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Policies,Clinical,UW Health Clinical,Infection Control

Infection Control in the Cystic Fibrosis Patient Population (4.1.2)

Infection Control in the Cystic Fibrosis Patient Population (4.1.2) - Policies, Clinical, UW Health Clinical, Infection Control

4.1.2


UW HEALTH CLINICAL POLICY 1
Policy Title: Infection Control in the Cystic Fibrosis Patient Population
Policy Number: 4.1.2
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: December 1, 2015

I. PURPOSE

To prevent the transmission of infectious agents among cystic f ibrosis (CF) patients, and betw een CF and
non-CF patient populations.

II. POLICY ELEMENTS

A. The UW Health policy for addressing issues of infection control in the cystic f ibrosis population w ill be based,
w ith some alterations, upon the Infection Prevention and Control Guideline for Cystic Fibrosis: 2013 Update.
(Complete reference and hyperlink included in section VI. of this policy).
B. This UW Health policy is limited to infection control issues in the care of cystic f ibrosis patients in UW Health
facilities. Clinicians are encouraged to refer to the guidance document cited in II.A. for additional
recommendations extending to home, family, and recreational environments.
C. Unless contraindications to immunization exist, physicians caring for CF patients should adhere to the
immunization schedule recommended by the Advisory Committee on Immunization Practices (ACIP).
D. All existing UW Health Infection Control policies apply to both CF and non-CF patients. Where modif ications
in the implementation of general infection control policies in the setting of CF are w arranted, they w ill be
specif ically noted w ithin this policy. In the absence of specif ic modif ications described w ithin this policy, it
may be assumed that UW Health Infection Control policies apply to CF patients as they are w ritten.

III. PROCEDURE

A. All UW Health patients should be offered immunization based upon the most current immunization schedule
promulgated by the ACIP (Advisory Committee on Immunization Practices). Current immunization schedules
can be accessed at: http://w w w.cdc.gov/vaccines/hcp/acip-recs/index.html
i. Of particular relevance to the CF patient is immunization for pneumococcus, pertussis, measles
and influenza.
B. Measures to prevent transmission of respiratory organisms w ill be implemented for CF patients because
they frequently develop chronic colonization of the respiratory tract w ith various agents of epidemiologic
concern to the general patient population (e.g., methicillin-resistant Staphylococcus aureus [MRSA],
multidrug-resistant Pseudomonas aeruginosa) and also w ith agents for w hich virulence is substantially
limited to the setting of CF disease (e.g., Burkholderia cepacia complex).
i. CF patients w ill w ear a barrier mask w henever they are in common areas of UW Health facilities as
a means of reducing their potential respiratory exposure to other individuals w ho may harbor
pathogens of concern. Once placed into an exam room or inpatient room, the patient no longer
needs to w ear the mask.
a. Example of acceptable masks include the standard yellow mask (Tecnol item 47117,
UWHC Central Supply order # 1213019) or, for pediatric patients w ith small faces, the
decorated Child's Face Mask, Kimberly Clark item 47127, UWHC Central Supply order #
4006742).
b. In clinic settings, CF patients w ill be provided a barrier mask w hen they arrive at the clinic.
1. It w ill be the responsibility of the staff member checking the patient into the clinic
to provide a barrier mask to the CF patient if the patient cannot be moved directly
into an exam room, as described in III.B.ii.b., below .
2. Patients w ith frequent clinic visits may, at the discretion of their physician, be
provided w ith several barrier masks to keep in their possession to be w orn upon
initial entry into UW Health facilities.
c. For CF patients admitted to an inpatient unit, it w ill be the responsibility of the nurse caring
for the patient to ensure that they w ear a barrier mask w henever they leave their room.
ii. CF patients should remain segregated from other CF patients in order to avoid transmission of
pathogens of epidemiologic concern among this patient population.
a. Clinic scheduling should be done, as much as practicable, to minimize the likelihood of
multiple CF patients aggregating in clinic w aiting areas at the same time.
b. Whenever possible, CF patients arriving for clinic appointments should be placed into the



