Effect of a Pathogenic Diet on Infection and

Mortality Rates in Stem Cell Transplant

Patients

Erica Abbarno
 Objectives
• Review of Hematopoietic Stem Cell Transplants
• Understand treatment progression and when pathogenic diet is initiated
• Discuss patient and nutrition intervention at University Hospitals
• Analyze a research article which discusses the possibility of “relaxing” the
pathogenic diet restrictions
 HSCT
• Replace stem cells after being destroyed by disease, chemo, or radiation
• Stem Cells: blood-forming cells that can mature into any type of cell that live in the
bone barrow and enter the bloodstream once they have matured
• HSCT
• BMT, PBSCT, UCBT
• Cancers affecting bone marrow
• Leukemias, multiple myeloma, lymphomas
 Allo Vs. Auto
• Use of donor’s cells whose tissue type closely
matches patient’s
• Patient’s own cells are transplanted
• Close family member or MUD • Benefits:
• MUD riskier than those with relative
• Benefits: • No worry for rejection
• Graft – versus – cancer effect • Risks:
• Donor can donate more stem or WBC
• Risks: • Grafts can still fail
• Donor cell death or destroyed • No graft-versus-cancer effect
• GVHD
• Immune system is the same
• Infection
 Phases of Transplant
1. Preparation (T- 60 to T-10)
2. Cytoreduction (~T-10 to T +0)
3. Neutropenia (T+1-T+20)
1. Low Pathogen Diet
4. Engraftment ( T+7-30) / Early Recovery (T+30-70)
5. Long Term Recovery Phase ( T+70 to 1 year+)
 Patient Case: CC
• 49 yo female
• Admission Reason: MDS – RAEB –II in 1st CR admitted for allogenic
MUD PBSCT (T=0, 01/25/21)
• PMHx: MDS, depression, anxiety, PTSD, insomnia, asthma, h/o MI
• Current Weight: 81.8kg
• No history of significant weight loss
 Assessment (01/20)
Food/Nutrition Related History
• Pt followed during induction chemo (09/2020-mid 10/2020)
• Appetite began well, some decline, improved at end
• Intermittent N/V, constipation, development of mucositis
• Accepted and liked Boost Plus
• Since Last Admit
• 2-3 meals/day with protein
• Intermittent constipation, No N/V/D or changes in taste
 Nutrition Diagnosis
• Increased nutrient needs related to increased metabolic demand as
evidenced by pt with MDS, admitted for transplant.
• Caloric Needs: 1800-2000kcal
• Protein Needs: 80-90g PRO
• mL fluid/day: 1mL/kcal or per MD/team
 Nutrition Intervention
• Boost Plus Daily (360kcal, 14g PRO each)
• Extended Stay Menu, Seidman Snack List
• Pathogenic Diet Education
• Importance and length of diet
• Foods to avoid
• Food safety
 Follow-Up
01/27
• T=0, 1/25/2021 – today is T + 2
• N (1/24), V (1/27), denies mouth sores and constipation
• Current Weight: 81.1kg (insignificant weight loss)
 Follow-Up
01/27
• Diagnosis:
• Inadequate oral intake related to treatment related side effects as evidenced by pt report of
declining PO x several days + vomiting and unable to keep any PO down on 01/27.
• Intervention:
• Nausea/Vomiting Handout Education & Lemon heads
• Recommendations:
• Continue Low pathogen Diet
• Consider scheduled and/or addition anti-emetics if N/V persists
 Current Patient Status
• 02/10
• Persistent oral and throat pain
• No N/V/D/C
• Weight: 78.9kg  No significant weight changes
• ANC Counts:
• 02/09: 8.06
• 02/10: 5.04
• 02/11: 3.65  Discharged
• Will continue to be followed outpatient
Article
 Objective
• Determine if there is adequate evidence that a neutropenic/pathogenic diet
decreases infection and mortality rates in neutropenic patients with cancer
(AML, MDS, HSCT, Myeloma) in comparison to a regular diet
• Outcomes of interest: mortality, infection-related mortality, bacteremia or fungemia,
major infections, neutropenic fever
 Methods
• Comprehensive literature search
(MEDLINE, EMBASE, CENTRAL)
• 19 pediatric patients and total of 918
patients aged 1-88 years old
• Statistical analysis using RevMan
version 5.2
• I2 : Heterogeneity across studies
• RR
• P < 0.05
 Intervention
• Neutropenic Diet (ND): exclude fresh fruits and veggies, raw or
undercooked meat, or soft cheeses including feta, brie, queso fresco which
are made from unpasteurized milk
• Regular Diet (RD)
• Antibiotics given to all patients
 Results
• Patients in ND group had no difference in major infection rates compared to the
RD group (RR = 1.08 , CI: 0.72 to 1.61, I 2 = 39%)
• Overall outcome (incidence of fever, major and minor infections): hazard ratio
significantly higher in ND than RD (P= 0.007 , RR= 1.18, CI: 1.05 to 1.34, I 2 = 0)
• No difference in risk of bacteremia or fungemia in RD vs. ND (RR= 0.79, CI:
0.33 to 1.90, I2 = 60%)
• Moderate heterogeneity most likely due to RCT vs. observational
• Possible time to relax restrictions of ND
 Strengths and Limitations

• Comprehensive nature • Observational study eliminated :

• Credible resources significance of overall outcome
was no longer significant
• Large pool of participants
• Small pool of articles
• Definition of ND not universal
Nutritional Implications & Future Research
• Questions whether focus should be on diet restrictions or improving foods
choices
• ND can impact adequate nutrient intake
• Opens the door for further research in gut diversity
• Further research in specifically stem cell patients esp. pediatric
populations
• Continue hospital protocol while focusing on positive education
 Special Thank You’s..
• Mandi Wells
• Heidi Blecick
• Rebecca Noernberg
 References
• Sonbol MB, Firwana B, Diab M, Zarzour A, Witzig TE. The Effect of a Neutropenic Diet on
Infection and Mortality Rates in Cancer Patients: A Meta-Analysis. Nutrition and Cancer.
2015;67(8):1232-1240. doi:10.1080/01635581.2015.1082109
• Taur Y, Jenq RR, Perales MA, Littmann ER, Morjaria S, et al.: The effects of intestinal tract
bacterial diversity on mortality following allogeneic hematopoietic stem cell transplantation.
Blood 124, 1174–1182, 2014. doi:10.1182/blood-2014-02-554725
• Types of Stem Cell and Bone Marrow Transplants. American Cancer Society.
https://www.cancer.org/treatment/treatments-and-side-effects/treatment-types/stem-cell-
transplant/types-of-transplants.html. Accessed February 15, 2021.
• University Hospitals Oncology Lecture