1
|
Blijlevens NMA, de Mooij CEM. Mucositis and Infection in Hematology Patients. Int J Mol Sci 2023; 24:ijms24119592. [PMID: 37298545 DOI: 10.3390/ijms24119592] [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: 05/12/2023] [Revised: 05/25/2023] [Accepted: 05/30/2023] [Indexed: 06/12/2023] Open
Abstract
Survival in patients with hematological malignancies has improved over the years, both due to major developments in anticancer treatment, as well as in supportive care. Nevertheless, important and debilitating complications of intensive treatment regimens still frequently occur, including mucositis, fever and bloodstream infections. Exploring potential interacting mechanisms and directed therapies to counteract mucosal barrier injury is of the utmost importance if we are to continue to improve care for this increasingly growing patient population. In this perspective, I highlight recent advances in our understanding of the relation of mucositis and infection.
Collapse
Affiliation(s)
- Nicole M A Blijlevens
- Department of Haematology, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Charlotte E M de Mooij
- Department of Haematology, Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| |
Collapse
|
2
|
Rahi MS, Jindal V, Pednekar P, Parekh J, Gunasekaran K, Sharma S, Stender M, Jaiyesimi IA. Fungal infections in hematopoietic stem-cell transplant patients: a review of epidemiology, diagnosis, and management. Ther Adv Infect Dis 2021; 8:20499361211039050. [PMID: 34434551 PMCID: PMC8381463 DOI: 10.1177/20499361211039050] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 07/24/2021] [Indexed: 12/18/2022] Open
Abstract
The advent of bone marrow transplant has opened doors to a different approach and
offered a new treatment modality for various hematopoietic stem-cell-related
disorders. Since the first bone marrow transplant in 1957, there has been
significant progress in managing patients who undergo bone marrow transplants.
Plasma-cell disorders, lymphoproliferative disorders, and myelodysplastic
syndrome are the most common indications for hematopoietic stem-cell transplant.
Despite the advances, invasive fungal infections remain a significant cause of
morbidity and mortality in this high-risk population. The overall incidence of
invasive fungal infection in patients with hematopoietic stem-cell transplant is
around 4%, but the mortality in patients with allogeneic stem-cell transplant is
as high as 13% in one study. Type of stem-cell transplant, conditioning regimen,
and development of graft-versus-host disease are some of the
risk factors that impact the risk and outcomes in patients with invasive fungal
infections. Aspergillus and candida remain the two most common organisms causing
invasive fungal infections. Molecular diagnostic methods have replaced some
traditional methods due to their simplicity of use and rapid turnaround time.
Primary prophylaxis has undoubtedly shown to improve outcomes even though
breakthrough infection rates remain high. The directed treatment has seen a
significant shift from amphotericin B to itraconazole, voriconazole, and
echinocandins, which have shown better efficacy and fewer adverse effects. In
this comprehensive review, we aim to detail epidemiology, risk factors,
diagnosis, and management, including prophylaxis, empiric and directed
management of invasive fungal infections in patients with hematopoietic
stem-cell transplant.
Collapse
Affiliation(s)
- Mandeep Singh Rahi
- Division of Pulmonary Diseases and Critical Care Medicine, Yale-New Haven Health Bridgeport Hospital, 267 Grant Street, Bridgeport, CT 06610, USA
| | - Vishal Jindal
- Division of Hematology and Oncology, Oakland University-William Beaumont School of Medicine, Royal Oak, MI, USA
| | - Prachi Pednekar
- Department of Internal Medicine, Yale-New Haven Health Bridgeport Hospital, Bridgeport, CT, USA
| | - Jay Parekh
- Department of Internal Medicine, Yale-New Haven Health Bridgeport Hospital, Bridgeport, CT, USA
| | - Kulothungan Gunasekaran
- Division of Pulmonary Diseases and Critical Care Medicine, Yale-New Haven Health Bridgeport Hospital, Bridgeport, CT, USA
| | - Sorabh Sharma
- Department of Internal Medicine, Banner University Medical Center, Tucson, AZ, USA
| | - Michael Stender
- Division of Hematology and Oncology, Oakland University-William Beaumont School of Medicine, Royal Oak, MI, USA
| | - Ishmael A Jaiyesimi
- Division of Hematology and Oncology, Oakland University-William Beaumont School of Medicine, Royal Oak, MI, USA
| |
Collapse
|
3
|
Murdaca G, Allegra A, Paladin F, Calapai F, Musolino C, Gangemi S. Involvement of Alarmins in the Pathogenesis and Progression of Multiple Myeloma. Int J Mol Sci 2021; 22:9039. [PMID: 34445745 PMCID: PMC8396675 DOI: 10.3390/ijms22169039] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 08/17/2021] [Accepted: 08/20/2021] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVE Multiple Myeloma (MM) is a haematological disease resulting from the neoplastic transformation of plasma cells. The uncontrolled growth of plasma cells in the bone marrow and the delivery of several cytokines causes bone erosion that often does not regress, even in the event of disease remission. MM is characterised by a multi-step evolutionary path, which starts with an early asymptomatic stage defined as monoclonal gammopathy of undetermined significance (MGUS) evolving to overt disease. DATA SOURCES AND STUDY SELECTION We have selected scientific publications on the specific topics "alarmis, MGUS, and MM", drawing from PubMed. The keywords we used were alarmines, MGUS, MM, and immune system. RESULTS The analysis confirms the pivotal role of molecules such as high-mobility group box-1, heat shock proteins, and S100 proteins in the induction of neoangiogenesis, which represents a milestone in the negative evolution of MM as well as other haematological and non-haematological tumours. CONCLUSIONS Modulation of the host immune system and the inhibition of neoangiogenesis may represent the therapeutic target for the treatment of MM that is capable of promoting better survival and reducing the risk of RRMM.
