Role of Infection Control Team in Oncology

1. Role of Infection Control Team in Oncology Dr Afia Zafar Associate Professor Chairperson, Infection Control Committee Department of Pathology Microbiology Aga Khan University

2. Oncology Patient • Medical oncology • Surgical oncology • Radiation oncology • Pediatric oncology • HSCT (Hemopoietic Stem Cell Transfusion) Allogeneic , Autologous

3. Risk of Infection • Factors determining immunosuppression: -Primary factor for infection: Defect in host defense -Type, dose, duration of anticancer medication or treatment -Invasive procedures, e.g central lines -HSCT -Exposure to high risk units, e.g ICU

4. Causes of Pediatric Hem/Onc Mortality

5. 6 5 SKIN(axilla & groin) 10 organisms/cm2 NASALSECRETIONS 10 organisms/mL 3 11 DENTAL PLAQUE 10 organisms/mL SKIN(other sites ) 10 organisms CONJUNCTIVA <10 organisms 8 SALIVA 10 organisms/mL LUNGS sterile PANCREAS sterile 3 KIDNEYS sterile STOMACH 10 organisms/mL 3 LIVER sterile BLADDER 10 organisms/mL BILE sterile UTERUS sterile 4 SMALL INTESTINE 10 organisms/mL 9 11 VAGINAL SECRETIONS 10 organisms/g LARGE INTESTINE 10 organisms/g

6. Cytoreductive Chemotherapy 40 Fever 39 38 37 Mucositis Potential pathogen Mucosa malabsorption 9 6 GRANULOCYTES x 10 /L 4 Bacteremia Catheter-related-infection Pulmonary infiltrate 2 0 Neutropenia 10 20 30 40 Days

11. Infections • Blood Stream Infections • Surgical Site Infections • Respiratory tract infections • Skin & Subcutaneous Infections culture of catheter tip &/or insertion site section of catheter

12. Organization of Infection Control • Infection Control Committee: Clinicians, Administrator, staff from support services, Infection control doctor, Infection control nurse, epidemiologist • Infection Control Team: infection control doctor, infection control nurse, epidemiologist

13. Infection Control Activities • Policies and Procedures • Surveillance& Trends • Outbreak investigation • Audit /Education

14. Hand Hygiene Isolation Intravascular catheters Food preparation & handling Visitors Healthcare workers Environment Surfaces Equipment Plants & Flowers Blood Product Screening Construction & renovation Prevention of Transmission Policies and Procedures

15. Hand HygieneFirst line of defense • Alcohol base handrub • Visibly contaminated-antimicrobial soap • Accessibility • Sinks • Alcohol based hand rub • ICN Daily round in high risk areas / Reinforce hand hygiene

16. Technique illustrated for use of liquid soap or antimicrobial soap. It is important to complete the entire sequences; however, the order in which you complete the sequence is not critical. Rub back side of hands and between fingers of both hands. Pinching motion in the palm of both hands to clean under fingernails. Apply 2-3 ml of soap palm to palm. hand washing procedure Rub palm to palm with fingers interlaced. Rub top of fingernails with fingers interlocked. Rotational rubbing of thumbs of both hands.

18. Personal Protective Equipment Policy • Gloves • Gowns • Masks • Patient Care Equipment

19. Isolation Precautions Category specific isolation

21. Isolation • Air Handling Systems • Not necessary in routine care of oncology patients • Selective use for HSCT • Total Protective Environment and HEPA filters • Not necessary in routine care of oncology patients • Selective use for HSCT

22. Protective isolation in hemopoietic stem cell transplants: a review of the literature and single institution experience Dadd G, McMinn P, Monterosso L. J Pediatr Oncol Nurs. 2003;20(6):293-300

23. Impact of portable air filtration units on exposure of hematology-oncology patients to airborne Aspergillus fumigatus spores under field conditions Engelhart S et al. J Hosp Infection.2003;54 (4):300-4.

24. Patient Hygiene Policy Oral Care: Education regarding oral & dental hygiene, Teeth brushing, Dental supervision Skin CareDaily showers or bath, Daily inspection of skin sites Perineal CareGood perineal care, Avoid the use of items that would cause mucosal breakdown

25. Environmental cleaning Policy • Surfaces: furniture & floors easy to clean, clean once/day, Wet cloths & mops • ICC approved disinfectant • Toys: easy to clean & disinfect, hard plastic toys • Do not stock pile in room • Plants and flowers

26. Intravascular Devices • Policies and Procedures Guidelines available • Special Insertion Teams&Trained persons for dressing • Maximal Sterile Barriers Sterile gloves & gowns, cap, large drape • Selection of type of catheter and site: No tunneled vs. tunneled catheters, Implantable ports, Subclavian, basilic, cephalic, IJ, femoral

27. Surveillance • High Risk Infections • Increased morbidity & mortality • Targeted Infections • Central line infections • Disseminated fungal infections • Denominators: • Central lines/1000 central line days • Infections/1000 patient days

28. Isolation of Candida tropicalis from Blood culture of patients with Portacath Dec. 2001-July 2002 Dec Jan Feb Mar Apr May Jun Jul Afia Zafar, Rumina Hasan,Nasim Sabir. Implications of use of contaminated drugs: a developing world scenario. The Lancet. July 2003. Vol. 362. 169-170

29. Result of Surveillance Cultures Afia Zafar, Rumina Hasan,Nasim Sabir. Implications of use of contaminated drugs: a developing world scenario. The Lancet. July 2003. Vol. 362. 169-170

30. Food Preparation & Handling • Low microbial diet • Adequately cooked food • Education • Policy • Practice • Audit by ICN

31. Visitors policy • Screened for potential infectious conditions • Visitors with active infection • Age requirement • Restriction of visitors • Education: • Communicable diseases • Hand hygiene • PPE if required for Additional Precautions

32. Health Care Workers • Immune Status & Immunization: • Measles, mumps, rubella, varicella • Inactivated polio vaccine • Restriction or Reassigned: • Diseases transmissible by air, droplet & direct contact: • Varicella • Gastroenteritis • HSV lesions of lips or fingers • Upper Respiratory Infections

33. Construction & Renovation • Increased risk of fungal infections • Aspergillus • Construction Guidelines new facilities or renovation: Involvement of infection control from planning phase

34. Conclusions • Problems of nosocomial infections in the oncology unit are more complex as in any other unit • Nonexistence of Infection control activities in these areas further exacerbate the problems resulting worse outcome • It is mandatory that each hospital treating cancer patients should have an active Infection Control group to handle these important issues

35. Thank you