Infection control recommendations for patients with cystic fibrosis: Microbiology, important pathogens, and infection control practices to prevent patient-to-patient transmission

Infection Control Recommendations for Patients With Cystic Fibrosis: Microbiology, Important Pathogens, and Infection Control Practices to Prevent Patient-to-Patient Transmission updates, expands, and replaces the consensus statement, Microbiology and Infectious Disease in Cystic Fibrosis published in 1994. This consensus document presents background data and evidence-based recommendations for practices that are intended to decrease the risk of transmission of respiratory pathogens among CF patients from contaminated respiratory therapy equipment or the contaminated environment and thereby reduce the burden of respiratory illness. Included are recommendations applicable in the acute care hospital, ambulatory, home care, and selected non-healthcare settings. The target audience includes all healthcare workers who provide care to CF patients. Antimicrobial management is beyond the scope of this document. The following information set the stage for the development of this guideline: (a) Studies published since 1994 that further our understanding of the modes of transmission of pathogens and effective strategies to interrupt transmission among CF patients provide the data needed for evidence-based guidelines. (b) Improved microbiology methods provide more accurate detection and further definition of the epidemiology of pathogens in CF patients. (c) The publication of the HICPAC/CDC (Healthcare Infection Control Practices Advisory Committee/ Centers for Disease Control and Prevention) Guideline for Isolation Precautions in Hospitals in 1996 defined standard precautions and recommended universal application to care for all patients at all times to prevent transmission of infectious agents that may not yet have been identified. (d) The previously published HICPAC/CDC guidelines for prevention of healthcare-associated infections have not included background information and recommendations for the specific circumstances of patients with CE Thus, specific guidelines for CF patients are needed. (e) The link between acquisition of pathogens and morbidity and mortality is well established. Prevention of acquisition of specific pathogens may further improve the mean survival of CF patients, which has increased to 33.4 years in 2001. A multidisciplinary committee consisting of healthcare professionals from the United States, Canada, and Europe with experience in CF care and healthcare epidemiology/infection control reviewed the relevant literature and developed evidence-based recommendations graded according to the published peer-reviewed supportive data. The participants chose to use the following CDC/HICPAC system for categorizing recommendations based on previous experience in crafting infection control guidelines beyond CF: Category IA. Strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies. Category IB. Strongly recommended for implementation and supported by some experimental, clinical, or epidemiologic studies and a strong theoretical rationale. Category IC. Required for implementation, as mandated by federal and/or state regulation or standard. Category II. Suggested for implementation and supported by suggestive clinical or epidemiologic studies or a theoretical rationale. No recommendation; unresolved issue. Practices for which insufficient evidence or no consensus regarding efficacy exist. Category IA and IB recommendations are strongly recommended for implementation by all CF centers and considered to be "best practice." Implementation of Category II recommendations is advised by the committee, but individual centers may determine which Category II recommendations would be appropriate for their CF centers. This document integrates knowledge of microbiology laboratory methods, infection control principles, and epidemiology of respiratory pathogens in CF patients. Standardization of infection control practices across CF centers will provide safer environments for patients by reducing the risk of transmission of CF pathogens. In addition to infection control practices that are applicable to all CF patients at all times, specific infection control practices are recommended for inpatient. ambulatory, and non-healthcare settings, based on the types of activities and risks associated with the various settings. CF care teams as well as patients and their families must be well educated concerning the known risks and the effective preventive measures to ensure adherence to the evidence-based recommendations in this document. It will be beneficial for each CF center to evaluate the effectiveness of its infection control program to reduce transmission of pathogens and improve clinical outcomes. Collaboration between the CF care team and the CF center's infection control team will facilitate effective implementation that takes into consideration the psychosocial impact of these recommendations. This document was reviewed by the members of HIC-PAC, and the recommendations were found to be consistent with the principles of infection control that serve as the foundation of HICPAC/CDC guidelines for prevention of healthcare-associated infections. This guideline was formally endorsed by The Society for Healthcare Epidemiology of America and the Association for Professionals in Infection Control and Epidemiology boards in 2002-2003. The National Committee for Clinical Laboratory Standards has endorsed the recommendations for susceptibility testing. Infection Control Principles CF pathogens are transmitted by the droplet and contact routes. Therefore, practices that contain respiratory secretions and prevent transmission of respiratory tract pathogens must be taught to patients and their families as well as to CF healthcare workers. Such practices must be followed with all CF patients and cannot be implemented according to the specific microbiology results of individual CF patients because microbiology methods are not 100% sensitive for the detection of CF pathogens. In addition to washing hands with an antimicrobial-containing soap and water, alcohol-based antiseptic hand rubs are now recommended when hands are not visibly soiled with blood or body fluids because of the improved efficacy of these products in removing microorganisms from the hands. Use of gowns, gloves, and masks follows the recommendations for standard, contact, and droplet precautions that have been developed by CDC/HICPAC2 to prevent healthcare-associated infections in all patients, ie, both CF and non-CF patients. Contact precautions plus standard precautions are recommended for all CF patients infected (or colonized) with methicillin-resistant Staphylococcus aureus (MRSA), Burkholderia cepacia complex, multidrug-resistant Pseudomonas aeruginosa, respiratory syncytial virus (RSV), parainfluenza, or vancomycin-resistant enterococci (VRE). Recommendations for room placement, activities outside the hospital room, CF clinic logistics, and adjuvant measures to prevent infections are provided. No recommendation can be made for the routine wearing of masks by CF patients when leaving an inpatient room or when in the waiting room of a CF clinic. Specific practices for the use and care of respiratory therapy equipment recommended in this document are based on principles of disinfection and sterilization as well as findings from investigations of outbreaks of infections associated with contaminated respiratory therapy equipment. Cleaning devices, such as nebulizers, with removal of debris as soon as possible and before disinfection, and complete air drying are the critical steps in both healthcare and home settings. Microbiology, Molecular Typing, and Surveillance Because aggressive antimicrobial treatment of P. aeruginosa at initial acquistion may be associated with a delay in chronic infection and an improved clinical course, respiratory tract cultures should be obtained at least quarterly in CF patients with stable pulmonary status as well as at the time of pulmonary exacerbations. Specific recommendations are made for transport and processing of specimens, including the preferred selective media. Agar-based diffusion assays, eg, antibiotic-containing disks or E-tests, rather than automated commercial microbroth dilution systems are recommended for susceptibility testing of P. aeruginosa isolates. Molecular typing using appropriate methods, eg, pulsed-field gel electrophoresis (PFGE), rapid amplified polymerase chain reaction (RAPD-PCR), and repetitive DNA sequence PCR (Rep-PCR), are recommended to assess strain relatedness of isolates from different patients when patient-to-patient transmission is suspected. Recommendations are made to develop surveillance in collaboration with the CF center's infection control team. S. aureus, including MRSA, P aeruginosa, and B. cepacia complex are always targeted, whereas Stenotrophomonas maltophilia, Achromobacter xylosoxidans, and nontuberculous mycobacteria (NTM) are included when considered epidemiologically important, eg, patient-to-patient transmission or an outbreak is suspected. Surveillance includes calculation of incidence and prevalence rates and review of antimicrobial susceptibility summaries with trend analysis. Surveillance reports should be shared between the infection control and CF care teams at least annually to evaluate effectiveness of the center's infection control program. Selected B. cepacia complex isolates and nonfermenting gram-negative organisms for which species identification cannot be established after routine analysis should be submitted to the Cystic Fibrosis Foundation (CFF) Burkholderia cepacia Research Laboratory and Repository for further study.