Infection Prevention in the Cancer Center Clinical Infectious Diseases 2013;57(4):579–85 R3 조영학 / Prof. 박기호

Background  Cancer center patients  frequently immunosuppressed  risk for a wide range of opportunistic and healthcare-associated infections  Good infection prevention program  reduce risks of both community-acquired infections and hospital- acquired infections  This review focuses on infection prevention measures  specific to patients, healthcare personnel, visitors in the cancer center  epidemiologically important pathogens  specific HAIs  extended to the outpatient cancer setting

Patient measures(1)  Hygiene  Skin : high risk for infection  Intravascular catheters, perineum  daily during nursing care with physician follow-up as needed  Hematopoietic stem cell transplant (HSCT) recipients : avoiding tampon use  Neutropenia : prevent mucosal breakdown (avoiding DRE, rectal thermometers, enemas, suppositories)  Daily chlorhexidine bathing : to reduce transmission of multidrug-resistant organisms (MDROs) and prevent infections

Patient measures(2)  Hygiene  Oral cavity  important source of potentially pathogenic bacteria  Complete periodontal examination : before management of head and neck cancers, high-dose chemotherapy, HSCT, expected immunosuppression  Routine oral hygiene  minimize infections (eg, pneumonia)  improve healing of mucositis  Oral rinses : 4–6 times per day

Patient measures(3)  Low Microbial Diet  for HSCT recipients  periods of neutropenia  No evidence in any patient population  Many HSCT recipients  bottled water - remove Cryptosporidium  during hospital outbreaks of Legionella : sterile water

Patient measures(4)  Antibiotic Prophylaxis to Prevent Infection  most commonly fluoroquinolones  high risk for serious infection  large metanalysis  with hematologic malignancies at high risk for infection  48% reduction in risk for all-cause mortality (relative risk, 0.52)  Quinolone prophylaxis  patients at high risk : hematologic malignancies or HSCT recipients, neutropenia (ANC 7 days  Resistance, Clostridium difficile infection  Prolonged antibiotic prophylaxis  only in HSCT recipients with chronic, active GVHD to prevent infection with Streptococcus pneumoniae

Patient measures(5)  Device-Associated Infections  tunneled or implantable catheters, longer durations  Catheter-related infections : common  nontunneled central venous catheters (CVCs) : HR 3.5  tunneled central venous catheters : HR 1.77  peripherally inserted central venous catheter line(PICC) : 1  best way to prevent CRI : minimize catheter use  removed when no longer needed  insertion by experienced personnel  rigorous exit site care  Urinary catheters  removal when no longer necessary  aseptic technique during insertion  maintaining closed-drainage system with unobstructed flow

Patient measures(6)  Community Respiratory Viruses  lead to serious disease and significant morbidity and mortality among patients with cancer  lower respiratory tract infection  respiratory syncytial virus, influenza viruses,parainfluenza viruses, human metapneumoviruses, adenoviruses  Due to limited effective treatments : prevention is essential  vaccination (influenza)  community & hospital outbreak surveillance  patient and personnel education  rapid diagnosis with early isolation  restriction of potentially infected visitors and healthcare personnel

Patient measures(7)  Fungal Pneumonia  invasive pulmonary aspergillosis  particularly prolonged neutropenia or HSCT recipients  mortality remains high  ubiquitous in the environment  CDC recommends  identification of Aspergillus from a pulmonary source  increase in positive clinical cultures  epidemiologic investigation to determine and eliminate the source  HEPA filters to maintain ultraclean air  directed air flow, positive air pressure, properly ventilated, well sealed, designed to minimize dust  outpatient setting : anti–Aspergillus-azole prophylaxis, preemptive detection strategies

Patient measures(8)  Multidrug-Resistant Organisms  VRE, MRSA, multidrug-resistant gram-negative organisms  MDRO surveillance  cultures of skin or perirectal areas to guide empiric antibiotic therapy for patients with neutropenic fevers  particularly in high-risk patients (eg, HSCT or acute leukemia)

Healthcare personnel and visitors  Immunizations for Healthcare Personnel  unique risk for both exposure to and transmission of many infectious diseases  live-attenuated vaccines : theoretical risk of transmission  absolutely contraindicated : Vaccine-strain polio virus in oral polio vaccine  Safe : measles-mumps-rubella vaccine  live-attenuated influenza vaccine (LAIV) : “severely” immunosuppressed patients  Varicella vaccine : first 42 days, rash that cannot be covered, until the rash is crusted

Healthcare personnel and visitors  Transmissible Diseases From Visitors and Healthcare Personnel  All visitors  basic infection prevention : hand hygiene, Isolation procedures  screened for potential transmissible diseases  restricted from visiting severely immunosuppressed patients  upper respiratory tract infection, flu-like illness, herpes zoster rash, recent known exposure to any transmittable disease  recent vaccinations : oral polio vaccination, rash within 6 weeks of live- attenuated varicella-zoster virus vaccination

Continued infection prevention outside the cancer center

 Patients and healthcare workers  educate regarding measures to reduce risk of exposure to infectious pathogens  Clinicians and infection prevention experts  aware of the local epidemiology and important antibiotic-resistant pathogens prevalent in the cancer center population  potential strategies to reduce exposure to and infection by these organisms  Infection prevention experts  aware of unique issues regarding HAI prevention in the cancer center Summary