What is the standard operating procedure (SOP) for infection control in a Bone Marrow Transplant (BMT) department?

Standard Operating Procedure for Infection Control in BMT Departments

BMT units require strict adherence to Standard Precautions as the foundation, with hand hygiene before and after each patient contact, appropriate barrier use, and careful sharps disposal, supplemented by risk-stratified isolation precautions based on patient immunosuppression phase and environmental controls to prevent opportunistic infections. 1

Core Infection Control Practices

Standard Precautions (Universal Application)

• Hand hygiene must be performed before and after every patient contact without exception 1
• Appropriate use of barriers (gloves, gowns, masks) for all patient interactions 1
• Safe handling and disposal of needles and sharp instruments 1
• Proper procedures for disinfection/sterilization of medical instruments 1
• Appropriate disposal of infectious waste following established protocols 1

Risk-Stratified Isolation Precautions

Additional isolation precautions (Airborne, Droplet, Contact) must be employed based on the hospital epidemiologist's and infectious disease specialist's judgment, considering transplant type, degree of immunosuppression, and patient symptoms. 1

Phase I (Preengraftment, <30 days post-HSCT):

• Utilize BMT unit rooms with anterooms and appropriate equipment for all patient care due to severe neutropenia 1
• Minimize number of caregivers entering rooms 1
• Trainees should NOT provide patient care during this phase 1
• Change PPE between each patient contact 1
• Initiate staff exposure tracking systems 1

Phase II (Postengraftment, 30-100 days):

• Continue isolation based on GVHD status and CMV risk 1
• Maintain protective environment for patients with active GVHD 1

Phase III (Late phase, >100 days):

• Allogeneic recipients with chronic GVHD require ongoing protective measures due to persistent immunodeficiency 1
• Autologous recipients typically require less stringent precautions 1

Respiratory Symptom Management

The most restrictive level of isolation must be used when patients exhibit respiratory symptoms because airborne transmission of infectious agents poses the greatest concern. 1

• Isolation precautions continue until diagnosis is established or symptoms resolve 1
• Reassess appropriateness of precautions when diagnosis changes, symptoms evolve, or at readmission/discharge 1

Environmental Controls

Aspergillus Prevention (Critical Priority)

Environmental disturbances from construction/renovation dramatically increase airborne Aspergillus spore counts and represent the most important extrinsic risk factor for invasive fungal infection in BMT patients. 1

• Implement protective barriers during any construction or renovation activities near BMT units 1
• Monitor air quality and spore counts during environmental disturbances 1
• For severely immunocompromised patients, consider combined approaches including continuous heating, particulate filtration, ultraviolet treatment, and monthly pulse hyperchlorination of water supply to the BMT unit 1
• Restrict immunosuppressed patients from taking showers; use only sterile water for drinking or flushing nasogastric tubes 1

Water System Management

• Maintain heated water at ≥50°C or <20°C at the tap, OR chlorinate to achieve 1-2 mg/L free residual chlorine 1
• Implement pulse thermal disinfection or hyperchlorination if Legionella contamination identified 1

Laboratory Specimen Handling

Biosafety Level 2 (BSL-2) standard and special practices, containment equipment, and facilities must be used for all clinical specimens from BMT recipients. 1

• Pay particular attention to sharps management and bioaerosol containment 1
• Upgrade to BSL-3 practices when propagating unidentified infectious agents isolated from BMT recipients 1

Surge Capacity Planning (Infectious Disease Outbreaks)

Conventional Capacity (1-2 infectious patients):

• Provide all care in BMT unit rooms with anterooms 1
• Consult infection control for PPE guidance and infectious disease for pathogen-specific protocols 1
• Ensure staff and visitor PPE compliance 1

Contingency Capacity (3-43 patients):

• Utilize MICU as isolation area with single entrance 1
• Establish temporary anteroom/changing areas 1
• Isolate ventilation: 50% supply, 100% exhaust 1
• Staff use PPE continuously within infectious areas 1

Crisis Capacity (Catastrophic events):

• Implement cohort care in designated areas 1
• Construct temporary anterooms adjacent to each cohort area 1
• Hospital-wide access control and staff screening/monitoring 1

Antimicrobial Prophylaxis

Fluconazole is indicated to decrease the incidence of candidiasis in patients undergoing bone marrow transplantation who receive cytotoxic chemotherapy and/or radiation therapy. 2

• Obtain fungal cultures before initiating prophylaxis 2
• Adjust therapy based on culture results when available 2

Staff Education and Compliance

• Provide discharge instructions including specific infection control practices and special precautions for biologic product disposal 1
• Ensure all personnel understand infection control procedures through continuing education 3
• Common pitfall: Studies show 54-62% of nursing staff do not believe procedures are being complied with, indicating need for ongoing training and monitoring 3

Documentation and Monitoring

• Maintain written SOPs accessible to all staff 4, 5
• Implement theater-level infection control standard operating procedures with expert consultant oversight 6
• Regular audits of hand hygiene compliance and isolation procedure adherence 7, 6