Detection and Control of a Nosocomial Respiratory Syncytial Virus Outbreak in a Stem Cell Transplantation Unit: The Role of Palivizumab

Respiratory syncytial virus (RSV) is a common community-acquired virus that causes upper and lower respiratory tract infections in children, hematologic malignancy patients, and hematopoietic stem cell transplant (HSCT) recipients. Nosocomial transmission of RSV in immunocompromised patients can significantly affect morbidity, mortality, and duration of hospitalization. Stringent infection control measurements are needed to control further hospital transmission. Prophylactic palivizumab was found to result in a significant reduction in hospitalization rates in high-risk children. In this article, we report a nosocomial outbreak of RSV in an adult HSCT unit (4 pods) from January 16 to February 4, 2004, including the infection control interventions used and the prophylactic administration of palivizumab in high-risk patients. Active surveillance identified 5 cases, a substantial increase from previous seasons (2 or 3 cases per season). All infected patients were isolated to 1 nursing pod and placed on contact isolation. All patients on the HSCT unit underwent rapid RSV antigen screening using nasal washes; this was repeated 1 week later, and 1 additional RSV case was identified. Patients identified to be at increased risk for RSV infection received prophylactic palivizumab. Routine screenings of the staff and visitors were undertaken. All patient and visitor areas were thoroughly cleaned with bleach. We educated health care workers about RSV transmission, highlighting proper hand hygiene and contact precautions. Four of 6 patients with RSV infection developed RSV pneumonia, and 2 of these patients died. Staff and visitors with upper respiratory symptoms were screened, and all were negative for RSV. Prophylactic palivizumab was administered in 16 patients who tested negative for RSV, but were considered to be at increased risk for RSV infection. None of these patients developed RSV infections. An RSV outbreak was controlled using prompt preventive measures, including cohorting patients, with a dedicated health care staff; contact isolation of patients; strict adherence to hand hygiene; and screening of visitors, family members, and health care staff for upper respiratory infection symptoms. Immunoprophylaxis with palivizumab, administered to high-risk patients, complemented strict infection control intervention. Thus, the role of palivizumab in the control of RSV hospital outbreaks merits further investigation. Respiratory syncytial virus (RSV) is a common community-acquired virus that causes upper and lower respiratory tract infections in children, hematologic malignancy patients, and hematopoietic stem cell transplant (HSCT) recipients. Nosocomial transmission of RSV in immunocompromised patients can significantly affect morbidity, mortality, and duration of hospitalization. Stringent infection control measurements are needed to control further hospital transmission. Prophylactic palivizumab was found to result in a significant reduction in hospitalization rates in high-risk children. In this article, we report a nosocomial outbreak of RSV in an adult HSCT unit (4 pods) from January 16 to February 4, 2004, including the infection control interventions used and the prophylactic administration of palivizumab in high-risk patients. Active surveillance identified 5 cases, a substantial increase from previous seasons (2 or 3 cases per season). All infected patients were isolated to 1 nursing pod and placed on contact isolation. All patients on the HSCT unit underwent rapid RSV antigen screening using nasal washes; this was repeated 1 week later, and 1 additional RSV case was identified. Patients identified to be at increased risk for RSV infection received prophylactic palivizumab. Routine screenings of the staff and visitors were undertaken. All patient and visitor areas were thoroughly cleaned with bleach. We educated health care workers about RSV transmission, highlighting proper hand hygiene and contact precautions. Four of 6 patients with RSV infection developed RSV pneumonia, and 2 of these patients died. Staff