Prevention of Infection: A Systematic Review of Evidence-Based Practice Interventions for Management in Patients With Cancer

A Systematic Literature Review to Identify Diagnostic Gaps in Managing Immunocompromised Patients With Cancer and Suspected Infection

Patients with cancer are increasingly vulnerable to infections, which may be more severe than in the general population. Improvements in rapid and timely diagnosis to optimize management are needed. We conducted a systematic literature review to determine the unmet need in diagnosing acute infections in immunocompromised patients with cancer and identified 50 eligible studies from 5188 records between 1 January 2012 and 23 June 2022. There was considerable heterogeneity in study designs and parameters, laboratory methods and definitions, and assessed outcomes, with limited evaluation of diagnostic impact on clinical outcomes. Culture remains the primary diagnostic strategy. Fewer studies employing molecular technologies exist, but emerging literature suggests that pathogen-agnostic molecular tests may add to the diagnostic armamentarium. Well-designed clinical studies using standardized methodologies are needed to better evaluate performance characteristics and clinical and economic impacts of emerging diagnostic techniques to improve patient outcomes.

CE: Febrile Neutropenia in the Chemotherapy Patient

ABSTRACT

Febrile neutropenia is a serious complication of chemotherapy treatment and may present as the only clinical sign of infection. If not addressed in a timely manner, it may progress to multisystem organ failure and may be fatal. Initial assessment of fever in those receiving chemotherapy requires prompt administration of antibiotics, ideally within one hour of presentation. Depending on the clinical status of the patient, antibiotic treatment may occur in the inpatient or outpatient setting. Nurses play an important role in the identification and treatment of patients at high risk for febrile neutropenia through assessment and adherence to clinical practice guidelines. In addition, nurses play an active role in patient education regarding risk factors, protective measures, and signs and symptoms of infection in the immunocompromised oncology patient.

Effects of Creative Arts Intervention on Anxiety, Depression and Sleep Quality Among Bone Marrow Transplantation Patients During Protective Isolation

BACKGROUND

Protective isolation remains part of the standard of care for patients undergoing hematopoietic stem cell transplant in many places of the world. The consequences of protective isolation include increased anxiety and depressive symptoms.

OBJECTIVE

The aim of this study was to determine the effects of creative interventions performed during the protective isolation period on anxiety, depression symptoms, and sleep quality of patients who underwent bone marrow transplantation (BMT).

INTERVENTIONS/METHODS

This study was a randomized, controlled, pre-post pilot design. A total of 20 patients made up the sample group. Participants were randomly assigned to the experimental (n = 9) or control group (n = 11). Hospital Anxiety and Depression Scale was applied to patients on the first day of admission to the unit and on the day of discharge. Questions prepared by researchers on sleep quantity and quality were administered every day during the patients' hospitalization. The patients in the experimental group carried out creative arts intervention for a total of 60 minutes a day, 3 to 4 days a week, while they were in the unit.

RESULTS

There was no difference in depression, anxiety, and sleep quality scores between the groups after intervention. However, depression and anxiety scores significantly decreased after the intervention in the experimental group, and sleep quality scores improved significantly.

CONCLUSION

Creative arts intervention may be beneficial for anxiety, depression, and sleep problems among patients undergoing BMT.

IMPLICATIONS FOR PRACTICE

Creative arts intervention is effective in coping with anxiety, depression, and sleep problems that patients may experience due to social isolation during the BMT process.

A sequential exploratory study to develop and validate neutropenic nursing care bundle for neutropenic patients admitted in a tertiary care hospital, Uttarakhand

BACKGROUND

Patients diagnosed with cancer and who undergo cancer treatment are at potential risk of bone marrow suppression leading to prolonged hospitalization, delay in treatment, and chemotherapy dose reductions, which ultimately results in significant morbidity and mortality. This sequential exploratory study using a mixed-method approach was aimed to develop and validate a neutropenic nursing care (NNC) bundle for neutropenic patients admitted in a tertiary care hospital, Uttarakhand.

MATERIAL AND METHODS

This sequential exploratory study design with an instrument developmental model was used to develop the NNC bundle. It consisted of two phases: Qualitative phase and quantitative phase. In the qualitative phase, focused group discussion with eight oncology nurses was performed to derive themes related to neutropenic nursing care using conventional content analysis. An extensive literature review was also performed on these themes to explore the current pieces of evidence for item pool generation. In the quantitative phase, a preliminary draft bundle was developed, and two Delphi rounds (I and II) were carried out among the five experts for the content validation of the NNC bundle and a final bundle was developed.

