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Protective isolation

Evidence-based approaches

Rationale

Protective isolation is used to minimize the exposure to infectious agents of patients who are particularly at risk of infection. Although the evidence that protective isolation successfully reduces the incidence of infection is limited (Wigglesworth 2003), probably because many infections are endogenous (i.e. caused by the patient’s own bacterial flora), it is used to reduce the risk of exogenous infection (cross-infection from other people or the environment) in groups who have greatly impaired immune systems (Fraise and Bradley 2009), such as autologous and allogenic bone marrow transplant patients. Patients who have compromised immune systems often have greatly reduced numbers of a type of white blood cell called a neutrophil; this condition is known as neutropenia and those people suffering from it are described as neutropenic. Neutropenia is graded from mild to severe according to how few neutrophils are in the circulation and hence how much the risk of infection is raised.

Single-occupancy rooms used for protective isolation should have neutral or positive air pressure with respect to the surrounding area. High-efficiency particulate air (HEPA) filtration of the air in the room may reduce exposure to airborne pathogens, particularly fungal spores. A room with positive pressure ventilation must not be used for any patient infected or colonized with an organism that may be spread through an airborne route; in this circumstance if an immunocompromised patient has such an organism, they should be nursed in a room with neutral air pressure or with a positive pressure lobby.

Principles of care

Diet for the immunocompromised patient

Educate the patient in the importance of good food hygiene in reducing their exposure to potential pathogens; they should choose only cooked food from the hospital menu and avoid raw fruit, salads and uncooked vegetables. Stress the importance of good hand hygiene before eating or drinking. Uncooked foods are often heavily colonized by micro-organisms, particularly Gram-negative bacteria (Moody et al. 2006); potential pathogens on the hands may be inadvertently consumed while eating or drinking.

Educate the patient’s family in the importance of good food hygiene, particularly good hand hygiene, and advise that any food brought in for the patient should be in undamaged, sealed tins and packets obtained from well-known, reliable firms and within the expiry date. Correctly processed and packaged foods are more likely to be of an acceptable food hygiene standard.

Provide the patient with filtered water or sealed cartons of fruit juice (not fresh) to drink (Vonberg et al. 2005). Do not supply bottled water. Tap water may occasionally be contaminated with potential pathogens; long-life fruit juice has been pasteurized to remove micro-organisms; bottled water very often contains more micro-organisms than tap water.

Discharging the neutropenic patient

Crowded areas, for example shops, cinemas, pubs and discos, should be avoided. Although the patient’s white cell count is usually high enough for discharge, the patient remains immunocompromised for some time (Calandra 2000).

Pets should not be allowed to lick the patient, and new pets should not be obtained. Pets are known carriers of infection (Lefebvre et al. 2006).

Certain foods, for example take-away meals, soft cheese and pâté, should continue to be avoided. These foodstuffs are more likely to be contaminated with potential pathogens (Gillespie et al. 2005).

Salads and fruit should be washed carefully, dried and, if possible, peeled, to remove as many pathogens as possible (Moody et al. 2006).

Any signs or symptoms of infection should be reported immediately to the patient’s general practitioner or to the discharging hospital. Any infection may have serious consequences if left untreated.

Procedure guideline 3.14 Protective isolation: preparing the room

Essential equipment

Single-occupancy room

Patient equipment

Personal protective equipment