Infection complications are most often predictable and possibly preventable through adequate infection control measures. In immunosuppressed patients this is of high importance, especially since the greater the impairment, the higher the risk of infection. Recognising patients with increased risk, identifying and correcting risk factors in advance, and reducing sources of infection are important aspects related to prevention of infection.
Immunosuppressed Patients
Immunosuppressed patients typically are those patients who have:
- extensive burns
- organ transplants
- particular genetic disorders eg. immunoglobulin A deficiency
- HIV infections
- leukaemias (cancer of white blood cells)
- lymphomas (cancer of the lymphatic system)
- high-dose chemotherapy
- haematological malignancies (cancers originating in blood-forming tissue eg. bone marrow, or in immune system cells)
- neutropenia (lack of neutrophils)
Neutropenia
Neutropenia is characterised by lack of neutrophils – white blood cells that help fight infections, especially those caused by bacteria. Normal range for neutrophils is 2.5-7.5 x 109/L. The lower the neutrophil count, the steeper the fall or the longer the duration of neutropenia, the higher the risk of infection.
Protective Precautions vs Protective Isolation
COMMENSAL MICRO-ORGANISMS – can be found on body surfaces which are covered by epithelial cells and exposed to the external environment (GI tract, respiration tract, vagina, skin, etc).
COMMENSAL BACTERIA – although co-evolved with their hosts, in specific circumstances can overcome protective responses in the host, causing pathologic effects.
NOSOCOMIAL INFECTIONS – eg. healthcare associated infections & MRSA.
OPPORTUNISTIC INFECTIONS – infections affecting solely the immunosuppressed patient eg. Kaposi’s sarcoma.
Infection-causing micro-organisms in immunosuppressed patients may be acquired through:
- the presence of the individual’s normal flora
- hospital staff hands
- hospital equipment
- food
Protective isolation components include:
- physical separation from the main population through the use of a single room
- restriction on movement, visitors and diet
- antimicrobial prophylaxis and selective decontamination of the digestive system
- care for the maintenance of skin and mucous membrane integrity
- application of hand hygiene to prevent exogenous acquisition of micro-organisms
NOTE: Signs & symptoms of infection are most commonly absent in immunosuppressed patients.
Transferring an immunosuppressed patient in Protective Isolation may not be enough to prevent subsequent development of infection.
Infection Control Measures
Infection control measures help prevent infection in immunosuppressed patients. Standard precautions should be applied when caring for neutropenic patients as well as severely immunosuppressed patients.
| Component | Recommendations |
| Hand hygiene | after contact with body fluids (including contaminated items), after glove removal, and between one patient and another |
| Gloves | use when touching body fluids (including contaminated items), when touching mucous membranes, and non-intact skin |
| Gown | use during procedures and patient care which require contact with clothing and exposed skin with anticipated exposure to body fluid |
| Face protection (eg. masks, goggles, visors) | use during procedures and patient care which are likely to generate splashes of body fluids, including aerosol-generating procedures with suspected or proven infections that transmit by respiratory aerosols (in which case wear an N95 or higher respirator along with gloves, gown, face and eye protection) |
| Soiled equipment | handle using preventative measures to avoid transferring micro-organisms to other individuals and to the environment; perform hand hygiene and wear gloves when handling visibly contaminated items |
| Environmental control | support/advocate for routine care, cleaning and disinfection of surroundings, especially surroundings close to patient-care areas |
Standard Precautions
| Textiles and laundry | handle using preventative measures to avoid transferring micro-organisms to other individuals and to the environment |
| Sharps | avoid recapping, bending, breaking or manipulating used needles; if recapping is needed, use one-hand scoop technique; use safety features if available; use appropriate sharps disposal containers |
| Patient resuscitation | use mouthpiece, resuscitation bag, or other ventilation devices to prevent oral contact and contact with oral secretions |
| Patient placement | use single-patient room if patient is at increased risk of transmission, contamination, lacking hygiene maintenance, or if patient is at increased risk of becoming infected or developing adverse outcomes following infection |
| Hygiene etiquiette | teach symptomatic patients to cover mouth and nose when sneezing and coughing, correct use and disposal of tissues, wearing of surgical mask if tolerated, or maintaining spatial separation (if possible more than 3 feet) |
Patient Placement
SINGLE ROOM – promotes reinforcement of infection control measures; should be prioritised for isolating individuals with communicable diseases or epidemiologically important organisms, to avoid exposing immunosuppressed patients to such organisms. A patient placed in a single room should:
- have an isolation notice displayed on the door
- have an ensuite bathroom
- have its door closed at all times
- have limited staff entering the room
- be provided with psychological support and reassurance whilst in isolation
- not have staff with infections to provide patient care
- not have staff to provide patient care whilst providing care to infectious patients in the same duty shift
SINGLE ROOM + HIGH EFFICIENCY PARTICULATE AIR (HEPA) FILTERS – promote reduction of risk to healthcare associated infections due to airborne fungi such as Aspergillus Genus (especially where construction-related work is in progress).
Patient Hygiene
FATIGUE – Immunosuppressed patients are often fatigued. Thus, patient hygiene must be assessed on a daily basis, and assistance must be provided where necessary.
PERINEAL CARE – Immunosuppressed patients frequently suffer from irritation or infection in the perineal area – an area which would be heavily colonised with bacteria. Thus, particular attention to this area is a must to maintain patient hygiene. Note that the use of soap may irritate the mucous membranes, leading to irritation exacerbation.
STAFF ILLNESS – immunosuppressed patients should not be nursed by staff with known or suspected infections or communicable diseases eg. oral-facial herpes simplex and upper respiratory tract infections; contact between such individuals should be reported to the infection control team and to the patient’s medical consultant.
Hand Hygiene
Environment and Equipment
- Removal of dust from surfaces may help prevent infection (routine use of chemical disinfectant has not yet been proven to reduce infection) – surfaces need to be damp-dusted daily with single use cleaning cloths and neutral detergent; mop head needs to be laundered daily
- Isolation rooms require cleaning with the use of gloves and aprons, followed by hand hygiene prior to leaving the room
- Vacated rooms must be cleaned thoroughly before they are reoccupied
- Medical equipment should be decontaminated after each use
- Single-use items must be discarded and not re-used
- Toys of immunosuppressed children should be decontaminated
- Flowers and plants have not been directly linked to infection in immunosuppressed patients, however, are usually not permitted since they may act as a reservoir for Gram Negative bacteria or fungal spores like Aspergillus
Personal protective equipment
- Use of face masks is not known to prevent infection in immunosuppressed patients, but can help protect healthcare staff from body fluid splashing
- Routine use of non-sterile gloves and aprons/gowns may help in preventing acquisition of micro-organisms
- PPEs must be minimally used to prevent contact with body fluids or contaminated items, and when in contact with non-intact skin and mucous membranes
- Must be removed and discarded of as clinical waste after use, followed by application of hand hygiene
- Sterile gloves are only required in certain aseptic or invasive procedures, or when in contact with sterile sites
Nutrition
- Immunosuppressed patients have an increased risk of acquiring food-borne illnesses and harmful micro-organisms, and so, should be advised to avoid high-risk foods such as shellfish, pate’, soft cheeses and foods that are made with raw eggs
- Neutropenic individuals have an increased risk of acquiring infection from Gram-Negative bacteria which is commonly found in sink plugholes and overflow outlets
Immunosuppressed Patient Visitors
Visitors should:
- report to a staff member prior to entering the patient’s room so precautions can be explained, and infections that may pose danger for the patient may be identified
- not visit if they have any transmissible infection
- not bring any pets, and plants or flowers (fresh or dried)
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