Extended-duration thromboprophylaxis following major abdominopelvic surgery - For everyone or selected cases only?

Major abdominopelvic surgery is an important risk factor for postoperative venous thromboembolism (VTE). VTE is the leading cause of 30-day postoperative mortality in patients with cancer undergoing major abdominopelvic surgery. Randomized controlled trials have shown that extended duration thromboprophylaxis using a low molecular weight heparin or a direct oral anticoagulant significantly decreases the risk of overall VTE (symptomatic events and asymptomatic deep vein thrombosis). Hence, several clinical practice guidelines suggest the use of extended duration thromboprophylaxis for all high-risk patients undergoing major abdominopelvic surgery. Despite these recommendations by clinical practice guidelines, adoption of extended duration thromboprophylaxis in clinical practice remains low and clinical equipoise seems to persist. In this narrative review, we aim is to highlight and summarize the reasons that may explain discrepancy between clinical guideline recommendations and current practice regarding extended duration thromboprophylaxis in this patient population. We also aim to review different personalized approaches based on patients' individualized risk of VTE that may foster shared decision making and improve patient outcomes by reducing decisional conflict, increasing patient knowledge, and increasing risk perception accuracy.

The 2018 Global Point Prevalence Survey of antimicrobial consumption and resistance in 47 Canadian hospitals: a cross-sectional survey

BACKGROUND

Patient-level surveillance of antimicrobial use (AMU) in Canadian hospitals empowers the reduction of inappropriate AMU and was piloted in 2017 among 14 hospitals in Canada. We aimed to describe AMU on the basis of patient-level data in Canadian hospitals in 2018 in terms of antimicrobial prescribing prevalence and proportions, antimicrobial indications, and agent selection in medical, surgical and intensive care wards.

METHODS

Canadian adult, pediatric and neonatal hospitals were invited to participate in the standardized web-based cross-sectional Global Point Prevalence Survey of Antimicrobial Consumption and Resistance (Global-PPS) conducted in 2018. An identified site administrator assigned all wards admitting inpatients to specific surveyors. A physician, pharmacist or nurse with infectious disease training performed the survey. The primary outcomes were point prevalence rates for AMU over the study period regarding prescriptions, indications and agent selection in medical, surgical and intensive care wards. The secondary outcomes were AMU for resistant organisms and practice appropriateness evaluated on the basis of quality indicators. Antimicrobial consumption is presented in terms of prevalence and proportions.

RESULTS

Forty-seven of 118 (39.8%) hospitals participated in the survey; 9 hospitals were primary care centres, 15 were secondary care centres and 23 were tertiary or specialized care centres. Of 13 272 patients included, 33.5% (n = 4447) received a total of 6525 antimicrobials. Overall, 74.1% (4832/6525) of antimicrobials were for therapeutic use, 12.6% (n = 825) were for medical prophylaxis, 8.9% (n = 578) were for surgical prophylaxis, 2.2% (n = 143) were for other use and 2.3% (n = 147) were for unidentified reasons. A diagnosis or indication was documented in the patient's file at the initiation for 87.3% (n = 5699) of antimicrobials; 62.9% (n = 4106) of antimicrobials had a stop or review date; and 72.0% (n = 4697) of prescriptions were guided by local guidelines.

INTERPRETATION

Overall, three-quarters of AMU was for therapeutic use across participating hospitals. Canadian hospitals should be further incentivized to create and adapt local guidelines on the basis of recent antimicrobial resistance data.

Prescribing patterns and outcomes of venous thromboembolism prophylaxis in hospitalized medical and cancer patients: Observations from the Ottawa Hospital

Guidelines suggest broad use of pharmacologic prophylaxis to prevent venous thromboembolism (VTE) in hospitalized medical patients, however little 'real-world' data exists to support this. Our goal was to describe the use of thromboprophylaxis among general medical and cancer patients admitted to hospital, compare VTE and bleeding outcomes according to use of thromboprophylaxis, and to determine what variables influence prescribing patterns and outcomes. Patients admitted to the general medical and oncology services at The Ottawa Hospital between 2010 and 2015 were retrospectively reviewed and classified according to whether they received initial, delayed, or no pharmacologic thromboprophylaxis during their first hospitalization. Patients with an alternate indication for anticoagulation or those admitted with a bleeding event were excluded from analysis. The primary efficacy outcome was any symptomatic VTE during index hospitalization or within 90 days of discharge, and the primary safety outcome was clinically relevant bleeding during the index hospitalization. 17,262 patients were included in our final analysis. General medical patients selected to receive no, initial, or delayed thromboprophylaxis had 0.4%, 0.7%, and 2.4% rates of VTE; and 0.2%, 0.7%, and 1.5% rates of clinically relevant bleeding complications, respectively. Cancer patients had significantly higher rates of VTE: 3.3%, 3.9%, and 5.0%; and 0.9%, 0.7%, and 3.0% rates of clinically relevant bleeding among those selected to receive no, initial, or delayed thromboprophylaxis, respectively. Overall, our study suggests that broad use of pharmacologic thromboprophylaxis may be unnecessary in select low-risk general medical patients and may be less effective in cancer patients in whom new studies are indicated.

Prevention and treatment of cancer-associated thrombosis

Cancer is a hypercoagulable state with an associated increased risk of venous thromboembolism (vte) that is further amplified in individuals who undergo chemotherapy. Compared with patients having cancer alone or vte alone, patients who develop cancer-associated vte have a significantly poorer prognosis. The risks of recurrent vte despite appropriate anticoagulation therapy and of bleeding are also higher in patients with cancer than in those without. For those reasons, the prevention and appropriate management of cancer-associated thrombosis is of paramount importance. Although low-molecular-weight heparin has been the standard of care for the prevention and treatment of cancer-associated thrombosis, direct oral anticoagulants are increasingly being adopted as an effective and safe alternative.

