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Cossey J, Cote MCB. Evaluation and management of febrile neutropenia in patients with cancer. JAAPA 2024; 37:16-20. [PMID: 38980295 DOI: 10.1097/01.jaa.0000000000000054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Abstract
ABSTRACT Febrile neutropenia is a common oncologic emergency that increases the risk for serious infection. This article reviews a joint American Society of Clinical Oncology and Infectious Diseases Society of America guideline for the evaluation and management of patients with cancer who present with fever and neutropenia. Knowledge and use of available risk assessment tools may reduce unnecessary hospitalizations, decrease inappropriate antibiotic use, and improve patient outcomes.
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Affiliation(s)
- Jason Cossey
- Jason Cossey is an assistant professor and director of didactic education in the PA program at High Point (N.C.) University, and practices in pulmonary and critical care medicine at Novant Health in Charlotte, N.C. Mary Claire B. Cote is a hospitalist at Indiana University Health in Lafayette, Ind. The authors have disclosed no potential conflicts of interest, financial or otherwise
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Singh N, Douglas AP, Slavin MA, Haeusler GM, Thursky KA. Antimicrobial use and appropriateness in neutropenic fever: a study of the Hospital National Antimicrobial Prescribing Survey data. J Antimicrob Chemother 2024; 79:632-640. [PMID: 38305582 DOI: 10.1093/jac/dkae015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 01/09/2024] [Indexed: 02/03/2024] Open
Abstract
BACKGROUND Neutropenic fever (NF) is a common complication in patients receiving chemotherapy. Judicious antimicrobial use is paramount to minimize morbidity and mortality and to avoid antimicrobial-related harms. OBJECTIVES To use an Australian national dataset of antimicrobial prescriptions for the treatment of NF to describe antimicrobial use, prescription guideline compliance and appropriateness; and to compare these findings across different healthcare settings and patient demographics. We also aimed to identify trends and practice changes over time. METHODS Data were extracted from the Hospital National Antimicrobial Prescribing Survey (Hospital NAPS) database from August 2013 to May 2022. Antimicrobial prescriptions with a NF indication were analysed for antimicrobial use, guideline compliance and appropriateness according to the Hospital NAPS methodology. Demographic factors, hospital classifications and disease characteristics were compared. RESULTS A total of 2887 (n = 2441 adults, n = 441 paediatric) NF prescriptions from 254 health facilities were included. Piperacillin-tazobactam was the most prescribed antimicrobial. Overall, 87.4% of prescriptions were appropriate. Piperacillin-tazobactam and cefepime had the highest appropriateness though incorrect piperacillin-tazobactam dosing was observed. Lower appropriateness was identified for meropenem, vancomycin, and gentamicin prescribing particularly in the private hospital and paediatric cohorts. The most common reasons for inappropriate prescribing were spectrum too broad, incorrect dosing or frequency, and incorrect duration. CONCLUSIONS This study provides insights into antimicrobial prescribing practices for NF in Australia. We have identified three key areas for improvement: piperacillin-tazobactam dosing, paediatric NF prescribing and private hospital NF prescribing. Findings from this study will inform the updated Australian and New Zealand consensus guidelines for the management of neutropenic fever in patients with cancer.
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Affiliation(s)
- Nikhil Singh
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Australia
- Pharmacy Department, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Abby P Douglas
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
- Department of Infectious Diseases, Austin Health, Melbourne, Australia
| | - Monica A Slavin
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne, Australia
| | - Gabrielle M Haeusler
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Karin A Thursky
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Australia
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
- National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, Melbourne Medical School, University of Melbourne, Melbourne, Australia
- RMH Guidance Group, Royal Melbourne Hospital, Melbourne, Australia
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Oda K, Yamaguchi A, Matsumoto N, Nakata H, Higuchi Y, Nosaka K, Jono H, Saito H. Dose Individualization of Cefepime for Febrile Neutropenia in Patients With Lymphoma or Multiple Myeloma: Implications for Therapeutic Drug Monitoring. Ther Drug Monit 2024; 46:80-88. [PMID: 37735762 DOI: 10.1097/ftd.0000000000001138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 07/22/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Optimal cefepime dosing is a challenge because of its dose-dependent neurotoxicity. This study aimed to determine individualized cefepime dosing for febrile neutropenia in patients with lymphoma or multiple myeloma. METHODS This prospective study enrolled 16 patients receiving cefepime at a dose of 2 g every 12 hours. Unbound concentrations were determined at 0.5 hours, 7.2 hours [at the 60% time point of the 12 hours administration interval (C7.2h)], and 11 hours (trough concentration) after the first infusion (rate: 2 g/h). The primary and secondary end points were the predictive performance of the area under the unbound concentration-time curve (AUC unbound ) and the effect of unbound cefepime pharmacokinetic parameters on clinical response, respectively. RESULTS The mean (SD) AUC unbound was 689.7 (226.6) mcg h/mL, which correlated with C7.2h (R 2 = 0.90), and the Bayesian posterior AUC unbound using only the trough concentration (R 2 = 0.66). Although higher exposure was more likely to show a better clinical response, each parameter did not indicate a statistical significance between positive and negative clinical responses ( P = 0.0907 for creatinine clearance (Ccr), 0.2523 for C7.2h, 0.4079 for trough concentration, and 0.1142 for AUC unbound ). Cutoff values were calculated as 80.2 mL/min for Ccr (sensitivity: 0.889, specificity: 0.714), 18.6 mcg/mL for C7.2h (sensitivity: 0.571, specificity: 1.000), and 9.2 mcg/mL for trough concentration (sensitivity: 0.571, specificity: 1.000). When aiming for a time above 100% the minimum inhibitory concentration, both continuous infusion of 4 g/d and intermittent infusion of 2 g every 8 hours achieved a probability of approximately 100% at a minimum inhibitory concentration of 8 mcg/mL. CONCLUSIONS Therapeutic drug monitoring by sampling at C7.2h or trough can facilitate rapid dose optimization. Continuous infusion of 4 g/d was recommended. Intermittent dosing of 2 g every 8 hours was alternatively suggested for patients with a Ccr of 60-90 mL/min.
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Affiliation(s)
- Kazutaka Oda
- Departments of Pharmacy and
- Infection Control, Kumamoto University Hospital, Chuo-ku, Kumamoto, Japan; and
| | - Ayami Yamaguchi
- Department of Clinical Pharmaceutical Sciences, Graduate School of Pharmaceutical Sciences, Kumamoto University, Chuo-ku, Kumamoto, Japan
| | - Naoya Matsumoto
- Department of Clinical Pharmaceutical Sciences, Graduate School of Pharmaceutical Sciences, Kumamoto University, Chuo-ku, Kumamoto, Japan
| | - Hirotomo Nakata
- Infection Control, Kumamoto University Hospital, Chuo-ku, Kumamoto, Japan; and
| | - Yusuke Higuchi
- Infection Control, Kumamoto University Hospital, Chuo-ku, Kumamoto, Japan; and
| | - Kisato Nosaka
- Infection Control, Kumamoto University Hospital, Chuo-ku, Kumamoto, Japan; and
| | - Hirofumi Jono
- Departments of Pharmacy and
- Department of Clinical Pharmaceutical Sciences, Graduate School of Pharmaceutical Sciences, Kumamoto University, Chuo-ku, Kumamoto, Japan
| | - Hideyuki Saito
- Departments of Pharmacy and
- Department of Clinical Pharmaceutical Sciences, Graduate School of Pharmaceutical Sciences, Kumamoto University, Chuo-ku, Kumamoto, Japan
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Shakerimoghaddam A, Moghaddam AD, Barghchi B, Pisheh Sanani MG, Azami P, Kalmishi A, Sabeghi P, Motavalli F, Khomartash MS, Mousavi SH, Nikmanesh Y. Prevalence of Pseudomonas aeruginosa and its antibiotic resistance in patients who have received Hematopoietic Stem-Cell Transplantation; A globally Systematic Review. Microb Pathog 2023; 184:106368. [PMID: 37769854 DOI: 10.1016/j.micpath.2023.106368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 09/20/2023] [Accepted: 09/20/2023] [Indexed: 10/03/2023]
Abstract
Gram-negative bacteria are infectious and life-threatening agents after hematopoietic stem cell transplantation (HSCT). So, this study aimed to investigate the prevalence of Pseudomonas aeruginosa and its antibiotic resistance in patients who have received Hematopoietic Stem-Cell Transplantation through a systematic review. The systematic search was done with key words; Pseudomonas aeruginosa, hematopoietic stem cell transplantation from 2000 to the end of July 2023 in Google Scholar and PubMed/Medline, Scopus, and Web of Science. Twelve studies were able to include our study. Quality assessment of studies was done by Appraisal tool for Cross-Sectional Studies. The most of the included studies were conducted as allo-HSCT. Infections such as respiratory infection, urinary infection and bacteremia have occurred. The rate of prevalence with P. aeruginosa has varied between 3 and 100%. The average age of the participants was between 1 and 74 years. The rate of prevalence of P. aeruginosa resistant to several drugs has been reported to be variable, ranging from 20 to 100%. The highest antibiotic resistance was reported against cefotetan (100%), and the lowest was related to tobramycin (1.8%) followed by amikacin, levofloxacin and ciprofloxacin with the prevalence of 16.6%. Our findings showed a high prevalence and antibiotic resistance rate of P. aeruginosa in Hematopoietic stem cell transplantation. Therefore, more serious health measures should be taken in patients after transplantation.
