Hospital Infection Control

Transplant patients - lung transplant

What specific infection control measures must be adhered to in order to prevent infection in transplant patients - lung transplant?

Lung transplant patients should optimally be in positive-pressure, HEPA-filtered rooms after transplant. Healthcare facilities should have contingency plans in case of disruption of HVAC services.

In general, this serves to reduce the risk of invasive fungal infections. When patients are moved within the hospital and outside of their protective environments, they should wear N95 masks in order to prevent acquisition of invasive fungal and other infections.

In general, construction should be avoided, and done very carefully when necessary. Construction sites should be monitored closely to ensure maintenance of proper barricades with careful taping, HEPA filtration, and/or negative pressure when needed, and sticky floor covering, etc.

Contact precautions should be used for patients with highly resistant gram-negative and gram-positive pathogens in their sputum, i.e., Pseudomonas, Burkholderia, MRSA, VRE or other such pathogens that should not be transmitted from patient-to-patient.

Droplet precautions should be used for patients with viral infections such as influenza and respiratory syncytial virus (RSV).

Contact and respiratory precautions should be used for those with multidermatomal or disseminated herpes zoster infection.

Airborne precautions should be used for people with Mycobacterium tuberculosis.

Person-to-person transmission has been reported with Pneumocystis carinii pneumonia. Clusters in healthcare settings have been reported, and it would seem prudent to cohort patients with active infection away from other transplant recipients.

Vaccination as a means to prevent infection, and thus spread of infection, is a frequently overlooked tool by both transplant clinicians and primary care providers both before and after lung transplant. In one survey of pediatric lung transplant centers, 11 of 16 centers reported following standardized vaccination guidelines post-transplant, and vaccines were more commonly provided by the primary-care physician pre-transplant (69%) rather than post-transplant (38%).

Last, meticulous hand hygiene should be performed before and after all patient encounters.

What are the key conclusions from available clinical trials or meta-analyses related to transplant patients - lung transplant - that guide infection control practices and policies?

Respiratory pathogens from cystic fibrosis patients can contaminate their hands and the clinic environment, however the actual risk of patient-to-patient transmission in the outpatient setting remains difficult to quantify.

In a study of hand carriage and environmental contamination with respiratory pathogens during clinic visits using molecular typing of recovered isolates at seven cystic fibrosis centers, Pseudomonas and Staphylococcus aureus were cultured from patients' hands (7%), the exam room air (8%), and less commonly, environmental surfaces (1%).

Due to the small cohort size in numerous institutions, there are no significant clinical trials or meta-analyses that guide infection control practices and policies in the lung transplant population. Most of the practices and policies were developed based on application of data from other immunocompromised host populations.

What are the consequences of ignoring the concepts related to transplant patients - lung transplant?

Infection in lung transplant recipients is one of the leading causes of morbidity and mortality. In addition, infections can trigger bronchiolitis obliterans syndrome (BOS), which in turn leads to a decline in lung function and is one of the top causes of mortality after lung transplant. Preventing both the direct effects of infection, as well as the indirect effects are both crucial in this vulnerable population.

What other information supports the key conclusions of studies of or advice from transplant patients - lung transplant (e.g., case control studies and case series)?

In a study during construction near a hematopoietic stem cell transplant unit in Finland, the HEPA filters performed well in preventing an aspergillosis outbreak.

Summary of current controversies.

Optimization of infection control in the outpatient clinics remains an area of controversy. Patients are seen both pre-transplant and post-transplant, and some are likely to be colonized with resistant pathogens (i.e., cystic fibrosis patients) while others are at risk for acquiring such infections from those patients. In addition, patients with zoster are at risk for transmitting such infection to non-immune patients.

The optimal duration of time needed in a HEPA-filtered positive-pressure hospital room following transplantation remains unstudied. Whenever possible, transplant patients should be admitted to such rooms, although this may not be feasible in all healthcare settings. Whether it is appropriate to cohort such vulnerable patients with other ill patients has not been well studied, but common sense would suggest that it should be avoided whenever possible.

References

2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings.

Guidelines for Environmental Infection Control in Health-Care Facilities.

Guidelines for the prevention of invasive mould diseases caused by filamentous fungi by the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC), Clin Microbiol Infect 2011; 17 (Suppl. 2): 1–24.

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