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Stohs EJ, Abbas A, Freifeld A. Approach to febrile neutropenia in patients undergoing treatments for hematologic malignancies. Transpl Infect Dis 2024; 26:e14236. [PMID: 38349035 DOI: 10.1111/tid.14236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 12/19/2023] [Accepted: 12/21/2023] [Indexed: 04/12/2024]
Abstract
Febrile neutropenia (FN) is common among hematologic malignancy patients, including recipients of hematopoietic cell transplantation (HCT) and cellular therapies such as chimeric antigen receptor (CAR)-T-cell therapy. Prompt empiric antibiotic use has been the mainstay for decades but a "one-size-fits-all" approach is no longer broadly accepted, as treatment-related infectious risk are more understood. Growing antimicrobial resistance is an increasing clinical challenge. Evolving strategies on de-escalation of broad-spectrum antibiotics in FN without identified infection are areas of particular interest.
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Affiliation(s)
- Erica J Stohs
- Division of Infectious Diseases, Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Anum Abbas
- Division of Infectious Diseases, Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Alison Freifeld
- Division of Infectious Diseases, Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
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Pérez-Lazo G, Del Valle-Mendoza J, Sandoval-Ahumada R, Soto-Febres F, Castillo-Córdova R, Zárate-Tantaleán M, Morales-Castillo L, Páucar-Miranda CJ, Altamirano-Molina M, Pacheco-Modesto I, Ruiz de Somocurcio-Cruzado C, Arana-Jurado D, Del Villar-Alarcón C, Vargas-Castro O, Díaz-Bardales C, Guerrero-Arismendiz B, Eyzaguirre-Zapata R, Aguilar-Luis MA, Martins-Luna J, Silva-Caso W. Impact of Adding a Rapid PCR-Based Blood Culture Identification Panel to the Antimicrobial Stewardship Program of Patients with Febrile Neutropenia in a Peruvian Referral Hospital. Antibiotics (Basel) 2023; 12:antibiotics12040648. [PMID: 37107010 PMCID: PMC10135419 DOI: 10.3390/antibiotics12040648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/20/2023] [Accepted: 03/21/2023] [Indexed: 04/29/2023] Open
Abstract
The addition of Biofire® FilmArray® Blood Culture Identification panel 2 (BCID2) to the antimicrobial stewardship program (ASP) could improve outcomes in bloodstream infections (BSI) of patients with febrile neutropenia (FN). A pre- and post-quasi-experimental single-center study was conducted at a reference hospital in Peru. Three groups were considered: patients with BSI before ASP intervention (control group), patients with BSI after ASP intervention (group 1), and patients with BSI after ASP intervention plus BCID2 PCR Panel implementation (group 2). Overall, 93 patients were identified (32 control, 30 group 1, 31 group 2). The median time to effective therapy was significantly shorter in group 2 compared to group 1 and control group, respectively (3.75 vs. 10 h, p = 0.004; 3.75 vs. 19 h, p < 0.001). No significant differences in terms of relapse of bacteremia, in-hospital mortality (all cause), and 30-day-all-cause hospital readmission between the three study periods were found. The appropriateness of empirical antimicrobial use, adding or change, and the following de-escalation or discontinuation was significant when the two intervention periods were compared with the control group (p < 0.001). In addition to the lack of local studies documenting the microbiological profile of FN episodes, adding syndromic panels-based testing could allow for the consolidation of ASP strategies.
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Affiliation(s)
- Giancarlo Pérez-Lazo
- Escuela de Medicina, Universidad César Vallejo, Piura 20001, Peru
- Division of Infectious Diseases, Guillermo Almenara Irigoyen National Hospital-EsSalud, Lima 15033, Peru
| | - Juana Del Valle-Mendoza
- Centro de Investigación e Innovación de la Facultad de Ciencias de la Salud, Universidad Peruana de Ciencias Aplicadas, Lima 15023, Peru
| | - Roxana Sandoval-Ahumada
- Clinical Pathology Department, Guillermo Almenara Irigoyen National Hospital-EsSalud, Lima 15033, Peru
| | - Fernando Soto-Febres
- Division of Infectious Diseases, Guillermo Almenara Irigoyen National Hospital-EsSalud, Lima 15033, Peru
| | - Raúl Castillo-Córdova
- Division of Infectious Diseases, Guillermo Almenara Irigoyen National Hospital-EsSalud, Lima 15033, Peru
| | - Melissa Zárate-Tantaleán
- Clinical Pathology Department, Guillermo Almenara Irigoyen National Hospital-EsSalud, Lima 15033, Peru
| | - Liliana Morales-Castillo
- Clinical Pathology Department, Guillermo Almenara Irigoyen National Hospital-EsSalud, Lima 15033, Peru
| | | | | | - Iván Pacheco-Modesto
- Clinical Hematology Service, Guillermo Almenara Irigoyen National Hospital-EsSalud, Lima 15033, Peru
| | | | - Denis Arana-Jurado
- Clinical Hematology Service, Guillermo Almenara Irigoyen National Hospital-EsSalud, Lima 15033, Peru
| | - Carmen Del Villar-Alarcón
