Assoc. Prof. Dr. Assoc. Prof. Dr. AkeauAkeau UnahalekhakaUnahalekhakaFaculty of NursingFaculty of Nursing
Chiang Mai UniversityChiang Mai University
Prevention of Prevention of NosocomialNosocomial Infection Infection in the in the ImmunocompromisedImmunocompromised
PatientsPatients
22
ImmunocompromisedImmunocompromised PatientsPatients
CancerCancerAIDSAIDSNeoplasticNeoplastic disease : disease : leukopenialeukopeniaOrgan transplant recipientsOrgan transplant recipientsUse of corticosteroidsUse of corticosteroidsImpaired cellular immune responseImpaired cellular immune response
33
Risk Factors for Infection Risk Factors for Infection
AgeAgeMalnutritionMalnutritionInvasive procedureInvasive procedureAntibiotic therapyAntibiotic therapyImmunocompromiseImmunocompromiseImmunosuppressionImmunosuppressionPresence of colonizing organismsPresence of colonizing organismsSkin and mucous membrane integritySkin and mucous membrane integrity
Chain of InfectionChain of Infection
Portal of entry
Mode of transmission
Host
Infectious agent
Reservoir
Portal of exit
Causative AgentsCausative Agents
BacteriaBacteriaVirusesVirusesFungiFungiProtozoaProtozoaHelminthsHelminthsPrionsPrions
ReservoirReservoir
Definition:Definition:place in which an infectious agent place in which an infectious agent can survive but may or may not can survive but may or may not multiplymultiply
Common reservoirsCommon reservoirshumanshumansanimalsanimalsequipment/equipment/fomitesfomites
Human ReservoirsHuman Reservoirs
Persons with acute Persons with acute or or subclinicalsubclinical illnessillness
CarriersCarriersduring incubationduring incubationconvalescent carriersconvalescent carrierschronic carrierschronic carriersintermittent carriersintermittent carriers
Portal of exitPortal of exit
The path by which an The path by which an infectious agent infectious agent leaves the reservoirleaves the reservoir
respiratory tractrespiratory tractGU tractGU tractGI tractGI tractskin/mucous membraneskin/mucous membranebloodbloodtransplacentaltransplacental
Mode of Transmission of NIMode of Transmission of NIThe mechanism for transfer of anThe mechanism for transfer of aninfectious agent from a reservoirinfectious agent from a reservoirto a susceptible hostto a susceptible host
Contact transmissionContact transmissionDirect contactDirect contactIndirect contactIndirect contactDroplet spreadDroplet spread
Common vehicleCommon vehicleAirborne transmissionAirborne transmissionVector borne transmissionVector borne transmission
Contact transmissionContact transmission
Direct contact Direct contact : person: person--toto--person spread, actual person spread, actual
physical contactphysical contact
Indirect contactIndirect contactcontact with contaminated contact with contaminated
intermediate objectintermediate object
Droplet transmissionDroplet transmission
LLarge droplets are generated by an arge droplets are generated by an infected or colonized person during infected or colonized person during coughing, sneezing, talking, suctioning, coughing, sneezing, talking, suctioning, etc.etc.Droplets propelled a short distance Droplets propelled a short distance
< 3 feet< 3 feet……the the ““spit spacespit space””
Droplets deposited on a susceptible Droplets deposited on a susceptible hosthost’’s eyes, nasal mucosa or mouths eyes, nasal mucosa or mouth
Airborne transmissionAirborne transmission
Droplet nuclei, dust particles or Droplet nuclei, dust particles or skin skin squamessquames containing containing microorganisms are transmitted microorganisms are transmitted to a susceptible host by air to a susceptible host by air currentscurrents
Common Vehicle transmissionCommon Vehicle transmission
Microorganisms are transmitted to susceptible hosts from common items, e.g.
