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.