- Clinical Hematology Service, Guillermo Almenara Irigoyen National Hospital-EsSalud, Lima 15033, Peru
| | - Olga Vargas-Castro
- Clinical Hematology Service, Guillermo Almenara Irigoyen National Hospital-EsSalud, Lima 15033, Peru
| | - Carol Díaz-Bardales
- Clinical Hematology Service, Guillermo Almenara Irigoyen National Hospital-EsSalud, Lima 15033, Peru
| | - Bruno Guerrero-Arismendiz
- Clinical Hematology Service, Guillermo Almenara Irigoyen National Hospital-EsSalud, Lima 15033, Peru
| | - Renee Eyzaguirre-Zapata
- Clinical Hematology Service, Guillermo Almenara Irigoyen National Hospital-EsSalud, Lima 15033, Peru
| | - Miguel Angel Aguilar-Luis
- Centro de Investigación e Innovación de la Facultad de Ciencias de la Salud, Universidad Peruana de Ciencias Aplicadas, Lima 15023, Peru
| | - Johanna Martins-Luna
- Centro de Investigación e Innovación de la Facultad de Ciencias de la Salud, Universidad Peruana de Ciencias Aplicadas, Lima 15023, Peru
| | - Wilmer Silva-Caso
- Centro de Investigación e Innovación de la Facultad de Ciencias de la Salud, Universidad Peruana de Ciencias Aplicadas, Lima 15023, Peru
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Keck JM, Wingler MJB, Cretella DA, Vijayvargiya P, Wagner JL, Barber KE, Jhaveri TA, Stover KR. Approach to fever in patients with neutropenia: a review of diagnosis and management. Ther Adv Infect Dis 2022; 9:20499361221138346. [DOI: 10.1177/20499361221138346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 10/22/2022] [Indexed: 11/28/2022] Open
Abstract
Febrile neutropenia (FN) is associated with mortality rates as high as 40%, highlighting the importance of appropriate clinical management in this patient population. The morbidity and mortality of FN can be attributed largely to infectious processes, with specific concern for infections caused by pathogens with antimicrobial resistance. Expeditious identification of responsible pathogens and subsequent initiation of empiric antimicrobial therapy is imperative. There are four commonly used guidelines, which have variable recommendations for empiric therapy in these populations. All agree that changes could be made once patients are stable and/or with an absolute neutrophil count (ANC) over 500 cells/mcL. Diagnostic advances have the potential to improve knowledge of pathogens responsible for FN and decrease time to results. In addition, more recent data show that rapid de-escalation or discontinuation of empiric therapy, regardless of ANC, may reduce days of therapy, adverse effects, and cost, without affecting clinical outcomes. Antimicrobial and diagnostic stewardship should be performed to identify, utilize, and respond to appropriate rapid diagnostic tests that will aid in the definitive management of this population.
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Affiliation(s)
- J. Myles Keck
- University of Mississippi Medical Center, Jackson, MS, USA
| | | | | | | | - Jamie L. Wagner
- University of Mississippi School of Pharmacy, Jackson, MS, USA
| | - Katie E. Barber
- University of Mississippi School of Pharmacy, Jackson, MS, USA
| | | | - Kayla R. Stover
- School of Pharmacy, University of Mississippi, 2500 N State Street, Jackson, MS 39216, USA
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Morgan JE, Phillips B, Haeusler GM, Chisholm JC. Optimising Antimicrobial Selection and Duration in the Treatment of Febrile Neutropenia in Children. Infect Drug Resist 2021; 14:1283-1293. [PMID: 33833534 PMCID: PMC8019605 DOI: 10.2147/idr.s238567] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 02/11/2021] [Indexed: 12/13/2022] Open
Abstract
Febrile neutropenia (FN) is a frequent complication of cancer treatment in children. Owing to the potential for overwhelming bacterial sepsis, the recognition and management of FN requires rapid implementation of evidenced-based management protocols. Treatment paradigms have progressed from hospitalisation with broad spectrum antibiotics for all patients, through to risk adapted approaches to management. Such risk adapted approaches aim to provide safe care through incorporating antimicrobial stewardship (AMS) principles such as implementation of comprehensive clinical pathways incorporating de-escalation strategies with the imperative to reduce hospital stay and antibiotic exposure where possible in order to improve patient experience, reduce costs and diminish the risk of nosocomial infection. This review summarises the principles of risk stratification in FN, the current key considerations for optimising empiric antimicrobial selection including knowledge of antimicrobial resistance patterns and emerging technologies for rapid diagnosis of specific infections and summarises existing evidence on time to treatment, investigations required and duration of treatment. To aid treating physicians we suggest the key features based on current evidence that should be part of any FN management guideline and highlight areas for future research. The focus is on treatment of bacterial infections although fungal and viral infections are also important in this patient group.