foodwatermedicationsdevices/equipment
VectorVector--borne transmissionborne transmission
Transfer of microorganisms by Transfer of microorganisms by insects, flies, rats, or other insects, flies, rats, or other verminvermin
uncommon mode of transmission uncommon mode of transmission in hospitals in hospitals
Portal of entryPortal of entry
The path by which an infectious agent The path by which an infectious agent enters the susceptible hostenters the susceptible host•• Respiratory tractRespiratory tract•• GU tractGU tract•• GI tractGI tract•• Skin/mucous membraneSkin/mucous membrane•• ParenteralParenteral•• TransplacentalTransplacental
Susceptible HostSusceptible Host
A person lacking effective A person lacking effective resistance to a particular resistance to a particular pathogenic organismpathogenic organism
1717
Mechanism of TransmissionMechanism of Transmission
AgentAgent HostHostEnvironmentEnvironment
Mode of Mode of TransmissionTransmission
1818
AgentAgent
EndogenousEndogenousExogenousExogenous
FoodFoodAirborneAirborneEnvironmentEnvironmentWaterWaterPersonnelPersonnel
CommensalCommensalOpportunisticOpportunistic
1919
Causes of Infection in Patients with Causes of Infection in Patients with CancerCancer
FactorFactor Type of InfectionType of Infection
MalignancyMalignancyAcute leukemiaAcute leukemia Bacterial, Bacterial, fungal,viralfungal,viralMultiple Multiple myelomamyeloma S.pneumoniaeS.pneumoniae
H.influenzaeH.influenzaeHodgkinHodgkin’’s diseases disease Viral, fungalViral, fungal
2020
Causes of Infection in Patients with Causes of Infection in Patients with CancerCancer
FactorFactor Type of InfectionType of Infection
TreatmentTreatmentChemotherapyChemotherapy Bacterial, fungal, viralBacterial, fungal, viral
gram gram ––veve colonizationcolonizationRadiationRadiation Altered skin integrity Altered skin integrity CorticosteroidsCorticosteroids ImmunosuppressionImmunosuppressionBone marrow Bone marrow Bacterial, fungal, viralBacterial, fungal, viral
transplantation transplantation PneumocystisPneumocystis cariniicarinii
2121
Most Frequent Bacterial Causes Most Frequent Bacterial Causes of Infections in Patients with Cancerof Infections in Patients with Cancer
Gram positiveGram positiveCorynebacteriumCorynebacterium sppspp..EnterococcusEnterococcus fecalisfecalisStaphylococcus Staphylococcus aureusaureusStaphStaph. . CoagulaseCoagulase--negativenegativeStreptococcus Streptococcus pneumoniaepneumoniaeStreptococcus Streptococcus pyogenespyogenes
Streptococcus Streptococcus viridansviridans
Gram negativeGram negativeEnterobacterEnterobacter sppspp..Escherichia coliEscherichia coliHaemophilusHaemophilus influenzaeinfluenzaeKlebsiellaKlebsiella sppspp..Proteus Proteus sppspp..Pseudomonas Pseudomonas aeruginosaaeruginosa
Salmonella Salmonella sppspp..
2222
NosocomialNosocomial Infection SitesInfection Sites
Primary bloodstream infectionPrimary bloodstream infectionRespiratory tract infectionRespiratory tract infectionUrinary tract infectionUrinary tract infectionSurgical site infectionSurgical site infectionGastrointestinal tract infectionGastrointestinal tract infectionPyrexia cause of unknown originPyrexia cause of unknown origin
Infection Control ProgramInfection Control Program
NI SurveillanceNI Surveillance
Isolation PrecautionsIsolation Precautions
Disinfection & SterilizationDisinfection & Sterilization
Employee Health Employee Health
Patient Care PracticePatient Care Practice
Microbiological ServicesMicrobiological Services
Education and Training Education and Training
Environmental ControlEnvironmental Control
Community CoordinationCommunity Coordination
ResearchResearch
Prevention of Prevention of NosocomialNosocomial Infections Infections in the in the ImmunocompromisedImmunocompromised patientspatients
Assess risk of infection of patientsAssess risk of infection of patientsSurveillanceSurveillanceHand hygieneHand hygieneEnvironmental controlEnvironmental controlEducation of patients and relativesEducation of patients and relativesPatient hygienePatient hygieneEmployee healthEmployee health
SurveillanceSurveillance
The The systematicsystematic,, activeactive,, ongoingongoing
observation of the occurrence and observation of the occurrence and distribution of NI within patients and of distribution of NI within patients and of the events or conditions that increase the the events or conditions that increase the risk of NI occurrencerisk of NI occurrence
PurposePurposess ofof SurveillanceSurveillance
Provide data that will guide effortsProvide data that will guide effortsto reduce nosocomial infection rateto reduce nosocomial infection rate
