EIS Alert: Don’t put Transplant Patients in Negative Pressure Rooms

May 10th, 2016

By Gary Evans, AHC Media Senior Staff Writer

Medical detectives with the CDC’s Epidemic Intelligence Service (EIS) are warning infection preventionists and their colleagues not to place solid-organ transplant patients in negative pressure isolation rooms.

An investigation recently presented in Atlanta at the annual EIS conference has linked placement in a negative pressure isolation room to three mucormycosis fungal infections in heart and lung transplant recipients last year at an acute care hospital in Pennsylvania.

"At the time of investigation two of the three probable case patients were deceased,” says lead investigator and EIS officer Amber M. Vasquez, MD. “These were patients who were very ill, who had solid organ transplants and multiple medical problems, so I can’t tell you with certainty whether or not the infection contributed to their death.”

As infection preventionists are well aware, negative pressure systems pull air into the room and thus protect others from patients isolated for tuberculosis or airborne viruses like measles. The perfect storm in this situation was that there was ongoing construction at the unidentified hospital, meaning dust and molds released into the air would be pulled into the room via the negative pressure.

Positive pressure where air flows out to hallways is recommended for bone marrow transplant patients, but there is no specific recommendation to do so for solid organ transplants, Vasquez says.

“The current guidelines actually don’t recommend that solid organ transplant patients avoid negative pressure rooms,” she tells Hospital Infection Control & Prevention. “The likely reason that the patients were in that room was that it was a little bit larger of a room, but ultimately the guidelines don’t necessarily state that negative pressure rooms should be avoided for solid organs transplant patients. That’s why we are trying to disseminate this and recommend specifically avoiding negative pressure rooms for immunocompromised patients unless it is medically or clinically indicated.”

The EIS investigators were perhaps a bit generous in concluding that “the probable case-patients had no documented indication for negative-pressure isolation.” Indeed, it seems strongly counter-intuitive to place any non-infectious immunocompromised patient in room that is going to draw any floating threat toward them. However, since the CDC followed standard procedures and did not identify the hospital, it is not known whether there was an airflow engineering problem or clinicians were simply unaware that the room was under negative pressure.

For more on this story see the June 2016 issue of Hospital Infection Control & Prevention.