Infection Prevention in Outpatient Oncology Settings CDC Offers Tools to Fight Back Against Infections Among Cancer Patients

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Infection prevention in outpatient oncology settings CDC offers tools to fight back against infections among cancer patients. BY ALICE Y. GUH, MD, MPH, LISA C. RICHARDSON, MD, MPH, AND ANGELA DUNBAR, BS

espite advances in oncology care, infections remain a major www.preventcancerinfections.org 1-3 cause of morbidity and mortality among cancer patients. 1. What? PREPARE: Watch Out for Fever! You should take your temperature any time you blood cell count is likely to be the lowest since in that you are a cancer patient undergoing When? feel warm, flushed, chilled or not well. If you get a this is when you’re most at risk for infection chemotherapy. If you have a fever, you might temperature of 100.4°F (38°C) or higher for more (also called nadir). have an infection. This is a life threatening Several factors predispose cancer patients to developing infec- than one hour, or a one-time temperature of 101° • Keep a working thermometer in a convenient condition, and you should be seen in a short F or higher, call your doctor immediately, even if location and know how to use it. amount of time. it is the middle of the night. DO NOT wait until the • Keep your doctor’s phone numbers with you at office re-opens before you call. all times. Make sure you know what number to call when their office is open and closed. tions, including immunosuppression from their underlying You should also: • If you have to go to the emergency room, it's • Find out from your doctor when your white important that you tell the person checking you • If you develop a fever during your chemotherapy treatment it is a medical emergency. Why? cancer and chemotherapy treatment. Frequent contact with • Fever may be the only sign that you have an infection, and an infection during chemotherapy can be life threatening. 2. What? PREVENT: Clean Your Hands! Keeping your hands clean is important in Clean your hands: • Before and after treating a cut or wound or When? preventing infections. This should include you, all • Before, during, and after cooking food caring for your catheter, port or other access healthcare settings may expose them to other patients with members of your household, your doctors, • Before you eat device nurses and anyone that comes around you. Don't • After going to the bathroom be afraid to ask people to clean their hands. If • After changing diapers or helping a child to use soap and water are not available, it's o.k. to use the bathroom an alcohol-based hand sanitizer. • After blowing your nose, coughing, or sneezing transmissible infections. Patients with cancer often require the placement • After touching your pet or cleaning up after your pet D • After touching trash • Many diseases and conditions are spread by not cleaning your hands. Why? of long-term intravascular devices, such as implanted ports, to provide • Cleaning your hands is EXTREMELY important during chemotherapy treatment because your body can’t fight off infections like it used to. 3. What? PROTECT: Know the Signs and Symptoms of an Infection!

During your chemotherapy treatment, your body • Nasal congestion Find out from your doctor when your white blood ease with chemotherapy infusion. However, these devices can provide When? will not be able to fight off infections like it used • Stiff neck cell count is likely to be the lowest since this is to. Call your doctor immediately if you notice any • Burning or pain with urination when you’re most at risk for infection. This usually of the following signs and symptoms of an • Unusual vaginal discharge or irritation occurs between 7 and 12 days after you finish infection: • Increased urination each chemotherapy dose—and will possibly last • Redness, soreness, or swelling in any area, up to one week. direct portal-of-entry for microorganisms to enter the bloodstream if • Fever (this is sometimes the only sign of including surgical wounds and ports an infection) • Diarrhea • Chills and sweats • Vomiting • Change in cough or new cough • Pain in the abdomen or rectum • Sore throat or new mouth sore • New onset of pain they are not appropriately disinfected prior to access. Thus, careful • Shortness of breath • Changes in skin, urination, or mental status • When your counts are low, take even the slightest sign or symptom of an infection as serious and call your doctor immediately. attention to proper infection prevention practices is essential to the care Why? • Infection during chemotherapy can be very serious, and can lead to hospitalization or death. Write the number(s) to call in Emergency Number Card of cancer patients to minimize their risks for infectious complications. an emergency here: 1. Treat a fever as an emergency. Doctor’s daytime number: 2. Call your doctor immediately if you develop a fever.

