Care of the Burn Wound

Policies and Procedures on Infection Control Ministry of Health Malaysia 129

6.9.1. Introduction

1. Haemato-oncology patients are immunocompromised. The predisposing factors are neutropaenia, monocytopaenia, lymphopaenia, qualitiative phagocytic defects and complement deficiency, hyposplenism, humoral deficiency as well as cellular immune dysfunction. 2. In addition, many patients have damage to their skin and mucous membranes as a result of chemotherapy-induced mucosal barrier injury to the oro-gastrointestinal tract.

6.9.2 Common pathogens and sites of infection

1. The common pathogens include bacterial commensals from the gastrointestinal tract or skin and fungi including candida, aspergillus and other species. 2. Opportunistic infections include toxoplasma, crytococccus, pneumocystis and cryptosporidium as well as infection or reactivation of viruses. 3. The common portals of infection include the oro-pharynx, periodontium, perianal, colon skin, lung and esophagus.

6.9.3 Patient hygiene

1. Patients should be advised to rinse orally 4-6Xday with sterile water, normal saline or sodium bicarbonate. Patients should be advised to brush their teeth at least twice a day with a soft-bristled toothbrush. Fixed orthodonthics and space retainers should not be worn. 2. Patients are advised to bath daily with a mild soap with attention to good perineal hygiene. 3. Avoid the use of rectal thermometers, enemas, suppositories or rectal examinations. 4. Dental clearance should be performed 10-14days before induction of chemotherapy. 5. Skin sites should be inspected daily.

6.9.4 High risk neutropaenic diet

1. A low microbial diet is recommended to reduce the number of pathogens in food 2. Attention should be paid to food preparation. Raw meats should be handled on separate surface. 3. Food handlers should wash their hands before and after handling food. 4. Consumption of raw or undercooked meats or eggs or foods that may contain these e.g. mayonnaise, hollandaise sauce is not allowed.

6.9 Haematology and Oncology Unit

Policies and Procedures on Infection Control Ministry of Health Malaysia 130 5. Avoid fresh salads, fresh fruits, raw peanuts and seeds and raw or undercooked seafood. 6. Avoid naturopathic foods that may contain moulds. Pepper is to be avoided. 7. Sterile foods, on the other hand are expensive, tasteless and not proven in benefit 8. Low microbial diet should continue at least 3 months after chemotherapy or autologous stem cell transplant. In allogenic stem cell transplant, it should continue until all immune-suppressives are stopped.

6.9.5 Facilities

1. Isolation in single rooms is beneficial in the setting of aplastic anaemia, induction therapy of high risk AML patients especially elderly and in haemopoietic stem cell transplant setting. All haemato-oncology patients should be placed in single rooms where possible. Where not possible, they can be nursed in open cubicles with isolation facilities made available when necessary e.g. during MRSA or ESBL- infections. 2. For isolation rooms, HEPA filter with a capacity of maintaining 310,000 atmospheric particles of 0.3microns with 12 air exchanges per hour will remove bacteria and fungal spores. This is most effective to prevent hospital acquired aspergillus. The use of laminar air flow rooms is controversial. 3. Isolation rooms should have self-closing doors and well-sealed windows. Avoid false ceilings. Flooring and wall finishing can be scrub, non-porous and easily disinfected. A constant positive pressure of 2.5 Pa between the patient’s room and hall way should be maintained. Back-up emergency power should be available. 4. Wards and rooms should be regularly cleaned at least once a day. Avoid vacuuming. Any water leaks should be attended to within 72 hours. 5. Avoid construction or renovation areas during transportation of patients to other facilities e.g. X-ray. Patients should wear an N95 mask if this is unavoidable. 6. Any construction or renovation activities adjacent to the units should be discussed with the infection control unit before proceeding. Refer to section on construction and renovation 7. Patients with concomitant active infectious diseases e.g. tuberculosis or measles should be nursed in isolation room with negative pressure with an adjacent anteroom. 8. Equipment should be cleaned regularly and disinfected at least once a week. 9. Plants – fresh or dried and soft toys are prohibited. Only toys, games and videos that can be cleaned are allowed.

6.9.6 Personnel precautions

1. Health care workers should practice standard precautions. Personnel should wear surgical masks when entering rooms. They should practice hand hygiene with alcohol based hand rubs before entering and after leaving rooms. Gloves should be worn after entering room and washing hands and discarded before exiting.