Collapse
Affiliation(s)
- Giuseppe Murdaca
- Department of Internal Medicine, University of Genoa, Ospedale Policlinico San Martino IRCCS, 20132 Genoa, Italy;
| | - Alessandro Allegra
- Division of Hematology, Department of Human Pathology in Adulthood and Childhood “Gaetano Barresi”, University of Messina, 98125 Messina, Italy; (A.A.); (C.M.)
| | - Francesca Paladin
- Department of Internal Medicine, University of Genoa, Ospedale Policlinico San Martino IRCCS, 20132 Genoa, Italy;
| | - Fabrizio Calapai
- Department of Chemical, Biological, Pharmaceutical and Environmental Sciences, University of Messina, 98168 Messina, Italy;
| | - Caterina Musolino
- Division of Hematology, Department of Human Pathology in Adulthood and Childhood “Gaetano Barresi”, University of Messina, 98125 Messina, Italy; (A.A.); (C.M.)
| | - Sebastiano Gangemi
- Department of Clinical and Experimental Medicine, School and Operative Unit of Allergy and Clinical Immunology, University of Messina, 98125 Messina, Italy;
| |
Collapse
|
4
|
Predictive and risk factor analysis for bloodstream infection in high-risk hematological patients with febrile neutropenia: post-hoc analysis from a prospective, large-scale clinical study. Int J Hematol 2021; 114:472-482. [PMID: 34170481 DOI: 10.1007/s12185-021-03183-x] [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: 05/11/2021] [Revised: 06/19/2021] [Accepted: 06/20/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Bloodstream infection (BSI) is a frequent complication observed in patients with febrile neutropenia (FN). BSI risk factors and incidence vary depending on chemotherapy types and prophylactic antimicrobial agents. We clarified these issues by post-hoc analysis of a prospective clinical trial cohort for severe FN in hematological malignancy. METHODS We performed an intention-to-treat analysis of 413 high-risk patients and 1272 blood culture sets. RESULTS Overall, 356 patients (86.2%) developed FN, and 20.8% had BSI complications. Prophylactic antimicrobials did not prevent complications of FN and BSI, but the incidence of BSIs of Gram-negative (GN) bacteria was lower than in the non-prophylaxis group (23.8% vs. 56.7%). Multinational Association of Supportive Care in Cancer (MASCC) scores < 20 were significantly correlated with the incidence of BSI, whereas MASCC scores > 21 were not (41.7% vs. 17.2%). The only significant risk factors were hypotension and dehydration. axillary temperatures were higher in GN-caused BSIs than in Gram-positive-caused BSIs and in patients with negative blood culture results (38.7 °C vs. 38.2 °C vs. 38.0 °C). The higher the fever, the higher the incidence of BSI and GN bacteremia. CONCLUSIONS MASCC score and axillary temperature are strong predictors of BSI. Non-administration of prophylactic antimicrobials and GN-caused BSI are correlated. THE CLINICAL TRIAL REGISTRATION NUMBER UMIN00010411.
Collapse
|
5
|
de Mooij CEM, van Groningen LFJ, de Haan AFJ, Biemond BJ, Bakker M, van der Velden WJFM, Blijlevens NMA. Anakinra: efficacy in the management of fever during neutropenia and mucositis in autologous stem cell transplantation (AFFECT-2)-study protocol for a multicenter randomized double-blind placebo-controlled trial. Trials 2020; 21:948. [PMID: 33225965 PMCID: PMC7681989 DOI: 10.1186/s13063-020-04847-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 10/28/2020] [Indexed: 02/02/2023] Open
Abstract
Background Since decades, fever and infections have been the most important complications of intensive chemotherapy and hematopoietic stem cell transplantation (HSCT) in the treatment of hematologic malignancies. Neutropenia has long been considered to be the most important risk factor for these complications. However, recent studies have shown that not neutropenia, but the development of mucositis is the most important cause of these complications. Currently, limited options for the prevention and treatment of mucositis are available, of which most are only supportive. The pro-inflammatory cytokine interleukin-1 (IL-1) plays a crucial role in the pathogenesis of mucositis. Pre-clinical studies of chemotherapy-induced mucositis have shown that recombinant human IL-1 receptor antagonist anakinra significantly ameliorated intestinal mucositis. In our pilot study AFFECT-1, we examined the safety and maximal tolerated dose of anakinra in patients with multiple myeloma, treated with high-dose melphalan (HDM) and autologous HSCT, selecting a dose of 300 mg daily for the phase IIb trial. The aim of the AFFECT-2 study is to determine the efficacy of anakinra in preventing fever during neutropenia (FN) and mucositis in this study population. Methods/design A multicenter, randomized, placebo-controlled, double-blind phase IIb trial will be conducted. Ninety patients with multiple myeloma scheduled for treatment with HDM and autologous HSCT will be included. Patients will be randomized between intravenous treatment with anakinra (300 mg) or placebo. Each group will be treated from day − 2 (day of HDM; day 0 is HSCT) up until day + 12. Outcome measures will be assessed at baseline, during admission, at discharge or day + 30, at day + 90, and + 1 year. The primary outcome will be reduction of FN. Secondary outcome measures include mucositis scores, bloodstream infections, citrulline levels, quality of life, and fatigue severity. Discussion The AFFECT-2 trial will examine the efficacy of anakinra in the management of fever during neutropenia and mucositis in patients with multiple myeloma treated with HDM and autologous HSCT. The results of this study may provide a new treatment option for these important complications. Also, this study will give us more insight in the pathophysiology of mucositis, including the role of IL-1 and the role of the microbiota in mucositis. Trial registration Clinicaltrials.gov NCT04099901. Registered on September 23, 2019. EudraCT: 2018-005046-10.
