1
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Mehta P, Campbell V, Maddox J, Floisand Y, Kalakonda AJM, O'Nions J, Coats T, Nagumantry S, Hodgson K, Whitmill R, Amott I, Flynn G, Taussig D, Zhao R, Cunningham N, Roset M, Cuadras D, Medalla G, Kuter H, Park S, Legg A, Khan AB. CREST-UK: Real-world effectiveness, safety and outpatient delivery of CPX-351 for first-line treatment of newly diagnosed therapy-related AML and AML with myelodysplasia-related changes in the UK. Br J Haematol 2024. [PMID: 38977430 DOI: 10.1111/bjh.19622] [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: 11/10/2023] [Accepted: 06/20/2024] [Indexed: 07/10/2024]
Abstract
Favourable outcomes with CPX-351 versus conventional 7 + 3 were demonstrated in the pivotal phase III trial in adults aged 60-75 years with newly diagnosed, highrisk/secondary acute myeloid leukaemia (AML). As a complement to the clinical trial and to address important data gaps, the CPX-351 Real-World Effectiveness and SafeTy (CREST-UK; NCT05169307) study evaluated the use of CPX-351 in routine clinical practice in the UK, in 147 patients with newly diagnosed therapy-related AML or AML with myelodysplasia-related changes. Best response of complete remission or complete remission with incomplete platelet or neutrophil recovery was achieved by 53% of evaluable patients. Kaplan-Meier median overall survival (OS) was 12.8 months (95% confidence interval 9.2-15.3). Fifty (34%) patients proceeded to haematopoietic cell transplantation (HCT); median OS landmarked from the HCT date was not reached. There were no new safety concerns with CPX-351 identified in CREST-UK. Patients treated with CPX-351 in the outpatient setting spent an average of 24.4, 16.7, 28.2, and 27.7 fewer days on the ward compared with inpatients during first induction, second induction, first consolidation, and second consolidation, respectively. The results from CREST-UK provide valuable insights into the effectiveness, safety, and outpatient delivery of CPX-351 in routine clinical practice in the UK.
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Affiliation(s)
- Priyanka Mehta
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | | | - Jamie Maddox
- South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Yngvar Floisand
- Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, UK
| | - Anita J M Kalakonda
- Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, UK
- NIHR CRN North West Coast, Liverpool, UK
| | - Jenny O'Nions
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Thomas Coats
- Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | | | | | | | - Ian Amott
- University Hospitals Derby & Burton, NHS Foundation Trust, Derby, UK
| | - Gillian Flynn
- Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - David Taussig
- Haemato-Oncology Department, Royal Marsden Hospital, UK
- Institute of Cancer Research, London, UK
| | - Rui Zhao
- Torbay and South Devon NHS Foundation Trust, UK
| | | | | | | | | | | | | | | | - Anjum B Khan
- Leeds Teaching Hospitals NHS Foundation Trust, Leeds, UK
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2
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Sun LH, Bai KH, Wu GY, Tian XP, Zou ZQ, Wang DW, Dai YJ, Chen SL. Mechanism of Abnormal Coagulation Induced by Tigecycline in Cancer Patients. Front Pharmacol 2022; 13:891952. [PMID: 35865948 PMCID: PMC9294380 DOI: 10.3389/fphar.2022.891952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 05/04/2022] [Indexed: 11/23/2022] Open
Abstract
Tigecycline is a broad-spectrum active intravenous antibiotic that is active against methicillin-resistant staphylococcus aureus. In Phase 3 and 4 clinical trials, increased all-cause mortality was observed in patients treated with tigecycline compared to patients in the control group. The reason for the increase is unclear. In this study, we found that tigecycline cause abnormal coagulation in tumor patients, especially in patients with hematological malignancies. The main manifestations were decreased fibrinogen and prolonged activated prothrombin time (APTT), thrombin time (TT), and D-dimer. In addition, through functional studies, we found that tigecycline inhibit platelet adhesion and aggregation, and the coagulation function of patients gradually recover after discontinuation. Gene sequencing results suggested that tigecycline significantly regulate the expression of genes related to platelet function pathways and increase the incidence of single nucleotide polymorphisms and the number of alternative splices in the Chinese hamster ovary (CHO) cells treated with tigecycline. An abnormal function and low numbers of platelets are common in patients with hematological malignancies. Our study can explain the mechanism of abnormal coagulation caused by tigecycline. Additionally, doctors who apply tigecycline to cure infections in tumor patients should be warned.
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Affiliation(s)
- Li-Hua Sun
- Department of Hematology, Peking University Shenzhen Hospital, Shenzhen, China
| | - Kun-Hao Bai
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
- Department of Endoscopy, Sun Yat-Sen University Cancer Center, Guangzhou, China
| | - Guo-Yan Wu
- Department of Critical Care Medicine, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiao-Peng Tian
- Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Zhi-Qing Zou
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Da-Wei Wang
- State Key Laboratory of Medical Genomics, Shanghai Institute of Hematology, National Research Center for Translational Medicine at Shanghai, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yu-Jun Dai
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
- Department of Hematologic Oncology, Sun Yat-Sen University Cancer Center, Guangzhou, China
- *Correspondence: Yu-Jun Dai , ; Si-Liang Chen ,
| | - Si-Liang Chen
- Department of Hematology, Peking University Shenzhen Hospital, Shenzhen, China
- *Correspondence: Yu-Jun Dai , ; Si-Liang Chen ,
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3
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Halpern AB, Othus M, Howard NP, Hendrie PC, Percival MEM, Scott BL, Gernsheimer TB, Baclig NV, Buckley SA, Cassaday RD, Hartley GA, Welch VL, Estey EH, Walter RB. Comparison of outpatient care following intensive induction versus post-remission chemotherapy for adults with acute myeloid leukemia and other high-grade myeloid neoplasms. Leuk Lymphoma 2020; 62:234-238. [PMID: 32921204 DOI: 10.1080/10428194.2020.1821008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Anna B Halpern
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center/University of Washington, Seattle, WA, USA
| | - Megan Othus
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Nicholas P Howard
- Clinical Research Division, Fred Hutchinson Cancer Research Center/University of Washington, Seattle, WA, USA
| | - Paul C Hendrie
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA
| | - Mary-Elizabeth M Percival
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center/University of Washington, Seattle, WA, USA
| | - Bart L Scott
- Clinical Research Division, Fred Hutchinson Cancer Research Center/University of Washington, Seattle, WA, USA.,Department of Medicine, Division of Medical Oncology, University of Washington, Seattle, WA, USA
| | - Terry B Gernsheimer