UW HEALTH CLINICAL POLICY 2
Policy Title: Infection Control in the Cystic Fibrosis Population
Policy Number: 4.1.2

exam room directly, avoiding the need to remain in common w aiting areas.
c. Segregation of CF patients should be maintained, even among those infected or colonized
w ith the same organism, due to the possibility of transmission of, and strain replacement
w ith, a more pathogenic strain of the same species.
1. CF patients w ho are siblings residing in the same household need not be
segregated from one another w hile in UW Health.
d. Unrelated hospitalized CF patients should not visit w ith each other in their hospital rooms
nor should unrelated CF patients be in common areas (e.g., classroom, child life room) at
the same time.
iii. To minimize potential for cross transmission of respiratory pathogens among CF patients,
Pulmonary Function Testing (PFT) should be performed in one of the follow ing w ays:
a. In the exam room at the beginning of the clinic visit.
b. In a negative pressure airborne infection isolation room.
c. In a PFT laboratory w ith a portable HEPA filtration unit.
d. If the PFT laboratory does not have HEPA filtration, allow 30 minutes to elapse before the
next patient w ith CF enters the location.
iv. Nebulizer care to minimize amplif ication of agents w ithin nebulizers or retained f luids.
a. Handheld disposable nebulizers are managed as follow s:
1. After each use, rinse out residual volume w ith sterile w ater and w ipe
mask/mouthpiece w ith an alcohol pad.
2. Discard nebulizer every 24 hours.
b. Handheld reusable nebulizers are managed as follow s:
1. After each use, clean, disinfect, rinse w ith sterile w ater.
2. Allow to air dry aw ay from the sink so that tap w ater does not recontaminate the
item.
C. Modif ications to isolation precautions, as they apply specif ically to the patient w ith cystic f ibrosis, are
described below . Except for the modif ications detailed in this section, all precautions addressed in UWHC
policy #13.07, "Standard Precautions and Transmission Based Precautions (Isolation) for Inpatient Settings,
#13.28, "Standard Precautions and Transmission Based Precautions (Isolation) for Ambulatory Settings, and
#13.29, Isolation Practice for Multidrug-Resistant Organisms" apply to the CF population as they are w ritten.
i. Cystic f ibrosis patients w ill routinely be placed under Contact Precautions for every inpatient and
outpatient encounter.
a. Contact Precautions w ill be implemented for all CF patients regardless of clinical
presentation or the reason for the encounter.
b. Contact Precautions w ill be implemented for all CF patients regardless of current or
remote culture or screening results.
c. Contact Precautions w ill be implemented for all CF patients regardless of the location of
service, w hether inpatient or outpatient and regardless of w hether the clinic is housed
w ithin a hospital setting or is a free standing ambulatory location.
ii. Burkholderia cepacia complex:
a. Cystic f ibrosis patients w ith respiratory colonization or infection w ith Burkholderia cepacia
complex species w ill be placed under Contact Precautions for the duration of their
inpatient stay and for subsequent inpatient stays indefinitely.
b. To initiate isolation for Burkholderia in the CF patient, choose the "Isolation - Contact -
Burkholderia - CF Patient" option w ithin the Order Entry function on Health Link.
c. Once selected, an alert w ill appear in the Infection f ield on the Health Link header
indicating B. CEPACIA so that this information is available to all providers.
d. Infection Control should be notif ied of CF patients w ith colonization or infection w ith
Burkholderia cepacia complex identif ied by an outside institution. This information w ill be
entered into the Infection f ield of the patient header.
e. The infection f ield w ill remain populated w ith B. CEPACIA, and the patient should be
placed under isolation for subsequent clinic visits or inpatient stays, indefinitely.
f. Although unlikely, Infection Control Practitioners may remove the B. CEPACIA infection
indicator if , after consulting w ith the Hospital Epidemiologist, it is deemed that the patient
has eradicated carriage of the organism.
iii. Methicillin-resistant Staphylococcus aureus (MRSA).
a. Both Contact Precautions and Droplet Precautions must be implemented for CF patients
w ith MRSA infection or colonization, regardless of the site from w hich MRSA w as cultured.



