion: prior MRSA carrier status, recent hospitalisation or institutional stay, expected length of stay exceeding six weeks, planned ICU admission, shared room with a detected case for more than 12 hours, geriatric index, oncological or haematological diagnosis, dialysis programme, or scheduled surgical intervention with implants. The nurse orders a triple swab (nose, throat, perineum or rectum), which is sent to the laboratory for pooled microbiological analysis. The result is published on Cliniweb. If negative and the stay exceeds six weeks, screening is repeated every six weeks. If positive, the laboratory result automatically triggers an MRSA flag on the patient record in Cliniweb.
Isolation begins immediately upon confirmed positivity. The patient is placed in a single room with a C3 sign on the door. The nurse encodes the isolation in H++ under specific care, selecting C3 and validating each individual measure. For all MRSA carriers, contact precautions apply: gloves, disposable gown, and hand hygiene with SHA before and after any contact. If the patient presents a respiratory MRSA infection or undergoes an aerosol-generating procedure (intubation, tracheotomy, wound irrigation, bronchoscopy), droplet precautions are added (DC1): surgical mask in addition to full contact precautions, updated in H++. The patient is informed of their carrier status and provided with an isolation brochure. Movement outside the room is restricted to urgent cases only; the patient always wears clean clothes and a surgical mask and is accompanied when leaving the room.
Decolonisation follows a five-day protocol. In the absence of iodine allergy, the standard regimen consists of Iso-Bétadine gel applied to the nose three times daily, Iso-Bétadine Uniwash for the body, and Iso-Bétadine mouthwash for the throat three times daily. Wounds are cleaned with saline and disinfected with Iso-Bétadine. For patients with iodine allergy, an alternative protocol is used: Bactroban or Affusine for the nose, Dermanios scrub 4% for the body, and Corsodyl mouthwash for the throat. Throughout decolonisation, the nurse ensures daily change of clothes, bed linen, washcloth, and hand towel. Control swabs are taken 48 hours after completion of the protocol, across three different days and all sites. If three consecutive negative results are not obtained, the decolonisation protocol is restarted. After a second failed attempt, the Infection Control team is contacted and a chlorhexidine gloves protocol is initiated. Persistent positivity leads to classification as a chronic carrier, with maintained isolation and reassessment by the Hospital Hygiene team.
End of isolation is triggered by three consecutive negative control swabs. The physician updates the patient record and the MRSA flag on Cliniweb. The nurse clears the room, disposing of non-disinfectable materials, disinfecting the isolation kit, and arranging sterilisation of dedicated equipment. The housekeeping team performs a full terminal cleaning of the room, including bed, mattress, furniture, sanitaries, floor, television, and curtains. If a roommate shared the room for more than 12 hours, a screening swab is ordered. The roommate is placed in a single room while awaiting results. A negative result unblocks the room; a positive result triggers contact isolation for the roommate following the same pathway.
1.2 Flowchart
2 CPE
2.1 Workflow Description
The CPE (Carbapenemase-Producing Enterobacteriaceae) and MDR Pa-Ab (Pseudomonas aeruginosa / Acinetobacter baumanii) workflow covers the management of patients carrying carbapenem-resistant Gram-negative bacteria. Transmission occurs via direct and indirect contact through hands, contaminated surfaces, and biological fluids (faeces, urine). These organisms can survive in the environment for several weeks to months. Unlike MRSA, no decolonisation protocol exists for CPE/MDR Pa-Ab: isolation is maintained for the entire duration of hospitalisation, or until three consecutive negative samples taken one week apart are obtained if the stay exceeds three months.
Screening is triggered at admission for any patient meeting at least one of the following criteria: prior CPE or MDR Pa-Ab carrier status, planned or recent ICU admission, hospitalisation in Belgium or abroad within the past year, return from a non-European country, shared room for more than 12 hours with a detected case, dialysis, diarrhoea, or outbreak situation on advice of the Hospital Hygiene team. The screening method consists of a rectal swab or stool sample at admission, with coproculture and specific CPE search noted on the laboratory request form. For known MDR Pa-Ab carriers, a pharyngeal swab or lower respiratory tract sample is additionally required, along with skin or mucosal swabs if lesions are present. In the ICU, screening is performed at admission and twice weekly (Monday and Thursday). During hospitalisation, coproculture with CPE screening is ordered for any patient presenting diarrhoea.
Isolation begins immediately upon confirmed positivity and is maintained for the entire stay. The patient is placed in a single room with a C3 sign on the door. The nurse encodes the isolation in H++ under nursing measures, selecting C3 and validating each individual measure. If the patient presents a cough, isolation is upgraded to DC1 and updated in H++. Contact precautions apply for all staff entering the room: non-sterile gloves, disposable long-sleeved gown, and SHA hand hygiene after glove removal. No stock is kept in the room; individualised care equipment and the isolation kit are used. Particular attention is given to cleaning and disinfecting equipment near the patient (computers, pumps, IV systems, keyboard, mouse) using Surfa’safe or Clinell spray. Patient movement outside the room is restricted to necessary examinations only; the patient always wears clean clothes and performs SHA hand hygiene before leaving and is always accompanied. A dedicated wheelchair is assigned; if not possible, it is disinfected after each use. Patient transfers are limited and always communicated to the receiving unit, with the transfer document completed on Cliniweb.
Daily environmental maintenance of the room is performed once per day, seven days a week. Floors are cleaned with Incidin Plus 1% (exception: ICU and operating theatre use Umonium Neutralis). Surfaces and equipment are disinfected with Surfa’safe or Clinell spray. Housekeeping always cleans the CPE room last and applies contact precautions throughout.
End of isolation occurs either at discharge or, for stays exceeding three months, after three consecutive negative samples taken one week apart. The nurse clears the room and disposes of unused materials, and disinfects the isolation kit. The housekeeping team performs a full terminal cleaning of the room including bed, mattress, furniture, sanitaries, floor, television, and curtains.
Roommate management follows the same logic as MRSA: any patient sharing a room for more than 12 hours is transferred to a single room, screened by rectal swab, and kept in isolation pending results. Standard precautions apply while awaiting the result. A positive result triggers contact isolation; a negative result unblocks the room. In the event of even a single nosocomial acquisition in the same unit, the Hospital Hygiene team is contacted immediately.
