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Stern A, Henig I, Cohen M, Gur I, Henig O, Zuckerman T, Paul M. Impact of discontinuing routine fluoroquinolone prophylaxis in neutropenic allogeneic haematopoietic stem cell transplant recipients: an observational study. J Antimicrob Chemother 2024:dkae360. [PMID: 39397650 DOI: 10.1093/jac/dkae360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Accepted: 09/13/2024] [Indexed: 10/15/2024] Open
Abstract
BACKGROUND Uncertainty exists as to the role of fluoroquinolone (FQ) prophylaxis for patients undergoing allogeneic haematopoietic stem cell transplantation (HSCT) in the era of rising antibiotic resistance. OBJECTIVES We aimed to evaluate rates of bloodstream infections (BSI), resistance patterns and outcomes of patients after discontinuing routine FQ prophylaxis administration. METHODS All adult recipients of first HSCT from 2017 to 2020 were retrospectively included and classified according to time of HSCT as FQ group (HSCT January 2017-December 2018) or no FQ group (January 2019-December 2020). The primary outcome was Gram-negative (GN) BSI from day -7 to 30 days post-HSCT. The independent association between the study period and BSI was assessed using survival analysis, and adjusting for confounders. RESULTS We included 254 patients, 130 (51%) and 124 (49%) in the FQ and no FQ groups, respectively. Compared to the FQ group, no FQ had significantly more GN BSI (21% versus 33%, P = 0.027) and the median time to first GN BSI was significantly shorter [4 (IQR 1-8) days versus 6 (1-10) days, P = 0.009]. Following adjustment, FQ prophylaxis remained associated with lower hazard for GN BSI (hazard ratio 0.57, 95% CI 0.34-0.93). Eighty-two GN BSI episodes had FQ susceptibility testing. More GN BSI episodes were FQ resistant in the FQ group (68.9% versus 41.6%, P = 0.021). No significant difference was found for 30-day mortality, time to first febrile neutropenia and time to first broad-spectrum antibiotics between the groups (P was not significant). CONCLUSIONS FQ prophylaxis is associated with fewer GN BSI in the early post-HSCT period even in high FQ resistance settings, with FQ resistance rates reaching >60% following prophylaxis.
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Affiliation(s)
- Anat Stern
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel
- Bruce Rappaport School of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Israel Henig
- Department of Hematology, Rambam Health Care Campus, Haifa, Israel
| | - Maya Cohen
- Bruce Rappaport School of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Ivan Gur
- Internal Medicine Department, Rambam Health Care Campus, Haifa, Israel
| | - Oryan Henig
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Infection Prevention and Control Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Tsila Zuckerman
- Bruce Rappaport School of Medicine, Technion Israel Institute of Technology, Haifa, Israel
- Department of Hematology, Rambam Health Care Campus, Haifa, Israel
| | - Mical Paul
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel
- Bruce Rappaport School of Medicine, Technion Israel Institute of Technology, Haifa, Israel
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Farhan S, Mazur I, Hartzell S, Xie P, Neme K, German A, Mikulandric N, Patel K, Wu M, Kortam N, Yaseen A, Sweidan A, Latack K, Emole J, Peres E, Abidi MH, Ramesh M. Ciprofloxacin versus levofloxacin prophylaxis in hematopoietic stem cell transplantation: A randomized trial. Int J Infect Dis 2024; 147:107172. [PMID: 39019103 DOI: 10.1016/j.ijid.2024.107172] [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: 05/08/2024] [Revised: 07/09/2024] [Accepted: 07/10/2024] [Indexed: 07/19/2024] Open
Abstract
OBJECTIVES We aimed to assess whether there is a difference between ciprofloxacin and levofloxacin as prophylaxis in hematopoietic stem cell transplant (SCT) recipients. METHODS This is a prospective, randomized trial in patients receiving SCT at Henry Ford Health in the United States of America. We randomly assigned patients (1:1) to receive ciprofloxacin or levofloxacin. The primary outcome was incidence of bloodstream bacterial infections (BSI) up to day 60 after SCT. RESULTS Between June 4, 2018, and May 23, 2022, we randomly assigned 308 consecutive patients to receive ciprofloxacin (154 patients) or levofloxacin (154 patients). BSI was similar in both the ciprofloxacin and levofloxacin groups (18 [11.7%] vs 18 [11.7%]). Pneumonia was more frequent in the ciprofloxacin group compared to the levofloxacin group (18 [18%] vs 7 [23%]; relative risk 2.57, 95% CI 1.11-5.98; p = 0.028). There were no differences in neutrophil engraftment, fever, Clostridium difficile infection, relapse incidence, overall survival, nonrelapse mortality, length of stay post-SCT, or intensive care unit admission. CONCLUSION Although both prophylaxis regimens demonstrated the same efficacy in SCT recipients, levofloxacin prophylaxis led to less pneumonia in the first 60 days post-SCT. TRIAL REGISTRATION This study is registered on ClinicalTrials.gov, NCT03850379.