______3. If you have to go to the emergency room, tell them right away that you are undergoing chemotherapy treatment. In recent decades, the vast majority of Furthermore, unlike acute care hospitals, Doctor’s after-hours number: Doctor’s daytime number:______Doctor’s after-hours number:______FEVER: TEMPERATURE OF 100.4°F (38°C) OR HIGHER FOR MORE THAN ONE HOUR OR A ONE-TIME TEMPERATURE OF 101° F OR HIGHER.

oncology services have shifted from inpa- there is limited federal and state regula- www.preventcancerinfections.org tient to outpatient settings. Each year nearly tory oversight of many outpatient settings, Cut out the emergency number card. Fill in your doctor’s information. Carry this card with you at all times. 650,000 patients with cancer receive out- including outpatient oncology facilities. As 4 The Three Steps Brochure was created for cancer patient chemotherapy. However, not all a result, many outpatient facilities are not patients and caregivers to help increase awareness outpatient facilities maintain regular access routinely inspected for infection prevention about the importance of infection prevention. to infection prevention expertise or have practices. Image COURTESY cdc/www.preventcancerinfections.org. dedicated infection prevention policies for Breaches in basic infection prevention prac- patient protection. tices have resulted in a number of outbreaks

www.apic.org | 65 involving outpatient oncology settings. For storage and handling; and 5) safe handling example, in a Nebraska oncology clinic, and cleaning/disinfection of potentially syringe reuse to access saline bags shared contaminated equipment or surfaces in among multiple patients led to the trans- the patient environment. Procedures for mission of hepatitis C virus to at least 99 each component of Standard Precautions cancer patients, resulting in one of the are detailed in the BICAPP. For example, largest healthcare-associated outbreaks of as part of respiratory hygiene, triaging of viral hepatitis.5 Similar lapses in injection patients upon entry to the facility should safety (e.g., reusing single-dose vials on be performed, especially during periods multiple patients, storing prefilled saline of increased community respiratory virus flush syringes for later use) have also been activity, to prevent spread of respiratory implicated in outbreaks of bacterial blood- infections among clinic patients. Safe stream infections among cancer patients.6-8 injection practices that are relevant to Other identified lapses have included poor oncology facilities include appropriate hand hygiene, suboptimal disinfection of preparation and handling of saline and injection caps (e.g., needleless connectors) heparin syringes for flushing central lines. prior to accessing central lines, and inad- Transmission-based precautions. equate environmental conditions for che- Implementation of additional precautions, motherapy preparation. BICAPP can be used by any outpatient oncology facil- such as Contact Precautions, Droplet To help combat this public health chal- ity to standardize and improve infection prevention Precautions, and Airborne Precautions, may practices. Image COURTESY the cdc. lenge, CDC launched its Preventing Infections be warranted in certain situations and should in Cancer Patients campaign in October assess adherence to recommended infection be applied based on a patient’s history and symptoms. 2011. This public health program offers prevention practices. healthcare providers, patients, and families a At Your Fingertips: A list of names of des- Central venous catheters. When accessing set of user-friendly resources designed to help ignated personnel and their specific roles a patient’s central line for infusions and reduce the risk of life-threatening infections and tasks and contact information that can blood draws, all facility staff should use during a cancer patient’s treatment. Each of be tailored to your facility is provided as an these tools is described in more detail in the appendix. following sections. Surveillance and reporting. Routine OUT OF SIGHT, OUT OF MIND... Basic Infection Control and Prevention surveillance of infections (e.g., bloodstream NOT THIS TIME! for Outpatient Oncology Settings (BICAPP) infections) and process measures related to The BICAPP (www.cdc.gov/hai/pdfs/guide- infection prevention practices (e.g., hand lines/basic-infection-control-prevention- hygiene) should be conducted for outbreak plan-2011.pdf) can be used by any outpatient detection and improvement of healthcare oncology facility to standardize and improve practices. Facility staff should also be aware infection prevention practices. The docu- of and adhere to local, state, and federal One of the most dangerous requirements for reportable diseases and side effects of chemotherapy ment is based on the CDC’s evidence-based cannot be seen? guidelines as well as relevant guidelines from outbreak reporting. That’s right, a low white blood cell count, professional societies and is tailored for quick At Your Fingertips: The BICAPP contains or neutropenia, puts cancer patients at a higher risk for getting an infection. implementation in outpatient oncology facil- an appendix where a facility can insert a list of An infection in people with cancer is an ities. It includes key policies and proce- reportable disease/conditions specific to their emergency. Be prepared, and remember the following three things during chemotherapy: dures that will ensure a facility meets or state and the appropriate contact information 1. Treat a fever as an emergency, and call your doctor right away if you develop a fever. exceeds minimal expectations of patient for their local and state health authorities. 2. Find out from your doctor when your white blood cell count will be the lowest because this is when you are most at risk for infection. safety. The main components of the plan Standard Precautions. 3. If you have to go to the emergency room, it’s important that All facility staff you tell the person checking you in that you have cancer and are receiving chemotherapy. If you have an infection you Learn more at: www.cdc.gov/ include the following: should not sit in the waiting room for a long time. Infections should adhere to Standard Precautions, can get very serious in a short amount of time. cancer/preventinfections Education and training. All facility staff which include: 1) hand hygiene; 2) use National Center for Chronic Disease Prevention and Health Promotion should receive appropriate education and of personal protective equipment (e.g., Division of Cancer Prevention and Control Made possible by a CDC Foundation partnership with Amgen training in infection prevention during gloves, gowns, facemasks) depending on The Out of Sight, Out of Mind poster alerts both provid- orientation as well as annually and any time the anticipated exposures; 3) respiratory ers and consumers that patients undergoing chemo- policies change. Competency evaluations of hygiene and cough etiquette; 4) safe injection therapy are at a higher risk of developing infections. facility staff should be regularly conducted to practices, including appropriate medication Image COURTESY cdc/www.preventcancerinfections.org.

