- Email: [email protected]
Survey of infection control policies for patients with cystic fibrosis in the United States
Survey of infection control policies for patients with cystic fibrosis in the United States Juyan Zhou, MS, MPH, Elizabeth Garber, MSc, and Lisa Saiman, MD, MPH New York, New York
Written infection control policies used at cystic fibrosis (CF) care sites in the United States were compared with recently published guidelines. Most policies recommended contact precautions for hospitalized patients infected with Burkholderia cepacia complex (73%), multidrug-resistant organisms (63%), and methicillin-resistant Staphylococcus aureus (64%). Socializing among CF patients was discouraged in 80% of inpatient policies and 55% of outpatient policies. Although routine mask use by patients remains an unresolved issue, many policies advocated this practice. Future studies should address barriers to implementation of these evidence-based guidelines and continue to monitor implementation. (Am J Infect Control 2008;36:220-2.)
Cystic fibrosis (CF) is the most common life-shortening, autosomal recessive disorder among those of white ethnicity.1 The major cause of morbidity and mortality in CF is chronic lung disease caused by a vicious cycle of infection and inflammation that leads to progressive deterioration in pulmonary function, respiratory failure, and death. The pathogens infecting the lungs of patients with CF include the ‘‘classic CF pathogens’’ Pseudomonas aeruginosa, Staphylococcus aureus, Haemophilus influenzae, and Burkholderia cepacia complex as well as emerging pathogens such as methicillin-resistant S aureus (MRSA), Stenotrophomonas maltophilia, Achromobacter xylosoxidans, and nontuberculous mycobacteria.2 The prevalence of different organisms varies; approximately 57% of patients in the United States are infected with P aeruginosa, whereas B cepacia complex and MRSA are harbored by 2.9% and 14.6% of patients, respectively.3 The source of pathogens for CF patients is often unknown, but there is increasing evidence that potential pathogens may be acquired from another CF patient or from the contaminated health care and nonhealth From the Department of Pediatrics, Columbia University, New York, NY. Address correspondence to Lisa Saiman, MD, MPH, Division of Infectious Diseases, Department of Pediatrics, Columbia University, College of Physicians and Surgeons, 650 West 168th Street, PH 4 West Room 470, New York, NY 10032. E-mail: [email protected]. Supported by the US Cystic Fibrosis Foundation. 0196-6553/$34.00 Copyright ª 2008 by the Association for Professionals in Infection Control and Epidemiology, Inc. doi:10.1016/j.ajic.2007.05.009
220
care environment via direct or indirect contact with infectious respiratory tract secretions or droplets of infectious secretions. In 2001, the CF Foundation convened a multidisciplinary committee to revise guidelines for infection control practices to prevent acquisition of potential pathogens, including the prevention of patient-to-patient transmission. These evidence-based guidelines were presented to the CF community in 2001, distributed to CF care sites for public comment in 2002, and published in 2003.2 The current study sought to compare the contents of written infection control policies used at CF care sites in the United States with the published guidelines.2
METHODS The CF Foundation provided the study team with a list of CF care sites that contribute data to the CF Foundation Patient Registry. One to 3 letters were sent to the directors of each site from July 2003 to January 2004 requesting a copy of CF-related infection control policies in use, including all written policies related to CF patients in the hospital, in outpatient settings, and/or in nonhealth care settings. If written requests failed to elicit a response, the study team contacted the site directors by telephone and/or by e-mail. The consensus guidelines for infection control in CF were categorized by the relative strength of the published supportive evidence.4 For example, category IA recommendations were those supported by well-designed experimental, clinical, or epidemiologic studies, and category IB recommendations were those supported by some experimental, clinical, or epidemiologic studies and a strong theoretic rationale.4 The
Zhou, Garber, and Saiman
April 2008
221
Table 1. Infection control guidelines reviewed in inpatient and outpatient policies for CF patients Guideline principles
Strength of evidence2
Perform hand hygiene Discourage socializing
Category 1A Category 1A Category 1B
Implement transmission precautions
Category 1A Category 1A
Develop CF clinic logistics
Category 1A Category 1A
Care of home nebulizers
Category 1B
Routine use of mask
Category 1B Unresolved
Specific guideline content Emphasize hand hygiene for staff and patients in all clinical settings. Discourage socialization among CF patients in all clinical settings to prevent contact with respiratory secretions Maintain at least 3 feet between CF patients in all clinical settings to prevent droplet transmission. Use contact precautions for MDROs, including MRSA Admit patients infected with B cepacia complex or MRSA to a single patient room Segregate patients infected with B cepacia complex from other CF patients Place patients with B cepacia complex and multidrug-resistant P aeruginosa in examination room immediately. Clean respiratory secretions from nebulizer and disinfect by one of the following methods: boiling, microwaving, or immersing in disinfectant Do not use acetic acid to disinfect nebulizers Published data do not provide evidence-based support for recommendation
MDRO, multidrug-resistant organism; MRSA, methicillin-resistant Staphylococcus aureus.
