INFECTION PREVENTION: INTERVENTIONS IN ONCOLOGY

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1 INFECTION PREVENTION: INTERVENTIONS IN ONCOLOGY Jennie L Mayfield, BSN, MPH, CIC Clinical Epidemiologist Siteman Cancer Center at Barnes-Jewish Hospital/ Washington University School of Medicine, jlm3246@bjc.org

2 Immune System Abnormalities Defects in skin/mucous membranes Obstruction Abnormal number/function of granulocytes Abnormal humoral immunity (B-cell immunity) Abnormal cell-mediated immunity (T-cell immunity) Defects in multiple arms of immunity

3 Infection Characteristics in Oncology Lack of inflammatory response Acceleration of disease progression Life-threatening complications from minor problems Fever most frequent manifestation

4 Hand Hygiene AHR alcohol hand rinse when not visibly soiled Antimicrobial soap & water (if available) if visibly soiled Make readily available

5 Bloodstream Infection Bloodstream infection 20% of all HAI Risk factors hematologic malignancy, blood or marrow transplant, central lines, prolonged hospitalization Sources respiratory tract, GI tract, skin/soft tissue (CVC, incision)

6 Gram-Negative Sepsis Approximately 27-46% all Gram-negative bacteremias (GNB) develop gram-negative sepsis Significant in oncology because GNB more frequent in heme malignancies, neutropenia Stage 1 early(warm) hyperdynamic, decreased tissue perfusion Stage 2 normodynamic, intermediate shock Stage 3 hypodynamic, late shock irreversible Treatment adequate oxygenation, effective circulation and tissue perfusion Immediate gram-negative antibiotic therapy

7 Central Lines in Oncology Pathogenesis of catheter-related BSI Maki: Skin contamination in short-term catheters (<10 days) 1 Sitges-Serra: hub contamination in long-term catheters (>30 days) 2 Raad: luminal colonization, biofilm 3

8 Central Lines in Oncology Most lines are intermediate (10-30 days) or long-term (>30 days) Types Implanted ports useful for intermittent venous access, periodic chemotherapy Tunneled catheters have dacron cuff which becomes enmeshed with fibrous tissue, creates mechanical barrier against migration of skin organisms along external cutaneous pathway pheresis catheters Non-tunneled catheters Hohn, PICC

9 CLABSI Bundle Site choice, hand hygiene before insertion, maximal sterile barriers for insertion, chlorhexidine skin antisepsis, daily assessment for necessity These focus on insertion site, may not impact longterm lines Follow recommendations for needleless devices Passive disinfection of catheter hubs with alcohol cap Wright et. al. 4, Menyhay & Maki 5 SHEA compendium CLABSI 6 : use if rates remain elevated

10 Hospital-Acquired Pneumonia Slightly more than 20% of all HAI Increased risk Leukemia/lymphoma Obstructing tumors of lung, head, & neck

11 Barnes-Jewish Hospital Oncology Patients Requiring Intubation Because of Pneumonia January 2009-August 2010

12 Type of Pneumonia in Ventilated Patients Oncology July 2009-August 2010

13 Pneumonia Prevention Pulmonary toilet Turn, cough, deep breathe Incentive spirometry Encourage mobility when patient able VAP bundle controversy O Grady et. al. in JAMA No large randomized study has demonstrated that reducing VAP using any VAP prevention strategy, including those in the IHI bundle, is associated with improvements in clinical outcomes.

14 Clostridum difficile (CDI) Risk factors antimicrobials/chemotherapy, length of stay, altered immune system Kyne: serum toxin A IgG levels higher If colonized 8 Higher levels decreased recurrence risk 9 Kamboj et. al. 10 survey of NCI-designated Comprehensive Cancer Centers (CCC) for CDI rates Rate of HO-CDI in 11 CCC more than double NHSN rate (15.8/10K days vs 7.4/10K days)

15 Clostridium difficile Tabak et. al. 11 six hospitals, propensity score matching Six hospitals, propensity score matching Hospital-onset CDI cases had higher mortality (P<.05), longer LOS (P<.01), higher cost (P<.01) Dubberke et. al. 12 case-control Cases more likely to: Develop BSI after CDI (p<.001) Develop new onset graft-vs-host disease (GVHD) (p<.001) Develop new onset severe GVHD (p<.001) Develop new onset gut GVHD (p=.007) Severe CDI a risk factor for death at 180 days in multivariable Cox proportional hazards regression