and visitors with upper respiratory symptoms were screened, and all were negative for RSV. Prophylactic palivizumab was administered in 16 patients who tested negative for RSV, but were considered to be at increased risk for RSV infection. None of these patients developed RSV infections. An RSV outbreak was controlled using prompt preventive measures, including cohorting patients, with a dedicated health care staff; contact isolation of patients; strict adherence to hand hygiene; and screening of visitors, family members, and health care staff for upper respiratory infection symptoms. Immunoprophylaxis with palivizumab, administered to high-risk patients, complemented strict infection control intervention. Thus, the role of palivizumab in the control of RSV hospital outbreaks merits further investigation. IntroductionRespiratory syncytial virus (RSV) is a well-known cause of lower respiratory tract infections in young children [1Izurieta H.S. Thompson W.W. Kramarz P. et al.Influenza and the rates of hospitalization for respiratory disease among infants and young children.N Engl J Med. 2000; 342: 232-239Crossref PubMed Scopus (897) Google Scholar], and is now increasingly recognized as an important cause of respiratory infections in adults, especially in the elderly and immunocompromised patients [2Falsey A.R. Treanor J.J. Betts R.F. et al.Viral respiratory infections in the institutionalized elderly: clinical and epidemiologic findings.J Am Geriatr Soc. 1992; 40: 115-119Crossref PubMed Scopus (176) Google Scholar]. By the age of 2 years, almost all children have been infected with RSV [3Shay D.K. Holman R.C. Newman R.D. et al.Bronchiolitis-associated hospitalizations among US children, 1980-1996.JAMA. 1999; 282: 1440-1446Crossref PubMed Scopus (1147) Google Scholar], but naturally acquired immunity is incomplete, and reinfection is common [4Fenton C. Scott L.J. Plosker G.L. Palivizumab: a review of its use as prophylaxis for serious respiratory syncytial virus infection.Paediatr Drugs. 2004; 6: 177-197Crossref PubMed Scopus (54) Google Scholar].The clinical features of reinfections are generally mild in immunocompetent patients, and the duration of viral shedding is relatively short. However, RSV infections have been associated with high morbidity and mortality rates (70%-100%) and prolonged viral shedding in both autologous and allogeneic adult stem cell transplant (HSCT) recipients [5Sable C.A. Hayden F.G. Orthomyxoviral and paramyxoviral infections in transplant patients.Infect Dis Clin N Am. 1995; 9: 987-1003PubMed Google Scholar, 6Whimbey E. Champlin R. Englund J. et al.Combination therapy with aerosolized ribavirin and intravenous immunoglobulin for respiratory syncytial virus disease in adult bone marrow transplant recipients.Bone Marrow Transplant. 1995; 16: 393PubMed Google Scholar]. The disease incidence varies seasonally, with a peak from November to April in the northern hemisphere. Outbreaks of RSV infections have been reported among nursing home patients and institutionalized young adults [7Falsey A.R. Hennessey P.A. Formica M.A. et al.Respiratory syncytial virus infection in elderly and high-risk adults.N Engl J Med. 2005; 352: 1749-1759Crossref PubMed Scopus (1334) Google Scholar, 8Osterweil D. Norman D. An outbreak of an influenza-like illness in a nursing home.J Am Geriatr Soc. 1990; 38: 659-662Crossref PubMed Scopus (43) Google Scholar, 9Falsey A.R. Noninfluenza respiratory virus infection in long-term care facilities.Infect Control Hosp Epidemiol. 1991; 12: 602-608Crossref PubMed Scopus (42) Google Scholar], but few reports have documented nosocomial RSV outbreaks among HSCT patients [10Abdallah A. Rowland K.E. Schepetiuk S.K. To L.B. Bardy P. An outbreak of respiratory syncytial virus infection in a bone marrow transplant unit: effect on engraftment and outcome of pneumonia without specific antiviral treatment.Bone Marrow Transplant. 2003; 32: 195-203Crossref PubMed Scopus (60) Google Scholar, 11Harrington R.D. Hooton T.M. Hackman R.C. et al.An outbreak of respiratory syncytial virus in a bone marrow transplant center.J Infect Dis. 1992; 165: 987-993Crossref PubMed Scopus (309) Google Scholar, 12Jalal H. Bibby D.F. Bennett J. et al.Molecular investigations of an outbreak of parainfluenza virus type 3 and respiratory syncytial virus infections in a hematology unit.J Clin Microbiol. 