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Affiliation(s)
- Ali Shakerimoghaddam
- Medical Biotechnology Research Center, AJA University of Medical Sciences, Tehran, Iran
| | - Arasb Dabbagh Moghaddam
- Infectious Diseases Research Center, Aja University of Medical Sciences, Tehran, Iran; Department of Public Health & Nutrition, Aja University of Medical Sciences, Tehran, Iran
| | - Bita Barghchi
- Medical School, Islamic Azad University, Tehran, Branch, Tehran, Iran
| | | | - Pouria Azami
- Cardiovascular Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Abolfazl Kalmishi
- Department of Internal and Surgical Nursing Faculty of Nursing and Midwifery, Sabzevar University of Medical Sciences, Sabzevar, Iran
| | - Paniz Sabeghi
- Medical School, Shiraz University of Medical Sciences, Shiraz Branch, Shiraz, Iran
| | - Farhad Motavalli
- Medical Biotechnology Research Center, AJA University of Medical Sciences, Tehran, Iran
| | | | - Seyyed Hossein Mousavi
- Department of Cardiology, School of Medicine, AJA University of Medical Sciences, Tehran, Iran
| | - Yousef Nikmanesh
- Gastroenterohepatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
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Geßner D, Berisha M, Esser T, Schalk E. Tigecycline as salvage treatment of febrile neutropenia in patients with haematological malignancies-a retrospective single-centre analysis of 200 cases. Ann Hematol 2023; 102:2607-2616. [PMID: 37186157 PMCID: PMC10444688 DOI: 10.1007/s00277-023-05222-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 04/10/2023] [Indexed: 05/17/2023]
Abstract
Tigecycline has been used to treat patients with febrile neutropenia (FN). This study aims to analyse the effectiveness of tigecycline as salvage treatment of FN. Patients records from 09/2004 to 04/2019 were reviewed. Cases were eligible if fever persisted/recurred (p/r-FN) after 3 days of second-line treatment with a carbapenem, and were divided into three groups: switch to tigecycline (TGC group), switch to other antibiotics (OAB group), and no switch (W&W group). The primary endpoint was response rate (defervescence for ≥ 7 days or at least until discharge); the key secondary endpoint was 30-day mortality rate. Two hundred cases from 176 patients (median 59 years; 53.5% men) treated were included, mostly acute myeloid leukaemias (61.0%). 45.5% of cases were in the TGC group (in combination with an anti-pseudomonal antibiotic, mostly ceftazidime [95.6%]); 35.5% were in the OAB and 19.0% in the W&W group. There was no significant difference in response rates (TGC, 73.6%; OAB, 62.0%; W&W, 78.9%; p = 0.12) or 30-day mortality rates (TGC, 7.7%; OAB, 7.0%; W&W, 5.3%; p = 0.94). Tigecycline plus an anti-pseudomonal antibiotic does not improve response or 30-day mortality rate compared to other antibiotics in patients with p/r-FN. Also, in some cases, no switch in antibiotics may be necessary at all.
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Affiliation(s)
- Daniel Geßner
- Department of Haematology and Oncology, Otto-von-Guericke University Magdeburg, Medical Centre, Leipziger Str. 44, 39120, Magdeburg, Germany
| | - Mirjeta Berisha
- Department of Haematology and Oncology, Otto-von-Guericke University Magdeburg, Medical Centre, Leipziger Str. 44, 39120, Magdeburg, Germany
| | - Torben Esser
- Institute of Medical Microbiology and Hospital Hygiene, Otto-von-Guericke University Magdeburg, Medical Centre, Magdeburg, Germany
| | - Enrico Schalk
- Department of Haematology and Oncology, Otto-von-Guericke University Magdeburg, Medical Centre, Leipziger Str. 44, 39120, Magdeburg, Germany.
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Joudeh N, Sawafta E, Abu Taha A, Hamed Allah M, Amer R, Odeh RY, Salameh H, Sabateen A, Aiesh BM, Zyoud SH. Epidemiology and source of infection in cancer patients with febrile neutropenia: an experience from a developing country. BMC Infect Dis 2023; 23:106. [PMID: 36814229 PMCID: PMC9944765 DOI: 10.1186/s12879-023-08058-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 02/06/2023] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND Febrile neutropenia (FN) is a life-threatening complication that predisposes cancer patients to serious infections. This study aims to describe the epidemiology and source of infection in cancer patients with FN in a tertiary care hospital. METHODS A hospital-based retrospective study was conducted in a large tertiary care hospital from January 2020 to December 2021. Data on cancer patients with FN were collected from the hospital information system. RESULTS 150 cancer patients with FN were identified during the study period. Most patients were males (98; 65.3%), and the mean age of participants was 42.2 ± 16.0 years. Most patients (127; 84.7%) had hematologic malignancies, and acute myeloid leukemia was the most common diagnosis (42; 28%), followed by acute lymphocytic leukemia (28; 18.7%) and Hodgkin's lymphoma (20; 13.3%). Fifty-four (36%) patients had a median Multinational Association for Supportive Care in Cancer (MASCC) scores greater than 21. Regarding the outcome, nine (6%) died, and 141(94%) were discharged. The focus of fever was unknown in most patients (108; 72%). Among the known origins of fever were colitis (12; 8%), pneumonia (8; 5.3%), cellulitis (6; 4%), bloodstream infections (7; 4.6%), perianal abscess (2; 1.3%) and others. The median duration of fever was two days, and the median duration of neutropenia was seven days. Sixty-three (42%) patients had infections: 56 (73.3%) were bacterial, four (2.6%) were viral, two (1%) were fungal and 1 (0.7%) was parasitic. Among the bacterial causes, 50 cases (89.2%) were culture-positive. Among the culture-positive cases, 34 (68%) were gram-positive and 22 (44%) were gram-negative. The most frequent gram-positive bacteria were E. faecalis (9; 18% of culture-positive cases), and the most frequent gram-negative organisms were Klebsiella pneumoniae (5; 10%). Levofloxacin was the most commonly used prophylactic antibiotic (23; 15.33%), followed by acyclovir (1610.7%) and fluconazole in 15 patients (10%). Amikacin was the most popular empiric therapy, followed by piperacillin/tazobactam (74; 49.3%), ceftazidime (70; 46.7%), and vancomycin (63; 42%). One-third of E. faecalis isolates were resistant to ampicillin. Approximately two-thirds of Klebsiella pneumoniae isolates were resistant to piperacillin/tazobactam and ceftazidime. Amikacin resistance was proven in 20% of isolates. CONCLUSIONS The majority of patients suffered from hematologic malignancies. Less than half of the patients had infections, and the majority were bacterial. Gram-positive bacteria comprised two-thirds of cases. Therefore, empiric therapy was appropriate and in accordance with the antibiogram of the isolated bacteria.
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Affiliation(s)
- Nagham Joudeh
- grid.11942.3f0000 0004 0631 5695Department of Medicine, College of Medicine and Health Sciences, An-Najah National University, Nablus, 44839 Palestine
| | - Elana Sawafta
- grid.11942.3f0000 0004 0631 5695Department of Medicine, College of Medicine and Health Sciences, An-Najah National University, Nablus, 44839 Palestine
| | - Adham Abu Taha
- grid.11942.3f0000 0004 0631 5695Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, An-Najah National University, Nablus, 44839 Palestine
- grid.11942.3f0000 0004 0631 5695Department of Pathology, An-Najah National University Hospital, Nablus, 44839 Palestine
| | - Majd Hamed Allah
- grid.11942.3f0000 0004 0631 5695Department of Hematology and Oncology, An-Najah National University Hospital, Nablus, 44839 Palestine
| | - Riad Amer
- grid.11942.3f0000 0004 0631 5695Department of Medicine, College of Medicine and Health Sciences, An-Najah National University, Nablus, 44839 Palestine
- grid.11942.3f0000 0004 0631 5695Department of Hematology and Oncology, An-Najah National University Hospital, Nablus, 44839 Palestine
| | - Razan Y. Odeh
- grid.11942.3f0000 0004 0631 5695Department of Hematology and Oncology, An-Najah National University Hospital, Nablus, 44839 Palestine
| | - Husam Salameh
- grid.11942.3f0000 0004 0631 5695Department of Medicine, College of Medicine and Health Sciences, An-Najah National University, Nablus, 44839 Palestine
- grid.11942.3f0000 0004 0631 5695Department of Hematology and Oncology, An-Najah National University Hospital, Nablus, 44839 Palestine
| | - Ali Sabateen
- grid.11942.3f0000 0004 0631 5695Infection Control Department, An-Najah National University Hospital, Nablus, 44839 Palestine
| | - Banan M. Aiesh
- grid.11942.3f0000 0004 0631 5695Infection Control Department, An-Najah National University Hospital, Nablus, 44839 Palestine
| | - Sa’ed H. Zyoud
- grid.11942.3f0000 0004 0631 5695Department of Clinical and Community Pharmacy, College of Medicine and Health Sciences, An-Najah National University, Nablus, 44839 Palestine
- grid.11942.3f0000 0004 0631 5695Poison Control and Drug Information Center (PCDIC), College of Medicine and Health Sciences, An-Najah National University, Nablus, 44839 Palestine
- grid.11942.3f0000 0004 0631 5695Clinical Research Center, An-Najah National University Hospital, Nablus, 44839 Palestine
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Supportive interventions for childhood cancer: An umbrella review of randomized evidence. Crit Rev Oncol Hematol 2022; 180:103845. [DOI: 10.1016/j.critrevonc.2022.103845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 09/10/2022] [Accepted: 10/12/2022] [Indexed: 11/07/2022] Open
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Pais GM, Chang J, Barreto EF, Stitt G, Downes KJ, Alshaer MH, Lesnicki E, Panchal V, Bruzzone M, Bumanglag AV, Burke SN, Scheetz MH. Clinical Pharmacokinetics and Pharmacodynamics of Cefepime. Clin Pharmacokinet 2022; 61:929-953. [PMID: 35764774 PMCID: PMC9345683 DOI: 10.1007/s40262-022-01137-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2022] [Indexed: 11/28/2022]
Abstract
Cefepime is a broad-spectrum fourth-generation cephalosporin with activity against Gram-positive and Gram-negative pathogens. It is generally administered as an infusion over 30-60 min or as a prolonged infusion with infusion times from 3 h to continuous administration. Cefepime is widely distributed in biological fluids and tissues with an average volume of distribution of ~ 0.2 L/kg in healthy adults with normal renal function. Protein binding is relatively low (20%), and elimination is mainly renal. About 85% of the dose is excreted unchanged in the urine, with an elimination half-life of 2-2.3 h. The pharmacokinetics of cefepime is altered under certain pathophysiological conditions, resulting in high inter-individual variability in cefepime volume of distribution and clearance, which poses challenges for population dosing approaches. Consequently, therapeutic drug monitoring of cefepime may be beneficial in certain patients including those who are critically ill, have life-threatening infections, or are infected with more resistant pathogens. Cefepime is generally safe and efficacious, with a goal exposure target of 70% time of the free drug concentration over the minimum inhibitory concentration for clinical efficacy. In recent years, reports of neurotoxicity have increased, specifically in patients with impaired renal function. This review summarizes the pharmacokinetics, pharmacodynamics, and toxicodynamics of cefepime contemporarily in the setting of increasing cefepime exposures. We explore the potential benefits of extended or continuous infusions and therapeutic drug monitoring in special populations.