Collapse
Affiliation(s)
- Charlotte E M de Mooij
- Radboud Institute of Health Sciences, Department of Hematology, Radboud University Medical Center, PO Box 9101, 6500, HB, Nijmegen, the Netherlands.
| | - Lenneke F J van Groningen
- Radboud Institute of Health Sciences, Department of Hematology, Radboud University Medical Center, PO Box 9101, 6500, HB, Nijmegen, the Netherlands
| | - Anton F J de Haan
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Bart J Biemond
- Department of Hematology, Amsterdam UMC, Amsterdam, the Netherlands
| | - Martijn Bakker
- Department of Hematology, University Medical Center Groningen, Groningen, the Netherlands
| | - Walter J F M van der Velden
- Radboud Institute of Health Sciences, Department of Hematology, Radboud University Medical Center, PO Box 9101, 6500, HB, Nijmegen, the Netherlands
| | - Nicole M A Blijlevens
- Radboud Institute of Health Sciences, Department of Hematology, Radboud University Medical Center, PO Box 9101, 6500, HB, Nijmegen, the Netherlands
| |
Collapse
|
6
|
Rodríguez-Lobato LG, Martínez-Roca A, Moreno DF, Gutiérrez-García G, Suárez-Lledó M, Rovira M, Martínez C, Rosiñol L, Almeida Jorge AS, Pedraza A, Cardozo C, Puerta-Alcalde P, Garcia-Vidal C, Marín P, Cid J, Lozano M, Gallego C, Hernando A, Segura S, Urbano-Ispizua Á, Fernández-Avilés F. Impact of intensifying primary antibiotic prophylaxis in at-home autologous stem cell transplantation program for lymphoma patients. Leuk Lymphoma 2020; 61:1565-1574. [PMID: 32208787 DOI: 10.1080/10428194.2020.1742901] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Despite the use of fluoroquinolone (FQ) prophylaxis, neutropenic fever (NF) is the most frequent cause of hospital readmission in ambulatory care programs for patients treated with autologous stem cell transplantation (ASCT). We analyzed the impact of intensifying primary prophylaxis with the addition of piperacillin/tazobactam (PT) to FQ. Between January 2002 and August 2018, 154 lymphoma patients conditioned with BEAM were included (40% received ceftriaxone (Ct) plus FQ and 60% PT plus FQ). NF and hospital readmission were required in 84 vs. 41% (p < .0001) and 12 vs. 1% (p = .007) of patients within the Ct and PT groups, respectively. The multivariate analysis showed that PT plus FQ retained its independent protective factor for NF (odds ratio (OR): 0.13; p < .001) and for hospital readmission (OR: 0.07; p = .01). The use of PT and FQ prophylaxis may effectively prevent episodes of NF and hospitalizations in lymphoma patients managed in our at-home ASCT care model.
Collapse
Affiliation(s)
- Luis Gerardo Rodríguez-Lobato
- Department of Hematology, Home Care and Bone Marrow Transplantation Unit, Hospital Clinic of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Alexandra Martínez-Roca
- Department of Hematology, Home Care and Bone Marrow Transplantation Unit, Hospital Clinic of Barcelona, Barcelona, Spain
| | - David F Moreno
- Department of Hematology, Home Care and Bone Marrow Transplantation Unit, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Gonzalo Gutiérrez-García
- Department of Hematology, Home Care and Bone Marrow Transplantation Unit, Hospital Clinic of Barcelona, Barcelona, Spain
| | - María Suárez-Lledó
- Department of Hematology, Home Care and Bone Marrow Transplantation Unit, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Montserrat Rovira
- Department of Hematology, Home Care and Bone Marrow Transplantation Unit, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Carmen Martínez
- Department of Hematology, Home Care and Bone Marrow Transplantation Unit, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Laura Rosiñol
- Department of Hematology, Home Care and Bone Marrow Transplantation Unit, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Ana Sofía Almeida Jorge
- Department of Hematology, Home Care and Bone Marrow Transplantation Unit, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Alexandra Pedraza
- Department of Hematology, Home Care and Bone Marrow Transplantation Unit, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Celia Cardozo
- Department of Infectious Diseases, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Pedro Puerta-Alcalde
- Department of Infectious Diseases, Hospital Clinic of Barcelona, Barcelona, Spain
| | | | - Pedro Marín
- Department of Hemotherapy and Hemostasis, Apheresis and Cellular Therapy Unit, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Joan Cid
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Department of Hemotherapy and Hemostasis, Apheresis and Cellular Therapy Unit, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Miquel Lozano
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Department of Hemotherapy and Hemostasis, Apheresis and Cellular Therapy Unit, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Cristina Gallego
- Department of Hematology, Home Care and Bone Marrow Transplantation Unit, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Adelina Hernando
- Department of Hematology, Home Care and Bone Marrow Transplantation Unit, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Susana Segura
- Department of Hematology, Home Care and Bone Marrow Transplantation Unit, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Álvaro Urbano-Ispizua
- Department of Hematology, Home Care and Bone Marrow Transplantation Unit, Hospital Clinic of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Francesc Fernández-Avilés
- Department of Hematology, Home Care and Bone Marrow Transplantation Unit, Hospital Clinic of Barcelona, Barcelona, Spain
| |
Collapse
|
7
|
Yeshurun M, Vaxman I, Shargian L, Yahav D, Bishara J, Pasvolsky O, Wolach O, Lahav M, Gurion R, Magen H, Vidal L, Herscovici C, Peck A, Moshe M, Sela-Navon M, Naparstek E, Raanani P, Rozovski U. Antibacterial prophylaxis with ciprofloxacin for patients with multiple myeloma and lymphoma undergoing autologous haematopoietic cell transplantation: a quasi-experimental single-centre before-after study. Clin Microbiol Infect 2017; 24:749-754. [PMID: 29208561 DOI: 10.1016/j.cmi.2017.11.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 11/14/2017] [Accepted: 11/22/2017] [Indexed: 11/19/2022]
Abstract
OBJECTIVES We aimed to study whether ciprofloxacin prophylaxis reduces infectious complications in patients undergoing autologous haematopoietic cell transplantation (AHCT). METHODS This is a quasi-experimental, retrospective, before-after study. We compared the incidence of bacterial-related complications among 356 patients with multiple myeloma (MM) (n = 202) and lymphoma (n = 154) who underwent AHCT with (n = 177) or without (n = 179) ciprofloxacin prophylaxis between 03/2007 and 10/2012 and between 10/2012 and 07/2016, respectively, at a single centre. RESULTS Febrile neutropaenia, bacteraemia, and pneumonia were significantly more common among patients who underwent AHCT during the second study period and did not receive antibacterial prophylaxis compared with patients who underwent AHCT during the first study period and received antibacterial prophylaxis (89.9% (161/179) vs. 83.1% (147/177), difference 6.9%, 95% CI 0-14.1%, P = 0.002; 15.1% (27/179) vs. 4.5% (8/177), difference 10.6%, 95% CI 4.4-16.9%, p < 0.0001; 12.3% (22/179) vs. 6.2% (11/177), difference 6.1%, 95% CI 0-12.3%, p = 0.04, respectively). The number-needed-to-treat to prevent one episode of bacteraemia, pneumonia, and febrile neutropaenia was 8.6, 8.5, and 13.7, respectively. Patients with ciprofloxacin prophylaxis had higher rates of ciprofloxacin-resistant bacteraemia (62.5% (5/8) vs. 18.5% (5/27), difference 44%, 95% CI 7-70%, p = 0.01). In multivariate analysis, ciprofloxacin prophylaxis significantly decreased the odds of bacteraemia (OR 0.19, 95% CI 0.07-0.52; p < 0.0001) and pneumonia (OR 0.37, 95% CI 0.16-0.85, p = 0.02). CONCLUSION According to our single-centre experience, patients with MM and lymphoma undergoing AHCT may benefit from antibacterial prophylaxis with ciprofloxacin.
