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Prevention of Infection in Patients with Cancer

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Prevention of Infection in Patients with Cancer 174 Seminars in Oncology Nursing, Vol 23, No 3 (August), 2007: pp 174–183 OBJECTIVES: To provide clinicians with the most reliable, updated evidence to support clinical decision-making PREVENTION OF and improve outcomes for pa- tients with cancer who are at in- creased risk for infection. DATA SOURCES: INFECTION IN Review of two evidence-based sum- maries of prevention of infection interventions published by the On- PATIENTS WITH cology Nursing Society; MEDLINE and guidelines.gov literature re- view. CANCER CONCLUSION: Handwashing is the most impor- tant intervention to prevent infec- tion in patients with cancer. Guide- lines-based intravascular catheter CHRISTOPHER R. FRIESE care and preventive activities can reduce infection incidence in this vulnerable patient population. Un- NFECTION refers to the symptoms caused by the multipli- derstanding risk factors for aggres- sive pathogens can help identify cation of microscopic organisms and subsequent invasion of 1,2 patients for rapid surveillance and I the body’s natural barriers. These organisms may be of isolation procedures. Additional bacterial, fungal, viral, or parasitic origin. Patients with cancer, multi-site research is required in compared with other clinical conditions, are at increased risk for oncology settings to recommend infectious complications. The factors that predispose patients with recent interventions for practice. cancer to infection include decreased supply and/or function of IMPLICATIONS FOR NURSING lymphocytes or granulocytes, wounds following invasive surgery, PRACTICE: the placement of vascular catheters, nutritional deficiencies, and 3 Oncology nurses should assess pre-existing or newly acquired comorbidities. In many cases, their adherence to evidence-based patients present with many or all of these factors at once. Preven- guidelines on infection prevention. tion of infection occurs through activities by patients, nurses, Outcomes are optimized when cli- physicians, and public health professionals to reduce the likeli- nicians identify high-risk patients hood of microbial multiplication and invasion.1 Despite the recog- and provide scientifically supported nition that patients with cancer are at increased risk for infection, interventions. preventive interventions often vary by setting and lack an evi- KEYWORDS: dence base. Infection, outcomes, cancer, The white paper on nursing-sensitive patient outcomes pub- interventions lished by the Oncology Nursing Society (ONS) recognized preven- tion of infection as an important safety outcome that is sensitive to nursing interventions.4 Four of the 15 outcomes endorsed by the National Quality Forum as nursing-sensitive performance mea- Christopher R. Friese, RN, PhD, AOCN®: sures are related to infection.5 Reimbursement strategies for Center for Outcomes & Policy Research, Dana-Farber Cancer Institute; Cancer Pre- health care services based on quality measures, termed “pay for vention Fellow, Harvard School of Public performance,” are anticipated to increase widely. Moreover, on- Health, Boston, MA. Address correspondence to Christopher R. cology nurses have an interest in preventing infection in patients Friese, RN, PhD, AOCN®, Harvard School of with cancer to facilitate timely anti-cancer therapies, promote Public Health, 44 Binney St. SM 271, Boston, quality of life, and improve patient satisfaction. It is with these MA 02115. Fax: (617) 344-0427. motivations that this article discusses the recent evidence base for interventions to prevent infection. The goal of this review is to © 2007 Elsevier Inc. All rights reserved. provide clinicians with the most reliable, updated evidence to 0749-2081/07/2303-$30.00/0 support clinical decision-making and improve outcomes for pa- doi:10.1016/j.soncn.2007.05.002 tients with cancer who are at increased risk for infection. PREVENTION OF INFECTION IN CANCER PATIENTS 175 Two principal documents were used to frame from phlebotomy. If the culture from the catheter this review. The first was a review completed by source is positive first, the difference in time to the author in 20041 as part of the initial ONS effort positive result is compared between the catheter to measure nursing-sensitive patient outcomes. and the phlebotomy sample. When the difference The second document is a summary of the 2005 exceeds 120 minutes, catheter-related infection is ONS Putting Evidence Into Practice (PEP) project more certain. Clinicians continue to debate the team to categorize interventions based on the frequency, number, and source(s) of blood cul- quality of the available evidence.6,7 Finally, com- tures required in the febrile patient with cancer. mon clinical problems, such as infections related