Table 183Summary of included studies

StudyIntervention/ComparisonPopulationOutcomesComments
OUTPATIENT SETTINGS
Cohorting into different pathogens by clinic times

USA
RCT
Intervention: Cohort segregation
  • Segregated clinics free of patients with PA held on a separate day in the same clinic space used for mixed clinics;
  • Large clinics and waiting rooms, and hygienic precautions.
Comparison: No cohort segregation
  • Mixed clinics that included PA positive patients;
  • Large clinics and waiting rooms, and hygienic precautions.
Infants and children with cystic fibrosis.
N=39
intervention group: n=21
comparison group: n=18
Age: not reported
Incidence of PA infection over 10 yearsStudy dates 1996–2005

Australia
Retrospective before and after study
Intervention: Cohort segregation by age.
  • Outpatients clinics were designated by colour as “red” (children 5 and under who were PA-free), “blue” (primary school age or children under 5 already colonised with PA) or “green” (secondary school age).
  • Additional infection measures (for example removal of toys from the waiting room and hand cleansing).
Comparison: No cohort segregation
  • One all age (0–18) clinic
  • Free mixing of patients in waiting area
Infants and children with cystic fibrosis.
N=Between 72 and 90 were seen in each year of the study
The results of 2837 sputum cultures were analysed for the study
Age: ≤5 years
Prevalence of culture results (MRSA, nonmucoid PA, mucoid PA)
Staff compliance
Segregation policy introduced in April and May 2003 and outcome data for 1999–2002 versus 2004–2007
The paper also mentions that all inpatients were treated in single rooms or in rooms shared with children without cystic fibrosis. However it is unclear if this policy started in 2003.
Cohorting into different pathogens by location

UK
Retrospective before and after study
Intervention: Cohort segregation.
  • Separate clinics for patients chronically infected with PA and uninfected patients.
  • Improved hygienic measures in a purpose-built cystic fibrosis centre
Comparison: No cohort segregation
  • Various management strategies over the years to reduce the prevalence of chronic PA, including regular microbiological monitoring
People with cystic fibrosis receiving paediatric care.
N=232 people 1990: n=966 patient months (mean age: 7.73) 2000: n=1803 patient months; (mean age: 9.42)
Incidence of PA infection Prevalence of chronic PA infection Prevalence of intermittent PA infectionPatients receiving full-time care at the Leeds Paediatric CF Centre. Separate clinics at the Leeds Regional CF Unit.
Intervention implemented in 1991, outcome data provided for 1990 and 2000.
Incidence reported narratively. Prevalence data calculated based on patient months
Combination strategies

USA
Retrospective before and after study
Intervention: Protective equipment and individual segregation
  • Contact precautions for all patients in the outpatient clinic, regardless of respiratory tract culture results: gowning and gloving and hand hygiene by all providers; requesting that all patients use hand gel and mask when entering the facility or when outside of the exam room
  • Abolishing the designated communal area for taking vital sign measurements and converting to exam rooms.
  • Re-enforcement of the “no-waiting” room policy (Immediate placement within the examination room)
  • Education of patients and families; cleaning rooms thoroughly.
Comparison: Incomplete use of protective equipment and incomplete individual separation
  • Any patient with respiratory tract cultures revealing a multi-resistant pathogen had a flag placed on the chart to indicate the need for contact precautions. However a consistent process for the use of this indicator was not systematic or routine.
  • Vital signs were performed in a common station in the hallway close to the exam rooms, without specific cleaning between patients.
  • “No-waiting” room policy
People with cystic fibrosis receiving paediatric care.
N= ranged from 126 to 177 during the study years.
Age range: 0 to 21.
Prevalence (% of patients cultured each quarter with positive tract cultures) of PA infections
Prevalence (% of patients cultured each quarter with positive tract cultures) of MRSA infections
Mean no. of respiratory tract cultures per quarter = 169
INPATIENT SETTINGS
Cohorting into different pathogens by location

USA
Retrospective before and after study
Intervention 1. Cohort segregation.
  • Cohorting of hospitalized patients with cystic fibrosis on the basis of B cepacia colonization status
Comparison 1: No cohort segregation
No details
People with cystic fibrosis.
N not reported
Age not reported.
Incidence of B cepacia complex infectionIntervention introduced in early 1990, incidence data for 1988, 1989, 1990 and 1991. We compare 1989 and 1991 (the closest pre-intervention full year and the closes post-intervention full year)