2.2 Flowchart
flowchart TD
A([Patient admission]) --> B
B{"🟠 DECISION POINT<br/>CPE / MDR Pa-Ab screening criteria ?<br/>Prior carrier · ICU planned or recent<br/>Hosp. Belgium or abroad <1yr · non-EU travel<br/>Roommate >12h · dialysis · diarrhoea · outbreak"}
B -- No --> C(["🟢 NURSE<br/>Standard care<br/>No isolation required"])
B -- Yes --> D
D["🟢 NURSE<br/>Order rectal swab or stool sample<br/>Tick coproculture + CPE search<br/>on laboratory request form"]
D --> E{"🟠 MDR Pa-Ab known carrier ?"}
E -- Yes --> F["🟢 NURSE<br/>Additional samples:<br/>Pharyngeal swab or lower resp. tract sample<br/>Skin/mucosal swab if lesions present"]
E -- No --> G
F --> G
G["🟡 LABORATORY<br/>Microbiological analysis<br/>CPE / MDR Pa-Ab search<br/>Result published on Cliniweb"]
G --> H{"🟠 RESULT ?"}
H -- Negative --> I{"🟠 Diarrhoea during stay ?"}
I -- No --> C
I -- Yes --> J["🟢 NURSE<br/>Order coproculture + CPE search<br/>Repeat for any new diarrhoea episode"]
J --> G
H -- Positive --> K["🟡 LABORATORY / CLINIWEB<br/>Automatic CPE / MDR Pa-Ab flag<br/>added to patient record on Cliniweb"]
K --> L
L["🔴 CPE / MDR Pa-Ab CONFIRMED — ALERT<br/>Single room mandatory<br/>C3 sign on door<br/>Isolation for entire hospitalisation"]
L --> M["🟢 NURSE<br/>Encode isolation in H++<br/>Nursing measures → C3<br/>Tick and validate each measure"]
M --> N{"🟠 Patient presenting cough ?"}
N -- No --> O["🟢 NURSE<br/>Contact precautions C3<br/>Gloves + disposable gown + SHA"]
N -- Yes --> P["🟢 NURSE<br/>Contact + Droplet precautions DC1<br/>Gloves + gown + surgical mask + SHA<br/>Update isolation to DC1 in H++"]
O --> Q["🟢 NURSE<br/>Inform patient<br/>Isolation brochure provided<br/>Room use of sanitaries only<br/>SHA hand hygiene before leaving room<br/>Always accompanied"]
P --> Q
Q --> R["🟢 HOUSEKEEPING<br/>Daily room cleaning 7 days/week<br/>Floors: Incidin Plus 1%<br/>Surfaces + equipment: Surfa'safe / Clinell spray<br/>CPE room cleaned last"]
R --> S{"🟠 Patient transfer required ?"}
S -- Yes --> T["🟢 NURSE<br/>Notify receiving unit<br/>Complete transfer document on Cliniweb<br/>Communicate isolation status"]
S -- No --> U
T --> U
U{"🟠 Stay > 3 months ?"}
U -- No --> V["🔴 ISOLATION MAINTAINED<br/>For entire hospitalisation<br/>No decolonisation protocol exists"]
V --> W
U -- Yes --> W{"🟠 3 consecutive negative samples<br/>one week apart ?"}
W -- No --> X["🟢 NURSE<br/>Maintain isolation<br/>Repeat sampling weekly"]
X --> W
W -- Yes --> Y
Y["🔵 PHYSICIAN<br/>Lift isolation order<br/>CPE flag updated on Cliniweb<br/>Team notified"]
Y --> Z["🟢 NURSE<br/>Clear room · dispose unused materials<br/>Disinfect isolation kit"]
Z --> AA["🟢 HOUSEKEEPING<br/>Full terminal cleaning<br/>Bed · mattress · furniture · sanitaries · floor · TV<br/>Wash curtains"]
AA --> AB{"🟠 Roommate exposed > 12h ?"}
AB -- No --> AC([End — room available])
AB -- Yes --> AD["🟢 NURSE<br/>Transfer roommate to single room<br/>Order rectal swab screening<br/>Standard precautions while awaiting results<br/>No new admission next to roommate"]
AD --> AE["🟡 LABORATORY<br/>Analysis of roommate swab<br/>Result on Cliniweb"]
AE --> AF{"🟠 Roommate result ?"}
AF -- Negative --> AG["🟢 NURSE<br/>Unblock room<br/>Standard precautions"]
AF -- Positive --> AH["🔴 ROOMMATE ISOLATION<br/>Single room<br/>Contact precautions C3"]
AG --> AC
AH --> AC
AI{"🟠 Nosocomial acquisition<br/>in same unit ?"}
AA --> AI
AI -- Yes --> AJ["🟣 INFECTION CONTROL TEAM ☎ 19765/19658<br/>Outbreak management<br/>Environmental sampling if advised<br/>Cohort isolation if necessary"]
AI -- No --> AC
AJ --> AC
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3 Clostridiode difficiles
3.1 Workflow Description
The Clostridioides difficile (CDI) workflow applies to any patient presenting with diarrhoea (liquid stools), whether at admission or during the hospital stay. C. difficile is a spore-forming anaerobic Gram-positive bacillus transmitted via the oro-faecal route through hands, the environment, and contaminated equipment (thermometer, blood pressure cuff, urinal, etc.). A critical specificity of this pathogen is that spores are not eliminated by alcohol-based hand rub alone: handwashing with soap and water followed by SHA disinfection is mandatory. The appropriate sporicidal disinfectant for surfaces and equipment is Anioxy spray with a 30-minute contact time, and Incidin Active for floors.
Screening is triggered for any patient with diarrhoea, with or without fever. The nurse orders a stool sample for coproculture and toxin testing. In cases of complication, additional samples may include colon biopsy, intestinal fluid, or colon sample.
Isolation is required for any patient with diarrhoea and a positive toxin result, any patient with diarrhoea and a prior positive toxin history, and — specifically in the Paediatrics unit — any patient with diarrhoea as a preventive measure pending results. The patient is placed in a single room with individual sanitary facilities and a C2 sign on the door. The door may remain open. The isolation is encoded in H++ under specific nursing care, with isolation type C selected and each measure individually validated. Contact precautions apply for all staff entering the room: gloves, disposable long-sleeved gown, shoe covers in cases of explosive diarrhoea, handwashing with soap and water followed by SHA both before and after glove removal. Gloves and gown are removed simultaneously before leaving the room. Patient movement is restricted to strictly necessary examinations, which are scheduled last; all care is preferably delivered in the room.
Treatment consists first of stopping antibiotics where possible. First-line treatment is Flagyl 3x500 mg per day for 10 days. In case of relapse or persistent diarrhoea, Flagyl is extended to 14 days. If there is no response to Flagyl, treatment is switched to Vancomycin syrup 4x250 mg per day for 10 days. Secondary prevention with Saccharomyces boulardii (Enterol 2x2 gel 250 mg per day) may be considered throughout the treatment course.