2007; : 1690-1696Crossref PubMed Scopus (62) Google Scholar].Active infection control surveillance strategies of RSV and other community-acquired respiratory viruses play crucial roles in identifying nosocomial transmission and controlling outbreaks. Studies have suggested that hand washing after patient contact, the use of gowns and gloves, and cohorting of staff and patients are effective preventive strategies [13Isaacs D. Dickson H. O'Callaghan C. Sheaves R. Winter A. Moxon E.R. Handwashing and cohorting in prevention of hospital acquired infections with respiratory syncytial virus.Arch Dis Child. 1991; 66: 227-231Crossref PubMed Scopus (100) Google Scholar, 14Madge P. Paton J.Y. McColl J.H. Mackie P.L. Prospective controlled study of four infection control procedures to prevent nosocomial infection with respiratory syncytial virus.Lancet. 1992; 340: 1079-1083Abstract PubMed Scopus (166) Google Scholar].Palivizumab (Synagis. MedImmune, Inc., Gaithersburg, MD, USA) is a humanized monoclonal antibody directed against the F glycoprotein of RSV; it was approved for the prophylaxis of RSV disease in high-risk infants [15American Academy of Pediatrics Committee on Infectious Diseases, Committee on Foetus and NewbornPrevention of respiratory syncytial virus infections: indications for the use of palivizumab and update on the use of RSV-IG PubMed Scopus Google Scholar, J. et for the use of humanized monoclonal for the prevention of RSV disease in high-risk a Med. 1999; 16: Scholar, R.C. et with palivizumab, a humanized respiratory syncytial virus monoclonal for prevention of respiratory syncytial virus infection in high risk a Infect Dis J. 1999; PubMed Scopus Google Scholar]. However, its in high-risk adults been this article, we an outbreak of nosocomial RSV among HSCT unit patients at was using strict infection control interventions and palivizumab in high-risk adult HSCT HSCT unit at The of is a unit and we or respiratory viral infections in hematologic malignancy patients. Patients with symptoms of upper respiratory infection RSV and using rapid antigen and of nasal the incidence of RSV infection in January and with a of and in and However, in January and February 2004, surveillance of patients identified 5 HSCT patients with nosocomial RSV infections. a substantial increase in incidence of RSV to that of previous We strict infection control and the outbreak on February of from all HSCT patients on all were and for rapid RSV antigen screening on February the strict infection control were All health care workers who reported upper respiratory symptoms were from patient contact and underwent rapid RSV antigen was placed at the of pod that that all visitors and family were to at the to patient for Respiratory was to all visitors at the The 2 have symptoms of a that are have a or and contact with that a the All who to were All visitors who were to a that have been and The nursing staff a of all visitors who been for upper respiratory that patient week after the screening been all patients underwent rapid RSV antigen screening of nasal respiratory RSV infection was as nasal or or with a with or without RSV pneumonia was as an respiratory illness in with or symptoms of lower respiratory tract disease and was considered nosocomial respiratory symptoms developed after hospital were for rapid antigen using the All were placed in a viral on or and to the on were and that respiratory were with the the RSV an a D. respiratory for rapid of respiratory viruses in clinical Clin Microbiol. 2000; 38: Google Scholar]. were 2 and reported to the The and of this is and D. respiratory for rapid of respiratory viruses in clinical Clin Microbiol. 