Because of immunosuppression from cancer or its treatment, patients are at a higher risk for viral, bacterial, and fungal infections. Patients who develop infections may experience dose delays or reductions that compromise optimal treatment outcomes, resulting in higher mortality rates, longer hospitalizations, and higher cost of care.
In their article in the April 2018 issue of the Clinical Journal of Oncology Nursing, Wilson et al. provided an update on ONS’s Putting Evidence Into Practice (PEP) prevention of infection team’s evidence review. Included are recommendations for nursing interventions for nurses caring for adult patients with cancer who develop infections.
How Infections Affect Cancer Care
Because patients with cancer are more susceptible to infection, they also have the potential for developing antibiotic resistance after recurring treatments, Wilson et al. said. Managing cancer-related infections in those situations can be challenging for practitioners, limiting effective antibiotic choices and increasing risk for morbidity and mortality. It also presents an economic burden for institutions because of additional costs associated with a longer duration of illness, expensive antimicrobials, and additional diagnostics.
Sepsis in particular has a high mortality rate in patients with cancer, Wilson et al. noted. Mortality from Staphylococcus aureus central line-associated bloodstream infections can be as high as 25%–30% in the oncology setting. Depending on cancer type, incidence of febrile neutropenia can range from 13%–21% and cost the inpatient setting $16,000–$19,000 per episode.
The Nurse’s Role in Assessing Infection Risk
Wilson et al. pointed to three risk assessments that oncology nurses can use to identify cancer-related infections early, when interventions have the most success.
Infection: Evaluate patients using patient and treatment factors for infection risk prior to each systemic cancer treatment, including the first cycle. High risk factors include:
- Allogeneic hematopoietic cell transplantation (HCT)
- Induction or consolidation for acute leukemia
- Alemtuzumab-containing regimens
- High-dose steroids for graft-versus-host disease
- Neutropenia expected to last more than 10 days.
- Intermediate risk factors include:
- Diagnosis of multiple myeloma, lymphoma, or chronic lymphocytic leukemia
- Autologous HCT
- Purine analog-containing regimens
- Neutropenia expected to last 7–10 days.
Febrile neutropenia: Guidelines from national and international cancer organizations identify fever in the presence of neutropenia as an increased risk factor for infection, Wilson et al. cited. Risk factors for developing febrile neutropenia are:
- Disease related
- Advanced-stage disease
- Previous, pre-existing, or prolonged neutropenia
- Leukemia, lymphomas, or myelodysplastic syndrome
- Primary breast, lung, colorectal, or ovarian cancer
- Patient related
- Age older than 65 years
- Female gender
- Recent surgery
- Open wounds
- Pre-existing infection
- Decreased neutrophil count at the start of treatment
- Renal or liver dysfunction,
- Poor performance status
- Poor nutritional status
- Treatment related
- Dose-dense, high-dose, or myeloablative chemotherapy regimens
- Immunosuppressive medications
- Targeted relative dose intensity 85% or higher
- Curative intent
- Previous myelosuppresive radiation or chemotherapy.
The Nurse’s Role in Managing Infections
The ONS prevention of infection PEP team reviewed the current evidence for new literature published since the PEP topic was last updated (from January 2009–January 2017). The rigorous inclusion criteria are outlined in Wilson et al. Based on the strength of evidence, the group categorized a list of nursing interventions to prevent infection in patients with cancer. Those that are recommended for practice or likely to be effective, based on the evidence, are included in Figure 1.
Oncology nurses must be aware of the risk of infection in their patients, watch for signs and symptoms, and use evidence-based prevention and management strategies to achieve best outcomes and reduce the high risk of mortality. Wilson et al. suggested developing organizational documentation and standardized tracking in patients’ electronic health records to support timely, accurate, and consistent care for patients facing infection. The authors also noted that opportunities exist for nurse scientists to build the body of evidence in this area, because current studies “lack the ability to replicate findings and many . . . are nonrandomized, single-institution studies with small sample sizes.”
This monthly feature offers readers a concise recap of full-length articles published in the Clinical Journal of Oncology Nursing (CJON) or Oncology Nursing Forum. This edition summarizes “Prevention of Infection: A Systematic Review of Evidence-Based Practice Interventions for Management in Patients With Cancer,” by Barbara J. Wilson, MS, RN, AOCN®, ACNS-BC, Laura J. Zitella, MS, RN, ACNP-BC, AOCN®, Colleen H. Erb, MSN, CRNP, ACNP-BC, AOCNP®, Jackie Foster, MPH, RN, OCN®, Mary Peterson, MS, APRN, ANP-BC, AOCNP®, and Sylvia K. Wood, DNP, APRN, ANP-BC, AOCNP®, which was published in the April 2018 issue of CJON. Questions regarding the information presented in this article should be directed to the CJON editor at CJONEditor@ons.org.