study team reviewed each of the sitesÕ submitted written infection control policies for language related to 6 specific guidelines as shown in Table 1.
RESULTS In all, 190 CF care sites including 116 CF care centers (programs that meet established criteria for clinical care, teaching, and research and fulfill geographic and consumer needs), 46 affiliate programs (smaller programs with fewer resources for teaching and research linked to larger CF centers), 24 adult programs (affiliated with care centers that care exclusively for adults with CF), and 4 outreach programs (geographically remote extensions of care centers) were contacted. Responses were received from 158 CF care sites, including 85% of CF care centers, 92% of adult programs, 74% of affiliate programs, and 75% of outreach programs. Fifty-five programs (35%) responded that they did not have written policies. Thus, written policies were received from 103 (65%) sites, including 67 inpatient policies specific for CF, 76 CF clinic policies, and 28 general hospitalbased policies with mention of CF. Larger care sites (defined as $100 patients) were more likely to have written policies than smaller care sites (,100 patients) because 63% (60/95) of large versus 45% (43/95) of small sites had written policies (P # .03). Hand hygiene practices for staff and patients were addressed in the majority (82%, 84/103) of policies. Most inpatient policies addressed hand hygiene for staff (72%, 48/67) and CF patients (90%, 60/67), whereas fewer outpatient policies addressed this practice for staff (57%, 43/76) and/or patients (67%, 51/76). Contact precautions were recommended for CF patients infected with B cepacia complex, multidrug-
resistant organisms (MDROs), and MRSA in 73% (49/ 67), 63% (42/67), and 64% (43/67) of inpatient policies, respectively. However, contact precautions for these pathogens were less frequently addressed in policies for CF clinics (58%, 44/76). Approximately half (54%, 36/67) of inpatient policies allowed CF patients who did not require contact precautions to share a room with non-CF patients at low risk for infection. Most (80%, 59/67) inpatient policies discouraged socializing among CF patients. The precise recommendations varied, however, and included the following: not visiting other CF patients (53%, 36/67), avoiding common areas (61%, 41/67), avoiding physical contact with other CF patients (55%, 37/67), and/or remaining 3 feet from other CF patients (52%, 35/67). Approximately half (55%, 42/76) of the outpatient policies also discouraged socializing among CF patients, which included recommendations to avoid socialization with other CF patients (47%, 36/76) and to remain 3 feet from other CF patients (41%, 31/76). Several additional strategies were recommended in the policies to prevent transmission during CF clinic. Approximately two thirds of outpatient policies (65%, 49/76) had strategies to identify CF patients by their pathogen status. Transmission precautions were described for B cepacia complex, MDROs, and MRSA in 53%, 47%, and 51% of policies, respectively. Strategies included a separate clinic schedule for patients infected with B cepacia complex, alternative waiting areas, identification of pathogen status with colored stickers on charts, a beeper or cell phone system to inform patients of an available examination room, minimizing waiting time, and/or placing patients requiring transmission precautions in an examination room immediately.