Thromboembolism prophylaxis during L-asparaginase therapy in acute lymphoblastic leukemia - time to reconsider current approaches?

Acute Lymphoblastic Leukemia (ALL) is the commonest malignancy in childhood with a second incidence peak in adulthood. Improvements in pediatric therapy including the addition of L-asparaginase (L-ASP) have enabled cure rates in excess of 90% to be achieved in children. More recently L-ASP-containing pediatric protocols are being used to treat younger adults with ALL and have improved survival by approximately 2-fold. However, a toxicity associated with L-ASP-containing therapy in ALL is venous thromboembolism (VTE) which is associated with significant morbidity in this patient population and results in interruptions in L-ASP therapy that can impact on survival outcomes. The incidence of VTE among adult patients with ALL receiving L-ASP containing therapy has been reported to be as high as 43%. Despite this, there is a lack of evidence-based recommendations for VTE prophylaxis in this clinical context; low-molecular weight heparin (LMWH) and/or AT replacement have mostly been used. The low-quality data and inconveniences associated with these VTE prophylaxis regimens highlight the need to evaluate alternatives such as direct oral anticoagulants for the prevention of L-ASP-associated VTE in ALL. This narrative will review the body of evidence on primary thromboprophylaxis in adult patients with ALL receiving L-ASP containing therapy.

Edoxaban for treatment of venous thromboembolism in patient groups with different types of cancer: Results from the Hokusai VTE Cancer study

BACKGROUND

The safety and efficacy of edoxaban and dalteparin is unclear for several cancer groups.

METHODS

We evaluated the occurrence of the primary outcome in large cancer groups. The primary outcome was the composite of recurrent VTE or major bleeding over 12 months.

RESULTS

In patients with gastrointestinal cancer, the primary outcome occurred in 19.4% patients given edoxaban and in 15.0% given dalteparin (risk difference [RD], 4.4%; 95%-CI, -4.1% to 12.8%). The corresponding rates for edoxaban and dalteparin were 10.4% and 10.7% for lung cancer (RD, -0.3%; 95%-CI, -10.0% to 9.5%), 13.6% and 12.5% for urogenital cancer (RD, 1.1; 95%-CI, -10.1-12.4), 3.1% and 11.7% for breast cancer (RD, -8.6; 95%-CI, -19.3-2.2), 8.9% and 10.9% for hematological malignancies (RD, -2.0; 95%-CI, -13.1-9.1), and 10.4% and 17.4% for gynecological cancer (RD, -7.0; 95%-CI, -19.8-5.7). In the subgroup of gastrointestinal cancer, edoxaban was associated with a 3.5% lower absolute risk of recurrent VTE and a 7.9% higher risk of major bleeding.

CONCLUSION

Edoxaban has a similar risk-benefit ratio to dalteparin in most cancer groups. In those with gastrointestinal cancer, the lower risk of recurrent VTE and the advantages of oral therapy need to be balanced against the increased risk of major bleeding.

1135. The 2018 Global Point Prevalence Survey of Antimicrobial Consumption and Resistance: Pediatric Results from 26 Canadian Hospitals

Background

Inappropriate antimicrobial use (AMU) is strongly associated with antimicrobial resistance. The Global Point Prevalence Survey (Global-PPS) is a standardized tool that is used worldwide to characterize inpatient AMU. We report pediatric results from 26 Canadian hospitals that participated in the Global-PPS in 2018.

Methods

The survey was completed by each site on the Global-PPS website for all patients aged 0–17 years hospitalized in a neonatal or pediatric ward on a chosen day between January and December 2018. Data collected included ward type, demographics, antimicrobials prescribed, diagnosis, type of indication (community-acquired [CA] vs. healthcare-associated [HA]) and type of therapy (empiric vs. targeted). Quality indicators included guideline compliance, medical record documentation of diagnosis, antimicrobial stop/review date, and surgical prophylaxis (SP) duration.

Results

Of the 26 sites, 23 were mixed and 3 were pediatric hospitals, with data on 767 inpatients. Overall, 25.8% (n = 198) of patients received at least one antimicrobial, and 21.9% (n = 168) were on at least one antibiotic. The highest AMU was found in Hematology-Oncology (84%), Pediatric Intensive Care (55.3%) and surgical (42.1%) units. Of the 330 antimicrobial prescriptions, 40.9% were for CA infections, 23% for medical prophylaxis, 20% for HA infections and 2.7% for SP. The most commonly treated infections were sepsis (16%) and lower respiratory tract infection (12.1%). The top five prescribed antibiotics were aminopenicillins (20.4%), aminoglycosides (16.1%), third-generation cephalosporins (15.4%), piperacillin–tazobactam (7.5%) and trimethoprim-sulfamethoxazole (7.5%). Diagnosis and stop/review date were documented for 88.1% and 65.1% of prescriptions, respectively. Compliance to local guidelines was found in 91.5% of therapies. SP exceeded 24 hours in 88.9% of courses.

Conclusion

The Global-PPS generated Canada-wide data on inpatient pediatric AMU, which will allow hospitals to benchmark and develop local quality improvement interventions to enhance appropriate AMU. Targets for improvement include suboptimal antimicrobial stop/review date documentation and prolonged SP.

Disclosures

All authors: No reported disclosures.