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The Need of Various Forms of Isolation in Hospitalized Adult Patients with Community
Acquired Pneumonia (CAP) in Jefferson County.
Rehab Abdelfattah MD MPH, Francisco Fernandez MD, Johnson Britto MD, Katherine Rivera MD, Daniel Curran MD, Joannis Baez MD, Kendra
Thompson BSc, Timothy Wiemken PhD MPH, Raul Nakamatsu MD, Arnold Forest DO, Ruth Carrico PhD.
ABSTRACT
Introduction: Community-acquired pneumonia (CAP) is a common and
potentially serious illness. It is associated with substantial morbidity and
mortality, especially in elderly patients and those with multiple
comorbidities. Pneumonia and Influenza combined is the eighth most
common cause of death in the US. Due to this, demand has increased for
preventing and controlling transmission of pneumonia in health care
settings. Proper protection of health care workers is a key to achieving this
objective. This study evaluates the need for different types of isolation for
CAP patients in Jefferson County.
Methods: A secondary data analysis of organisms isolated from CAP
patients enrolled in Rapid Empiric Therapy with Oseltamivir Study
(RETOS) database was performed. Organisms were grouped according to
types of isolation required; airborne isolation for particles 5 microns or
smaller in size (Tuberculosis), droplet isolation for particles greater than 5
microns in size (Influenza, Respiratory Syncytial Virus (RSV),
Parainfluenza Virus, Adenovirus, Human Metapneumovirus), and contact
isolation {Methicillin Resistant Staph Aureus (MRSA)}.
Results: A total of 801 hospitalized adult patients with Community
Acquired Pneumonia (CAP) were included in the study. Results showed
that; 262 patients required droplet isolation, (33%), 30 patients required
contact isolation (4%), and 1 patient required airborne isolation (0.1%).
Conclusion: Our results showed that one in every three (about 35%) adult
patients hospitalized with Community Acquired Pneumonia (CAP) in
Jefferson County required some form of isolation precaution. This reflects
the great need for developing and implementing an effective respiratory
protection program in various health care settings to prevent and control
transmission of these pathogens.
INTRODUCTION
Influenza, as well as other respiratory pathogens that may present as
community-acquired pneumonia (CAP) may be transmissible person-toperson. Three elements are required for transmission of infectious agents
within a healthcare setting: infectious agent, a susceptible host, and a mode
of transmission. The mode of transmission differs according to the type of
organism; however, some infectious agents might be transmitted by more
than one route. (1)
Airborne transmission occurs by dissemination of either airborne droplet
nuclei or small particles (<5 microns) containing infectious agents in an
inhalational range and could remain infective over a long time (e.g.
Mycobacterium tuberculosis). Microorganisms transmitted in this way may be
dispersed over long distances by air currents and may be inhaled by
susceptible individuals who have not had face-to-face contact with or been in
the same room with the infectious individual. Airborne isolation precautions
include personal respiratory protection (N95 respirator) or powered airpurifying respirator (PAPR) and use of an airborne infection isolation room
(AIIR). (1)
Respiratory droplets (>5 microns) are generated when an infected person
coughs, sneezes, or talks or during procedures such as suctioning and
endotracheal intubation. (2) Some infectious agents transmitted by the droplet
route could be transmitted also by direct or indirect contact (e.g., influenza,
respiratory Syncytial virus, parainfluenza virus, adenovirus, and human
metapneumovirus). Respiratory droplets carry infectious pathogens and
travel directly from the respiratory tract of the infectious individual to the
mucus membranes of the susceptible subject over short a short distance (3
feet), which necessitates facial barrier protection. Droplet precautions include
the use of barrier protection (e.g., a surgical mask with or without face shield)
worn when working within 3 feet of the patient.
INTRODUCTION, CONTINUED
RESULTS
RESULTS, CONTINUED
Contact transmission is the most common mode of transmission; it is divided
into two types: direct contact and indirect contact. Contact precautions are
used with specified patients known or suspected to be infected or colonized
with epidemiologically important micro-organisms (e.g., MRSA) that can be
transmitted by direct contact with the patients or indirect contact with
environmental surfaces or patient-care items in the patients’ environment.