Assess quality of careAssess quality of care
Usefulness of Surveillance systemUsefulness of Surveillance system
1. D1. Detect NI in a timely wayetect NI in a timely way2. P2. Provide estimates of the magnitude of morbidity rovide estimates of the magnitude of morbidity
and mortalityand mortality3. 3. IdentiIdentifyfy factors associated with the eventfactors associated with the event4. D4. Detect trends including outbreaks etect trends including outbreaks 4. A4. Assessment effect of prevention program ssessment effect of prevention program 5. L5. Lead to improved behavioral practicesead to improved behavioral practices6. S6. Stimulate research intended to preventtimulate research intended to prevent NINI
Define the population and typeDefine the population and type((ss)) of infections of infections to be studiedto be studiedCollect data using systematic methodsCollect data using systematic methodsConsolidate data to aid in evaluationConsolidate data to aid in evaluationAnalyze and interpret dataAnalyze and interpret dataReport results to those who can bring about changeReport results to those who can bring about change
Action
Essential ComponentsEssential Componentsof a Surveillance Programof a Surveillance Program
IgnacIgnac SemmelweisSemmelweis18181818--18651865
18401840’’s: General Hospital s: General Hospital of Viennaof ViennaDivided into two clinics, Divided into two clinics, alternating admissions alternating admissions every 24 hours:every 24 hours:
First Clinic: Doctors and First Clinic: Doctors and medical studentsmedical studentsSecond Clinic: MidwivesSecond Clinic: Midwives 0
2468
10121416
Mat
erna
l mor
talit
y, 1
842
First Clinic SecondClinic
The Intervention:The Intervention:Hand scrub with chlorinated lime Hand scrub with chlorinated lime
solutionsolution
Hand hygiene basin at the LyingHand hygiene basin at the Lying--In WomenIn Women’’s Hospital in Vienna, 1847.s Hospital in Vienna, 1847.
Hand Hygiene :Not a New ConceptHand Hygiene :Not a New ConceptMaternal Mortality due to Postpartum Infection
General Hospital, Vienna, Austria, 1841-1850
0
2
4
6
8
10
12
14
16
18
1841 1842 1843 1844 1845 1946 1847 1848 1849 1850
Mat
erna
l Mor
talit
y (%
)
MDs Midwives
Semmelweis’ Hand
Hygiene Intervention
Hand antisepsis reduces the frequency of Hand antisepsis reduces the frequency of patient infections patient infections
Adapted from: Hosp Epidemiol Infect Control, 2nd Edition, 1999.
Microorganism on Microorganism on HandsHands
Transient floraTransient floraResident floraResident flora
DefinitionsDefinitionsHand hygieneHand hygiene
Performing Performing handwashinghandwashing, antiseptic , antiseptic handwashhandwash,, alcoholalcohol--based based handrubhandrub, surgical , surgical hand hygiene/antisepsishand hygiene/antisepsis
HandwashingHandwashingWashing hands with plain soap and waterWashing hands with plain soap and water
Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.
Hand decontamination levelsHand decontamination levels
•• Normal Normal handwashinghandwashing
•• Hygienic antisepsis Hygienic antisepsis
•• Surgical antisepsisSurgical antisepsis
Normal Normal handwashinghandwashing
Objective :Objective :
Remove dirt and transient flora Remove dirt and transient flora contaminating skin of medicalcontaminating skin of medical--staff staff hands as a result of contact with hands as a result of contact with infected or colonized patients and/orinfected or colonized patients and/orcontaminated environmental objectscontaminated environmental objects
Hygienic antisepsis of handsHygienic antisepsis of hands(Hygienic (Hygienic handwashinghandwashing))
Objective:Objective:Remove or kill transient micro flora on hands.Remove or kill transient micro flora on hands.
IndicationsIndications::•• Before performing individual proceduresBefore performing individual procedures•• Before working with especially susceptible patients or Before working with especially susceptible patients or
neonatesneonates•• Before and after procedures involving wounds or cathetersBefore and after procedures involving wounds or catheters•• Before and after donning glovesBefore and after donning gloves•• After contact with excreta or objects containing blood or After contact with excreta or objects containing blood or
probably contaminated with microbesprobably contaminated with microbes
Surgical Hand HygieneSurgical Hand Hygiene(Surgical antisepsis)(Surgical antisepsis)
Objective:Objective:Remove or kill transient flora and reduce Remove or kill transient flora and reduce population of resistant flora.population of resistant flora.
