This document discusses infection prevention for immunocompromised patients. It defines immunocompromised as having a diminished ability to resist infection. It also defines infection and outlines six key skills for infection preventionists. These include education, managing infection prevention programs, implementing employee health policies, preventing transmission of infectious agents, conducting surveillance and investigations, and identifying infectious disease processes. The document then discusses risk factors for immunocompromised patients including grades of immunocompromised based on absolute neutrophil count. It outlines the roles of nurses in providing isolation, periodic assessments, caring for lines and tubes, mouth/skin care, providing an appropriate diet, sterilizing equipment, and educating patients.

1. Infection Prevention &
Immunocompromized Patient
Manjunathan C.
RN RPN., M.Sc.(N)., M.Sc.,(CP)., PhD.,(N)
Deputy Nursing Superintendent,
Apollo CBCC Cancer Care,
Apollo Hospitals International Ltd.

2. What is Immunocompromized?
In a condition of diminished ability to resist infection, to reject foreign material
gaining access to the body, and to react aggressively at a cellular level to early
cancerous change.
https://medical-dictionary.thefreedictionary.com/immunocom
What is Infection?
It is the invasion of an organism's body tissues by disease-causing agents, their
multiplication, and the reaction of host tissues to the infectious agents and
the toxins they produce.
https://en.wikipedia.org/wiki/Infection

3. Six Key Skills: Every Infection
Preventionist needs
Murphy DM, Hanchett M, Olmsted RN, Farber MR, Lee TB, Haas JP, Streed SA.Competency in infection prevention:
a conceptual approach to guide current and future practice. Am J Infect Control. 2012 May;40(4):296-303.
Education and Research
Management of Infection prevention program
& communication of patient findings
Implementation of employee health policies
and procedures
Prevention and Control of infectious agent
transmission
Surveillance and epidemiologic investigation
Infectious disease process indentification

4. Risk Factors of
Immunocompromized/Neutropenia

5. Cont...

6. Absolute Neutrophil Count
Total WBC count x (% neutrophils + % bands) = ANC
Normal ANC 1500 to 8000 cells/mm³
Example:
Total WBC count is 2,500;
neutrophils = 32%;
bands = 8%
2,500 x (0.32 + 0.08) = ANC 2,500 x 0.40 = 1,000 ANC—absolute neutrophil
count; WBC— white blood cell
Based on information from Pagana & Pagana, 2002.

7. Grades of Immunocompromized /
Neutropenia
GRADE ABSOLUTE NEUTROPHIL
COUNT
RISK FOR INFECTION
1 1,500/mm³ or less to more
than 2,000/mm³
No increased risk
2 1,000/mm³ or less to more
than 1,500/mm³
Slight increase in risk
3 500/mm³ or less to more
than 1,000/mm³
Moderate risk
4 Less than 500/mm³ High risk

8. Role of Nurse
Isolation
Periodic assessment and Investigations
Care of lines, tubes and drains
Mouth Care, Nostrils, axilla & Groin
care
Neutropenic Diet
Sterlization of articles
& Room Cleaning
Medication
Management
Immunocompromized /
Neutropenia-Special
Care

9. Role of bedside RN- Isolation
• Positive pressure
• HEPA filter
• PPEs
• Visitor Restriction
• Aseptic Precautions

10. Cont...
• Hand Hygiene: Hand wash before and after using toilet.
• Hand washing to be done while entering the unit
• Advice Health professional to wear mask and to avoid encoutering patients
when they have a cold or URI
• Advice patient to wear mask when they walk in the corridor
• Protect client from others with infections and those who have recently been
vaccinated (a person may have a subclinical infection after a vaccination)

11. Role of bedside RN- Periodic
Assessment and Investigation
• Hemodynamic stabilization
• Investigation:
– Complete Blood Count (with Differential)
-White cells, haemoglobin, platelets
– Biochemistry
-Electrolytes, urea, creatinine, Liver function
– Microbiology
-Blood cultures (peripheral and all central line lumens)
-Oral ulcers or sores –send swabs ( Viral Cx and fungal Cx )
-Exit site swabs
-Wound swabs
-Urine Cultures
-Stool Cultures
– Radiology
-Chest Xray