2000; 38: Google January and 2004, 3 patients to the pod were with nosocomial RSV infections. Patients 1 and 3 of pneumonia, patient 2 an upper respiratory infection with a negative January patient 4, to the was with pneumonia to RSV. later, on February patient to the pod was with RSV pneumonia increase in incidence of nosocomial RSV infection was that in previous years, We an outbreak as of infection control 2 or nosocomial RSV or other respiratory virus infections are in patients in the and the of All HSCT patients and health care workers on all were using a rapid RSV antigen of nasal health care workers were found to have upper respiratory but were for RSV February a patient was with a RSV upper respiratory tract infection 1 the and clinical of all 6 patients. All patients were with aerosolized ribavirin and palivizumab for at the patients with RSV pneumonia, 2 of RSV infections among the 6 identified and of Patients with Nosocomial RSV and of from to of and of cell 2 for and and infection respiratory tract 2 for and and infection 2 for and for 3 and infection cell 2 for and and patient 2 for and for 3 6 later, was but patient from respiratory respiratory tract 2 for and and infection patients an of at of of RSV infection at a of respiratory syncytial stem cell in a patients, with a respiratory care and a were to the RSV pod All patients on this pod with or without RSV infection were placed on contact with additional patients were to the visitors with upper respiratory symptoms or a or who been to with the were from patient The infection control an for on all that proper hand and strict adherence to contact isolation with with and for patient nursing and identified HSCT patients who be at high risk for RSV infection is acquired using the allogeneic disease or with patients these All 16 were negative for RSV antigen and were a of of intravenous palivizumab. week later, we screening of all HSCT patients; cases of RSV infection were identified. None of the 16 high-risk HSCT patients who received palivizumab developed RSV infections 2 and 3 all RSV outbreaks in the and adult of RSV Outbreaks in the of of of the of on the at of of with of to RSV of Prophylactic of RSV after of et J. et of palivizumab a nosocomial outbreak in a unit at the of Med. 2000; care et P. C. The use of palivizumab monoclonal antibody to control an outbreak of respiratory syncytial virus infection in a care unit.J Hosp PubMed Scopus Google Respiratory syncytial virus (RSV) outbreak in the of PubMed Scopus Google et Nosocomial respiratory syncytial a in the care unit.J PubMed Scopus Google care et Nosocomial respiratory syncytial a in the care unit.J PubMed Scopus Google care et C. D. of palivizumab to control an outbreak of syncytial respiratory virus in a care unit.J 2004; PubMed Scopus (43) Google et C. D. of palivizumab to control an outbreak of syncytial respiratory virus in a care unit.J 2004; PubMed Scopus (43) Google et et and of a respiratory syncytial virus outbreak in a care Infect Dis J. 2005; PubMed Scopus Google care infected et H. et with the use of palivizumab with infection control to prevent respiratory syncytial virus outbreaks in care Hosp PubMed Scopus Google care RSV, respiratory syncytial in a of RSV Outbreaks in Outbreaks in of of of the of Patients on the at of of Patients with of to RSV of Patients Prophylactic of RSV after of et 11Harrington R.D. Hooton T.M. Hackman R.C. et al.An outbreak of respiratory syncytial virus in a bone marrow transplant center.J Infect Dis. 1992; 165: 987-993Crossref PubMed Scopus (309) Google et et of an outbreak of respiratory syncytial virus infection in immunocompromised Hosp 2000; PubMed Scopus Google 5 et A. Rowland K.E. Schepetiuk S.K. To L.B. Bardy P. An outbreak of respiratory syncytial virus infection in a bone marrow transplant unit: effect on engraftment and outcome of pneumonia without specific antiviral treatment.Bone Marrow Transplant. 2003; 32: 195-203Crossref PubMed Scopus (60) Google Outbreaks in et M.A. et al.An outbreak of respiratory syncytial virus pneumonia in a nursing home for the 9: PubMed Scopus Google et et al.An respiratory syncytial virus nosocomial outbreak in an adult J Infect Dis. Google patients and et L.B. J. et al.Respiratory syncytial virus outbreak in a long-term care using an for Am Geriatr Soc. PubMed Scopus Google care bone marrow health care RSV, respiratory syncytial in a later, control were and isolation was for all patients. of health care staff and visitors was The use of and patient contact was is a cause of both upper and lower respiratory