|Year : 2005 | Volume
| Issue : 4 | Page : 547-555
|Infection Control and the Immunocompromised Host
King Fahad National Guard Hospital, King Abdulaziz Medical City, Riyadh, Saudi Arabia
Click here for correspondence address and email
|How to cite this article:|
Alothman A. Infection Control and the Immunocompromised Host. Saudi J Kidney Dis Transpl 2005;16:547-55
| Introduction|| |
Immunocompromised patients are at high risk for opportunistic infections. Traditionally, there are infections that arise from endogenous reactivation of latent infections, and nosocomial transmission. Therefore, it is deemed likely that special infection control (IC) interventions are required to prevent transmission in healthcare settings. 
Epidemiological investigations and airsampling experiments lend support to the hypothesis that reinfection with a pathogenic organism does occur, airborne transmission is possible and nosocomial spread is a plausible explantation for new cases in immunocompromised population. ,, These observations support the view that infectious complications in immunocompromised patients are exogenous in origin and more epidemiological studies are needed to define the risk of nosocomial spread and need for better infection control practices to prevent these infections.
The fact that infectious complications in immunocompromised patients are often predictable and may be preventable makes infection control practices a very important step in the improvement of the quality of care provided to such patients. ,
In addition, by reducing infectious morbidity, infection control practices will contribute significantly to cost savings.
| Who is the Immunocompromised Host?|| |
The immunocompromised host is a person with one or more defects in the body's normal defense mechanisms that predispose him to infections, often life-threatening, which would not otherwise occur. The categories of host defects that are commonly associated with impaired resistance are listed in [Table - 1].
| Risk for Developing an Infection|| |
The immunocompromised patient's risk is best evaluated by defining the net state of immunosuppression and is determined by the interaction of multiple factors including: 1) the underlying disease, 2) the patients' age, 3) the dose and duration of immunosuppression therapy, 4) the state of humoral and cellular host defences, 5) the integrity of the skin and mucosal membrane, 6) metabolic factors, 7) abnormalities of the reticuloendothelial system, and 8) the presence of immunomodulating infections, such as those caused by cytomegalovirus, and Epstein-Barr virus. 
| Interventions to Prevent Infections in the compromised patient|| |
Interventions have been categorized into two kinds: pre-emptive and concurrent measures. Pre-emptive measures:
- Identification and correction of risk factors
- Augmentation of host resistance to infection ,,,
- Avoidance of hospitalization 
However, Concurrent measures could include:
- Reduction of exposure to exogenous pathogens.
- Reduction of endogenous flora e.g. neutropenia ,
- Antimicrobial prophylaxis ,
This article will evaluate the reduction of exposure to exogenous pathogens:
Fresh fruits and vegetables appear to carry several species of gram-negative rods as part of their natural flora. ,, . It has been demonstrated that several kinds of salads were colonized by Pseudomonas aeuroginosa, E. coli and Klebsiella spp. 
The cooked food diet or the low bacterial diet is recommended to reduce the exposure of immunocompromised patients to these potential pathogens. ,,, Gamma-irradiation has been implemented successfully to eliminate viable bacteria with no health hazard to the patient. 
Water has known potential as a vehicle of infectious diseases transmission. Several microorganisms have been shown capable of replication in water. In addition, water and ice have been proven sources for nosocomial outbreak of infection. 
It is known that neither tap water nor hospital water are sterile. Hospital water should have < 1 coliform bacterium/ 100ml, levels higher than that in hospital water. Dialysate water, sinks, faucets and shower heads have been associated with disease outbreaks or hand colonization. 
Patterson et al have reported that Legionella spp. were isolated from the water supplies in 55% transplant units. Furthermore, free-living protozoa were isolated from water supplies in 68% transplant units.  They concluded that the quality of cold water may be improved by provision of a dedicated supply taken directly from the incoming mains, and of hot water by the use of a calorifier, able to maintain a minimum circulating hot water return temperature of 60 o C. Another study of how safe is potable water for hospitalized immunocompromised patients concluded that endline commercially available water filters were the optimal way to provide drinking water to such patients. 
In general, it is recommended that whenever possible, the immunocompromised patient should avoid tap water and ice made from tap water. 
Plants and Fresh Flowers
Fresh flowers and other plants can carry microorganisms that are pathogenic for the immunocompromised patient.  A study showed that flowers and related items were colonized by over 40 different species of bacteria. Overall, 90% of the isolated organisms were known as causative agents of infection.  The authors recommended that:
i) Ban flowers in high-risk areas, such as cancer wards and burn units.
ii) Designate handling of flowers to support staff with no patient contact.
iii)Hand washing after contact with plant materials
iv) Change vase water at least every 48 hours
v) Dispose vase water into designated sinks.