USA
Retrospective before and after study
Intervention: Incomplete cohort segregation
  • All patients with Pseudomonas cepacia recovered from sputum or throat culture were admitted to 1 floor of the hospital - other patients with cystic fibrosis were not admitted to this floor.
  • The patients on this ward were not permitted to visit other inpatient wards but were not isolated in any other way. They had free access to the elevators, hospital cafeteria, and other common areas. No special precautions were taken to totally avoid chance meetings of the 2 groups of patients in the radiology department, outpatient areas, pulmonary function laboratory, or other hospital areas.
  • Equipment in pulmonary function lab was sterilized or changed between patients. Handwashing was emphasised.
  • Masks or other isolation equipment were not used by patients or hospital personnel.
  • Summer camp facility was reserved for patients free of P. cepacia, another camp site was provided for colonized patients.
Comparison: No cohort segregation in hospital
  • Basic infection control procedures (no details)
  • No segregation in camp facility
People with cystic fibrosis receiving paediatric care admissions pre-segregation: n=453 admissions post-segregation: n=389
Age: not reported
Incidence of hospitalassociated colonisation of P cepaciaIntervention introduced in August 1983. Data on 1 year and 5 months before the intervention compared to 1 year and 5 months afterwards Serotyping
Individual segregation

UK
Survey. Questionnaire with both closed-ended and open-ended questions
Intervention: individual segregation.
  • Policy of segregation requiring all patients to remain in their individual rooms for the duration of their hospital stay
Comparison: Usual care
Children and young people with cystic fibrosis and their parents N= 192 parents, 101 people with cystic fibrosis.
Mean age of eligible participants: 13 (range 10 to 17)
Patient and carer satisfaction: % of parents and children who supported segregated treatmentViews were elicited in preparation for the process of implementing a formal policy of segregation
MIXED POPULATIONS (BOTH OUTPATIENT AND INPATIENT SETTINGS)
Cohorting into different pathogens

UK
Retrospective before and after study
Intervention 2. Complete cohort segregation.
  • Patients with Burkholderia species infection were cohorted into separate wards to non-Bcc infected patients and each inpatient has their own single room.
  • Patients with Burkholderia species infection have also continued to attend a different outpatient clinic.
  • Isolation policy for patients with B. species not yet implemented
Intervention 1: Incomplete cohort segregation.
  • Patients with Burkholderia species infection were admitted to inpatient beds on the opposite side of the corridor to non-Burkholderia species infected patients.
  • There was continued patient mixing within a day-room facility on the ward and within areas such as the radiology department.
  • Patients with Burkholderia species infection attended separate outpatient clinics to other cystic fibrosis patients.
Comparison 1. No infection control measures to prevent B cepacia complex cross-infection No details
Adults with cystic fibrosis.
N not reported.
Age not reported.
Incidence of Burkholderia species infectionIncomplete inpatient and complete outpatient A lot of graphic reporting, some numbers are mentioned, see below:
Intervention 1 versus comparison 1: Intervention 1 implemented in 1991, range of incidence of Burkholderia species infection for 1983–1990, incidence 1992.
Intervention 2 versus intervention 1: Intervention 2 implemented from November 1993 onwards.
Incidence 1992 and incidence “following complete cohort segregation”

