REPLY
Are Protected Environments Necessary for Recipients of Bone Marrow Transplants?
Jacob M. Rowe, MD, and
Hillard M. Lazarus, MD
1 July 1994 | Volume 121 Issue 1 | Page 76
IN RESPONSE:
We appreciate the opportunity to review the issue of protective environments for recipients of bone marrow transplantation. The precise need for protection from airborne organisms is controversial. Most patients are treated in single rooms with some form of protective isolation, which varies from handwashing before entering the room to the use of laminar air flow along with sterile food and gut and skin decontamination. The choice of protective environment is affected by the type of transplantation, the duration of neutropenia and immunosuppression, and the institutional prevalence of Aspergillus species [1]. Concern about infection with Aspergillus is the most important consideration in determining the type of isolation.
Early studies compared patients treated in laminar air-flow rooms and given prophylactic "decontamination" antibiotics with patients treated without a specialized air-handling system and found in the former patients a lower incidence of infection [2], as well as a lower incidence and delayed onset of acute graft-versus-host disease (GVHD) [3]. However, autologous and allogeneic transplantations have also been done in standard single rooms without a specialized air filtration system and without the need for continuous hospitalization. In such cases, rates of infection, GVHD, and overall mortality were within the expected range [4].
For all of these reasons, the following are recommended by the Eastern Cooperative Oncology Group:
1. Uncomplicated patients receiving autologous bone marrow transplantation can be safely treated in single rooms with strict handwashing as the only protective measure, assuming a rigorous approach to infection control is in place.
2. Patients receiving allogeneic bone marrow transplantation should be treated with an air filtration system (either a high-efficiency particulate air or laminar air-flow system) capable of excluding Aspergillus species. This approach should also be required for the patient receiving autologous bone marrow transplantation in the proximity of construction activity or a known outbreak of Aspergillus infection.
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Author and Article Information
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University of Rochester Medical Center; Rochester, NY 14642
University Hospitals of Cleveland; Cleveland, OH 44106
1. Sherertz RJ, Belani A, Kramer BS, Elfenbein GJ, Weiner RS, Sullivan ML, et al. Impact of air filtration on nosocomial aspergillus infections: unique risk of bone marrow transplant recipients. Am J Med. 1987; 83:709-18.
2. Bucker CD, Clift RA, Sanders JE, Meyers JD, Counts GW, Farewell VT, et al. Protective environment for marrow transplant recipients. A prospective study. Ann Intern Med. 1978; 89:893-901.
3. Storb R, Prentice RL, Buckner CD, Clift RA, Appelbaum F, Deeg J, et al. Graft-versus-host disease and survival in patients with aplastic anemia in patients treated by marrow grafts by HLA identical siblings. Beneficial effects of a protective environment. N Engl J Med. 1983; 308:302-7.
4. Russell JA, Poon MC, Jones AR, Woodman RC, Ruether BA. Allogeneic bone marrow transplantation without protective isolation in adults with malignant disease. Lancet. 1992; 339:38-40.
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