Handwashing is an important modality for prevention of infection and should be done by patients, visitors and healthcare workers.  It is known that simple soap-and-water handwashing will remove almost all transient gramnegative rods in 10 seconds. Regretfully, most doctors and nurses in intensive care units do not wash their hands after each patient contact. On average, compliance with recommended hand washing is only 40 % in intensive care units. 
Alcohol may be as good as or better than simple soap-and-water handwashing for removing transient bacteria. However, chlorhexidine may be better than non-medicated soaps for removal of transient gram-positive organisms. ,
Patients and visitors should be taught proper techniques of handwashing and encouraged to do so before and after contact.
Handwashing Related Issues
The nature of job of health care workers requires an infection control department to watch not only the worker but also their performance of a certain duty.
i) Gloves: Studies have shown extreme variability in the quality of disposable gloves. Vinyl gloves have a leakage rate of 463% ,, In addition, latex gloves have a leakage rate of 3-52% . ,,,
The increased moisture content from perspiration of the hand after wearing glove will increase bacterial counts.  It is advisable that handwashing should take place after gloves removal.
ii) Jewelry: Field et al compared bacterial counts from skin under rings and watches of dental surgeons and non-clinical staff. Both groups showed a significantly greater number of bacteria isolated from skin under rings and watches compared to control sites.  Rings and other jewelries have been shown to have total bacterial counts on hands higher when jewelry is worn. ,
It was recommended that rings and other jewelry should be removed prior to hand disinfection and donning of gloves.
iii)Fingernails and artificial nails: Gram-negative rods have increased growth under artificial nails.  Short nails are preferable, because the majority of bacteria are found under and around fingernails. 
Visitors of immunosuppressed patients should be screened by health care providing team. Those who are currently suffering either from a diagnosed illness that is communicable by airborne, droplet nuclei or contact routes, or who have symptoms of viral illness should be discouraged from visiting immunocompromised patients. Appropriate infection control precautions for visiting the immunosuppressed patients should be employed. 
It is also advisable that visitors under the age of 12 years be permitted only with physician approval even if they appear healthy because of the high incidence of subclinical viral and non-viral illness in the age group.  Pediatric visitors should be screened for known illness or exposure in the previous month to: varicella, rubella, measles, mumps, hepatitis A, hepatitis E, streptococcal pharyngitis, pertussis, upper respiratory tract infections, diarrhea, fever, skin rash or attenuated live viral vaccination (MMR, varicella vaccine or oral polio).
Some authorities have advocated pet therapy as psychologically beneficial for patients.  However, pets in health care institutions pose potential serious infection control hazards because of organisms that may be transmitted to humans.  Certain circumstances argue against allowing pet visitations. For example patients who had a splenectomy are at high risk for invasive infection from oral flora of dogs, e.g. Capnocytophaga canimorsus. Also, some pets can act as fomites for the transmission of bacteria between patients. Patients who are situated in contact isolation should not be allowed to interact with animals ,
Control of Environmental Factors
It is well established that environmental sources can contribute to colonization and infection by several microorganisms, particularly in immunocompromised patients.  Environmental sources that are to be considered are air, water, and inanimate surfaces surrounding the patient. Air contaminated by fungal spores can lead to invasive aspergillosis, water contaminated by Legionellea pneumophila can cause legionnaire' disease and contaminated inanimate surfaces may result in the acquisition of Clostridium difficile.
Invasive aspergillosis remains a life-threatening infection in immunocompromised patient despite the newly developed antifungal medications. , If the immunocompromised patients need to be admitted to a hospital, they should be placed in rooms equipped with high-efficiency particulate air (HEPA) filters ,, In addition, water should be properly disinfected (chlorination, superheating, ozonization or other methods) to avoid infection by certain bacteria e.g. Legionella pneumophila or certain protozoa like Cryptosporidium parvum,,.
Adequate disinfection of endoscopes and other inanimate objects that can serve as vehicles for transmission of C. difficille can significantly reduce the incidence of C. difficile diarrhea. , The disinfections of patient areas with phosphate-buffered hypochlorite or aldehyde-containing disinfectants has been shown to be highly effective in decreasing environmental contamination and is recommended on wards and rooms involving Clostridium difficile carriers. 
Immunocompromised patients vary in their susceptibility to nosocomial infections, depending on the severity and duration of immunosuppression. Generally, these patients are at increased risk for infection from both endogenous and exogenous sources. , Ideally, if the standard precautions for all patients and transmission-based precautions for a specified patient get applied properly, the end result will be a reduction in exposing the compromised host to pathogenic organisms.