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center/University of Washington, Seattle, WA, USA
| | - Nikita V Baclig
- Department of Medicine, Residency Program, University of Washington, Seattle, WA, USA
| | - Sarah A Buckley
- Clinical Research Division, Fred Hutchinson Cancer Research Center/University of Washington, Seattle, WA, USA.,Department of Medicine, Residency Program, University of Washington, Seattle, WA, USA
| | - Ryan D Cassaday
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center/University of Washington, Seattle, WA, USA
| | | | | | - Elihu H Estey
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center/University of Washington, Seattle, WA, USA
| | - Roland B Walter
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center/University of Washington, Seattle, WA, USA.,Department of Pathology, University of Washington, Seattle, WA, USA.,Department of Epidemiology, University of Washington, Seattle, WA, USA
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4
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Rodrigues ALM, do Nascimento DM, de Lima JM, Reis MLP, Leão LBC, Azevedo MC, Muccini SR, da Silva PC, Carneiro TX. Safety and Feasibility of Outpatient High Dose Cytarabine for Acute Myeloid Leukemia in the Brazilian Amazon. Int J Hematol Oncol Stem Cell Res 2020; 14:151-156. [PMID: 33024520 PMCID: PMC7521396 DOI: 10.18502/ijhoscr.v14i3.3722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background: The attempt to manage patients with acute myeloid leukemia as outpatients has become increasingly common due to high hospitalization costs, low availability for beds and patient preference. Publications on the subject are scarce, especially in low-income regions and the safety in this population remains to be determined. The present study aims to assess the safety of consolidation with high-dose cytarabine in the outpatient setting. Materials and Methods: We retrospectively analyzed 39 patients who underwent consolidation with high-dose cytarabine, between 2009 and 2018, at Ophir Loyola Hospital, in Belém, Brazil. Patients treated after 2015 were given high-dose cytarabine as outpatients due to the decision of medical staff. Results: Twenty-seven patients received 76 cycles of cytarabine as outpatients; males were 48.14% of the total population, with a median age of approximately 45 years. The occurrence of delay between cycles was significantly lower among outpatients (48.14% vs. 83.33%, p = 0.04). There was no difference in relapse rates, transfusion requirements and non-relapse mortality between both groups. Hospitalization was required in 40.74% of patients during outpatient cycles and 18.51% of blood cultures were positive for pathogens. Non-relapse mortality was significantly higher among patients above 50 years old and treated on an outpatient basis (44.4% vs. 5.60%, p = 0.03). Conclusion: High-dose cytarabine administration on an outpatient basis appears to be safe and effective in a low-income population at the Brazilian Amazon region, but toxicity seems to be increased for patients older than 50 years.
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Affiliation(s)
| | | | - Josy Marinho de Lima
- Division of Hematology-Oncology and Stem Cell Transplantation, Ophir Loyola Hospital, Belém - PA, Brazil
| | - Marcos Laércio Pontes Reis
- Division of Hematology-Oncology and Stem Cell Transplantation, Ophir Loyola Hospital, Belém - PA, Brazil
| | | | | | | | | | - Thiago Xavier Carneiro
- Division of Hematology-Oncology and Stem Cell Transplantation, Ophir Loyola Hospital, Belém - PA, Brazil
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5
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Talati C, Frantz D, Lubas A, Salamanca C, Tobon K, Kubal T. How I treat newly diagnosed acute myeloid leukemia in an outpatient setting: a multidisciplinary team perspective. Future Oncol 2020; 16:281-291. [PMID: 31985277 DOI: 10.2217/fon-2019-0781] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Historically, patients with acute myeloid leukemia received intensive chemotherapy requiring hospitalization, which can diminish quality of life and increase healthcare costs. The introduction of new therapies facilitated a shift toward outpatient therapy, which requires coordination of a multidisciplinary team, thorough patient evaluation, careful preparation and rigorous patient monitoring. Many patients are candidates for multiple treatment approaches; we generally employ CPX-351 (Vyxeos®) as an intensive outpatient approach and venetoclax (Venclyxto/Venclexta®) plus hypomethylating agents as a lower-intensity approach, with 2-3 visits/week during treatment. Treatment infusions are scheduled in the morning to leave sufficient time for transfusions and other supportive care later the same day, to prevent additional visits. With careful planning and patient monitoring, acute myeloid leukemia treatment can be successfully administered in the outpatient setting.
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Affiliation(s)
- Chetasi Talati
- Moffitt Cancer Center, 12901 Magnolia Drive, Tampa, FL 33612, USA
| | - Diedra Frantz
- Moffitt Cancer Center, 12901 Magnolia Drive, Tampa, FL 33612, USA
| | - Amber Lubas
- Moffitt Cancer Center, 12901 Magnolia Drive, Tampa, FL 33612, USA
| | | | - Katherine Tobon
- Moffitt Cancer Center, 12901 Magnolia Drive, Tampa, FL 33612, USA
| | - Timothy Kubal
- Moffitt Cancer Center, 12901 Magnolia Drive, Tampa, FL 33612, USA
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6
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The Value of Adding Surveillance Cultures to Fluoroquinolone Prophylaxis in the Management of Multiresistant Gram Negative Bacterial Infections in Acute Myeloid Leukemia. J Clin Med 2019; 8:jcm8111985. [PMID: 31731650 PMCID: PMC6912560 DOI: 10.3390/jcm8111985] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 11/02/2019] [Accepted: 11/13/2019] [Indexed: 12/31/2022] Open
Abstract
Multidrug resistant Gram-Negative Bacterial Infections (MR-GNBI) are an increasing cause of mortality in acute myeloid leukemia (AML), compromising the success of antineoplastic therapy. We prospectively explored a novel strategy, including mandatory fluoroquinolone prophylaxis, weekly surveillance cultures (SC) and targeted antimicrobial therapy for febrile neutropenia, aimed to reduce infectious mortality due to MR-GNBI. Over 146 cycles of chemotherapy, cumulative incidence of colonization was 50%. Half of the colonizations occurred in the consolidation phase of treatment. Application of this strategy led to a significant reduction in the incidence of GNB and carbapenemase-producing Klebisella pneumoniae (cpKp) species, resulting in a reduction of infectious mortality (HR 0.35 [95%, CI 0.13–0.96], p = 0.042). In multivariate analysis, fluroquinolone prophylaxis in addition to SC was associated with improved survival (OR 0.55 [95% CI 0.38–0.79], p = 0.001). Targeted therapy for colonized patients did not overcome the risk of death once cpKp or XDR Pseudomonas aeruginosa infections were developed. Mortality rate after transplant was similar between colonized and not colonized patients. However only 9% of transplanted patients were colonized by cpkp. In conclusion, colonization is a common phenomenon, not limited to the induction phase. This strategy reduces infectious mortality by lowering the global incidence of GN infections and the spread of resistant species.
