Medical detectives with the CDC’s Epidemic Intelligence Service (EIS) are warning infection preventionists and their colleagues not to place solid-organ transplant patients in negative pressure isolation rooms.
An investigation recently presented in Atlanta at the annual EIS conference has linked placement in a negative pressure isolation room to three mucormycosis fungal infections in heart and lung transplant recipients last year at an acute care hospital in Pennsylvania.1
“At the time of investigation, two of the three probable case patients were deceased,” says lead investigator and EIS officer Amber M. Vasquez, MD. “These were patients who were very ill, who had solid organ transplants and multiple medical problems, so I can’t tell you with certainty whether or not the infection contributed to their death.”
As infection preventionists are well aware, negative pressure systems pull air into the room and thus protect others from patients isolated for tuberculosis or airborne viruses like measles. The perfect storm in this situation was that there was ongoing construction at the unidentified hospital, meaning dust and molds released into the air would be pulled into the room via the negative pressure.
Positive pressure where air flows out to hallway is recommended for bone marrow transplant patients, but there is no specific recommendation to do so for solid organ transplants, Vasquez says.
“The current guidelines actually don’t recommend that solid organ transplant patients avoid negative pressure rooms,” she tells Hospital Infection Control & Prevention. “The likely reason that the patients were in that room was that it was a little bit larger of a room, but ultimately the guidelines don’t necessarily state that negative pressure rooms should be avoided for solid organs transplant patients. That’s why we are trying to disseminate this and recommend specifically avoiding negative pressure rooms for immunocompromised patients unless it is medically or clinically indicated.”
The EIS investigation began in September 2015 when the Pennsylvania Department of Health reported a mucormycosis cluster among solid organ transplant recipients (SOTRs) at an acute care hospital.
“We looked at the construction as a possible source,” EIS says. “The construction was going on at the time of our investigation and also over the long time period when the patients would have been admitted to the cardiothoracic ICU. However, our investigation didn’t find any single construction project that would explain all three probable case patients and would link that as a common exposure. What we did find as the common exposure was the room, which can still draw dust and dirt from the environment even in the absence of construction. That’s why we are focusing on the importance of clinicians and infection preventionists considering the potential risks of negative pressure rooms to immunocompromised patients.”
Plans are to present the findings to the CDC’s Healthcare Infection Control Practices Advisory Committee for consideration to formally amend the current guidelines.
- Vasquez A, Novosad S,E. Christensen, et al. Concurrent Session K2: Healthcare-Associated Outbreaks. Mucormycosis Among Solid Organ Transplant Recipients at an Acute Care Hospital — Pennsylvania, 2014–2015. CDC EIS Conference. Atlanta, May 2-5, 2016.