Does a neutropenic diet reduce adverse outcomes in patients undergoing chemotherapy?

Evaluating the efficacy and impact of neutropenic diet in pediatric hematology patients: a longitudinal cohort study on adherence, clinical outcomes, and socioeconomic factors

Background and aim

A neutropenic diet aims to reduce hospitalizations from febrile neutropenia and sepsis in pediatric hematology patients during chemotherapy. This study aimed to evaluate its effectiveness in improving mortality, morbidity, and overall outcomes while considering limitations, adherence rates, and its impact on hospital admissions and culture positivity.

Method

A prospective 18-month observational study was conducted on pediatric hematology patients in a pediatric department at a tertiary care center. Using a baseline questionnaire at the introduction of a neutropenic diet, the study assessed the clinical history, diagnosis, clinicopathological parameters, dietary recommendations, and socio-demographic data of the patients. Patients were followed up for up to 1 year to evaluate diet adherence, outcomes, mortality, and morbidity, as indicated by hospital admissions for febrile neutropenia.

Results

An analysis involving 100 patients was conducted to assess adherence to a neutropenic diet and its ramifications on clinical outcomes over a period of 18 months. Initial follow-up data were accessible for 83 patients, revealing an adherence rate of 66%, which subsequently declined to 57% following a 6-month interval. Patients were categorized as compliant or non-compliant, but no correlation was found between adherence and febrile admissions, sepsis, hospitalizations, or mortality. Among compliant patients, 62% showed sepsis signs, though only 19% had positive blood cultures in the whole study group. Non-adherence was linked to demographic factors such as large family size, financial constraints, and limited resources. The neutropenic diet showed minimal impact on morbidity and mortality.

Conclusion

Our study does not support the strict adherence to the neutropenic diet, as there is no evidence of reduced infections and the dietary adherence also imposes an undue financial burden on patients. Instead, focusing on the safe acquisition of food, food processing, and proper hand cleanliness will probably provide superior protection against infection.

A Neutropenic Diet in Haemato-Oncological Patients Receiving High-Dose Therapy and Hematopoietic Stem Cell Transplantation: A Systematic Review

BACKGROUND/OBJECTIVES

Although the benefits of low-germ diets for patients are increasingly being questioned, their application in practice is widespread. The aim of this review is to summarise the current data and evaluate the effectiveness of the neutropenic diet (ND) in adult haemato-oncological patients to provide a basis for practical guidelines.

METHODS

A systematic search was conducted in four electronic databases (Medline (Ovid), CINAHL (EBSCO), EMBASE (Ovid) and Cochrane CENTRAL) to identify English and German randomised controlled trials (RCTs) concerning the effectiveness of an ND in adult haematological patients. The main endpoints were fever and systemic infections, gastrointestinal (GI) infections, mortality, nutritional status and hospitalisation length.

RESULTS

A total of five RCTs with 510 adult patients were included in this systematic review. All patients received high-dose chemotherapy in order to treat haemato-oncological malignancies. None of the analysed endpoints showed a significant advantage of the ND compared to the control group.

CONCLUSIONS

An ND does not have a beneficial effect on infection rates, GI health, mortality or hospitalisation length for haemato-oncological patients. On the contrary, an ND tends to negatively affect the patient's nutritional status; therefore, an adaption in clinical routine should take place.

[Diet guidelines in adult and pediatric patient after allogeneic stem cell transplantation (SFGM-TC)]

The nutritional status after bone marrow transplant plays an important role in the outcome of patients. Post-allograft dietary instructions are therefore essential to ensure quality nutrition while minimizing the risk of infection. For patients, this is one of their main concerns on discharge from hospital. With the aim of harmonizing post-allograft dietary instructions, a multidisciplinary working group has been set up within a number of French centers performing hematopoietic stem cell allogenic transplantation. The dietary guidelines have been updated by this working group, through videoconference meetings, an online questionnaire, a review of the literature and deliberations at harmonization days. These instructions will be incorporated into the next update of the adult and pediatric post-transplant follow-up booklet.