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7
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Halpern AB, Howard NP, Othus M, Hendrie PC, Baclig NV, Buckley SA, Percival MEM, Becker PS, Scott BL, Oehler VG, Gernsheimer TB, Keel SB, Orozco JJ, Cassaday RD, Shustov AR, Hartley GA, Welch VL, Estey EH, Walter RB. Early hospital discharge after intensive induction chemotherapy for adults with acute myeloid leukemia or other high-grade myeloid neoplasm. Leukemia 2019; 34:635-639. [PMID: 31586148 DOI: 10.1038/s41375-019-0586-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 07/12/2019] [Accepted: 07/22/2019] [Indexed: 11/09/2022]
Affiliation(s)
- Anna B Halpern
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Nicholas P Howard
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Megan Othus
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Paul C Hendrie
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA
| | - Nikita V Baclig
- Department of Medicine, Residency Program, University of Washington, Seattle, WA, USA
| | - Sarah A Buckley
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Mary-Elizabeth M Percival
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Pamela S Becker
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Bart L Scott
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.,Department of Medicine, Division of Medical Oncology, University of Washington, Seattle, WA, USA
| | - Vivian G Oehler
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Terry B Gernsheimer
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Siobán B Keel
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA
| | - Johnnie J Orozco
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.,Department of Medicine, Division of Medical Oncology, University of Washington, Seattle, WA, USA
| | - Ryan D Cassaday
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Andrei R Shustov
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | | | | | - Elihu H Estey
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Roland B Walter
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA. .,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA. .,Department of Pathology, University of Washington, Seattle, WA, USA. .,Department of Epidemiology, University of Washington, Seattle, WA, USA.
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8
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Fridthjof KS, Kampmann P, Dünweber A, Gørløv JS, Nexø C, Friis LS, Nørskov KH, Welinder PC, Moser C, Kjeldsen L, Møller T. Systematic patient involvement for homebased outpatient administration of complex chemotherapy in acute leukemia and lymphoma. Br J Haematol 2018; 181:637-641. [PMID: 29676445 DOI: 10.1111/bjh.15249] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 03/01/2018] [Indexed: 11/27/2022]
Abstract
Based on experience with comprehensive patient involvement, we present data from implementation of portable, programmable infusion pumps (PPP) for home-based chemotherapy administration in patients with acute leukaemia and in lymphoma patients receiving (carmustine, etoposide, cytarabine, melphalan) BEAM regimen. Data from 84 patients, receiving 177 cycles of PPP administered chemotherapy, showed convincing safety with minor equipment errors encountered and with high patient satisfaction. In-hospital days could be reduced with 52% out of a total of 1197 treatment days. Homebased PPP has several advantages from a patient perspective and furthermore frees up in-hospital beds for patients in need of them.
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Affiliation(s)
- Katrine S Fridthjof
- Department of Haematology, University Hospital of Copenhagen Rigshospitalet Denmark, Copenhagen, Denmark
| | - Peter Kampmann
- Department of Haematology, University Hospital of Copenhagen Rigshospitalet Denmark, Copenhagen, Denmark
| | - Anne Dünweber
- Department of Haematology, University Hospital of Copenhagen Rigshospitalet Denmark, Copenhagen, Denmark
| | - Jette S Gørløv
- Department of Haematology, University Hospital of Copenhagen Rigshospitalet Denmark, Copenhagen, Denmark
| | - Connie Nexø
- Department of Haematology, University Hospital of Copenhagen Rigshospitalet Denmark, Copenhagen, Denmark
| | - Lone S Friis
- Department of Haematology, University Hospital of Copenhagen Rigshospitalet Denmark, Copenhagen, Denmark
| | - Kristina H Nørskov
- Department of Haematology, University Hospital of Copenhagen Rigshospitalet Denmark, Copenhagen, Denmark
| | - Pernille C Welinder
- Department of Haematology, University Hospital of Copenhagen Rigshospitalet Denmark, Copenhagen, Denmark
| | - Claus Moser
- Department of Clinical Microbiology, University Hospital of Copenhagen Rigshospitalet Denmark, Copenhagen, Denmark
| | - Lars Kjeldsen
- Department of Haematology, University Hospital of Copenhagen Rigshospitalet Denmark, Copenhagen, Denmark
| | - Tom Møller
- The University Hospitals Centre for Health Research, UCSF, University Hospital of Copenhagen, Rigshospitalet, Copenhagen, Denmark
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9
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Kumar AJ, Henzer T, Rodday AM, Parsons SK. Risk factors for length of stay and charge per day differ between older and younger hospitalized patients with AML. Cancer Med 2018; 7:2744-2752. [PMID: 29663689 PMCID: PMC6010796 DOI: 10.1002/cam4.1492] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 03/15/2018] [Accepted: 03/20/2018] [Indexed: 02/02/2023] Open
Abstract
Acute myeloid leukemia (AML) is associated with frequent hospitalizations. We evaluated factors associated with length of stay (LOS) and charge per day (CPD) for admissions in older (≥60 years) and younger patients (<60 years). We identified patients with ICD‐9‐CM codes for AML or myeloid sarcoma in the 2012 HCUP‐NIS. In separate models based on age, we examined patient (sex, race, income, insurance payer, chronic conditions, chemotherapy administration, death) and hospital (type, geography) characteristics. Multivariable negative binomial regression estimated factor effects on LOS and CPD using rate ratios, with HCUP‐NIS weights. In 43,820 discharges, LOS was longer in patients <60 than ≥60 (6.8 vs. 5.4 days). For patients <60, longer LOS was seen with more chronic conditions (RR = 1.10), Black race (RR = 1.16), chemotherapy (RR = 2.27), and geography; shorter LOS was associated with older age (RR = 0.93), Medicare (RR = 0.83), and hospital type. For patients ≥60, longer LOS associated with chronic conditions (RR = 1.07) and Asian race (RR = 1.33). Shorter LOS associated with older age (RR = 0.86), higher income (RR = 0.93), and hospital type. For patients <60, higher CPD associated with chronic conditions (RR = 1.05), death (RR = 1.93), and geography; lower CPD associated with increasing age (RR = 0.96), Medicaid (RR = 0.93), and rural hospitals (RR = 0.65). For patients ≥60, higher CPD associated with Medicare (RR = 1.05), more chronic conditions (RR = 1.02), younger age (RR = 1.1), west geography (RR = 1.37), death (RR = 1.45), and Hispanic race (RR = 1.15). We identify predictors for increased healthcare utilization in hospitalized patients with AML, which differ within age groups. Future efforts are needed to link utilization outcomes with clinical treatments and response.