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Affiliation(s)
- Shatha Farhan
- Stem Cell Transplant and Cellular Therapy, Henry Ford Health, Detroit, MI, USA.
| | - Izabela Mazur
- Stem Cell Transplant and Cellular Therapy, Henry Ford Health, Detroit, MI, USA
| | - Susan Hartzell
- Wayne State University School of Medicine, Detroit, MI, USA
| | - Peter Xie
- MetroHealth System, Cleveland, OH, USA
| | - Klodiana Neme
- Stem Cell Transplant and Cellular Therapy, Henry Ford Health, Detroit, MI, USA
| | - Angela German
- Stem Cell Transplant and Cellular Therapy, Henry Ford Health, Detroit, MI, USA
| | - Nancy Mikulandric
- Stem Cell Transplant and Cellular Therapy, Henry Ford Health, Detroit, MI, USA
| | - Kunj Patel
- Department of Internal Medicine, Henry Ford Hospital, Detroit, MI, USA
| | - Min Wu
- Wayne State University School of Medicine, Detroit, MI, USA
| | - Neda Kortam
- Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA
| | - Aseel Yaseen
- Division of Endocrinology, Diabetes, & Metabolism, Henry Ford Health, Detroit, MI, USA
| | - Aroob Sweidan
- Hematology Oncology, Henry Ford Health, Detroit, MI, USA
| | - Katie Latack
- Public Health Sciences, Henry Ford Health, Detroit, MI, USA
| | - Josephine Emole
- Stem Cell Transplant and Cellular Therapy, Henry Ford Health, Detroit, MI, USA
| | - Edward Peres
- Stem Cell Transplant and Cellular Therapy, Henry Ford Health, Detroit, MI, USA
| | - Muneer H Abidi
- Stem Cell Transplant and Cellular Therapy, Henry Ford Health, Detroit, MI, USA
| | - Mayur Ramesh
- Transplant Infectious Diseases and Immunotherapy, Henry Ford Hospital, Detroit, MI, USA
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Gavriilaki E, Mallouri D, Laspa E, Papakonstantinou A, Lazaridou A, Varelas C, Baldoumi E, Giannakopoulou A, Demosthenous C, Vardi A, Bousiou Z, Batsis I, Gkioula G, Anagnostopoulos A, Sakellari I. Open-Label Randomized Controlled Study of Ciprofloxacin vs Rifaximin as Neutropenia Prophylaxis in Allogeneic Hematopoietic Stem Cell Transplantation. Transplant Proc 2024; 56:380-385. [PMID: 38368126 DOI: 10.1016/j.transproceed.2023.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 12/11/2023] [Accepted: 12/28/2023] [Indexed: 02/19/2024]
Abstract
Loss of microbiota diversity has been clearly associated with poor outcomes in the allogeneic hematopoietic stem cell transplantation setting. However, the choice of the optimal antibiotic prophylaxis during the pre-engraftment phase remains unclear. We designed a prospective randomized study to compare our standard-of-care neutropenia prophylaxis (ciprofloxacin) with rifaximin. We enrolled 38 consecutive adult patients who underwent allogeneic hematopoietic stem cell transplantation setting and were randomly assigned to receive ciprofloxacin (20 patients) or rifaximin (18 patients) at day -1. Pretransplant and transplant characteristics did not differ between groups. Cumulative incidence (CI) of acute graft-vs-host disease grade II to IV and moderate/severe chronic graft-vs-host disease was similar in both groups. With a median follow-up of 13.2 months (range, 6.8-30.2) in surviving patients, the 1-year CI of relapse was 20.8% in ciprofloxacin vs 17.8% in rifaximin (P = .616). Importantly, the 1-year CI of treatment-related mortality was significantly reduced in the ciprofloxacin group (10.2% vs 27.8%, P = .032), leading to higher 1-year overall survival (88.9% vs 74.6%, P = .038). In Cox-regression multivariate analysis, antibiotic prophylaxis remained the only predictor of overall survival, independently of donor type, disease risk index, and moderate/severe chronic graft-vs-host disease. Further studies are needed to assess the effects on microbiota diversity and confirm these outcomes.
