Safe Care



Preventing Infections in Your Cancer Patients

Educational Media

(Excerpted from the CDC website)

An estimated 1.5 million new cases of cancer were diagnosed in the United States in 2010 [1]. With improvements in survivorship and the growth and aging of the U.S. population, the total number of persons living with cancer will continue to increase [2].

Despite advances in oncology care, infections remain a major cause of morbidity and mortality among cancer patients [3-5]. Increased risks for infection are attributed, in part, to immunosuppression caused by the underlying malignancy and chemotherapy.


In addition patients with cancer come into frequent contact with healthcare settings and can be exposed to other patients in these settings with transmissible infections. Likewise, patients with cancer often require the placement of indwelling intravascular access devices or undergo surgical procedures that increase their risk for infectious complications. Given their vulnerable condition, great attention to infection prevention is warranted in the care of these patients.


In recent decades, the vast majority of oncology services have shifted to outpatient settings, such as physician offices, hospital-based outpatient clinics, and non-hospital-based cancer centers. Currently, more than one million cancer patients receive outpatient chemotherapy or radiation therapy each year [6]. Acute care hospitals continue to specialize in the treatment of many patients with cancer who are at increased risk for infection (e.g., hematopoietic stem cell transplant recipients, patients with febrile neutropenia), with programs and policies that promote adherence to infection control standards.


In contrast, outpatient oncology facilities vary greatly in their attention to and oversight of infection control and prevention. This is reflected in a number of outbreaks of viral hepatitis and bacterial bloodstream infections that resulted from breaches in basic infection prevention practices (e.g., syringe reuse, mishandling of intravenous administration sets) [7-10]. In some of these incidents, the implicated facility did not have written infection control policies and procedures for patient protection or regular access to infection prevention expertise.

Basic Infection Control and Prevention Plan for Outpatient Oncology Settings

More Resources to Download from the CDC

Hand Hygiene Saves Lives Video

Intent and Implementation

This document has been developed for outpatient oncology facilities to serve as a model for a basic infection control and prevention plan. It contains policies and procedures tailored to these settings to meet minimal expectations of patient protections as described in the CDC Guide to Infection Prevention in Outpatient Settings. The elements in this document are based on CDC’s evidence-based guidelines and guidelines from professional societies (e.g., Oncology Nursing Society).


This plan is intended to be used by all outpatient oncology facilities. Those facilities that do not have an existing plan should use this plan as a starting point to develop a facility-specific plan that will be updated and further supplemented as needed based on the types of services provided. Facilities that have a plan should ensure that their current infection prevention policies and procedures include the elements outlined in this document.


While this plan may essentially be used "as is," facilities are encouraged to personalize the plan to make it more relevant to their setting (e.g., adding facility name and names of specific rooms/locations; inserting titles/positions of designated personnel; and providing detailed instructions where applicable).


This plan does not replace the need for an outpatient oncology facility to have regular access to an individual with training in infection prevention and for that individual to perform on-site evaluation and to directly observe and interact regularly with staff. Facilities may wish to consult with an individual with training and expertise in infection prevention early on to assist with their infection control plan development and implementation and to ensure that facility design and work flow is conducive to optimal infection prevention practices.

Aspects of Care That Are Beyond the Scope of This Plan

This model plan focuses on the core measures to prevent the spread of infectious diseases in outpatient oncology settings. It is not intended to address facility-specific issues or other aspects of patient care such as:


Infection prevention issues that are unique to blood and marrow transplant centers (a.k.a. bone marrow transplant or stem cell transplant centers)


Occupational health requirements, including recommended personal protective equipment for handling antineoplastic and hazardous drugs as outlined by the Occupational Safety and Health Administration and the National Institute for Occupational Safety


Appropriate preparation and handling (e.g., reconstituting, mixing, diluting, compounding) of sterile medications, including antineoplastic agents


Clinical recommendations and guidance on appropriate antimicrobial prescribing practices and the assessment of neutropenia risk in patients undergoing chemotherapy.


American Cancer Society. Cancer Facts & Figures 2010 Tables & Figures.

Warren JL, Mariotto AB, Meekins A, Topor M, Brown ML. Current and future utilization of services from medical oncologists. J Clin Oncol 2008;26:3242−7.