Isolation policies should be based upon the latest recommendations from the
Centers for Disease Control and Prevention. However, we do not know how
frequently different types of isolation precautions need to be applied. The
objective of this study was to evaluate the need for different types of isolation
precautions in hospitalized, adult adult patients with CAP in Jefferson
County.
30 patients required contact isolation (4%).
CONCLUSIONS
MATERIAL AND METHODS
Unrecognized transmissible diseases represent a risk to healthcare
personnel. Exploration of activities that include a systems approach to
prevention can be important elements in healthcare personnel safety
programs. These activities may include processes that recognize risk early
in the patient encounter and preemptive use of respiratory protection and
environmental controls.
This was a secondary analysis of the Rapid Empiric Treatment with
Oseltamivir Study (RETOS) is a Centers for Disease Control and
Prevention (CDC) randomized clinical trial to evaluate the effectiveness of
early antiviral (Oseltamivir/Tamiflu) use in patients with lower respiratory
tract Infections due to influenza.
Study population: All adult patients (>18y) admitted to any hospital in
Jefferson County with Community Acquired Pneumonia (CAP) were
included in the analysis. Hospitals in Jefferson County include; University
of Louisville Hospital, Robley Rex VA medical center, Norton Brownsboro,
Norton Suburban, Norton Audubon, Norton Downtown, Jewish hospital,
and Baptist East hospital.
Implementing an effective respiratory protection program requires many
steps include but not limited to; developing aerosol transmissible diseases
exposure control plan, evaluating infectious hazards and who is exposed,
exposure control procedures including respiratory protection (using
respirators), staff training and record keeping. (3)
Microbiological culture results for those patients were collected, analyzed
and classified into three groups according to the etiology. These
included; 1) airborne precautions when Mycobacterium tuberculosis was
identified; 2) droplet precautions for all respiratory viruses including;
Influenza, Respiratory Syncytial Virus (RSV), Parainfluenza Virus,
Adenovirus, and Human Metapneumovirus, and 3) contact precautions
for MRSA.
Although we classified our patients into three groups based on the type of
isolation needed, we do not have any documented data regarding what
percentage of those patients had the appropriate method of isolation
precaution in place.
RESULTS
A total of 801 hospitalized adult patients with CAP were included in the
study.
1 patient required airborne isolation (0.1%).
45 years female patient with history of COPD, essential hypertension, HIV
and recurrent hospital admissions due to pneumonia. Patient was 10% less
than ideal body weight and had recent exposure to active tuberculosis.
During her hospital stay, sputum culture came back positive for
Mycobacterium tuberculosis, and her chest x-ray showed multiple opacities
and apical cavitations.
262 patients required droplet isolation, (33%).
Type of respiratory
virus
Adenovirus
Corona Virus
Influenza Virus
Metapneumovirus
Parainfluenza Virus
Respiratory Syncytial
Virus
Rhinovirus
Other Virus
Number of CAP
patients infected with
that virus
1
14
117
33
12
28
67
1
The hospital environment contains hazards such as bacteria, viruses, and
fungi that might be inhaled by workers, cause illness and transmit diseases
among patients. Due to this, hospitals need respiratory protection programs
to control respiratory hazards. In order to protect employees from aerosol
transmissible diseases, health care facilities must always implement a
combination of engineering, administrative, and work practice controls.
Due to H1N1 influenza outbreak in spring 2009 there has been
considerable interest in the use of surgical masks (facemasks) and
respirators as infection control measures. Respirators and facemasks are
both called “masks” in many health care settings; however, they are very
different in their design and in their purpose.
Our results showed that one in every three (about 35%) adult patients
hospitalized with CAP in Jefferson County had a pathogen identified that
indicated the need for some form of isolation precaution. This reflects the
importance of developing and implementing an effective respiratory
protection program for hospitals that recognize CAP as a transmission risk
to healthcare personnel
REFERENCES
1- Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices
Advisory Committee, 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious
Agents in Healthcare Settings. http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf
2- Healthcare Infection Control Practices Advisory Committee (HICPAC), , and National Center for
Preparedness, Detection, and Control of Infectious Diseases (NCPDCID) . 2007 Guideline for Isolation
Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings . Atlanta, GA: Centers
for Disease Control and Prevention, 2009. **Date Accessed**
<http://www.cdc.gov/hicpac/2007ip/2007ip_part1.html