Daily environmental maintenance is performed every day, 7 days a week. Floors are cleaned with Incidin Active powder (160g in 8L cold water). Surfaces and equipment are disinfected with Anioxy spray with a mandatory 30-minute contact time. The CDI room is always cleaned last. Housekeeping staff apply contact precautions throughout. The bedpan washer is used after each defecation on the intensive programme.
End of isolation requires a minimum of 72 hours without diarrhoea and at least one solid stool. Coproculture is only repeated if diarrhoea recurs. In the event of relapse, C2 isolation is reinstated.
Room clearance follows the same logic as other MDROs. The nurse clears the room and disposes of unused materials, disinfects the isolation kit with Anioxy spray (30 minutes contact time), and returns it to the Hospital Hygiene team (route 530). Housekeeping performs a full terminal cleaning with Anioxy spray (30 minutes) for all surfaces and Incidin Active (5 minutes) for floors, including bed, mattress, furniture, sanitaries, and curtains.
Roommate management: if the confirmed CDI patient was in a shared room, they are transferred to a single room. The roommate is monitored; if diarrhoea develops, a coproculture is ordered and preventive isolation initiated. The shared room is disinfected with Incidin Active and Anioxy spray. In the event of an outbreak (minimum three nosocomial cases among patients and staff within three days in the same unit), the Hospital Hygiene team is contacted immediately at ☎ 19744 or 19658.
3.2 Flowchart
flowchart TD
A([Patient admission or during stay]) --> B{"🟠 DECISION POINT<br/>Patient presenting diarrhoea<br/>liquid stools ?"}
B -- No --> C(["🟢 NURSE<br/>Standard care<br/>Monitor for new symptoms"])
B -- Yes --> D
D["🟢 NURSE<br/>Order stool sample<br/>Coproculture + toxin test<br/>Additional samples if complication:<br/>colon biopsy · intestinal fluid"]
D --> E["🟡 LABORATORY<br/>Coproculture + toxin analysis<br/>Result published on Cliniweb"]
E --> F{"🟠 RESULT ?"}
F -- Negative --> G{"🟠 Prior positive<br/>toxin history ?"}
G -- No --> C
G -- Yes --> H
F -- Positive --> H
F -- Pending + Paediatrics unit --> I["🔴 PREVENTIVE ISOLATION<br/>Single room + individual sanitary<br/>C2 sign on door — door may remain open"]
H["🔴 CDI CONFIRMED — ISOLATION<br/>Single room + individual sanitary<br/>C2 sign on door — door may remain open"]
H --> J
I --> J
J["🟢 NURSE<br/>Encode isolation C2 in H++<br/>Specific nursing care → patient isolation follow-up<br/>Tick and validate each measure"]
J --> K["🟢 NURSE<br/>Contact precautions<br/>Gloves + disposable long-sleeved gown + SHA<br/>Soap + water handwash BEFORE and AFTER glove removal<br/>Shoe covers if explosive diarrhoea<br/>Remove gloves + gown together before leaving room"]
K --> L["🟢 NURSE<br/>Inform patient<br/>Isolation brochure provided<br/>Movement restricted — examinations scheduled last<br/>Patient always accompanied"]
L --> M["🔵 PHYSICIAN<br/>Stop antibiotics if possible<br/>Prescribe Flagyl 3x500mg/day × 10 days"]
M --> N["🟢 HOUSEKEEPING<br/>Daily room cleaning 7 days/week<br/>Floors: Incidin Active 160g/8L cold water<br/>Surfaces + equipment: Anioxy spray 30min contact<br/>CDI room cleaned last"]
N --> O{"🟠 Response to treatment ?<br/>Min 72h without diarrhoea<br/>+ at least one solid stool ?"}
O -- No --> P{"🟠 Relapse or<br/>persistent diarrhoea ?"}
P -- Relapse/persistent --> Q["🔵 PHYSICIAN<br/>Extend Flagyl to 14 days"]
Q --> O
P -- No response --> R["🔵 PHYSICIAN<br/>Switch to Vancomycin syrup<br/>4x250mg/day × 10 days<br/>Consider Saccharomyces boulardii<br/>Enterol 2x2 gel 250mg/day"]
R --> O
O -- Yes --> S["🔵 PHYSICIAN<br/>Lift isolation order<br/>Flag updated on Cliniweb<br/>Team notified"]
S --> T["🟢 NURSE<br/>Clear room · dispose unused materials<br/>Disinfect isolation kit: Anioxy spray 30min<br/>Return kit to HH team — route 530"]
T --> U["🟢 HOUSEKEEPING<br/>Full terminal cleaning<br/>Surfaces: Anioxy spray 30min<br/>Floors: Incidin Active 5min<br/>Bed · mattress · furniture · sanitaries · TV<br/>Wash curtains"]
U --> V{"🟠 Shared room<br/>before confirmed diagnosis ?"}
V -- No --> W([End — room available])
V -- Yes --> X["🟢 NURSE<br/>Transfer CDI patient to single room<br/>Disinfect shared room:<br/>Incidin Active + Anioxy spray<br/>Monitor roommate for diarrhoea"]
X --> Y{"🟠 Roommate<br/>develops diarrhoea ?"}
Y -- No --> W
Y -- Yes --> Z["🟢 NURSE<br/>Order coproculture for roommate<br/>Initiate preventive C2 isolation"]
Z --> W
U --> AA{"🟠 Outbreak suspected ?<br/>≥ 3 nosocomial cases<br/>same unit within 3 days"}
AA -- No --> W
AA -- Yes --> AB["🟣 INFECTION CONTROL TEAM<br/>☎ 19744 / 19658<br/>Outbreak management<br/>Cohort isolation if advised"]
AB --> W
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4 Scabies
4.1 Workflow Description
The scabies workflow applies to any patient, staff member, or visitor presenting with symptoms suggestive of Sarcoptes scabiei infestation within the hospital. Transmission occurs through prolonged direct or indirect contact of 10 to 15 minutes or more. The mite does not survive long outside the skin (2 to 5 days), which means environmental contamination is limited but linen and clothing require specific management. The incubation period ranges from 2 to 6 weeks, which makes early identification and contact tracing essential.
Clinical presentation includes intense itching, predominantly nocturnal, with typical skin lesions (pearly vesicles and scabietic nodules) located in interdigital spaces, palms, wrists, forearms, elbows, armpits, inner thighs, feet, peri-umbilical region, buttocks, penis, and knees. The presentation is frequently atypical and may be difficult to distinguish from eczema, allergies, or other skin infections. Bacterial superinfection after scratching is the main complication.
Upon suspicion, the Hospital Hygiene team is notified immediately. An urgent dermatology consultation is requested for any patient presenting with pruritus and skin lesions. Family members or other patients with identical symptoms must be identified and assessed.
Isolation type C1 is initiated immediately upon suspicion, without waiting for dermatology confirmation. The isolation is encoded in H++ and the Hospital Hygiene team is alerted. Staff members in contact with the patient are also assessed.
