Laura Zitella is a nurse practitioner in the division of oncology at Stanford Hospital and Clinics in California, and her work has focused for many years on infection management. At the 38th Annual Oncology Nursing Society Congress, Laura is presenting a talk called "Best Practices in Infection Risk, Prevention, and Management." Today, Laura will be sharing her insights and perspectives with Cancer Network, and discussing challenges and considerations for management and prevention of infection in the oncology setting—in both patients with solid tumors and those with hematologic malignancies.
—Interviewed by Anne Landry
Cancer Network: Since 2006 you've worked on developing and updating ONS's PEP card—Putting Evidence Into Practice—on managing infections. Can you talk about what that process has been like?
Laura Zitella: I would love to. I think that the PEP project is one of the most exciting projects that ONS has worked on, and it's turned out to be really successful. It's interesting because the whole idea started in 2004 at an advanced practice nursing retreat that ONS conducted. The theme of that retreat was to look at nursing-sensitive outcomes, and how nurses play a role in making a difference in good patient outcomes.
Christopher R. Friese, RN, PhD, AOCN, FAAN, currently assistant professor at the University of Michigan School of Nursing, division of nursing business and health systems, presented on infection, and he looked at all of the interventions that could prevent infection, based on the strongest evidence available, which is randomized controlled trials and meta-analyses. We found that presentation to be very interesting, but we raised the question of, "what about all of those other questions that come up so often, that don't have a lot of research available to answer them—for example, the use of masks to prevent infection, the use of a low-microbial diet to prevent infection—and at that time, there was not a lot of evidence regarding these and certain other interventions, but there were some smaller phase II trials that did give us some idea of how we should counsel patients and what was the best thing to do to manage a particular infection-related risk or situation.
So, rather than focusing on the meta-analyses, we decided “Well, what if we came up with a guideline that could help answer some of these questions, and we could rank all of the answers by the level of evidence that was available to answer that question?” That's how we got this idea of stratifying specific infection management strategies into “Effectiveness Completely Established” (by a lot of data) vs “May Be Effective, But Has No Harm” (so that's okay, we could give that a try), or “May Be Beneficial But Does Have Some Harm" (and so you need to proceed with caution) or "Effectiveness Not Established.”
Since then, we looked at all of the literature, we've developed guidelines on what was out there and what wasn't in terms of information and recommendations related to infection management, and we published our first set of PEP cards on infection management in 2006. We did an update of the literature in 2009, and we're doing another update this year. We'll be publishing this year with the most recent updates, because there are so many more studies that have been done on looking at how we can prevent infection in cancer patients.
Cancer Network: So, what are some of the most important things oncology nurses should know regarding infection?
Laura Zitella: Well, since there's so much literature out there, and our patient population is so diverse, I think the most important thing an oncology nurse should be aware of is risk assessment. There's a really big difference between a patient who is low risk, for example, a patient who has a solid tumor, like colon cancer, who undergoes very mildly myelosuppressive chemotherapy, to the very high-risk patient, such as the patient who has acute leukemia, who is undergoing significantly myelosuppressive therapy, or maybe even immunotherapy.
I think that risk assessment is probably the most important thing, and it can be thought of in three categories: patient-related risk factors, disease-related risk factors, and treatment-related risk factors.
Of the treatment-related risk factors, myelosuppression certainly is the most recognized risk; we've known since the 1960s that the depth and breadth of neutropenia correlate with the risk of infection. So there are very solid guidelines for the prevention of neutropenic-related infections, using interventions such as growth factors (if the risk of febrile neutropenia is greater than 20%), or using antibiotic prophylaxis in high-risk patients.
But with the advent of all of these newer cancer therapies, such as immunotherapy, monoclonal antibodies, tyrosine kinase inhibitors, and other agents, we're recognizing that other types of immunity are affected, and that needs to be taken into consideration. An example of that would be bortezomib (Velcade), which turns out to increase the risk of herpes zoster infection, so one of the recommendations for patients on bortezomib is that they receive Acyclovir prophylaxis.
I think that now that we have so much more information about the risks for infection and what we can do to prevent them, the recommendations are very specific—and so it's important to know your patient; know what patient-related risk factors they have, like comorbidities; the disease-related risk factors (solid tumor vs lymphoma or leukemia); and the treatment-related risk factors, which would be the myelosuppressive nature of the chemotherapy, or the immunosuppressive effects of the therapy, or bone marrow transplant.
