Review of the value of colony stimulating factors for prophylaxis of febrile neutropenic episodes in adult patients treated for haematological malignancies

Costo- Efectividad Del Uso Profiláctico Del Factor Estimulante De Colonias De Granulocitos En Adultos Con Leucemia Linfoblástica Aguda en Colombia

OBJECTIVE

To assess the cost-effectiveness of prophylactic administration of Granulocyte Colony-Stimulating Factor (G-CSF) compared with no use of it, during the induction phase of chemotherapy in Adults with Acute Lymphoblastic Leukemia (ALL) in Colombia.

METHODS

A decision tree with a time horizon of 30 days was built under colombian health system perspective including only direct costs. The costs of procedures and medications were taken from official sources and an institution of national reference of oncology services. The safety and effectiveness data were taken from the literature and two Colombian cohorts with patients older than 15 years. The unit of outcome was the proportion of deaths avoided.

RESULTS

Base-case results on a clinical trial indicate that using factor is a dominant strategy. The variable that most impacted the outcome was the incidence of febrile neutropenia. Considering a threshold of $22.228 USD in 80% of cases using factor was cost effective. However, the use of factor is not cost-effective for the country for incidences of febrile neutropenia > 48%. It was not possible to establish cost-effectiveness of pegfilgrastim because no information was found.

CONCLUSION

As per Colombian data, the use of prophylactic factor under chemotherapeutic induction in adults with ALL, turns out to be not cost effective. The difference in the results suggests the need of a careful extrapolation of information from clinical trials (ideal world) for developing economic evaluations in Colombia.

Infectious complications of stem cell transplantation

Hematopoietic stem cell transplantation (HSCT) is an accepted treatment for a variety of hematologic malignancies. The profound immunosuppression these patients experience adversely affects their risk of infection. This risk is much higher than in the general population and requires aggressive diagnostic and therapeutic interventions. The chapter will outline the major infections after HSCT.

Infections in myelodysplastic syndromes

Myelodysplastic syndromes are associated with a risk of severe infections. While neutropenia is likely to be the main predisposing factor, several other immune defects have been reported, including impaired neutrophil function, B-, T- and NK-cell defects and the possible consequences of iron overload due to red blood cell transfusions. The advanced age of most patients, their frequent comorbidities, and the fact that drugs such as hypomethylating agents and lenalidomide, which are effective in myelodysplastic syndromes but can transiently worsen neutropenia, may increase the risk of infection and their severity in this context. The majority of infections in myelodysplastic syndromes are bacterial, while the incidence of fungal infections is not well known and viral infections seem to be rare. No prophylactic measures against infections have demonstrated efficacy in myelodysplastic syndromes. However, pending more data, we propose here some recommendations for the management of patients with myelodysplastic syndromes. In the future, an important contribution can be made by prospective trials testing the efficacy of prophylactic and therapeutic approaches to infection in these patients, especially in the context of the new drugs available for myelodysplastic syndromes.

Epidemiology of febrile neutropenia in children with central nervous system tumor: results from a single center prospective study

Data regarding the epidemiology febrile neutropenia during chemotherapy for pediatric central nervous system neoplasia are scarce. Data retrieved from a prospective study performed from January 2002 to December 2004 at G.Gaslini Children Hospital, Genoa, Italy, where analyzed to evaluate proportions, rate for 1000 neutropenic days and etiology of fever in neutropenic children receiving gentle, standard, or peripheral blood stem cell transplant (PBSCT) therapy for central nervous system tumor. During the study duration, 243 periods of neutropenia (granulocyte count <1000/cmm), accounting for 3544 patient-days at risk, were documented in 62 children. A total of 72 febrile episodes were observed in 66 (27%) neutropenic periods, for a rate of 20.31. A primary febrile episode was observed in 10% of neutropenic periods after gentle chemotherapy, in 30% after standard chemotherapy, and in 48% after PBSCT (P<0.0001). The rate of primary febrile episodes was 6.19 after a gentle chemotherapy, 27.02 after standard treatment, and 31.02 after PBSCT (P<0.0001). In a multivariable regression model, the type of chemotherapy (gentle vs. standard and PBSCT) and the thresholds of granulocyte count at neutropenia onset (999-501/cmm and 500-101/cmm vs. ≤100/cmm) were the only factors significantly associated with the development of febrile neutropenia.

Epidemiology and outcome of Rhodotorula infection in haematological patients

Rhodotorula spp. are emergent opportunistic pathogens, particularly in haematological patients. However, no systematic review of this infection has been undertaken in this high-risk patient group. The aim of this study was to review all reported cases of Rhodotorula infection to determine the epidemiology and outcome of this infection in this high-risk population. The 29 reported cases were fungaemias. The most common underlying haematological disorder was the presence of acute leukaemia (65.5%). Rhodotorula mucilaginosa was the species found more frequently (79.3%). Most cases (58.6%) had several risk factors (≥ 3) simultaneously. The most common predisposing factors were the presence of central venous catheter (CVC, 100%) and neutropenia (62.1%). A substantial number of patients (81.5%) received antifungal treatment with amphotericin B. The overall mortality was higher (13.8%) than that described in non-haematological patients (5.8% in solid-organ neoplasms and 9% in AIDS or other chronic diseases). Patients with acute leukaemia had a higher mortality rate (15.7%) than patients with non-Hodgkin's lymphoma (0%). Our data suggest that patients with acute leukaemia might be managed as high-risk patients and intensive measures might be taken. In addition, it appears that the subgroup of patients without acute leukaemia have a good outcome and might be managed as low-risk patients with a less intensive approach.

Acute Myelogenous Leukemia and Febrile Neutropenia

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.