Infectious complications of chemotherapy in a protected environment

Efficacy of selective digestive decontamination in patients with multiple myeloma undergoing high-dose chemotherapy and autologous stem cell transplantation

Selective digestive decontamination (SDD) with the oral, non-absorbable antimicrobial substances gentamicin, vancomycin and amphotericin B was optionally used at our institution to reduce the risk of gastrointestinal tract derived infections in multiple myeloma (MM) patients undergoing high-dose chemotherapy with subsequent autologous stem cell transplantation (HDCT/ASCT). The majority of patients received sulfamethoxazole-trimethoprim as pneumocystis pneumonia prophylaxis. From 203 patients receiving their first HDCT/ASCT between 2009 and 2015, we compared retrospectively 90 patients receiving SDD to 113 patients not receiving SDD. The administration of SDD was associated with a reduction of bacterial infections after HDCT/ASCT (overall: 8% versus 24%, p = .002; gram-negative pathogens: 1% versus 11%, p = .006) and less use of systemic antibiotics (62% versus 77%, p = .022). Omission of SDD was an independent risk factor for developing neutropenic fever and bloodstream infections. SDD could be an option to reduce bacterial infections in patients undergoing HDCT/ASCT that needs to be tested in prospective trials.

The Effect of the Neutropenic Diet in the Outpatient Setting: A Pilot Study

PURPOSE/OBJECTIVES

To determine whether use of the neutropenic diet in the outpatient setting decreases the number of febrile admissions and positive blood cultures associated with chemotherapy-induced neutropenia.

DESIGN

Descriptive pilot study.

SETTING

Outpatient chemotherapy unit of a medical center in a major metropolitan area.

SAMPLE

Convenience sample of 28 patients aged 33-67 years beginning treatment with 1 of 13 chemotherapy regimens.

METHODS

Twelve-week prospective study beginning on day 1 of chemotherapy cycle 1. Patients received instructions regarding the neutropenic diet before starting chemotherapy. Adherence assessment telephone calls were made at weeks 6 and 12. Hospital admission charts were reviewed at study completion.

MAIN RESEARCH VARIABLES

Adherence with neutropenic diet, number of febrile admissions, and number of positive blood cultures.

FINDINGS

Sixteen patients were compliant with the neutropenic diet, four of which were admitted for neutropenia with gram-negative rods. No significant differences were found in the rates of febrile admissions or positive blood cultures between compliant and noncompliant patients.

CONCLUSIONS

Clinical significance in this pilot study is related to the time required for diet education, content of diet education regarding food restrictions, and difficulty adhering to diet requirements given the multitude of side effects (e.g., nausea, vomiting, mouth sores, diarrhea) of chemotherapy.

IMPLICATIONS FOR NURSING

No clear evidence exists that the neutropenic diet makes a difference in overall rates of infection. Nursing research to compare the neutropenic diet with a less restrictive food safety education-focused diet is needed to guide clinical practice.

The neutropenic diet: what's the evidence?

Despite improved survival of children with cancer, opportunistic infections remain a significant cause of morbidity and mortality in this population. Several interventions have been tried to decrease the incidence of infection by reducing patients' exposure to bacteria during neutropenia. The neutropenic diet is one such intervention that was intended to limit the introduction of bacteria into the host's gastrointestinal tract. The only studies evaluating this diet have used this strategy in combination with multiple other interventions, and the independent effect of this diet remains unknown. More research about the neutropenic diet is needed to establish its effectiveness in clinical practice.

Psychological evaluation and management of pediatric oncology patients in protected environments

Specific aspects of psychological investigation and management of pediatric patients with widely disseminated solid tumors treated in semiportable, laminar airflow patient isolators are discussed. Information was obtained prospectively from a psychosocial study c-ordinated with a medical investigation of the use of protected environments (PE) employing barrier isolation as an adjunct to intensive anticancer therapy. Included are description of the development of psychological criteria for patient eligibility, psychometric evaluation, longitudinal behavioral observation, pre-entry and predischarge orientation techniques, as well as approaches to the ongoing management of patients and families. No debilitating psychological disturbance has been observed in these patients, and no patients have had to be removed for psychological reasons. Specific transitory psychological changes are noted as are the problems encountered by staff members functioning in such a setting. The adoption of a well-coordinated psychosocial program of investigation and clinical intervention has proved useful in maximizing patient adjustment to prolonged treatment in protected environments.

Infection in immunodepressed patients. The approach to diagnosis and treatment

Infection is an important cause of death in patients receiving cytostatic drugs or with any other impairment of host resistance. Such infections are frequently due to opportunist micro-organisms usually belonging to the endogenous flora of the patient. It is often difficult to obtain an exact diagnosis of the cause and localization of the infection. The problems associated with the prevention of infection are manifold. Exogenous infections can be prevented by proper isolation and a sterile diet. Endogenous infections can only be prevented by eradication of the patient's endogeous flora, so-called decontamination. Special attention should be given to treatment of foci of chronic infection and of the carrier state of certain microorganisms. However, the prophylactic use of antibiotics should be avoided. The curative use of antibiotics should be based on the most probable micro-organism. We consider the inventory of the patient's microflora, repeated weekly, of great help in the choice of antibiotics in cases of septicaemia of unknown aetiology. The initial therapy usually consists of a broad-spectrum combination of antibiotics, which should be bactericidal. When the causative bacteria have been isolated and the sensitivity is known, antibiotic therapy should be adjusted to the narrowest spectrum possible.

Infections in cancer patients on a protected environment-prophylactic antibiotic program

A total of 102 studies were conducted on 89 patients receiving cancer chemotherapy while on a protected environment-prophylactic antibiotic program. Major infections occurred during 22 studies. The majority of both minor and major infections originated during the first five weeks after the patients entered the protected environment units. The frequency of infectious complications was inversely related to the circulating neutrophil count. The majority of infections were cases of cellulitis, pharyngitis, pneumonia and septicemia. Most of the infections were caused by gram-negative bacilli. The majority of organisms causing infection had persisted in the patients after their entry into the protected environment units despite the use of prophylactic antibiotics.

Bacterial flora and infection in patients with brain injury

✓ Twenty-five patients with acute head trauma were studied prospectively for appearance of infection during hospitalization in an acute care unit. The study demonstrates: multiple changes in bacterial flora particularly in the respiratory tract, a significant morbidity due to bacterial changes in the respiratory tree, a negligible incidence of bacterial disease due to physiological monitoring procedures, and an inability to correlate changing flora with specific therapeutic or manipulative procedures except tracheostomy. Mortality correlates well with the severity of illness and indirectly with changes in bacterial flora. Despite the frequent isolation of coagulase-positive staphylococci, severity of infectious complications correlate most closely with the acquisition of gram-negative organisms in the respiratory tract.

Care and observation of a germ-free neonate

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