66 | WINTER 2013 | Prevention EMERGENCY ROOM PERSONNEL Cancer Patients campaign also created an educational tool for patients and their caregivers that addresses one of the most com- At your fingertips: Basic mon and potentially deadly side effects in Infection Control and patients receiving chemotherapy treatments: Prevention for Outpatient A fever in neutropenia (low white blood cell count). Oncology Settings cancer patients may be more Patients with neutropenia are more sus- (BICAPP) than meets ceptible to bacterial infections. Their risk The BICAPP can be used by any outpatient the eye. for acquiring a life-threatening infection oncology facility to standardize and improve increases progressively with both the dura- infection prevention practices. This is tion and magnitude of neutropenia. The • The BICAPP also includes the CDC Infection especially CDC used knowledge gained through Prevention Checklist for Outpatient Settings true for a cancer patient formative research to tailor messages and that can be tailored by an outpatient oncology undergoing launch a website aimed at helping cancer facility to systematically assess personnel chemotherapy patients understand their risk for developing adherence to recommended infection preven- who develops a fever. tion practices. Get the full picture about people with a low white blood cell count and steps they cancer who are receiving chemotherapy. can take to lower their risk of infection when • The appendix provides a list of relevant If they have a fever, remember— 1. A fever may be the only sign of infection and should be treated as an emergency. they are most vulnerable. resources, including the United States 2. Developing an infection is a life-threatening complication. Learn more at: www.cdc.gov/ 3. A minor infection can turn serious fast. Quick action can cancer/preventinfections Three Steps Toward Preventing Pharmacopeia (USP) Chapter <797> save a life. Infections During Cancer Treatment Guidebook to Pharmaceutical Compounding— National Center for Chronic Disease Prevention and Health Promotion Division of Cancer Prevention and Control (www.preventcancerinfections.org , Sterile Preparations. All oncology facilities that Made possible by a CDC Foundation partnership with Amgen ) is an evidence-based tool that assesses a cancer provide on-site chemotherapy preparation Intended for healthcare personnel, the Emergency should follow USP guidance in consultation Room Personnel poster increases awareness of the patient’s risk for developing neutropenia dur- dangers of fevers in cancer patients. ing chemotherapy. After the assessment is with the state pharmacy board. Image COURTESY cdc/www.preventcancerinfections.org. completed, patients can receive downloadable • The BICAPP contains an appendix where a information about how to help lower their facility can insert a list of reportable dis- aseptic technique, including scrubbing the risk for infection and keep themselves healthy ease/conditions specific to their state and access port with an appropriate antiseptic while receiving chemotherapy. Educational the appropriate contact information for their agent. Additional maintenance and access information is available for everyone even local and state health authorities. procedures, such as