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Infection Control Recommendations for Patients with Cystic Fibrosis

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Infection Control Recommendations for Patients with Cystic Fibrosis S6 INFECTION CONTROL AND HOSPITAL EPIDEMIOLOGY May 2003 INFECTION CONTROL RECOMMENDATIONS FOR PATIENTS WITH CYSTIC FIBROSIS: MICROBIOLOGY, IMPORTANT PATHOGENS, AND INFECTION CONTROL PRACTICES TO PREVENT PATIENT-TO-PATIENT TRANSMISSION Lisa Saiman, MD, MPH; Jane Siegel, MD; and the Cystic Fibrosis Foundation Consensus Conference on Infection Control Participants EXECUTIVE SUMMARY (d) The previously published HICPAC/CDC guidelines for Infection Control Recommendations for Patients With prevention of healthcare-associated infections have not Cystic Fibrosis: Microbiology, Important Pathogens, and included background information and recommenda- Infection Control Practices to Prevent Patient-to-Patient tions for the specific circumstances of patients with CF. Transmission updates, expands, and replaces the con- Thus, specific guidelines for CF patients are needed. sensus statement, Microbiology and Infectious Disease in (e) The link between acquisition of pathogens and morbidity Cystic Fibrosis published in 1994.1 This consensus docu- and mortality is well established. Prevention of acquisi- ment presents background data and evidence-based rec- tion of specific pathogens may further improve the mean ommendations for practices that are intended to decrease survival of CF patients, which has increased to 33.4 years the risk of transmission of respiratory pathogens among in 2001.3-9 CF patients from contaminated respiratory therapy equip- A multidisciplinary committee consisting of health- ment or the contaminated environment and thereby reduce care professionals from the United States, Canada, and the burden of respiratory illness. Included are recommen- Europe with experience in CF care and healthcare epi- dations applicable in the acute care hospital, ambulatory, demiology/infection control reviewed the relevant litera- home care, and selected non-healthcare settings. The tar- ture and developed evidence-based recommendations get audience includes all healthcare workers who provide graded according to the published peer-reviewed sup- care to CF patients. Antimicrobial management is beyond portive data. The participants chose to use the following the scope of this document. CDC/HICPAC system for categorizing recommendations The following information set the stage for the devel- based on previous experience in crafting infection control opment of this guideline: guidelines beyond CF: (a) Studies published since 1994 that further our under- • Category IA. Strongly recommended for implementa- standing of the modes of transmission of pathogens and tion and strongly supported by well-designed experi- effective strategies to interrupt transmission among CF mental, clinical, or epidemiologic studies. patients provide the data needed for evidence-based • Category IB. Strongly recommended for implementation guidelines. and supported by some experimental, clinical, or epidemi- (b) Improved microbiology methods provide more accurate ologic studies and a strong theoretical rationale. detection and further definition of the epidemiology of • Category IC. Required for implementation, as mandated pathogens in CF patients. by federal and/or state regulation or standard. (c) The publication of the HICPAC/CDC (Healthcare • Category II. Suggested for implementation and support- Infection Control Practices Advisory Committee/ ed by suggestive clinical or epidemiologic studies or a Centers for Disease Control and Prevention) Guideline theoretical rationale. for Isolation Precautions in Hospitals in 19962 defined • No recommendation; unresolved issue. Practices for which standard precautions and recommended universal insufficient evidence or no consensus regarding efficacy application to care for all patients at all times to prevent exist. transmission of infectious agents that may not yet have Category IA and IB recommendations are strongly been identified. recommended for implementation by all CF centers and Dr. Saiman is from the Department of Pediatrics, Columbia University, New York, New York. Dr. Siegel is from the Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas. Address reprint requests to Cystic Fibrosis Foundation, 6931 Arlington Road, Bethesda, MD 20814; telephone: (800) FIGHT-CF; website: [email protected]. The authors thank Sherrie Myers and Elizabeth Garber for their assistance in the preparation of this document. This material is being published simultaneously in Infection Control and Hospital Epidemiology and the American Journal of Infection Control. Copyright SLACK Incorporated. Vol. 24 No. 5, Suppl. RECOMMENDATIONS FOR PATIENTS WITH CYSTIC FIBROSIS S7 considered to be “best practice.” Implementation of