222
Zhou, Garber, and Saiman
Vol. 36 No. 3
Disinfecting home nebulizers was addressed in a minority of policies (25%, 26/103). A variety of methods was recommended and included boiling parts (13%, 13/103), use of bleach (13%, 13/103), alcohol (15%, 15/103), and/ or hydrogen peroxide (13%, 13/103). None of the policies recommended the use of acetic acid to disinfect nebulizers. The routine use of masks by CF patients to prevent transmission of potential pathogens was considered an unresolved issue by the consensus committee because of insufficient evidence.2 Nevertheless, numerous inpatient (69%, 46/67) and outpatient (35%, 27/76) policies advocated the use of masks when a patient was out of their hospital room or in the clinic waiting area.
DISCUSSION This report details the implementation of infection control guidelines for CF in the United States. Until recently, CF care providers were primarily concerned about transmission of B cepacia complex. Thus, infection control practices for other pathogens and for CF clinics were largely neglected.5 However, the revised recommendations not only address other potentially transmissible pathogens but provide guidelines for outpatient and nonhealth care settings as well.2 In addition, the recommendations emphasize that all CF patients can harbor potentially transmissible pathogens, and, thus, all patients should practice strategies to contain their respiratory tract secretions, avoid contaminating the health care environment, and avoid contact with other CF patients. However, in some centers in Europe and Australia, separate CF clinics are held for patients harboring the same pathogen with documentation of curtailed transmission of P aeruginosa using this strategy.6,7 Notably, routine mask use was not supported by published data and, thus, not recommended in the guidelines. However, as evidenced by review of written policies, many CF centers do advocate mask use. The precise reasons for this are unknown but may reflect reluctance to change existing practices or the belief that mask use will reduce transmission of potential pathogens. Further studies are needed to determine the efficacy of mask use in the settings caring for CF patients.
There are some limitations to this study. It is difficult to assess the relative impact of specific infection control guidelines on the acquisition of pathogens by CF patients because numerous recommendations have been introduced together. Written guidelines may not correlate with true practice. In addition, CF care sites interpret and implement guidelines appropriate to their site as evidenced by the varied recommendations to avoid socialization among CF patients. Since collecting the infection control protocols, some sites may have implemented the recommendations from the revised guidelines. In conclusion, since publication and dissemination of the guidelines for infection control in CF, many CF care sites have written infection control guidelines to reflect these recommendations. However, some sites lack written infection control guidelines, and not all guidelines are consistent with evidence-based recommendations. Infection control professionals should intervene to help craft suitable guidelines for CF patients. Future studies should address barriers to implementation of the guidelines, monitor implementation, and measure the impact of the recommendations on transmission of potential pathogens. References 1. Moss RB. Cystic fibrosis: pathogenesis, pulmonary infection, and treatment. Clin Infect Dis 1995;21:839-49. 2. Saiman L, Siegel J, and the Cystic Fibrosis Foundation Consensus Conference on Infection Control Participants. Infection control recommendations for patients with cystic fibrosis: microbiology, important pathogens, and infection control practices to prevent patientto-patient transmission. Infect Control Hosp Epidemiol 2003; 24(Suppl 5):S6-S52. 3. Cystic Fibrosis Foundation. Patient registry 2004 annual report. Bethesda, MD: Cystic Fibrosis Foundation; 2005. 4. Garner JS. Guideline for isolation precautions in hospitals. The Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1996;17:53-80. 5. Saiman L, Schidlow D, Smith A. Concepts in care: microbiology and infectious disease in cystic fibrosis. Washington, DC: Cystic Fibrosis Foundation; 1994. 6. Griffiths AL, Jamsen K, Carlin JB, Grimwood K, Carzino R, Robinson PJ, et al. Effects of segregation on an epidemic Pseudomonas aeruginosa strain in a cystic fibrosis clinic. Am J Respir Crit Care Med 2005;171: 1020-5. 7. Jones AM, Dodd ME, Govan JR, Doherty CJ, Smith CM, Isalska BJ, et al. Prospective surveillance for Pseudomonas aeruginosa cross-infection at a cystic fibrosis center. Am J Respir Crit Care Med 2005;171:257-60.
