Ann Surg Treat Res.  2024 Oct;107(4):195-202. 10.4174/astr.2024.107.4.195.

Lesson from COVID-19 outbreak; importance of standard precautions to febrile neutropenia prevention in patients with breast cancer who received adjuvant chemotherapy: a retrospective observational study

• Park JE
• Yang J
• Han S
• Yoo JR
• Kim M
• Lee D
• Jo J

• KMID: 2560004
• DOI: http://doi.org/10.4174/astr.2024.107.4.195

Abstract

Purpose
Intensive cytotoxic chemotherapy increases the risk of infection in patients with cancer by inducing bone marrow suppression and mucosal injury. Febrile neutropenia (FN) is the most important clinical adverse event in patients with cancer receiving cytotoxic chemotherapy. To prevent FN, standard precautions including hand and respiratory hygiene are generally recommended, but the exact effect of non-pharmacologic intervention has not been clearly proven in the clinical setting. We aimed to compare the incidence of FN between the pre-coronavirus disease 19 (COVID-19) era vs. the postCOVID-19 era.
Methods
We retrospectively enrolled patients with breast cancer who received an adriamycin and cyclophosphamide (AC) regimen containing adjuvant chemotherapy at Jeju National University Hospital. We compared the incidence of FN between the pre- and post-COVID-19 period and analyzed characteristics of the event and other clinical risk factors.
Results
In total, 149 patients were enrolled, including 94 who received AC chemotherapy in the pre-COVID-19 era and 55 who received it in the post-COVID-19 era. Sixteen patients (10.7%) experienced FN. Fourteen (14.9%) and 2 events (3.6%) occurred in pre-COVID-19 and post-COVID-19 eras, respectively. The post-COVID-19 era was the only risk factor for FN (P = 0.032).
Conclusion
We found an association between FN occurrence and the COVID-19 outbreak, providing indirect evidence of the importance of non-pharmacological measures to reduce FN risk in patients with breast cancer. Further research is required to confirm the standard precautions for FN prevention in patients with cancer.

Keyword

Febrile neutropenia; Universal precautions; COVID-19

Figure

• 

  Fig. 1 (A) Disease-free survival and (B) overall survival based on occurrence of febrile neutropenia (FN).

Reference

1. Kang MJ, Won YJ, Lee JJ, Jung KW, Kim HJ, Kong HJ, et al. Cancer statistics in Korea: incidence, mortality, survival, and prevalence in 2019. Cancer Res Treat. 2022; 54:330–344. PMID: 35313102.

2. Shiels MS, Lipkowitz S, Campos NG, Schiffman M, Schiller JT, Freedman ND, et al. Opportunities for achieving the cancer moonshot goal of a 50% reduction in cancer mortality by 2047. Cancer Discov. 2023; 13:1084–1099. PMID: 37067240.

3. Barnes G, Pathak A, Schwartzberg L. Pharmacoeconomics of granulocyte colony-stimulating factor: a critical review. Adv Ther. 2014; 31:683–695. PMID: 24989316.

4. Klastersky J, de Naurois J, Rolston K, Rapoport B, Maschmeyer G, Aapro M, et al. Management of febrile neutropaenia: ESMO Clinical Practice Guidelines. Ann Oncol. 2016; 27(Suppl 5):v111–v118. PMID: 27664247.

5. Taplitz RA, Kennedy EB, Bow EJ, Crews J, Gleason C, Hawley DK, et al. Antimicrobial prophylaxis for adult patients with cancer-related immunosuppression: ASCO and IDSA clinical practice guideline update. J Clin Oncol. 2018; 36:3043–3054. PMID: 30179565.

6. Carmona-Bayonas A, Jimenez-Fonseca P, de Castro EM, Mata E, Biosca M, Custodio A, et al. SEOM clinical practice guideline: management and prevention of febrile neutropenia in adults with solid tumors (2018). Clin Transl Oncol. 2019; 21:75–86. PMID: 30470991.

7. Siegel JD, Rhinehart E, Jackson M, Chiarello L. Health Care Infection Control Practices Advisory Committee. 2007 Guideline for isolation precautions: preventing transmission of infectious agents in health care settings. Am J Infect Control. 2007; 35(10 Suppl 2):S65–164. PMID: 18068815.

