Infection control and prevention (ICP) strategies represent an integral part of care for patients with oncologic diseases. Although the relevant guidelines often include established practices such as hand hygiene, barrier isolation, control of air quality, prevention of device-related infections, and prophylactic antifungal and antibiotic use, there are currently no consensus recommendations pertaining to ICP strategies for this patient group.

In a review published in CA: A Cancer Journal for Clinicians, Ella J. Ariza-Heredia, MD, and Roy F. Chemaly, MD, MPH, from the University of Texas MD Anderson Cancer Center, Houston, provided an overview of comprehensive ICP programs for facilities that care for patients with cancer.1

In addition to the standard measures, the study authors discussed the importance of maintaining a protective environment in these settings, including air quality and water controls. For centers treating hematopoietic cell transplant recipients, the use of laminar air flow units and high-efficiency particulate air filters is recommended, with the primary aim of reducing the risk for aspergillosis. Results of a 2009 meta-analysis revealed that a combination of air quality control, barrier isolation, and antimicrobial prophylaxis was associated with decreased infections and all-cause mortality (risk ratio [RR], 0.79; 95% CI, 0.72-0.87).2

It is also recommended that patients and healthcare personnel avoid areas that are under construction because of the increased risk for airborne mold dispersal and development of subsequent fungal infections associated with these sites. The study authors explained that they have “implement[ed] an ICP plan during construction, renovation, and structural repair activities that includes a barrier between construction and patients’ areas…to prevent Aspergillus and other potentially pathogenic molds from being generated or released into the air”1 at MD Anderson.

Additional selected topics from the paper are summarized here.

Multidrug-resistant organisms (MDRO)

In patients with cancer, the main risk factors for MDRO acquisition are admission to the intensive care unit within the preceding 3 months, prior antibiotic therapy, and urinary catheter use. Patients with the highest risk for MDRO-related complications are those with hematologic malignancies and hematopoietic cell transplant (HCT) recipients, with an associated mortality rate of 80%.3

Screening practices for MDRO vary across institutions, based on factors such as patient population and prevalence of MDR gram-negative bacilli in a specific facility. It may also be necessary to modify these measures both in the event of a local outbreak and for patients who have traveled to or emigrated from areas with high endemicity of MDR gram-negative bacilli.

Findings have demonstrated that rectal screening for vancomycin-resistant enterococci (VRE) on admission and each week thereafter, in addition to patient isolation as indicated, decreased the incidence of nosocomial infections among patients with hematologic malignancies.1 This practice has been observed at MD Anderson, among other centers.

When MDROs are detected in hospitalized patients, contact precautions should be used to prevent transmission. “Most recommendations to reduce the transmission of MDROs in hospitalized patients involve a bundle of best practices, including hand hygiene, active screening of patients with swabs for cultures, contact barrier precautions, enhanced environmental cleaning, decolonization in the case of MRSA, and antimicrobial stewardship,”1 the study authors noted.

Catheter-related infections

Central venous catheters are commonly used in patients with oncologic disease and are linked to an increased risk for central line-associated bloodstream infections (CLABSIs).4 Risk factors for CLABSIs in this population include difficult insertion, neutropenia, total parenteral nutrition, age, thrombosis, hematologic malignancies, and hematopoietic cell transplantHCT.1 The most common cause of CLABSI is “contamination of the hub by hand manipulation or blood products. Thus aseptic techniques during catheter insertion, specialized ‘intravenous teams,’ and postinsertion care bundles are best practices that have been shown to decrease the rates of CLABSI, especially for short-term catheters,” according to the review.1

Environmental cleaning

Studies have found that organisms can survive on surfaces for extended periods of time (>12 days for viruses, 2 months for methicillin-resistant staphylococcus aureus (MRSA), and 36 months for VRE, underscoring the importance of environmental cleaning in healthcare settings. However, it has been found that manual cleaning adequately disinfects only 47% of surfaces.1 Emerging evidence supports the benefits of supplementing these techniques with automated, no-touch methods such as portable ultraviolet light germicidal devices using pulsed xenon lamps.

This ultraviolet treatment has been observed to reduce total aerobic colony counts by 90% compared with 76% with manual cleaning, and a systematic review of more than 20 studies demonstrated that such devices led to significant reductions in Clostridioides (formerly Clostridium) difficile (RR, 0.64; 95% CI, 0.49-0.84) and vancomycin-resistant enterococci (risk ratio, RR, 0.42; 95% CI, 0.28-0.65) infections.5,6 Although these results are promising, there is a need for further research to elucidate the benefits of automated methods and to address drawbacks including logistical challenges and cost-effectiveness.

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Along with these various topics, the authors noted the increasing interest in whole-genome sequencing for outbreak management, which “has yielded important insights into transmission pathways for several significant pathogens and has revealed outbreaks in situations in which standard infection control surveillance and definitions showed no indications of causative pathogens.”1 The role of antibiotic stewardship and ICP programs for outpatient oncology settings were also discussed.

Ariza-Herida and Chemaly highlighted that local patterns of infections should provide central guidance for the application of current recommendations to cancer care and other healthcare environments, and that these recommendations must continuously be reevaluated by a multidisciplinary team. They concluded that, “A good ICP program depends on current and open communication within the institution to ensure constant guidance on evolving infection control ICP practices, especially those that cover the needs of the immunosuppressed patient.”

References

1. Ariza‐Heredia EJ, Chemaly RF. Update on infection control practices in cancer hospitals. CA: Cancer J Clin. 2018;68(5):340-355.

2. Schlesinger A, Paul M, Gafter‐Gvili A, Rubinovitch B, Leibovici L. Infection‐control interventions for cancer patients after chemotherapy: a systematic review and meta‐analysis. Lancet Infect Dis. 2009;9:97-107.

3. Tacconelli E, Cataldo MA, Dancer SJ, et al. ESCMID guidelines for the management of the infection control measures to reduce transmission of multidrug‐resistant Gram‐negative bacteria in hospitalized patients. Clin Microbiol Infect. 2014;20(suppl 1):1-55.

4. O’Grady NP, Alexander M, Burns LA, et al. Guidelines for the prevention of intravascular catheter‐related infections. Am J Infect Control. 2011;39(4 Suppl 1):S1-S34.

5. Beal A, Mahida N, Staniforth K, Vaughan N, Clarke M, Boswell T. First UK trial of Xenex PX‐UV, an automated ultraviolet room decontamination device in a clinical haematology and bone marrow transplantation unit. J Hosp Infect. 2016;93(2):164-168.

6. Marra AR, Schweizer ML, Edmond MB. No‐touch disinfection methods to decrease multidrug‐resistant organism infections: a systematic review and meta‐analysis. Infect Control Hosp Epidemiol. 2018;39(1):20-31.