Collapse
Affiliation(s)
- M Yeshurun
- Institute of Haematology, Davidoff Cancer Centre, Rabin Medical Centre, Petah Tikva, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - I Vaxman
- Institute of Haematology, Davidoff Cancer Centre, Rabin Medical Centre, Petah Tikva, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - L Shargian
- Institute of Haematology, Davidoff Cancer Centre, Rabin Medical Centre, Petah Tikva, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - D Yahav
- Infectious Diseases Unit, Rabin Medical Centre, Petah Tikva, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - J Bishara
- Infectious Diseases Unit, Rabin Medical Centre, Petah Tikva, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - O Pasvolsky
- Institute of Haematology, Davidoff Cancer Centre, Rabin Medical Centre, Petah Tikva, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - O Wolach
- Institute of Haematology, Davidoff Cancer Centre, Rabin Medical Centre, Petah Tikva, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - M Lahav
- Institute of Haematology, Davidoff Cancer Centre, Rabin Medical Centre, Petah Tikva, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - R Gurion
- Institute of Haematology, Davidoff Cancer Centre, Rabin Medical Centre, Petah Tikva, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - H Magen
- Institute of Haematology, Davidoff Cancer Centre, Rabin Medical Centre, Petah Tikva, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - L Vidal
- Institute of Haematology, Davidoff Cancer Centre, Rabin Medical Centre, Petah Tikva, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - C Herscovici
- Institute of Haematology, Davidoff Cancer Centre, Rabin Medical Centre, Petah Tikva, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - A Peck
- Institute of Haematology, Davidoff Cancer Centre, Rabin Medical Centre, Petah Tikva, Israel
| | - M Moshe
- Institute of Haematology, Davidoff Cancer Centre, Rabin Medical Centre, Petah Tikva, Israel
| | - M Sela-Navon
- Institute of Haematology, Davidoff Cancer Centre, Rabin Medical Centre, Petah Tikva, Israel
| | - E Naparstek
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - P Raanani
- Institute of Haematology, Davidoff Cancer Centre, Rabin Medical Centre, Petah Tikva, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - U Rozovski
- Institute of Haematology, Davidoff Cancer Centre, Rabin Medical Centre, Petah Tikva, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
8
|
Low circulating mannan-binding lectin levels correlate with increased frequency and severity of febrile episodes in myeloma patients who undergo ASCT and do not receive antibiotic prophylaxis. Bone Marrow Transplant 2017; 52:1537-1542. [PMID: 28805791 DOI: 10.1038/bmt.2017.172] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 06/11/2017] [Accepted: 06/27/2017] [Indexed: 11/08/2022]
Abstract
Patients with multiple myeloma (MM) who undergo autologous stem cell transplantation (ASCT) are susceptible to severe infections. Low levels of circulating mannan-binding lectin (MBL) are associated with increased risk of infection. In this prospective study, we evaluated 100 patients who underwent ASCT regarding the effect of MBL on the incidence and severity of febrile episodes. Seventeen patients had MBL levels <500 ng/mL (11 received antibiotic prophylaxis and 6 did not). Although there was no statistical difference regarding the development of febrile episodes between patients with low and normal MBL, among 17 patients with low MBL levels, six out of eleven patients who received antibiotic prophylaxis developed a febrile episode compared with six out of six patients who did not receive antibiotic prophylaxis and developed a febrile episode. Patients with low MBL levels who responded less frequently to first line antibiotic therapy required more frequent administration of a second more advanced line of antibiotics, independently of receiving or not prophylaxis, and required prolonged hospitalization. In the univariate analysis low MBL associated with shorter OS. Our results suggest that patient with low MBL levels should receive antibiotic prophylaxis to reduce the number of febrile episodes and raise the issue of MBL replacement for these patients.
Collapse
|
9
|
Hematopoietic Cell Transplantation in Patients with Medication-Related Osteonecrosis of the Jaws. Biol Blood Marrow Transplant 2016; 22:344-348. [DOI: 10.1016/j.bbmt.2015.08.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Accepted: 08/12/2015] [Indexed: 01/04/2023]
|
10
|
Herbers AHE, de Haan AFJ, van der Velden WJFM, Donnelly JP, Blijlevens NMA. Mucositis not neutropenia determines bacteremia among hematopoietic stem cell transplant recipients. Transpl Infect Dis 2014; 16:279-85. [PMID: 24621081 DOI: 10.1111/tid.12195] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Revised: 07/16/2013] [Accepted: 09/07/2013] [Indexed: 01/08/2023]
Abstract
BACKGROUND In the 1960s, it was reported that infectious complications were the main cause of fever during neutropenia that followed hematopoietic stem cell transplant (HSCT). More recently, mucositis has become recognized as an important determinant of the inflammatory response and infectious complications. METHODS The objective of this prospective study was to determine the impact of intestinal mucositis, as measured by plasma citrulline, and neutropenia on the systemic inflammatory response (C-reactive protein) and the occurrence of bacteremia among 2 cohorts of HSCT recipients: 1 composed of 18 patients who had been treated with a myeloablative (MA) regimen (high-dose melphalan) and the other involving 19 patients who had received the non-myeloablative (NMA) regimen (fludarabine and cyclophosphamide). Blood cultures were obtained for surveillance from admission onwards as well as at the onset of fever. RESULTS The MA regimen induced severe intestinal mucositis manifest by citrullinemia <10 μmol/L, which was accompanied by an inflammatory response, and bacteremia affected 8 (44%) of 18 patients and coincided with the nadir of citrullinemia. By contrast, those who had been treated with the NMA regimen did not develop severe intestinal mucositis, had a moderate inflammatory response, and only 2 (11%) of the 19 patients developed bacteremia. However, both groups experienced profound neutropenia and its duration was significantly longer for those receiving the NMA regimen. CONCLUSION This study suggests that severe intestinal mucositis, i.e., citrullinemia <10 μmol/L, defines the period of risk of bacteremia better than does neutropenia, and that measuring plasma citrulline may prove useful in deciding who needs empirical antimicrobial therapy and when.