Treatment is determined by the dermatologist (Zalvor or Stromectol). It is important to note that itching may persist for up to 4 weeks after successful treatment and does not indicate treatment failure.
Linen management is critical throughout. Soiled linen is placed immediately in a sealed yellow laundry bag and sprayed with Biokill directly in the laundry cart. During the treatment period, bed linen, hand towels, washcloths, and patient clothing are changed daily. Staff in contact with the patient change their own clothing daily as well. After treatment, all linen, towels, washcloths, and clothing are changed. Clothing worn in the 96 hours prior to treatment is sprayed with Biokill and washed at the highest possible temperature, above 60°C.
End of isolation occurs 48 hours after treatment. At that point, a thorough deep cleaning of the room is performed, with particular attention to contact points, curtains, and the mattress if possible.
4.2 Flowchart
flowchart TD
A([Patient / Staff / Visitor<br/>presenting pruritus or skin lesions]) --> B{"🟠 DECISION POINT<br/>Suggestive symptoms ?<br/>Nocturnal itching · vesicles · nodules<br/>Typical skin distribution"}
B -- No --> C(["🟢 NURSE<br/>Standard care<br/>Monitor for new symptoms"])
B -- Yes --> D
D["🟣 INFECTION CONTROL TEAM<br/>Notify Hospital Hygiene team immediately<br/>☎ 19744 / 19658"]
D --> E["🔴 IMMEDIATE ISOLATION C1<br/>Single room · door closed<br/>Encode C1 isolation in H++<br/>Do not wait for dermatology confirmation"]
E --> F["🔵 PHYSICIAN<br/>Urgent dermatology consultation<br/>Clinical diagnosis confirmation"]
F --> G{"🟠 Scabies confirmed<br/>by dermatologist ?"}
G -- No --> H["🔵 PHYSICIAN / 🟣 HH TEAM<br/>Reassess diagnosis<br/>Lift isolation if ruled out"]
G -- Yes --> I
I["🔵 DERMATOLOGIST<br/>Prescribe treatment<br/>Zalvor or Stromectol"]
I --> J["🟣 INFECTION CONTROL TEAM<br/>Identify contacts:<br/>Family members · patients · staff<br/>with identical symptoms → assess"]
J --> K["🟢 NURSE<br/>During treatment period<br/>Change daily: bed linen · hand towels<br/>washcloths · patient clothing<br/>Staff in contact change clothing daily"]
K --> L["🟢 NURSE<br/>Linen management<br/>Sealed yellow laundry bag<br/>Spray Biokill immediately in laundry cart"]
L --> M["🟢 HOUSEKEEPING<br/>Daily standard room cleaning 1x/day<br/>Standard contact precautions"]
M --> N{"🟠 Treatment completed ?"}
N -- No --> K
N -- Yes --> O["🟢 NURSE<br/>After treatment:<br/>Change all linen · towels · washcloths · clothing<br/>Clothing worn 96h before treatment:<br/>Spray Biokill + wash > 60°C"]
O --> P{"🟠 48h after treatment<br/>elapsed ?"}
P -- No --> P
P -- Yes --> Q["🔵 PHYSICIAN<br/>Lift isolation order<br/>Flag updated on Cliniweb<br/>Team notified<br/>Note: itching may persist up to 4 weeks —<br/>does not indicate treatment failure"]
Q --> R["🟢 NURSE<br/>Clear room · dispose unused materials<br/>Disinfect isolation kit"]
R --> S["🟢 HOUSEKEEPING<br/>Deep terminal cleaning<br/>Focus on contact points · curtains · mattress<br/>Standard disinfectants"]
S --> T([End — room available])
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5 Tuberculose
5.1 Workflow Description
The tuberculosis (TB) workflow at Clinique Saint-Jean applies to any patient suspected or confirmed to carry Mycobacterium tuberculosis. Pulmonary and laryngeal forms are contagious; extra-pulmonary forms are not, unless concurrent pulmonary involvement is present. Transmission is exclusively airborne via droplet nuclei of 1–5 microns. Surfaces play no role in transmission. Airborne precautions must be initiated immediately upon clinical suspicion, without waiting for bacteriological confirmation. Immunocompromised patients may present atypical clinical pictures.
Screening and diagnosis is triggered by persistent cough (more than 3 weeks), chest pain, dyspnoea, haemoptysis, fever, weight loss, night sweats, fatigue, suggestive chest X-ray findings, or a relevant epidemiological history (prior TB, high-risk geographic origin). Three morning sputum samples of 5–10 ml are collected at 24-hour intervals, in the room or outside the building. Each sample undergoes direct microscopy (AFB smear), culture for mycobacteria, and identification of the M. tuberculosis complex. A negative smear does not exclude active contagious tuberculosis. Tuberculosis is a notifiable disease: any confirmed or suspected case must be declared without delay to Vivalis (Brussels health agency) by email at notif-hyg@vivalis.brussels or by phone at 02 552 01 91. The Hospital Hygiene team is copied on the declaration.
Isolation type A (airborne precautions) is initiated immediately upon suspicion. The patient is placed in a single room with the door permanently closed. Ideally, a negative pressure room is used (5–7 Pa, minimum 6 air changes per hour, with an anteroom). All staff entering the room must wear an FFP2 respirator mask, put on before entering and removed only after the door is closed. Strict hand hygiene applies before and after any contact. The patient wears a surgical mask for any movement outside the room and is educated on cough hygiene. Sputum is collected in single-use containers, evacuated daily via the biological waste pathway. Visitors are limited; FFP2 masks are mandatory for all visitors. Children under 5 years may not visit.
End of isolation is decided by the responsible physician in consultation with the Hospital Hygiene team. For unconfirmed suspicion: isolation is lifted after 3 negative direct smears and an alternative diagnosis, or after 15 days of empirical treatment with favourable clinical evolution. For confirmed cases (positive smear, sensitive strain): isolation is lifted after 3 consecutive negative direct smears under adequate treatment and favourable radio-clinical evolution. Upon lifting isolation, the room is kept in quarantine until complete air renewal (minimum 2 hours with windows open if no mechanical ventilation). FFP2 mask remains mandatory for anyone entering during this period.
Contact tracing is coordinated by the head nurse and the Hospital Hygiene team using a concentric circle approach: first circle (daily contacts), second (regular), third (occasional). The contagiousness period to trace back is 3 months if the smear was positive, 1 month if culture only. Community contacts are referred to FARES (Brussels/French community) or VRGT (Flemish community). Occupational exposure is managed by the occupational health service (CESI).