Kamboj M, Sepkowitz KA. Nosocomial infections in patients with cancer. Lancet Oncol 2009;10:589−97.

Maschmeyer G, Haas A. The epidemiology and treatment of infections in cancer patients. Int J Antimicrob Agents 2008;31:193−7.

Guinan JL, McGuckin M, Nowell PC. Management of health-care−associated infections in the oncology patient. Oncology 2003;17:415−20.

Halpern MT, Yabroff KR. Prevalence of outpatient cancer treatment in the United States: estimates from the Medical Panel Expenditures Survey (MEPS). Cancer Invest 2008;26:647−51.

Macedo de Oliveria A, White KL, Leschinsky DP, Beecham BD, Vogt TM, Moolenaar RL et al. An outbreak of hepatitis C virus infections among outpatients at a hematology/oncology clinic. Ann Intern Med 2005;142:898−902.

Watson JT, Jones RC, Siston AM, Fernandez JR, Martin K, Beck E, et al. Outbreak of catheter-associated Klebsiella oxytoca and Enterobacter cloacae bloodstream infections in an oncology chemotherapy center.  Arch Intern Med 2005;165:2639−43.

Greeley RD, Semple S, Thompson ND, High P, Rudowski E, Handschur E et al. Hepatitis B outbreak associated with a hematology-oncology office practice in New Jersey, 2009.  Am J Infect Control 2011 Jun 8. Epub ahead of print.

Herndon E. Rose Cancer Center shut down; patients advised to get screening. Enterprise-Journal.  July 31, 2011. Accessed September 9, 2011

How Can My Patient Prevent Infections During Chemotherapy?

People receiving chemotherapy are at risk for developing an infection when their white blood cell count is low. White blood cells are the body's main defense against infection.


This condition, called neutropenia, is common after receiving chemotherapy. For patients with this condition, any infection can become serious quickly.


Cancer patients who are treated with chemotherapy are more likely to get infections through everyday activities, or from health care settings. One out of every 10 cancer patients who receives chemotherapy gets an infection that requires a hospital visit.


Prepare: Watch Out for Fever


If a fever occurs during chemotherapy treatment, it's a medical emergency. Fever may be the only sign that an infection exists, and an infection during chemotherapy can be life-threatening.


If body temperature is 100.4°F (38°C) or higher for more than one hour, or 101°F (38.3°C) or higher for any length of time, the physician should be called right away, even if it happens in the middle of the night.


Prevent Infection: Clean Your Hands


Clean hands help prevent infections. Many diseases are spread by not cleaning your hands, which is especially dangerous when your patient is receiving chemotherapy treatment because their body may not be able to fight off infections like it used to.


You and anyone who comes around the patient should clean their hands frequently. Use soap and water or an alcohol-based hand sanitizer. Before and after treating a cut or wound or caring for their catheter, port, or other access device, practice hand hygiene.


Protect: Know the Signs and Symptoms of Infection


During chemotherapy treatment, your patient’s body

may not be able to fight off infections like usual. Infection symptoms should never be ignored. Infection during chemotherapy can lead to hospitalization or death.


Symptoms of a potential infection follow:


Fever (this is sometimes the only sign of an infection).

Chills and sweats.

Change in cough or a new cough.

Sore throat or new mouth sore.

Shortness of breath.

Nasal congestion.

Stiff neck.

Burning or pain with urination.

Unusual vaginal discharge or irritation.

Increased urination.

Redness, soreness, or swelling in any area, including surgical wounds and ports.



Pain in the abdomen or rectum.

New onset of pain.

Fundamental Principles of Infection Prevention

Standard Precautions


Standard Precautions represent the minimum infection prevention measures that apply to all patient care, regardless of suspected or confirmed infection status of the patient, in any setting where healthcare is delivered. These evidence-based practices are designed to both protect healthcare personnel and prevent the spread of infections among patients. Standard Precautions replaces earlier guidance relating to Universal Precautions and Body Substance Isolation. Standard Precautions include:  1) hand hygiene, 2) use of personal protective equipment (e.g., gloves, gowns, facemasks), depending on the anticipated exposure, 3) respiratory hygiene and cough etiquette, 4) safe injection practices, and 5) safe handling of potentially contaminated equipment or surfaces in the patient environment.


