Clinical Practice Guidelines

NPA

  • Admission of oncology patients with known or suspected respiratory infections

    Background

    • Most viral respiratory infections are transmitted via direct contact with respiratory droplets or fomites.
    • Influenza, parainfluenza, RSV, adenovirus, human metapneumovirus and Bordetella pertussis may also be transmitted by large particle droplets created by coughing and sneezing.
    • Transmission of large-particle droplets requires close contact between source and recipient because droplets do not remain suspended in the air and generally travel only short distances (< 1m). Special air handling and ventilation are not required to prevent droplet transmission.
    • Some viruses (ie. RSV) can persist on hands or environmental surfaces for up to several hours.

    Management of any patient with known or suspected respiratory infections

    • Patients with respiratory infections, including suspected or laboratory-confirmed viral infections, should be managed in a single room with their own ensuite or cohorted with patients with similar infections.
    • In general, these patients should be kept away from patients at increased risk of complications from viral infections. This includes oncology/haematology patients, those with congenital cyanotic heart disease, chronic respiratory illness, congenital or acquired immunodeficiency and neonates. Early post BMT patients are particularly vulnerable.
    • Negative pressure rooms may be utilised when not occupied by other patients with airborne infections (such as pulmonary tuberculosis, varicella/chicken pox and measles).
    • The positive pressure rooms should not be used, as airborne viruses can 'spill' into the connecting corridors.

    Management of an oncology patient with a symptomatic respiratory infection

    • Oncology patients with respiratory infections, including suspected or laboratory-confirmed viral infections, should ideally be managed on wards other than 6th floor. This is the 'Gold Standard' approach to limit the opportunity for nosocomial transmission.
    • The Oncology Unit should be used when other wards are unavailable or when specialist care by oncology staff is required. Examples where management on 6th floor may be most appropriate include patients on high risk treatment protocols including ALL in induction therapy, AML, stage IV neuroblastoma, pre or post HSCT or any relapse disease.
    • Patients must be in a single room (occasionally double room if both patients have the same laboratory confirmed respiratory virus) with own en-suite. The door should remain closed.
    • To avoid nosocomial transmission:
      • Contact Precautions are recommended for the duration of all respiratory illnesses. This includes gown with any close patient contact and strict adherence to hand hygiene,
      • In addition, Droplet Precautions are recommended for confirmed RSV, influenza, parainfluenza, human metapneumovirus, adenovirus and B. pertussis.  This includes wearing a mask during any aerosol generating procedures (ie. suctioning or chest physio).
    • Parents are at risk of infection and should limit contact with other families and observe hand hygiene on leaving the room. Parents with respiratory symptoms should wear a mask on room exit.
    • A NPA or nasal swab (if patient is thrombocytopenic) should only be performed if there is a clinical indication and following medical review.
    • In a symptomatic patient, results of NPA or nasal swab are not required before deciding on ward transfer from the Emergency Department.

    Management of an asymptomatic oncology patient with recently documented viral respiratory infection

    • Immunosuppressed patients with viral respiratory infections may shed virus for prolonged periods and provide a reservoir for transmission to others.
    • Asymptomatic patients who continue to have evidence of viral shedding should be managed with contact precautions. They can be admitted to the 6th floor provided they have a single room (occasionally double room if both patients have the same laboratory confirmed respiratory virus) with own en-suite.
    • Asymptomatic patients who are not neutropenic can be placed with non-immunocompromised patients, provided contact precautions are maintained.
    • Asymptomatic patients with a laboratory confirmed respiratory virus in the last 8 weeks, and who require admission should be managed according to their most recent NPA result if a repeat NPA result is not immediately available.
    • Admission from the emergency department should not be delayed while awaiting a repeat NPA.
    • Following admission, contact precautions can be ceased if repeat results are negative.
    • Specimens for respiratory viral testing should not be performed more frequently than weekly.

    References

    Simon et al. Viral infections paediatric patients receiving conventional cancer chemotherapy. Arch Dis Child. 2008; 93: 880-889

    Tomblyn et al. Guidelines for Preventing Infectious Complication among Hematopoietic Cell Transplantation Recipients. Biol Blood Marrow Transplant 2009: 15: 1143-1238