5.2 Flowchart
flowchart TD
A([Patient with respiratory symptoms]) --> B{"🟠 DECISION POINT<br/>Suggestive symptoms ?<br/>Cough >3w · chest pain · dyspnoea<br/>Haemoptysis · fever · weight loss<br/>Night sweats · suggestive X-ray<br/>High-risk epidemiological history"}
B -- No --> C(["🟢 NURSE<br/>Standard care<br/>Monitor for new symptoms"])
B -- Yes --> D
D["🔴 IMMEDIATE AIRBORNE ISOLATION — TYPE A<br/>Single room · door permanently closed<br/>Ideally: negative pressure room<br/>5–7 Pa · min 6 air changes/hour<br/>Do NOT wait for bacteriological confirmation"]
D --> E["🟢 NURSE<br/>Encode isolation A in H++<br/>Specific nursing care → patient isolation follow-up<br/>Tick and validate each measure"]
E --> F["🟢 NURSE / ALL STAFF<br/>FFP2 respirator mandatory in room<br/>Put on BEFORE entering<br/>Remove AFTER door is closed<br/>Strict hand hygiene before and after contact"]
F --> G["🔵 PHYSICIAN<br/>Order 3 morning sputum samples<br/>5–10 ml · at 24h intervals<br/>Collected in room or outside building<br/>AFB smear + culture + M. tuberculosis ID"]
G --> H["🟡 LABORATORY / MICROBIOLOGIST<br/>Direct microscopy · culture · identification<br/>If positive: notify prescribing physician<br/>Copy to Hospital Hygiene + Vivalis by mail"]
H --> I{"🟠 Direct smear result ?"}
I -- Negative --> J{"🟠 Culture result<br/>or clinical evolution ?"}
J -- Alternative diagnosis retained<br/>+ 3 negative smears --> K["🔵 PHYSICIAN<br/>Lift isolation in concertation<br/>with Hospital Hygiene team"]
J -- 15 days empirical treatment<br/>+ favourable clinical evolution --> K
J -- Culture positive --> L
I -- Positive --> L
L["🔴 TB CONFIRMED<br/>Positive smear or culture"]
L --> M["🔵 PHYSICIAN<br/>Mandatory declaration to Vivalis<br/>notif-hyg@vivalis.brussels<br/>☎ 02 552 01 91 (weekdays 9h–17h)<br/>Copy to Dr Markiewicz: chmarkiewicz@clstjean.be"]
M --> N["🟣 INFECTION CONTROL TEAM<br/>Verify declaration to Vivalis<br/>Supervise airborne isolation measures<br/>Epidemiological follow-up"]
N --> O["🟢 HEAD NURSE<br/>Establish contact list for the unit<br/>Transmit to Hospital Hygiene + Occupational Health CESI<br/>Alert linked departments:<br/>Radiology · Physiotherapy · ICANE · Lab · Housekeeping"]
O --> P["🟢 NURSE<br/>Patient education:<br/>Surgical mask for any movement outside room<br/>Cough hygiene training<br/>Sputum in single-use containers<br/>Daily evacuation via biological waste pathway"]
P --> Q["🟣 INFECTION CONTROL TEAM<br/>Contact tracing — concentric circles<br/>1st: daily contacts · 2nd: regular · 3rd: occasional<br/>Contagiousness period: 3 months if smear+ / 1 month if culture only<br/>Community contacts → FARES / VRGT"]
Q --> R{"🟠 End of isolation criteria met ?<br/>3 consecutive negative smears<br/>under adequate treatment<br/>+ favourable radio-clinical evolution"}
R -- No --> S["🟢 NURSE<br/>Maintain isolation<br/>Continue monitoring"]
S --> R
R -- Yes --> K
K["🔵 PHYSICIAN<br/>Lift isolation order<br/>Flag updated on Cliniweb<br/>Team notified"]
K --> T["🟢 HOUSEKEEPING<br/>Room quarantine until full air renewal<br/>Min 2h windows open if no mechanical ventilation<br/>FFP2 mandatory for anyone entering during this period"]
T --> U["🟢 HOUSEKEEPING<br/>Full terminal cleaning<br/>Standard disinfectants<br/>Bed · mattress · furniture · sanitaries · floor · TV<br/>Wash curtains"]
U --> V["🟤 OCCUPATIONAL HEALTH — CESI<br/>Evaluate exposed staff<br/>Organise screening per risk groups CSS 8579<br/>Medical follow-up of exposed workers<br/>Declaration if occupational TB: FMP code 1.404.01"]
V --> W([End])
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6 Bacterial Meningitis (Neisseria meningitidis)
6.1 Workflow Description
The bacterial meningitis workflow at Clinique Saint-Jean applies to any patient suspected or confirmed to carry Neisseria meningitidis (meningococcus), a Gram-negative diplococcus with 13 serogroups, of which B, C, W135, and Y are most prevalent in Belgium. The reservoir is strictly human. Transmission occurs person-to-person via droplets from nasal or oro-pharyngeal secretions at a distance of less than 1 metre, face-to-face, for at least 1 hour. The incubation period is 2 to 7 days (most commonly 3 to 4 days). Contagiousness begins approximately 7 days before the first clinical signs and ends 24 hours after initiation of effective antibiotic therapy.
Clinical suspicion is raised by any of the following: meningeal signs, purpura (haemorrhagic rash not fading under pressure), septic shock, or septic arthritis. Laboratory confirmation requires at least one of: isolation of N. meningitidis from a normally sterile site or purpuric skin lesion, detection of specific DNA or antigens in CSF or sterile site, or detection of Gram-negative diplococci in CSF. Indirect signs of bacterial versus viral meningitis on CSF analysis include turbidity, neutrophilic leucocytosis, elevated protein, and reduced glucose. Isolation precautions (droplet type DC) are initiated immediately upon clinical suspicion, without waiting for laboratory confirmation.
Isolation is of droplet type and maintained until 24 hours after initiation of adequate antibiotic therapy. The patient is placed in a single room. All staff in close contact wear a surgical mask. The isolation is encoded in H++ with the appropriate measures validated individually.
Mandatory declaration to Vivalis is required for any suspected or confirmed invasive meningococcal infection, without delay, by email at notif-hyg@vivalis.brussels or by phone at 02 552 01 91 (weekdays 9h–17h, with redirection to the sanitary on-call outside office hours). The declaration is confirmed to the Hospital Hygiene physician by email at chmarkiewicz@clstjean.be. The microbiologist or hospital pharmacist notifies the prescribing physician and the responsible physician upon receipt of a positive sample, copying the Hospital Hygiene team and Vivalis.