Transmission-Based Precautions


Transmission-Based Precautions are intended to supplement Standard Precautions in patients with known or suspected colonization or infection of highly transmissible or epidemiologically important pathogens. These additional precautions are used when the route of transmission is not completely interrupted using Standard Precautions.  The three categories of Transmission-Based Precautions include:  1) Contact Precautions, 2) Droplet Precautions, and 3) Airborne Precautions.  For diseases that have multiple routes of transmission, a combination of Transmission-Based Precautions may be used. Whether used singly or in combination, they are always used in addition to Standard Precautions.


The risk of infection transmission and the ability to implement elements of Transmission-Based Precautions may differ between outpatient and inpatient settings (e.g., facility design characteristics). However, because patients with infections are routinely encountered in outpatient settings, ambulatory care facilities need to develop specific strategies to control the spread of transmissible diseases pertinent to their setting. This includes developing and implementing systems for early detection and management of potentially infectious patients at initial points of entry to the facility.


For detailed information on Standard and Transmission-Based Precautions, and summary guidance for outpatient settings, refer to the following documents:


CDC Guide to Infection Prevention in Outpatient Settings

CDC 2007 Guideline for Isolation Precautions


Education and Training


Ongoing education and training of facility staff are required to maintain competency and ensure that infection prevention policies and procedures are understood and followed. A list of names of designated personnel and their specific roles and tasks and contact information is provided in Appendix A.


All facility staff, including contract personnel (e.g., environmental services workers from an outside agency) are educated and trained by designated personnel regarding:


Proper selection and use of PPE

Job- or task-specific infection prevention practices

Personnel providing training have demonstrated and maintained competency related to the specific jobs or tasks for which they are providing instruction

Training is provided at orientation, repeated at least annually and anytime polices or procedures are updated, and is documented as per facility policy


Competency Evaluations


Competency of facility staff is documented initially and repeatedly, as appropriate for the specific job or task

Regular audits of facility staff adherence to infection prevention practices (e.g., hand hygiene, environmental cleaning) are performed by designated personnel


Surveillance and Reporting


Routine performance of surveillance activities is important to case-finding, outbreak detection, and improvement of healthcare practices. This includes the surveillance of infections associated with the care provided by the facility (defined as healthcare-associated infections) and process measures related to infection prevention practices (e.g., hand hygiene).


HAI Surveillance


Standard definitions are developed for specific HAIs under surveillance (e.g., central-line associated bloodstream infections)

Designated personnel collect, manage, and analyze relevant data

Surveillance reports are prepared and distributed periodically to appropriate personnel for any necessary follow-up actions (e.g., high incidence of certain HAIs may prompt auditing of specific procedures or a thorough infection control assessment)


Disease Reporting


Facility staff adhere to local, state and federal requirements for reportable diseases and outbreak reporting


Hand Hygiene


Hand hygiene procedures include the use of alcohol-based hand rubs (containing 60-95% alcohol) and handwashing with soap and water. Alcohol-based hand rub is the preferred method for decontaminating hands, except when hands are visibly soiled (e.g., dirt, blood, body fluids), or after caring for patients with known or suspected infectious diarrhea (e.g., Clostridium difficile, norovirus), in which case soap and water should be used. Hand hygiene stations should be strategically placed to ensure easy access


Sample Procedures for Performing Hand Hygiene

Using Alcohol-based Hand Rub (follow manufacturer’s directions):


Dispense the recommended volume of product

Apply product to the palm of one hand

Rub hands together, covering all surfaces of hands and fingers until they are dry (no rinsing is required)


Handwashing with Soap and Water:


Wet hands first with water (avoid using hot water)

Apply soap to hands

Rub hands vigorously for at least 15 seconds, covering all surfaces of hands and fingers

Rinse hands with water and dry thoroughly with paper towel

Use paper towel to turn off water faucet


Indications for Hand Hygiene


Always perform hand hygiene in the following situations:

Before touching a patient, even if gloves will be worn

Before exiting the patient’s care area after touching the patient or the patient’s immediate environment

After contact with blood, body fluids or excretions, or wound dressings

Prior to performing an aseptic task (e.g., accessing a port, preparing an injection)

If hands will be moving from a contaminated-body site to a clean-body site during patient care