Although no published studies answer the ques- to vascular catheters, pneumonia, and aggressive tion empirically, a sound protocol was developed organisms (Clostridium difficile,vancomycin-re- by Penwarden and Montgomery.9 The steps in- sistant Enterococcus [VRE], and methicillin-resis- clude: (1) obtaining the cultures within 30 min- tant Staphylococcus aureus [MRSA]) were ad- utes of fever; (2) obtaining one peripheral set of dressed specifically because of their high cultures with the initial fever, with cultures ob- prevalence and potential for poor outcomes in the tained only via the vascular catheter during sub- oncology patient population. This review con- sequent febrile episodes; and (3) cultures ob- cludes with knowledge gaps and suggestions for tained from each lumen of the catheter, with no future research. blood discarded. While individual scenarios may dictate a different response by clinicians, a stan- EVIDENCE-BASED SUMMARY OF NURSING- dardized approach to blood cultures improves the validity and reliability of the diagnostic test. SENSITIVE OUTCOMES:PREVENTION OF Catheter-related blood stream infections have INFECTION been measured using standardized terminology endorsed by the Centers for Disease Control and he first review conducted for the ONS focused Prevention (CDC), among other groups.10 The Ton: (1) available measures, and (2) effective number of infections per 1,000 catheter days is a interventions with a high level of evidence for the widely used metric in the literature. For example, prevention of infection in patients with cancer.1 A assume in 1 month a clinic cared for 100 patients computerized search of the Cumulative Index to who had their catheters for 3 days each (300 Nursing & Allied Health Literature (CINAHL) and catheter days/month). In that month, 4 patients the United States’ National Library of Medicine acquired a blood stream infection. The catheter- bibliographic database (MEDLINE) was conducted related blood stream infection rate would be using the search terms “registered nurses” and 4/300 ϫ 1,000 ϭ 13.33. While the calculation may “infection” or “infection control.” Searches were not be intuitive it accounts for the fact that differ- limited to papers published between 2000 to 2003, ent clinics vary in their patient volumes and the and classified as systematic reviews or meta-anal- length of time catheters are used. yses. Meta-analyses are quantitative syntheses of The reviewed literature was then categorized separate but related research studies. In addition, into five domains of infection prevention interven- the Agency for Healthcare Research and Quality’s tions: (1) hygiene, (2) intravenous therapy, (3) online database of clinical practice guidelines nutrition/gastrointestinal, (4) environment, and (www.guidelines.gov) was searched using similar (5) chemoprevention. Readers are referred to the terms. source document for a complete discussion of the The findings showed scant attention to mea- review findings. However, important findings are surement techniques of infection. While this is presented in Table 1. partly because of the heterogeneity of infection, The 2004 review concluded that several inter- very little empirical research is available on how ventions had strong support to recommend wide- clinicians or researchers should measure infection spread adoption, but many common practices, from the quality of care perspective. One paper such as diet modifications and “protective isola- addressed the concept of time to positivity to tion” of patients with neutropenia, lacked strong infection as a tool to discern vascular catheter- evidence. Measurement of infection was varied related blood stream infection.8 In this approach, and few clear approaches were available for clini- paired blood cultures are obtained; one from the cal use. Specific gaps in the infection prevention distal port of the vascular catheter, and a second literature were noted in the outpatient oncology 176 C.R. FRIESE TABLE 1. Major Findings from the 2004 Prevention of Infection Review1 Domain and Intervention Findings Discussion Hygiene Handwashing The single most important nursing intervention Antimicrobial soap and water, or the use of to prevent infection alcohol-based hand gel have equal efficacy Oral care Frequent oral care, including gentle The frequency of oral care and the ideal toothbrushing and flossing (as tolerated) are oral cleansing agent are unknown effective Intravenous therapy Catheter placement Avoid placement of catheters when patient is Not always possible in certain clinical functionally or quantitatively neutropenic circumstances. Aseptic practice and full barrier precautions during placement are recommended Injection port cleansing Injection ports on intravenous tubing or Sufficient time between swabbing and vascular catheters should be cleansed with
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