Infection Control Today: Clinical Update

Infection Control Practices for the Immunocompromised Patient Population

By Kathy Dix

Caring for immunocompromised patients requires much greater vigilance than in other departments of the hospital. The patients natural defense mechanisms are suppressed due to an immune disorder, chemotherapy, radiation, or medication leaving them vulnerable to pathogens that would cause no problems to people with normal immune systems. Nursing staff, cleaning staff, and infection control must work as a cohesive unit to preserve the health of these delicate patients.

The staff must be able to assess the patient regularly for signs and symptoms of infection, not just on admission, but continually throughout his or her stay. Asepsis and handwashing are not the only watchwords for this patient population; there must be constant attention paid to nutrition, oral hygiene, skin care, and psychological support. Guidelines for care can be found at

http://infectioncontrol.ucsfmedicalcenter.org/Infection_Control_Manual/4____Medical_Center-wide_Polic/4_8____Care_of_the_Immunosuppr/body_4_8____care_of_the_immunosuppr.html

Tools for Maintaining a Healthy Environment

David Fink, director of research and development for patient care and wound care at TycoKendall Healthcare, offers a simple tool for preserving patient health wound dressings that are targeted specifically to help the infection control practitioner (ICP) and nurse prevent infection, rather than treat it after the fact. As the old adage says, An ounce of prevention is worth a pound of cure.

This particular tool is designed to prevent bacterial contamination through a dressing or colonization of bacteria in a dressing. We recognize that hospital-acquired infections (HAIs) are a very serious problem and are very expensive to treat in excess of $14,000 as an average cost to treat one infection, Fink says. Its easier to help deal with these infections before they get heavily colonized and heavily infected. A cleaned and treated wound is covered with a dressing that might be gauze, non-adherent, or a sponge that covers and protects a drain site, such as a tracheotomy.

These dressings can be impregnated with a broad-spectrum antiseptic that kills a variety of bacteria; the goal is not to change the hospital protocol in other words, the different types of dressings they use to care for their patients but to make those dressings more effective. It is well documented that patients begin with a wound thats healing, and it suddenly becomes contaminated, from patient to patient, from caregiver to patient and so forth. Our focus is to help reduce the incidence of that, adds Fink.

Mary Jo Beneke, RN, wound care nurse at Yuma Regional Medical Center in Yuma, Ariz., points out, Anyone with an open wound is especially vulnerable to infection, and if they are immunocompromised, they are at even greater risk for infections like methicillin-resistant Staphylococcus aureus (MRSA) and other antibiotic-resistant infections.

Most people in the hospital have compromised immune systems. We usually think about cancer patients receiving chemotherapy, or patients with acquired immunodeficiency syndrome (AIDS) or other types of diseases that directly affect the immune system, but other conditions and diseases and/or their treatments can also affect the immune system. Infection control considerations are incorporated in all aspects of patient care, including care of the environment, equipment and supplies used, procedures and treatments, patient/family teaching, and discharge planning, in addition to direct patient care. Regardless of whether or not it is known that a patient has an infection or is at risk for infection, standard precautions developed by the Centers for Disease Control and Prevention (CDC) should always be followed for the protection of patients and healthcare workers. Patient care is tailored to an individual patients problems, but prevention and infection control should be included in all patient care.

Beneke continues, At Yuma Regional, we conducted a study using a gauze dressing impregnated with a solution proven to prevent bacterial colonization (which reduced infection) as one way to reduce some of the variability in patient care. In a nine-month study for approximately 7,500 surgical patients in the hospital, we used AMD hypoallergenic gauze (impregnated with a solution that has been proven to resist bacterial colonization within the dressing and inhibit bacterial penetration through the dressing) and experienced a 47 percent reduction in surgical site infections. Based on the results of this trial, our value analysis committee agreed to continue use of the AMD dressings as an infection control measure for all patients requiring gauze dressing in the facility.