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Affiliation(s)
- Anita J Kumar
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts.,Division of Hematology/Oncology, Tufts Medical Center, Boston, Massachusetts
| | - Tobi Henzer
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
| | - Angie Mae Rodday
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
| | - Susan K Parsons
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts.,Division of Hematology/Oncology, Tufts Medical Center, Boston, Massachusetts
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10
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Fluoroquinolone prophylaxis in haematological cancer patients with neutropenia: ECIL critical appraisal of previous guidelines. J Infect 2017; 76:20-37. [PMID: 29079323 DOI: 10.1016/j.jinf.2017.10.009] [Citation(s) in RCA: 96] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 10/03/2017] [Accepted: 10/13/2017] [Indexed: 01/24/2023]
Abstract
OBJECTIVES Fluoroquinolone (FQ) prophylaxis was recommended in 2005 by European Conference on Infections in Leukemia (ECIL) for patients with prolonged neutropenia. In consideration of a worldwide increase in antibiotic resistance, the issue of FQ prophylaxis during neutropenia was re-evaluated. METHODS Literature review of randomised controlled trials (RCT) and observational studies published in years 2006-2014 was performed. Their results were analysed in meta-analysis. Meta-regression model was applied to evaluate whether the rates of FQ resistance in community and hospital settings influenced the efficacy of FQ prophylaxis. The impact of FQ prophylaxis on colonisation and infection with resistant bacteria was reviewed. RESULTS Two RCTs and 12 observational studies were identified. FQ prophylaxis did not have effect on mortality (pooled OR 1.01, 95%CI 0.73-1.41), but was associated with lower rate of bloodstream infections (BSI) (pooled OR 0.57, 95%CI 0.43-0.74) and episodes of fever during neutropenia (pooled OR 0.32, 95%CI 0.20-0.50). No effect of the background rate of FQ resistance on the efficacy of FQ prophylaxis was observed. In few studies, FQ prophylaxis resulted in an increased colonisation or infection with FQ- or multi-drug resistant strains. CONCLUSIONS The possible benefits of FQ prophylaxis on BSI rate, but not on overall mortality, should be weighed against its impact in terms of toxicity and changes in local ecology in single centres.
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11
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Hershenfeld SA, Maki K, Rothfels L, Murray CS, Nixon S, Schimmer AD, Doherty MC. Sharing post-AML consolidation supportive therapy with local centers reduces patient travel burden without compromising outcomes. Leuk Res 2017; 59:93-96. [PMID: 28599190 DOI: 10.1016/j.leukres.2017.05.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 05/12/2017] [Accepted: 05/29/2017] [Indexed: 11/26/2022]
Abstract
Acute myeloid leukemia (AML) is frequently treated with induction and consolidation chemotherapy. Consolidation chemotherapy can be delivered on an ambulatory basis, requiring some patients to travel long distances for treatment at specialized centers. We developed a shared care model where patients receive consolidation chemotherapy at a quaternary center, but post-consolidation supportive care at local hospitals. To evaluate the impact of our model on patient travel and outcomes we conducted a retrospective analysis of AML and acute promyelocytic leukemia patients receiving consolidation over four years at our quaternary center. 73 patients received post-consolidation care locally, and 344 at the quaternary center. Gender, age and cytogenetic risk did not significantly differ between groups. Shared care patients saved mean round trip distance of 146.5km±99.6 and time of 96.7min±63.4 compared to travelling to quaternary center. There was no significant difference in overall survival between groups, and no increased hazard of death for shared care patients. 30, 60, and 90day survival from start of consolidation was 98.6%, 97.2%, and 95.9% for shared care and 98.8%, 97.1%, and 95.3% for quaternary center patients. Thus, a model utilizing regional partnerships for AML post-consolidation care reduces travel burden while maintaining safety.
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Affiliation(s)
- Samantha A Hershenfeld
- Princess Margaret Cancer Center, University Health Network, 610 University Ave, Toronto, Ontario, Canada M5G 2M9
| | - Kimberly Maki
- Princess Margaret Cancer Center, University Health Network, 610 University Ave, Toronto, Ontario, Canada M5G 2M9
| | - Lana Rothfels
- Princess Margaret Cancer Center, University Health Network, 610 University Ave, Toronto, Ontario, Canada M5G 2M9
| | - Cindy S Murray
- Princess Margaret Cancer Center, University Health Network, 610 University Ave, Toronto, Ontario, Canada M5G 2M9
| | - Shannon Nixon
- Princess Margaret Cancer Center, University Health Network, 610 University Ave, Toronto, Ontario, Canada M5G 2M9
| | - Aaron D Schimmer
- Princess Margaret Cancer Center, University Health Network, 610 University Ave, Toronto, Ontario, Canada M5G 2M9
| | - Mary C Doherty
- Princess Margaret Cancer Center, University Health Network, 610 University Ave, Toronto, Ontario, Canada M5G 2M9.
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12
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Ben IO, Woode E, Koffuor GA, Boakye-Gyasi E, Titiloye NA. Effect of Trichilia monadelpha (Meliaceae) extracts on bone histomorphology in complete Freund's adjuvant-induced arthritis. JOURNAL OF COMPLEMENTARY MEDICINE RESEARCH 2017; 6:177-185. [PMID: 28512599 PMCID: PMC5429077 DOI: 10.5455/jice.20170218092913] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 01/31/2017] [Indexed: 12/29/2022]
Abstract
AIM This study aimed to assess the effect of petroleum ether extract (PEE), ethyl acetate extract (EthE), and ethanol extract (EAE) of Trichilia monadelpha stem bark on bone histomorphology in arthritis. METHODS Percentage inhibition of edema and arthritic scores in complete Freund's adjuvant-induced (0.1 ml of 5 mg/ml1 of heat-killed Mycobacterium tuberculosis in paraffin oil-injected subplantar into the right hind paw) arthritic Sprague-Dawley rats treated with PEE, EthE, or EAE (10,30, and 100 mg/kg1, respectively), dexamethasone (0.3-3.0 mg/kg1), or methotrexate (0.1-1.0 mg/kg1) over a 28-day period were estimated. Rat paws were radiographed and scored. Body weights were taken and paw tissues were harvested for histopathological studies. RESULTS The extracts significantly (P ≤ 0.01-0.0001) and dose dependently reduced the polyarthritic phase of arthritis. EAE and PEE significantly (P ≤ 0.01-0.0001) minimized edema spread from acute arthritic phase (days 0-10) to polyarthritic phase (days 10-28). EthE improved which deteriorated body weight in arthritis. All extracts significantly (P ≤ 0.05-0.01) improved arthritic score; reducing erythema, swelling and joint rigidity, and also significantly (P ≤ 0.05-0.01) reduced hyperplasia, pannus formation, and exudation of inflammatory cells into synovial spaces. CONCLUSION The stem bark extracts of T. monadelpha reduce bone tissue damage and resorption associated with adjuvant-induced arthritis, hence could be useful in managing arthritis in humans.
