Guidelines for Preventing OpportunisticInfections Among …

1 Inside: Continuing Medical Education for Physicians and NursesGuidelines for Preventing OpportunisticInfections Among Hematopoietic StemCell Transplant RecipientsRecommendations of CDC,the Infectious disease Society of America,and the American Society of Bloodand Marrow DEPARTMENT OF HEALTH & HUMAN SERVICESC enters for disease control and prevention (CDC)Atlanta, GA 30333 October 20, 2000 / Vol. 49 / No. RR-10 RecommendationsandReportsInside: Continuing Medical Education for Physicians and NursesInside: Continuing Education Examination2 MMWRO ctober 20, 2000 centers for disease control and prevention .. Jeffrey P. Koplan, , material in this report was prepared for publication byNational center for Infectious Diseases .. James M. Hughes, of AIDS, STD, and TB Laboratory Research .. Harold W. Jaffe, production of this report as an MMWR serial publication was coordinated inEpidemiology Program Office.

2 Barbara R. Holloway, DirectorOffice of Scientific and Health Communications .. John W. Ward, , MMWR SeriesRecommendations and Reports ..Suzanne M. Hewitt, Kay Smith-Akin, G. CupellMorie HigginsVisual Information SpecialistsMichele D. RenshawErica R. ShaverTechnical Information SpecialistsThe MMWR series of publications is published by the Epidemiology Program Office, centers for disease control and prevention (CDC), Department of Health andHuman Services, Atlanta, GA CITATIONC enters for disease control and prevention . Guidelines for Preventing OpportunisticInfections Among hematopoietic stem cell transplant recipients: recommendationsof CDC, the Infectious disease Society of America, and the American Society ofBlood and Marrow Transplantation. MMWR 2000;49(No. RR-10):[inclusive pagenumbers].Vol. 49 / No. RR-10 MMWRiInside: Continuing Medical Education for Physicians and 1 Using These Guidelines .

3 2 Immune System Recovery After HSCT .. 4 Opportunistic Pathogens After HSCT .. 5 Bacterial Infections .. 8 General 8 Preventing Exposure .. 8 Preventing disease .. 8 Recommendations Regarding Stre. pneumoniae ..9 Preventing Exposure .. 9 Preventing disease .. 9 Recommendations Regarding Streptococci viridans ..10 Preventing Exposure .. 10 Preventing disease .. 10 Recommendations Regarding Ha. influenzae type b .. 10 Preventing Exposure .. 10 Preventing disease .. 11 Viral Infections .. 11 Recommendations Regarding Cytomegalovirus .. 11 Preventing Exposure .. 11 Preventing disease and disease Recurrence .. 12 Recommendations Regarding EBV .. 15 Preventing Exposure .. 15 Preventing disease .. 15 Recommendations Regarding HSV .. 15 Preventing Exposure .. 15 Preventing disease and disease Recurrence .. 15 Other Recommendations.

4 16 Recommendations Regarding VZV .. 16 Preventing Exposure .. 16 Preventing disease .. 17 Other Recommendations .. 18 Recommendations Regarding CRV Infections: Influenza, Respiratory SynctialVirus, Parainfluenza Virus, and Adenovirus .. 18 Preventing Exposure .. 18 Preventing disease .. 19 Other disease prevention Recommendations .. 21 Fungal Infections ..22 General 22 Preventing Exposure .. 22 Preventing disease .. 22iiMMWRO ctober 20, 2000 Contents ContinuedRecommendations Regarding Yeast Infections .. 22 Preventing Exposure .. 22 Preventing disease .. 22 Other Recommendations .. 23 Recommendations Regarding Mold Infections .. 23 Preventing Exposure .. 23 Preventing disease .. 24 Protozoal and Helminthic Infections .. 25 Recommendations Regarding PCP .. 25 Preventing Exposure .. 25 Preventing disease and disease Recurrence.

5 25 Other Recommendations .. 25 Recommendations Regarding Toxoplasma gondii ..26 Preventing Exposure .. 26 Preventing disease and disease Recurrence .. 26 Other Recommendations .. 26 Recommendations Regarding Strongyloides stercoralis ..26 Preventing Exposure .. 26 Preventing disease and disease Recurrence .. 27 Other Recommendations .. 27 Recommendations Regarding Trypanosoma cruzi ..27 Preventing Exposure .. 27 Preventing disease .. 28 Other Recommendations .. 28 Hospital Infection control .. 28 Room Ventilation .. 28 Construction, Renovation, and Building Cleaning .. 29 Construction and Renovation .. 31 Isolation and Barrier Precautions .. 31 Hand Hygiene .. 32 Plants, Play Areas, and Toys .. 34 HSCT center Visitors .. 34 Patient Skin and Oral Care .. 35 Preventing Bacterial Intravascular Catheter-Related Infections.

6 36 control of Specific Nosocomial Infections .. 36 Recommendations Regarding Legionella Species .. 36 Recommendations Regarding Methicillin-Resistant Sta. aureus ..38 Recommendations Regarding StaphylococcusSpecies with Reduced Susceptibility to Vancomycin .. 38 Recommendations Regarding VRE .. 39 Vol. 49 / No. RR-10 MMWRiiiContents ContinuedRecommendations Regarding Cl. difficile ..40 Recommendations Regarding CRV Infections .. 41 Recommendations Regarding TB .. 43 Infection control Surveillance .. 44 Strategies for Safe Living After HSCT Preventing Exposure and disease .. 44 Avoiding Environmental Exposures .. 44 Preventing Infections Transmitted by Direct Contact .. 44 Preventing Respiratory Infections .. 45 Preventing Infections Transmitted Through DirectContact and Respiratory Transmission .. 46 Safe Sex.

