Prevention of Infection Interventions

What interventions are effective in preventing infection in people with cancer?

Recommended for Practice

Interventions for which effectiveness has been demonstrated by strong evidence from rigorously designed studies, meta-analyses, or systematic reviews and for which the expectation of harms is small compared to the benefits

Hand hygiene using soap and water or an antiseptic hand rub for all patients with cancer and their caregivers ^1-7

. Wash hands with soap and water, especially if hands are visibly soiled or contaminated with proteinaceous material.

. Use either soap and water or alcohol-based hand rubs when hands are not visibly soiled or contaminated.

. Hands may remain colonized with microorganisms after handwashing if hands are not dried properly.

Colony-stimulating factors (CSFs) for all patients with cancer undergoing chemotherapy with > 20% risk of febrile neutropenia ^6,8-12

Influenza vaccine annually for all patients with cancer ^13,14

. The potential benefit significantly outweighs the low risk for adverse effects. The timing and efficacy of influenza vaccination has not been clearly established based on conflicting evidence in the literature.

23-valent pneumococcal polysaccharide vaccine for all patients with cancer older than five years of age and 7-valent pneumococcal polysaccharide protein-conjugate vaccine for all patients with cancer younger than five years of age ¹

Trimethoprim-sulfamethoxazole (TMP-SMZ) to prevent Pneumocystis carinii pneumonia (PCP) for all patients at risk ¹⁵

. Consider TMP-SMZ desensitization, atovaquone, dapsone, or aerosolized pentamidine when PCP (recently renamed as Pneumocystis jiroveci ) prophylaxis is required and patients are TMP-SMZ intolerant. ¹⁴

Antifungal drugs absorbed or partially absorbed from the gastrointestinal (GI) tract to prevent oral candidiasis in patients with cancer undergoing chemotherapy ^16,17

. Antifungal drugs absorbed from the GI tract (fluconazole, ketoconazole, and itraconazole) or partially absorbed from the GI tract (miconazole and clotrimazole) prevented oral candidiasis.

. Antifungal drugs not absorbed from the GI tract (amphotericin B, nystatin, nystatin plus chlorhexidine, thymostimulin, amphotericin B plus nystatin, polyenes, natamycin, and norfloxacin plus amphotericin B) did not prevent oral candidiasis.

(Recommended for Practice continued)

Antifungal prophylaxis for severely neutropenic afebrile patients (absolute neutrophil count [ANC] < 1,000 for more than one week)

. In general, antifungal prophylaxis is not recommended for all neutropenic patients with cancer; however, it is recommended for high-risk patients such as those with acute leukemia or those undergoing hematopoietic stem cell transplantation (HSCT). ^14,15,18-23

. Antifungal prophylaxis reduces fungal colonization and risk of invasive fungal infection in severely neutropenic patients (ANC < 1,000 for more than one week). ^{14,18,19,21-23}

. Effective agents include fluconazole, ^{14,18-20,23,24} itraconazole suspension 400 mg po, ^14,18,20,21 itraconazole 200 mg IV daily, ^18,20,21,23 or IV amphotericin B. ^{14,18,20,22-24} Lipid-based formulations of IV amphotericin B may increase efficacy because of increased patient tolerability. ²² Itraconazole capsules are not effective.²¹

Antibacterial prophylaxis with quinolones for high-risk afebrile neutropenic patients with cancer undergoing chemotherapy

. Quinolones (e.g., ciprofloxacin 500-750 mg bid x 7 days or levofloxacin 500 mg qd x 7 days) are recommended for the prevention of infection in high-risk afebrile neutropenic patients after chemotherapy. ^6,14,25-30 Patients at high risk for infection include patients with hematologic malignancies, HSCT patients, or patients expected to have prolonged neutropenia. Most of the patients evaluated in clinical trials had hematologic malignancies or were undergoing HSCT, although one recent randomized controlled trial demonstrated a decreased rate of infection in patients with solid tumors undergoing chemotherapy. Nonetheless, controversy exists regarding its use in patients with solid tumors because of concerns about antibiotic resistance. ^14,15,25-30 The benefit of antibiotic prophylaxis if patients are receiving CSFs requires further study. ³¹

Herpes viral prophylaxis (acyclovir or valacyclovir) for selected seropositive patients with cancer ¹⁴

. During cytotoxic therapy-induced neutropenia in patients with cancer who have had prior reactivations requiring treatment

. Patients receiving T-cell-depleting agents (i.e., fludarabine)

. During allogeneic marrow transplant until day 30 post-transplant

. During induction or reinduction therapy for acute leukemia through the neutropenic period

Protective gowns if soiling with respiratory secretions is anticipated¹

Do not allow visitors with symptoms of respiratory infections.¹

Environmental interventions ⁴

. Keep windows closed.