Isolation procedures are needed by 7-12% of patient admitted to hospitals. However, only 17-43% of the patients who should be isolated do so. Only half of isolation procedures are maintained for those started on isolation. ,
There are three basic kinds of isolation; contact, airborne (respiratory) and droplet isolation, depending on which organism has caused an infection in a patient. 
For neutropenic patients, most hospitals use a form of protection isolation. This has ranged from total protective environment (TPE) to simple reverse isolation with standard precautions.  Currently, the only circumstance in which TPE is recommended, is for patients who are post allogeneic bone marrow transplantation for severe aplastic anemia. 
Burn units, still rely heavily on more complete barrier-precautions i.e. gowns, gloves, masks and surgical caps.
Medical Instruments and Patient Areas
It has been demonstrated that necessary instruments to health care providers may be colonized by hospital bacteria. These instruments can serve as vectors for cross-transmission among patients if not properly disinfected. ,
It was also shown that some parts of the hospital environment have served as reservoir for multiple organisms.  Possible reservoirs of infectious agents are summarized in [Table - 2]. For example, Bernard et al have shown that among 355 stethoscopes 54 were significantly contaminated (≥ 20 cfu/membrane). The investigators recommended systematic disinfection of stethoscopes with 70% alcohol or liquid soap, or the use of disposable covers to minimize the chance of spreading nosocomial pathogens. 
Patient Hospital Charts
Marinella et al have shown that patients' hospital charts are contaminated by several bacteria.  An investigative study in a tertiary care hospital showed that patient hospital charts are contaminated by coagulase-negative Staphylococcus in 100%, gram positive bacilli in 75% and also methicillin-resistant Staphylococcus aureus in 2%. 
It is recommended that health care workers should wash their hands before and after contact with the chart. Also, patients' hospital charts should not be allowed inside the patients' rooms and should remain on the chart rack.
| Conclusions|| |
The care of immunocompromised hosts is evolving with new therapies, emerging infectious complications and changes in health care delivery. On the other hand, the level of education of the population being served and the presence of endemic infectious diseases in that geographic location are important factors. All of these factors need to be considered in more studies in the field of infection control and the compromised patients.
| References|| |
|1.||Gerberding JL. Nosocomial transmission of opportunistic infections. Infect Control Hosp Epidemiol 1998;19:574-7. |
|2.||Hennequin C, Page B, Roux P, Legendre C, Kreis H. Outbreak of Pneumocystic carinii pneumonia in a renal transplant unit. Eur J Clin Microbiol Infect Dis 1995;14:122-6. |
|3.||Lundgren B, Elvin K, Rothman LP, et al. Transmission of Pneumocytis carinii from patients to hospital staff. Thorax 1997;52: 422-4. |
|4.||Beard CB, Navin TR. Molecular epidemiology of pneumocystis carinii pneumonia. Emerg Infect Dis 1996;2:147-50. |
|5.||Risi GF, Tomascak V. Prevention of infection in the immunocompromised host, Am J Infect Control 1998;26:594-606. |
|6.||Young L, Robin R. Introduction In: Rubin RH, Young LS, editors. Clinical Approach to infection in the compromised host. 3rd ed. New York; Plenum; 1994.p 1-5. |
|7.||Advisory Committee on Immunization Practices (ACIP). Guide for adult immunization. 3rd ed. Philadelphia: American College of Physicians; 1994. |
|8.||Jacobs, D. Scheltinga M. Metabollic assessment. In: Rombeau, Caldwell, editors. Parenteral nutrition, 2nd ed. Philadelphia: WB Saunders Co; 1993 p. 245-50. |
|9.||Niederman MS, Craven DE. Devising strategies for preventing nosocomial pneumonia- should we ignore the stomach? Clin Infect Dis 1997;24:320-3. |
|10.||Cook DJ, Reeve B, Guyatt GH, et al. Stress ulcer prophylaxis in critically ill patients. Resolving discordant in meta-analysis. JAMA 1996;275:308-14. |