8. Freifeld AG, Bow EJ, Sepkowitz KA, Boeckh MJ, Ito JI, Mullen CA, 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:e56–e93. PMID: 21258094.

9. Klastersky J, Paesmans M, Rubenstein EB, Boyer M, Elting L, Feld R, et al. The Multinational Association for Supportive Care in Cancer risk index: a multinational scoring system for identifying low-risk febrile neutropenic cancer patients. J Clin Oncol. 2000; 18:3038–3051. PMID: 10944139.

10. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987; 40:373–383. PMID: 3558716.

11. Lepak AJ, Taylor LN, Stone CA, Schulz LT, Anderson MC, Fox BC, et al. Association of changes in seasonal respiratory virus activity and ambulatory antibiotic prescriptions with the COVID-19 pandemic. JAMA Intern Med. 2021; 181:1399–1402. PMID: 34152385.

12. Schimpff SC, Young VM, Greene WH, Vermeulen GD, Moody MR, Wiernik PH. Origin of infection in acute nonlymphocytic leukemia: significance of hospital acquisition of potential pathogens. Ann Intern Med. 1972; 77:707–714. PMID: 4628214.

13. Boyce JM, Pittet D. Healthcare Infection Control Practices Advisory Committee. HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America. MMWR Recomm Rep. 2002; 51:RR-16:1–45.

14. Ehrenkranz NJ. Bland soap handwash or hand antisepsis?: the pressing need for clarity. Infect Control Hosp Epidemiol. 1992; 13:299–301. PMID: 1593113.

15. Allegranzi B, Pittet D. Role of hand hygiene in healthcare-associated infection prevention. J Hosp Infect. 2009; 73:305–315. PMID: 19720430.

16. Meidani M, Mirmohammad Sadeghi SA. Respiratory viruses in febrile neutropenic patients with respiratory symptoms. Adv Biomed Res. 2018; 7:5. PMID: 29456976.

17. Santolaya ME, Alvarez AM, Acuña M, Avilés CL, Salgado C, Tordecilla J, et al. Efficacy and safety of withholding antimicrobial treatment in children with cancer, fever and neutropenia, with a demonstrated viral respiratory infection: a randomized clinical trial. Clin Microbiol Infect. 2017; 23:173–178. PMID: 27856269.

18. Pizzo PA. Management of patients with fever and neutropenia through the arc of time: a narrative review. Ann Intern Med. 2019; 170:389–397. PMID: 30856657.

19. Nessle CN, Braun T, Chopra V, Choi SW, Mody R. Impact of socio-behavioral measures implemented during the SARS-CoV-2 pandemic on the outcomes of febrile neutropenia episodes in pediatric cancer patients: a single center quasi-experimental pre-post study. Pediatr Hematol Oncol. 2023; 40:412–421. PMID: 36125251.

20. Baus CJ, Kelley B, Dow-Hillgartner E, Kyriakopoulos CE, Schulz LT, Lepak AJ, et al. Neutropenic fever-associated admissions among patients with solid tumors receiving chemotherapy during the COVID-19 pandemic. JAMA Netw Open. 2023; 6:e234881. PMID: 36972053.

21. Baracy MG Jr, Hagglund K, Kulkarni S, Afzal F, Arends K, Morris RT, et al. Decreased incidence of febrile neutropenia in Michigan following masking and social distancing orders for the COVID-19 pandemic: a population based cohort study. World J Clin Oncol. 2022; 13:609–615. PMID: 36157163.

22. Gwak H, Lim ST, Jeon YW, Park HS, Kim SH, Suh YJ. COVID-19 prevention guidance and the incidence of febrile neutropenia in patients with breast cancer receiving TAC chemotherapy with prophylactic pegfilgrastim. J Clin Med. 2022; 11:7053. PMID: 36498628.

23. Toriumi R, Yaegashi H, Kadomoto S, Iwamoto H, Iijima M, Kawaguchi S, et al. Decreased febrile neutropenia during inpatient chemotherapy for urologic cancer during coronavirus disease 2019 pandemic. Cancer Sci. 2023; 114:201–210. PMID: 35838191.