changing catheter site if the assessment is not completed. The • A list of names of designated personnel and dressing and injection caps, are outlined in CDC hopes this information will lead can- their specific roles and tasks and contact the BICAPP for various types of central lines. cer patients and caregivers to take actions information that can be tailored to your facility At Your Fingertips: The appendix pro- to seek care if they develop this potentially is provided as an appendix. vides a list of relevant resources, including life-threatening condition. the United States Pharmacopeia (USP) For more information, action steps, and Chapter <797> Guidebook to Pharmaceutical tools to help reduce a cancer patient’s risk of Compounding—Sterile Preparations. All 6. watson JT, Jones RC, Siston AM, Fernandez JR, Martin K, Beck developing potentially life-threatening infec- E, et al. Outbreak of catheter-associated Klebsiella oxytoca and oncology facilities that provide on-site che- tions during chemotherapy treatment, please Enterobacter cloacae bloodstream infections in an oncology chemotherapy preparation should follow USP visit www.cdc.gov/cancer/preventinfections or motherapy center. Arch Intern Med 2005;165:2639−643. guidance in consultation with the state phar- 7. abe K, Tobin D’Angelo M, Sunenshine R, Noble-Wang J, Cope J, www.preventcancerinfections.org. Jensen B, et al. Outbreak of Burkholderia cepacia bloodstream macy board. infection at an outpatient hematology and oncology practice. Infect At Your Fingertips: The BICAPP also Control Hosp Epidemiol 2007; 28:1311-1313. includes the CDC Infection Prevention References 8. kim MJ, Bancroft E, Lehnkering E, Donlan RM, and Mascola L. 1. kamboj M, Sepkowitz KA. Nosocomial infections in patients with Alcaligenes xylosoxidans bloodstream infections in outpatient Checklist for Outpatient Settings that can cancer. Lancet Oncol 2009;10:589−597. office. Emerg Infect Dis 2008;14:1046-1052. be tailored by an outpatient oncology facility 2. Maschmeyer G, Haas A. The epidemiology and treatment of infections in cancer patients. Int J Antimicrob Agents 2008;31:193−197. to systematically assess personnel adherence to Alice Y. Guh, MD, MPH, is with the Centers recommended infection prevention practices. 3. Guinan JL, McGuckin M, Nowell PC. Management of healthcare-associated infections in the oncology patient. Oncology for Disease Control and Prevention’s Division of 2003;17:415−420. Healthcare Quality Promotion in Atlanta, Georgia. Interactive website for cancer 4. halpern MT, Yabroff KR. Prevalence of outpatient cancer treat- Lisa C. Richardson, MD, MPH, is with the Centers patients and caregivers to ment in the United States: estimates from the Medical Panel Expenditures Survey (MEPS). Cancer Invest 2008;26:647−651. for Disease Control and Prevention’s Division prevent infections 5. Macedo de Oliveria A, White KL, Leschinsky DP, Beecham BD, of Cancer Prevention and Control in Atlanta, Vogt TM, Moolenaar RL et al. An outbreak of hepatitis C virus While the BICAPP is a resource for health- infections among outpatients at a hematology/oncology clinic. Georgia. Angela Dunbar, BS, is with the CDC care providers, the Preventing Infections in Ann Intern Med 2005;142:898−902. Foundation in Atlanta, Georgia.