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Affiliation(s)
- Gwendolyn M Pais
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, 555 31st St., Downers Grove, IL, 60515, USA
- Chicago College of Pharmacy Pharmacometrics Center of Excellence, Midwestern University, Downers Grove, IL, USA
| | - Jack Chang
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, 555 31st St., Downers Grove, IL, 60515, USA
- Chicago College of Pharmacy Pharmacometrics Center of Excellence, Midwestern University, Downers Grove, IL, USA
| | | | - Gideon Stitt
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kevin J Downes
- Center for Clinical Pharmacology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Infectious Diseases, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Mohammad H Alshaer
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
- Infectious Disease Pharmacokinetics Lab, Emerging Pathogens Institute, University of Florida, Gainesville, FL, USA
| | - Emily Lesnicki
- College of Graduate Studies, Midwestern University, Downers Grove, IL, USA
| | - Vaidehi Panchal
- Chicago College of Osteopathic Medicine, Midwestern University, Downers Grove, IL, USA
| | - Maria Bruzzone
- Division of Neurology, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Argyle V Bumanglag
- Department of Neuroscience, College of Medicine, University of Florida, Gainesville, FL, USA
- Cognitive Aging and Memory Center, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Sara N Burke
- Department of Neuroscience, College of Medicine, University of Florida, Gainesville, FL, USA
- Cognitive Aging and Memory Center, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Marc H Scheetz
- Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, 555 31st St., Downers Grove, IL, 60515, USA.
- Chicago College of Pharmacy Pharmacometrics Center of Excellence, Midwestern University, Downers Grove, IL, USA.
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Wang N, Zhan M, Liu J, Wang Y, Hou Y, Li C, Li J, Han X, Liu J, Chen Y, Fan J, Tang J, Lu W, Zhong X, Zhang Z, Zhang W. Prevalence of Carbapenem-Resistant Klebsiella pneumoniae Infection in a Northern Province in China: Clinical Characteristics, Drug Resistance, and Geographic Distribution. Infect Drug Resist 2022; 15:569-579. [PMID: 35228807 PMCID: PMC8881927 DOI: 10.2147/idr.s347343] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 02/01/2022] [Indexed: 12/11/2022] Open
Affiliation(s)
- Na Wang
- Microbiology Department, The First Affiliated Hospital of Hebei North University, Zhangjiakou, Hebei, 075000, People’s Republic of China
| | - Minghua Zhan
- Microbiology Department, The First Affiliated Hospital of Hebei North University, Zhangjiakou, Hebei, 075000, People’s Republic of China
- Clinical Laboratory, Peking University People’s Hospital, Beijing, 100730, People’s Republic of China
| | - Jianhua Liu
- Respiratory Department, The First Affiliated Hospital of Hebei North University, Zhangjiakou, Hebei, 075000, People’s Republic of China
| | - Yao Wang
- Clinical Laboratory, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, People’s Republic of China
| | - Yongwang Hou
- Clinical Laboratory, The First Affiliated Hospital of Hebei North University, Zhangjiakou, Hebei, 075000, People’s Republic of China
| | - Caiqing Li
- Microbiology Department, The First Affiliated Hospital of Hebei North University, Zhangjiakou, Hebei, 075000, People’s Republic of China
| | - Jia Li
- Microbiology Department, The First Affiliated Hospital of Hebei North University, Zhangjiakou, Hebei, 075000, People’s Republic of China
| | - Xuying Han
- Microbiology Department, The First Affiliated Hospital of Hebei North University, Zhangjiakou, Hebei, 075000, People’s Republic of China
| | - Jinlu Liu
- Microbiology Department, The First Affiliated Hospital of Hebei North University, Zhangjiakou, Hebei, 075000, People’s Republic of China
| | - Yong Chen
- Infectious Disease Department, The First Affiliated Hospital of Hebei North University, Zhangjiakou, Hebei, 075000, People’s Republic of China
| | - Jingjing Fan
- Infectious Disease Department, The First Affiliated Hospital of Hebei North University, Zhangjiakou, Hebei, 075000, People’s Republic of China
| | - Jianhua Tang
- Clinical Pharmacy Department, The First Affiliated Hospital of Hebei North University, Zhangjiakou, Hebei, 075000, People’s Republic of China
| | - Wenhua Lu
- Dental Department, Beijing Fengtai Tieying Community Health Service Center, Beijing, 100730, People’s Republic of China
| | - Xinran Zhong
- Microbiology Department, The First Affiliated Hospital of Hebei North University, Zhangjiakou, Hebei, 075000, People’s Republic of China
| | - Zhihua Zhang
- Respiratory Department, The First Affiliated Hospital of Hebei North University, Zhangjiakou, Hebei, 075000, People’s Republic of China
| | - Wei Zhang
- Microbiology Department, The First Affiliated Hospital of Hebei North University, Zhangjiakou, Hebei, 075000, People’s Republic of China
- Clinical Laboratory, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, 100730, People’s Republic of China
- Correspondence: Wei Zhang; Zhihua Zhang, Tel +86-15369318318, Email ;
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10
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Tan X, Li Y, Xi J, Guo S, Su H, Chen X, Liang X. Comparative efficacy and safety of antipseudomonal β-lactams for pediatric febrile neutropenia: A systematic review and Bayesian network meta-analysis. Medicine (Baltimore) 2021; 100:e27266. [PMID: 34918626 PMCID: PMC8678002 DOI: 10.1097/md.0000000000027266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 08/31/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Antipseudomonal β-lactams have been used for the treatment of febrile neutropenia (FN); however, the efficacy and safety of antipseudomonal β-lactams in pediatric patients remain unclear. The aim of this study was to comprehensively compare the efficacy and side effects of optional antipseudomonal β-lactams for pediatric FN. METHODS PubMed, Embase, Medline, and Cochrane Library were systematically searched from their inception to December 18, 2020. Eligible randomized controlled trials in which pediatric FN patients were treated with an empiric monotherapy of antipseudomonal β-lactams were selected. Data synthesis was performed using WinBUGS 14.0 software and meta packages implemented in R 3.6.2. Random-effects network meta-analysis was performed, and dichotomous data were pooled as odds ratios with 95% confidence intervals. The primary outcome was treatment success without modification; the secondary outcomes were adverse events (AEs), all-cause mortality, and new infections. The GRADE tool was used to assess the quality of the evidence. The protocol was registered with PROSPERO ID CRD42021226763. RESULTS Eighteen studies with 2517 patients were included. The results showed no statistically significant difference between the optional antipseudomonal β-lactams in the outcomes of treatment success without modification, all AEs, all-cause mortality, and new infections for pediatric FN. Based on the results of Bayesian rank probability, meropenem was ranked highest among all the treatment options with regard to treatment success without modification benefit; ceftazidime and meropenem were associated with a lower risk of AEs; cefoperazone/sulbactam and piperacillin/tazobactam were associated with a lower risk of mortality, and piperacillin/tazobactam and meropenem were associated with a lower risk of new infections. The quality of evidence was moderate. CONCLUSIONS Meropenem and piperacillin/tazobactam were found to be better with regard to treatment success without modification, with a comparable safety profile. Therefore, our findings support the use of meropenem and piperacillin/tazobactam as a treatment option for pediatric FN patients.
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Affiliation(s)
- Xinmei Tan
- Department of anesthesiology, The People's Hospital of Hechi, Hechi, Guangxi, China
| | - Yan Li
- Department of Pharmacy, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, People's Republic of China
| | - Jiaxi Xi
- Department of Pharmacy, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, People's Republic of China
| | - Sitong Guo
- Department of Pharmacy, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, People's Republic of China
| | - Henghai Su
- Department of Pharmacy, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, People's Republic of China
| | - Xiaoyu Chen
- Department of Pharmacy, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, People's Republic of China
| | - Xueyan Liang
- Department of Pharmacy, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, People's Republic of China
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11
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A Practical Approach to Antibiotic Use in Critically Ill Obstetric Patients. Obstet Gynecol 2021; 138:459-465. [PMID: 34352843 DOI: 10.1097/aog.0000000000004473] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 05/20/2021] [Indexed: 12/13/2022]
Abstract
In recent years, several new antimicrobials have become available that are safer and more effective compared with older agents commonly used in obstetrics. Basic knowledge of these agents is of paramount importance to obstetricians and maternal fetal medicine specialists, as administration of early adequate broad-spectrum empiric antibiotic coverage plays a pivotal role in the management of septic patients. Of particular importance is the critically ill pregnant patient with life-threatening infectious processes in whom poor initial antibiotic selection may result in higher mortality and significant side effects from antibiotics themselves. In this article we aim to provide a guide for clinicians to select an adequate empirical antibiotic regimen for the most common severe infections that may affect pregnant individuals.