After glove removal


CDC Guideline for Hand Hygiene in Health-Care Settings  [PDF 496 KB]

WHO Guidelines on Hand Hygiene in Healthcare 2009  [PDF - 4.25 MB]


Personal Protective Equipment


Personal Protective Equipment (PPE) use involves specialized clothing or equipment worn by facility staff for protection against infectious materials. The selection of PPE is based on the nature of the patient interaction and potential for exposure to blood, body fluids or infectious agents. A review of available PPE should be performed periodically (e.g., annually) due to new product developments and improvements. Please note that this section does not address issues related to PPE for the preparation and handling of antineoplastic and hazardous drugs. The recommended PPE for those procedures should be determined in accordance with OSHA and NIOSH


Use of PPE




Wear gloves when there is potential contact with blood (e.g., during phlebotomy), body fluids, mucous membranes, nonintact skin or contaminated equipment

Wear gloves that fit appropriately (select gloves according to hand size)

Do not wear the same pair of gloves for the care of more than one patient

Do not wash gloves for the purpose of reuse

Perform hand hygiene before and immediately after removing gloves




Wear a gown to protect skin and clothing during procedures or activities where contact with blood or body fluids is anticipated

Do not wear the same gown for the care of more than one patient

Remove gown and perform hand hygiene before leaving the patient’s environment (e.g., exam room)


Facemasks (Procedure or Surgical Masks)


Wear a facemask:


When there is potential contact with respiratory secretions and sprays of blood or body fluids (as defined in Standard Precautions and/or Droplet Precautions)

May be used in combination with goggles or face shield to protect the mouth, nose and eyes

When placing a catheter or injecting material into the spinal canal or subdural space (to protect patients from exposure to infectious agents carried in the mouth or nose of healthcare personnel)

Wear a facemask to perform intrathecal chemotherapy


Goggles, Face Shields


Wear eye protection for potential splash or spray of blood, respiratory secretions, or other body fluids

Personal eyeglasses and contact lenses are not considered adequate eye protection

May use goggles with facemasks, or face shield alone, to protect the mouth, nose and eyes




If available, wear N95-or higher respirators for potential exposure to infectious agents transmitted via the airborne

route (e.g., tuberculosis).

All healthcare personnel that use N95-or higher respirator are fit tested at least annually and according to OSHA requirements


Recommendations for Donning PPE


Always perform hand hygiene before donning PPE

If wearing a gown, don the gown first and fasten in back accordingly


If  wearing a facemask or respirator:


Secure ties or elastic band at the back of the head and/or neck

Fit flexible band to nose bridge

Fit snug to face and below chin

If wearing goggles or face shield, put it on face and adjust to fit

If wearing gloves in combination with other PPE, don gloves last


Recommendations for Removing PPE


Remove PPE before leaving the exam room or patient environment (except respirators which should be removed after exiting the room)


Removal of gloves:


Grasp outside of glove with opposite gloved hand; peel off

Hold removed glove in glove hand

Slide ungloved fingers under the remaining glove at the wrist; peel off and discard


Removal of gowns:


Remove in such a way to prevent contamination of clothing or skin

Turn contaminated outside surface toward the inside

Roll or fold into a bundle and discard


Removal of facemask or respirator:


Avoid touching the front of the mask or respirator

Grasp the bottom and the ties/elastic to remove and discard

Removal of goggles or face shield

Avoid touching the front of the goggles or face shield

Remove by handling the head band or ear pieces and discard

Always perform hand hygiene immediately after removing PPE


CDC 2007 Guideline for Isolation Precautions

CDC’s tools for personal protective equipment



Respiratory Hygiene and Cough Etiquette


To prevent the transmission of respiratory infections in the facility, the following infection prevention measures are implemented for all potentially infected persons at the point of entry and continuing throughout the duration of the visit. This applies to any person (e.g., patients and accompanying family members, caregivers, and visitors) with signs and symptoms of respiratory illness, including cough, congestion, rhinorrhea, or increased production of respiratory secretions. Additional precautions (e.g., Transmission-Based Precautions) can be found in Section V


Identifying Persons with Potential Respiratory Infection


Facility staff remain alert for any persons arriving with symptoms of a respiratory infection