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Affiliation(s)
- Inemesit Okon Ben
- Department of Pharmacology, Faculty of Pharmacy and Pharmaceutical Sciences, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.,Department of Pharmacology and Toxicology, Faculty of Pharmacy, Madonna University, Livonia, Michigan, USA
| | - Eric Woode
- Department of Pharmacology, Faculty of Pharmacy and Pharmaceutical Sciences, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - George Asumeng Koffuor
- Department of Pharmacology, Faculty of Pharmacy and Pharmaceutical Sciences, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Eric Boakye-Gyasi
- Department of Pharmacology, Faculty of Pharmacy and Pharmaceutical Sciences, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Nicholas Akinwale Titiloye
- Department of Pharmacology, Faculty of Pharmacy and Pharmaceutical Sciences, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
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Vaughn JE, Buckley SA, Walter RB. Outpatient care of patients with acute myeloid leukemia: Benefits, barriers, and future considerations. Leuk Res 2016; 45:53-8. [PMID: 27101148 PMCID: PMC5383350 DOI: 10.1016/j.leukres.2016.03.011] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 03/14/2016] [Accepted: 03/31/2016] [Indexed: 11/23/2022]
Abstract
Patients with acute myeloid leukemia (AML) who receive intensive induction or re-induction chemotherapy with curative intent typically experience prolonged cytopenias upon completion of treatment. Due to concerns regarding infection and bleeding risk as well as significant transfusion and supportive care requirements, patients have historically remained in the hospital until blood count recovery-a period of approximately 30 days. The rising cost of AML care has prompted physicians to reconsider this practice, and a number of small studies have suggested the safety and feasibility of providing outpatient supportive care to patients following intensive AML (re-) induction therapy. Potential benefits include a significant reduction of healthcare costs, improvement in quality of life, and decreased risk of hospital-acquired infections. In this article, we will review the currently available literature regarding this practice and discuss questions to be addressed in future studies. In addition, we will consider some of the barriers that must be overcome by institutions interested in implementing an "early discharge" policy. While outpatient management of selected AML patients appears safe, careful planning is required in order to provide the necessary support, education and rapid management of serious complications that occur among this very vulnerable patient population.
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Affiliation(s)
- Jennifer E Vaughn
- Department of Internal Medicine, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA; Virginia Tech Carilion Research Institute, Roanoke, VA, USA; Blue Ridge Cancer Care, Roanoke, VA, USA.
| | - Sarah A Buckley
- Hematology/Oncology Fellowship Program, University of Washington, Seattle, WA, USA
| | - Roland B Walter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA; Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA
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14
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Vaughn JE, Othus M, Powell MA, Gardner KM, Rizzuto DL, Hendrie PC, Becker PS, Pottinger PS, Estey EH, Walter RB. Resource Utilization and Safety of Outpatient Management Following Intensive Induction or Salvage Chemotherapy for Acute Myeloid Leukemia or Myelodysplastic Syndrome: A Nonrandomized Clinical Comparative Analysis. JAMA Oncol 2016; 1:1120-7. [PMID: 26355382 DOI: 10.1001/jamaoncol.2015.2969] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Adults with acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS) typically remain hospitalized after induction or salvage chemotherapy until blood cell count recovery, with resulting prolonged inpatient stays being a primary driver of health care costs. Pilot studies suggest that outpatient management following chemotherapy might be safe and could reduce costs for these patients. OBJECTIVE To compare safety, resource utilization, infections, and costs between adults discharged early following AML or MDS induction or salvage chemotherapy and inpatient controls. DESIGN Nonrandomized, phase 2, single-center study conducted at the University of Washington Medical Center. Over a 43-month period (January 1, 2011, through July 31, 2014), 178 adults receiving intensive AML or MDS chemotherapy were enrolled. After completion of chemotherapy, 107 patients met predesignated medical and logistical criteria for early discharge, while 29 met medical criteria only and served as inpatient controls. INTERVENTIONS Early-discharge patients were released from the hospital at the completion of chemotherapy, and supportive care was provided in the outpatient setting until blood cell count recovery (median, 21 days; range, 2-45 days). Controls received inpatient supportive care (median, 16 days; range, 3-42 days). MAIN OUTCOMES AND MEASURES We analyzed differences in early mortality, resource utilization including intensive care unit (ICU) days, transfusions per study day, and use of intravenous (IV) antibiotics per study day), numbers of infections, and total and inpatient charges per study day among early-discharge patients vs controls. RESULTS Four of the 107 early-discharge patients and none of the 29 control patients died within 30 days of enrollment (P=.58). Nine early-discharge patients (8%) but no controls required ICU-level care (P=.20). No differences were noted in the median daily number of transfused red blood cell units (0.27 vs 0.29; P=.55) or number of transfused platelet units (0.26 vs 0.29; P=.31). Early-discharge patients had more positive blood cultures (37 [35%] vs 4 [14%]; P=.04) but required fewer IV antibiotic days per study day (0.48 vs 0.71; P=.01). Overall, daily charges among early-discharge patients were significantly lower than for inpatients (median, $3840 vs $5852; P<.001) despite increased charges per inpatient day when readmitted (median, $7405 vs $5852; P<.001). CONCLUSIONS AND RELEVANCE Early discharge following intensive AML or MDS chemotherapy can reduce costs and use of IV antibiotics, but attention should be paid to complications that may occur in the outpatient setting.