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Egorov AM, Ulyashova MM, Rubtsova MY. Inhibitors of β-Lactamases. New Life of β-Lactam Antibiotics. BIOCHEMISTRY (MOSCOW) 2021; 85:1292-1309. [PMID: 33280574 DOI: 10.1134/s0006297920110024] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
β-Lactam antibiotics account for about 60% of all produced antibiotics. Due to a high activity and minimal side effects, they are the most commonly used class of antibacterial drugs for the treatment of various infectious diseases of humans and animals, including severe hospital infections. However, the emergence of bacteria resistant to β-lactams has led to the clinical inefficiency of these antibiotics, and as a result, their use in medicine has been limited. The search for new effective ways for overcoming the resistance to β-lactam antibiotics is an essential task. The major mechanism of bacterial resistance is the synthesis of β-lactamases (BLs) that break the antibiotic β-lactam ring. Here, we review specific inhibitors of serine β-lactamases and metallo-β-lactamases and discuss approaches for creating new inhibitors that would prolong the "life" of β-lactams.
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Affiliation(s)
- A M Egorov
- Faculty of Chemistry, Lomonosov Moscow State University, Moscow, 119991, Russia
| | - M M Ulyashova
- Faculty of Chemistry, Lomonosov Moscow State University, Moscow, 119991, Russia
| | - M Yu Rubtsova
- Faculty of Chemistry, Lomonosov Moscow State University, Moscow, 119991, Russia.
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13
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Álvarez JC, Cuervo SI, Silva E, Díaz JA, Jiménez LL, Parra DS, Gómez JC, Sánchez R, Cortés JA. Pharmacokinetics and Pharmacodynamics of Cefepime in Adults with Hematological Malignancies and Febrile Neutropenia after Chemotherapy. Antibiotics (Basel) 2021; 10:504. [PMID: 33946665 PMCID: PMC8146514 DOI: 10.3390/antibiotics10050504] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 04/17/2021] [Accepted: 04/21/2021] [Indexed: 12/04/2022] Open
Abstract
Patients with chemotherapy-induced febrile neutropenia (CIFN) may have changes in the pharmacokinetics (PK) compared to patients without malignancies or neutropenia. Those changes in antibiotic PK could lead to negative outcomes for patients if the therapy is not adequately adjusted to this. In this, open-label, non-randomized, prospective, observational, and descriptive study, a PK model of cefepime was developed for patients with hematological neoplasms and post-chemotherapy febrile neutropenia. This study was conducted at a cancer referral center, and study participants were receiving 2 g IV doses of cefepime every 8 h as 30-min infusions. Cefepime PK was well described by a two compartment model with a clearance dependent on a serum creatinine level. Using Monte Carlo simulations, it was shown that continuous infusions of 6g q24h could have a good achievement of PK/PD targets for MIC levels below the resistance cut-off point of Enterobacteriaceae. According to the simulations, it is unnecessary to increase the daily dose of cefepime (above 6 g daily) to increase the probability of target attainment (PTA). Cumulative fraction of response (CFR) using interment dosing was suboptimal for empirical therapy regimens against K. pneumoniae and P. aeruginosa, and continuous infusions could be used in this setting to maximize exposure. Patients with high serum creatinine levels were more likely to achieve predefined PK/PD targets than patients with low levels.
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Affiliation(s)
- José C Álvarez
- Facultad de Medicina, Universidad Nacional de Colombia, 111321 Bogotá, Colombia
- Grupo en Enfermedades Infecciosas en Cáncer y Alteraciones Hematológicas (GREICAH), Universidad Nacional de Colombia, 111321 Bogotá, Colombia
| | - Sonia I Cuervo
- Facultad de Medicina, Universidad Nacional de Colombia, 111321 Bogotá, Colombia
- Grupo en Enfermedades Infecciosas en Cáncer y Alteraciones Hematológicas (GREICAH), Universidad Nacional de Colombia, 111321 Bogotá, Colombia
- Instituto Nacional de Cancerología (INC)-Empresa Social del Estado, 111511 Bogotá, Colombia
| | - Edelberto Silva
- Grupo en Enfermedades Infecciosas en Cáncer y Alteraciones Hematológicas (GREICAH), Universidad Nacional de Colombia, 111321 Bogotá, Colombia
- Departamento de Farmacia, Facultad de Ciencias, Universidad Nacional de Colombia, 111321 Bogotá, Colombia
| | - Jorge A Díaz
- Grupo en Enfermedades Infecciosas en Cáncer y Alteraciones Hematológicas (GREICAH), Universidad Nacional de Colombia, 111321 Bogotá, Colombia
- Departamento de Farmacia, Facultad de Ciencias, Universidad Nacional de Colombia, 111321 Bogotá, Colombia
- Grupo de Investigación en Enfermedades Infecciosas, Facultad de Medicina, Universidad Nacional de Colombia, 111321 Bogotá, Colombia
| | - Lorena L Jiménez
- Grupo en Enfermedades Infecciosas en Cáncer y Alteraciones Hematológicas (GREICAH), Universidad Nacional de Colombia, 111321 Bogotá, Colombia
- Instituto Nacional de Cancerología (INC)-Empresa Social del Estado, 111511 Bogotá, Colombia
| | - Daniel S Parra
- Departamento de Farmacia, Facultad de Ciencias, Universidad Nacional de Colombia, 111321 Bogotá, Colombia
| | - Julio C Gómez
- Grupo en Enfermedades Infecciosas en Cáncer y Alteraciones Hematológicas (GREICAH), Universidad Nacional de Colombia, 111321 Bogotá, Colombia
- Instituto Nacional de Cancerología (INC)-Empresa Social del Estado, 111511 Bogotá, Colombia
| | - Ricardo Sánchez
- Facultad de Medicina, Universidad Nacional de Colombia, 111321 Bogotá, Colombia
- Grupo en Enfermedades Infecciosas en Cáncer y Alteraciones Hematológicas (GREICAH), Universidad Nacional de Colombia, 111321 Bogotá, Colombia
- Instituto Nacional de Cancerología (INC)-Empresa Social del Estado, 111511 Bogotá, Colombia
| | - Jorge A Cortés
- Facultad de Medicina, Universidad Nacional de Colombia, 111321 Bogotá, Colombia
- Grupo de Investigación en Enfermedades Infecciosas, Facultad de Medicina, Universidad Nacional de Colombia, 111321 Bogotá, Colombia
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Rahem LR, Franck B, Roy H, Lebel D, Ovetchkine P, Bussières JF. Profile of Antimicrobial Use in the Pediatric Population of a University Hospital Centre, 2015/16 to 2018/19. Can J Hosp Pharm 2021; 74:21-29. [PMID: 33487651 PMCID: PMC7801337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
BACKGROUND Antimicrobial stewardship is a standard practice in health facilities to reduce both the misuse of antimicrobials and the risk of resistance. OBJECTIVE To determine the profile of antimicrobial use in the pediatric population of a university hospital centre from 2015/16 to 2018/19. METHODS In this retrospective, descriptive, cross-sectional study, the pharmacy information system was used to determine the number of days of therapy (DOTs) and the defined daily dose (DDD) per 1000 patient-days (PDs) for each antimicrobial and for specified care units in each year of the study period. For each measure, the ratio of 2018/19 to 2015/16 values was also calculated (and expressed as a proportion); where the value of this proportion was ≤ 0.8 or ≥ 1.2 (indicating a substantial change over the study period), an explanatory rating was assigned by consensus. RESULTS Over the study period, 94 antimicrobial agents were available at the study hospital: 70 antibiotics (including antiparasitics and antituberculosis drugs), 14 antivirals, and 10 antifungals. The total number of DOTs per 1000 PDs declined from 904 in 2015/16 to 867 in 2018/19. The 5 most commonly used antimicrobials over the years, expressed as minimum/maximum DOTs per 1000 PDs, were piperacillin-tazobactam (78/105), trimethoprim-sulfamethoxazole (74/84), ampicillin (51/69), vancomycin (53/68), and cefotaxime (55/58). In the same period, the care units with the most antimicrobial use (expressed as minimum/maximum DOTs per 1000 PDs) were hematology-oncology (2529/2723), pediatrics (1006/1408), and pediatric intensive care (1328/1717). CONCLUSIONS This study showed generally stable consumption of antimicrobials from 2015/16 to 2018/19 in a Canadian mother-and-child university hospital centre. Although consumption was also stable within drug groups (antibiotics, antivirals, and antifungals), there were important changes over time for some individual drugs. Several factors may explain these variations, including disruptions in supply, changes in practice, and changes in the prevalence of infections. Surveillance of antimicrobial use is an essential component of an antimicrobial stewardship program.
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Affiliation(s)
- Lydia R Rahem
- is a candidate for the DPharm degree in the Faculty of Pharmacy, Université de Montréal, Montréal, Quebec. She is also an intern with the Department of Pharmacy, CHU Sainte-Justine, Montréal, Quebec
| | - Bénédicte Franck
- is a candidate for the DPharm degree, Université Paul Sabatier, Toulouse, France. She is also a Research Assistant with the Pharmacy Practice Research Unit, CHU Sainte-Justine, Montréal, Quebec
| | - Hélène Roy
- , BPharm, MSc, is a Pharmacist with the Department of Pharmacy, CHU Sainte-Justine, Montréal, Quebec
| | - Denis Lebel
- , BPharm, MSc, FCSHP, is a Pharmacist and Assistant Director, Teaching and Research with the Pharmacy Practice Research Unit and the Department of Pharmacy, CHU Sainte-Justine, Montréal, Quebec
| | - Philippe Ovetchkine
- , MD, is a Pediatrician with the Department of Pediatrics, CHU Sainte-Justine, Montréal, Quebec
| | - Jean-François Bussières
- , BPharm, MSc, MBA, FCSHP, is a Pharmacist and Director with the Pharmacy Practice Research Unit and the Department of Pharmacy, CHU Sainte-Justine, and a Clinical Professor with the Faculty of Pharmacy, Université de Montréal, Montréal, Quebec
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15
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Kern WV, Horn S, Fink G. Aktuelle Entwicklungen im Bereich Antibiotic Stewardship. Dtsch Med Wochenschr 2020; 145:1758-1763. [DOI: 10.1055/a-0982-8842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Was ist neu?
