DEPARTMENT: Cochrane Nursing Summary
Neutropenia is a potentially serious adverse effect of chemotherapy for patients with solid tumors and hematologic malignancies and is a major risk factor for infections and sepsis. It has been hypothesized that a low-bacterial diet (LBD) can prevent the occurrence of infections and infection-related mortalities in patients with neutropenia as a result of chemotherapy. A systematic review was therefore warranted to update nurses and dieticians to enable them to provide updated evidence for patient education.
The primary objective of the review was to determine the efficacy of an LBD versus a control diet in preventing the occurrence of infections and to decrease infection-related mortality in adult and pediatric cancer patients with chemotherapy-related neutropenia. The secondary objectives were to assess the time to first febrile episode, the need for empirical antibiotic therapy, diet acceptability, and quality of life.
Three randomized controlled trials (RCTs) with a total of 192 participants were included in this review.1 Participants of interest were adults and children (aged ≥1 year) who received chemotherapy causing episodes of neutropenia. The intervention was LBD, defined as any diet intended to reduce the ingestion of bacterial and fungal contaminants by the exclusion of foods. Interventions were compared with control diets, described as any other diet. The primary outcome measures were infection rate and infection-related mortality; secondary outcomes included the time to first febrile episode, the need for empirical antibiotic therapy, diet acceptability, and quality of life.
Two RCTs reported rigorous randomization using computer or block randomization, but the risk of selection bias was unclear in 1 RCT. The risk of performance and detection bias was unclear in 2 RCTs and high in 1 study. The risk of attrition bias was low in 2 RCTs and unclear in 1 RCT. In all included studies, the risk of selective reporting was low. This review appeared to accept any cointerventions as inclusion criteria. However, pooling of results for all 3 studies was not possible because of differences in cointerventions, outcome definitions used, and intervention and control diets.
When comparing 2 of the studies, no statistically significant difference in infection rate between patients receiving the intervention and control diet was identified. The third RCT did not present necessary data for this analysis. Infection-related mortality was not mentioned in any of the studies. Only 1 study examined diet acceptability, time to fever, quality of life, and need for empirical antibiotic therapy, and no statistically significant data between the treatment arms were found.
Currently, there is no evidence from individual RCTs that can support or refute the use of an LBD for the prevention of infection and related outcomes in children and adults with different malignancies. All studies differed with regard to cointerventions, outcome definitions, and intervention and control diets, and all studies had methodological limitations, resulting in inconclusive recommendations on the use of LBD.
Implications for Practice
More high-quality research is needed for definitive conclusions to be made. Data from this review should be interpreted with caution.
Lim Chi Ching, RN, BSc (Nursing) (Hons)
National University Cancer Institute, Singapore
1. Van Dalen EC, Mank A, Leclercq E, Mulder RL, Davies M, Kersten MJ, van de Wetering MD. Low bacterial diet versus control diet to prevent infection in cancer patients treated with chemotherapy causing episodes of neutropenia. Cochrane Database Syst Rev. 2012; 9: CD006247. doi:10.1002/14651858.CD006247.pub2.