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Affiliation(s)
- Eleni Gavriilaki
- Hematology Department-BMT Unit, G Papanikolaou Hospital, Thessaloniki, Greece
| | - Despina Mallouri
- Hematology Department-BMT Unit, G Papanikolaou Hospital, Thessaloniki, Greece
| | - Evgenia Laspa
- Hematology Department-BMT Unit, Geneva University Hospital, Geneva, Switzerland.
| | - Anna Papakonstantinou
- Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Andriana Lazaridou
- Hematology Department-BMT Unit, G Papanikolaou Hospital, Thessaloniki, Greece
| | - Christos Varelas
- Hematology Department-BMT Unit, G Papanikolaou Hospital, Thessaloniki, Greece
| | - Eirini Baldoumi
- Hematology Department-BMT Unit, G Papanikolaou Hospital, Thessaloniki, Greece
| | | | | | - Anna Vardi
- Hematology Department-BMT Unit, G Papanikolaou Hospital, Thessaloniki, Greece
| | - Zoi Bousiou
- Hematology Department-BMT Unit, G Papanikolaou Hospital, Thessaloniki, Greece
| | - Ioannis Batsis
- Hematology Department-BMT Unit, G Papanikolaou Hospital, Thessaloniki, Greece
| | - Georgia Gkioula
- Microbiology Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Ioanna Sakellari
- Hematology Department-BMT Unit, G Papanikolaou Hospital, Thessaloniki, Greece
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Singh N, Thursky K, Maron G, Wolf J. Fluoroquinolone prophylaxis in patients with neutropenia at high risk of serious infections: Exploring pros and cons. Transpl Infect Dis 2023; 25 Suppl 1:e14152. [PMID: 37746769 DOI: 10.1111/tid.14152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 08/30/2023] [Accepted: 09/06/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND The use of fluoroquinolones to prevent infections in neutropenic patients with cancer or undergoing hematopoietic stem cell transplantation (HSCT) is a controversial issue, with international guidelines providing conflicting recommendations. Although potential benefits are clear, concerns revolve around efficacy, potential harms, and antimicrobial resistance (AMR) implications. DISCUSSION Fluoroquinolone prophylaxis reduces neutropenic fever (NF) bloodstream infections and other serious bacterial infections, based on evidence from systematic reviews, randomized controlled trials, and observational studies in adults and children. Fluoroquinolone prophylaxis may also reduce infection-related morbidity and healthcare costs; however, evidence is conflicting. Adverse effects of fluoroquinolones are well recognized in the general population; however, studies in the cancer cohort where it is used for a defined period of neutropenia have not reflected this. The largest concern for routine use of fluoroquinolone prophylaxis remains AMR, as many, but not all, observational studies have found that fluoroquinolone prophylaxis might increase the risk of AMR, and some studies have suggested negative impacts on patient outcomes as a result. CONCLUSIONS The debate surrounding fluoroquinolone prophylaxis calls for individualized risk assessment based on patient characteristics and local AMR patterns, and prophylaxis should be restricted to patients at the highest risk of serious infection during the highest risk periods to ensure that the risk-benefit analysis is in favor of individual and community benefit. More research is needed to address important unanswered questions about fluoroquinolone prophylaxis in neutropenic patients with cancer or receiving HSCT.
