Reassessing neutropenic vs liberalized diets in post-chemotherapy and hematopoietic stem cell transplantation patients: An updated meta-analysis.

Abstract

e18571 Background: Neutropenia following high-dose chemotherapy or hematopoietic stem cell transplantation (HSCT) in patients with hematologic malignancies heightens infection risk. While recent guidelines de-emphasize neutropenic diets (ND), this meta-analysis reevaluates their role across pediatric and adult populations with different types of hematologic malignancies, consolidating all available evidence on infection and nutritional outcomes of ND versus liberalized diets (LD). Methods: A total of 489 articles were retrieved from ScienceDirect, PubMed, Embase, Cochrane Library, and Scopus; 14 studies were included that compared ND vs LD in patients with hematologic malignancies. Data were pooled in R (v4.5.2) using random-effects models to calculate risk ratios (RR) with 95% confidence intervals (CI), including subgroup analyses by study design (RCTs vs non-RCTs), age group (adults vs pediatric), HSCT status (HSCT vs non-HSCT), cancer types (non-Hodgkin lymphoma (NHL), multiple myeloma, Hodgkin lymphoma, acute myeloid leukemia, acute lymphoblastic leukemia(ALL)) and geographic region (USA vs other). The primary outcomes were neutropenic infection and all-cause mortality. Results: A total of 3,469 patients received ND (n=1,777) and LD (n=1,692). ND showed no significant association with neutropenic infection (RR = 1.06, 95% CI 0.99–1.14, I² = 14%) and all-cause mortality (RR = 0.95, 95% CI 0.67–1.34, I² = 0%) compared to LD. Subgroup analyses by geographic region, HSCT status, age group, cancer type, and study design yielded similar results across most categories, except for pediatric patients, NHL, and ALL, where ND was significantly associated with higher neutropenic infections and all-cause mortality compared to LD. For secondary outcomes, ND increased the risk of graft-versus-host disease (RR = 1.86, P = 0.03), while fever and diarrhea showed no significant differences. Microbiologically confirmed infections were similar between diets overall (RR = 1.14, P = 0.27); however, ND conferred a higher risk in the non-HSCT subgroup (RR = 1.29, 95% CI 1.09–1.52). Specific bloodstream infections (Streptococcus, Staphylococcus, Pseudomonas, Klebsiella, Enterococcus, E. coli, and Clostridium difficile) showed no differences between the two groups, with dietary adherence and meal intake compliance also being comparable. No evidence of publication bias was detected, with consistently low heterogeneity across analyses. Conclusions: ND offers no overall benefit against neutropenic infections or mortality compared to LD. Exceptions include increased risks with ND in pediatric patients, NHL and ALL subgroups along with greater microbiologically confirmed infections among non-HSCT patients. LDs align with current guidelines, supporting food safety education over restrictions given comparable adherence and low heterogeneity.