Cancer Network: Can you highlight a few useful resources that nurses should be aware of for infection management or prevention?
Laura Zitella: Yes, I would love to, because with all of this data, we often think, “Well, where do we start? How do we know the best way to manage our patients, and how to give them the best advice?” So, there are really nice guidelines from a number of different organizations. Of course, I'd like to highlight the ONS PEP card on infection, which has a lot of useful information regarding diet, handwashing, masks, gowns, protective isolation, but there are other really nice guidelines, too.
The National Comprehensive Cancer Network (NCCN) has guidelines, which are updated every year, that address a lot of the medical interventions, such as which patients should have antibiotic prophylaxis, which patients should have hepatitis B prophylaxis, PCP (Pneumocystis carinii pneumonia) prophylaxis—and those guidelines I use daily in my practice.
In the bone marrow transplant (BMT) setting, there's a really nice set of guidelines that was published in 2009, and that was a compilation, a consensus of guidelines, from American Society for Blood and Marrow Transplantation (ASBMT), the Infectious Diseases Society of America (IDSA), and the Canadian Infectious Disease Society, and a number of other organizations, and that is extremely comprehensive. It covers just about every known pathogen that can affect bone marrow transplant patients. Other useful guidelines would be the IDSA febrile neutropenia guidelines, which were published in 2011; and the American Society of Clinical Oncology Clinical Practice Guidelines on antibiotic prophylaxis and febrile neutropenia in outpatients, which was just published a few months ago; and there are also guidelines for the prevention of central line infections, which is also a significant issue in our patient population.
Cancer Network: You've written a new book this year with clinical nurse specialist Mikaela Olsen from Johns Hopkins. And that discusses disease- and treatment-related complications in patients with hematologic malignancies. How has infection management evolved for these patients specifically?
Laura Zitella: Well, patients with hematologic malignancies have the greatest risk of infection, in general, and for each specific hematologic disease, there are specific recommendations. So, in the book, we included that for each disease group. So, for example, chronic lymphocytic leukemia (CLL) patients tend to be hypogammaglobulinemic, and they tend to have a higher risk of infections from deficits in B-cell immunity—and there are specific guidelines on how to prevent infection in that population. In the lymphoma patients who are treated with rituximab (Rituxan), there are specific recommendations on testing for hepatitis B virus and using prophylaxis in hepatitis B carriers.
In our book, each chapter was written by an expert in that particular malignancy, and the authors are all nurse practitioners or clinical nurse specialists. We really tried to tailor the chapters of the book to be practical and useful, and specific for that particular patient population.
Cancer Network: That sounds excellent. Can you tell us who publishes the book? I guess you can get it online?
Laura Zitella: Yes, you can get it online, and hopefully soon! The Oncology Nursing Society publishes it, and it's anticipated that it will be published in July. There will be a print copy, and then eventually, there will also be an online version of it. And then, to supplement the book, the ONS has developed a Web course called the Hematology Web Course, and it will be offered through ONS University online. You can take this Web course and go through it, and the text is offered as part of the course, so you can use the book as the text for the course. And then the Web course has additional information, and case studies, and other methods of learning.
Cancer Network: Wow, that's great; that really reinforces everything. Terrific. Okay, well, Laura, thanks so much for your time. I appreciate your joining us today!
Laura Zitella: Well, thank you for inviting me to speak. It was a pleasure.
Flowers CR, Seidenfeld J, Bow EJ, et al. Antimicrobial prophylaxis and outpatient management of fever and neutropenia in adults treated for malignancy: American Society of Clinical Oncology clinical practice guideline. J Clin Oncol. 2013;31(6):794-810.
Freifeld AG, Bow EJ, Sepkowitz KA, et al. Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the Infectious Diseases Society of America. Clin Infect Dis. 2011;52(4):427-31.
National Comprehensive Cancer Network. 2012. NCCN Clinical Practice Guidelines in Oncology: Prevention and Treatment of Cancer-Related Infections [v.1.2012]. Available from: http://www.nccn.org/professionals/physician_gls/pdf/infections.pdf
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