Collapse
Affiliation(s)
- A H E Herbers
- Department of Hematology, Nijmegen Institute for Infection, Inflammation and Immunity (N4i), Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | | | | | | | | |
Collapse
|
11
|
Antibiotic prophylaxis in hematopoietic stem cell transplantation. A meta-analysis of randomized controlled trials. J Infect 2014; 69:13-25. [PMID: 24583063 DOI: 10.1016/j.jinf.2014.02.013] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Revised: 01/07/2014] [Accepted: 02/18/2014] [Indexed: 01/05/2023]
Abstract
OBJECTIVES We performed a meta-analysis to evaluate the impact of systemic antibiotic prophylaxis in hematopoietic stem cell transplantation (HSCT) recipients. METHODS We collected reports from PubMed, the Cochrane Library, EMBASE, CINAHL, and Web of Science, along with references cited therein. We included prospective, randomized studies on systemic antibiotic prophylaxis in HSCT recipients. RESULTS Seventeen trials with 1453 autologous and allogeneic HSCT recipients were included. Systemic antibiotic prophylaxis was compared with placebo or no prophylaxis in 10 trials and with non-absorbable antibiotics in two trials. Systemic antibiotics other than fluoroquinolones were evaluated in five of these 12 trials. Four trials evaluated the effect of the addition of antibiotics for gram-positive bacteria to fluoroquinolones. One trial compared two different systemic antibiotic regimens: fluoroquinolones versus trimethoprim-sulfamethoxazole. As a result, systemic antibiotic prophylaxis reduced the incidence of febrile episodes (OR 0.16; 95%CI 0.09-0.30), clinically or microbiologically documented infection (OR 0.38; 95%CI 0.22-0.63) and bacteremia (OR 0.31; 95%CI 0.16-0.59) without significantly affecting all-cause mortality or infection-related mortality. CONCLUSIONS Systemic antibiotic prophylaxis successfully reduced the incidence of infection. However, there was no significant impact on mortality. The clinical benefits of prophylaxis with fluoroquinolones were inconclusive because of the small number of clinical trials evaluated.
Collapse
|
12
|
Castagnola E, Faraci M. Management of bacteremia in patients undergoing hematopoietic stem cell transplantation. Expert Rev Anti Infect Ther 2014; 7:607-21. [DOI: 10.1586/eri.09.35] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
|
13
|
Vidal L, Ben dor I, Paul M, Eliakim‐Raz N, Pokroy E, Soares‐Weiser K, Leibovici L. Oral versus intravenous antibiotic treatment for febrile neutropenia in cancer patients. Cochrane Database Syst Rev 2013; 2013:CD003992. [PMID: 24105485 PMCID: PMC6457615 DOI: 10.1002/14651858.cd003992.pub3] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Fever occurring in a neutropenic patient remains a common life-threatening complication of cancer chemotherapy. The common practice is to admit the patient to hospital and treat him or her empirically with intravenous broad-spectrum antibiotics. Oral therapy could be an alternative approach for selected patients. OBJECTIVES To compare the efficacy of oral antibiotics versus intravenous (IV) antibiotic therapy in febrile neutropenic cancer patients. SEARCH METHODS The Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 1) in The Cochrane Library, MEDLINE (1966 to January week 4, 2013), EMBASE (1980 to 2013 week 4) and LILACS (1982 to 2007). We searched several databases for ongoing trials. We checked the conference proceedings of the Interscience Conference of Antimicrobial Agents and Chemotherapy (ICAAC) (1995 to 2007), and all references of included studies and major reviews were scanned. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing oral antibiotic(s) to intravenous antibiotic(s) for the treatment of neutropenic cancer patients with fever. The comparison between the two could be started initially (initial oral) or following an initial course of intravenous antibiotic treatment (sequential). DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial eligibility and methodological quality and extracted data. Data concerning mortality, treatment failures and adverse events were extracted from the included studies assuming an 'intention-to-treat' basis for the outcome measures whenever possible. Risk ratios (RR) with 95% confidence intervals (CI) were estimated for dichotomous data. Risk of bias assessment was also made in line with methodology of The Cochrane Collaboration. MAIN RESULTS Twenty-two trials (3142 episodes in 2372 patients) were included in the analyses. The mortality rate was similar when comparing oral to intravenous antibiotic treatment (RR 0.95, 95% CI 0.54 to 1.68, 9 trials, 1392 patients, median mortality 0, range 0% to 8.8%). Treatment failure rates were also similar (RR 0.96, 95% CI 0.86 to 1.06, all trials). No significant heterogeneity was shown for all comparisons but adverse events. The effect was stable in a wide range of patients. Quinolones alone or combined with another antibiotic were used with comparable results. Adverse reactions, mostly gastrointestinal, were more common with oral antibiotics. AUTHORS' CONCLUSIONS Based on the present data, oral treatment is an acceptable alternative to intravenous antibiotic treatment in febrile neutropenic cancer patients (excluding patients with acute leukaemia) who are haemodynamically stable, without organ failure, and do not have pneumonia, infection of a central line or a severe soft-tissue infection. The wide CI for mortality allows the present use of oral treatment in groups of patients with an expected low risk for mortality, and further research should be aimed at clarifying the definition of low risk patients.