Category nosa, respiratory syncytial virus (RSV), parainfluenza, or van- II recommendations is advised by the committee, but indi- comycin-resistant enterococci (VRE). Recommendations for vidual centers may determine which Category II recommen- room placement, activities outside the hospital room, CF clin- dations would be appropriate for their CF centers. ic logistics, and adjuvant measures to prevent infections are This document integrates knowledge of microbiology provided. No recommendation can be made for the routine laboratory methods, infection control principles, and epidemi- wearing of masks by CF patients when leaving an inpatient ology of respiratory pathogens in CF patients. Standardization room or when in the waiting room of a CF clinic. of infection control practices across CF centers will provide Specific practices for the use and care of respirato- safer environments for patients by reducing the risk of trans- ry therapy equipment recommended in this document are mission of CF pathogens. In addition to infection control prac- based on principles of disinfection and sterilization14,15 as tices that are applicable to all CF patients at all times, specific well as findings from investigations of outbreaks of infec- infection control practices are recommended for inpatient, tions associated with contaminated respiratory therapy ambulatory, and non-healthcare settings, based on the types equipment. Cleaning devices, such as nebulizers, with of activities and risks associated with the various settings. CF removal of debris as soon as possible and before disinfec- care teams as well as patients and their families must be well tion, and complete air drying are the critical steps in both educated concerning the known risks and the effective pre- healthcare and home settings. ventive measures to ensure adherence to the evidence-based recommendations in this document. It will be beneficial for Microbiology, Molecular Typing, and each CF center to evaluate the effectiveness of its infection Surveillance control program to reduce transmission of pathogens and Because aggressive antimicrobial treatment of P. improve clinical outcomes. Collaboration between the CF care aeruginosa at initial acquistion may be associated with a delay team and the CF center’s infection control team will facilitate in chronic infection and an improved clinical course,16-18 res- effective implementation that takes into consideration the psy- piratory tract cultures should be obtained at least quarterly in chosocial impact of these recommendations. CF patients with stable pulmonary status as well as at the This document was reviewed by the members of HIC- time of pulmonary exacerbations. Specific recommendations PAC, and the recommendations were found to be consistent are made for transport and processing of specimens, includ- with the principles of infection control that serve as the foun- ing the preferred selective media. Agar-based diffusion dation of HICPAC/CDC guidelines for prevention of health- assays, eg, antibiotic-containing disks or E-tests, rather than care-associated infections. This guideline was formally automated commercial microbroth dilution systems are rec- endorsed by The Society for Healthcare Epidemiology of ommended for susceptibility testing of P. aeruginosa iso- America and the Association for Professionals in Infection lates.19-21 Molecular typing using appropriate methods, eg, Control and Epidemiology boards in 2002-2003. The National pulsed-field gel electrophoresis (PFGE), rapid amplified poly- Committee for Clinical Laboratory Standards has endorsed merase chain reaction (RAPD-PCR), and repetitive DNA the recommendations for susceptibility testing. sequence PCR (Rep-PCR), are recommended to assess strain relatedness of isolates from different patients when patient-to- Infection Control Principles patient transmission is suspected.22-25 CF pathogens are transmitted by the droplet and con- Recommendations are made to develop surveillance in tact routes. Therefore, practices that contain respiratory collaboration with the CF center’s infection control team. S. secretions and prevent transmission of respiratory tract aureus, including MRSA, P. aeruginosa, and B. cepacia pathogens must be taught to patients and their families as complex are always targeted, whereas Stenotrophomonas well as to CF healthcare workers. Such practices must be fol- maltophilia, Achromobacter xylosoxidans, and nontuberculous lowed with all CF patients and cannot be implemented mycobacteria (NTM) are included when considered according to the specific microbiology results of individual epidemiologically important, eg, patient-to-patient transmis- CF patients because microbiology methods are not 100% sen- sion or an outbreak is suspected. Surveillance includes cal- sitive for the detection of CF pathogens.10,11
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