Indications:Indications:Before all surgical operations.Before all surgical operations.
Surgical Hand HygieneSurgical Hand Hygiene
Use either an antimicrobial soap or alcoholUse either an antimicrobial soap or alcohol--based based handrubhandrubAntimicrobial soap: scrub hands and forearms for length Antimicrobial soap: scrub hands and forearms for length of time recommended by manufacturerof time recommended by manufacturerAlcoholAlcohol--based based handrubhandrub: follow manufacturer: follow manufacturer’’s s recommendations. Before applying, prerecommendations. Before applying, pre--wash hands wash hands and forearms with nonand forearms with non--antimicrobial soapantimicrobial soap
Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.
4343
Isolation PrecautionsIsolation Precautions
Standard precautionsStandard precautionsTransmissionTransmission--based precautionsbased precautions
•• Contact precautionsContact precautions•• Droplet precautionsDroplet precautions•• Airborne precautionsAirborne precautions
4444
Hospital PersonnelHospital Personnel
Hand hygiene with antiseptic soap or alcoholHand hygiene with antiseptic soap or alcohol--based hand rubbased hand rubDaily screening or selfDaily screening or self--screening for symptoms screening for symptoms of communicable diseaseof communicable diseaseVaccination of Vaccination of HCWsHCWs for influenza for influenza
4545
EnvironmentEnvironment
Environmental surfaceEnvironmental surfaceLinenLinenPlants and flowersPlants and flowersFood and drinking waterFood and drinking waterWater systemsWater systemsDialysisDialysisToysToysAirAirConstructionConstruction
4646
Environmental ControlEnvironmental Control
Cleaning should be performed by trained Cleaning should be performed by trained personnelpersonnelDaily cleaning of frequently touched horizontal Daily cleaning of frequently touched horizontal surfaces (avoid dry dusting and mopping)surfaces (avoid dry dusting and mopping)Reduce personal belongings or provide other Reduce personal belongings or provide other storage areasstorage areas
4747
LinenLinen
Using standard linen handling Using standard linen handling and managementand managementUnnecessary to provide sterile linen Unnecessary to provide sterile linen for for immunocompromisedimmunocompromised patients patients
4848
Plants and FlowersPlants and Flowers
Flowers and plants are known to harbor Flowers and plants are known to harbor microorganismsmicroorganismsVast water from fresh flowers has yielded Vast water from fresh flowers has yielded gram negative bacilli, e.g. P. gram negative bacilli, e.g. P. aeruginosaaeruginosaDried and fresh flowers and potted plants Dried and fresh flowers and potted plants can harbor fungi e.g. can harbor fungi e.g. aspergillusaspergillusExclude plants and flowers, both fresh and Exclude plants and flowers, both fresh and dried from dried from immunocompromisedimmunocompromised patient units patient units
4949
Food and Drinking WaterFood and Drinking Water
••Immunosuppressive Immunosuppressive therapytherapy
•• ChemotherapyChemotherapy•• RadiationRadiation•• Antimicrobial TherapyAntimicrobial Therapy•• H2 blockersH2 blockers•• Impaired intestinal Impaired intestinal motilitymotility
•• HematopoieticHematopoietic Stem Stem Cell transplantationCell transplantation
•• Solid organ transplantSolid organ transplant
Increased Risk of Food-borne Illness
5050
Food and Drinking WaterFood and Drinking Water
Low microbial dietsLow microbial diets-- Restricting raw fruits and vegetablesRestricting raw fruits and vegetables-- Concern about contamination with gram Concern about contamination with gram
negative bacillinegative bacilli
Safe food preparation at homeSafe food preparation at home-- HandwashingHandwashing before handling foodbefore handling food-- Using clean utensilsUsing clean utensils-- Cooking to temperature recommendedCooking to temperature recommended
5151
Food and Drinking WaterFood and Drinking Water
EnteralEnteral feedingsfeedings•• Has potential to become contaminated by Has potential to become contaminated by
bacteriabacteria•• Capable of causing severe infection, Capable of causing severe infection,
gastrointestinal colonization, gastrointestinal colonization, nosocomialnosocomialpneumoniapneumonia
•• Organisms cultured from Organisms cultured from enteralenteral feeding feeding included included S.epidermidisS.epidermidis, S. , S. aureusaureus and gram and gram negative bacilli such as negative bacilli such as SerratiaSerratia, , klebsiellaklebsiella,,and and Pseudomonas Pseudomonas sppspp..