Denmark
Retrospective before and after study
Intervention: Cohort segregation:
  • The cystic fibrosis centre was reconstructed, separating the wards and the outpatient clinic
  • Patients with PA in their sputum were separated from patients without PA in the wards, in the outpatient clinic, and during social events.
Comparison: No cohort segregation
  • The wards with inpatients receiving iv treatment were near the outpatient clinic visited by all cystic fibrosis patients
  • Cystic fibrosis patients were not segregated according to presence or absence of PA in their sputum
People with cystic fibrosis.
1974: n=107. Median age: 9.0
1995: n=256. Median age: 18.5
Incidence of intermittent PA infection
Incidence of chronic PA infection
Cohort segregation introduced in 1981. Incidence given for each year from 1974 and 1995, we compare 1980 and 1982.
and
Australia
Retrospective before and after study
Intervention: Cohort segregation
  • Cohorts: PA (negative, positive non-epidemic, epidemic PA (AES-1))
  • Separation of cohorts was maintained at outpatient visits and during hospital admissions.
  • Standard infection control measures were reinforced, and education seminars were arranged for staff and families.
Comparison: No cohort segregation.
  • No segregation based on PA.
  • Standard infection control measures, B cepacia complex and MRSA strict individual segregation
People with cystic fibrosis receiving paediatric care.
1999: n=325 Sputum producers: n=153
2002: n=291
Sputum producers: n=149
Age range: from <10 to ≥16 years, exact age range not reported.
Prevalence of AES-1 (PA epidemic strain)Cohort segregation in 2000, outcome data for 1999 and 2002

Denmark
Retrospective before and after study
Intervention 2: Cohort segregation (by multiply resistant PA strain)
  • Three groups: Patients with multiply resistant PA strain; cohort with normally sensitive strains of chronic PA infection; PA negative patients
  • Improved hygiene precautions
Intervention 1. Cohort segregation (by PA infection, but not multiply resistant PA strain)
  • Two cohorts, cohort with chronic PA infection separated from PA negative patients
  • Segregated from each other in different wards and seen on different days in the outpatient clinic.
People with cystic fibrosis.
N (range): 54 to 226 (between 1970 and 1987).
Subgroup of people with PA infection in 1983: n=119
Age: Not reported
Incidence of multiply resistant PA strain Prevalence of multiply resistant PA strainIntervention 2 (compared to intervention 1) was implemented in April 1983. Incidence and prevalence of multiply resistant PA is provided for Jan, Feb, Mar, Apr, May, June 1983

UK
Retrospective before and after study
Intervention 1: Incomplete cohort segregation.
  • Patients without chronic PA infection attended outpatient clinic appointments on a different day than other patients with cystic fibrosis.
  • Inpatients without chronic PA infection were housed on the same cystic fibrosis ward as patients with chronic PA infection, but in rooms with en-suite facilities, and were advised not to socialise with other patients on the ward. However there was still some social mixing between patients on the ward.
Comparison: No cohort segregation.
  • Purpose-built facilities: all inpatients had their own bedroom, although only 2 of 11 rooms had en-suite facilities.
  • Treatments with door closed
  • Practice of strict hygiene. Rooms are cleaned between patients, equipment not shared between patients, hand hygiene for staff.
People with cystic fibrosis who attend an adult centre.
1999: n= 216
2000: n=221
2001: n=228
Age not reported
Prevalence of chronic PA infection
Prevalence of transmissible PA infection
Prevalence of chronic infection with transmissible PA strain
Outpatient policy of segregation instituted in 2000. Outcome data provided for 1999, 2000, 2001, 2002 and 2003. We compare 1999 to 2001

UK
Retrospective Before and after study
Intervention. Cohort segregation.
  • Children with B cepacia were admitted to a separate ward
  • Children with B cepacia were moved to a different waiting area and given appointment times at the end of the clinic.
  • Recommendations to parents to avoid close physical contact outside the hospital
Comparison: no cohort segregation
  • No cohort segregation for children with B cepacia
  • Children with cystic fibrosis needing inpatient care were admitted to 1 ward where they had complete freedom to play together and socialise
  • Each child had an individual peak flow meter and nebuliser for use throughout the admission
  • Children colonised with PA had their chest physiotherapy separately from children without PA
Infants, children and young people with cystic fibrosis.
N=115.
Mean (range) age: 7.6 years (0.6 to 15.8 year)
Incidence of B cepacia infectionIntervention introduced in June 1992; number of cases given for each month of 1992., 114 at risk in Jan 1992
Individual segregation

UK
Survey
Intervention: Individual separation
Not mixing with others with cystic fibrosis
Comparison: no separation
Mixing with others with cystic fibrosis
Adults with cystic fibrosis.
N=94 respondents (184 invited to participate)
Mean (SD age: 27.2 (8.5) years
Patient satisfaction % of those who mixed with others who said that if they avoided others with cystic fibrosis, their quality of life would be: significantly or greatly affected / not sufferAll patients attending a clinic appointment/inpatients at the West Midlands Adult CF Centre were offered a questionnaire.
Questionnaires were posted to 8 patients colonized with the B cepacia complex who attended a separate clinic.
Combination of strategies