tract and the of clinical on patient age and health In immunocompromised patients, as hematopoietic HSCT RSV upper respiratory disease to viral pneumonia Englund E. Respiratory viral infections in immunocompetent and immunocompromised J Med. PubMed Scopus Google Scholar]. In a previous study at RSV was isolated in of cases of respiratory illness from to in and HSCT patients R.F. et al.Respiratory viral infections in adults with hematologic and stem cell a study at a PubMed Scopus Google Scholar]. developed in of of RSV cases, and 6 of patients for RSV pneumonia died. high rates of pneumonia and have been at other et al.Respiratory tract viral infections in bone marrow transplant 2003; PubMed Scopus Google respiratory with aerosolized or in with is to mortality in patients with pneumonia E. Englund respiratory virus infections in immunocompromised patients with J Med. PubMed Scopus Google Scholar, Champlin Englund J. et al.Respiratory syncytial virus upper respiratory tract in adult and marrow transplant therapy with aerosolized ribavirin and intravenous Marrow Transplant. 2000; PubMed Scopus Google Scholar]. the use of aerosolized therapy in immunocompromised patients with isolated upper respiratory symptoms can the of to pneumonia R.F. et al.Respiratory viral infections in adults with hematologic and stem cell a study at a PubMed Scopus Google Scholar]. Thus, screening of HSCT patients with upper respiratory symptoms is especially high this article, we an outbreak of nosocomial RSV in 6 HSCT patients developed RSV infections. patients isolated upper respiratory and developed All 6 patients were on aerosolized ribavirin but 2 developed respiratory and infection control measures, including cohorting patients and staff to 1 all patients on contact and screening visitors and were to control the RSV is and rapid among patients been The virus to on gloves, and and on of transmission of PubMed Scopus Google Scholar]. of or after contact with virus or of respiratory RSV of Scholar]. transmission been shedding of respiratory syncytial virus in Infect Dis. PubMed Scopus Google Scholar]. and strict of contact including and be the important of nosocomial et use of to control nosocomial respiratory syncytial virus PubMed Scopus Google Scholar, L.J. R. et for health pneumonia, of and infection control 2004; Google Scholar]. patients and in patients are placed in or with other patients and health care workers are from for patients, is effective at controlling further nosocomial transmission L.J. R. et for health pneumonia, of and infection control 2004; Google Scholar, R. et for respiratory syncytial virus and to a at to nosocomial 1990; PubMed Scopus Google Scholar]. visitors with upper respiratory symptoms from patient contact and all and family be in outbreak L.J. R. et for health pneumonia, of and infection control 2004; Google in a care unit RSV outbreak C. D. of palivizumab to control an outbreak of syncytial respiratory virus in a care unit.J 2004; PubMed Scopus (43) Google Scholar], the infection control were effective at further RSV infections with significant therapy was for all infants to the and further cases were is a humanized monoclonal antibody that an at the of the F of RSV and to the F 2 it infection the viral from with the respiratory cell it of the the of and the of in the L.J. Drugs. 1999; PubMed Scopus Google Scholar]. the for its clinical In the a humanized respiratory syncytial virus monoclonal hospitalization from respiratory syncytial virus infection in high-risk Scopus Google Scholar], a prophylactic palivizumab in a significant reduction in hospitalization rates in high-risk this to its and of palivizumab for RSV prophylaxis in high-risk children in was administered the at 5 of in high-risk it in a reduction in the of RSV hospitalization in the in the palivizumab children with a reduction in the RSV hospitalization and children with a reduction these R.C. et with palivizumab, a humanized respiratory syncytial virus monoclonal for prevention of respiratory syncytial virus infection in high risk a Infect Dis J. 1999; PubMed Scopus Google Scholar, R. D. et of palivizumab prophylaxis on respiratory syncytial virus hospitalizations in high