Antibiotikaverbrauch in Deutschland In Deutschland wurden in den letzten Jahren sowohl im Krankenhausbereich als auch im ambulanten Setting immer weniger Fluorchinolone verordnet. Auch der Verbrauch der Cephalosporine ging etwas zurück.
Renaissance von Aminoglykosiden? Die inzwischen relativ seltenen Substanzen können aufgrund einer recht guten Resistenzlage bei Harnwegsinfektionen als geeignete Alternative – allerdings nur parenteral – eingesetzt werden. Bei akuten schweren Infektionen ist eine einmalige Gabe, z. B. von Tobramycin, initial zusätzlich zu einem geeigneten Betalactam ebenfalls eine Option, aber keine klare Empfehlung.
Antibiotikaeinsatz in der Hämatologie/Onkologie Bei Fieber und Neutropenie gilt nach wie vor die initiale empirische Gabe von Piperacillin-Tazobactam oder einem pseudomonasaktiven Carbapenem als Standard. Diese Betalactame sollten mit verlängerter Infusionsdauer, z. B. über 4 h, verabreicht werden. Linezolid ist ein Reservemedikament und sollte auch bei hämatoonkologischen Patienten nicht empirisch, sondern nur in der gezielten Therapie verwendet werden.
Penicillinallergie Die anamnestische Angabe einer Penicillinallergie sollte durch genaues Hinterfragen differenziert werden. Patienten können so bezüglich ihres Risikos für allergische Reaktionen gruppiert werden – oft besteht kein oder ein sehr geringes Risiko bei einer (erneuten) Behandlung mit Penicillinderivaten. Niedrigrisikopatienten dürfen ohne weitergehende allergologische Untersuchungen reexponiert werden.
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Affiliation(s)
- Winfried V. Kern
- Abteilung Infektiologie, Klinik für Innere Medizin II, Universitätsklinikum Freiburg
| | - Stephan Horn
- Abteilung Infektiologie, Klinik für Innere Medizin II, Universitätsklinikum Freiburg
| | - Geertje Fink
- Abteilung Infektiologie, Klinik für Innere Medizin II, Universitätsklinikum Freiburg
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Cooksley T, Font C, Scotte F, Escalante C, Johnson L, Anderson R, Rapoport B. Emerging challenges in the evaluation of fever in cancer patients at risk of febrile neutropenia in the era of COVID-19: a MASCC position paper. Support Care Cancer 2020; 29:1129-1138. [PMID: 33230644 PMCID: PMC7682766 DOI: 10.1007/s00520-020-05906-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 11/18/2020] [Indexed: 12/13/2022]
Abstract
Patients with cancer are at higher risk of more severe COVID-19 infection and have more associated complications. The position paper describes the management of cancer patients, especially those receiving anticancer treatment, during the COVID-19 pandemic. Dyspnea is a common emergency presentation in patients with cancer with a wide range of differential diagnoses, including pulmonary embolism, pleural disease, lymphangitis, and infection, of which SARS-CoV-2 is now a pathogen to be considered. Screening interviews to determine whether patients may be infected with COVID-19 are imperative to prevent the spread of infection, especially within healthcare facilities. Cancer patients testing positive with no or minimal symptoms may be monitored from home. Telemedicine is an option to aid in following patients without potential exposure. Management of complications of systemic anticancer treatment, such as febrile neutropenia (FN), is of particular importance during the COVID-19 pandemic where clinicians aim to minimize patients' risk of infection and need for hospital visits. Outpatient management of patients with low-risk FN is a safe and effective strategy. Although the MASCC score has not been validated in patients with suspected or confirmed SARS-CoV-2, it has nevertheless performed well in patients with a range of infective illnesses and, accordingly, it is reasonable to expect efficacy in the clinical setting of COVID-19. Risk stratification of patients presenting with FN is a vital tenet of the evolving sepsis and pandemic strategy, necessitating access to locally formulated services based on MASCC and other national and international guidelines. Innovative oncology services will need to utilize telemedicine, hospital at home, and ambulatory care services approaches not only to limit the number of hospital visits but also to anticipate the complications of the anticancer treatments.
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Affiliation(s)
- Tim Cooksley
- Department of Acute Medicine and Critical Care, The Christie, Wilmslow Road, Manchester, UK.
| | - Carme Font
- Hospital Clinic de Barcelona, Barcelona, Spain
| | - Florian Scotte
- Interdisciplinary Cancer Course Department (DIOPP), Gustave Roussy Cancer Institute, Villejuif, France
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17
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Ogura S, Kimura M, Takagi S, Mitsuki T, Yuasa M, Kageyama K, Kaji D, Nishida A, Taya Y, Ishiwata K, Yamamoto H, Asano-Mori Y, Yamamoto G, Uchida N, Wake A, Taniguchi S, Araoka H. Characteristics of gram-negative bacteremia during febrile neutropenia among allogeneic hematopoietic stem cell transplant recipients on levofloxacin prophylaxis. Eur J Clin Microbiol Infect Dis 2020; 40:941-948. [PMID: 33185742 DOI: 10.1007/s10096-020-04096-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 10/30/2020] [Indexed: 11/27/2022]
Abstract
The aim of this study is to clarify the characteristics of gram-negative bacteremia (GNB), including extended-spectrum β-lactamase (ESBL)-producing pathogens, among allogeneic hematopoietic stem cell transplant (allo-HSCT) recipients on levofloxacin (LVFX) prophylaxis. A retrospective analysis on GNB at the first episode of febrile neutropenia (FN) was conducted among allo-HSCT recipients (age ≥ 20 years) on 500 mg/day of oral LVFX prophylaxis. Epidemiological and microbiological features of GNB were investigated and compared between the inappropriate and appropriate empiric therapy groups. In total, FN occurred in 414 allo-HSCT cases, and bacteremia at the first episode of FN occurred in 169 cases. Overall, 29 GNB cases were documented, and the causative organisms identified were Escherichia coli in 21 cases (including 10 ESBLs), Klebsiella pneumoniae in 2, Pseudomonas aeruginosa in 2, and other in 4. The crude 30-day mortality rate was not significantly different among cases of GNB (6.9%), gram-positive bacteremia (GPB) (7.1%), or non-bacteremia (5.4%; P = 0.78). Cefepime (CFPM) was administered in all cases in the inappropriate empiric therapy group, and all causative organisms were ESBL-producing E. coli (ESBL-EC). All patients in the inappropriate empiric therapy group had a low Pitt bacteremia score (≤ 2). Thirty-day mortality did not differ significantly between the inappropriate and appropriate empiric therapy groups (1/10 vs. 1/15, P = 0.61). In conclusion, GNB was not a significant cause of death. In LVFX breakthrough ESBL-EC bacteremia among allo-HSCT recipients, the administration of CFPM as empiric therapy did not lead to significantly poor prognosis. Empiric CFPM administration might be an acceptable strategy.
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Affiliation(s)
- Sho Ogura
- Department of Infectious Diseases, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan
| | - Muneyoshi Kimura
- Department of Infectious Diseases, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan.
| | | | | | | | - Kosei Kageyama
- Department of Hematology, Toranomon Hospital, Tokyo, Japan
| | - Daisuke Kaji
- Department of Hematology, Toranomon Hospital, Tokyo, Japan
| | - Aya Nishida
- Department of Hematology, Toranomon Hospital, Tokyo, Japan
| | - Yuki Taya
- Department of Hematology, Toranomon Hospital, Tokyo, Japan
| | | | | | | | - Go Yamamoto
- Department of Hematology, Toranomon Hospital, Tokyo, Japan
| | - Naoyuki Uchida
- Department of Hematology, Toranomon Hospital, Tokyo, Japan
| | - Atsushi Wake
- Department of Hematology, Toranomon Hospital, Tokyo, Japan
| | | | - Hideki Araoka
- Department of Infectious Diseases, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan
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Chung PH, Wong KK, Tam PK. Standard management protocol to improve the short-term outcome of biliary atresia. J Paediatr Child Health 2020; 56:1774-1778. [PMID: 33197970 DOI: 10.1111/jpc.14698] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 10/08/2019] [Accepted: 11/03/2019] [Indexed: 11/27/2022]
Abstract
AIM This study compared the outcomes of patients with biliary atresia (BA) treated according to a standardised protocol with historical patients. METHODS This is a single-centred retrospective study of BA patients treated from 1980 to 2016. A standardised treatment protocol was established since 2008 regarding peri-operative management. The outcomes being compared between the two groups (Groups I and II = before and after 2008, respectively) were jaundice clearance (JC), incidence of recurrent cholangitis, hospital admission and native liver survival (NLS). RESULTS A total of 128 patients were included (Group I = 100, Group II = 28). The overall median follow-up period was 15.3 years (I vs. II = 20.6 years vs. 5.1 years, respectively). There was no significant difference in the JC at the sixth month between the two groups (I vs. II = 60.0 vs. 82.1%, respectively, P = 0.07). The incidence of recurrent cholangitis was similar between the two groups (I vs. II = 39 vs. 35.7%, respectively, P = 0.45), but the median hospital admission episode per patient was non-significantly higher in Group I (I vs. II = 4.2 vs. 2.7, respectively, P = 0.08). There was an improvement in the 1-year NLS rate in Group II (I vs. II = 69.0 vs. 85.7%, respectively, P = 0.05). CONCLUSIONS The introduction of a standardised management protocol has improved the short-term outcome of BA patients, with a better 1-year NLS observed.