Contact management focuses on high-risk contacts: staff who performed aerosol-generating procedures without a respirator mask from the time of admission until 24 hours after antibiotic initiation, or staff who were in close face-to-face contact (less than 1 metre, more than 1 hour) with the patient. Routine daily care does not constitute a high-risk exposure. Prophylaxis must be administered within 24 to 48 hours of last contact and no later than 7 days after. The standard prophylaxis is a single dose of Ciproxine 500 mg; azithromycin is used in case of pregnancy. The head nurse establishes the contact list for the unit, transmits it to the Hospital Hygiene team and Occupational Health, and coordinates prophylaxis distribution. The responsible physician prescribes the required doses for pharmacy dispensing based on the risk level of each staff member. Community contacts are managed by the treating physician or Vivalis.
Occupational health (CESI) evaluates exposed staff and ensures medical follow-up.
6.2 Flowchart
flowchart TD
A([Patient with neurological symptoms<br/>or haemorrhagic rash]) --> B{"🟠 DECISION POINT<br/>Suggestive clinical signs ?<br/>Meningeal signs · purpura<br/>Septic shock · septic arthritis"}
B -- No --> C(["🟢 NURSE<br/>Standard care<br/>Monitor for new symptoms"])
B -- Yes --> D
D["🔴 IMMEDIATE DROPLET ISOLATION — DC<br/>Single room<br/>Surgical mask mandatory for all staff<br/>Do NOT wait for laboratory confirmation"]
D --> E["🟢 NURSE<br/>Encode droplet isolation DC in H++<br/>Tick and validate each measure"]
E --> F["🔵 PHYSICIAN<br/>Order diagnostic workup:<br/>CSF analysis · blood cultures<br/>N. meningitidis DNA/antigen detection<br/>Initiate antibiotic therapy without delay"]
F --> G["🟡 LABORATORY / MICROBIOLOGIST<br/>CSF: turbidity · neutrophilia<br/>elevated protein · reduced glucose<br/>Culture · DNA · antigen detection<br/>Gram-negative diplococci"]
G --> H{"🟠 Result ?"}
H -- Negative → alternative diagnosis --> I["🔵 PHYSICIAN<br/>Reassess · lift isolation<br/>if meningococcal infection ruled out"]
H -- Positive or<br/>strong clinical suspicion --> J
J["🔴 MENINGOCOCCAL INFECTION CONFIRMED<br/>OR STRONGLY SUSPECTED"]
J --> K["🔵 PHYSICIAN<br/>Mandatory declaration to Vivalis<br/>notif-hyg@vivalis.brussels<br/>☎ 02 552 01 91 (weekdays 9h–17h)<br/>Copy to Dr Markiewicz: chmarkiewicz@clstjean.be"]
K --> L["🟡 MICROBIOLOGIST<br/>Confirm positive result by email<br/>to prescribing physician + responsible physician<br/>Copy to Hospital Hygiene + Vivalis"]
L --> M["🟣 INFECTION CONTROL TEAM<br/>Verify declaration to Vivalis<br/>Supervise isolation measures<br/>Epidemiological follow-up"]
M --> N["🟢 HEAD NURSE<br/>Establish contact list for the unit<br/>Transmit to Hospital Hygiene + Occupational Health CESI<br/>Alert linked departments:<br/>Radiology · Physiotherapy · ICANE · Lab · Housekeeping"]
N --> O{"🟠 High-risk contact identified ?<br/>Aerosol-generating procedure without mask<br/>OR face-to-face <1m · >1h<br/>from admission to 24h after antibiotic start"}
O -- No --> P["🟢 NURSE<br/>Standard precautions<br/>No prophylaxis required"]
O -- Yes --> Q
Q["🔵 PHYSICIAN<br/>Prescribe prophylaxis for exposed staff<br/>Ciproxine 500mg — single dose<br/>Azithromycin if pregnancy<br/>Within 24–48h of last contact<br/>Maximum 7 days after last contact"]
Q --> R["💊 PHARMACY<br/>Dispense prophylaxis<br/>Based on physician prescription<br/>per unit and risk level"]
R --> S["🟢 HEAD NURSE<br/>Distribute prophylaxis to exposed staff<br/>Ensure compliance and traceability"]
S --> T{"🟠 24h after adequate<br/>antibiotic therapy initiated ?"}
T -- No --> T
T -- Yes --> U["🔵 PHYSICIAN<br/>Lift isolation order<br/>Flag updated on Cliniweb<br/>Team notified"]
U --> V["🟢 HOUSEKEEPING<br/>Terminal cleaning of room<br/>Standard disinfectants<br/>Bed · furniture · sanitaries · floor<br/>Wash curtains"]
V --> W["🟤 OCCUPATIONAL HEALTH — CESI<br/>Evaluate exposed staff<br/>Medical follow-up<br/>Monitor for secondary cases"]
W --> X([End])
P --> X
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7 Bed Bugs (Cimex lectularius)
7.1 Workflow Description
The bed bug workflow at Clinique Saint-Jean applies to any patient identified as carrying or infested with Cimex lectularius (bed bugs), whether detected at admission or during the hospital stay. Bed bugs are nocturnal parasites that feed exclusively on human blood and hide in cracks, crevices, mattress seams, furniture, walls, and any dark narrow space. Unlike lice, they do not live on the human body. They are not vectors of disease but cause painful, irritating bites presenting as grouped lesions of three or four in a line on exposed body parts. They spread passively through clothing, luggage, and personal belongings.
Detection occurs during clinical examination at the emergency department or in the care unit. Signs include grouped bite marks in lines of three or four on exposed skin (arms, legs, abdomen, back), or the visible presence of bugs on the patient’s body or belongings. If the infestation is identified at the point of admission, the patient must transit through as few areas as possible, all clothing must be removed from rooms the patient will pass through, and a shower must be taken immediately.
Immediate patient management follows a fixed sequence. The patient’s clothing and all personal belongings are placed in a sealed plastic bag, sprayed with Biokill, hermetically sealed, and labelled with the patient’s identification. If the patient is hospitalised, the bag is placed in the freezer at -45°C for 72 hours in the biotechnique department at level -2 (access via security: ☎ 19730). If the patient is not hospitalised, the sealed bag is returned to the accompanying person and must not be kept in the unit. The patient is given a shower (body and hair) and provided with hospital clothing. The patient is then transferred to a clean room.
Room management follows immediately. The original room and all rooms the patient transited through are blocked. Adjacent rooms to the left and right of the infested room are also identified and communicated. The Hospital Hygiene team is notified at Hygienehospitaliere@clstjean.be. The HH team transmits the information to the technical services, who contact the specialist pest control company APC as quickly as possible.
Isolation precautions (C3) apply to the infested room only: closed door, gown, gloves, and shoe covers in cases of heavy infestation. SHA hand hygiene applies throughout.