Collapse
Affiliation(s)
- Liat Vidal
- Beilinson Hospital, Rabin Medical CenterDepartment of Medicine E39 Jabotinski StreetPetah TikvaIsrael49100
| | - Itsik Ben dor
- Beilinson Hospital, Rabin Medical CenterDepartment of Medicine E39 Jabotinski StreetPetah TikvaIsrael49100
| | - Mical Paul
- Rambam Health Care CampusDivision of Infectious DiseasesHa‐aliya 8 StHaifaIsrael33705
| | - Noa Eliakim‐Raz
- Beilinson Hospital, Rabin Medical CenterDepartment of Medicine E39 Jabotinski StreetPetah TikvaIsrael49100
| | - Ellisheva Pokroy
- Beilinson Hospital, Rabin Medical CenterDepartment of Medicine A39 Jabotinski StreetPetah TikvaIsrael49100
| | - Karla Soares‐Weiser
- CochraneCochrane Editorial UnitSt Albans House, 57 ‐ 59 HaymarketLondonUKSW1Y 4QX
| | - Leonard Leibovici
- Beilinson Hospital, Rabin Medical CenterDepartment of Medicine E39 Jabotinski StreetPetah TikvaIsrael49100
| | | |
Collapse
|
14
|
Bacteremia in Blood or Marrow Transplantation Patients: Clinical Risk Factors for Infection and Emerging Antibiotic Resistance. Biol Blood Marrow Transplant 2013; 19:102-8. [DOI: 10.1016/j.bbmt.2012.08.016] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Accepted: 08/20/2012] [Indexed: 11/21/2022]
|
15
|
Hamadah A, Schreiber Y, Toye B, McDiarmid S, Huebsch L, Bredeson C, Tay J. The use of intravenous antibiotics at the onset of neutropenia in patients receiving outpatient-based hematopoietic stem cell transplants. PLoS One 2012; 7:e46220. [PMID: 23029441 PMCID: PMC3460853 DOI: 10.1371/journal.pone.0046220] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Accepted: 08/28/2012] [Indexed: 11/19/2022] Open
Abstract
Empirical antibiotics at the onset of febrile neutropenia are one of several strategies for management of bacterial infections in patients undergoing Hematopoietic Stem Cell Transplant (HSCT) (empiric strategy). Our HSCT program aims to perform HSCT in an outpatient setting, where an empiric antibiotic strategy was employed. HSCT recipients began receiving intravenous antibiotics at the onset of neutropenia in the absence of fever as part of our institutional policy from 01 Jan 2009; intravenous Prophylactic strategy. A prospective study was conducted to compare two consecutive cohorts [Year 2008 (Empiric strategy) vs. Year 2009 (Prophylactic strategy)] of patients receiving HSCT. There were 238 HSCTs performed between 01 Jan 2008 and 31 Dec 2009 with 127 and 111 in the earlier and later cohorts respectively. Infection-related mortality pre- engraftment was similar with a prophylactic compared to an empiric strategy (3.6% vs. 7.1%; p = 0.24), but reduced among recipients of autologous HSCT (0% vs. 6.8%; p = 0.03). Microbiologically documented, blood stream infections and clinically documented infections pre-engraftment were reduced in those receiving a prophylactic compared to an empiric strategy, (11.7% vs. 28.3%; p = 0.001), (9.9% vs. 24.4%; p = 0.003) and (18.2% vs. 33.9% p = 0.007) respectively. The prophylactic use of intravenous once-daily ceftriaxone in patients receiving outpatient based HSCT is safe and may be particularly effective in patients receiving autologous HSCT. Further studies are warranted to study the impact of this Prophylactic strategy in an outpatient based HSCT program.
Collapse
Affiliation(s)
- Aziz Hamadah
- The Ottawa Hospital Blood and Marrow Programme, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Yoko Schreiber
- Division of Infectious Diseases, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Baldwin Toye
- Division of Infectious Diseases, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Sheryl McDiarmid
- The Ottawa Hospital Blood and Marrow Programme, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Lothar Huebsch
- The Ottawa Hospital Blood and Marrow Programme, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Christopher Bredeson
- The Ottawa Hospital Blood and Marrow Programme, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Jason Tay
- The Ottawa Hospital Blood and Marrow Programme, The Ottawa Hospital, Ottawa, Ontario, Canada
- * E-mail:
| |
Collapse
|
16
|
Alexander S, Nieder M, Zerr DM, Fisher BT, Dvorak CC, Sung L. Prevention of bacterial infection in pediatric oncology: what do we know, what can we learn? Pediatr Blood Cancer 2012; 59:16-20. [PMID: 22102612 PMCID: PMC4008322 DOI: 10.1002/pbc.23416] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2011] [Accepted: 10/11/2011] [Indexed: 11/10/2022]
Abstract
Bacterial sepsis continues to be a leading cause of morbidity and toxic death in children receiving intensive therapy for cancer. Empiric therapy for suspected infections and treatment of documented infections are well-established standards of care. The routine use of prophylactic strategies is much less common in pediatric oncology. This paper will review the current literature on the use and risks of antimicrobial prophylaxis as well as non-pharmacological methods for infection prevention and will address areas in need of further research.
Collapse
Affiliation(s)
- Sarah Alexander
- Division of Hematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada.
