Stoll, P., Silla, L.M., Cola, C.M., Splitt, B.I., & Moreira, L.B. (2013). Effectiveness of a Protective Environment implementation for cancer patients with chemotherapy-induced neutropenia on fever and mortality incidence. American Journal of Infection Control, 41, 357–359.

To evaluate the significance of a protective environment (PE) on febrile neutropenia and mortality in patients with cancer with chemotherapy-induced neutropenia

The intervention was comprised of engineering and design interventions, incorporating high-efficiency particulate filters, positive air pressure, well-sealed rooms, and infection control routines according to international recommendations for a PE. Outcomes were compared to those of patients admitted prior to the implementation of standard environmental practices.

• N = 371
• MALES: 47%, FEMALES: 53%
• KEY DISEASE CHARACTERISTICS: Acute myeloid leukemia, chronic myeloid leukemia, acute lymphoid leukemia, chronic lymphoid leukemia, multiple myeloma, Hodgkin disease, non-Hodgkin lymphoma, myelodysplastic syndrome, other hematologic malignancies, aplastic anemia, solid tumors
• OTHER KEY SAMPLE CHARACTERISTICS: Risk categories of autologous hematopoietic stem cell transplantation (HSCT), allogeneic HSCT, acute myeloid leukemia, and other diseases

• SITE: Single site 
• SETTING TYPE: Inpatient hospital  
• LOCATION: Brazil

• PHASE OF CARE: Active treatment

• Descriptive cohort

• Cumulative incidence of febrile neutropenia and death were determined by the Kaplan-Meier method.
• The adjusted hazard ratios were computed in a Cox regression model.

Fever occurred in 74.7% of episodes of neutropenia in the PE group and in 86.7% in the control group (p = 0.003). Adjusting for length of neutropenia, risk, category, antibacterial prophylaxis, and central venous catheter use, the PE reduced febrile neutropenia (p = 0.009). The PE also decreased overall mortality (p = 0.001) and 30-day mortality (p = 0.002). Gram-negative bacterial infections were more frequent after the intervention (p = 0.18), while gram-positive bacterial infections were similar (p = 0.85). Fungal infections were more frequent in the control group (p = 0.04).

This study shows the advantages of the PE on reducing febrile neutropenia and mortality among patients with cancer and indicates that multiple infection control interventions significantly can diminish hospital-acquired infections.

• Risk of bias (no control group)
• Risk of bias (no blinding)
• Risk of bias (no random assignment)

Although the study does not delineate what they are, an important part of the intervention is infection control routines. These routines include hand hygiene and the routine use of personal protective equipment. Infection control is essential not only to protect nurses, but also to prevent the transmission of infection from one patient to another, particularly when those patients are at higher risk because of chemotherapy-induced neutropenia, and their importance cannot be overstated.