UW HEALTH CLINICAL POLICY 3
Policy Title: Infection Control in the Cystic Fibrosis Population
Policy Number: 4.1.2

b. Use of antimicrobial therapy w ith the specif ic goal of decolonizing a CF patient w ith MRSA
is NOT RECOMMENDED. Such use of antibiotics is unlikely to eradicate MRSA from the
CF patient's respiratory tract, w ill increase antibiotic pressure and may promote antibiotic
resistance.
1. Any consideration of decolonizing the CF patient due to unusual clinical factors,
despite the strong recommendation against this, must f irst be discussed w ith the
Infectious Disease Service physician on call.
iv. Multidrug-resistant (MDR) and Extensively drug-resistant (XDR) gram negative organisms, and
carbapenem-resistant Enterobacteriaceae (CRE).
a. Contact Precautions must be implemented for CF patients for the duration of their
hospitalization and all subsequent inpatient admissions.
b. Once identif ied by the clinical laboratory or verif ied as having been identif ied at an outside
institution, the MDR, XDR, or CRE indicator w ill appear in the Infection f ield in the Health
Link header and the patient must be placed under isolation for subsequent encounters,
indefinitely.
v. Tuberculosis.
a. It is not necessary to institute Airborne Precautions for patients w ith CF pending results of
acid fast bacilli (AFB) smear and culture w hen these assays are performed solely as part
of routine annual sputum induction to monitor disease progression and assess for the
presence of nontuberculous mycobacterial infections, provided that there is no evidence of
latent tuberculosis infection nor suspicion of recent tuberculosis exposure.
1. Factors w hich nullify this narrow exemption from Airborne Precautions w hen AFB
smear and culture are ordered, and w hich w ould require immediate institution of
Airborne Precautions include:
ξ AFB smear and culture are ordered on suspicion of tuberculosis,
regardless of CF diagnosis.
ξ AFB smear and culture are ordered on a CF patient w ith positive
tuberculin skin test (TST) or positive interferon gamma release assay
(IGRA; e.g., Quantiferon gold test).
ξ AFB smear and culture are ordered on a CF patient w ith know n or
suspected exposure to a case of active pulmonary tuberculosis.
ξ AFB smear and culture are ordered on a CF patient w ho is an immigrant
from an area of hyperendemic tuberculosis, if negative TST or negative
IGRA result has not been documented since arrival in US.
2. While this routine screening among CF patients does not require that the patient
be placed under airborne precautions during hospitalization, precautions must
still be observed during sputum induction, as described in UWHC policy #13.17,
Control of Tuberculosis.
D. Cleaning of environmental surfaces.
i. Outpatient Cystic Fibrosis clinic.
a. Check-in room is w iped w ith hospital disinfectant after each CF patient has departed the
check-in room.
b. Surfaces in exam rooms, pulmonary function testing laboratory, and diagnostic locations
are w iped w ith hospital disinfectant after each CF patient has departed.
ii. Inpatient.
a. After CF patient departs the classroom/child life room, the area that they vacated is w iped
dow n w ith hospital disinfectant.
b. Surfaces in pulmonary function testing laboratory or diagnostic locations are w iped w ith
hospital disinfectant after each CF patient has departed.

IV. COORDINATION

Author: Infection Control Practitioner
Senior Management Sponsor: VP, Patient Care Services and CNO
Approval committees: Infection Control Committee; UW Health Clinical Policy Committee
UW Health Clinical Policy Committee Approval: October 19, 2015

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.



UW HEALTH CLINICAL POLICY 4
Policy Title: Infection Control in the Cystic Fibrosis Population
Policy Number: 4.1.2

This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

V. APPROVAL

Jeff Grossman, MD
UW Health CEO

Teresa Neely
SVP and CAAO

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VI. REFERENCES

-Saiman, L. et. al., 2013. Infection Prevention and Control Guideline for Cystic Fibrosis: 2013 Update.
Infection Control and Hospital Epidemiology vol. 35, no. S1; August 2014. Accessible at:
http://w w w.jstor.org.ezproxy.library.wisc.edu/stable/10.1086/676941
-UWHC Policy #13.07, Standard Precautions and Transmission Based Precautions (Isolation) for Inpatient
Settings
-UWHC Policy #13.28, Standard Precautions and Transmission Based Precautions (Isolation) for
Ambulatory Settings
-UWHC Policy #13.08, Hand Hygiene
-UWHC Policy #13.17, Control of Tuberculosis
-UWHC Policy #13.19, Toy Cleaning Procedure
-UWHC Policy #13.29, Isolation Practice for Multidrug-Resistant Organisms

VII. REVIEW DETAILS
Version: Revision
Next Revision Due: December 1, 2018
Formerly Know n as: Hospital Administrative policy #13.25