Introduction

Concern about the effectiveness of strategies routinely recommended for preventing infection in neutropenic cancer patients prompted interest in evaluating the evidence base for current recommendations and promoting research on this important topic.  The effectiveness of strategies for preventing infection was specifically listed as an area of emphasis in the Oncology Nursing Society’s 2005 Research Agenda, and Prevention of Infection was one of the four topics addressed in the first round of the “Putting Evidence into Practice” project.[1],[2] The review of evidence produced in this project highlights the limited research available on various environmental and pharmacologic strategies other than prophylactic antibiotics and colony stimulating factors such as filgrastim or pegfilgrastim for preventing infection in neutropenic cancer patients.

The recommendations for practice developed from the evidence review focus on neutropenic cancer patients who are not undergoing hematopoietic stem cell or bone marrow transplant and who do not have febrile neutropenia and do not have an established infection. The results of the evidence review are available in a brief card format for quick reference in the clinical setting (PEP Card), a more detailed version of the PEP card, and an evidence table.[3],[4],[5] All three of these documents are available on the Oncology Nursing Society Web site at http://www.ons.org/research/outcomes. 

Preventing, recognizing, and managing infection emerged as major themes of the 2007 ONS Congress held in Las Vegas, Nevada. Podium and poster sessions included research reports, clinical recognition and management of febrile neutropenia and sepsis, analysis of ethical issues in preventing infection, and reports of clinical projects designed to improve use of the evidence base for preventing infection. 

Preventing Infection

Dietary Restriction:  Raw Fruits and Vegetables

One of the controversial strategies recommended for preventing infection is a dietary manipulation prohibiting the consumption of raw fruits and vegetables by neutropenic cancer patients. The initial recommendation for the neutropenia diet was based on concern about the possibility of bacterial contamination of raw fruits and vegetables. The neutropenic diet has been adopted in many institutions but there have not been any published randomized controlled trials to test the underlying assumption that eliminating raw fruits and vegetables would prevent infection. 

Alison Gardner, PhD, RN, of M D Anderson Cancer Center, Houston, Texas, reported on a randomized trial comparing a neutropenic diet that does not allow raw fruits or vegetables to a diet that includes raw fruits and vegetables in patients with acute myelogenous leukemia or myelodysplastic syndrome receiving inpatient front-line chemotherapy in a ‘protected environment.’[6] The primary outcomes are infection and death.  Preliminary results from 150 of the projected 188 subjects showed similar rates of infection between the two diet groups (29% raw fruit and vegetable group vs. 32% neutropenic diet group). This study is especially important because it uses a rigorous study design and is being conducted with patients hospitalized in a setting designed to minimize exposure to other potential sources of infection.  

A team from the University of Iowa Hospitals and Clinics led by Linda Moeller, RN, BSN, used the Iowa Model of Evidence-Based Practice to Promote Quality Care to evaluate the evidence supporting the restriction of fresh fruit and vegetables in the diet of neutropenic cancer patients.[7] This team concluded that diet could not be linked to bloodstream infection and that safe food handling practices were more likely to reduce food-borne infection than restricting fresh fruits and vegetables. A practice change was implemented that included provider education, eliminating most dietary restrictions, educating patients about safe food handling/food preparation, and modification of the institutional neutropenia precautions policy. The team compared blood stream infection rates before and after the practice change and found no increase in infection rates. 

Prohibition of Enemas and Suppositories

Another practice raising questions is the prohibition against using enemas and suppositories in thrombocytopenic or neutropenic cancer patients. This prohibition is especially concerning because of the implications for the management of constipation in a population that has many risk factors for constipation such as the use of opioid analgesics, immobility, anorexia, and low fluid intake. In addition, the practice eliminates the rectal route for administering medications in a population that may be experiencing barriers to oral intake such as nausea, vomiting, or mucositis. Elizabeth Sorensen, MSN, APRN, BC of the M D Anderson Cancer Center, Houston, Texas, reported on an evidence-based practice project designed to locate and evaluate the nature and strength of the evidence related to this practice.[8] The literature search revealed limited evidence either supporting or countering the prohibition on using enemas or suppositories in cancer patients with neutropenia or thrombocytopenia.   

