How I manage haematology patients with septic shock

Treatment-Related Mortality From Infectious Complications in an Acute Leukemia Clinic

Background

The main causes of mortality in patients with acute leukemia are the infectious complications. The author wanted to know the induction-related mortality and treatment-related mortality in the acute leukemia patients at the Instituto Nacional de Cancerologia (INCan), Mexico. Also the author is interested in finding out the micro-organism and the main site of infection to make some changes in the management of patients in these clinics. Primary objective was induction chemotherapy-related mortality and treatment-related mortality. Secondary objective was to determine the site of infection, micro-organism, type of chemotherapy related with more mortality and relapse mortality.

Methods

This was a retrospective case-series analysis of all patients who were admitted to the INCan Acute Leukemia Clinic between January 2012 and December 2015 with febrile neutropenic complications. We reviewed the case histories of all patients, including those with acute lymphoblastic leukemia (ALL), acute myeloblastic leukemia (AML), acute biphenotypic leukemia and acute promyelocytic leukemia, regardless of disease status (newly diagnosed or relapsed) at the time of clinic attendance. Patients who died as the result of an infectious complication during the analysis window were identified, and their demographics, disease characteristics, treatment history (chemotherapy within 45 days of date of death) and details of the infectious complication resulting in death were collected.

Results

Of the 313 patients studied during that time period, 84 (27%) died as a result of infectious complications. Lung infections were the most common, accounting for 67% of all deaths from infectious complications. Escherichia coli producing extended-spectrum beta-lactamases was the most frequently isolated infectious organism (12 patients; 14%). The majority of deaths occurred during either induction therapy (27 patients; 32%) or treatment for a first relapse (25 patients; 30%). Hyperfractionated cyclophosphamide, vincristine, doxorubicin and dexamethasone (hyper-CVAD) was the chemotherapy regimen most commonly received within 45 days prior to death (17 patients; 20%).

Conclusions

Our findings suggest a need for long-term management and supportive care to prevent infectious complication-associated fatalities during both initial chemotherapy and subsequent disease relapse in patients with acute leukemia. The use of prophylaxis will help patients to prevent complications.

Early discontinuation of antibiotics for febrile neutropenia versus continuation until neutropenia resolution in people with cancer

BACKGROUND

People with cancer with febrile neutropenia are at risk of severe infections and mortality and are thus treated empirically with broad-spectrum antibiotic therapy. However, the recommended duration of antibiotic therapy differs across guidelines.

OBJECTIVES

To assess the safety of protocol-guided discontinuation of antibiotics regardless of neutrophil count, compared to continuation of antibiotics until neutropenia resolution in people with cancer with fever and neutropenia, in terms of mortality and morbidity. To assess the emergence of resistant bacteria in people with cancer treated with short courses of antibiotic therapy compared with people with cancer treated until resolution of neutropenia.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 10) in the Cochrane Library, MEDLINE, Embase, and LILACS up to 1 October 2018. We searched the metaRegister of Controlled Trials and the US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov for ongoing and unpublished trials. We reviewed the references of all identified studies for additional trials and handsearched conference proceedings of international infectious diseases and oncology and haematology conferences.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared a short antibiotic therapy course in which discontinuation of antibiotics was guided by protocols regardless of the neutrophil count to a long course in which antibiotics were continued until neutropenia resolution in people with cancer with febrile neutropenia. The primary outcome was 30-day or end of follow-up all-cause mortality.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed all studies for eligibility, extracted data, and assessed risk of bias for all included trials. We calculated risk ratios (RRs) with 95% confidence intervals (CIs) whenever possible. For dichotomous outcomes with zero events in both arms of the trials, we conducted meta-analysis of risk differences (RDs) as well. For continuous outcomes, we extracted means with standard deviations (SD) from the studies and computed mean difference (MD) and 95% CI. If no substantial clinical heterogeneity was found, trials were pooled using the Mantel-Haenszel fixed-effect model.

MAIN RESULTS

We included eight RCTs comprising a total of 662 distinct febrile neutropenia episodes. The studies included adults and children, and had variable design and criteria for discontinuation of antibiotics in both study arms. All included studies but two were performed before the year 2000. All studies included people with cancer with fever of unknown origin and excluded people with microbiological documented infections.We found no significant difference between the short-antibiotic therapy arm and the long-antibiotic therapy arm for all-cause mortality (RR 1.38, 95% CI 0.73 to 2.62; RD 0.02, 95% CI -0.02 to 0.05; low-certainty evidence). We downgraded the certainty of the evidence to low due to imprecision and high risk of selection bias. The number of fever days was significantly lower for people in the short-antibiotic treatment arm compared to the long-antibiotic treatment arm (mean difference -0.64, 95% CI -0.96 to -0.32; I² = 30%). In all studies, total antibiotic days were fewer in the intervention arm by three to seven days compared to the long antibiotic therapy. We found no significant differences in the rates of clinical failure (RR 1.23, 95% CI 0.85 to 1.77; very low-certainty evidence). We downgraded the certainty of the evidence for clinical failure due to variable and inconsistent definitions of clinical failure across studies, possible selection bias, and wide confidence intervals. There was no significant difference in the incidence of bacteraemia occurring after randomisation (RR 1.56, 95% CI 0.91 to 2.66; very low-certainty evidence), while the incidence of any documented infections was significantly higher in the short-antibiotic therapy arm (RR 1.67, 95% CI 1.08 to 2.57). There was no significant difference in the incidence of invasive fungal infections (RR 0.86, 95% CI 0.32 to 2.31) and development of antibiotic resistance (RR 1.49, 95% CI 0.62 to 3.61). The data on hospital stay were too sparse to permit any meaningful conclusions.