. Patients with airborne respiratory viruses (e.g., varicella , tuberculosis) should be placed in rooms equipped with an anteroom to maintain proper air balance. High-efficiency particulate air (HEPA) filters should be used for air recirculation. Portable HEPA filters should be used when anterooms are not available.

. Negative-pressure rooms should be used for patients with documented or suspected airborne infections or viral hemor

Interventions for which the evidence is less well established than for those listed under "Recommended for Practice"

Oxygen and respiratory care ¹

. Oxygen humidifiers: Change the humidifier tubing, nasal prongs, and/or mask when it malfunctions or becomes visibly contaminated.

. Small-volume medication nebulizers: (1) Disinfect, rinse with sterile water, and dry between uses on the same patient; (2) use only sterile fluid for nebulization, and dispense fluid aseptically; (3) single-dose dispensing is preferred.

. Mist tent: (1) Replace mist tents and their nebulizers, reservoirs, and tubing with those that have undergone sterilization or high-level disinfection between uses on different patients; (2) mist tent nebulizers and tubing that are used on the same patient should undergo daily low-level disinfection or pasteurization followed by air drying.

HEPA filters and HEPA filter masks for patients with prolonged neutropenia ^4,6,14

. It is reasonable to use HEPA filters in nontransplant patients with prolonged neutropenia. Immunocompromised patients placed in protective environments should have mask protection when traveling outside of their protected area.

Flower and plant guidelines

. Patients with cancer should avoid fresh or dried flowers and plants because of the risk of Aspergillus infection. ^4,6,32

. Limit plant care to staff not directly caring for patients. ⁴

. If plant care by patient care staff is unavoidable, staff should wear gloves while handling plants/flowers and perform hand hygiene after glove removal. ⁴

. Change vase water every two days; discharge water outside the patient's room. ⁴

. Clean and disinfect vases after use. ⁴

Ice handling ⁴

. Automated ice-dispensing systems are preferred to ice bins, but adherence to cleaning procedures and schedules is essential.

. Do not handle ice by hand, and wash hands prior to obtaining ice.

Animal encounters ⁴

. Advise patients to avoid contact with animal feces, saliva, urine, or solid litter box material.

. Promptly clean and treat scratches, bites, or other wounds that break the skin.

. Advise patients to avoid direct or indirect contact with reptiles.

. Practice hand hygiene after any animal contact.

Preconstruction planning ⁴

. Planning should include risk assessment, documentation and monitoring of the construction barrier, and education to the clinical staff about appropriate precautionary measures.

. High-risk patients should wear high-efficiency masks when not in a functioning protective environment room during construction/renovation activities.

(Likely to Be Effective continued)

Uniform/protective garment washing by employer when contaminated ⁴

Mattress maintenance to maintain integrity of mattress ⁴

. Replace mattresses that have lost integrity. Do not puncture mattresses with needles.

Effectiveness Not Established

Interventions for which insufficient data or data of inadequate quality currently exist

Immune globulin for respiratory syncytial virus 1

Enhanced infection control policy to prevent the trans-mission of vancomycin-resistant enterococci (VRE) ^33-35

. Nonrandomized, single-institution studies suggest that enhanced infection control measures may decrease the transmission of VRE. Interventions evaluated include contact isolation, limiting the use of empiric vancomycin, spatial separation of patients based on VRE status, infection control surveillance, and staff and patient education. Multiple interventions were implemented simultaneously, so the effect of each intervention is unknown.

Protective isolation ^5,6,36,37

Diet modifications for neutropenic patients

. No recent studies have linked dietary restrictions with a lower risk of infection for neutropenic patients with cancer; however, basic principles, such as avoiding uncooked meats, seafood, eggs, and unwashed fruits and vegetables, may be prudent. ^{6,7,32,36,38-40} Multivitamin supplementation for patients with cancer anticipating neutropenia requires further study.⁴¹

Effectiveness Unlikely

Interventions for which lack of effectiveness is less well established than for those listed under "Not Recommended for Practice"

Laminar air flow ^4,14

Not Recommended for Practice

Interventions for which clear evidence has demonstrated ineffectiveness or harmfulness or for which the cost or burden necessary for the intervention exceeds the anticipated benefit

Antifungal prophylaxis for neutropenic patients with cancer with solid tumors ^14,15,18-23

. Antifungal prophylaxis is not recommended for all neutropenic patients with cancer. It is only recommended for high-risk patients such as those with acute leukemia and those undergoing HSCT.

