Managing the Risk of Foodborne Infections in Pediatric Patients with Cancer: Is the Neutropenic Diet Still an Option?

Infections pose a significant threat to morbidity and mortality during treatments for pediatric cancer patients. Efforts to minimize the risk of infection necessitate preventive measures encompassing both environmental and host-focused strategies. While a substantial number of infections in oncologic patients originate from microorganisms within their native microbiological environment, such as the oral cavity, intestines, and skin, the concrete risk of bloodstream infections linked to the consumption of contaminated food and beverages in the community cannot be overlooked. Ensuring food quality and hygiene is essential to mitigating the impact of foodborne illnesses on vulnerable patients. The neutropenic diet (ND) has been proposed to minimize the risk of sepsis during neutropenic periods. The ND aims to minimize bacterial entry into the gut and bacterial translocation. However, a standardized definition for ND and consensus guidelines for specific food exclusions are lacking. Most centers adopt ND during neutropenic phases, but challenges in achieving caloric intake are common. The ND has not demonstrated any associated benefits and does not ensure improved overall survival. Consequently, providing unified and standardized food safety instructions is imperative for pediatric patients undergoing hematopoietic cell transplantation (HCT). Despite the lack of evidence, ND is still widely administered to both pediatric and adult patients as a precautionary measure. This narrative review focuses on the impact of foodborne infections in pediatric cancer patients and the role of the ND in comparison to food safety practices in patients undergoing chemotherapy or HCT. Prioritizing education regarding proper food storage, preparation, and cooking techniques proves more advantageous than merely focusing on dietary limitations. The absence of standardized guidelines underscores the necessity for further research in this field.

Low-Bacterial Diet in Cancer Patients: A Systematic Review

The low-bacterial diet (LBD) is a widely used dietary regimen to reduce the risk of food-borne infections in patients with neutropenic cancer, but its role is controversial due to its unclear benefits. The purpose of this study was to provide an updated analysis of the available evidence on the efficacy of the LBD to reduce the risk of infections, mortality rates, and quality of life (QoL) in neutropenic patients with cancer. A systematic literature search was conducted in the biomedical databases Cochrane Library, PubMed, CINHAL, and EMBASE. The process of the screening, selection, inclusion of articles, and assessment of risk of bias and methodological quality was conducted by two reviewers. Of the 1985 records identified, 12 were included. The LBD demonstrated heterogeneity in definition, composition, and initiation timing; moreover, the LBD did not demonstrate a reduction in infection and mortality rates compared to a free diet, showing a negative correlation with quality of life. The LBD, in addition to not bringing benefits in terms of reductions in infection and mortality rates, has been shown to worsen the quality of life due to the reduced palatability and limited variety of the food supply, negatively impacting nutritional status.

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.

Neutropenic Diet Cannot Reduce the Risk of Infection and Mortality in Oncology Patients With Neutropenia

Background

The purpose of this systematic review and meta-analysis was to evaluate the effect of a neutropenic diet and a control diet on infection and mortality rates in oncology patients with neutropenia.

Methods

We searched the following English electronic databases: PubMed, Embase, Cochrane Central Register of Controlled Trials, and Google Scholar Engine. Published studies involving neutropenic diets (study group) and control diets (control group) in oncology patients with neutropenia were searched. The focus of the meta-analysis was on the outcomes of infection and mortality rates. A subgroup analysis was also performed.

Results

A total of 6 studies were included, with a total sample size of 1114 patients. The patients in the study group had a similar infection rate compared with the patients in the control group (P = 0.11). The patients in the study group had a similar mortality rate compared with the patients in the control group (P = 0.74). Another subgroup analysis showed that the incidence of infection was also similar for pediatric (P = 0.74) and adult (P = 0.11) oncology patients between the study and control groups.

Conclusions

Based on the current evidence, this meta-analysis showed that the application of a neutropenic diet cannot reduce the risk of infection and mortality in oncology patients with neutropenia. However, more rigorous randomized controlled trials are needed to confirm this conclusion in the future.

Response to "CAR T-Cell Therapy: Updates in Nursing Management"

I have found Clinical Journal of Oncology Nursing (CJON) articles to be enlightening and well written, and I look forward to reading CJON monthly to expand my general cancer care knowledge. I have been a blood and marrow transplantation (BMT) nurse since 1976; our BMT program birthed the chimeric antigen receptor (CAR) T-cell program. In October 2020, I retired as a BMT supervisor and policy keeper from the Seattle Cancer Care Alliance (SCCA), so I am very familiar with both specialties. I was lucky to spend my career at the Fred Hutchinson Cancer Research Center (FHCRC), which has emphasized research at its core. Clinical nutrition research has been a mainstay since the beginning of the program.

