Infection prevention strategies in a stem cell transplant unit: impact of change of care in isolation practice and routine use of high dose intravenous immunoglobulins on infectious complications and transplant related mortality

Clinical, humanistic and economic outcomes, including experiencing of patient safety events, associated with admitting patients to single rooms compared with shared accommodation for acute hospital admissions: a systematic review and narrative synthesis

OBJECTIVES

Assess the impact of single rooms versus multioccupancy accommodation on inpatient healthcare outcomes and processes.

DESIGN

Systematic review and narrative synthesis.

DATA SOURCES

Medline, Embase, Google Scholar and the National Institute for Health and Care Excellence website up to 17 February 2022.

ELIGIBILITY CRITERIA

Eligible papers assessed the effect on inpatients staying in hospital of being assigned to a either a single room or shared accommodation, except where that assignment was for a direct clinical reason like preventing infection spread.

DATA EXTRACTION AND SYNTHESIS

Data were extracted and synthesised narratively, according to the methods of Campbell et al. RESULTS: Of 4861 citations initially identified, 145 were judged to be relevant to this review. Five main method types were reported. All studies had methodological issues that potentially biased the results by not adjusting for confounding factors that are likely to have contributed to the outcomes. Ninety-two papers compared clinical outcomes for patients in single rooms versus shared accommodation. No clearly consistent conclusions could be drawn about overall benefits of single rooms. Single rooms were most likely to be associated with a small overall clinical benefit for the most severely ill patients, especially neonates in intensive care. Patients who preferred single rooms tended to do so for privacy and for reduced disturbances. By contrast, some groups were more likely to prefer shared accommodation to avoid loneliness. Greater costs associated with building single rooms were small and likely to be recouped over time by other efficiencies.

CONCLUSIONS

The lack of difference between inpatient accommodation types in a large number of studies suggests that there would be little effect on clinical outcomes, particularly in routine care. Patients in intensive care areas are most likely to benefit from single rooms. Most patients preferred single rooms for privacy and some preferred shared accommodation for avoiding loneliness.

PROSPERO REGISTRATION NUMBER

CRD42022311689.

A Preliminary Study of the Comfort in Patients with Leukemia Staying in a Positive Pressure Isolation Room

Background and Aim: Patients with leukemia who are isolated in positive pressure rooms for infection prevention usually experience significant physical and psychological distress. This study aimed to examine changes in leukemia patients' comfort level during chemotherapy in isolation wards. Methods: A longitudinal survey was conducted with measures which were repeated four times. Data were collected before chemotherapy, on the first and second week after receiving chemotherapy in positive pressure isolation rooms, and on the third week in the non-isolated hematology ward. Each patient received six questionnaires measuring demographic data, comfort status, functional status, fatigue related to cancer therapy, anxiety level, and distress symptoms. A mixed model with repeated measure analysis was used to examine the changing trajectories in physical and psychological health. Results: Twenty-one patients completed the study. During the process, the highest score for comfort level was shown before chemotherapy, and this decreased from the second week under isolation. Anxiety and uncertainty (p < 0.05) declined over time, and emotional states improved during the recovery period in the third and fourth weeks outside isolation. Physical well-being (p < 0.01), cancer-related fatigue (p < 0.05), hemoglobin (p < 0.01) and white blood cell count (p < 0.05) began to rise two weeks after chemotherapy. Conclusion: Comfort levels declined after chemotherapy until the third week of treatment. Anxiety, fatigue and distress symptoms varied across the four time points of chemotherapy from isolation to return to the non-isolated ward. Health care professionals should be aware of psychological symptoms when patients are in isolation rooms, and interventions for promoting a humanized environment, quality of life, and comfort should be considered and provided along with the treatment stages of chemotherapy.

Immunoglobulin prophylaxis in pediatric hematopoietic stem cell transplant

BACKGROUND

After allogeneic hematopoietic stem cell transplantation (HSCT), patients have an increased susceptibility to infections, thought to be due in part to hypogammaglobulinemia. Thus, prophylactic administration of intravenous immunoglobulins (IVIG) has been administered to patients after HSCT as standard of care. This study compares the viral infection rate between dosing IVIG by IgG levels versus by routine monthly administration in pediatric patients after HSCT.