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Affiliation(s)
- Jennifer E Vaughn
- Hematology/Oncology Fellowship Program, University of Washington, Seattle2Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington3now with Blue Ridge Cancer Care, Department of Medicine, Virginia Tech Carilion School of Med
| | - Megan Othus
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Morgan A Powell
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | | | - Paul C Hendrie
- Division of Hematology, Department of Medicine, University of Washington, Seattle
| | - Pamela S Becker
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington6Division of Hematology, Department of Medicine, University of Washington, Seattle
| | - Paul S Pottinger
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle
| | - Elihu H Estey
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington6Division of Hematology, Department of Medicine, University of Washington, Seattle
| | - Roland B Walter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington6Division of Hematology, Department of Medicine, University of Washington, Seattle8Department of Epidemiology, University of Washington, Seattle
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15
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Møller T, Moser C, Adamsen L, Rugaard G, Jarden M, Bøtcher TS, Wiedenbein L, Kjeldsen L. Early warning and prevention of pneumonia in acute leukemia by patient education, spirometry, and positive expiratory pressure: A randomized controlled trial. Am J Hematol 2016; 91:271-6. [PMID: 26661344 PMCID: PMC5067626 DOI: 10.1002/ajh.24262] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 11/19/2015] [Accepted: 11/28/2015] [Indexed: 11/13/2022]
Abstract
Long‐lasting neutropenia associated with acute myeloid leukemia (AML) and its treatment gives rise to a high risk of pneumonia. The use of broad‐spectrum antibiotic prophylaxis during outpatient management has not completely protected patients against admission due to infections and neutropenic fever, emphasizing the need to approach infection protection with complementary efforts. In a randomized controlled design, we examined the applicability of patient‐performed daily spirometry [forced expiratory volume in one second (FEV1)] as an early warning tool and explored the effectiveness of positive expiratory pressure (PEP) in preventing pneumonia among 80 AML patients. Twenty‐five incidences of pneumonia were detected among 23 patients (6 interventions, 17 controls), giving a prevalence of 28.75% during 5420 days of observation. We found a significant difference in incidence between intervention versus control group (2.17 per 1000 days vs. 6.52 per 1000 days, P = 0.021, respectively). A cross point at 80‐76% of the personal FEV1 reference value showed high sensitivity and specificity on pneumonia development. Our data demonstrate the feasibility of educating AML patients in their continuous daily measurement of FEV1 and use of PEP. Daily measures of FEV1 may be an important early warning tool for assessment of pulmonary deterioration during critical phases of neutropenia. We suggest that strategic patient education in the use of spirometry and PEP should be part of standard of care for AML patients undergoing induction chemotherapy. Am. J. Hematol. 91:271–276, 2016. © 2015 The Authors. American Journal of Hematology Published by Wiley Periodicals, Inc.
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Affiliation(s)
- Tom Møller
- University Hospitals Centre for Health Research (UCSF)Copenhagen Denmark
| | - Claus Moser
- Department of Clinical MicrobiologyCopenhagen University HospitalRigshospitalet Denmark
| | - Lis Adamsen
- University Hospitals Centre for Health Research (UCSF)Copenhagen Denmark
| | - Grith Rugaard
- University Hospitals Centre for Health Research (UCSF)Copenhagen Denmark
| | - Mary Jarden
- University Hospitals Centre for Health Research (UCSF)Copenhagen Denmark
| | - Tina S. Bøtcher
- Department of HaematologyCopenhagen University Hospital Herlev, Copenhagen Denmark
| | - Liza Wiedenbein
- University Hospitals Centre for Health Research (UCSF)Copenhagen Denmark
| | - Lars Kjeldsen
- Department of HaematologyCopenhagen University HospitalRigshospitalet Denmark
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16
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Miller TP, Getz KD, Kavcic M, Li Y, Huang YSV, Sung L, Alonzo TA, Gerbing R, Daves M, Horton TM, Pulsipher MA, Pollard J, Bagatell R, Seif AE, Fisher BT, Gamis AS, Aplenc R. A comparison of discharge strategies after chemotherapy completion in pediatric patients with acute myeloid leukemia: a report from the Children's Oncology Group. Leuk Lymphoma 2016; 57:1567-74. [PMID: 26727639 DOI: 10.3109/10428194.2015.1088652] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
While most children receive acute myeloid leukemia (AML) chemotherapy as inpatients, there is variability in timing of discharge after chemotherapy completion. This study compared treatment-related morbidity, mortality and cumulative hospitalization in children with AML who were discharged after chemotherapy completion (early discharge) and those who remained hospitalized. Chart abstraction data for 153 early discharge-eligible patients enrolled on a Children's Oncology Group trial were compared by discharge strategy. Targeted toxicities included viridans group streptococcal (VGS) bacteremia, hypoxia and hypotension. Early discharge occurred in 11% of courses post-Induction I. Re-admission occurred in 80-100%, but median hospital stay was 7 days shorter. Patients discharged early had higher rates of VGS (adjusted risk ratio (aRR) = 1.67, 95% CI = 1.11-2.51), hypoxia (aRR = 1.92, 95% CI = 1.06-3.48) and hypotension (aRR = 4.36, 95% CI = 2.01-9.46), but there was no difference in mortality. As pressure increases to shorten hospitalizations, these results have important implications for determining discharge practices in pediatric AML.
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Affiliation(s)
| | - Kelly D Getz
- a Division of Oncology ;,b Center for Pediatric Clinical Effectiveness , The Children's Hospital of Philadelphia , Philadelphia , PA , USA
| | | | - Yimei Li
- a Division of Oncology ;,c Center for Clinical Epidemiology and Biostatistics , University of Pennsylvania School of Medicine , Philadelphia , PA , USA
| | - Yuan-Shun V Huang
- b Center for Pediatric Clinical Effectiveness , The Children's Hospital of Philadelphia , Philadelphia , PA , USA
| | - Lillian Sung
- d Department of Haematology/Oncology , The Hospital for Sick Children , Toronto , Canada
| | - Todd A Alonzo
- e Department of Preventative Medicine , University of Southern California , Arcadia , CA , USA ;,f Children's Oncology Group , Monrovia , CA , USA
| | | | - Marla Daves
- g Department of Pediatrics , Children's Healthcare of Atlanta , Atlanta , GA , USA
| | - Terzah M Horton
- h Department of Pediatrics , Section of Hematology-Oncology, Texas Children's Hospital , Houston , TX , USA
| | - Michael A Pulsipher
- i Hematology Division , University of Utah School of Medicine , Salt Lake City , UT , USA
| | - Jessica Pollard
- j Cancer and Blood Disorders Center , Seattle Children's Hospital , Seattle , WA , USA
| | - Rochelle Bagatell
- a Division of Oncology ;,k Departments of Pediatrics , University of Pennsylvania School of Medicine , Philadelphia , PA , USA
| | - Alix E Seif
- a Division of Oncology ;,k Departments of Pediatrics , University of Pennsylvania School of Medicine , Philadelphia , PA , USA
| | - Brian T Fisher
- b Center for Pediatric Clinical Effectiveness , The Children's Hospital of Philadelphia , Philadelphia , PA , USA ;,c Center for Clinical Epidemiology and Biostatistics , University of Pennsylvania School of Medicine , Philadelphia , PA , USA ;,k Departments of Pediatrics , University of Pennsylvania School of Medicine , Philadelphia , PA , USA ;,l Infectious Diseases , The Children's Hospital of Philadelphia , Philadelphia , PA , USA
| | - Alan S Gamis
- m Pediatric Hematology/Oncology , Children's Mercy Hospital , Kansas City , MO , USA
| | - Richard Aplenc
- a Division of Oncology ;,c Center for Clinical Epidemiology and Biostatistics , University of Pennsylvania School of Medicine , Philadelphia , PA , USA ;,k Departments of Pediatrics , University of Pennsylvania School of Medicine , Philadelphia , PA , USA ;,l Infectious Diseases , The Children's Hospital of Philadelphia , Philadelphia , PA , USA
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17
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Luo C, Hussaini T, Lacaria K, Yeung J, Lau TTY, Broady RC. Evaluation of a Once-Daily Vancomycin Regimen in an Outpatient Leukemia/Bone Marrow Transplant Clinic (OD-VANCO Study). Can J Hosp Pharm 2014; 67:280-5. [PMID: 25214659 DOI: 10.4212/cjhp.v67i4.1372] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND The Leukemia/Bone Marrow Transplant Program of British Columbia manages patients with high-risk febrile neutropenia and those with non-neutropenic immunocompromised states in an outpatient clinic setting. Because the program treats outpatients only, once-daily administration of IV antibiotics is desirable. A high-dose, once-daily vancomycin nomogram was developed and implemented as part of the antibiotic treatment regimen. OBJECTIVE To determine if therapeutic vancomycin trough levels could be achieved with a high-dose, once-daily regimen in this outpatient setting. METHODS A prospective, single-centre, observational cohort study was conducted over a 7-month period. Outpatients in the Leukemia/Bone Marrow Transplant Program were started on IV vancomycin with the high-dose, once-daily vancomycin nomogram, and outcomes were assessed. RESULTS Of 48 outpatients treated over the 7-month period, 10 (21%) had therapeutic vancomycin trough concentrations (i.e., greater than 10 mg/L). Thirty-five (90%) of the 39 patients with suspected clinical infection experienced clinical cure, and 6 (67%) of the 9 patients with documented microbiological infection experienced microbiological cure. Thirty (62%) of the 48 patients experienced symptoms of "red man syndrome", and 7 (15%) experienced some degree of nephrotoxicity. Two of 3 patients with laboratory-reported minimum inhibitory concentration (MIC) for identified pathogens had a calculated area under the curve to MIC ratio greater than or equal to 400. CONCLUSION The high-dose, once-daily vancomycin nomogram was effective in attaining trough levels greater than 10 mg/L in only 21% of patients in this study. A substantial number of adverse drug reactions were observed. Given these results, high-dose, once-daily vancomycin is no longer recommended for outpatient therapy.
