San Antonio, TX—Speakers from the Oncology Nursing Society’s Special Interest Group on Neutropenia reinforced infection prevention at a session during the 2016 Oncology Nursing Society Annual Congress.
Barbara Wilson, MS, RN, AOCN, ACNS-BC, Clinical Nurse Specialist and Director of Oncology Professional Practice, WellStar Regional Medical System, Marietta, GA, provided some background first, and shared the podium with Allison Streeter, RN, BSN, OCN, St. Alexius Medical Center, Bismarck, ND.
Infections are observed in approximately 50% of patients with solid tumors and in 80% of patients with hematologic malignancies, and they result in hospitalization for approximately 60,000 patients annually. An astounding 1 in 14 patients will die of infection, she said.
“Septic shock is a big alarm, and 1 patient in 14 dying seems very serious….We have to identify who is at risk for infection, and prevent it,” Ms Wilson said.
Risk for Infection, by Treatment Regimen
An assessment of risk is critical. Patient-related risk factors include age >65 years, being a woman, low body mass index, presence of comorbidities, laboratory abnormalities, poor performance or nutritional status, and active infection, open wound, or recent surgery. Disease-based factors include advanced disease stage, bone marrow involvement, type of cancer (ie, hematologic, lung, breast, colorectal, or ovarian), genotype, and history or presence of neutropenia.
The risk is also increased when the treatment is intended to be curative or is a high-intensity regimen, when the relative dose intensity is ≥85%, and when patients are receiving immunosuppressive medications.
The risk can be high, intermediate, or low, based on the treatment regimen and the anticipated absolute neutrophil counts (ANCs):
- High: ANC <500 for >10 days (acute leukemia induction or consolidation, allogeneic stem-cell transplant)
- Intermediate: ANC <500 for 7 to 10 days (autologous transplant, chemotherapy with purine analog, multiple myeloma, lymphoma, chronic lymphocytic leukemia)
- Low: ANC <500 for <7 days (standard treatment for most solid tumors).
“Remember these factors ahead of time, and identify the patient’s risk,” Ms Wilson said.
Education Is Most Important
“The most important thing we can do is educate our patients in both the inpatient and outpatient settings,” Ms Streeter told attendees. This is also true for staff and family members.
Evidence-based policies should be developed and adhered to, but information and resources should be individualized.
The “first and foremost” principle is hand hygiene, she emphasized. “Wash long enough. Sing the happy birthday song. Describe to patients the very high-risk areas they touch,” Ms Streeter noted. Hand hygiene also involves properly drying hands; moisture simply attracts more bacteria.
“Use teach-back strategies. Have them [patients and family members] demonstrate proper hand-washing back to you, and have them tell you why they can’t do things such as garden daily,” she advised.
Inconsistencies and noncompliance should also be addressed among nurses, and best practices rewarded, Ms Streeter added.
Simple Infection Control Practices to Emphasize
Other measures are also important. Oral care should include a soft toothbrush, nonalcoholic mouthwash, and frequent rinsing, but not necessarily flossing. After bathing, patients should pat dry, not rub with the towel, and use an effective moisturizer. Shaving should be done with electric razors. Women should avoid tampons or douching, and after toileting wipe from front to back. Shoes should fit properly. Safe sex should be practiced to protect against sexually transmitted infections.
“Skin is the first line of defense,” Ms Streeter emphasized.
Other personal care recommendations are to avoid crowds and people with infections or open sores; wear sunscreen; avoid gardening (or wear protective gloves); do not use rectal thermometers, suppositories, or catheters; eat a proper diet with well-cooked foods; and balance exercise with rest.
In the household, shoes should be removed upon entry, standing water should be eliminated, and animal waste should be removed by someone other than the patient.
Ms Wilson informed listeners that the neutropenic diet is no longer advocated. “There is no evidence that elimination of fruits and vegetables is protective,” she said. “But we do promote safe handling. Anything that cannot be washed or cooked cannot be eaten.”
Prophylactic Medications: For Whom?
For patients who are expected to have prolonged, severe neutropenia, prophylactic antibiotics—especially fluoroquinolones—and antifungals are recommended; the antifungals are especially important for patients undergoing transplant and patients using steroids long-term.
Colony-stimulating factors reduce the risk for febrile neutropenia and hospitalizations and are best given prophylactically, not reactively. They can also prevent secondary episodes of neutropenia after a primary infection.
No differences have been shown between filgrastim and pegfilgrastim, but the timing of these drugs is different. Filgrastim is short-acting and peaks the next day; it is normally given the day after chemotherapy, for 2 to 3 days, for a total of 3 doses, and is most appropriate for chemotherapy that is given weekly. Pegfilgrastim is longer acting and is used for chemotherapy that is given every 3 weeks.
Keeping Patients Safe
“Patients are very aware they are at risk of infection,” Ms Wilson said.
If possible, patients with certain diagnoses need to be isolated from other patients, and those who may be contagious should be rescheduled.
When patients present with stool incontinence, loss of skin integrity, or secretions that are not contained, they should be separated from other patients. Nurses should protect themselves with gloves (and other personal protective equipment, depending on the risk), hand hygiene, and a disinfected environment. When droplets are present, masks and perhaps even face shields and gowns are warranted.
“Until you rule out the nature of that droplet, don’t expose others to it,” Ms Wilson added.
For disinfecting the environment, housekeeping plays an integral role. “When patients and families see housekeeping wipe down all surfaces, they feel protected,” she noted.
Catheter-related infections can be prevented with aseptic techniques for peripheral intravenous starts, cleansing skin with 0.5% chlorhexidine with alcohol, using sterile dressing without ointment at the infection site, and having a care bundle for central lines.
In closing, Ms Wilson emphasized that to reduce the opportunity for infection, staff need to be consistent with evidence-based preventive practices, monitor for compliance, and address shortcomings.
“The main thing is to work as a team for all who have a stake in this,” she said.