PROCEDURE

In this retrospective chart review, we abstracted from electronic medical records data on pediatric patients undergoing HSCT from 2010 to 2012 for 6 months post-HSCT. We compared rates of infection between patients treated with routine IVIG prophylaxis and patients given IVIG prophylaxis based on IgG tough levels (IgG levels were checked every 2 weeks).

RESULTS

Data were available and reviewed for 50 patients dosed with IVIG every 28 days (Group 1) and 100 patients dosed with IVIG based on IgG level > 400 mg/dl (Group 2). There was no significant difference in age (P = 0.98) or sex (P = 0.42), reason for HSCT, alemtuzumab use (P = 0.602), or reduced intensity conditioning (P = 1.00). Significantly more haploidentical donors were in Group 1 (P = 0.04), otherwise there was no significant difference in donor type between groups. Significantly less acute graft versus host disease occurred (P = <0.001) in Group 2 (P = <0.001). PCR documented viral infections were not significantly different (P = 0.412) (Table 1). Group 2 patients received significantly less IVIG (P < 0.001).

CONCLUSION

Dosing IVIG to maintain an IgG level > 400 mg/dl is a cost-effective and safe way to prevent viral infections in pediatric patients undergoing HSCT.

Role of Natural Killer Cells in Intravenous Immunoglobulin-Induced Graft-versus-Host Disease Inhibition in NOD/LtSz-scidIL2rg(-/-) (NSG) Mice

Although clinical studies have yet to demonstrate clearly the use of intravenous immunoglobulin (IVIG) for prevention of graft-versus-host disease (GVHD), their effective use in a xenogeneic mouse model has been demonstrated. We aimed to determine the mechanism of action by which IVIG contributes to GVHD prevention in a xenogeneic mouse model. NOD/LtSz-scidIL2rg(-/-) (NSG) mice were used for our xenogeneic mouse model of GVHD. Sublethally irradiated NSG mice were injected with human peripheral blood mononuclear cells (huPBMCs) and treated weekly with PBS or 50 mg IVIG. Incidence of GVHD and survival were noted, along with analysis of cell subsets proliferation in the peripheral blood. Weekly IVIG treatment resulted in a robust and consistent proliferation of human natural killer cells that were activated, as demonstrated by their cytotoxicity against K562 target cells. IVIG treatment did not inhibit GVHD when huPBMCs were depleted in natural killer (NK) cells, strongly suggesting that this NK cell expansion was required for the IVIG-mediated prevention of GVHD in our mouse model. Moreover, inhibition of T cell activation by either cyclosporine A (CsA) or monoclonal antihuman CD3 antibodies abolished the IVIG-induced NK cell expansion. In conclusion, IVIG treatment induces NK cell proliferation, which is essential for IVIG-mediated protection of GVHD in our mouse model. Furthermore, activated T cells are mandatory for effective IVIG-induced NK cell proliferation. These results shed light on a new mechanism of action of IVIG and could explain why the efficacy of IVIG in preventing GVHD in a clinical setting, where patients receive CsA, has never been undoubtedly demonstrated.

Use of immunoglobulins in the prevention of GvHD in a xenogeneic NOD/SCID/γc- mouse model

The efficacy of IVIG in preventing GvHD has not been definitely demonstrated clinically. Using a xenogeneic model of GvHD in NOD/SCID/γc- (NSG) mice, we showed that weekly administration of IVIG significantly reduced the incidence and associated mortality of GvHD to a degree similar to CsA. Unlike CsA and OKT3, IVIG were not associated with inhibition of human T-cell proliferation in mice. Instead, IVIG significantly inhibited the secretion of human IL-17, IL-2, IFN-γ and IL-15 suggesting that IVIG prevented GvHD by immunomodulation. Furthermore, the pattern of modification of the human cytokine storm differed from that observed with CsA and OKT3. Finally, in a humanized mouse model of immune reconstitution, in which NSG mice were engrafted with human CD34(+) stem cells, IVIG transiently inhibited B-cell reconstitution, whereas peripheral T-cell reconstitution and thymopoiesis were unaffected. Together these in vivo data raise debate related to the appropriateness of IVIG in GvHD prophylaxis. In addition, this model provides an opportunity to further elucidate the precise mechanism(s) by which IVIG inhibit GvHD.