Editor’s note: One in a series of articles on managing cancer-related symptoms from the Oncology Nursing Society.
Cancer treatments such as chemotherapy, radiation therapy, biologic therapy, and surgery are known to compromise patients’ immune functions. That immunocompromised state can lead to infections affecting the morbidity and mortality rates of patients with cancer. Oncology nurses are in a unique position to deal with these infections by monitoring patients post-therapy and enacting evidence-based practices to reduce the risk of infection. Their efforts help improve patients’ quality of life and ease the economic impact of treatment on families and the healthcare system (Zitella, Gobel, & O’Leary, 2009).
Assessment of risk factors, a physical examination, and a diagnostic evaluation are some of the ways oncology nurses can identify patients who are likely to become immunocompromised. Some common comorbidities seen in immunocompromised patients are chronic obstruction pulmonary disease, cardiovascular disease, liver disease, renal insufficiency, diabetes mellitus, and baseline anemia (Klastersky et al., 2000; Maxwell & Stein, 2006; Wujcik, 2004). Patient-related risk factors include being older than age 65, being female, and having a poor performance status (i.e., Eastern Cooperative Oncology Group score of 2 or higher), poor nutritional status, decreased immune function, and decreased body surface area (Klastersky et al., 2000; Maxwell & Stein, 2006; Wujcik, 2004).
When performing a physical examination, oncology nurses should pay specific attention to conditions associated with increased risk for infection: open wounds, active infection, and grade 3–4 mucositis. Nurses’ evaluations should also include reviewing results from the CBC, blood and other cultures, chemistry profile, and chest x-ray (Klastersky et al., 2000; Maxwell & Stein, 2006; Wujcik, 2004).
Limited evidence exists regarding what clinical measurement tools are best for physicians and nurses to use. Table 1 lists some of the common assessment scales or tools used to identify infection risk.
Table 1. Common assessment tools for identifying infection risk
- National Quality Forum (NFQ): A set of 15 nursing-sensitive standards for inpatient care were accepted by NQF in 2003. While not cancer specific, information regarding catheter-related infections, urinary catheter-related infections, support measurements, education, and standards of care is useful (NQF, 2007).
- Multinational Association of Supportive Care in Cancer (MASCC) risk index: This tool is validated as a scoring system for patients with febrile neutropenia, classifying them as either low risk or high risk. Age, outpatient status, comorbid conditions, illness burden, and tumor type are given numeric values. A score of 21 or less classifies the patient as low risk, a score of greater than 21 signifies high risk (Baskaran, Gan, & Adeeba, 2008).
- National Comprehensive Cancer Network (NCCN) guidelines: Focusing on fever, neutropenia, and myeloid growth factors, the NCCN guidelines identify risk factors associated with poor clinical outcome, stratify risk and assessment, and offer interventions to prevent and manage infection (NCCN, 2008).
- Patient Care Monitor–Neutropenia Index and Functional Assessment of Cancer Therapy–Neutropenia: These two quality-of-life instruments have been identified as reliable in a limited amount of studies. More data are needed on the use of these tools (Moore, Johnson, Fortner, & Houts, 2008; Padilla & Ropka, 2005).
- Common Terminology Criteria for Adverse Events: This tool often is used for grading WBC and absolute neutrophil count. The tool is readily used in oncology practice; however, its grading scale does not directly correlate with incidence of infection (National Cancer Institute Cancer Therapy Evaluation Program, 2006).
Putting evidence into practice
To promote nursing practice that is based on evidence, ONS launched the Putting Evidence Into Practice (PEP) program in 2005. ONS PEP teams consisting of advanced practice nurses, staff nurses, and a nurse scientist were charged with reviewing the literature to determine what treatments and interventions are proven to alleviate many cancer-related problems that are sensitive to nursing interventions. Each team classified interventions under the following categories: recommended for practice, likely to be effective, benefits balanced with harms, effectiveness not established, effectiveness unlikely, and not recommended for practice.
