Hygiene:

• Handwashing is the single most important intervention to prevent infection and may be accomplished with antimicrobial soap and water.

• When hands are not visibly soiled, alcohol-based hand rubs that come in contact with all surfaces of the hand are acceptable substitutes. Alcohol-based hand rubs cannot be used when caring for patients with C. difficile diarrhea, norovirus infection, and when hands are visibly soiled.

• Avoid urinary catheterization. If not clinically feasible, intermittent catheterization—using sterile technique and a closed drainage system—is preferred to continuous catheterization.

• When long-term catheterization is necessary, suprapubic catheters may be considered.

• Document insertion and care of urinary catheters.

• To prevent infection in malignant cutaneous wounds, irrigate thoroughly between dressing changes, débride necrotic material, and dress appropriately to absorb exudate.

• Give neutropenic patients with cancer frequent oral care (toothbrushing and gentle flossing as tolerated). Oral rinses should be “palatable,” and antimicrobial rinses should be considered when gingivitis or poor hygiene is noted.

Intravenous therapy:

• Select intravascular catheter type and site for insertion that considers risk for complications related to the planned type and duration of intravenous therapy.

• Avoid placement of permanent or semipermanent catheters when patients are functionally or quantitatively neutropenic.

• Insert a central venous catheter (CVC) using full barrier precautions (i.e., sterile field, caps, gowns, masks, sterile gloves).

• Always aseptically place catheters, regardless of site.

• Two percent chlorhexidine preparation is the preferred cleansing agent of catheter sites.

• Remove catheters promptly when deemed unnecessary.

• Cleanse injection ports and diaphragms of multidose vials with 70% alcohol before accessing.

• Replace catheter dressings promptly when damp, soiled, or loosened.

• Replace intravenous administration sets, extensions, and secondary sets no more frequently than 96 hours, unless infection is suspected or documented.

Nutrition and GI system:

• When clinically appropriate, enteral nutrition is preferred to the parenteral route in the patient population with cancer.

• Appropriate dietary restrictions for the patient with neutropenic cancer include fruits and vegetables well washed with tap water and avoidance of raw and unwashed meat, eggs, fish, and shellfish.

• Outcomes related to other dietary restrictions popular in clinical care are not supported by the literature.

Environment:

• No systematic evidence exists for the practice of protective isolation of the neutropenic patient with cancer. Such measures may be substituted with aggressive hygienic measures.

• Neutropenic patients with cancer should not be in contact with fresh flowers or plants.

Drug prevention:

• To prevent oral candidiasis in the patient with cancer, the use of prophylactic antifungals that are entirely or partially absorbed in the GI tract (e.g., fluconazole, clotrimazole) is preferable to use of nonabsorbed agents such as Mycostatin.

• Prophylactic anti-infectives are indicated in specific situations:

  • Allogeneic bone marrow transplantation against:

    • Mycoses: fluconazole, itraconazole, or amphotericin B

    • Herpes simplex virus: acyclovir, famciclovir, or valacyclovir

    • Pneumocystis carinii: trimethoprim-sulfamethoxazole

  • Acute leukemia undergoing induction against:

    • Mycoses: fluconazole, itraconazole, or amphotericin B

    • Herpes simplex virus: acyclovir, famciclovir, or valacyclovir

Protocols for prevention of catheter-related infections:

• Obtain paired blood cultures: one peripherally, the second set obtained from the distal port of the CVC.

• Obtain the peripheral culture first; both sets should contain the same volume of blood.

• The time to positivity (the time between obtaining culture and a positive result) should be compared for set obtained from the CVC versus peripherally. If the culture obtained from the CVC is positive first, the difference between the two is greater than 120 minutes, and colonization is focused within the CVC, catheter-related infection should be strongly suspected.

Protocol for obtaining blood cultures for CVC-related infections:

• Obtain cultures within 30 minutes of the order.

• One peripheral set of blood cultures is obtained at the first fever.

• One set of cultures is obtained from each lumen of a CVC, with no blood discarded.

• Subsequent cultures are drawn from central lines only. Only one set of CVC cultures is obtained after the fever has occurred outside the initial 48-hour period.