| | | | | | | | | | | |
Collapse
|
17
|
Gafter-Gvili A, Fraser A, Paul M, Vidal L, Lawrie TA, van de Wetering MD, Kremer LCM, Leibovici L. Antibiotic prophylaxis for bacterial infections in afebrile neutropenic patients following chemotherapy. Cochrane Database Syst Rev 2012; 1:CD004386. [PMID: 22258955 PMCID: PMC4170789 DOI: 10.1002/14651858.cd004386.pub3] [Citation(s) in RCA: 117] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Bacterial infections are a major cause of morbidity and mortality in patients who are neutropenic following chemotherapy for malignancy. Trials have shown the efficacy of antibiotic prophylaxis in reducing the incidence of bacterial infections but not in reducing mortality rates. Our systematic review from 2006 also showed a reduction in mortality. OBJECTIVES This updated review aimed to evaluate whether there is still a benefit of reduction in mortality when compared to placebo or no intervention. SEARCH METHODS We searched the Cochrane Cancer Network Register of Trials (2011), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2011), MEDLINE (1966 to March 2011), EMBASE (1980 to March 2011), abstracts of conference proceedings and the references of identified studies. SELECTION CRITERIA Randomised controlled trials (RCTs) or quasi-RCTs comparing different types of antibiotic prophylaxis with placebo or no intervention, or another antibiotic, to prevent bacterial infections in afebrile neutropenic patients. DATA COLLECTION AND ANALYSIS Two authors independently appraised the quality of each trial and extracted data from the included trials. Analyses were performed using RevMan 5.1 software. MAIN RESULTS One-hundred and nine trials (involving 13,579 patients) that were conducted between the years 1973 to 2010 met the inclusion criteria. When compared with placebo or no intervention, antibiotic prophylaxis significantly reduced the risk of death from all causes (46 trials, 5635 participants; risk ratio (RR) 0.66, 95% CI 0.55 to 0.79) and the risk of infection-related death (43 trials, 5777 participants; RR 0.61, 95% CI 0.48 to 0.77). The estimated number needed to treat (NNT) to prevent one death was 34 (all-cause mortality) and 48 (infection-related mortality).Prophylaxis also significantly reduced the occurrence of fever (54 trials, 6658 participants; RR 0.80, 95% CI 0.74 to 0.87), clinically documented infection (48 trials, 5758 participants; RR 0.65, 95% CI 0.56 to 0.76), microbiologically documented infection (53 trials, 6383 participants; RR 0.51, 95% CI 0.42 to 0.62) and other indicators of infection.There were no significant differences between quinolone prophylaxis and TMP-SMZ prophylaxis with regard to death from all causes or infection, however, quinolone prophylaxis was associated with fewer side effects leading to discontinuation (seven trials, 850 participants; RR 0.37, 95% CI 0.16 to 0.87) and less resistance to the drugs thereafter (six trials, 366 participants; RR 0.45, 95% CI 0.27 to 0.74). AUTHORS' CONCLUSIONS Antibiotic prophylaxis in afebrile neutropenic patients significantly reduced all-cause mortality. In our review, the most significant reduction in mortality was observed in trials assessing prophylaxis with quinolones. The benefits of antibiotic prophylaxis outweighed the harm such as adverse effects and the development of resistance since all-cause mortality was reduced. As most trials in our review were of patients with haematologic cancer, we strongly recommend antibiotic prophylaxis for these patients, preferably with a quinolone. Prophylaxis may also be considered for patients with solid tumours or lymphoma.
Collapse
Affiliation(s)
- Anat Gafter-Gvili
- Department of Medicine E, Beilinson Hospital, Rabin Medical Center, 39 Jabotinski Street, PetahTikva, 49100, Israel.
| | | | | | | | | | | | | | | |
Collapse
|
18
|
Saria M. Preventing and Managing Infections in Neutropenic Stem Cell Transplantation Recipients: Evidence-Based Review. Clin J Oncol Nurs 2011; 15:133-9. [DOI: 10.1188/11.cjon.133-139] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
19
|
Impact of bloodstream infections on outcome and the influence of prophylactic oral antibiotic regimens in allogeneic hematopoietic SCT recipients. Bone Marrow Transplant 2010; 46:1231-9. [PMID: 21113186 DOI: 10.1038/bmt.2010.286] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
This study aimed to determine the impact of blood stream infections (BSIs) on outcome of allogeneic hematopoietic SCT (HSCT), and to examine the influence of old (non-levofloxacin-containing) and new (levofloxacin-based) prophylactic antibiotic protocols on the pattern of BSIs. We retrospectively enrolled 246 allogeneic HSCT recipients between January 1999 and June 2006, dividing patients into BSI (within 6 months post-HSCT, n=61) and non-BSI groups (n=185). We found that Gram-negative bacteria (GNB) predominated BSI pathogens (54%). Multivariate analyses showed that patients with a BSI, compared with those without, had a significantly greater 6-month mortality (hazard ratio, 1.75; 95% confidence interval, 1.09-2.82; P=0.021) and a significantly increased length of hospital (LOH) stay (70.8 vs 55.2 days, P=0.014). Moreover, recipients of old and new protocols did not have a significantly different 6-month mortality and time-to-occurrence of BSIs. However, there were significantly more resistant GNB to third-generation cephalosporins and carbapenem in recipients of levofloxacin-based prophylaxis. Our data suggest that BSIs occur substantially and impact negatively on the outcome and LOH stay after allogeneic HSCT despite antibiotic prophylaxis. Levofloxacin-based prophylaxis, albeit providing similar efficacy to non-levofloxacin-containing regimens, may be associated with increased antimicrobial resistance.
Collapse
|
20
|
Eleutherakis-Papaiakovou E, Kostis E, Migkou M, Christoulas D, Terpos E, Gavriatopoulou M, Roussou M, Bournakis E, Kastritis E, Efstathiou E, Dimopoulos MA, Papadimitriou CA. Prophylactic antibiotics for the prevention of neutropenic fever in patients undergoing autologous stem-cell transplantation: results of a single institution, randomized phase 2 trial. Am J Hematol 2010; 85:863-7. [PMID: 20882526 DOI: 10.1002/ajh.21855] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
One hundred and fifty-seven patients undergoing high-dose chemotherapy (HDT) and autologous stem-cell transplantation (ASCT) for hematopoietic malignancies and solid tumors were randomly assigned to receive (Group A) or not (Group B) prophylaxis with ciprofloxacin, orally, and vancomycin, intravenously. Prophylactic antibiotics were given from day 0 until resolution of neutropenia or the appearance of a febrile event. Furthermore, patients in both groups received once a day fluconazole, orally. The primary end-point of our study was the incidence of neutropenic febrile episodes attributed to infection. One hundred and twelve (71.3%) patients developed neutropenic fever, 50 (56.2%) in Group A and 62 (91.2%) in Group B (P < 0.001) with the majority (82%) of patients developing fever of unknown origin. Patients on prophylactic antibiotics had a significantly lower rate of bacteremias (5.6%) than did those randomized to no prophylaxis (29.4%) (P = 0.005) and, when developing neutropenic fever, they had a lower probability of response to first-line empirical antibiotics (P = 0.025). Prophylactic administration of ciprofloxacin and vancomycin reduced the incidence of neutropenic fever in patients receiving HDT with ASCT, however, without affecting the total interval of hospitalization, time to engraftment, or all-cause mortality. Therefore, our results do not support the use of antibiotic prophylaxis for patients undergoing HDT and ASCT.
