Health System Eliminates Neutropenic Diet in Patients With Cancer With No Rise in Infections

The neutropenic diet, which requires patients to avoid certain foods, is a common strategy in cancer care. Yet there’s no scientific evidence that it helps the population it’s meant to protect — those who face an increased risk of infection because they are experiencing neutropenia, or low white blood counts, after chemotherapy or other cancer treatments.

That finding, based on a literature review, was shared by Chelsea Nee, B.S.N., RN, OCN, of the University of Pittsburgh Medical Center (UPMC)-Shadyside, during the 42nd Annual Congress of the Oncology Nursing Society, held May 4-7 in Denver, Colorado. Based on that data, Nee and colleagues launched a quality improvement project at their facility that tested the elimination of the neutropenic diet in patients with cancer.

“In a literature review that included two meta-analyses, we found that not one study has ever shown a reduction in infection or mortality rates,” Nee said in a poster and discussion detailing the improvement project. The poster was co-authored by Sharon Hanchett, M.S.N., RN, OCN, also of UPMC-Shadyside; Jennifer Wilson, LDN, RDN, of Nestle, also in Pittsburgh; and Jan Cipkala-Gaffin, Dr.Ph., PMHCNS-BC, of UPMC.

Patients on the neutropenic diet are asked to avoid foods that might carry bacteria, such as fresh fruits and vegetables; unpasteurized juices, milk, honey, yogurt and cheese; cheese that is soft or contains molds; cold-brewed tea; raw oats and nuts; and deli meat and sushi. Doctors began prescribing it to patients with cancer in the 1970s, after a study was published that included it, among other protective measures, as a strategy to support the well-being of patients who had undergone stem cell transplant, Nee said. The study “showed a decrease in infections,” she said, “but there were other interventions, too,” with no specific evidence that the neutropenic diet was a contributing factor.

Based on the lack of evidence supporting the diet and the fact that “it was very restrictive” for patients, Nee and her colleagues wanted to try eliminating it, and launched the quality improvement project at UPMC-Shadyside. It took about a year to get the program going, as nurses, physicians and dieticians learned about the concept and prepared to remove the diet from electronic health records.

Clinicians were taught, instead, to ask patients with cancer to eat regularly but engage in standard safe food handling practices, including washing hands, washing fresh fruits and vegetables carefully, cooking meat to temperature and refrigerating perishables, Nee said.

For stem cell transplant patients only, staff members replaced the neutropenic diet with one that includes many of the same restrictions, but allows fresh fruits and vegetables, Nee said.

“They are our most vulnerable patient population, and their immune systems are incredibly compromised,” she said. “The literature actually supports a regular diet for stem cell transplant patients, despite that vulnerability. However, after discussion with our hematologists at UPMC, we decided to continue some restrictions for the stem cell transplant population, but allow fresh fruits and vegetables.”

A total of 5,773 patients included in the project were admitted to UPMC-Shadyside between Dec. 1, 2014 and July 31, 2016. The neutropenic diet was officially removed from clinical practice there on May 13, 2015. Data on the incidence of bacteremia, clostridium difficile infections and pneumonia were collected before and after the program was launched, and did not show any increase in infections after the neutropenic diet was eliminated, the authors wrote in an abstract. In fact, patients who adhered to the neutropenic diet were more likely to develop pneumonia, they found.

Based on those results, the entire UPMC health care system has eliminated the neutropenic diet from practice.

“Many oncology patients have a difficult time meeting nutritional requirements, so the liberalization of diet restrictions has improved the selection of what they can safely eat,” the authors wrote. “Oncology nurses from other institutions who currently utilize the neutropenic diet can use this information to make a positive change for their patients and allow a more diverse diet.”