Written infection control policies used at cystic fibrosis (CF) care sites in the United States were compared with recently published guidelines. Most policies recommended contact precautions for hospitalized patients infected with Burkholderia cepacia complex (73%), multidrug-resistant organisms (63%), and methicillin-resistant Staphylococcus aureus (64%). Socializing among CF patients was discouraged in 80% of inpatient policies and 55% of outpatient policies. Although routine mask use by patients remains an unresolved issue, many policies advocated this practice. Future studies should address barriers to implementation of these evidence-based guidelines and continue to monitor implementation. (Am J Infect Control 2008;36:220-2.)
Cystic fibrosis (CF) is the most common life-shortening, autosomal recessive disorder among those of white ethnicity.1 The major cause of morbidity and mortality in CF is chronic lung disease caused by a vicious cycle of infection and inflammation that leads to progressive deterioration in pulmonary function, respiratory failure, and death. The pathogens infecting the lungs of patients with CF include the ‘‘classic CF pathogens’’ Pseudomonas aeruginosa, Staphylococcus aureus, Haemophilus influenzae, and Burkholderia cepacia complex as well as emerging pathogens such as methicillin-resistant S aureus (MRSA), Stenotrophomonas maltophilia, Achromobacter xylosoxidans, and nontuberculous mycobacteria.2 The prevalence of different organisms varies; approximately 57% of patients in the United States are infected with P aeruginosa, whereas B cepacia complex and MRSA are harbored by 2.9% and 14.6% of patients, respectively.3 The source of pathogens for CF patients is often unknown, but there is increasing evidence that potential pathogens may be acquired from another CF patient or from the contaminated health care and nonhealth From the Department of Pediatrics, Columbia University, New York, NY. Address correspondence to Lisa Saiman, MD, MPH, Division of Infectious Diseases, Department of Pediatrics, Columbia University, College of Physicians and Surgeons, 650 West 168th Street, PH 4 West Room 470, New York, NY 10032. E-mail: [email protected]. Supported by the US Cystic Fibrosis Foundation. 0196-6553/$34.00 Copyright ª 2008 by the Association for Professionals in Infection Control and Epidemiology, Inc. doi:10.1016/j.ajic.2007.05.009
220
care environment via direct or indirect contact with infectious respiratory tract secretions or droplets of infectious secretions. In 2001, the CF Foundation convened a multidisciplinary committee to revise guidelines for infection control practices to prevent acquisition of potential pathogens, including the prevention of patient-to-patient transmission. These evidence-based guidelines were presented to the CF community in 2001, distributed to CF care sites for public comment in 2002, and published in 2003.2 The current study sought to compare the contents of written infection control policies used at CF care sites in the United States with the published guidelines.2
METHODS The CF Foundation provided the study team with a list of CF care sites that contribute data to the CF Foundation Patient Registry. One to 3 letters were sent to the directors of each site from July 2003 to January 2004 requesting a copy of CF-related infection control policies in use, including all written policies related to CF patients in the hospital, in outpatient settings, and/or in nonhealth care settings. If written requests failed to elicit a response, the study team contacted the site directors by telephone and/or by e-mail. The consensus guidelines for infection control in CF were categorized by the relative strength of the published supportive evidence.4 For example, category IA recommendations were those supported by well-designed experimental, clinical, or epidemiologic studies, and category IB recommendations were those supported by some experimental, clinical, or epidemiologic studies and a strong theoretic rationale.4 The
Zhou, Garber, and Saiman
April 2008
221
Table 1. Infection control guidelines reviewed in inpatient and outpatient policies for CF patients Guideline principles
Strength of evidence2
Perform hand hygiene Discourage socializing
Category 1A Category 1A Category 1B
Implement transmission precautions
Category 1A Category 1A
Develop CF clinic logistics
Category 1A Category 1A
Care of home nebulizers
Category 1B
Routine use of mask
Category 1B Unresolved
Specific guideline content Emphasize hand hygiene for staff and patients in all clinical settings. Discourage socialization among CF patients in all clinical settings to prevent contact with respiratory secretions Maintain at least 3 feet between CF patients in all clinical settings to prevent droplet transmission. Use contact precautions for MDROs, including MRSA Admit patients infected with B cepacia complex or MRSA to a single patient room Segregate patients infected with B cepacia complex from other CF patients Place patients with B cepacia complex and multidrug-resistant P aeruginosa in examination room immediately. Clean respiratory secretions from nebulizer and disinfect by one of the following methods: boiling, microwaving, or immersing in disinfectant Do not use acetic acid to disinfect nebulizers Published data do not provide evidence-based support for recommendation
MDRO, multidrug-resistant organism; MRSA, methicillin-resistant Staphylococcus aureus.