RESULTS

Major domains identified for the bundle were hand hygiene, care of central and peripheral lines, routine oral care, antiseptic bath, peri-anal care, diet, and environmental hygiene. The content validity index (CVI) of the bundle was found to be >80% for all the items with I-CVI >0.8 and S-CVI = 0.99 after conducting two rounds of Delphi.

CONCLUSION

The present study has provided a set of valid written neutropenic nursing interventions to prevent complications in neutropenic patients. The NNC bundle should be subjected to other levels of evaluation that measure the bundle's practicability and suitability for the intended field.

A novel intervention: Implementation of a neutropenic infection-prevention bundle and audit tool in an oncology unit

Infectious complications are a significant cause of morbidity and mortality in patients with chemotherapy-induced neutropenia. Specific infection control practices targeting this patient population are widely endorsed, but little guidance exists on how to implement and monitor compliance with these practices. At our institution, we increased compliance with infection control measures by using a bundled neutropenic precaution (NP) audit and feedback tool.

The role of procalcitonin and presepsin in the septic febrile neutropenia in acute leukemia patients

BACKGROUND

The source of bacterial infection in neutropenic acute leukemia patients is detected in about 20-30% of cases. Bacterial cultures may require a long incubation period and risk false-positive and false- negative results. Therefore, biomarkers distinguishing septic febrile neutropenia from other etiologies in acute leukemia patients play the important role in patient assessment and treatment planning. This study aims to determine the role of procalcitonin (PCT) and presepsin (PSPN) in infectious complication in comparison to C-reactive protein (CRP) on the first and third day at the onset of febrile neutropenia in patients with acute leukemia.

METHODS

Between June 2018 and February 2019, 60 acute leukemia patients with febrile neutropenia receiving chemotherapy. The 41 acute myeloid leukemia patients and 19 acute lymphoblastic leukemia patients were recruited in this study. Their ages ranged from 14 to 65 years. PCT and PSPN were measured and were compared to CRP at the onset of febrile neutropenia and after 48 hours. 20 patients had a fever of unknown origin (FUO) and 40 patients had a bacterial infection.

FINDINGS

Our results showed that the values of these markers were higher in patients with infection than patients without. The area under the curve (AUC) of PCT were 0.931 and 0.813 on day one and three respectively, which was the best in determination of infection. The cut-off values of PCT were 1.27 and 1.23 ng/mL and the cut off values of PSPN were 1.75 and 2.9 μg/L in the successive days, their clinical sensitivities were high. PCT and PSPN were capable of distinguishing the cause of febrile neutropenia from the onset of infection and predicting its complications (p<0.05). The PSPN level couldn't differentiate gram-positive or gram-negative bacterial infection. Significant differences were found between the mean values of the PSPN during the successive days in all patients and patients with bacteremia. This study illustrated a weak positive correlation between PCT and Sequential Organ Failure Assessment (SOFA) score, the negligible correlation between CRP and SOFA score and no significant correlation between PSPN and SOFA score.

INTERPRETATION

PCT is an accurate biomarker in identifying infection in acute leukemia patients, its concentration is associated with the severity of bacterial sepsis. PSPN is superior to PCT for follow-up of patients.

Loneliness among cancer caregivers: A narrative review

OBJECTIVE

Providing care to a loved one with cancer places demands on caregivers that result in changes to their daily routines and disruptions to their social relationships that then contribute to loneliness. Though caregivers' psychosocial challenges have been well studied, loneliness - a determinant of health - has not been well studied in this population. This narrative review sought to describe the current evidence on loneliness among caregivers of cancer patients. We aimed to (1) define loneliness, (2) describe its prevalence, (3) describe the association between loneliness and health outcomes, (4) describe risks and consequences of loneliness among cancer caregivers, (5) identify ways to assess loneliness, and (6) recommend strategies to mitigate loneliness in this unique population.