Mediterranean Diet: Outcomes from an Education Session Among Patients With Cancer and Nursing Staff

BACKGROUND

Strong evidence supports the benefits of the Mediterranean diet, but little is reported among patients and nurses regarding knowledge about the diet and its health benefits.

OBJECTIVES

A pre-/post-test practice initiative was implemented to identify level of knowledge about the Mediterranean diet in patients with cancer and nursing staff and to provide education about the diet's health benefits.

METHODS

A 17-item survey was developed to assess knowledge and willingness to try or recommend the Mediterranean diet, current practices, and general nutrition knowledge. A 10-minute education session was provided to patients and nursing staff. Descriptive statistics were used.

FINDINGS

The majority of patients reported eating from one to four servings of fruits and vegetables daily. For patients and nursing staff, post-education session scores demonstrated increased knowledge, willingness to try the diet, and perceived effectiveness of the diet.

Neutropenic diets to prevent cancer infections: updated systematic review and meta-analysis

INTRODUCTION

Multiple studies have questioned the benefit of neutropenic diets in decreasing infections in patients with cancer, but recent surveys showed that such diets are still prescribed. In this study, we sought to evaluate the effectiveness of neutropenic diet in decreasing infection and mortality in neutropenic patients with cancer with neutropenia. This review is an update of a previously published systematic review.

MATERIALS AND METHODS

We searched different databases to identify comparative studies that investigated the effect of neutropenic diet compared with regular diet in neutropenic adults and children with cancer. We conducted random-effects meta-analyses using the Der-Simonian and Laird method to pool treatment effects from included studies. Outcomes of interest were mortality, bacteremia/fungemia, major infections, quality of life, and the composite outcome for neutropenic fever and/or infection.

RESULTS

We included six studies (five randomised) with 1116 patients, with 772 (69.1%) having underwent haematopoietic cell transplant. There was no statistically significant difference between neutropenic diet and regular diet in the rates of major infections (relative risk [RR] 1.16; 95% CI 0.94 to 1.42) or bacteremia/fungemia (RR 0.96; 95% CI 0.60 to 1.53). In haematopoietic cell transplant patients, neutropenic diet was associated with a slightly higher risk of infections (RR 1.25; 95% CI 1.02 to 1.54). No difference in mortality was seen between neutropenic diet and regular diet (RR 1.08, 95% CI 0.78 to 1.50).

CONCLUSION

There is currently no evidence to support the use of neutropenic diet or other food restrictions in neutropenic patients with cancer. Patients and clinicians should continue to follow the safe food-handling guidelines as recommended by the U.S. Food and Drug Administration.

Significant inconsistency among pediatric oncologists in the use of the neutropenic diet

BACKGROUND

The role of the neutropenic diet in the development of infections in oncology and stem cell transplant (SCT) patients is controversial. There is no data on the use of the neutropenic diet among pediatric oncologists.

METHODS

A self-administered electronic survey was sent to 1,639 pediatric oncologists at 198 institutions who are members of Children's Oncology Group. A pediatric dietitian and pediatric oncologists developed, pretested, and modified the survey for item clarification.

RESULTS

Five hundred fifty-seven physicians (34%) responded representing 174 (87%) of the 198 member institutions. More than half of respondents (57%) report implementing the neutropenic diet at their facility. In a multivariate analysis, being a stem cell transplant (SCT) center was the only significant factor associated with implementing a neutropenic diet (OR: 6.06, 95% CI, 2.88-12.738, P < 0.001) after controlling for years in practice, gender, center size, and academic versus private practice. Among physicians who implemented a neutropenic diet, absolute neutrophil count was the trigger for initiating the diet in oncology patients (72%) while admission and start of preparative regimen was used for SCT patients (84%). The majority of respondents (82%) stop the neutropenic diet when oncology patients are no longer neutropenic while the practice varied significantly with SCT patients. Providers at the same institution were not consistent with implementation of the diet, patient populations placed on the neutropenic diet and parameters for initiation, discontinuation of the diet and specific food restrictions.

CONCLUSION

The implementation of the neutropenic diet by pediatric oncologists remains quite variable even among those at the same institution.