Collapse
|
21
|
Gang AO, Arpi M, Gang UJO, Vangsted AJ. Early infections in patients undergoing high-dose treatment with stem cell support: a comparison of patients with non-Hodgkin lymphoma and multiple myeloma. Hematology 2010; 15:222-9. [PMID: 20670481 DOI: 10.1179/102453309x12583347113979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Infections are life-threatening complications in patients undergoing high-dose chemotherapy with stem cell support (HDT). Knowledge of the infectious pathogens is essential to make a safe outpatient setting. METHODS We conducted a retrospective study of 208 patients treated with HDT. The population included non-Hodgkin lymphoma (NHL) and multiple myeloma (MM) patients. No patients received prophylactic antibacterial treatment. RESULTS Pathogens were isolated from 44% of all patients. MM patients more frequently had multiple pathogens in blood cultures (38% versus 25%). Transplantation related mortality was similar between the groups. CONCLUSION The frequency of isolated pathogens, positive blood cultures, and the diversity of pathogens were higher in MM patients as compared to NHL patients. However, this did not translate into higher transplantation-related mortality, probably because broad-spectrum antibiotic treatment could be initiated immediately. A safe outpatient setting with prophylactic antibiotic treatment is dependent on continuous collection and registration of microbiological findings.
Collapse
Affiliation(s)
- A O Gang
- Center for Cancer Immune Therapy, Department of Haematology, Herlev University Hospital, Copenhagen, Denmark.
| | | | | | | |
Collapse
|
22
|
Hoyt R, Ritchie DS, Wirth A, Szer J, Grigg AP. Etoposide induces more severe mucositis than CY when added to TBI as conditioning in allograft recipients receiving CsA and MTX. Bone Marrow Transplant 2010; 45:1457-62. [DOI: 10.1038/bmt.2009.365] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
|
23
|
Hämäläinen S, Kuittinen T, Matinlauri I, Nousiainen T, Koivula I, Jantunen E. Severe sepsis in autologous stem cell transplant recipients: Microbiological aetiology, risk factors and outcome. ACTA ACUST UNITED AC 2009; 41:14-20. [DOI: 10.1080/00365540802454706] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
24
|
Hiemenz JW. Management of Infections Complicating Allogeneic Hematopoietic Stem Cell Transplantation. Semin Hematol 2009; 46:289-312. [DOI: 10.1053/j.seminhematol.2009.03.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
25
|
Blijlevens NMA, Logan RM, Netea MG. The changing face of febrile neutropenia-from monotherapy to moulds to mucositis. Mucositis: from febrile neutropenia to febrile mucositis. J Antimicrob Chemother 2009; 63 Suppl 1:i36-40. [PMID: 19372181 DOI: 10.1093/jac/dkp081] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
The treatment of patients with cancer is often accompanied by life-threatening complications caused by chemotherapy and radiotherapy. They are known to result from neutropenia, but damage to the mucosal barrier as well as the humoral and cellular immune defences play a significant role in various infectious complications and aggravate diverse inflammatory processes. The article describes the journey from febrile neutropenia to febrile mucositis in patients treated with immunocompromising therapy.
Collapse
Affiliation(s)
- Nicole M A Blijlevens
- Department of Haematology, Radboud University Medical Center, PO Box 9101, NL-6500 HB Nijmegen, The Netherlands.
| | | | | |
Collapse
|
26
|
Acute Myelogenous Leukemia and Febrile Neutropenia. MANAGING INFECTIONS IN PATIENTS WITH HEMATOLOGICAL MALIGNANCIES 2009. [PMCID: PMC7121946 DOI: 10.1007/978-1-59745-415-5_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Aggressive chemotherapy has a deleterious effect on all components of the defense system of the human body. The resulting neutropenia as well as injury to the pulmonary and gastrointestinal mucosa allow pathogenic micro-organisms easy access to the body. The symptoms of an incipient infection are usually subtle and limited to unexplained fever due to the absence of granulocytes. This is the reason why prompt administration of antimicrobial agents while waiting for the results of the blood cultures, the so-called empirical approach, became an undisputed standard of care. Gram-negative pathogens remain the principal concern because their virulence accounts for serious morbidity and a high early mortality rate. Three basic intravenous antibiotic regimens have evolved: initial therapy with a single antipseudomonal β-lactam, the so-called monotherapy; a combination of two drugs: a β-lactam with an aminoglycoside, a second β-lactam or a quinolone; and, thirdly, a glycopeptide in addition to β-lactam monotherapy or combination. As there is no single consistently superior empirical regimen, one should consider the local antibiotic susceptibility of bacterial isolates in the selection of the initial antibiotic regimen. Not all febrile neutropenic patients carry the same risk as those with fever only generally respond rapidly, whereas those with a clinically or microbiologically documented infection show a much slower reaction and less favorable response rate. Once an empirical antibiotic therapy has been started, the patient must be monitored continuously for nonresponse, emergence of secondary infections, adverse effects, and the development of drug-resistant organisms. The averageduration of fever in serious infections in eventually successfully treated neutropenic patients is 4–5 days. Adaptations of an antibiotic regimen in a patient who is clearly not responding is relatively straightforward when a micro-organism has been isolated; the results of the cultures, supplemented by susceptibility testing, will assist in selecting the proper antibiotics. The management of febrile patients with pulmonary infiltrates is complex. Bronchoscopy and a high resolution computer-assisted tomographic scan represent the cornerstones of all diagnostic procedures, supplemented by serological tests for relevant viral pathogens and for aspergillosis. Fungi have been found to be responsible for two thirds of all superinfections that may surface during broad-spectrum antibiotic treatment of neutropenic patients. Antibiotic treatment is usually continued for a minimum of 7 days or until culture results indicate that the causative organism has been eradicated and the patient is free of major signs and symptoms. If a persistently neutropenic patient has no complaints and displays no evidence of infection, early watchful cessation of antibiotic therapy or a change to the oral regimen should be considered.
Collapse
|
27
|
|