|11.||Ambrosino DM, Molrine DC. Critical appraisal of immunization strategies for prevention of infection in the compromised host. Hematol Oncol Clin North Am 1993; 7:1027-50. |
|12.||American Society of Clinical Oncology: Update of recommendations for the use of hematopoitic colony stimulating factors: evidence-based clinical practice guidelines. J Clin Oncol 1996;14:1957-60. |
|13.||Hindes R, Winkler C, Kane C, et al. Outpatient intravenous antibiotic therapy in medicare patients: Cost savings analysis. Infect Dis Clin Prac 1995;4:211-7. |
|14.||Reed EC. Infectious complications during autotransplantation. Hematol Oncol Clin North Am 1993;7: 717-35. |
|15.||Lim VK. Prevention of infection in the immunocompromised. Ann Acad Med Singapore 1997;26:331-5. |
|16.||Hughes WT, Armstrong D, Bodey GP, et al. 2002 guidelines for the use of antimicrobial agents in neutropenic patients with cancer. Clin Infect Dis 2002;34:730-51. |
|17.||Remington JS, Schimpff SC. Occational notes. Please don't eat the salads. N Engl J Med 1981; 304: 433-5. |
|18.||Casewell M, Phillips I. Food as a source of Klebsiella species for colonization and infection of intensive care patients. J Clin Pathol 1978; 31: 845-9. |
|19.||Shooter RA, Cooke EM, Faeirs MC, Breaden Al, O'Farrell SM, et al. Isolation of Escherichia coli, Pseudomonas aeruginosa and Klebsiella from food in hospitals, canteens and schools. Lancet 1971;2:390-2. |
|20.||Todd J, Schmidt M, Christian J, Williams R. The low-bacteria diet for immunocompromised patients. Reasonable prudence or clinical superstition? Cancer Pract 1999;7:205-7. |
|21.||Sike M. Nutrition therapy for the cancer patient. Hematol Oncol Clin Am 1996; 10:221-34. |
|22.||Henry L. Immunocompromised patients and nutrition. Prof Nurse 1997;12:655-9. |
|23.||Monk J, Beuchat L, Doyle M. Irradiation inactivation of food borne microorganisms. J Food Protec 1995;58:197-208. |
|24.||Pannuti CS. Hospital environment for highrisk patients. In: Wenzel RP, ed. Prevention and control of nosocomial infections, 3rd ed. Baltimore: Williams & Wilkins; 1997 p. 463-89. |
|25.||Rangel-Frausto MS. Water. In Wenzel RP, Brewer T, Butzler J-P. editors. A Guide to Infection Control in the Hospital. 3rd edition. Inter Society Infect Dis (ISID) 2004 p. 97-100. |
|26.||Patterson WJ, Hay J, Seal DV, McLuckie JC. Colonization of transplant unit water supply with Legionella and protozoa: precautions required to reduce the risk of legionellosis. J Hosp Infect 1997;37:7-17. |
|27.||Hall J, Hodgson G, Kerr KG. Provision of safe potable water for immunocompromised patients in hospital. J Hosp. Infect 2004;58: 155-8. |
|28.||Kates SG, McGinley KJ, Larson EL, Leyder JJ. Indigenous multiresistant bacteria from flowers in hospital and nonhospital environments. Am J Infect Control 1991;19:156-61. |
|29.||Larson EL - APIC Guidelines for handwashing and hand antisepsis in health care settings. Am J Infect Control 1995;23:251-69. |
|30.||Pittet D. Hand Hygiene. In: Wenzel RP, Brewer T, Butzler J-P editors. A Guide to Infection Control in the hospital. 3rd edition. Inter Society Infect Dis (ISID) 2004 p. 29-37. |
|31.||Doebbeling BN, Stanley GL, Sheetz CT, et al. Comparative efficacy of alternative handwashing agents in reducing nosocomial infections in intensive care units. N Engl J Med 1992;327:88-93. |
|32.||Korniewicz DM, Laughon BE, Butz A, Larson E. Integrity of vinyl and latex procedure gloves. Nurs Res 1989;38:144-6. |
|33.||Korniewicz DM, Laughon BE, Cyr WH, Lytle CD, Larson E. Leakage of virus through used vinyl and latex examination gloves. J Clin Microbiol 1990;28:787-8. |
|34.||DeGroot-Kosolcharoen J, Jones JM. Parmeability of latex and vinyl gloves to water and blood. Am J Infect Control 1989; 17:196-201. |
|35.||Korniewicz DM, Kirwin M, Cresci K, Markut C, Larson E. In use comparison of latex gloves in two high-risk units: Surgical intensive care and acquired immunodeficiency syndrome. Heart Lung 1992;21:81-4 |
|36.||Field EA, McGowan P, Pearce PK, Martin MV. Rings and watches: should they be removed prior to operative dental procedures? J Dent 1996;24: 65-9. |