Desinfestation by APC follows a two-visit protocol. Before the first visit, bed linen is evacuated in a hermetically sealed double yellow plastic bag; the bed, mattress, and furniture remain in the room. After the first treatment, the room remains closed for 48 hours, after which housekeeping cleans the floor. A second treatment is carried out 7 to 15 days after the first, with the same 48-hour closure and floor cleaning. Daily cleaning with C3 precautions is maintained between the two treatments. A single treatment is sufficient if the APC technician finds no active bed bug presence during the first visit. Adjacent rooms are treated preventively if there is a risk of massive infestation, based on the HH team’s risk assessment.
Room clearance occurs after the first or second APC treatment, confirmed by the HH team. The housekeeping service performs a full terminal cleaning: bed, mattress, furniture, sanitaries, floor, television, and curtains. Curtains are sprayed with Biokill in a sealed plastic bag and left for one week before washing. Clothing and bed linen are washed at a minimum of 60°C. Furniture integrity is checked; damaged items are discarded.
7.2 Flowchart
flowchart TD
A([Patient at admission or during stay]) --> B{"🟠 DECISION POINT<br/>Signs of bed bug infestation ?<br/>Grouped bites in lines of 3–4<br/>on exposed skin<br/>OR bugs visible on body/belongings"}
B -- No --> C(["🟢 NURSE<br/>Standard care<br/>Monitor for new symptoms"])
B -- Yes --> D
D{"🟠 Infestation identified<br/>at point of admission ?"}
D -- Yes --> E["🟢 NURSE<br/>Minimise patient transit areas<br/>Remove clothing from rooms patient will pass through<br/>Immediate shower before room assignment"]
D -- No — already in room --> F["🟢 NURSE<br/>Transfer patient to clean room immediately<br/>Block original room + all transit rooms<br/>Block adjacent rooms left and right"]
E --> G
F --> G
G["🟢 NURSE<br/>Remove all patient clothing + personal belongings<br/>Place in sealed plastic bag<br/>Spray with Biokill · seal hermetically<br/>Label with patient ID"]
G --> H{"🟠 Patient hospitalised ?"}
H -- Yes --> I["🟢 NURSE<br/>Place bag in freezer -45°C for 72h<br/>Biotechnique dept · level -2<br/>Access via security ☎ 19730<br/>Use cold-protection gloves"]
H -- No --> J["🟢 NURSE<br/>Return sealed bag to accompanying person<br/>Do NOT keep bag in the unit"]
I --> K
J --> K
K["🟢 NURSE<br/>Patient shower — body + hair<br/>Provide hospital clothing<br/>Install patient in clean room"]
K --> L["🟣 INFECTION CONTROL TEAM<br/>Notify HH team:<br/>Hygienehospitaliere@clstjean.be<br/>Communicate: infested room number<br/>all transit rooms · adjacent rooms left + right"]
L --> M["🟠 TECHNICAL SERVICES<br/>Contact specialist pest control APC<br/>Provide all room numbers<br/>Coordinate intervention timing"]
M --> N["🟢 NURSE<br/>Apply C3 isolation precautions<br/>on infested room only<br/>Gown + gloves + shoe covers if heavy infestation<br/>Door closed · SHA hand hygiene"]
N --> O["🟢 HOUSEKEEPING<br/>Before APC visit:<br/>Evacuate bed linen in double sealed yellow bag<br/>Leave bed · mattress · furniture in room"]
O --> P["🟠 APC — 1st treatment visit<br/>Room closed during treatment<br/>+ 48h after treatment"]
P --> Q["🟢 HOUSEKEEPING<br/>Clean floor after 48h<br/>Daily cleaning with C3 precautions<br/>maintained between two treatments"]
Q --> R{"🟠 Active bed bugs found<br/>by APC technician ?"}
R -- No active bugs found --> S["🟠 APC SINGLE TREATMENT SUFFICIENT<br/>Confirmed by technician<br/>Validate with HH team"]
R -- Yes → 2nd treatment needed --> T["🟠 APC — 2nd treatment visit<br/>7 to 15 days after 1st visit<br/>Same precautions as 1st visit<br/>Room closed during treatment + 48h"]
T --> U["🟢 HOUSEKEEPING<br/>Clean floor after 48h"]
U --> S
S --> V["🟣 INFECTION CONTROL TEAM<br/>Confirm room clearance<br/>Risk assessment for adjacent rooms<br/>Extended perimeter if also infested"]
V --> W["🟢 HOUSEKEEPING<br/>Full terminal cleaning<br/>Bed · mattress · furniture · sanitaries · floor · TV<br/>Curtains: spray Biokill in sealed bag · leave 1 week<br/>Clothing + linen: wash ≥ 60°C<br/>Discard damaged furniture"]
W --> X([End — room available])
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8 Measles (Rougeole)
8.1 Workflow Description
The measles workflow at Clinique Saint-Jean applies to any patient suspected or confirmed to carry the measles virus (Morbillivirus), a strictly human RNA virus with no healthy carrier state. Transmission is exclusively airborne via direct contact or aerosolisation of naso-pharyngeal secretions. Aerosols remain infectious for up to 2 hours after the patient has left a closed room. The incubation period averages 10 days (range 7–18 days), with rash appearing approximately 14 days after exposure. The contagious period spans 9 days: 4 days before the rash appears to 4 days after, with maximum contagiousness during the catarrhal phase (fever, cough, rhinitis, conjunctivitis). Airborne precautions must be initiated immediately upon clinical suspicion, without waiting for biological confirmation.
Screening is triggered for any patient presenting fever combined with a maculo-papular rash and at least one of: cough, rhinitis, or conjunctivitis, particularly with a suggestive history (geographic origin, contact with a case, absence of documented vaccination). The Koplik sign is pathognomonic but fugitive. Preferred diagnostic test is RT-PCR on a salivary (Oracol) or nasopharyngeal swab, taken within 7 days of rash onset. Alternatives include specific IgM on serum or saliva (day 3 to 28 of rash), or a fourfold increase in IgG titre on two samples 2 weeks apart. The National Reference Centre (CNR RRO, Sciensano) is contacted for sampling materials. A negative test does not exclude measles in the first 3 days of rash. Measles is a notifiable disease: any suspicion must be declared without delay to Vivalis at notif-hyg@vivalis.brussels or ☎ 02 552 01 91, without waiting for biological confirmation.
Isolation type A (airborne precautions) is initiated immediately. The patient is placed in a single room with the door permanently closed, ideally in a negative pressure room (5–7 Pa, minimum 6 air changes per hour, with an anteroom). An airborne precaution sign (A) is posted at the room entrance. All staff entering the room must wear an FFP2 respirator mask, put on before entering and removed only after the door is closed. Priority is given to immune staff for patient care. Non-immune or unknown-status staff must wear FFP2 plus full PPE. Strict hand hygiene applies before and after any contact. The patient wears a surgical mask for any movement outside the room and is educated on cough hygiene (elbow technique, disposable tissues). Visitors are informed of the risk; FFP2 masks are mandatory and children under 5 are not permitted to visit.