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Affiliation(s)
- Jessica E Morgan
- Centre for Reviews and Dissemination, University of York, Heslington, YO10 5DD, UK.,Department of Paediatric Oncology, Leeds Teaching Hospitals NHS Trust, Leeds, LS1 3EX, UK
| | - Bob Phillips
- Centre for Reviews and Dissemination, University of York, Heslington, YO10 5DD, UK.,Department of Paediatric Oncology, Leeds Teaching Hospitals NHS Trust, Leeds, LS1 3EX, UK
| | - Gabrielle M Haeusler
- NHMRC National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, 3010, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, 3010, Australia.,Infection Diseases Unit, Department of General Medicine, Royal Children's Hospital, Parkville, Victoria, 3168, Australia.,Murdoch Children's Research Institute, Parkville, Victoria, 3052, Australia
| | - Julia C Chisholm
- Royal Marsden Hospital and Institute of Cancer Research, Sutton, SM2 5PT, UK
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Erickson RM, Tritle BJ, Spivak ES, Timbrook TT. Impact of an Antimicrobial Stewardship Bundle for Uncomplicated Gram-Negative Bacteremia. Open Forum Infect Dis 2019; 6:ofz490. [PMID: 32128333 PMCID: PMC7047945 DOI: 10.1093/ofid/ofz490] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 11/12/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Recent studies in gram-negative bacteremia (GNB) suggest that intravenous (IV) to oral (PO) switch and short treatment durations yield similar clinical outcomes and fewer adverse events. Antimicrobial stewardship program (ASP) bundled initiatives have been associated with improved clinical outcomes for bloodstream infections. METHODS This single-center retrospective cohort evaluation included inpatient adults from 11/2014-10/2015 and 10/2017-9/2018 with GNB. The pre-ASP period was before the establishment of an ASP program. In the post period, the ASP promoted IV-to-PO switches, avoidance of repeat blood cultures, and short treatment durations for patients with uncomplicated GNB. The primary outcome was duration of antibiotic therapy. Secondary outcomes included process measures associated with the bundle and clinical outcomes. RESULTS One hundred thirty-seven patients met criteria for inclusion, with 51 patients in the pre group and 86 patients in the post group. Background characteristics were similar between groups. The median duration of therapy (interquartile range) was 14 (10-16) days in the pre group and 10 days (7-14) in the post group (P < .001). The median day of IV-to-PO switch was day 5 (4-6) in the pre group vs day 4 (3-5) in the post group (P = .046). The average total hospital cost per case decreased by 27% in the post group (P = .19). Mortality rates and bacteremia recurrence were not significantly different between groups. CONCLUSIONS An ASP bundle for uncomplicated GNB was associated with reduced durations of therapy and earlier PO switch. These findings highlight the synergistic role of ASPs in optimizing antibiotic use and promoting patient safety.
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Affiliation(s)
| | - Brandon J Tritle
- Department of Pharmacy, University of Utah Health, Salt Lake City, Utah, USA
| | - Emily S Spivak
- Division of Infectious Diseases, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Tristan T Timbrook
- Department of Pharmacy, University of Utah Health, Salt Lake City, Utah, USA
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Pillinger KE, Bouchard J, Withers ST, Mediwala K, McGee EU, Gibson GM, Bland CM, Bookstaver PB. Inpatient Antibiotic Stewardship Interventions in the Adult Oncology and Hematopoietic Stem Cell Transplant Population: A Review of the Literature. Ann Pharmacother 2019; 54:594-610. [PMID: 31771337 DOI: 10.1177/1060028019890886] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Objective: To review the use of antibiotic stewardship interventions in the adult oncology and hematopoietic cell transplantation (HCT) populations. Data Sources: A literature search of PubMed was performed from inception to October 31, 2019. The general search terms used were oncology, cancer, hematologic malignancy, antimicrobial stewardship, antibiotic stewardship, febrile neutropenia, neutropenic fever, de-escalation, discontinuation, prophylaxis, practice guidelines, clinical pathway, rapid diagnostics, Filmarray, Verigene, MALDI-TOF, antibiotic allergy, and antimicrobial resistance. Study Selection and Data Extraction: Relevant English-language studies describing interventions supported by the Infectious Diseases Society of America guidelines on "Implementing an Antibiotic Stewardship Program" were included. Data Synthesis: Antibiotic stewardship publications in the oncology population have increased in recent years. Studies have described the impact of stewardship interventions, including preauthorization, prospective audit and feedback, implementation of clinical pathways, de-escalation of empirical antibiotics for febrile neutropenia (FN) prior to neutrophil recovery, allergy assessments, and use of rapid diagnostic testing. Many of these interventions have been shown to decrease antibiotic use without increased negative consequences, such as affecting length of stay or mortality. Relevance to Patient Care and Clinical Practice: This review synthesizes available evidence for implementing antibiotic stewardship interventions, particularly de-escalation of antibiotics for FN and implementation of clinical pathways for FN and sepsis, in oncology patients and HCT recipients. Summary tables highlight studies and specific research needs for clinicians. Conclusions: Immunocompromised populations, including oncology patients, have often been excluded from stewardship studies. Antibiotic stewardship is effective in reducing antibiotic consumption and improving outcomes in this patient population, although more quality data are needed.
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