|37.||Hoffman PN, Cooke EM, McCarville MR, Emmerson AM. Microorganisms isolated from skin under wedding rings worn by hospital staff. Br Med J. 1985;290:206-7. |
|38.||Jacobson G, Thiele JE, McCune JH, Farrell LD. Handwashing: ring wearing and number of microorganisms. Nurs Res 1985;34:186-188. |
|39.||Pottinger J, Burns S, Manske C. Bacterial carriage by artificial versus natural nails. Am J Infect Control 1989;17:340-4. |
|40.||Garner JS. Guidelines for isolation precautions in hospitals. Hospital Infection Control Practices Advisory Committee. Am J Infect Control 1996;24:24-31. |
|41.||Levy J. The pediatric patients In: Wenzel RP ed. Prevention and control of nosocomial infections. 3rd ed. Baltimore: Williams & Wilkins; 1997 p. 1039-58. |
|42.||Anon A. Hospitals dogs raise spirits, not infection rates. Hosp Infect Control 1992; 12:162-64. |
|43.||Anaissie EJ, Stratton SL, Dignani MC, et al. Pathogenic Aspergillus species recovered from a hospital water system; a 3 year prospective study. Clin Infect Dis 2002;34: 780-9. |
|44.||Manuel RJ, Kibbler CC. The epidemiology and prevention of invasive aspergillosis. J Hosp Infect 1998;39: 95-109. |
|45.||Kontogiannis DP, Mantadakis E, Somonis G. Systemic mycoses in the immunocompromised host; an update in antifungal therapy. J Hosp Infect 2003;53:243-58. |
|46.||Meunier F. Prevention and mycoses in immunocompromised patients. Rev Infect Dis 1987;9: 408-16. |
|47.||Loo VG, Bertrand C, Dixon C, et al. Control of construction-associated nosocomial aspergillosis in an antiquated hematology unit. Infect Control Hosp Epidemiol 1996;17:360-4. |
|48.||Hahn T, Cummings KM, Michalek AM, et al. Efficacy of high efficiency particulate air filtration in preventing aspergillosis in immunocompromised patients with hematologic malignancies. Infect Control Hosp Epidemiol 2002;23:525-31. |
|49.||Ferreira MS, Borges AS. Some aspects of protozoan infections in immunocompromised patients-a review. Mem Inst Oswaldo Cruz 2002;97:443-57. |
|50.||Hughes CE, Gebhard RL, Peterson LR, Gerding DN. Efficacy of routine fiberoptic endoscope cleaning and disinfection for killing clostridium difficile. Gastro intest Endosc 1986;32;7-9. |
|51.||Rutala WA, Gergen MF, Weber DJ. Inactivation of clostridium difficile spores by disinfectants. Infect Control Hosp Epidemiol 1993;14;36-9. |
|52.||Struelens MJ, Maas A, Nonhoff C, et al. Control of nosocomial transmission of clostridium difficile based on sporadic case surveillance. Am J Med 1991;91:138S- 44S. |
|53.||Gordfs B. Isolation of communicable diseases. In: Wenzel RP, Brewer T, Butzler J-P editors. A guide to infection control in the hospital. 3rd edition. Inter Society Infect Dis (ISID) 2004: p 38-44. |
|54.||Garner JS. Guideline for isolation precaution in hospitals. The Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1996;17:53-80. |
|55.||Navari RM, Buckner CD, Clift RA, et al. Prophylaxis of infection in patients with aplastic anemia receiving allogeneic marrow transplants. Am J Med 1984;76:564-72. |
|56.||Wendt C. Patient areas In: Wenzel RP, Brewer T, Butzler J-P. editors. A guide to infection control in the hospital. 3rd edition. Inter Society Infect Dis (ISID) 2004:p.89-92. |
|57.||Marinella MA, Pierson C, Chenoweth C. The stethoscope. A potential source of nosocomial infection? Arch Intern Med 1997;157:786-90. |
|58.||Weber D, Rutala W. Environmental Issues and Nosocomial Infections In: Wenzel RP. Ed. Prevention and control of nosocomial infections. 3 rd edition. Baltimore: Williams and Wilkins; 1997: p. 491-514. |
|59.||Bernard L, Kereveur A, Durand D, et al. Bacterial Contamination of Hospital Physicians Stethoscopes. Infect Control Hosp Epidemiol 1999; 20: 626-8. |
|60.||Marinella M, Elder B. bacterial contamiantion of patients hospital charts. Infect Dis Clin Prac 2000;9:39-40. |
|61.||Alothman A, Jelani A, Althaqafi A, et al. Contamination of patients hospital charts by bacteria. J Hosp Infect 2003;55:304-5. |
Consultant, Infectious Diseases, King Fahad National Guard Hospital, King Abdulaziz Medical City, P.O. Box 22490, Riyadh 11426
[Table - 1], [Table - 2]
| Article Access Statistics|
| Viewed||18595 |
| Printed||215 |
| Emailed||0 |
| PDF Downloaded||932 |
| Comments ||[Add] |