Centers for Disease Control and Prevention, Infectious Disease Society of America, & American Society of Blood and Marrow Transplantation. (2000). Guidelines for preventing opportunistic infections among hematopoietic stem cell transplant recipients. MMWR Recommendations and Reports, 49, 1–125, CE1–CE7.

To summarize the current data and provide comprehensive evidence-based recommendations for the prevention of opportunistic infections in adult and pediatric hematopoietic stem cell transplant (HSCT) recipients.

This was an evidence-based guideline. Evidence was reviewed by multiple professional groups and panels under Centers for Disease Control and Prevention (CDC) guidance.

• Patients were undergoing multiple phases of care.
• The study has clinical applicability for pediatrics.

No results were stated. 

This guideline identified infection risks during preengraftment, postengraftment (30–100 days), and late phase (>100 days) for HSCT recipients, associated with immune system defects, device risks, and incidence of specific viral, bacterial, fungal, and mold infectious risks; very specific prevention strategies per treatment phase for allogeneic and autologous HSCT, as well as for both adult and pediatric patients; information on dosage and timing of prophylactic medication, vaccinations, and other specific medical interventions; recommendations for vaccination and behaviors of household members and close contacts; and recommendations for healthcare workers and environmental infection control practices in transplant centers. It identified phase-specific and life-long behavioral prevention, including food preparation, avoiding specific exposures, pet safety, sexual safety, travel safety, water safety, occupational exposures, and general areas to avoid for patients. 

Evidence Rating System

A - Strong evidence and substantial clinical benefit (strongly recommended)
B - Strong or moderate evidence, but only limited clinical benefit (generally recommended)
C - Insufficient evidence for efficacy or efficacy does not outweigh possible adverse consequences (optional)
D - Moderate evidence against efficacy or for adverse outcome (generally not recommended)
E- Strong evidence against (never recommended)

I - Evidence from at least one well-executed randomized trial
II - Evidence from at least one well-designed clinical trial without randomization, cohort, or case controlled, time series
III - Evidence from opinions of respected authorities

Recommendations With at Least Optional Recommendation Level

Vaccinations

• Pneumococcal vaccination (23-valent) at 12 to 24 months post HSCT in adults and children 2 years and older (BII)
• Haemophilus influenzae type b (HiB) vaccination at 12, 14, and 24 months post HSCT (BII)
• Diptheria vaccination at 14 and 24 months post HSCT if older than 7 years (BII)
• Pertussis revaccination 25 months post HSCT if not immunosuppressed
• Annual influenza vaccination for household contacts, health providers (AI), and recipients (BII)
• Polio: Not recommended for adults.  Others should be vaccinated according to guidelines with inactive. (BII)
• Hepatitis A: Recommended if patients have chronic liver disease or travel to endemic countries and for children older than 24 months living in endemic areas (BII)
• Measles, mumps, and rubella (MMR): recommended for patients older than 12 months, 24 months post HSCT, if they are not immunocompromised (AI)
• Varicella: Candidate testing and history.  Vaccinate household members and health providers who are seronegative four to six weeks before HSCT. (AIII).  Only vaccinate patients if they are seronegative and exposed.
• Live attenuated vaccinations should not be used (EIII).

Other Recommendations

• Candidate testing and sexual partner testing for herpes simplex virus (HSV) (AII)
• Antiviral prophylaxis in seropositive patients (AI)
• Use of condoms in nonmonogamous or seropositive partner relationships (applies to cytomegalovirus [CMV] and HSV prevention (BIII)
• Avoid sharing cups and eating utensils. (BIII)
• Frequent hand washing (AIII)
• Avoid contact with potentially infected respiratory secretions or saliva. (AIII)
• Candidate and partner testing for CMV antibodies (AIII)
• Antiviral prophylaxis for seropositive patients (AI)
• Avoid exposure to dust and construction areas. (AIII)
• Trimethoprim-sulfamethasaxole (TMP-SMZ) prophylaxis for pneumocystis in allogeneic patients and consideration for autologous patients (BIII)
• Antifungal prophylaxis in allogeneic patients (AI)
• Allogeneic patients should avoid contact with outhouses and skin exposure to soil or human fecal contaminants. (BIII)
• Dental evaluation and treatment before conditioning (AIII)

Food-Related

• No raw or undercooked meat or eggs should be eaten for three months post HSCT, and all immunosuppressive drugs should be stopped. (AIII)
• Antimicrobial diet restrictions are included but have no evidence base beyond expert opinion.  These include safe food handling in general, avoiding fruit with rough textures, washing fresh fruits and vegetables well, avoiding fresh-squeezed fruit and vegetable juices, raw honey, deli meats, raw uncooked grain products, unroasted raw nuts or nuts in the shell, and unpasteurized beer (such as homemade).

Environmental

• There is no strong evidence, but most researchers recommend that plants and fresh or dried flowers should not be allowed in patient rooms during hospitalization.
• For children, play areas should be disinfected at least weekly. (BIII)
• No rectal thermometers, enemas, suppositories, or rectal examinations should be used or performed while the patient is immunosuppressed. (DIII)
• Menstruating women should avoid using tampons.
• Patients should avoid exposure to crowded areas while in the hospital.  Wearing a mask when off the unit is not recommended as necessary.
• High-efficiency particulate absorption (HEPA) filtration, positive air pressure rooms, and at least 12 air exchanges/hour are recommended for allogeneic patients (BIII).  This need is not established for autologous patients, and the value of laminar air flow is not established.
• No hospital visitors with respiratory or other infectious symptoms should visit. (AIII)

Pet Safety

• Avoid exposure to animals for the first six months and during immunosuppression (no rating).
• Avoid cleaning litter boxes, cages, or feces; if necessary, wear gloves.
• Frequent hand washing after touching pets or contact with feces is recommended.

This summary is not intended to provide all content from these guidelines.  The reader should refer to the original document for complete information.

Some recommendations are not supported by research data but are provided as best current knowledge in the area.

This was a comprehensive resource, with extensive specific recommendations and identification of the evidence classification of each recommendation.  This is an excellent reference for individuals working with HSCT recipients.