16 How do I Prevent CDI? Good question..... Modifiable risk factors Exposure to C difficile Antimicrobial exposure

17 CDI Prevention--Technologies for Terminal Cleaning Hydrogen Peroxide Vapor Effective in decreasing rates of hospital-acquired MDRO 13,14 Drawback is cycle time, ranged from 2-3 hours for one room Ultraviolet radiation device Nerandzic 15, Rutala 16, & Boyce 17 all found UV radiation effective in decreasing environmental contamination with MDRO May need 2-step process if want bathroom included Cycle is 15 min. for aerobic bacteria, 50 min for spores Hand-held far-ultraviolet radiation device also effective 18 Presence of organic material decreases efficacy

18 Antimicrobial Stewardship Has been effective in UK in helping control after outbreaks of BI/NAP1/O27 strain We (IPs and Hosp Epis) need to push for more and better antimicrobial controls THIS IS A PATIENT SAFETY ISSUE!!!

19 Filamentous Molds Aspergillus spp., Rhizopus spp., Mucor spp., etc. Environmental Risk factors prolonged neutropenia, neutrophil dysfunction, cytotoxic chemotherapy, exposure to high levels of mold spores in environment

20 Aspergillosis Clinical Syndromes

21 Invasive aspergillosis Neutropenic host fever, progressive pulmonary consolidation with nodules, halo Mortality 90% without count recovery Sino-nasal also lifethreatening Courtesy Dr. A Chandrasekhar, Loyola

22 Skin Primary Trauma, burns Contaminated supplies, nonintact skin 40 yo, pre-b-cell ALL, MUD Sept. Readmit Dec, w/ Gr IV GVHD liver Copious drainage from paracentesis sites Ostomy bag placed to contain drainage Tissue culture Rhizopus Karaya on ostomy products not sterile, implicated in several cases cutaneous zygomycetes Before 1 st surgery Before 2 nd surgery

23 IP Recommendations Ostomy products Change per manufacturer recommendations (had not been changed prior to development of lesions) Use sterile product if Lung tx within 6 mos Autologous transplant until engraftment Allogeneic transplant within 6 mos or at MD discretion Leukemics with ANC <500

24 Skin Secondary Bloodstream from upper, lower respiratory tracts Means your patient has invasive mold disease

25 Aspergillus Outbreaks

26 Invasive Mold Prevention Repair all water leaks immediately, check ceiling tiles and drywall Inspect packaging materials Discard expired, damaged, or visibly contaminated by dust, debris or moisture Wound/IV dressing supplies should be monitored for contamination Use sterile dressing materials on arm boards used to provide support for lines Boards should be changed daily

27 Invasive Mold Prevention Construction/Renovation Do risk assessment based on tasks to be done Patients, HCWs, & visitors should avoid construction/renovation areas Pedestrian traffic should be directed away from const areas & pt. care areas Equipment & supplies should not be exposed to construction/renovation areas

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29 References 1 Maki et. al. Program & abstracts, Abstract 269, 28 th ICAAC (Los Angeles, 1989) 2 Sitges-Serra et. al. J Parent Nutr 1984; 8: Raad et. al. J Infect Dis 1993; 168: Wright et. al. Am J Infect Control 2013; 41(1): Menyhay & Maki. Am J Infect Control 2008; 36(10):S174.e1-5 6 Marschall et. al. Infect Control Hosp Epidemiol 2014; 35(7): Grady et. al. JAMA 2012; 307: Kyne et. al. NEJM 2000; 342(6): Kyne et. al. Lancet 2001; 357: Kamboj et. al. Infect Control Hosp Epidemiol 2012; 33(11): Tabak et. al. Infect Control Hosp Epidemiol 2013; 34(6): Dubberke et. al. Clin Transplant 2010; 24: Passaretti et. al. Clin Infect Dis 2013;56: Boyce et. al. Infect Control Hospital Epidemiol 2008;29: Nerandzic et. al Rutala et. al. Infect Control Hospital Epidemiol 2010; 31(10): Boyce et. al. Infect Control Hospital Epidemiol 2011:32(8): Nerandzic et. al.