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Affiliation(s)
- Nikhil Singh
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Australia
- Department of Pharmacy, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Karin 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
- Department of Infectious Diseases, Melbourne Medical School, University of Melbourne, Melbourne, Australia
- National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, Melbourne, Australia
| | - Gabriela Maron
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
- Department of Pediatrics, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| | - Joshua Wolf
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
- Department of Pediatrics, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
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Malagola M, Turra A, Signorini L, Corbellini S, Polverelli N, Masina L, Del Fabro G, Lorenzotti S, Fumarola B, Farina M, Morello E, Radici V, Buttini EA, Colnaghi F, Bernardi S, Re F, Caruso A, Castelli F, Russo D. Results of an Innovative Program for Surveillance, Prophylaxis, and Treatment of Infectious Complications Following Allogeneic Stem Cell Transplantation in Hematological Malignancies (BATMO Protocol). Front Oncol 2022; 12:874117. [PMID: 35785189 PMCID: PMC9247274 DOI: 10.3389/fonc.2022.874117] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 05/12/2022] [Indexed: 11/13/2022] Open
Abstract
Background Infectious complications are a significant cause of morbidity and mortality in patients undergoing allogeneic haematopoietic stem cell transplantation (Allo-SCT). The BATMO (Best-Antimicrobial-Therapy-TMO) is an innovative program for infection prevention and management and has been used in our centre since 2019. The specific features of the BATMO protocol regard both prophylaxis during neutropenia (abandonment of fluoroquinolone, posaconazole use in high-risk patients, aerosolized liposomal amphotericin B use until engraftment or a need for antifungal treatment, and letermovir use in CMV-positive recipients from day 0 to day +100) and therapy (empirical antibiotics based on patient clinical history and colonization, new antibiotics used in second-line according to antibiogram with the exception of carbapenemase-producing K pneumoniae for which the use in first-line therapy is chosen). Methods Data on the infectious complications of 116 transplant patients before BATMO protocol (Cohort A; 2016 - 2018) were compared to those of 84 transplant patients following the introduction of the BATMO protocol (Cohort B; 2019 - 2021). The clinical and transplant characteristics of the 2 Cohorts were comparable, even though patients in Cohort B were at a higher risk of developing bacterial, fungal, and CMV infections, due to a significantly higher proportion of myeloablative regimens and haploidentical donors. Results No change in the incidence of infections with organ localization was observed between the two Cohorts. A significant reduction in Clostridioides difficile infections by day +100 was observed in Cohort B (47% vs. 15%; p=0.04). At day +30, a higher incidence of Gram-negative bloodstream infections (BSIs) was observed in Cohort B (12% vs. 23%; p=0.05). By day +100 and between days +100 and +180, the incidence of BSIs and of the various etiological agents, the mortality from Gram-negative bacteria, and the incidence of invasive fungal infections were not different in the two Cohorts. The incidence of CMV reactivations by day +100 dropped drastically in patients of Cohort B, following letermovir registration (51% vs. 15%; p=0.00001). Discussion The results of this study suggest that the BATMO program is safe. In particular, the choice to avoid prophylaxis with fluoroquinolone was associated with an increase in Gram-negative BSIs by day +30, but this did not translate into higher levels of mortality. Moreover, this strategy was associated with a significant reduction of Clostridiodes difficile infections. The efficacy of anti-CMV prophylaxis with letermovir was confirmed by a significant reduction in CMV reactivations. Even though patients in Cohort B were at higher risk of developing fungal infections (more haploidentical transplants with more myeloablative regimens), the extensive use of posaconazole for prophylaxis balanced this risk, and no increase in the incidence of fungal-associated complications was observed.