Itraconazole capsules are not effective for any cancer population ²¹

(Not Recommended for Practice continued)

Nonabsorbable topical antifungal drugs to prevent oral candidiasis ^16,17

. Antifungal drugs not absorbed from the GI tract (amphotericin B, nystatin, nystatin plus chlorhexidine, thymostimulin, amphotericin B plus nystatin, polyenes, natamycin, and norfloxacin plus amphotericin B) did not have significant benefit in preventing oral candidiasis.

TMP-SMZ for antibacterial prophylaxis in afebrile neutropenic patients with cancer ^15,26-28,42

Gram-positive prophylaxis and fluoroquinolone in combination for antibacterial prophylaxis in afebrile neutropenic patients with cancer ⁴²

FluMist ^® (intranasal attenuated influenza vaccine) ¹⁴

What interventions are effective in preventing oral mucositis in people with cancer?

Mucositis was included in this review because it is associated with a significantly increased risk of infection when present in people with cancer. ⁴³

Recommended for Practice

Interventions for which effectiveness has been demonstrated by strong evidence from rigorously designed studies, meta-analyses, or systematic reviews and for which the expectation of harms is small compared to the benefits

Oral care protocols

. Oral care protocols, including regular cleansing of the teeth and mucosal tissue, as well as patient education, significantly reduce the severity of mucositis from chemotherapy or radiotherapy. ⁴⁴

Cryotherapy for patients receiving bolus 5-fluorouracil (5-FU) ^17,44-47

. Patients should be instructed to hold ice chips in their mouth starting 5 minutes prior to the bolus 5-FU and for 30 minutes after. The effectiveness of this intervention is related to the short half-life of bolus 5-FU and is NOT proven for other chemotherapy agents.

Likely to Be Effective

Interventions for which the evidence is less well established than for those listed under "Recommended for Practice"

Amifostine for patients with head and neck cancer treated with radiotherapy ⁴⁶

Granulocyte macrophage-colony-stimulating factor for patients with solid tumors ⁴⁶

Hydrolytic enzymes for patients with head and neck cancer ⁴⁶

Topical antibiotic pastille or paste for patients with solid tumors ⁴⁶

Effectiveness Not Established

Interventions for which insufficient data or data of inadequate quality currently exist

Allopurinol ^17,46

Benzydamine ⁴⁶

Clarithromycin ⁴⁶

Povidone ⁴⁶

Effectiveness Unlikely

Interventions for which lack of effectiveness is less well established than for those listed under "Not Recommended for Practice"

Chamomile ^17,46

Folinic acid ⁴⁶

Pentoxifylline ⁴⁶

Prednisolone ⁴⁶

Propantheline ⁴⁶

Prostaglandin ^17,46

Traumeel ⁴⁶

Not Recommended for Practice

Interventions for which clear evidence has demonstrated ineffectiveness or harmfulness or for which the cost or burden necessary for the intervention exceeds the anticipated benefit

Acyclovir ⁴⁶

Chlorhexidine ^17,44,46

Glutamine ⁴⁶

Sucralfate ⁴⁶

Recommendations are intended for the prevention of infection for the general hematology and oncology patient population. Recommendations for the prevention of infection for transplant (HSCT) recipients are excluded. Recommendations for the treatment of febrile neutropenia or established infections are excluded.

Authors: Laura Zitella, RN, MS, NP, AOCN^® , Christopher Friese, PhD, MS, RN, AOCN^®, Barbara Holmes Gobel, MS, RN, AOCN^®, Myra Woolery, RN, MN, Colleen O'Leary, RN, BSN, OCN^® , Jody Hauser, RN, MS, NP, and Felicia Andrews, RN, BSN

Oncology Nursing Society

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Definitions of the interventions and full citations: www.ons.org/outcomes

Literature search completed through June 2005.

This card, published by the Oncology Nursing Society (ONS), reflects a scientific literature review. There is no representation nor guarantee that the practices described herein will, if followed, ensure safe and effective patient care. The descriptions reflect the state of general knowledge and practice in the field as described in the literature as of the date of the scientific literature review. The descriptions may not be appropriate for use in all circumstances. Those who use this card should make their own determinations regarding safe and appropriate patient care practices, taking into account the personnel, equipment, and practices available at their healthcare facility. ONS does not endorse the practices described herein. The editors and publisher cannot be held responsible for any liability incurred as a consequence of the use or application of any of the contents of this card.

This card was printed through the support of the Breast Cancer Fund of the National Philanthropic Trust.