key: cord-0825644-pcg4u0bw authors: Lands, Larry C. title: Infection prevention and control in cystic fibrosis: One size fits all? date: 2020-06-20 journal: Paediatr Respir Rev DOI: 10.1016/j.prrv.2020.06.011 sha: 6a94c667c311dfdbe20b726f51995fd4430f2c27 doc_id: 825644 cord_uid: pcg4u0bw nan Infection control is a core part of patient care in Cystic Fibrosis (CF). In this time of the COVID-19 pandemic, much of the world is now dealing with many of the infection control issues that our CF patients and families deal with on a daily basis. In many ways, our patients and families are better prepared than most, and the adaptation has been less abrupt. Moreover, our COVID-19 experiences are somewhat re-enforcing our CF infection control approaches. We now have a pro-con debate about how to achieve the goals of protection without unduly encumbering our patients and families, CF teams, and healthcare facilities. You will see that there is much commonality between the two, and I very much appreciate the careful literature review and opinions provided [1, 2] . You, the reader, will need to see what works best for you and your clinic. Here, I will share some personal reflections that I hope will give yet another way for you to compare. I must point out that my hospital is in a city with one of the world's highest rates of COVID-19 infection, yet children are rarely symptomatic. Overall, it is generally simpler to consider all CF patients as a potential source of communicable microbes, as suggested in the paper by Haggie and Fitzgerald [1] . Certain microbes, particularly Burholderia cepacia, need respect and extra precautions (e.g. separate clinics) that have proven their worthiness. Methicillin-resistant Staphylococcus aureus is not a particularly prevalent organism in Canada, but this does not mean that clinics should be lax. In our clinic, we do not see these patients in a separate clinic, but they are the last to be seen in clinic. We have a similar approach to patients with Mycobacterium abscessus. There are three situations that need to be considered: the home environment, the in-patient situation, and the outpatient clinic and pulmonary function laboratory. In the home environment, the principal threat is contamination of nebulization equipment and airway clearance devices. The proper cleaning, drying, and timely replacement of older or cracked equipment is key. Most clinics have a team member who oversees this, with some clinics requiring patients to bring in their equipment for assessment. This surveillance is a vital and underappreciated task. However, it is important that the patient and family become partners in this activity, as emphasised in the paper by Smyth, Smith and Rowbotham [2] . There is still limited data on the best approach for hospitalized patients and patients in clinic. As with much of our care, we must rely on our best estimates and shared experiences. Nosocomial infection while hospitalized is unfortunately not infrequent and requires continual vigilance. If possible, CF patients should not be on the same ward and should not share nursing personnel [3, 4] . Ideally, nursing personnel should not be simultaneously caring for patients with common respiratory viral infections. We do not place our hospitalized patients in negative pressure hospital rooms, but when available, double doored rooms are used. For in-patients, most clinics have adopted a droplet protection approach, with patients hospitalized in single patient rooms, and staff wearing gowns, masks, and gloves. We have organized to move exercise equipment into the patient's room to promote physical activity during hospitalization while avoiding the need to go to the common physiotherapy gymnasium. Gloves often provide a false sense of security. Good handwashing on entrance and leaving the patient's room are key. Ready access to sinks or alcohol-based cleansers is key. Our hospital actually has deputized ward personnel to act as undercover police and publish regular statistics on handwashing. I have advised families to not be shy to ask if people have washed their hands before coming in the room. Gowns are important if there is a risk of droplet contact, e.g. participating in airway clearance or performing a physical exam. Masks again would seem to be most important in a situation of potential droplet contact. Interestingly, neither of the reviews discussed cleaning of stethoscopes. Perhaps it my work with lung transplant recipients, but I think a wipe down of the stethoscope with a 70% isopropyl alcohol wipe after examining the patient is reasonable, and is recommended by the US Centers for Disease Control and Prevention [5] . Wipes containing materials other than isopropyl alcohol can cause chemical breakdown of the materials in your stethoscope. The biggest challenge is the outpatient clinic. With COVID-19, patients must feel secure enough to come to the facility. As mentioned in the debate, most clinics ask patients to wear a mask upon entering the facility. With COVID-19, all hospital attendees, CF or otherwise and the accompanying caregiver, are doing this, so it has become a routine. Mask wearing can decrease droplet spread [6] . If it is feasible, patients should be able to go directly into the examining room and not use the waiting room. Waiting room alternatives include a call system while patients wander about nearby, much like restaurants do. Those with clinics in winter climes may not be able to readily do this. If waiting rooms are required, social distancing should be practiced, and wait times minimized. Again, social distancing has become part of daily life. Patients use a single examination room, with team members coming to them. Rooms are wiped down with a sanitary wipe between patients. As our facility was undergoing new construction, we pushed to have most of our examination rooms, and the adjacent pulmonary function testing rooms under negative pressure, with air turnover rates between 8 and 11 per hour. Clinic personnel are advised to wear masks, gowns, and gloves. I am always unsure if staff wear masks to protect themselves or the patient, but in our present COVID-19 situation, it has become routine (and visors currently). Writing a note or typing on the computer with gloves can be difficult, so at least practice good hand hygiene. Those of us in Pediatrics learned early on in residency to practice good hand hygiene as a self-protective activity. Some clinics use portable spirometry and move this from patient to patient. This needs adequate cleaning and changing of filters between patients. If you are using a pulmonary function lab, several precautions need to be taken. If the testing room does not use negative pressure or a HEPA filter, then there should be time given between patients, typically 30 minutes. We previously changed the flow sensor and re-calibrated between patients even though we used a disposable filter. We have now opted to simply use a disposable filter capable of filtering 99% and change this, thus eliminating the need for re-calibration and the extra time required for this. We do not consider spirometry, oscillometry, lung clearance, or plethysmography as aerosol generating, although some respiratory societies do consider these as aerosol generating [7] . If sputum induction is being done, this is considered aerosol generating and even with a negative pressure room, we leave 45 minutes before using the room again. Before COVID, our technicians would wear gloves, gowns, changing gloves and gowns between patients. Technicians wipe the equipment and room surfaces between patients. Our respiratory technicians are responsible for collecting the sputum or throat culture for those old enough to do spirometry. While our CF patients can pick up organisms in a variety of environments, it is important that we, as healthcare providers, minimize the risk when patients come to our facilities and in their own homes. A fact-based approach is in everyone's interest. More research would be welcomed so that we do these precautions in a safe but cost-effective manner. Infection prevention and control in cystic fibrosis: One size fits all? The argument in favour Infection prevention and control in cystic fibrosis: One size fits all? The argument against Infection prevention and control guideline for cystic fibrosis: 2013 update Infection prevention and control in cystic fibrosis: a systematic review of interventions The Healthcare Infection Control Practices Advisory Committee (HICPAC) Transmission of communicable respiratory infections and facemask ERS Statement on lung function during COVID-19