12.  Central line dressing once in two/three days
 Frequent flushing of line
 Minimal use of lines
 Avoid invasive procedures (e.g. urinary catheterizations, arterial and venous punctures,
injections) whenever possible; if such procedures are necessary, perform them using
sterile technique
 Change intravenous insertion sites/tubings according to hospital policy
• Anchor catheters/tubings (e.g. urinary, intravenous) securely in order to reduce trauma to
the tissues and the risk for introduction of pathogens associated with the in-and-out
movement of the tubing
• Maintain a closed system for drains (e.g. urinary catheter) and intravenous infusions
whenever possible
Role of bedside RN- Care of
Lines & Tubes

13. Role of bedside RN- Care of Mouth,
Nostrils, Axilla and Groins
 Rinse mouth with chlorhexidine/ cephasole solution thrice a day
 Sitz bath twice a day
 Neosporin powder in the groin and axilla
 Candid mouth paint for the tongue
 Fusidin ointment for nostrils
 Zinc oxide to prevent excoriation
 Avoid Clipping Nails
 Preventing constipation: Initiate measures to prevent constipation & prevent damage
to the bowel mucosa from hard stool
 Avoid unnecessary rectal invasion (e.g. temperature taking, enemas, suppositories,
rectal tube) to prevent trauma to rectal mucosa and possible abscess formation

14. Role of bedside RN- Medication
Management
• Antibacterial, antiviral and antifungal systemically
• < 7 days of neutropenia
~ response rates to initial antimicrobial therapy was 95%, compared to only
32% in patients with more than 14 days of Immunocompromized /
neutropenia ( <.001)
~ patients with intermediate durations of neutropenia between 7 and 14 days
had response rates of 79%
1988,Rubin and colleagues

15. Role of bedside RN-
Immunocompromized / Neutropenic Diet
• Avoid raw and undercooked meat
• Double boiled Foods
• Preservatives should not be used: Tinned foods, cheese etc
• Outdated products should not be consumed.
• In patients with periodontitis and stomatitis, a soft or full liquid diet is
indicated.
• Maintain a fluid intake of at least 2500 ml/day unless contraindicated
• Avoid spicy and acidic foods
• Eat only fruits and vegetables that can be washed or cooked.
• Eat only meat that is fully cooked.
• Avoid drinking unpasteurized milk or other unpasteurized beverages.

16. Role of bedside RN- Sterlization &
Cleaning
• Autoclave
– RN Scrub
– Patient gowns
– Pillow cover
– Bed spread
– Linens
• Regular room cleaning : Advice cleaning of the room when patient is not in the
room
• Deep Cleaning when required
• Before using equipments (stethoscope, infusion pumps, etc.) from this
room for other patients clean them thoroughly with Sterilium
• Advice not to use sharp play material and have all items sterilized

17. Role of IC Nurse
• Daily surveillance
• Coordination with HIC committee members and other Medical team
Operations team-
• Auditing practices
Deep cleaning
Nursing practices
• Maintaining schedule of Air vent cleaning, HEPA filter validation / change
• Coordination with Biomedical Engineers on Room Pressure
• Educating Bedside nurses on Reverse barrier techniques
• Conducting link nurses meeting with supervisors and other important
• Tracking Quality Indicators

18. Best Infection Control Practices In
Our Immunocompromized Unit
Ventilation
Construction
Isolation
Hand
Hygiene
EquipmentPlants
Play
Areas &
Toys
Health
Care
Workers
Visitors

19. Cont...
Patient
Skin Care
Oral & Dental
Care
Prevention of
Bacterial Infection
Related to
Intravascular
Catheter
Drug-
Resistant
Organisms
Specific
Nosocomical
Infections
Legionellosis
Community
Respiratory
Virus
Infection
Mycobact
erium
Tuberculo
sis
Infection
Control
Surveillance
Ref: Clare A. Dykewicz-Centers for Disease Control and Prevention, Atlanta, Georgia, USA.

20. Patient Education
• Oncology nurses play a vital role in the education of patients and caregivers
concerning Immunocompromized / neutropenia precautions. Patients will need
to know how to avoid infection, what the signs of infection are, and when to
seek medical care.
(Loerzel, 2005; NCCN & ACS, 2002; Wilson, 2002)

23. “We have two jobs: Our job and
the job of improving our job”.
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