AUTHORS' CONCLUSIONS

We could make no strong conclusions on the safety of antibiotic discontinuation before neutropenia resolution among people with cancer with febrile neutropenia based on the existing evidence and its low certainty. Results of microbiological outcomes favouring long antibiotic therapy may be misleading due to lower culture positivity rates under antibiotic therapy and not true differences in infection rates. Well-designed, adequately powered RCTs are required that address this issue in the era of rising antibiotic resistance.

Clinical research in febrile neutropenia in cancer patients: Past achievements and perspectives for the future

Febrile neutropenia (FN) is responsible for significant morbidity and mortality. It can also be the reason for delaying or changing potentially effective treatments and generates substantial costs. It has been recognized for more than 50 years that empirical administration of broad spectrum antibiotics to patients with FN was associated with much improved outcomes; that has become a paradigm of management. Increase in the incidence of microorganisms resistant to many antibiotics represents a challenge for the empirical antimicrobial treatment and is a reason why antibiotics should not be used for the prevention of neutropenia. Prevention of neutropenia is best performed with the use of granulocyte colony-stimulating factors (G-CSFs). Prophylactic administration of G-CSFs significantly reduces the risk of developing FN and consequently the complications linked to that condition; moreover, the administration of G-CSF is associated with few complications, most of which are not severe. The most common reason for not using G-CSF as a prophylaxis of FN is the relatively high cost. If FN occurs, in spite of prophylaxis, empirical therapy with broad spectrum antibiotics is mandatory. However it should be adjusted to the risk of complications as established by reliable predictive instruments such as the Multinational Association for Supportive Care in Cancer. Patients predicted at a low level of risk of serious complications, can generally be treated with orally administered antibiotics and as out-patients. Patients with a high risk of complications should be hospitalized and treated intravenously. A short period of time between the onset of FN and beginning of empirical therapy is crucial in those patients. Persisting fever in spite of antimicrobial therapy in neutropenic patients requires a special diagnostic attention, since invasive fungal infection is a possible cause for it and might require the use of empirical antifungal therapy.

Evaluating the effectiveness and safety of hydrocortisone therapy in cancer patients with septic shock

PURPOSE

To evaluate the effectiveness and safety of hydrocortisone (HC) in cancer patients with septic shock.

METHODS

This was a retrospective study of adult cancer patients with septic shock who received low-dose HC therapy (200 mg/day). The effectiveness of HC was assessed by determining the proportion of patients with reversal of septic shock, time to reversal, and mortality. The safety was assessed by determining the incidences of hyperglycemia, hypernatremia, and secondary infections, using a case-control approach.

RESULTS

During the study period, 96 patients were enrolled. Reversal of septic shock was reported in 46 (47.9%) patients, median time to reversal was 1.9 days (range 0.2-7.6), ICU mortality was reported in 62 (65.26%) patients, and 28-day mortality in 64 (66.7%) patients. The incidence of secondary infections was higher in patients who received HC therapy, compared to patients who did not receive HC during septic shock: 44.8% vs 27.4%, P = 0.028.

CONCLUSIONS

HC therapy was associated with resolution of septic shock in about half of the patients and a high incidence of secondary infections. Prospective studies are needed to fully assess the efficacy and safety of HC in cancer patients with septic shock.

Neurologic complications of bone marrow transplantation

Although bone marrow transplantation has been recognized as an effective therapy for malignant and nonmalignant blood disorders, the modality has also been associated with side-effects and complications. Among these adverse events, neurologic complications emerged as an important and frequent source of treatment-related morbidity and mortality. The survival of patients who died from complications related to central nervous system abnormalities appears to be shorter compared to those who died from non-neurological complications. The incidence of neurologic complications appears to correlate with the degree of human leukocyte antigen (HLA) disparity and the risk status of the underlying disease. Nonrelapse mortality associated with reduced intensity regimens is lower compared to myeloablative conditioning regimens. However, reduced intensity regimens are still associated with significant incidence of complications, including graft-versus-host disease, opportunistic infections, organ toxicity, and neurologic complications. Complications of sepsis-related encephalopathy in mechanically ventilated patients are frequently either overlooked or misdiagnosed. Obtaining a microbiological diagnosis through body fluid cultures or tissue identification is important in order to identify the source of infection and guide an effective antimicrobial therapy. However, pursuing a microbiological diagnosis must not delay the administration of antibiotics and resuscitation of a patient with septic shock.

Improving the immediate management of neutropenic sepsis in the UK: lessons from a national audit

Recent disquiet at inadequacies in the immediate management of neutropenic sepsis in the UK led to a new, gold standard 'door-to-needle' time of 1 h for the administration of intravenous antibiotics. The aim of this audit was to identify whether that target is being met nationally, the potential barriers to its achievement, and concrete recommendations for how to overcome these. We also sought to establish the degree of regional heterogeneity in current local management protocols. Questionnaires were sent to haematologists across the UK to determine their unit's immediate management of patients presenting from the community with possible neutropenic sepsis. Local protocols and audits were also requested. Data covering 95 different hospitals were received, covering a combined catchment area of nearly 30 million people. There were marked regional inconsistencies in the definition of 'neutropenic sepsis' and almost every aspect of its immediate management. Only 26% of audited patients (n=627) received intravenous antibiotics within the target time of 1 h. Median door-to-needle times ranged from 30 min to 4 h. Long delays of over 5 h were not uncommon.