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Affiliation(s)
- Patrick Hy Chung
- Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Kenneth Ky Wong
- Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Paul Kh Tam
- Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
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Tang X, Chen L, Li Y, Jiang J, Li X, Liang X. Carbapenems versus alternative β-lactams monotherapy or in combination for febrile neutropenia: Systematic review and meta-analysis of randomized controlled trial. Medicine (Baltimore) 2020; 99:e22725. [PMID: 33120768 PMCID: PMC7581108 DOI: 10.1097/md.0000000000022725] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Febrile neutropenia (FN) in cancer patients can be life threatening and require the timely antimicrobial agents treatment. METHODS To compare the effectiveness and safety of carbapenems versus β-lactams for FN. PubMed, Medline (Ovid SP), Cochrane CENTRAL, and Embase were searched up to March 2019. FN in patients due to undergoing chemotherapy and treated with carbapenems and β-lactams were included. Odds ratio (OR) and 95% confidence interval (CI) were estimated. RESULTS Fifty randomized controlled trials (RCTs) studies involving 10,995 participants were included. Carbapenems were more likely to experience treatment success without modification (OR = 1.34, 95% CI = 1.24-1.46) compared with β-lactams. Meropenem (OR = 1.36, 95% CI = 1.18-1.56; OR = 1.24, 95% CI = 1.01-1.53), imipenem/cilastatin (OR = 1.40, 95% CI = 1.19-1.65; OR = 1.31, 95% CI = 1.04-1.67) showed higher effectiveness from that by β-lactams monotherapy or in combination with aminoglycoside, respectively. Carbapenems-aminoglycoside combination therapy does not provide an advantage over carbapenems alone. Meropenem showed similar risk of adverse events (AEs) versus β-lactams. Imipenem/cilastatin was related to higher risk of AEs compared with β-lactams. There was no significant difference between carbapenems and β-lactams monotherapy or in combination. CONCLUSION Meropenem and imipenem/cilastatin monotherapy appears to be available treatment for FN compared with β-lactams. Imipenem/cilastatin was related to higher risk of AEs. Balancing the evidence for drug efficacy and side effects, meropenem monotherapy appears to be available treatment for FN. Individual centers should select the best matching therapy regimens according to local epidemiology and susceptibility patterns.
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Affiliation(s)
| | | | | | - Junsong Jiang
- Department of Reproductive Medicine, The People's Hospital of Hechi, Hechi, China
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20
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Christopeit M, Schmidt-Hieber M, Sprute R, Buchheidt D, Hentrich M, Karthaus M, Penack O, Ruhnke M, Weissinger F, Cornely OA, Maschmeyer G. Prophylaxis, diagnosis and therapy of infections in patients undergoing high-dose chemotherapy and autologous haematopoietic stem cell transplantation. 2020 update of the recommendations of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO). Ann Hematol 2020; 100:321-336. [PMID: 33079221 PMCID: PMC7572248 DOI: 10.1007/s00277-020-04297-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 10/03/2020] [Indexed: 12/14/2022]
Abstract
To ensure the safety of high-dose chemotherapy and autologous stem cell transplantation (HDC/ASCT), evidence-based recommendations on infectious complications after HDC/ASCT are given. This guideline not only focuses on patients with haematological malignancies but also addresses the specifics of HDC/ASCT patients with solid tumours or autoimmune disorders. In addition to HBV and HCV, HEV screening is nowadays mandatory prior to ASCT. For patients with HBs antigen and/or anti-HBc antibody positivity, HBV nucleic acid testing is strongly recommended for 6 months after HDC/ASCT or for the duration of a respective maintenance therapy. Prevention of VZV reactivation by vaccination is strongly recommended. Cotrimoxazole for the prevention of Pneumocystis jirovecii is supported. Invasive fungal diseases are less frequent after HDC/ASCT, therefore, primary systemic antifungal prophylaxis is not recommended. Data do not support a benefit of protective room ventilation e.g. HEPA filtration. Thus, AGIHO only supports this technique with marginal strength. Fluoroquinolone prophylaxis is recommended to prevent bacterial infections, although a survival advantage has not been demonstrated.
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Affiliation(s)
- Maximilian Christopeit
- Department of Stem Cell Transplantation, University Medical Center Eppendorf, Hamburg, Germany.
| | - Martin Schmidt-Hieber
- Department of Hematology and Oncology, Carl-Thiem-Klinikum, Cottbus, Cottbus, Germany
| | - Rosanne Sprute
- Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany
- Department I of Internal Medicine, University Hospital of Cologne, University of Cologne, Cologne, Germany
- Partner Site Bonn-Cologne, German Centre for Infection Research, Cologne, Germany
| | - Dieter Buchheidt
- Department of Hematology and Oncology, Mannheim University Hospital, Heidelberg University, Mannheim, Germany
| | - Marcus Hentrich
- Department of Medicine III-Hematology/Oncology, Red Cross Hospital, Munich, Germany
| | - Meinolf Karthaus
- Department of Internal Medicine, Hematology and Oncology, Klinikum Neuperlach, Städtisches Klinikum München, Munich, Germany
| | - Olaf Penack
- Department of Internal Medicine, Division of Hematology and Oncology, Charité Universitätsmedizin Berlin, Campus Rudolf Virchow, Berlin, Germany
| | - Markus Ruhnke
- Department of Hematology, Oncology and Palliative Medicine, Helios Hospital Aue, Aue, Germany
| | - Florian Weissinger
- Department of Internal Medicine, Hematology, Oncology, Stem Cell Transplantation and Palliative Medicine, Protestant Hospital of Bethel Foundation, Bielefeld, Germany
| | - Oliver A Cornely
- Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany
- Department I of Internal Medicine, University Hospital of Cologne, University of Cologne, Cologne, Germany
- Partner Site Bonn-Cologne, German Centre for Infection Research, Cologne, Germany
- Clinical Trials Centre Cologne (ZKS Köln), University of Cologne, Cologne, Germany
| | - Georg Maschmeyer
- Klinikum Ernst von Bergmann, Department of Hematology, Oncology and Palliative Care, Potsdam, Germany
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21
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Tori K, Tansarli GS, Parente DM, Kalligeros M, Ziakas PD, Mylonakis E. The cost-effectiveness of empirical antibiotic treatments for high-risk febrile neutropenic patients: A decision analytic model. Medicine (Baltimore) 2020; 99:e20022. [PMID: 32443305 PMCID: PMC7254453 DOI: 10.1097/md.0000000000020022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Febrile neutropenia has a significant clinical and economic impact on cancer patients. This study evaluates the cost-effectiveness of different current empiric antibiotic treatments. METHODS A decision analytic model was constructed to compare the use of cefepime, meropenem, imipenem/cilastatin, and piperacillin/tazobactam for treatment of high-risk patients. The analysis was performed from the perspective of U.S.-based hospitals. The time horizon was defined to be a single febrile neutropenia episode. Cost-effectiveness was determined by calculating costs and deaths averted. Cost-effectiveness acceptability curves for various willingness-to-pay thresholds (WTP), were used to address the uncertainty in cost-effectiveness. RESULTS The base-case analysis results showed that treatments were equally effective but differed mainly in their cost. In increasing order: treatment with imipenem/cilastatin cost $52,647, cefepime $57,270, piperacillin/tazobactam $57,277, and meropenem $63,778. In the probabilistic analysis, mean costs were $52,554 (CI: $52,242-$52,866) for imipenem/cilastatin, $57,272 (CI: $56,951-$57,593) for cefepime, $57,294 (CI: $56,978-$57,611) for piperacillin/tazobactam, and $63,690 (CI: $63,370-$64,009) for meropenem. Furthermore, with a WTP set at $0 to $50,000, imipenem/cilastatin was cost-effective in 66.2% to 66.3% of simulations compared to all other high-risk options. DISCUSSION Imipenem/cilastatin is a cost-effective strategy and results in considerable health care cost-savings at various WTP thresholds. Cost-effectiveness analyses can be used to differentiate the treatments of febrile neutropenia in high-risk patients.
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Affiliation(s)
- Katerina Tori
- Division of Infectious Diseases, Brown University, Warren Alpert Medical School
| | | | - Diane M. Parente
- Department of Pharmacy, The Miriam Hospital, Providence, Rhode Island, USA
| | - Markos Kalligeros
- Division of Infectious Diseases, Brown University, Warren Alpert Medical School
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22
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Zhang Y, Zheng Y, Dong F, Ma H, Zhu L, Shi D, Li X, Li J, Hu J. Epidemiology of Febrile Neutropenia Episodes with Gram-Negative Bacteria Infection in Patients Who Have Undergone Chemotherapy for Hematologic Malignancies: A Retrospective Study of 10 Years' Data from a Single Center. Infect Drug Resist 2020; 13:903-910. [PMID: 32273735 PMCID: PMC7105367 DOI: 10.2147/idr.s241263] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 02/07/2020] [Indexed: 12/31/2022] Open
Abstract
Background The epidemiology of Gram-negative bacteria in patients with febrile neutropenia (FN) and their susceptibility to initial empirical antibiotic therapy is key to successful treatment during the treatment of hematologic malignancies. Methods A retrospective study was conducted. Patients with FN and confirmed laboratory results of Gram-negative bacteria infections were included. If no direct sensitivity of the identified pathogen to the initially prescribed antibiotic regimen was confirmed, it was defined as inappropriate initial antibiotic treatment (IIAT). Results A total of 247 patients with FN were proven to be infected with Gram-negative bacteria, and 200 were diagnosed with acute leukemia. The most commonly detected bacteria were Escherichia coli (40%), Klebsiella pneumoniae (20%), and Pseudomonas aeruginosa (11%). In sum, 176 patients were classified as IIAT. The mortality rate in the IIAT group was significantly higher (37.7% vs 23.9%, P=0.038). With monotherapy as empirical treatment, high possibility of IIAT with fluoroquinolones (52%) and cephalosporins (35%) was detected, while more sensitivity to carbapenems (16%) and glycopeptides antibiotics (19%) was noticed. With combined treatment, cephalosporins/carbapenems had with the lowest percentage of IIAT (18%). Conclusion In conclusion, inappropriate initial empirical antibiotic treatments were associated with higher mortality in patients with hematologic malignancies. The current empirical antibiotic regimen needs to be further optimized.