risk Infect Dis J. 2003; Google Scholar, prophylaxis of respiratory syncytial virus disease in from The 2003; PubMed Scopus Google Scholar, of palivizumab for serious RSV Dis. 2000; Scholar, of of respiratory syncytial hospitalizations in high-risk of a of infants with palivizumab as RSV PubMed Scopus Google Scholar, C. J. et of palivizumab prophylaxis in respiratory syncytial virus hospitalizations in Infect Dis J. 2003; PubMed Scopus Google Scholar, P. et in infants with age or without 2007; PubMed Scopus Google Scholar, R. A. et use in with from the PubMed Scopus Google Scholar]. The Academy of Pediatrics that palivizumab be in children with Academy of Pediatrics Committee on Infectious and Committee on and indications for the use of palivizumab and respiratory syncytial virus intravenous for the prevention of respiratory syncytial virus 2003; 12: Scopus Google Scholar]. In a to the effect of prophylactic palivizumab on mortality in stem cell transplant the increased from to with palivizumab et prophylaxis to prevent respiratory syncytial virus mortality after bone marrow a 2007; PubMed Scopus Google Scholar].Palivizumab is or in with aerosolized in the upper and lower RSV respiratory tract infections R.F. et al.Respiratory viral infections in adults with hematologic and stem cell a study at a PubMed Scopus Google Scholar, Champlin Englund J. et al.Respiratory syncytial virus upper respiratory tract in adult and marrow transplant therapy with aerosolized ribavirin and intravenous Marrow Transplant. 2000; PubMed Scopus Google Scholar, et 1 of the respiratory syncytial monoclonal antibody palivizumab in recipients of hematopoietic stem cell Infect Dis. PubMed Scopus Google Scholar]. However, on its use in adult HSCT patients an and be at and RSV infections in immunocompromised adults but in its R.F. Palivizumab: to from 9: PubMed Scopus Google Scholar]. In the outbreak in this article, palivizumab was administered to all HSCT patients at high risk for RSV including all allogeneic and transplant patients on and patients upper or lower RSV infections in these patients. The use of prophylactic palivizumab have to the further nosocomial of RSV, but the from this be in study as other infection control were as surveillance of all patients and health care especially RSV the for identifying RSV outbreaks. The prevention and strict contact isolation and Patients RSV for and after of the be to these patients and to care for screening of patients, health care and visitors, especially is in further nosocomial RSV increase of RSV among patients, and family for respiratory syncytial J Google Scholar]. that prophylactic palivizumab be administered to high-risk HSCT patients to nosocomial RSV transmission, in with the and preventive of hand Active surveillance for respiratory viruses be as rapid and strict adherence to all preventive infection control are needed to the role of prophylactic palivizumab in nosocomial RSV and this is IntroductionRespiratory syncytial virus (RSV) is a well-known cause of lower respiratory tract infections in young children [1Izurieta H.S. Thompson W.W. Kramarz P. et al.Influenza and the rates of hospitalization for respiratory disease among infants and young children.N Engl J Med. 2000; 342: 232-239Crossref PubMed Scopus (897) Google Scholar], and is now increasingly recognized as an important cause of respiratory infections in adults, especially in the elderly and immunocompromised patients [2Falsey A.R. Treanor J.J. Betts R.F. et al.Viral respiratory infections in the institutionalized elderly: clinical and epidemiologic findings.J Am Geriatr Soc. 1992; 40: 115-119Crossref PubMed Scopus (176) Google Scholar]. By the age of 2 years, almost all children have been infected with RSV [3Shay D.K. Holman R.C. Newman R.D. et al.Bronchiolitis-associated hospitalizations among US children, 1980-1996.JAMA. 1999; 282: 1440-1446Crossref PubMed Scopus (1147) Google Scholar], but naturally acquired immunity is incomplete, and reinfection is common [4Fenton C. Scott L.J. Plosker G.L. Palivizumab: a review of its use as prophylaxis for serious respiratory syncytial virus infection.Paediatr Drugs. 