End of isolation is decided by the responsible physician in consultation with the Hospital Hygiene team. For unconfirmed suspicion: after 3 negative tests and an alternative diagnosis retained, or after 15 days of empirical treatment with favourable clinical evolution. For confirmed cases: 4 days after the appearance of the rash, with favourable clinical evolution. Upon lifting isolation, the room is quarantined until complete air renewal (minimum 2 hours with windows open if no mechanical ventilation); FFP2 remains mandatory during this period.
Post-exposure management targets any person who had face-to-face contact or spent more than 15 minutes in the same room as the patient. For waiting areas, contact is considered up to 30 minutes after the patient’s departure (with HEPA filter or minimum 8 air changes per hour) or up to 2 hours (inadequate ventilation). Post-exposure vaccination is offered within 72 hours of first contact for anyone aged 6 months and over. For high-risk groups without access to vaccination (infants under 6 months, pregnant women, immunocompromised patients), immunoglobulins are evaluated on a case-by-case basis. All exposed persons must monitor for symptoms for 21 days and avoid contact with vulnerable individuals.
Treatment is symptomatic only; no specific antiviral exists. Antibiotics are used only if a documented bacterial superinfection occurs (otitis, pneumonia). Pre-exposure prevention relies on RRO vaccination (85–90% efficacy after 1 dose, 95–97% after 2 doses); unimmunised healthcare staff are a priority for vaccination.
8.2 Flowchart
flowchart TD
A([Patient with fever + rash<br/>or suggestive history]) --> B{"🟠 DECISION POINT<br/>Suggestive symptoms ?<br/>Fever + maculo-papular rash<br/>+ cough · rhinitis · conjunctivitis<br/>Suggestive history / no documented vaccination"}
B -- No --> C(["🟢 NURSE<br/>Standard care<br/>Monitor for new symptoms"])
B -- Yes --> D
D["🔴 IMMEDIATE AIRBORNE ISOLATION — TYPE A<br/>Single room · door permanently closed<br/>Ideally: negative pressure room<br/>5–7 Pa · min 6 air changes/hour<br/>Airborne sign A posted at room entrance<br/>Do NOT wait for biological confirmation"]
D --> E["🟢 NURSE<br/>Encode isolation A in H++<br/>Patient isolation follow-up<br/>Tick and validate each measure"]
E --> F["🟢 NURSE / ALL STAFF<br/>FFP2 respirator mandatory in room<br/>Put on BEFORE entering<br/>Remove AFTER door is closed<br/>Priority to immune staff for patient care<br/>Non-immune staff: FFP2 + full PPE<br/>Strict hand hygiene before and after contact"]
F --> G["🔵 PHYSICIAN<br/>Mandatory declaration to Vivalis<br/>WITHOUT waiting for biological confirmation<br/>notif-hyg@vivalis.brussels<br/>☎ 02 552 01 91 (weekdays 9h–17h)<br/>Platform TIW monitored 7 days/7<br/>Copy to Dr Markiewicz: chmarkiewicz@clstjean.be"]
G --> H["🔵 PHYSICIAN<br/>Order diagnostic workup:<br/>RT-PCR salivary swab (Oracol) or nasopharyngeal<br/>within 7 days of rash onset<br/>Alt: specific IgM serum/saliva D3–D28<br/>Contact CNR RRO Sciensano for sampling material"]
H --> I["🟡 LABORATORY / MICROBIOLOGIST<br/>RT-PCR · IgM · IgG analysis<br/>If positive: notify prescribing physician<br/>+ responsible physician<br/>Copy to Hospital Hygiene + Vivalis"]
I --> J{"🟠 Result ?"}
J -- Negative<br/>first 3 days of rash --> K["⚠️ NURSE / PHYSICIAN<br/>Negative does NOT exclude measles<br/>in first 3 days of rash<br/>Maintain isolation · repeat testing"]
K --> J
J -- Negative<br/>+ alternative diagnosis --> L["🔵 PHYSICIAN<br/>Lift isolation in concertation<br/>with Hospital Hygiene team"]
J -- Positive --> M
M["🔴 MEASLES CONFIRMED"]
M --> N["🟣 INFECTION CONTROL TEAM<br/>Verify declaration to Vivalis<br/>Centralise information<br/>Supervise airborne isolation measures<br/>Epidemiological follow-up"]
N --> O["🟢 HEAD NURSE<br/>Establish contact list for the unit<br/>Transmit to Hospital Hygiene + Occupational Health<br/>Alert linked departments:<br/>Radiology · Physiotherapy · Lab · Housekeeping"]
O --> P{"🟠 Contact at risk identified ?<br/>Face-to-face contact<br/>OR >15 min in same room<br/>Waiting room: up to 30min after departure<br/>HEPA/8 ACH · or 2h if inadequate ventilation"}
P -- No --> Q["🟢 NURSE<br/>Standard precautions<br/>Monitor for symptoms 21 days<br/>Avoid contact with vulnerable persons"]
P -- Yes --> R{"🟠 Contact immune status ?<br/>Documented vaccination<br/>or prior confirmed measles ?"}
R -- Immune --> Q
R -- Not immune or unknown --> S["🔵 PHYSICIAN<br/>Post-exposure vaccination within 72h<br/>if aged ≥ 6 months<br/>Immunoglobulins if: infant <6m<br/>pregnant · immunocompromised<br/>→ evaluate case by case"]
S --> T["🟤 OCCUPATIONAL HEALTH — CESI<br/>Evaluate immune status of exposed staff<br/>Organise screening + vaccination if indicated<br/>Declare if occupational measles:<br/>FMP + Contrôle Bien-être au travail"]
T --> U{"🟠 End of isolation criteria met ?<br/>Confirmed: 4 days after rash onset<br/>+ favourable clinical evolution<br/>Unconfirmed: 3 negative tests<br/>+ alternative diagnosis"}
U -- No --> V["🟢 NURSE<br/>Maintain isolation<br/>Symptomatic treatment only<br/>Antibiotics only if bacterial superinfection"]
V --> U
U -- Yes --> L
L --> W["🟢 HOUSEKEEPING<br/>Room quarantine until full air renewal<br/>Min 2h windows open if no mechanical ventilation<br/>FFP2 mandatory for anyone entering during this period"]
W --> X["🟢 HOUSEKEEPING<br/>Full terminal cleaning<br/>Standard disinfectants<br/>Bed · mattress · furniture · sanitaries · floor · TV<br/>Wash curtains"]
X --> Y([End])
Q --> Y
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