Produce Safety Behaviors, Motivators, Barriers, and Beliefs in Pediatric Cancer Patient Caretakers

Cancer patients, who face increased foodborne illness susceptibility and severity, are often placed on neutropenic diets (NDs), which eliminate the consumption of fresh produce, among other foods perceived as high-risk. Such diets are clinically disputed because they have never been proven effective in reducing foodborne illness, leading to unstandardized dietary guideline content, format, and delivery methods. To inform a strategic communication approach, this study explored the produce safety handling behavior, barriers, motivators, and beliefs of pediatric cancer patient caretakers using a mixed methods convergent parallel design. A quantitative survey revealed high frequencies (>60%) for generally recommended produce safety behaviors, such as rinsing produce and washing cutting boards, and more mixed responses for restrictive produce safety behaviors, such as peeling produce and avoiding precut, self-serve, and school cafeteria produce. Total produce safety frequency scores were not significantly affected by demographic factors or Child Vulnerability Scale (CVS) scores. Qualitative interviews established a wide domain of caretaker produce safety experiences and beliefs, finding that eight of seventeen interview participants from different hospitals received produce restrictions typical of the ND. Ultimately, five caretaker archetypes were identified, with common motivators and barriers linked to materials received, child's health and perceived susceptibility, and self-efficacy beliefs. Finally, response-driven communication strategy improvements were recommended. Although sample sizes in this work were small, and further validation is advised, this work highlights the inconsistent use of the restrictive ND, advances understanding of the drivers of produce safety behaviors in cancer patient caretakers, and supports future endeavors to streamline communication strategy interventions.

The neutropenic diet and its impacts on clinical, nutritional, and lifestyle outcomes for people with cancer: a scoping review

The neutropenic diet (ND) is often recommended to people with cancer to reduce infection risk despite recommendations of clinical guidelines advising against its use. While recent literature suggests the ND does not reduce infection risk, other outcomes related to health, nutrition, and lifestyle are unknown. The aim of this review is to systematically scope the literature on the ND in people with cancer for all outcomes related to clinical health, nutrition, and lifestyle. Scientific databases were systematically searched. Eligible studies were in English, people with any cancer type, consuming an ND, any age group, date, or setting. Eligible study types were randomised control trials, observational studies, systematic reviews, and meta-analyses. Twenty-one studies met the inclusion criteria. Outcomes of interest found were infection rates, fever, mortality, antibiotic use, gastrointestinal side effects, comorbidities, biochemistry, hospitalisation, nutritional status, quality of life (QoL), well-being, and financial costs. Most research has focused on infection and mortality rates with few assessing hospitalisation rates, nutritional status, financial costs, and QoL. Most included studies found no significant differences between ND and comparator diet for mortality, antibiotics use, comorbidities, and QoL; however, several studies reported the ND significantly increased the risk of infection. Gaps in the literature included effect of ND on QoL in an adult population, microbiome, lifestyle changes, and financial burden. Further research is needed regarding how the ND affects the microbiome and QoL of its consumers, but in the interim, it is important for hospitals providing an ND to their patients to liberalise the ND wherever possible.

Microbiological profiling and knowledge of food preservation technology to support guidance on a neutropenic diet for immunocompromised patients

The current society consists of an increasing number of people vulnerable to infections. For certain people with severe immunodeficiency, a neutropenic or low-microbial diet is being prescribed, which substitutes high-risk foods that are more likely to contain human (opportunistic) pathogens with lower-risk alternatives. These neutropenic dietary guidelines are typically set up from a clinical and nutritional perspective, rather than from a food processing and food preservation perspective. In this study, the current guidelines in use by the Ghent University Hospital were evaluated based on the current knowledge of food processing and preservation technologies and the scientific evidence on microbiological quality, safety, and hygiene of processed foods. Three criteria are identified to be important: (1) the microbial contamination level and composition; (2) the potential presence of established foodborne pathogens such as Salmonella spp. (to which a zero-tolerance policy is recommended); and (3) an increased vigilance for L. monocytogenes as an opportunistic foodborne pathogen with a high mortality rate in immunocompromised individuals (to which a zero-tolerance policy should apply). A combination of these three criteria was used as a framework for the evaluation of the suitability of foodstuffs to be included in a low-microbial diet. Differences in processing technologies, initial contamination of products, etc., however, lead to a high degree of variability in microbial contamination and make it difficult to unambiguously accept or reject a certain type of foodstuff without prior knowledge of the ingredients and the processing and preservation technologies applied during manufacturing and subsequent storage conditions. A restricted screening on a selection of (minimally processed) plant-based foodstuffs on the retail market in Flanders, Belgium supported decision-making on the inclusion of these food types in a low-microbial diet. Still, when determining the suitability of a foodstuff to be included in a low-microbial diet, not only the microbiological status but also nutritional and sensorial properties should be assessed, which requires multidisciplinary communication and collaboration.

