Bacterial Infections in Patients With Solid Tumors

ABSTRACT: The employment of best practices is essential for minimizing the disease burden of cancer and optimizing patient outcomes. However, areas of clinical confusion remain and patients continue to receive inappropriate therapies. The aim of this article is to present key evidence-based strategies for initial assessment, early management, and prevention of bacterial infection in patients with common solid tumors. First, the need for astute clinical assessment, including risk assessment and symptom-based diagnostic testing, will be discussed. Then, the selection of therapeutics for early intervention will be outlined, along with key nursing considerations regarding monitoring for toxicities. The efficacy of innovations, such as antimicrobial central venous catheters, will also be reviewed. Recommendations are based on practice guidelines from the National Comprehensive Cancer Network, Infectious Diseases Society of America, Healthcare Infection Control Practices Advisory Committee, Centers for Disease Control and Prevention, Surviving Sepsis Campaign, and Oncology Nursing Society.

Early and appropriate management of infection in the patient with cancer is critical to optimizing patient outcomes. Practices that are not recommended by current guidelines continue to be used frequently, however.[1] Examples include routine fluoroquinolone prophylaxis, reactive use of colony-stimulating factors, and inappropriate selection of anti-infectives for empiric therapy in low-risk patients. The purpose of this article is to summarize pharmacologic and nonpharmacologic management and prevention strategies for bacterial infection in adult patients with solid tumors. For prevention and management strategies for fungal and viral processes in both solid tumors and hematologic malignancies, readers are referred to guidelines from the National Comprehensive Cancer Network (NCCN), Infectious Diseases Society of America (IDSA), and Centers for Disease Control and Prevention (CDC).

Patients with cancer are at increased risk of infection and at greater risk of complications from infectious processes. Multiple factors escalate their susceptibility: the absence of granulocytes; disruption of integumentary, mucosal, and mucociliary barriers; foreign devices such as vascular catheters; nutritional deficiencies; and pre-existing or newly acquired comorbidities.[2,3] Timely and effective management of infection increases the likelihood of timely receipt of anticancer therapies, decreased disease burden and symptom distress, and enhanced quality of life. In this article, we will focus first on initial assessment and interventions, and will conclude with a summary of strategies for prevention of infection.

Initial Assessment

Early management of an infectious process is of utmost importance in the patient with cancer, to decrease the risk of sepsis and related complications. The NCCN defines neutropenia as either (1) an absolute neutrophil count (ANC) < 500/ L, or (2) an ANC < 1,000/ L and a predicted decline to 500/ L over the next 48 hours. Fever is defined as a single temperature of 38.3°C (about 101°F) or higher orally or of 38.0°C (100.4°F) or higher lasting longer than 1 hour in the absence of an obvious cause.[3]

FIGURE 1

Fever and Infection-Initial Assessment, Intervention, and Evaluation. Information adapted from Reference 3.

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