5252
Food and Drinking WaterFood and Drinking Water
Contamination of Contamination of EnteralEnteral feedingfeeding•• Manipulation of the Manipulation of the enteralenteral feeding product and feeding product and
system during preparation and administration.system during preparation and administration.•• Mixing Mixing enteralenteral feeding on site results in more highly feeding on site results in more highly
contaminated solutions compared with premixed contaminated solutions compared with premixed feeds.feeds.
•• Colony counts in Colony counts in enteralenteral feedings increase with feedings increase with the hang time of product and the administration set.the hang time of product and the administration set.
•• High risk patients should receive readyHigh risk patients should receive ready--to feed to feed enteralenteral feeding via closed systems and feeding via closed systems and administration sets should be changed every 24 hrs.administration sets should be changed every 24 hrs.
5353
Water SystemsWater Systems
Water quality can pose different risks for Water quality can pose different risks for acquisition of infectious diseaseacquisition of infectious diseaseInterventions for testing and treatment of Interventions for testing and treatment of hospital water depend upon the water supply, hospital water depend upon the water supply, susceptibility of patients, and historical outbreak susceptibility of patients, and historical outbreak information information
5454
ToysToys
Risk of personRisk of person--toto--person transmissionperson transmissionIt is essential that all toys are cleaned and It is essential that all toys are cleaned and disinfected regularly and when visibly soiled or disinfected regularly and when visibly soiled or mouthedmouthedOnly toys that are easily cleaned and disinfected Only toys that are easily cleaned and disinfected are appropriate are appropriate Appropriate toy cleaning involves scrubbing with Appropriate toy cleaning involves scrubbing with soap and water to remove secretions and soap and water to remove secretions and surface dirt, followed by disinfection with non surface dirt, followed by disinfection with non toxic disinfectant and need to be thoroughly toxic disinfectant and need to be thoroughly rinsed with waterrinsed with water
5555
AirAir
Private rooms with air filtration and positive Private rooms with air filtration and positive pressure pressure Well sealed windowsWell sealed windowsAt least 12 air changes per hourAt least 12 air changes per hourA HEPA (high efficiency particulate air) filtrationA HEPA (high efficiency particulate air) filtrationsystem removes up to 99.97% of particles system removes up to 99.97% of particles measuring measuring >> 0.30.3 micron from the air micron from the air
5656
ConstructionConstruction
Substantial planning is required to protect Substantial planning is required to protect patients from the fungal infections, primarily patients from the fungal infections, primarily aspergillosisaspergillosisContainment measures necessary to protect Containment measures necessary to protect atat--risk populations include adequate barriers risk populations include adequate barriers and negative pressure inside the construction and negative pressure inside the construction sitesite
5757
PatientsPatientsMany infections are caused by patientMany infections are caused by patient’’s s endogenous floraendogenous floraMaintaining good personal hygieneMaintaining good personal hygieneGood oral and dental hygieneGood oral and dental hygieneChanging cleaned clothes regularlyChanging cleaned clothes regularlyDaily showers using mild soapDaily showers using mild soapInspection of skin integrity, especially perineum, Inspection of skin integrity, especially perineum, periperi--anal area and intravascular access sitesanal area and intravascular access sitesHand hygiene (both patients and family Hand hygiene (both patients and family members)members)
5858
VisitorsVisitorsWellWell--developed and strongly enforced policiesdeveloped and strongly enforced policiesto screen all visitors for symptoms of to screen all visitors for symptoms of communicable illness, including communicable illness, including
DiarrheaDiarrhea VomitingVomitingFeverFever ConjunctivitisConjunctivitisUndiagnosed rash Undiagnosed rash Upper respiratory tract symptomsUpper respiratory tract symptoms