Kitchen-Scale Treatments for Reduction of Listeria monocytogenes in Prepared Produce

ABSTRACT

Listeriosis, a foodborne illness caused by Listeria monocytogenes, has relatively low incidence, but a substantial mortality rate, particularly in immunocompromised populations. Because of the known risk of L. monocytogenes and other pathogens in produce, immunocompromised individuals are often placed on neutropenic diets that exclude fresh produce. Therefore, this study aimed to evaluate several kitchen-scale treatments as potential interventions to reduce L. monocytogenes in prepared produce. Cucumbers, apples, and celery were dip inoculated with a three-strain cocktail of L. monocytogenes and dried for 24 h. Inoculated products were subjected to the following treatments as applicable: commercial sanitizer soak (90 s, with agitation), tap water rinse (15 s), tap water soak (90 s, with agitation), surface blanching (25 s), tap water rinse (15 s) followed by peeling, and surface blanching (25 s) followed by peeling. In addition, inoculum uptake in celery and the impact of two types of peelers (mechanical crank and manual) were assessed. Treated samples were plated on differential media and incubated for 48 h at 37°C. L. monocytogenes populations were then enumerated and compared with the untreated control (in log CFUs per gram). All treatments lacked efficacy for celery, with reductions significantly less (P < 0.05) than in other products, likely because of inoculum internalization. The sanitizer soak, tap water rinse, and tap water soak did not differ in efficacy (P > 0.05), which was low for cucumbers (<1.5 log CFU/g), apples (<1.3 log CFU/g), and celery (<0.7 log CFU/g). The two types of apple peelers did not differ in efficacy (P > 0.05). Surface blanching and surface blanching followed by peeling were the most effective treatments for both cucumbers and apples (P < 0.05), with average reductions of 4.2 to 5.1 and 3.5 to 5.9 log CFU/g, respectively.

HIGHLIGHTS

Neutropenic Enterocolitis and Sepsis: Towards the Definition of a Pathologic Profile

Background: Neutropenic enterocolitis (NE), which in the past was also known as typhlitis or ileocecal syndrome for the segment of the gastrointestinal tract most affected, is a nosological entity that is difficult to diagnose and whose pathogenesis is not fully known to date. Initially described in pediatric patients with leukemic diseases, it has been gradually reported in adults with hematological malignancies and non-hematological conditions, such as leukemia, lymphoma, multiple myeloma, aplastic anemia, and also myelodysplastic syndromes, as well as being associated with other immunosuppressive causes such as AIDS treatment, therapy for solid tumors, and organ transplantation. Therefore, it is associated with high mortality due to the rapid evolution in worse clinical pictures: rapid progression to ischemia, necrosis, hemorrhage, perforation, multisystem organ failure, and sepsis. Case report: A case report is included to exemplify the clinical profile of patients with NE who develop sepsis. Literature Review: To identify a specific profile of subjects affected by neutropenic enterocolitis and the entity of the clinical condition most frequently associated with septic evolution, a systematic review of the literature was conducted. The inclusion criteria were as follows: English language, full-text availability, human subjects, and adult subjects. Finally, the papers were selected after the evaluation of the title and abstract to evaluate their congruity with the subject of this manuscript. Following these procedures, 19 eligible empirical studies were included in the present review. Conclusions: Despite the recent interest and the growing number of publications targeting sepsis and intending to identify biomarkers useful for its diagnosis, prognosis, and for the understanding of its pathogenesis, and especially for multi-organ dysfunction, and despite the extensive research period of the literature review, the number of publications on the topic "neutropenic enterocolitis and sepsis" appears to be very small. In any case, the extrapolated data allowed us to conclude that the integration of medical history, clinical and laboratory data, radiological imaging, and macroscopic and histological investigations can allow us to identify a specific pathological profile.

Change in Body Weight and Serum Albumin Levels in Febrile Neutropenic Lung Cancer Patients

Although advances have been made in the treatment and prevention of febrile neutropenia (FN) in cancer patients treated with chemotherapy, it is still a complication that requires clinical attention. Impaired nutritional status in patients who develop FN can affect the continuation of cancer treatment, but it has not been investigated. We conducted a retrospective longitudinal study in order to clarify (1) if body weight and serum albumin levels change in lung cancer patients who do and do not develop FN, and (2) if these indicators are more likely to worsen in patients with FN than in patients without FN. Patients undergoing cytotoxic chemotherapy between January 2011 and June 2020 were consecutively included in the study. Changes in body weight and serum albumin levels were investigated in a case-control study of patients with FN, and control patients without FN who were matched by age, gender, histopathology, and stage of lung cancer, at a ratio of 1:2. During the study period, 226 patients received cytotoxic chemotherapy. Among those, 33 (14.6%) patients developed FN during the first course of cytotoxic chemotherapy. We found a more pronounced decrease in both body weight and serum albumin level at four weeks after the initiation of chemotherapy in FN patients. In order to safely administer effective chemotherapy, medical staff need to pay close attention to the nutritional status of patients receiving chemotherapy.