2004; 6: 177-197Crossref PubMed Scopus (54) Google Scholar].The clinical features of reinfections are generally mild in immunocompetent patients, and the duration of viral shedding is relatively short. However, RSV infections have been associated with high morbidity and mortality rates (70%-100%) and prolonged viral shedding in both autologous and allogeneic adult stem cell transplant (HSCT) recipients [5Sable C.A. Hayden F.G. Orthomyxoviral and paramyxoviral infections in transplant patients.Infect Dis Clin N Am. 1995; 9: 987-1003PubMed Google Scholar, 6Whimbey E. Champlin R. Englund J. et al.Combination therapy with aerosolized ribavirin and intravenous immunoglobulin for respiratory syncytial virus disease in adult bone marrow transplant recipients.Bone Marrow Transplant. 1995; 16: 393PubMed Google Scholar]. The disease incidence varies seasonally, with a peak from November to April in the northern hemisphere. Outbreaks of RSV infections have been reported among nursing home patients and institutionalized young adults [7Falsey A.R. Hennessey P.A. Formica M.A. et al.Respiratory syncytial virus infection in elderly and high-risk adults.N Engl J Med. 2005; 352: 1749-1759Crossref PubMed Scopus (1334) Google Scholar, 8Osterweil D. Norman D. An outbreak of an influenza-like illness in a nursing home.J Am Geriatr Soc. 1990; 38: 659-662Crossref PubMed Scopus (43) Google Scholar, 9Falsey A.R. Noninfluenza respiratory virus infection in long-term care facilities.Infect Control Hosp Epidemiol. 1991; 12: 602-608Crossref PubMed Scopus (42) Google Scholar], but few reports have documented nosocomial RSV outbreaks among HSCT patients [10Abdallah A. Rowland K.E. Schepetiuk S.K. To L.B. Bardy P. An outbreak of respiratory syncytial virus infection in a bone marrow transplant unit: effect on engraftment and outcome of pneumonia without specific antiviral treatment.Bone Marrow Transplant. 2003; 32: 195-203Crossref PubMed Scopus (60) Google Scholar, 11Harrington R.D. Hooton T.M. Hackman R.C. et al.An outbreak of respiratory syncytial virus in a bone marrow transplant center.J Infect Dis. 1992; 165: 987-993Crossref PubMed Scopus (309) Google Scholar, 12Jalal H. Bibby D.F. Bennett J. et al.Molecular investigations of an outbreak of parainfluenza virus type 3 and respiratory syncytial virus infections in a hematology unit.J Clin Microbiol. 2007; : 1690-1696Crossref PubMed Scopus (62) Google Scholar].Active infection control surveillance strategies of RSV and other community-acquired respiratory viruses play crucial roles in identifying nosocomial transmission and controlling outbreaks. Studies have suggested that hand washing after patient contact, the use of gowns and gloves, and cohorting of staff and patients are effective preventive strategies [13Isaacs D. Dickson H. O'Callaghan C. Sheaves R. Winter A. Moxon E.R. Handwashing and cohorting in prevention of hospital acquired infections with respiratory syncytial virus.Arch Dis Child. 1991; 66: 227-231Crossref PubMed Scopus (100) Google Scholar, 14Madge P. Paton J.Y. McColl J.H. Mackie P.L. Prospective controlled study of four infection control procedures to prevent nosocomial infection with respiratory syncytial virus.Lancet. 1992; 340: 1079-1083Abstract PubMed Scopus (166) Google Scholar].Palivizumab (Synagis. MedImmune, Inc., Gaithersburg, MD, USA) is a humanized monoclonal antibody directed against the F glycoprotein of RSV; it was approved for the prophylaxis of RSV disease in high-risk infants [15American Academy of Pediatrics Committee on Infectious Diseases, Committee on Foetus and NewbornPrevention of respiratory syncytial virus infections: indications for the use of palivizumab and update on the use of RSV-IG PubMed Scopus Google Scholar, J. et for the use of humanized monoclonal for the prevention of RSV disease in high-risk a Med. 1999; 16: Scholar, R.C. et with palivizumab, a humanized respiratory syncytial virus monoclonal for prevention of respiratory syncytial virus infection in high risk a Infect Dis J. 1999; PubMed Scopus Google Scholar]. However, its in high-risk adults been this article, we an outbreak of nosocomial RSV among HSCT unit patients at was using strict infection control interventions and palivizumab in high-risk adult HSCT patients.