She observes that if a patient has a very low white blood cell count (neutropenia), he or she is at very high risk for infection because the white blood cells are lacking to help the body fight infection. If a patient has a disease or infection that is transmitted through contact or through the air, then contact, droplet, or airborne precautions are followed. ICPs and nurses are expected to follow Standard Precautions when caring for patients to protect them from acquiring an infection while in the hospital. If a patient has signs and symptoms of infection, the ICP must identify the source and causative organism(s) of that infection, and treat the infection appropriately. If a patient has a wound, or any break in the skin, even if its not infected, wound care should be provided to keep the wound clean, covered, and protected from exposure to potential infection. When applying a dressing, we want to cover the wound to impede entrance of bacteria into the wound. Practicing good hand hygiene is an important prevention measure, Benke says.

During hospitalization, nurses assess the patient every shift. Vital signs are monitored on a regular basis, usually every four hours, but may be more or less frequently depending on the acuity of the patient, Beneke points out. Any deterioration in patient status, including signs and symptoms of infection, is reported to the ICP.

Necessary Precautions

Roberta Kaplow, RN, PhD, CCNS, CCRN, is a clinical nurse specialist in the perioperative services department at De Kalb Medical Center in Atlanta. She had previously spent years in the intensive care unit (ICU) at a specialty cancer treatment center, working with patients who were undergoing bone marrow transplants.

I can tell you that the standards have changed during my 20 years in a comprehensive cancer center, she states. We used to do things that were way beyond what was required for a patient to prevent infection. It was very expensive and very labor intensive, and we found that it did nothing more than regular reverse isolation.

Times have now changed for the better, she states. The bone marrow transplant patients were considered high risk and confined to a special unit specifically built for them, which included laminar flow to keep pathogens out of the air they breathed. All items in these patients rooms were sterile including the linens, as well as respiratory equipment. Any person who went into the patient room had to do a ten-minute surgical scrub, had to do full garb as if they were going into the OR, with hats and masks, sterile gowns, sterile shoe covers, Kaplow recalls. Essentially, they were living in a bubble. The patients never got to see anything but the eyes of their healthcare provider, so they couldnt recognize one person from another. It was costing over $1 million a year, and we found out that over time, the incidence of infection was no greater in patients who had regular reverse isolation which is just strict handwashing before and after entering and leaving the room, wearing a mask and plain exam gloves, not sterile gloves. For a while, they were using paper disposable gowns, but found out that you dont even need the gowns.

Strict handwashing is crucial. For this patient population, the patients bodies are essentially sterilized completely rid of pathogens. High doses of chemotherapy are given; then aggressive radiation is applied, sometimes as often as two to three times a day for a week. The patients are then given antibiotics to kill off any residual bacteria within the body.

Visitors, including healthcare providers, must wear masks and gloves, and visitors are warned not to visit if they are unwell, or if they have been exposed to someone else sick, or if they have received a live vaccine.

Precautions are draconian; rectal temperatures are not taken in this population. If female patients are menstruating, they should use sanitary napkins rather than tampons, so as not to introduce germs into the body but menstruation is discouraged to prevent the loss of platelets, which might further compromise the patients health. If the patient must leave the unit for testing, they are not allowed to walk on the floor, to prevent cuts from anything on the floor. If they must walk, they should wear foot protection.

Diet and nutrition are crucial. No fresh fruits or vegetables are permitted, unless the fruits have a thick skin, such as oranges or bananas. Grapefruit, despite their thick skins, are forbidden, because of potential food/drug interactions. Applies, pears, strawberries, and grapes are prohibited. So too are sushi and lettuce. Meat must be well-cooked and nothing with raw eggs is permitted. Not only that, but live plants and fresh flowers are prohibited the flowers because the water can grow mold and Pseudomonas, which could cause pneumonia.

One stethoscope is confined to each room, so it cannot transfer pathogens from patient to patient. Only glass thermometers are used, and these are also kept in each patients room.

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