study team reviewed each of the sitesÕ submitted written infection control policies for language related to 6 specific guidelines as shown in Table 1.
RESULTS In all, 190 CF care sites including 116 CF care centers (programs that meet established criteria for clinical care, teaching, and research and fulfill geographic and consumer needs), 46 affiliate programs (smaller programs with fewer resources for teaching and research linked to larger CF centers), 24 adult programs (affiliated with care centers that care exclusively for adults with CF), and 4 outreach programs (geographically remote extensions of care centers) were contacted. Responses were received from 158 CF care sites, including 85% of CF care centers, 92% of adult programs, 74% of affiliate programs, and 75% of outreach programs. Fifty-five programs (35%) responded that they did not have written policies. Thus, written policies were received from 103 (65%) sites, including 67 inpatient policies specific for CF, 76 CF clinic policies, and 28 general hospitalbased policies with mention of CF. Larger care sites (defined as $100 patients) were more likely to have written policies than smaller care sites (,100 patients) because 63% (60/95) of large versus 45% (43/95) of small sites had written policies (P # .03). Hand hygiene practices for staff and patients were addressed in the majority (82%, 84/103) of policies. Most inpatient policies addressed hand hygiene for staff (72%, 48/67) and CF patients (90%, 60/67), whereas fewer outpatient policies addressed this practice for staff (57%, 43/76) and/or patients (67%, 51/76). Contact precautions were recommended for CF patients infected with B cepacia complex, multidrug-
resistant organisms (MDROs), and MRSA in 73% (49/ 67), 63% (42/67), and 64% (43/67) of inpatient policies, respectively. However, contact precautions for these pathogens were less frequently addressed in policies for CF clinics (58%, 44/76). Approximately half (54%, 36/67) of inpatient policies allowed CF patients who did not require contact precautions to share a room with non-CF patients at low risk for infection. Most (80%, 59/67) inpatient policies discouraged socializing among CF patients. The precise recommendations varied, however, and included the following: not visiting other CF patients (53%, 36/67), avoiding common areas (61%, 41/67), avoiding physical contact with other CF patients (55%, 37/67), and/or remaining 3 feet from other CF patients (52%, 35/67). Approximately half (55%, 42/76) of the outpatient policies also discouraged socializing among CF patients, which included recommendations to avoid socialization with other CF patients (47%, 36/76) and to remain 3 feet from other CF patients (41%, 31/76). Several additional strategies were recommended in the policies to prevent transmission during CF clinic. Approximately two thirds of outpatient policies (65%, 49/76) had strategies to identify CF patients by their pathogen status. Transmission precautions were described for B cepacia complex, MDROs, and MRSA in 53%, 47%, and 51% of policies, respectively. Strategies included a separate clinic schedule for patients infected with B cepacia complex, alternative waiting areas, identification of pathogen status with colored stickers on charts, a beeper or cell phone system to inform patients of an available examination room, minimizing waiting time, and/or placing patients requiring transmission precautions in an examination room immediately.