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Affiliation(s)
- Michele Malagola
- Chair of Hematology, Bone Marrow Transplant Unit, ASST-Spedali Civili Brescia, Depatment of Clinical and Experimental Sciences University of Brescia, Brescia, Italy
- *Correspondence: Michele Malagola,
| | - Alessandro Turra
- Chair of Hematology, Bone Marrow Transplant Unit, ASST-Spedali Civili Brescia, Depatment of Clinical and Experimental Sciences University of Brescia, Brescia, Italy
| | - Liana Signorini
- Department of Infectious and Tropical Diseases, Azienda Socio Sanitaria Territoriale (ASST) Spedali Civili Hospital, University of Brescia, Brescia, Italy
| | - Silvia Corbellini
- Department of Molecular and Translational Medicine, Section of Microbiology and Virology, University of Brescia Medical School, Brescia, Italy
| | - Nicola Polverelli
- Chair of Hematology, Bone Marrow Transplant Unit, ASST-Spedali Civili Brescia, Depatment of Clinical and Experimental Sciences University of Brescia, Brescia, Italy
| | - Lorenzo Masina
- Chair of Hematology, Bone Marrow Transplant Unit, ASST-Spedali Civili Brescia, Depatment of Clinical and Experimental Sciences University of Brescia, Brescia, Italy
| | - Giovanni Del Fabro
- Department of Infectious and Tropical Diseases, Azienda Socio Sanitaria Territoriale (ASST) Spedali Civili Hospital, University of Brescia, Brescia, Italy
| | - Silvia Lorenzotti
- Department of Infectious and Tropical Diseases, Azienda Socio Sanitaria Territoriale (ASST) Spedali Civili Hospital, University of Brescia, Brescia, Italy
| | - Benedetta Fumarola
- Department of Infectious and Tropical Diseases, Azienda Socio Sanitaria Territoriale (ASST) Spedali Civili Hospital, University of Brescia, Brescia, Italy
| | - Mirko Farina
- Chair of Hematology, Bone Marrow Transplant Unit, ASST-Spedali Civili Brescia, Depatment of Clinical and Experimental Sciences University of Brescia, Brescia, Italy
| | - Enrico Morello
- Chair of Hematology, Bone Marrow Transplant Unit, ASST-Spedali Civili Brescia, Depatment of Clinical and Experimental Sciences University of Brescia, Brescia, Italy
| | - Vera Radici
- Chair of Hematology, Bone Marrow Transplant Unit, ASST-Spedali Civili Brescia, Depatment of Clinical and Experimental Sciences University of Brescia, Brescia, Italy
| | - Eugenia Accorsi Buttini
- Chair of Hematology, Bone Marrow Transplant Unit, ASST-Spedali Civili Brescia, Depatment of Clinical and Experimental Sciences University of Brescia, Brescia, Italy
| | - Federica Colnaghi
- Chair of Hematology, Bone Marrow Transplant Unit, ASST-Spedali Civili Brescia, Depatment of Clinical and Experimental Sciences University of Brescia, Brescia, Italy
| | - Simona Bernardi
- Chair of Hematology, Bone Marrow Transplant Unit, ASST-Spedali Civili Brescia, Depatment of Clinical and Experimental Sciences University of Brescia, Brescia, Italy
- Centro di Ricerca Ematologico – Associazione Italiana per la Lotta alle Leucemie, Linfomi e Mieloma (AIL), Azienda Socio Sanitaria Territoriale (ASST) Spedali Civili di Brecia, Brescia, Italy
| | - Federica Re
- Chair of Hematology, Bone Marrow Transplant Unit, ASST-Spedali Civili Brescia, Depatment of Clinical and Experimental Sciences University of Brescia, Brescia, Italy
- Centro di Ricerca Ematologico – Associazione Italiana per la Lotta alle Leucemie, Linfomi e Mieloma (AIL), Azienda Socio Sanitaria Territoriale (ASST) Spedali Civili di Brecia, Brescia, Italy
| | - Arnaldo Caruso
- Department of Molecular and Translational Medicine, Section of Microbiology and Virology, University of Brescia Medical School, Brescia, Italy
| | - Francesco Castelli
- Department of Infectious and Tropical Diseases, Azienda Socio Sanitaria Territoriale (ASST) Spedali Civili Hospital, University of Brescia, Brescia, Italy
| | - Domenico Russo
- Chair of Hematology, Bone Marrow Transplant Unit, ASST-Spedali Civili Brescia, Depatment of Clinical and Experimental Sciences University of Brescia, Brescia, Italy
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