USA
Retrospective before and after study
Intervention 2: Individual segregation in addition to cohort segregation
  • Hospitalized non-colonized patients were prohibited from sharing rooms, then this policy was expanded so that all patients with cystic fibrosis irrespective of B cepacia colonization were in separate rooms.
  • Separate waiting rooms were established for outpatients.
Intervention 1. Cohort segregation.
  • Cohorting of hospitalized patients with cystic fibrosis on the basis of B cepacia colonization status
Intervention 3: Cohort segregation combined with individual segregation and with protective equipment.
  • Cohorting of hospitalized patients on the basis of B cepacia colonization status.
  • Furthermore inpatients colonized with B cepacia were placed in contact isolation and were required to wear mask and gloves when out of their rooms.
  • In the outpatient setting, patients infected with B cepacia were restricted to separate clinic days during which no non-colonized patients were seen.
  • Patients were required to wear masks while in the waiting room.
  • A hospital-wide educational program regarding infection control measures was introduced
  • Particular attention was given to disinfection of clinic rooms and equipment
Comparison 3: Usual care No details
People with cystic fibrosis.
N not reported.
Age not reported.
Annual incidence of B cepacia complex infection.
Prevalence of B cepacia complex infection
Intervention 2 versus intervention 1: Progressive isolation measures in mid-1996, 1997, 1998, and prevalence data for 1992 and 1999
Intervention 3 versus comparison 3: Measures introduced in early 1997, annual incidence given for 1996, 1997 and “since time of implementation”

UK
Retrospective before and after study
  • Intervention 3. Cohort segregation combined with individual segregation.
  • A policy of isolation was introduced for patients infected with all Burkholderia species. This policy involves patients not having any contact with other patients, either at an inpatient or outpatient level.
  • Patients being admitted to single rooms during admissions and attending outpatient appointments and being immediately isolated within their own clinic room.
  • Patients with Burkholderia species infection were cohorted into separate wards to non-Bcc infected patients and attended a different outpatient clinic.
Intervention 2. Cohort segregation.
  • Patients with Burkholderia species infection were cohorted into separate wards to non-Bcc infected patients and each inpatient had their own single room.
  • Patients with Burkholderia species infection attended a different outpatient clinic.
  • Isolation policy for patients with Burkholderia species not yet implemented
Adults with cystic fibrosis.
N not reported.
Age not reported.
Prevalence of Burkholderia species
Prevalence of transmissible B cepacia complex infection.
Policy of isolation in 2000 Peak prevalence of Burkholderia species infection 1994 and prevalence 2005.
Prevalence of B cepacia complex transmissible infections for 1993/94 and for 2005.

Australia
Survey
Intervention: Combination of cohort and individual segregation.
  • Cohort segregation was based on five separate groups: PA positive; epidemic strain PA; B cepacia; MRSA; and PA negative.
  • Inpatients were nursed in separate sections and attended physiotherapy sessions at different times.
  • Children infected with epidemic strain PA, MRSA or BC were isolated from each other and all other patients
  • Those within the other groups were allowed to mix within their cohort groups.
Comparison: Usual care
People with cystic fibrosis receiving paediatric care and their parents N= 190 questionnaires were completed (291 people were sent the questionnaire)
114 parents alone
75 parents completed the questionnaire together with a person with cystic fibrosis aged >=12 years
1 questionnaire completed by child only.
Mean age: unclear
Patient and carer satisfaction: Children’s and parents’ overall response to segregation measures: positive / negative / unsureSurvey was conducted 2 years after the introduction of the intervention.
Royal Children’s Hospital, Melbourne, not clear if both inpatient and outpatient

PA: P aeruginosa; B cepacia: B cepacia; MRSA: Meticillin-resistant S aureus

From: 11, Prevention of cross infection

Cover of Cystic Fibrosis
Cystic Fibrosis: Diagnosis and management.
NICE Guideline, No. 78.
National Guideline Alliance (UK).
Copyright © NICE 2017.

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