222
Zhou, Garber, and Saiman
Vol. 36 No. 3
Disinfecting home nebulizers was addressed in a minority of policies (25%, 26/103). A variety of methods was recommended and included boiling parts (13%, 13/103), use of bleach (13%, 13/103), alcohol (15%, 15/103), and/ or hydrogen peroxide (13%, 13/103). None of the policies recommended the use of acetic acid to disinfect nebulizers. The routine use of masks by CF patients to prevent transmission of potential pathogens was considered an unresolved issue by the consensus committee because of insufficient evidence.2 Nevertheless, numerous inpatient (69%, 46/67) and outpatient (35%, 27/76) policies advocated the use of masks when a patient was out of their hospital room or in the clinic waiting area.
DISCUSSION This report details the implementation of infection control guidelines for CF in the United States. Until recently, CF care providers were primarily concerned about transmission of B cepacia complex. Thus, infection control practices for other pathogens and for CF clinics were largely neglected.5 However, the revised recommendations not only address other potentially transmissible pathogens but provide guidelines for outpatient and nonhealth care settings as well.2 In addition, the recommendations emphasize that all CF patients can harbor potentially transmissible pathogens, and, thus, all patients should practice strategies to contain their respiratory tract secretions, avoid contaminating the health care environment, and avoid contact with other CF patients. However, in some centers in Europe and Australia, separate CF clinics are held for patients harboring the same pathogen with documentation of curtailed transmission of P aeruginosa using this strategy.6,7 Notably, routine mask use was not supported by published data and, thus, not recommended in the guidelines. However, as evidenced by review of written policies, many CF centers do advocate mask use. The precise reasons for this are unknown but may reflect reluctance to change existing practices or the belief that mask use will reduce transmission of potential pathogens. Further studies are needed to determine the efficacy of mask use in the settings caring for CF patients.
There are some limitations to this study. It is difficult to assess the relative impact of specific infection control guidelines on the acquisition of pathogens by CF patients because numerous recommendations have been introduced together. Written guidelines may not correlate with true practice. In addition, CF care sites interpret and implement guidelines appropriate to their site as evidenced by the varied recommendations to avoid socialization among CF patients. Since collecting the infection control protocols, some sites may have implemented the recommendations from the revised guidelines. In conclusion, since publication and dissemination of the guidelines for infection control in CF, many CF care sites have written infection control guidelines to reflect these recommendations. However, some sites lack written infection control guidelines, and not all guidelines are consistent with evidence-based recommendations. Infection control professionals should intervene to help craft suitable guidelines for CF patients. Future studies should address barriers to implementation of the guidelines, monitor implementation, and measure the impact of the recommendations on transmission of potential pathogens. References 1. Moss RB. Cystic fibrosis: pathogenesis, pulmonary infection, and treatment. Clin Infect Dis 1995;21:839-49. 2. Saiman L, Siegel J, and the Cystic Fibrosis Foundation Consensus Conference on Infection Control Participants. Infection control recommendations for patients with cystic fibrosis: microbiology, important pathogens, and infection control practices to prevent patientto-patient transmission. Infect Control Hosp Epidemiol 2003; 24(Suppl 5):S6-S52. 3. Cystic Fibrosis Foundation. Patient registry 2004 annual report. Bethesda, MD: Cystic Fibrosis Foundation; 2005. 4. Garner JS. Guideline for isolation precautions in hospitals. The Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1996;17:53-80. 5. Saiman L, Schidlow D, Smith A. Concepts in care: microbiology and infectious disease in cystic fibrosis. Washington, DC: Cystic Fibrosis Foundation; 1994. 6. Griffiths AL, Jamsen K, Carlin JB, Grimwood K, Carzino R, Robinson PJ, et al. Effects of segregation on an epidemic Pseudomonas aeruginosa strain in a cystic fibrosis clinic. Am J Respir Crit Care Med 2005;171: 1020-5. 7. Jones AM, Dodd ME, Govan JR, Doherty CJ, Smith CM, Isalska BJ, et al. Prospective surveillance for Pseudomonas aeruginosa cross-infection at a cystic fibrosis center. Am J Respir Crit Care Med 2005;171:257-60.