Decisions make on a caseDecisions make on a case--byby--case basiscase basis(taking the patient(taking the patient’’s medical status and emotional s medical status and emotional needs into account, as well as the family memberneeds into account, as well as the family member’’s s ability to implement isolation techniques well enough ability to implement isolation techniques well enough to protect the patient)to protect the patient)
5959
AnimalsAnimals
Rehabilitation medicine has advocated animalRehabilitation medicine has advocated animal--assisted therapy to enhance physical, cognitive, assisted therapy to enhance physical, cognitive, and emotional participation in treatmentsand emotional participation in treatmentsPet therapy programs should be carefully Pet therapy programs should be carefully considered considered
6060
Solid Organ Transplant (SOT)Solid Organ Transplant (SOT)
SOT patients are at risk for both HAI and SOT patients are at risk for both HAI and opportunistic infectionsopportunistic infectionsType of organ transplant, Type of organ transplant, immunosuppressionimmunosuppressionlevel and time lapsed postlevel and time lapsed post--transplant are factors transplant are factors that influence infection riskthat influence infection riskThorough preThorough pre--operative history and assessment operative history and assessment may predict opportunistic infection riskmay predict opportunistic infection riskStandard precautions, including hand hygiene, Standard precautions, including hand hygiene, and isolation precautions are key to preventing and isolation precautions are key to preventing HAI HAI
6161
PostPost--Transplant Transplant Risk Factors for InfectionRisk Factors for Infection
Bacterial or fungal colonization of the Bacterial or fungal colonization of the respiratory tractrespiratory tractFrequent or prolonged exposure in the Frequent or prolonged exposure in the healthcare systemhealthcare systemSeverity of illness prior to surgerySeverity of illness prior to surgeryLongstanding malnutritionLongstanding malnutritionPatient agePatient ageDisruption of physical barriers Disruption of physical barriers (e.g. surgery, intravascular catheters)(e.g. surgery, intravascular catheters)
6262
Infections in SOT PatientsInfections in SOT PatientsBacterialBacterial MRSA, VRE, Clostridium MRSA, VRE, Clostridium difficiledifficile, ,
LegionellaLegionella, , M.tuberculosisM.tuberculosis, atypical , atypical mycobacterium, pseudomonasmycobacterium, pseudomonas
FungiFungi Candida, Candida, AspergillusAspergillus, , Cryptococcus, Cryptococcus, PneumocystisPneumocystis cariniicarinii
Endemic mycosesEndemic mycoses HistoplasmosisHistoplasmosis, , BlastomycosisBlastomycosis, , coccidioidomycosiscoccidioidomycosis
VirusesViruses Cytomegalovirus, Herpes simplex virus, Cytomegalovirus, Herpes simplex virus, VaricellaVaricella zoster virus, Epsteinzoster virus, Epstein--Barr virus, Barr virus, HepHep B , B , HepHep C, Adenovirus, respiratory C, Adenovirus, respiratory syncitialsyncitial virus, Influenzavirus, Influenza
6363
Infection ControlInfection Control
Monitoring infection ratesMonitoring infection ratesPostPost--transplant immunizationstransplant immunizationsEnvironmental control measuresEnvironmental control measuresPatient educationPatient education
6464
Monitoring InfectionsMonitoring Infections
Bloodstream infectionBloodstream infectionSurgical site infectionSurgical site infectionPneumoniaPneumoniaUrinary tract infectionUrinary tract infection
6565
PostPost--transplant immunizationstransplant immunizations
LiveLive--virus vaccines are not recommended virus vaccines are not recommended Killed immunizations are recommended for Killed immunizations are recommended for both adult and pediatric transplant recipients : both adult and pediatric transplant recipients : Hepatitis A and B if negative Hepatitis A and B if negative serostatusserostatus, , InfluenzaInfluenzaSOT recipients should receive influenza vaccine SOT recipients should receive influenza vaccine annuallyannually
6666
Patient educationPatient education
Avoid contact with persons with URIAvoid contact with persons with URIFood preparation safelyFood preparation safelyAvoid raw seafoodAvoid raw seafoodAvoid construction sitesAvoid construction sitesDecreasing molds in householdDecreasing molds in householdMonitoring of infectionMonitoring of infectionGood Good handwashinghandwashing techniquestechniques
Infection control education to prevent Infection control education to prevent opportunistic infection should be addressed opportunistic infection should be addressed
with SOT recipients prior to discharge.with SOT recipients prior to discharge.