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Affiliation(s)
- Cindy Luo
- BSc(Pharm), ACPR, is a Clinical Pharmacist at Vancouver General Hospital and a Clinical Instructor in the Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia
| | - Trana Hussaini
- BSc(Pharm), ACPR, PharmD, is a Pharmacotherapeutic Specialist, Solid Organ Transplantation, Vancouver General Hospital, and a Clinical Instructor, Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia
| | - Katie Lacaria
- BSc, BSc(Pharm), ACPR, is a Clinical Pharmacist, Leukemia/Bone Marrow Transplant Program of British Columbia, Vancouver General Hospital, and a Clinical Instructor, Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia
| | - Janice Yeung
- BSc(Pharm), ACPR, PharmD, is Coordinator, Lower Mainland Pharmacy Services Pharmacy Practice Residency Program; a Pharmacotherapeutic Specialist, Leukemia/Bone Marrow Transplant Program of British Columbia, Vancouver General Hospital; and a Clinical Assistant Professor, Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia
| | - Tim T Y Lau
- PharmD, ACPR, FCSHP, is a Pharmacotherapeutic Specialist, Infectious Diseases and Antimicrobial Stewardship, Vancouver General Hospital, and is also a Clinical Professor, Faculty of Pharmaceutical Sciences, and an Associate Member, Division of Infectious Diseases, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia
| | - Raewyn C Broady
- MBChB, FRACP, is Director, Ambulatory Leukemia/Bone Marrow Transplant Program of British Columbia, Vancouver General Hospital, and Clinical Associate Professor, Division of Hematology, The University of British Columbia, Vancouver, British Columbia
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18
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Saini L, Rostein C, Atenafu EG, Brandwein JM. Ambulatory consolidation chemotherapy for acute myeloid leukemia with antibacterial prophylaxis is associated with frequent bacteremia and the emergence of fluoroquinolone resistant E. Coli. BMC Infect Dis 2013; 13:284. [PMID: 23800256 PMCID: PMC3694510 DOI: 10.1186/1471-2334-13-284] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2012] [Accepted: 06/19/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Ambulatory consolidation chemotherapy for acute myeloid leukemia (AML) is frequently associated with bloodstream infections but the spectrum of bacterial pathogens in this setting has not been well-described. METHODS We evaluated the emergence of bacteremias and their respective antibiotic susceptibility patterns in AML patients receiving ambulatory-based consolidation therapy. Following achievement of complete remission, 207 patients received the first cycle (C1), and 195 the second cycle (C2), of consolidation on an ambulatory basis. Antimicrobial prophylaxis consisted of ciprofloxacin, amoxicillin and fluconazole. RESULTS There were significantly more positive blood cultures for E. coli in C2 as compared to C1 (10 vs. 1, p=0.0045); all E. coli strains for which susceptibility testing was performed demonstrated resistance to ciprofloxacin. In patients under age 60 there was a significantly higher rate of Streptococccus spp. bacteremia in C2 vs. C1; despite amoxicillin prophylaxis all Streptococcus isolates in C2 were sensitive to penicillin. Patients with Staphylococcus bacteremia in C1 had significantly higher rates of Staphylococcus bacteremia in C2 (p=0.009, OR=8.6). CONCLUSIONS For AML patients undergoing outpatient-based intensive consolidation chemotherapy with antibiotic prophylaxis, the second cycle is associated with higher rates of ciprofloxacin resistant E. coli, penicillin-sensitive Streptococcus bacteremias and recurrent Staphylococcus infections.
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Affiliation(s)
- Lalit Saini
- Department of Medical Oncology and Hematology, Princess Margaret Hospital, University of Toronto, 610 University Avenue, Rm. 5-109, Toronto, ON M5G 2M9, Canada
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19
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Hocking C, Taylor A, Hayward A. Early discharge and ambulatory care of low-risk patients with neutropenic fever in Australia. Intern Med J 2013; 43:591-5. [DOI: 10.1111/imj.12117] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Accepted: 10/10/2012] [Indexed: 12/01/2022]
Affiliation(s)
- C. Hocking
- Department of Medical Oncology; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - A. Taylor
- Department of Medical Oncology; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - A. Hayward
- Department of Medical Oncology; Royal Adelaide Hospital; Adelaide South Australia Australia
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20
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Claxton D, Erba HP, Faderl S, Arellano M, Lyons RM, Kovacsovics T, Gabrilove J, Huebner D, Gandhi PJ, Kantarjian H. Outpatient consolidation treatment with clofarabine in a phase 2 study of older adult patients with previously untreated acute myelogenous leukemia. Leuk Lymphoma 2011; 53:435-40. [PMID: 21877883 DOI: 10.3109/10428194.2011.616960] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
This report describes outpatient (OP) administration of clofarabine in older patients (≥60 years) with untreated acute myelogenous leukemia (AML). Overall, 112 patients underwent clofarabine induction. Clofarabine was administered to 35 OPs for a total of 72 OP cycles, with 81% of these cycles representing consolidation treatment. Median length of hospital stay was 0-6 days and 5-25 days across OP and inpatient (IP) cycles, respectively. The most common adverse events (AEs) were nausea, vomiting, diarrhea, febrile neutropenia, edema, hypokalemia and pneumonia. The overall frequency of treatment-emergent grade ≥3 AEs and serious AEs was generally not different with IP or OP administration of clofarabine. No deaths were reported within 30 days following OP or IP consolidation cycles. In the appropriately selected older patient, OP administration of clofarabine consolidation appears feasible, is as well tolerated as IP administration and has potential to contribute to the quality of life in elderly patients with AML.