METHOD

We used evidence from articles listed in PubMed, PsycINFO, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases, book chapters, and reports. Articles were reviewed for the following inclusion criteria: (1) published in English, (2) caregivers of cancer patients, (3) loneliness as a study variable, and (4) peer-reviewed with no restriction on the timeframe of publication. Caregivers were defined as relatives, friends, or partners who provide most of the care and support for someone with cancer.

RESULTS

Eighteen studies met inclusion criteria and were included in the analysis. Caregivers' experiences of loneliness can contribute to negative effects on one's social, emotional, and physical well-being. Social support interventions may not be sufficient to address this problem. Existing recommendations to mitigate loneliness include cognitive and psychological reframing, one-on-one and group therapy, befriending, resilience training, and technology-based interventions.

SIGNIFICANCE OF RESULTS

Limited attention to loneliness in cancer caregivers poses a twofold problem that impacts patient and caregiver outcomes. Interventions are critically needed to address loneliness as a determinant of health in caregivers, given their pivotal role in providing care and impacting health outcomes for people with cancer.

Effect of a dietary supplement composed of hydrolyzed milk proteins and vanillin on the reduction of infection and oxidative stress induced by chemotherapy

This study evaluates the antioxidant and antibacterial activity of a mixture of lactoferrin hydrolysate (LfH), whey protein hydrolysate (WPH) and vanillin in vitro and in vivo to design a chemoprotective supplement for reducing the infection and oxidative stress induced by chemotherapy. The designed supplement showed significant antibacterial activity against E. coli. The supplement with the highest concentration exhibited considerable antioxidant activity in (2,2-diphenyl-1-picrylhydrazyl) DPPH free radicals, (2,2'-azino-bis (3-ethylbenzothiazoline-6-sulfonic acid) ABTS, and reducing power assays. In the biochemical analysis of liver homogenate, the supplement 3 increased the level of enzymes Catalase (CAT), Glutathione peroxidase (GPx), Superoxide dismutase (SOD), and also the Ferric Reducing Ability of Plasma (FRAP) while decreased thiobarbituric acid reactive substances (TBARS) in comparison to paclitaxel group, indicative of activity against oxidative stress. Antibacterial and antioxidant activity of the designed supplement makes it a good candidate for use as a functional food to reduce the side effects of chemotherapy. PRACTICAL APPLICATIONS: A dietary supplement composed of lactoferrin hydrolysate (LfH), whey protein hydrolysate (WPH) and vanillin showed antibacterial activity against E. coli and S. aureus in vitro. The studied supplement also exhibited significant antioxidant properties in the model system and anti-oxidative stress activity in mice exposed to paclitaxel. This supplement has a potential for use in the food matrix to reduce the chemotherapy side effects and to act as a chemoprotective agent.

Microbial Growth on the Nails of Direct Patient Care Nurses Wearing Nail Polish

OBJECTIVES

To determine whether nurses wearing nail polish pose a greater infection risk to patients than nurses who are not wearing nail polish.

SAMPLE & SETTING

89 direct patient care oncology nurses at a large midwestern National Cancer Institute-designated comprehensive cancer center.

METHODS & VARIABLES

The investigators assigned participants' three middle fingers of their dominant hand to three groups.

RESULTS

Comparison of colony-forming units revealed that one-day-old polish exhibited fewer gram-positive microorganisms than the unpolished nail (p = 0.04). The four-day-old polish showed significantly more microorganisms than the one-day-old polish (p = 0.03). The same trend was demonstrated for gram-negative microorganisms, but the difference was not statistically significant (p = 0.3 and p = 0.17, respectively).

IMPLICATIONS FOR NURSING

The results should be interpreted and applied to expert nursing practice in the care of vulnerable patient populations. Each institution and practitioner should make their own decisions and interpretation of evidence into practice.

Sepsis: Symptoms, Assessment, Diagnosis, and the Hour-1 Bundle in Patients With Cancer

Sepsis has a higher incidence of hospital stays and poorer morbidity and mortality outcomes in patients with cancer. The development of infection in weakened immune systems and prolonged treatment courses increase the risk for sepsis in patients with cancer. The causes of infection that can lead to sepsis in patients with cancer are further complicated by disease- or therapy-related neutropenia. Early recognition of sepsis is critical for prompt treatment to prevent tissue damage, organ failure, and mortality. The Surviving Sepsis Campaign recommends the Hour-1 bundle as best practice for sepsis management.