7 46 Pet Safety .. 47 Preventing Pet-Transmitted Zoonotic Infections .. 47 Preventing Toxoplasmosis .. 48 Water and Other Beverage Safety .. 48 Food Safety .. 50 Food Safety Practices Appropriate for All Persons .. 50 Additional Food Safety Practices Appropriate for HSCT Recipients .. 51 Travel Safety .. 51 HSCT Recipient Vaccinations .. 52 Hematopoietic Stem Cell Safety .. 53 Preventing Transmission of Infections from HSCT Donors to Recipients .. 54 Pediatric Donors .. 58 Preventing Infection from Extraneous Contamination of Donated Units .. 58In Utero or Fetal HSCT .. 82 Appendix: Dosing Charts for Preventing OpportunisticInfections Among Hematopoietic Stem CellTransplant Recipients .. 95 Continuing Education Activity .. CE-1ivMMWRO ctober 20, 2000 Abbreviations Used in This PublicationANCabsolute neutrophil countBALbronchoalveolar lavageCDAchlorodeoxyadenosineCJDC reutzfeldt-Jakob diseaseCMVcytomegalovirusCRVcommunity-ac quired respiratory virusDNAdeoxyribonucleic acidEBVE pstein-Barr virusEPAE nvironmental Protection AgencyFDAFood and Drug AdministrationG-CSFgranulocyte colony-stimulating factor (filgastrim)GM-CSFgranulocyte-macrophage colony-stimulating factor (sargramostim)GVHD graft-versus-host diseaseHCWhealth-care workerHEPA filterhigh-efficiency (>90%) particulate air filterHibHaemophilus influenzae type bHIVhuman immunodeficiency virusHLAhuman lymphocyte antigenHSCT hematopoietic stem cell transplant.

8 For this report, includes all blood- andmarrow-derived hematopoietic stem cell transplantsHSVherpes simplex virusHTLV human T-lymphotropic virusIgAimmunoglobulin AIgGimmunoglobulin GIgMimmunoglobulin MIVIG intravenous immunoglobulinLAFlaminar air flowLDLegionnaires diseaseLRIlower respiratory infectionMICminimum inhibitory concentrationMRSA methicillin-resistant Staphylococcus aureusnvCJDnew variant Creutzfeldt-Jakob diseaseOIopportunistic infectionPCPP neumocystis carinii pneumoniaPCRpolymerase chain reactionPZA/RIFpyrazinamide/rifampinRNAr ibonucleic acidRSVrespiratory syncytial virusTBMycobacteria tuberculosisTMP-SMZtrimethoprim-sulfamet hasaxoleTSTtuberculin skin testUCBumbilical cord bloodURIupper respiratory infectionVREvancomycin-resistant EnterococcusVZIG varicella-zoster immunoglobulinVZVvaricella-zoster virusVol. 49 / No. RR-10 MMWRvThe following CDC staff members prepared this report:Clare A.

9 Dykewicz, , W. Jaffe, , DirectorDivision of AIDS, STD, and TB Laboratory ResearchNational center for Infectious DiseasesJonathan E. Kaplan, of AIDS, STD, and TB Laboratory ResearchNational center for Infectious DiseasesDivision of HIV/AIDS prevention Surveillance and EpidemiologyNational center for HIV, STD, and TB Preventionin collaboration withthe Guidelines Working Group Members from CDC,the Infectious disease Society of America,and the American Society of Blood and Marrow TransplantationClare A. Dykewicz, , , ChairHarold W. Jaffe, J. Spira, of AIDS, STD, and TB Laboratory ResearchWilliam R. Jarvis, Infections ProgramNational center for Infectious Diseases, CDCJ onathan E. Kaplan, of AIDS, STD, and TB Laboratory ResearchNational center for Infectious DiseasesDivision of HIV/AIDS prevention Surveillance and EpidemiologyNational center for HIV, STD, and TB prevention , CDCB rian R.

10 Edlin, of HIV/AIDS prevention Surveillance and EpidemiologyNational center for HIV, STD, and TB prevention , CDCR obert T. Chen, , Hibbs, , and Surveillance DivisionNational Immunization Program, CDCR aleigh A. Bowden, Sullivan, Hutchinson Cancer Research CenterSeattle, WashingtonviMMWRO ctober 20, 2000 David Emanuel, UniversityIndianapolis, IndianaDavid L. Longworth, Clinic FoundationCleveland, OhioPhilip A. Rowlings, , Bone Marrow Transplant Registry/Autologous Blood and Marrow Transplant RegistryMilwaukee, WisconsinRobert H. Rubin, General HospitalBoston, MassachusettsandMassachusetts Institute of TechnologyCambridge, MassachusettsKent A. Sepkowitz, Kettering Cancer CenterNew York, New YorkJohn R. Wingard, of FloridaGainesville, FloridaAdditional ContributorsJohn F. Modlin, Medical SchoolHanover, New HampshireDonna M. Ambrosino, Cancer InstituteBoston, MassachusettsNorman W.