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Affiliation(s)
- David Claxton
- Division of Hematology/Oncology, Penn State Milton S. Hershey Medical Center, Hershey, PA 17033, USA.
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21
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Kako S, Nakasone H, Endo H, Sakamoto K, Ashizawa M, Sato M, Terasako K, Kikuchi M, Kimura SI, Okuda S, Yamazaki R, Oshima K, Tanihara A, Nishida J, Usuki K, Kanda Y. Clinical course of patients with aplastic anemia or myelodysplastic syndrome associated with persistent neutropenia. Hematol Oncol 2011; 30:82-8. [PMID: 21692099 DOI: 10.1002/hon.1001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Revised: 05/02/2011] [Accepted: 05/04/2011] [Indexed: 12/20/2022]
Abstract
Patients with aplastic anemia (AA) or myelodysplastic syndrome (MDS) often have persistent severe neutropenia and are susceptible to infectious complications. We retrospectively reviewed the clinical course of patients with AA or MDS who had neutropenia (neutrophil count < 500/µl) for more than 25 days. A total of 46 patients, 11 with AA and 35 with MDS, were included. Twenty-three patients had infectious events (IE), and the cumulative incidence of IE was 30% at 6 months and 51% at 1 year. The cumulative incidence of IE was 67% at 1 year in 30 patients who experienced very severe neutropenia of less than 200/µl. Overall survival in all patients was 76% at 6 months and 65% at 1 year. In a multivariate analysis, male sex, underlying diseases, and a neutrophil count of less than 200/µl as a time-dependent covariate significantly affected IE. In analyses that excluded patients with AA, male sex was the only factor. In conclusion, severe neutropenia was significantly associated with IE in patients with AA or MDS, and IE might be lethal. When we only considered patients with MDS, the neutrophil count alone could not be used to predict the prognosis.
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Affiliation(s)
- Shinichi Kako
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Saitama, Japan
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22
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Walter RB, Lee SJ, Gardner KM, Chai X, Shannon-Dorcy K, Appelbaum FR, Estey EH. Outpatient management following intensive induction chemotherapy for myelodysplastic syndromes and acute myeloid leukemia: a pilot study. Haematologica 2011; 96:914-7. [PMID: 21393334 DOI: 10.3324/haematol.2011.040220] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Due to infectious and bleeding risks, adults with acute myeloid leukemia or high-risk myelodysplastic syndromes typically remain hospitalized after remission induction chemotherapy until blood count recovery. Here, we explored the medical and financial effects of discharge immediately after chemotherapy completion with close outpatient follow up. Within 12 months, 15 patients fulfilling both medical and logistical criteria were discharged early, whereas 5 patients meeting medical criteria only served as inpatient controls. No patient died. Patients discharged early spent a median of 8 days (range 3-36 days), or 54% of their study time, as outpatients. These patients required less time on intravenous antibiotics (6 vs. 16 days; P=0.11), received fewer red blood cell transfusions (0.25 vs. 0.48 units/day; P=0.08), and incurred lower median daily charges ($3,270 vs. $5,467; P=0.01) than controls. Thus, early discharge of selected patients appears, safe and may reduce cost and resource utilization. (ClinicalTrials.gov Identifier: NCT00844441).
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Affiliation(s)
- Roland B Walter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N, D2-190; Seattle, WA 98109-1024, USA.
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23
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Worth LJ, Lingaratnam S, Taylor A, Hayward AM, Morrissey S, Cooney J, Bastick PA, Eek RW, Wei A, Thursky KA. Use of risk stratification to guide ambulatory management of neutropenic fever. Intern Med J 2011; 41:82-9. [DOI: 10.1111/j.1445-5994.2010.02339.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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24
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The duration of functioning of a subcutaneous implantable port for the treatment of hematological tumors: a single institution-based study. Int J Clin Oncol 2010; 15:172-8. [DOI: 10.1007/s10147-010-0039-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2009] [Accepted: 10/21/2009] [Indexed: 10/19/2022]
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25
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Bakhshi S, Singh P, Swaroop C. Outpatient consolidation chemotherapy in pediatric acute myeloid leukemia: a retrospective analysis. ACTA ACUST UNITED AC 2010; 14:255-60. [PMID: 19843379 DOI: 10.1179/102453309x446144] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND To assess the outcomes of outpatient high dose cytosine arabinoside consolidation cycles in pediatric acute myeloid leukemia (AML) patients in comparison to inpatient treatment. METHODS We retrospectively analyzed 90 cycles of AML consolidation given to 30 patients between July 2003 and July 2007. RESULTS Median age was 8 years (range 1.5-15) and 22/30 (73.3%) were males. Sixty-nine of 90 (76.7%) cycles were given on an ambulatory basis; readmission occurred in 25/69 (36.2%) and there was one death. The outpatient cycles in comparison to the inpatient cycles required significantly fewer invasive blood investigations (p<0.001) but had comparable number of blood products administered as supportive therapy. There was no significant difference in the frequency of granulocyte colony stimulating factor usage and recovery time of absolute neutrophil count and platelet count. The incidence of febrile neutropenia though was comparable in the groups (72.5% outpatient versus 76.2% inpatient), but the duration (p=0.003) and subsequent therapeutic antifungal usage (p=0.001) was significantly more in inpatient administered cycles. Second line antibiotics were needed in 16/50 (32%) outpatient episodes of febrile neutropenia in contrast to 10/16 (72.5%) episodes of febrile neutropenia in inpatient courses (p=0.030). CONCLUSIONS Outpatient AML consolidation therapy is safe and feasible in children. It appears to result in less frequent invasive blood studies; shorter duration of febrile neutropenia and consequently less antimicrobial and antifungal usage as compared to inpatient consolidation cycles. To our knowledge, this report is the first of its kind looking specifically at outpatient consolidation chemotherapy in AML.
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Affiliation(s)
- Sameer Bakhshi
- Department of Medical Oncology, Dr B R A Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India.
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