Schlesinger, A., Paul, M., Gafter-Gvili, A., Rubinovitch, B., & Leibovici, L. (2009). Infection-control interventions for cancer patients after chemotherapy: a systematic review and meta-analysis. The Lancet Infectious Diseases, 9, 97–107.
To review prospective comparative studies that address infection prevention for high-risk patients undergoing chemotherapy and stem cell transplant recipients to evaluate the evidence for best practice and assess for mortality.
Databases searched were CENTRAL (the Cochrane Library issue 4, 2006), PubMed (1966–2008), and LILACS (1982–2006). Unpublished trials that were presented at the following conferences were also queried: American Society of Hematology (2001–2006), American Society of Clinical Oncology (1995–2006), and European Society for Medical Oncology (2002–2006). The references lists from all included studies were reviewed to identify additional studies.
Keywords searched were not provided by the authors.
Studies were included if they
Studies were excluded if they were nonrandomized studies that compared patients with different types of cancer or compared different treatment protocols (i.e. stem cell transplant versus chemotherapy) or if they assessed pharmacological interventions, such as antimicrobial prophylaxis and mouth rinse preparations, unless these interventions were applied together or as a control for the infection-control interventions.
Forty studies were included.
Method of Study Evaluation
Prevention of infection measures used in the studies were identified and grouped together: control of air quality (air filtration), protective isolation, and suppression of the endogenous flora (antibiotics). Subgroup analyses were performed for two major outcomes: all-cause mortality at 100 days and documented infections.
The primary outcome, all-cause mortality, was assessed at 30 days, 100 days, and at the longest follow-up reported in each study. Secondary outcomes included the rate and types of infections (including bacteremia), the need for hospitalization and length of hospital stay, the length of the febrile period, infection-related mortality, bacterial and fungal colonization, and antibiotic and antifungal treatment.
A combination of air quality control, barrier isolation, and prophylactic antibiotics is estimated to reduce 30-day all-cause mortality by 40% in high-risk cancer patients, including allogeneic or autologous HSCT recipients and patients with acute leukemia. Prophylactic antibiotic use is the most significant preventive strategy; air quality control and barrier isolation did not show an independent contribution, and their use should be reserved for patients at highest risk of infection. Survival significantly improved with outpatient management, which included the use of prophylactic antibiotics without environmental controls.
The reduced mortality seen in outpatient management may be due to
There is no evidence that any of these preventive strategies (air quality control, barrier isolation, or prophylactic antibiotics) are necessary or appropriate for low-risk cancer patients with solid tumors.