1. Neutropenic Diet Clinical Effectiveness vs. Quality of Life Yasuko Kato Sodexo Distance Intern 2014

2. What is Neutropenic diet? AKA: a sterile diet, low microbial diet, or a low bacterial diet First developed in 1960s No standardized definition established Variations of the neutropenic diet include: – a germ free diet – a low bacterial diet (LBD) – a modified house diet

3. Neutropenic diet at hospitals Controversial – Several studies in 60’s~80’s led the use of diet Neutropenia = Major risk factor of infection Isolated microorganism in foods Bacterial translocation: GI to lymph and other organs – Benefit never scientifically proven 2 small randomized trial showed no differences Use of Neutropenic diet, initiation and discontinuation point varies Burden for inadequate oral intake d/t chemo

4. Survey result (7 hospitals) Use Neutropenic Diet No Fresh Fruits and Vegetables No Fresh Flowers 444  Community cancer centers’ survey (2000): 78% (n=120)  Stem cell transplantation centers’ survey (2011): 100% (n=15)

5. Find High Risk Food L QUEENSO KBFM IREI MITS CAESARSALAD HULL ESFM EHAO MISOLN COFFEE NEWYEAR

6. Answers L QUEENSO KBFM IREI MITS CAESARSALAD HULL ESFM EHAO MISOLN COFFEE NEWYEAR

7. Who is at risk? Absolute Neutrophil Count (ANC) less than 1500 or 1000 and – ANC 100 or less for a week or more – Age 60 or older – Liver and/or kidney dysfunction – Emphysema or COPD – Inadequate oral intake d/t severe mouth sores – Dehydration – low blood pressure – On alemtuzumab (Campath®) – Signs of pneumonia or another complex infection

8. Study Descriptions Van Tiel 2007Gardner 2008Trifilio 2012 MethodRCT No RCT Participants20 CA patients Reg – mean 53.3yo Low Bacterial Diet (LBD) – mean 51.8yo 153 CA patients Raw – median 63yo Cooked – median 64yo 726 Stem Cell Transplant pts General hospital diet (GD) – median 57 yo Neutropenic Diet (ND) – median 57 yo Study days20 chemo cycles Reg - 509 days LBD - 406 days 24 days - median (range 6-42 days) 2004/10-2008/08 GD – 24 months ND – 23 months

9. Study Descriptions Van Tiel 2007 Netherlands Gardner 2008 USA Trifilio 2012 USA Supportive careAntimicrobial Prophylaxis Air-filtered room Antimicrobial Prophylaxis Central Venous Catheter care/Oral care Unclear/UnclearYes/UnclearUnclear/Unclear Measured Outcomes ≥38.5°C or < 36°C Major infections Minor infections Fever of unknown origin Microbiologically confirmed infection LOS Diarrhea Bias/LimitationMany unclear bias; small study (n≤ 30) Intervention was obvious that both patients and health care providers were not blinded Not randomized; exclusively at one hospital

10. Gardner 2008

11. Trifilio 2012 P-value =.51

12. Result and Conclusion comparison Van Tiel 2007Gardner 2008Trifilio 2012 Result# of chemo cycle with infection: Regular – 17/21 chemo cycles (80%) LBD – 14/20 chemo cycles (70%) Infection rate: Raw – 76% (46% major; 4% minor; 47% unknown origin) Cooked – 87 % (34% major; 7% minor; 59% unknown origin) Infection rate: ND – 135 GD – 106 LOS: ND – 18 GD – 18 Diarrhea: ND – 294 GD – 276 ConclusionNo significant difference in chemo cycles was analyzed due to data insufficiency No statistically significant difference in infection rate between two diets Infection rate and Diarrhea are significantly fewer in GD group UTI and C. Diff rate higher in ND group

13. My conclusion Not enough scientific evidence Safe food handling practice is MUST Importance of maintaining normal gut flora with probiotics?

14. Therapeutic diet or Liberalized diet?

15. Reference American Cancer Society. (2013, November 06). Infections in people with cancer. Retrieved from http://www.cancer.org/acs/groups/cid/documents/webcontent/002871-pdf.pdf French MR, Levy-Milne R, Zibrik D. A survey of the use of low microbial diets in pediatric bone marrow transplant programs. Journal of American Dietetic Association 2001;101 (10):1194–8. Gardner A, Mattiuzzi G, Faderl S, Borthakur G, Garcia- Manero G, Pierce S, et al.Randomized comparison of cooked and noncooked diets in patients undergoing remission induction therapy for acute myeloid leukemia. Journal of Clinical Oncology 2008;26(35):5684–8. Smith LH, Besser SG. Dietary restrictions for patients with neutropenia: a survey of institutional practices. Oncology Nursing Forum 2000;27(3):515–20. Trifilio S, Helenowshi I, Giel M, et al. Questioning the role of a neutropenic diet following hematopoetic stem cell transplantation. Biol Blood Marrow Transplant. Mar 16, 2012;1-6 Van Tiel FH, Harbers MM, Terporten PHW, van Boxtel RTC, Kessels AG, Voss GBWE, et al.Normal hospital and low-bacterial diet in patients with cytopenia after intensive chemotherapy for hematological malignancy: a study of safety. Annals of Oncology 2007;18:1080–4.