Signs are posted at the reception area instructing patients and accompanying persons to:

Self-report symptoms of a respiratory infection during registration

Practice respiratory hygiene and cough etiquette (technique described below) and wear facemask as needed


Availability of Supplies


The following supplies are provided in the reception area and other common waiting areas:


Facemasks, tissues, and no-touch waste receptacles for disposing of used tissues

Dispensers of alcohol-based hand rub


Respiratory Hygiene and Cough Etiquette


All persons with signs and symptoms of a respiratory infection (including facility staff) are instructed to:

Cover the mouth and nose with a tissue when coughing or sneezing

Dispose of the used tissue in the nearest waste receptacle

Perform hand hygiene after contact with respiratory secretions and contaminated objects/materials


Masking and Separation of Persons with Respiratory Symptoms


If patient calls ahead:


Have patients with symptoms of a respiratory infection come at a time when the facility is less crowded or through a separate entrance, if available

If the purpose of the visit is non-urgent, patients are encouraged to reschedule the appointment until symptoms have resolved

Upon entry to the facility, patients are to be instructed to don a facemask (e.g., procedure or surgical mask)

Alert registration staff ahead of time to place the patient in an exam room with a closed door upon arrival


If identified after arrival:


Provide facemasks to all persons (including persons accompanying patients) who are coughing and have symptoms of a respiratory infection

Place the coughing patient in an exam room with a closed door as soon as possible (if suspicious for airborne transmission, refer to Airborne Precautions in Section V.D.); if an exam room is not available, the patient should sit as far from other patients as possible in the waiting room

Accompanying persons who have symptoms of a respiratory infection should not enter patient-care areas and are encouraged to wait outside the facility


Healthcare Personnel Responsibilities


Healthcare personnel observe Droplet Precautions (refer to Section V.C.), in addition to Standard Precautions, when examining and caring for patients with signs and symptoms of a respiratory infection (if suspicious for an infectious agent spread by airborne route, refer to Airborne Precautions in Section V.D.)

These precautions are maintained until it is determined that the cause of the symptoms is not an infectious agent that requires Droplet or Airborne Precautions

All healthcare personnel are aware of facility sick leave policies, including staff who are not directly employed by the facility but provide essential daily services

Healthcare personnel with a respiratory infection avoid direct patient contact; if this is not possible, then a facemask should be worn while providing patient care and frequent hand hygiene should be reinforced

Healthcare personnel are up-to-date with all recommended vaccinations, including annual influenza vaccine


Staff Communication


Designated personnel regularly review information on local respiratory virus activity provided by the health department and CDC to determine if the facility will need to implement enhanced screening for respiratory symptoms as outlined above


During Periods of Increased Community Respiratory Virus Activity (e.g., Influenza Season)


In addition to the aforementioned infection prevention measures, the following enhanced screening measures are implemented:


When scheduling and/or confirming appointments:


Pre-screen all patients and schedule those with respiratory symptoms to come when the facility might be less crowded, if possible

Instruct patients with respiratory symptoms to don a facemask upon entry to the facility

If the purpose of the visit is non-urgent, patients with symptoms of respiratory infection are encouraged to schedule an appointment after symptoms have resolved

Encourage family members, caregivers, and visitors with symptoms of respiratory infection to not accompany patients during their visits to the facility

If possible, prepare in advance for the registration staff a daily list of patients with respiratory symptoms who are scheduled for a visit


Upon entry to the facility and during visit:


At the time of patient registration, facility staff identify pre-screened patients (from the list) and screen all other patients and accompanying persons for symptoms of respiratory infection

Patients identified with respiratory symptoms are placed in a private exam room as soon as possible; if an exam room is not available, patients are provided a facemask and placed in a separate area as far as possible from other patients while awaiting care


If patient volume is anticipated to be higher than usual with prolonged wait time at registration:


A separate triage station is established to identify pre-screened patients (from the list) and to screen all other patients and accompanying persons immediately upon their arrival and prior to registration

Patients identified with respiratory symptoms are registered in a separate area, if possible, and placed immediately in a private exam room; if an exam room is not available, patients are  provided a face mask and placed in a separate area as far as possible from other patients while awaiting care

If possible, encourage family members, caregivers, and visitors with symptoms of respiratory infection to not enter the facility