Restriction of Fresh Fruits and Vegetables

Restriction of Fresh Fruits and Vegetables

PEP Topic 
Prevention of Infection: Transplant

The low microbial diet involves proper food and drink preparation and avoiding specific foods that may contain infection-causing organisms, such as bacteria and fungi.  Low microbial diets generally eliminate raw, unprocessed, and fresh fruits and vegetables and drinking tap water and emphasize well-cooked foods and appropriate food handling to reduce cross-contamination.  Use of a low microbial diet has been recommended for the prevention of infection in patients with cancer but has not been extensively studied.

Effectiveness Unlikely

Research Evidence Summaries

Trifilio, S., Helenowski, I., Giel, M., Gobel, B., Pi, J., Greenberg, D., & Mehta, J. (2012). Questioning the role of a neutropenic diet following hematopoetic stem cell transplantation. Biology of Blood and Marrow Transplantation: Journal of the American Society for Blood and Marrow Transplantation, 18, 1385–1390.


Study Purpose:

To evaluate the effects of a general hospital diet (GD) and a neutropenic diet (ND) on the incidence of microbiologically confirmed infections in hematopoietic stem cell transplantation (HSCT) recipients.

Intervention Characteristics/Basic Study Process:

In 2006, the organization replaced its ND with a GD that retained restrictions for undercooked meat, fish, and some unpasteurized dairy products but allowed fresh fruits and vegetables. Data were obtained from electronic medical records of consecutive hospitalized HSCT recipients who received the GD or the ND during neutropenia.  All patients were receiving standard antibiotic, antifungal, and antiviral prophylaxis.  The ND excluded all fresh fruits and vegetables, black pepper, raw and undercooked meats and cheeses, cold smoked fish, raw or unpasteurized dairy products, raw miso and grain products, and brewer’s yeast. The GD permitted black pepper and well-washed fresh fruits and vegetables but excluded raw tomatoes, seeds, and grains. Other diet restrictions remained in place.  All patients were placed on these particular diets around the time of neutropenia and reverted back to a GD once neutropenia resolved.

Sample Characteristics:

  • In total, 726 patients (58.6% male, 41.4% female) were included. 
  • Mean age was 57 (range 18–78).
  • All patients were HSCT recipients. 
  • The majority of patients had myeloma, non-Hodgkin lymphoma, or acute myeloid leukemia.
  • Sixty to seventy percent of patients developed neutropenic fever.


  • Single site
  • Inpatient 
  • Chicago

Phase of Care and Clinical Applications:

Patients were undergoing the active antitumor treatment phase of care.

Study Design:

This was a retrospective descriptive study.

Measurement Instruments/Methods:

  • Neutropenic fever (defined as a temperature of >101°F or two temperatures >100.5°F with an absolute neutrophil count of <500/mm3)
  • All positive microbial cultures from onset of neutropenia until hospital discharge


There were significantly fewer confirmed infections in the GD group (p < 0.0272). Diarrhea (p < 0.095) and urinary tract infection (p < 0.003) were more common in the ND group. Overall mortality and hospital length of stay was similar between the groups.  The ND group had a higher rate of infection after resolution of neutropenia, with more frequent Clostridium difficile and vancomycin-resistant enterococci infections (p < 0.07).


Maintaining an ND that restriced fresh fruits and vegetables did not reduce infection and was associated with an increased risk of infection after resolution of neutropenia.


  • Risk of bias (no control group, no blinding, no random assignment) 
  • Retrospective descriptive study design

Nursing Implications:

The study findings provide further evidence that restricting fresh fruits and vegetables from the diet of patients who are neutropenic is not beneficial.  These findings suggest that such restrictions may have a negative impact.

Systematic Review/Meta-Analysis

van Dalen, E.C., Mank, A., Leclercq, E., Mulder, R.L., Davies, M., Kersten, M.J., & van de Wetering, M.D. (2012). Low bacterial diet versus control diet to prevent infection in cancer patients treated with chemotherapy causing episodes of neutropenia. Cochrane Database of Systematic Reviews, 9, CD006247.

doi: 10.1002/14651858.CD006247.pub2


To determine the efficacy of a low bacterial diet (LBD) versus a control diet in preventing the occurrence of infection and reducing related mortality in patients with cancer receiving immunosuppressive chemotherapy.

Search Strategy:

Databases searched were the Cochrane Central Register (CENTRAL), DARE, PubMed, EMBASE, and CINAHL, as were conference proceedings from multiple professional groups.

Included in the study were patients with cancer receiving chemotherapy causing episodes of neutropenia, use of an LBD versus a control diet, with an LBD defined as any diet intended to reduce the ingestion of bacterial and fungal contaminants by exclusion of uncooked fruits and vegetables, cold cuts, undercooked eggs and meat, unsterilized water, unpasteurized milk products, and soft cheeses. The control diet was any other diet.

Children younger than 1 year were excluded from the study.

Literature Evaluated:

Six hundred nineteen total references were retrieved.

Risk of study bias was evaluated using the Cochrane Handbook for Systematic Reviews of Interventions.


Sample Characteristics:

  • After exclusion, the final number of studies examined was three.
  • The sample range across studies was 19 to 153.
  • Samples included patients treated with remission induction chemotherapy for acute myeloid leukemia, high-risk myelodysplastic disease, or acute lymphoblastic leukemia.
  • One study had a pediatric population.

Phase of Care and Clinical Applications:

  • Patients were undergoing the active antitumor treatment phase of care.
  • The study has clinical applicability for pediatrics.


Included studies had different definitions of infection rate and different outcomes measured and defined. Blinding and selection bias were problems in the study design, and only one study provided explicit data on the use of empirical antibiotics and antimycotics. Data could not be pooled for meta-analysis. In all three studies, there was no significant difference in outcomes between groups.


There is currently no strong evidence demonstrating the need or effectiveness of LBDs, and due to differing outcome measures, diets used and cointerventions for prophylaxis pooling of results was not possible. No firm conclusions can be drawn, and no recommendations for clinical practice are made.


  • Small number of studies
  • Various study design limitations and risks of study bias

Nursing Implications:

The results suggest that no firm conclusions can be made about the usefulness of an LBD and that there is no strong evidence to show the effect. Additional well-designed research in this area would be helpful.