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Affiliation(s)
- Yunxiang Zhang
- Department of Hematology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China.,State Key Laboratory of Medical Genomics, Shanghai Institute of Hematology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Yu Zheng
- Department of Hematology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China.,State Key Laboratory of Medical Genomics, Shanghai Institute of Hematology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Fangyi Dong
- Department of Hematology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China.,State Key Laboratory of Medical Genomics, Shanghai Institute of Hematology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Handong Ma
- John Hopcroft Center for Computer Science, Department of Computer Science and Engineering, Shanghai Jiao Tong University, Shanghai, People's Republic of China
| | - Liping Zhu
- Department of Hematology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Dake Shi
- Department of Clinical Microbiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Xiaoyang Li
- Department of Hematology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China.,State Key Laboratory of Medical Genomics, Shanghai Institute of Hematology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Junmin Li
- Department of Hematology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China.,State Key Laboratory of Medical Genomics, Shanghai Institute of Hematology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Jiong Hu
- Department of Hematology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China.,State Key Laboratory of Medical Genomics, Shanghai Institute of Hematology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
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Abstract
Resistance to β-lactam antibiotics in Gram-negative bacteria is commonly associated with production of β-lactamases, including extended-spectrum β-lactamases (ESBLs) and carbapenemases belonging to different molecular classes: those with a catalytically active serine and those with at least one active-site Zn2+ to facilitate hydrolysis. To counteract the hydrolytic activity of these enzymes, combinations of a β-lactam with a β-lactamase inhibitor (BLI) have been clinically successful. However, some β-lactam-BLI combinations have lost their effectiveness against prevalent Gram-negative pathogens that produce ESBLs, carbapenemases or multiple β-lactamases in the same organism. In this Review, descriptions are provided for medically relevant β-lactamase families and various BLI combinations that have been developed or are under development. Recently approved inhibitor combinations include the inhibitors avibactam and vaborbactam of the diazabicyclooctanone and boronic acid inhibitor classes, respectively, as new scaffolds for future inhibitor design.
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24
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A multicenter prospective study of 515 febrile neutropenia episodes in Argentina during a 5-year period. PLoS One 2019; 14:e0224299. [PMID: 31671108 PMCID: PMC6822758 DOI: 10.1371/journal.pone.0224299] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 10/09/2019] [Indexed: 12/27/2022] Open
Abstract
For better management of patients with febrile neutropenia, our study investigated the epidemiologic, microbiologic, and clinical characteristics of adult inpatients with febrile neutropenia and their mortality-associated factors. To this end, we carried out a prospective, observational, multicenter study in 28 Argentinian hospitals between 2007 and 2012. We included 515 episodes of febrile neutropenia from 346 patients, median age 49 years. Neutropenia followed chemotherapy in 77% of cases, half of the cases due to hematological malignancies. Most episodes were classified as high-risk according to MASCC criteria, and 53.6% of patients were already hospitalized at the onset of febrile neutropenia. Bloodstream infections were detected in 14% episodes; whereas an infectious source of fever was identified in 80% of cases. Mortality rate achieved to 14.95%. The binary regression analysis showed that persistence of fever at day 7, or neutropenia at day 14, dehydration and tachycardia at the onset of febrile neutropenia as well as prior infections were significantly associated with mortality. In addition to expanding our current knowledge on the features of adult patients with febrile neutropenia, present findings provide useful information for better management of them in Argentina, given the appropriate representativeness of centers participating in the study.
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25
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Han MS, Park KS, Jeon JH, Lee JK, Lee JH, Choi EH, Lee SH. SHV Hyperproduction as a Mechanism for Piperacillin-Tazobactam Resistance in Extended-Spectrum Cephalosporin-Susceptible Klebsiella pneumoniae. Microb Drug Resist 2019; 26:334-340. [PMID: 31651221 DOI: 10.1089/mdr.2019.0079] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
This study aimed to determine the mechanism of resistance to piperacillin-tazobactam (TZP) in Klebsiella pneumoniae bloodstream isolates that are susceptible to extended-spectrum cephalosporins (ESCs). Antibiotic susceptibility was determined for K. pneumoniae isolated from children with bacteremia. The β-lactamase genes were detected using a large-scale bla detection method (LARGE-SCALEblaFinder) and confirmed by sequencing analysis. The isolates were further characterized by β-lactamase activity assays and multilocus sequence typing. Among the 300 bloodstream isolates of K. pneumoniae, 11 (3.7%) were TZP resistant but ESC susceptible. The TZP minimum inhibitory concentrations (MICs) of the isolates ranged from 128/4 to >2,048/4 mg/L. Avibactam markedly inhibited piperacillin resistance, reducing the MICs to the range of ≤1 to 8 mg/L. Among the 11 isolates, four hyperproduced SHV-1 and two hyperproduced SHV-11, exhibiting 77- to 496-fold higher β-lactamase activity compared with the SHV-1- and SHV-11-producing reference strains that are susceptible to TZP. OXA-1 was coproduced in three isolates, and the remaining two isolates produced TEM-30. Transformants with recombinant plasmids carrying the β-lactamase genes demonstrated an increase in MICs of TZP. The TZP-resistant and ESC-susceptible isolates were not epidemiologically related. Hyperproduction of SHV-1 and SHV-11 represents a novel mechanism for reducing TZP activity in K. pneumoniae isolates resistant to ESCs. Continuous monitoring and investigation of TZP-resistant isolates are needed in the current era of high TZP consumption.
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Affiliation(s)
- Mi Seon Han
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea.,Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Kwang Seung Park
- National Leading Research Laboratory of Drug Resistance Proteomics, Department of Biological Sciences, Myongji University, Yongin, Korea
| | - Jeong Ho Jeon
- National Leading Research Laboratory of Drug Resistance Proteomics, Department of Biological Sciences, Myongji University, Yongin, Korea
| | - Joon Kee Lee
- Department of Pediatrics, Chungbuk National University Hospital, Cheongju, Korea
| | - Jung Hun Lee
- National Leading Research Laboratory of Drug Resistance Proteomics, Department of Biological Sciences, Myongji University, Yongin, Korea
| | - Eun Hwa Choi
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea.,Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Sang Hee Lee
- National Leading Research Laboratory of Drug Resistance Proteomics, Department of Biological Sciences, Myongji University, Yongin, Korea
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26
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Jacquet J, Catala G, Machiels JP, Penaloza A. Neutropénie fébrile aux urgences, stratification du risque et conditions du retour à domicile. ANNALES FRANCAISES DE MEDECINE D URGENCE 2019. [DOI: 10.3166/afmu-2019-0133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
La neutropénie fébrile (NF) est une situation fréquemment rencontrée aux urgences avec un taux de mortalité non négligeable variant de 5 à 40 %. Cette variabilité importante met en avant l’importance de stratifier le risque afin de permettre un traitement ambulatoire per os de certains patients à faible risque. En plus du MASCC (The Multinational Association for Supportive Care in Cancer) score, d’autres outils permettent d’évaluer ce risque ou sont à l’étude dans ce but, tels que le dosage de la CRP, la procalcitonine ou encore le score CISNE. Après une prise en charge rapide aux urgences incluant l’administration sans délai d’un traitement adéquat, la poursuite de l’antibiothérapie per os à domicile est envisageable chez les patients à faible risque. La combinaison amoxicilline–acide clavulanique et ciprofloxacine est le plus souvent recommandée, mais la moxifloxacine ou la lévofloxacine en monothérapie peuvent également être utilisées pour les patients traités à domicile. Le retour à domicile permet de réduire fortement les coûts engendrés par l’hospitalisation, de diminuer le risque d’infection nosocomiale et d’améliorer la qualité de vie des patients avec NF à faible risque. Dans cette optique, plusieurs critères doivent être remplis, et une discussion avec le patient reste primordiale à la prise de décision. Parmi ceux-ci, nous retiendrons notamment un score MASCC supérieur à 21, une durée attendue de neutropénie inférieure à sept jours, l’accord du patient et de son entourage ainsi que la proximité entre le domicile et un service de soin adapté.
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27
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Schmidt-Hieber M, Teschner D, Maschmeyer G, Schalk E. Management of febrile neutropenia in the perspective of antimicrobial de-escalation and discontinuation. Expert Rev Anti Infect Ther 2019; 17:983-995. [PMID: 30686067 DOI: 10.1080/14787210.2019.1573670] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Introduction: Infections are among the most frequent complications in patients with hematological and oncological diseases. They might be classified as fever of unknown origin and microbiologically or clinically documented infections. Optimal duration of antimicrobial treatment is still unclear in these patients.Areas covered: We provide an overview on the management of febrile neutropenia in the perspective of antimicrobial de-escalation and discontinuation.Expert opinion: Patients with febrile high-risk neutropenia should be treated empirically with an anti-pseudomonal agent such as piperacillin/tazobactam. Several clinical studies support the assumption that the primary antibiotic regimen might be safely discontinued prior to neutrophil reconstitution if the patient is afebrile for several days and all infection-related symptoms have been resolved. Primary empirical treatment with carbapenems or antibiotic combinations should commonly only be considered in selected patient subgroups, such as patients with severe neutropenic sepsis or colonization with multidrug-resistant bacteria. Preemptive antifungal treatment guided by lung imaging and other parameters (e.g. serial Aspergillus galactomannan antigen screening) might reduce the consumption of antifungals compared to the classical empirical approach.Multidrug-resistant pathogens are emerging, and novel anti-infective agents under development are scarce. Therefore, a rational use of antimicrobials based on the principles of antibiotic stewardship is crucial.