Use of Face Masks by Providers

Ms. Sorensen also assessed the evidence underlying the use of masks and reported the results in a poster presentation.[9] The review of literature did not provide support for the idea that masks decrease infection in neutropenic cancer patients undergoing hematopoietic stem cell transplant or patients being treated for hematologic malignancies. Similar to the review of dietary restrictions, there were few studies and even fewer randomized trials. Most studies were dated, and few studies addressed the target population. Mask use varies from institution to institution with no standard for the type of mask, how it is worn, when it is worn, and how often the mask is changed. The results of this evidence-based practice project are being used to determine what types of studies are necessary to provide the evidence base needed to determine what practice should be recommended to prevent exposing patients to respiratory infection while avoiding unnecessarily restrictive provider behavior. 

Provider Uptake of Flu Vaccine

The concern that healthcare workers who do not receive the annual flu vaccine may pose a risk of exposure to neutropenic cancer patients was addressed from two different perspectives in poster presentations. Anita Reedy, RN, MSN, OCN reported on the results of a proactive approach to flu vaccination in which a nurse ‘champion’ for the flu vaccine program was designated on each unit and each of the staff members was queried to determine if she/he  received the vaccine or actively—rather than passively—declined the vaccine.[10] The rates of vaccination among the staff on the nursing units were from 60% to 85%, which is higher than the national estimate for health care providers of 35% to 45%.  While the effect of vaccination on infection among neutropenic cancer patients was not assessed in this project, the results of the combined nurse ‘champion’ and systematic reporting system on flu vaccine uptake were judged to be positive. 

Concern about provider refusal of flu vaccine posing a risk of infection to neutropenic cancer patients raises concern about the balance between the moral obligation to the patient and the provider’s right of self-determination. Suzanne Cowperthwaite, RN, BSN, of the Johns Hopkins University Sidney Kimmel Cancer Center discussed this issue in relation to recommendations to consider mandatory flu vaccination for healthcare providers.[11] Cowperthwaite concluded that mandatory vaccination is defensible because the moral obligation to the patient exceeds other considerations. However, she goes on to recommend a strategy similar to that used in Reedy’s project in which providers are required to either accept or actively decline the vaccination rather than insisting upon mandatory vaccination. A number of additional strategies to decrease barriers to vaccination and to present the vaccination as a condition of employment are also suggested as part of a program to increase oncology provider vaccination rates. 

Summary and Conclusions         

It is clear that oncology nurses are interested in examining the evidence base for a number of existing practices included under the umbrella of ‘neutropenic precautions.’  Systematic reviews of the evidence base for these interventions reveal that most were based on expert opinion and that the studies that are available do not provide strong support either for or against existing practices. The neutropenia precaution research, projects, and issues presented at the ONS Congress provide a variety of perspectives on a set of complicated issues that have important implications for direct patient care, clinical program administration, research, education, and health policy within the spheres of patient safety and nurse-sensitive patient outcomes. The challenge will be maintaining the momentum in addressing the need for evidence-based practice for preventing infection in neutropenic cancer patients.

To successfully complete this CME activity, please read the additional articles from the 2007 ONS Conference Coverage before you take the post test:

Updates in the Management of Thrombocytopenia 
Kimberly Noonan, RN, NP, Division of Hematologic Oncology, Dana Farber Cancer Institute

Myelosuppression: Oncology Nursing Society Congress 2007 
Lillian Nail, PhD, RN, FAAN, Rawlinson Professor & Senior Scientist, Oregon Health & Science University School of Nursing, Portland, Oregon

2007 ONS Congress: Issues and Prospects in Colorectal Cancer 
Lillian Nail, PhD, RN, FAAN, Rawlinson Professor & Senior Scientist, Oregon Health & Science University School of Nursing, Portland, Oregon 

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References