Recommended for practice
The following are recommended for practice based on effectiveness established through rigorously designed studies, meta-analysis, systemic reviews, or professional guidelines (Zitella et al., 2009):
- Hand hygiene using soap and water or an antiseptic hand rub for all patients and their caregivers
- Colony-stimulating factors for all patients undergoing chemotherapy with a 20% or greater risk of febrile neutropenia
- Receiving an annual influenza vaccine
- Receiving the 23-valent pneumococcal polysaccharide vaccine for patients older than age 5; receiving the 7-valent pneumococcal polysaccharide protein-conjugate vaccine for patients younger than age 5
- Trimethoprim-sulfamethoxazole to prevent Pneumocystis carinii pneumonia
- Antifungal drugs absorbed or partially absorbed in the gastrointestinal tract to prevent oral candidiasis in patients undergoing chemotherapy
- Antifungal prophylaxis to prevent fungal infections in high-risk patients
- Antibacterial prophylaxis with quinolones for patients at high risk for infection
- Penicillin prophylaxis to prevent pneumococcal infection in patients who have undergone a splenectomy or who are functionally asplenic, allogenic hematopoietic stem cell transplantation (HSCT) recipients, or patients with chronic graft-versus-host disease (GVHD)
- Herpes viral prophylaxis for selected seropositive patients with cancer
- Cytomegalovirus prophylaxis for patients at high risk for disease
- Herpes B prophylaxis with lamivudine in immunocompromised patients with a positive hepatitis B surface antigen
- Protective gowns for expected body fluid contamination. Gloves should be worn during direct patient care or if contact with blood, body fluids, excretions, or secretions are expected.
- No visitors with symptoms of respiratory infection should be allowed.
- Environmental interventions such as keeping windows closed, using negative-pressure rooms, and using high-efficiency particulate air (HEPA) filters
- Contact precautions for patients known to be colonized or infected with resistant organisms.
Likely to be effective
The ONS PEP team found several avenues that were likely to be effective in preventing infection. To be classified as likely to be effective in the PEP program, an intervention must have effectiveness demonstrated by strong evidence from rigorously designed studies, meta-analyses, or systemic reviews. Also, expectation of harm must be small compared with benefits (Eaton & Tipton, 2009).
Two studies identified private rooms as a way to decrease the transmission of infection (Chaundhury, Mahmood, & Valente, 2003; Siegel et al., 2007). In addition, Tablan, Anderson, Besser, and Hajjeh (2004) recommended a focus on oxygen and respiratory care through the use of oxygen humidifiers, small-volume medication nebulizers, or even a mist tent. In the same vein, three studies suggested HEPA filters and HEPA filter masks for patients with prolonged neutropenia (NCCN, 2007; Sehulster & Chinn, 2003; Shelton, 2003).
A series of environment-related efforts also can be conducted by oncology nurses. According to three studies, patients should avoid fresh or dried flowers and plants due to the risk of Aspergillus infection (Sehulster & Chinn, 2003; Shelton, 2003; Smith & Kagan, 2005). Sehulster and Chinn (2003) also recommended automated ice-dispensing systems so as to avoid ice touched by hands, and encouraging patients to avoid contact with animal feces, saliva, urine, or litter boxes. Hand hygiene is important if any of these interactions occur. Lastly, during a hospital construction project, healthcare providers should enact a construction barrier, document and monitor adherence to this barrier, and provide HEPA filter masks to patients when they are being moved through a construction area (Kidd, Buttner, & Kressel, 2007; Sehulster & Chinn, 2003; Siegel et al., 2007).
Effectiveness not established
Two interventions were listed in this category, which indicates that they contain insufficient data or data of inadequate quality; however, no clear indication of harm has been noted. The first, supported in Tablan et al. (2004) advises immune globulin for respiratory syncytial virus. The second, protective isolation (Larson & Nirenberg, 2004; Mank & van der Lelie, 2003; Nauseef & Maki, 1981; Shelton, 2003; Siegel et al., 2007), is recommended for allogeneic HSCT recipients in order to decrease airborne fungal spore counts and to reduce the risk of invasive fungal infections via the environment. Protective isolation is described as a private room with HEPA filtration, positive pressure air flow, and adequate ventilation. Gowns, gloves, and masks are worn by the healthcare team when treating the patient.
Three randomized studies (Gardner et al., 2008; Moody et al., 2006; Van Tiel et al., 2007) demonstrated no significant difference in infection rate between patients consuming a regular diet (including raw fruits and vegetables) and patients on a low microbial diet. However, basic food safety principles should still be adhered to, such as not eating uncooked meat, seafood, and eggs and not consuming unwashed fruits and vegetables. In addition, laminar air flow (NCCN, 2007; Sehulster & Chinn, 2003) and the routine donning of gowns when entering a high-risk area (Siegel et al., 2007) were listed in the effectiveness unlikely level of evidence. This level of evidence includes those interventions for which there is evidence of lack of effectiveness.
As mentioned earlier, oncology nurses are a vital component in the prevention of infection in patients with cancer. Armed with Putting Evidence Into Practice resources from the Oncology Nursing Society, oncology nurses can enact change in a healthcare institution’s policies and, on an individual patient basis, decide which assessment tools and preventative measures are appropriate for care.
Sean Pieszak is a copy editor in the Publications department at the Oncology Nursing Society in Pittsburgh, PA. More information about the ONS PEP classification for Prevention of Infection can be found at http://www.ons.org/Research/PEP/Infection.
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