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Affiliation(s)
| | - Daniel Teschner
- Department of Hematology, Medical Oncology & Pneumology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Georg Maschmeyer
- Clinic of Hematology, Oncology and Palliative Care, Klinikum Ernst von Bergmann, Potsdam, Germany
| | - Enrico Schalk
- Department of Hematology and Oncology, Medical Center, Otto-von-Guericke University, Magdeburg, Germany
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28
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Comparison of antipseudomonal β-lactams for febrile neutropenia empiric therapy: systematic review and network meta-analysis: authors' reply. Clin Microbiol Infect 2018; 24:664-665. [DOI: 10.1016/j.cmi.2018.01.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 01/16/2018] [Accepted: 01/18/2018] [Indexed: 11/19/2022]
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29
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Khoo AL, Zhao YJ, Teng M, Ying D, Jin J, Chee YL, Poon LM, Lim SE, Koh LP, Chng WJ, Lim BP, Hsu LY, Chai LYA. Evaluation of a risk-guided strategy for empirical carbapenem use in febrile neutropenia. Int J Antimicrob Agents 2018; 52:350-357. [PMID: 29751120 DOI: 10.1016/j.ijantimicag.2018.04.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 04/18/2018] [Accepted: 04/29/2018] [Indexed: 11/28/2022]
Abstract
Febrile neutropenia (FN) is associated with substantial morbidity and necessitates empirical broad-spectrum antimicrobial treatment. In this prospective cohort study, a risk-guided management strategy for FN using empirical piperacillin/tazobactam (TZP) or a carbapenem was evaluated. The analysis involved 723 FN episodes in hospitalised adult patients, including those with severe sepsis or prior infection/colonisation with extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae. Propensity score matching analysis was used to adjust for baseline differences between treatment groups and produced 267 matched pairs. The primary outcome was all-cause mortality. Secondary outcomes were the incidences of drug-resistant Gram-negative (including ESBL-producing) and Gram-positive bacterial isolates and of invasive pulmonary aspergillosis (IPA) and their associated mortality. There was no difference in mortality between empirical carbapenem and TZP [18/267 (6.7%) vs. 14/267 (5.2%); P = 0.466]. Higher incidences of drug-resistant Gram-negative isolates [77/267 (28.8%) vs. 26/267 (9.7%); P < 0.001], including ESBL-producing bacteria [57/267 (21.3%) vs. 16/267 (6.0%); P < 0.001], were observed in carbapenem-treated episodes where its use lowered mortality. Mortality rates for ESBL-positive infections were 5.3% (3/57) and 25.0% (4/16) (P = 0.037) and for drug-resistant Gram-negative infections were 6.5% (5/77) and 23.1% (6/26) (P = 0.018) in carbapenem- and TZP-treated episodes, respectively. More IPA was observed with carbapenem use [16/267 (6.0%) vs. 6/267 (2.2%); P = 0.029]. Antifungal prophylaxis reduced the risk of death (odds ratio = 0.39, 95% confidence interval 0.17-0.87; P = 0.017). Risk-guided carbapenem prescribing in FN correctly identified cases prone to drug-resistant Gram-negative infections and reduced the mortality in these episodes.
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Affiliation(s)
- Ai Leng Khoo
- Pharmacy and Therapeutics Office, Group Health Informatics, National Healthcare Group, Singapore
| | - Ying Jiao Zhao
- Pharmacy and Therapeutics Office, Group Health Informatics, National Healthcare Group, Singapore
| | - Monica Teng
- Pharmacy and Therapeutics Office, Group Health Informatics, National Healthcare Group, Singapore
| | - Ding Ying
- Department of Infectious Diseases, Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, Singapore
| | - Jing Jin
- Children's Minnesota Research Institute, Children's Hospitals and Clinics of Minnesota, Minneapolis-Saint Paul, MN, USA
| | - Yen Lin Chee
- Department of Haematology-Oncology, National University Cancer Institute, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Li Mei Poon
- Department of Haematology-Oncology, National University Cancer Institute, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Siew Eng Lim
- Department of Haematology-Oncology, National University Cancer Institute, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Liang Piu Koh
- Department of Haematology-Oncology, National University Cancer Institute, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Wee Joo Chng
- Department of Haematology-Oncology, National University Cancer Institute, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Boon Peng Lim
- Pharmacy and Therapeutics Office, Group Health Informatics, National Healthcare Group, Singapore
| | - Li Yang Hsu
- Department of Infectious Diseases, Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Louis Yi Ann Chai
- Department of Haematology-Oncology, National University Cancer Institute, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Infectious Diseases, University Medicine Cluster, National University Health System, Singapore.
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30
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Chastain DB, Wheeler S, Franco-Paredes C, Olubajo B, Hawkins WA. Evaluating guideline adherence regarding empirical vancomycin use in patients with neutropenic fever. Int J Infect Dis 2018; 69:88-93. [PMID: 29477362 DOI: 10.1016/j.ijid.2018.02.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 02/14/2018] [Accepted: 02/16/2018] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE The purpose of this study was to evaluate the use of empirical vancomycin for patients with neutropenic fever (NF) with regard to adherence to treatment guidelines. METHODS Adult patients with a diagnosis of neutropenia, who met the definition of NF as per treatment guidelines, were identified. Use of vancomycin was evaluated as part of empirical therapy and again after 72h. Outcomes were assessed using descriptive statistics, the Chi-square or Fisher's exact test, and univariate exact logistic regression analyses. RESULTS Sixty-four patients were included. Overall, inappropriate empirical vancomycin use was observed in more than 30% of patients. Of 35 patients with indications for empirical vancomycin, only 68% received it. At 72h, appropriate vancomycin continuation, de-escalation, or discontinuation occurred in 21 of 33 patients. On univariate regression, hematological malignancy was associated with appropriate empirical vancomycin prescribing, whether initiating or withholding (odds ratio 4.0, 95% confidence interval 1.31-12.1). No variable was independently associated with inappropriate continuation at 72h. CONCLUSIONS There is poor guideline adherence to vancomycin prescribing as empirical therapy and at 72-h reassessment in patients with NF. Further efforts are needed to foster a more rational use of vancomycin in patients with NF.
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Affiliation(s)
- Daniel B Chastain
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Albany, GA 31701, USA.
| | - Sarah Wheeler
- Department of Pharmaceutical Services, UF Health Shands Cancer Hospital, Gainesville, FL 32608, USA.
| | - Carlos Franco-Paredes
- Division of Infectious Diseases, University of Colorado Denver, Anschutz Medical Campus, Aurora, CO 80045, USA; Hospital Infantil de Mexico, Federico Gomez, Mexico City, Mexico.
| | | | - W Anthony Hawkins
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Albany, GA 31701, USA; Department of Pharmacology and Toxicology, Medical College of Georgia at Augusta University, Albany, GA 31701, USA.
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31
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Horita N, Shibata Y, Watanabe H, Namkoong H, Kaneko T. Comparison of antipseudomonal β-lactams for febrile neutropenia empiric therapy: authors' response. Clin Microbiol Infect 2018; 24:325. [DOI: 10.1016/j.cmi.2017.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 11/17/2017] [Accepted: 11/18/2017] [Indexed: 11/27/2022]
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32
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Comparison of antipseudomonal beta-lactams for febrile neutropenia empiric therapy. Clin Microbiol Infect 2018; 24:324. [DOI: 10.1016/j.cmi.2017.10.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 10/24/2017] [Accepted: 10/30/2017] [Indexed: 11/18/2022]
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Averbuch D, Orasch C, Mikulska M, Livermore DM, Viscoli C, Gyssens IC, Kern WV, Klyasova G, Marchetti O, Engelhard D, Akova M, Calandra T, Cordonnier C. Re: "Comparison of antipseudomonal betalactams for febrile neutropenia empiric therapy: systematic review and network metaanalysis" by Horita et al. Clin Microbiol Infect 2018; 24:662-663. [PMID: 29410224 DOI: 10.1016/j.cmi.2018.01.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 01/08/2018] [Accepted: 01/10/2018] [Indexed: 11/27/2022]
Affiliation(s)
- D Averbuch
- Hadassah-Hebrew University Medical Centre, Jerusalem, Israel.
| | - C Orasch
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital (CHUV, Centre Hospitalier Universitaire Vaudois), Lausanne, Switzerland; Division for Infectious Diseases and Hospital Epidemiology, Hirslanden Klinik St. Anna, Lucerne, Switzerland
| | - M Mikulska
- Infectious Disease Unit, University of Genova (DISSAL) and Ospedale Policlinico San Martino, Genova, Italy
| | - D M Livermore
- Norwich Medical School, University of East Anglia, Norwich, Norfolk, NR4 7TJ, UK
| | - C Viscoli
- Infectious Disease Unit, University of Genova (DISSAL) and Ospedale Policlinico San Martino, Genova, Italy
| | - I C Gyssens
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands; Hasselt University, Hasselt, Belgium
| | - W V Kern
- Division of Infectious Diseases, University Hospital and Medical Centre, Freiburg, Germany
| | - G Klyasova
- Department of Clinical Microbiology, Mycology and Antimicrobial Treatment, National Research Centre for Haematology, Moscow, Russia
| | - O Marchetti
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital, CH-1011 Lausanne, Switzerland; Department of Medicine, Ensemble Hospitalier de la CÔte, CH-1110 Morges, Switzerland
| | - D Engelhard
- Hadassah-Hebrew University Medical Centre, Jerusalem, Israel
| | - M Akova
- Hacettepe University School of Medicine, Department of Infectious Diseases, Ankara, 06100 Turkey
| | - T Calandra
- Infectious Diseases Service, Department of Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - C Cordonnier
- Assistance Publique-Hôpitaux de Paris (APHP) - Henri Mondor, Haematology Department and University Paris-Est Créteil, F-94010, Créteil, France
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