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Takigawa M, Tanaka H, Suwa J, Obara T, Maeda Y, Sato M, Shimazaki Y, Onoda T, Ishigami A, Ishii T. Accuracy of Therapeutic Drug Monitoring of Teicoplanin at the Onset of Febrile Neutropenia. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59040758. [PMID: 37109716 PMCID: PMC10145105 DOI: 10.3390/medicina59040758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 04/12/2023] [Indexed: 04/29/2023]
Abstract
Background and Objectives: Teicoplanin (TEIC) is an effective drug for patients with febrile neutropenia (FN); however, it has been reported that these patients may have increased TEIC clearance compared with patients who do not have FN. The purpose of this study was to study therapeutic drug monitoring in patients with FN when the TEIC dosing design was based on the population mean method. Materials and Methods: Thirty-nine FN patients with hematological malignancy were included in the study. To calculate the predicted blood concentration of TEIC, we used the two population pharmacokinetic (population PK) parameters (parameters 1 and 2) reported by Nakayama et al. and parameter 3, which is a modification of the population PK of Nakayama et al. We calculated the mean prediction error (ME), an indicator of prediction bias, and the mean absolute prediction error (MAE), an indicator of accuracy. Furthermore, the percentage of predicted TEIC blood concentration within 25% and 50% of the measured TEIC blood concentration was calculated. Results: The ME values were -0.54, -0.25, and -0.30 and the MAE values were 2.29, 2.19, and 2.22 for parameters 1, 2, and 3, respectively. For all of the three parameters, the ME values were calculated as minus values, and the predicted concentrations tended to be biased toward smaller values relative to the measured concentrations. Patients with serum creatinine (Scr) < 0.6 mg/dL and neutrophil counts < 100/μL had greater ME and MAE values and a smaller percentage of predicted TEIC blood concentration within 25% of measured TEIC blood concentrations compared with other patients. Conclusions: In patients with FN, the accuracy of predicting TEIC blood concentrations was good, with no significant differences between each parameter. However, patients with a Scr < 0.6 mg/dL and a neutrophil count < 100/μL showed slightly inferior prediction accuracy.
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Affiliation(s)
- Masaki Takigawa
- Department of Pharmacy, Tokyo Metropolitan Geriatric Hospital, 35-2 Sakae-cho, Itabashi, Tokyo 173-0015, Japan
- Molecular Regulation of Aging, Tokyo Metropolitan Institute of Gerontology, 35-2 Sakae-cho, Itabashi, Tokyo 173-0015, Japan
- Department of Practical Pharmacy, Faculty of Pharmaceutical Sciences, Toho University, 2-2-1 Miyama, Funabashi, Chiba 274-8510, Japan
| | - Hiroyuki Tanaka
- Department of Practical Pharmacy, Faculty of Pharmaceutical Sciences, Toho University, 2-2-1 Miyama, Funabashi, Chiba 274-8510, Japan
| | - Junichi Suwa
- Department of Pharmacy, Tokyo Metropolitan Children's Medical Center, 2-8-28 Musashidai, Huchu, Tokyo 183-8561, Japan
| | - Tomoya Obara
- Department of Pharmacy, Tokyo Metropolitan Geriatric Hospital, 35-2 Sakae-cho, Itabashi, Tokyo 173-0015, Japan
| | - Yohei Maeda
- Department of Pharmacy, Tokyo Metropolitan Geriatric Hospital, 35-2 Sakae-cho, Itabashi, Tokyo 173-0015, Japan
| | - Mamoru Sato
- Department of Pharmacy, Tokyo Metropolitan Geriatric Hospital, 35-2 Sakae-cho, Itabashi, Tokyo 173-0015, Japan
| | - Yoshitomo Shimazaki
- Department of Pharmacy, Tokyo Metropolitan Geriatric Hospital, 35-2 Sakae-cho, Itabashi, Tokyo 173-0015, Japan
| | - Toshihisa Onoda
- Department of Practical Pharmacy, Faculty of Pharmaceutical Sciences, Toho University, 2-2-1 Miyama, Funabashi, Chiba 274-8510, Japan
| | - Akihito Ishigami
- Molecular Regulation of Aging, Tokyo Metropolitan Institute of Gerontology, 35-2 Sakae-cho, Itabashi, Tokyo 173-0015, Japan
| | - Toshihiro Ishii
- Department of Practical Pharmacy, Faculty of Pharmaceutical Sciences, Toho University, 2-2-1 Miyama, Funabashi, Chiba 274-8510, Japan
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Douglas A, Thursky K, Slavin M. New approaches to management of fever and neutropenia in high-risk patients. Curr Opin Infect Dis 2022; 35:500-516. [PMID: 35947070 DOI: 10.1097/qco.0000000000000872] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
PURPOSE OF REVIEW Patients receiving treatment for acute leukaemia and haematopoietic cell transplantation (HCT) have prolonged neutropenia and are at high risk of neutropenic fever, with bacterial and particularly invasive fungal infections as feared complications, possessing potentially serious consequences including intensive care admission and mortality. Concerns for these serious complications often lead to long durations of broad-spectrum antimicrobial therapy and escalation to even broader therapy if fever persists. Further, the default approach is to continue neutropenic fever therapy until count recovery, leaving many patients who have long defervesced on prolonged antibiotics. RECENT FINDINGS This article details recent progress in this field with particular emphasis on early discontinuation studies in resolved neutropenic fever and improved imaging techniques for the investigation of those with persistent neutropenic fever. Recent randomized controlled trials have shown that early cessation of empiric neutropenic fever therapy is well tolerated in acute leukaemia and autologous HCT patients who are clinically stable and afebrile for 72 h. Delineation of the best approach to cessation (timing and/or use of fluoroquinolone prophylaxis) and whether this approach is well tolerated in the higher risk allogeneic HCT setting is still required. Recent RCT data demonstrate utility of FDG-PET/CT to guide management and rationalize antimicrobial therapy in high-risk patient groups with persistent neutropenic fever. SUMMARY Acute leukaemic and autologous HCT patients with resolved neutropenic fever prior to count recovery can have empiric therapy safely discontinued or de-escalated. There is an emerging role of FDG-PET/CT to support decision-making about antibiotic and antifungal use in high-risk persistent/recurrent neutropenic fever patients.
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Affiliation(s)
- Abby Douglas
- National Centre for Infections in Cancer.,Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne
| | - Karin Thursky
- National Centre for Infections in Cancer.,Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne.,National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne.,Department of Health Services Research, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Monica Slavin
- National Centre for Infections in Cancer.,Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne.,Victorian Infectious Diseases Service, Royal Melbourne Hospital.,Department of Health Services Research, Peter MacCallum Cancer Centre, Melbourne, Australia
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Fida M, Wolf MJ, Hamdi A, Vijayvargiya P, Esquer Garrigos Z, Khalil S, Greenwood-Quaintance KE, Thoendel MJ, Patel R. Detection of Pathogenic Bacteria From Septic Patients Using 16S Ribosomal RNA Gene-Targeted Metagenomic Sequencing. Clin Infect Dis 2021; 73:1165-1172. [PMID: 33893492 PMCID: PMC8492209 DOI: 10.1093/cid/ciab349] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Conventional blood cultures were compared to plasma cell-free DNA-based 16S ribosomal RNA (rRNA) gene polymerase chain reaction (PCR)/next-generation sequencing (NGS) for detection and identification of potential pathogens in patients with sepsis. METHODS Plasma was prospectively collected from 60 adult patients with sepsis presenting to the Mayo Clinic (Minnesota) Emergency Department from March through August 2019. Results of routine clinical blood cultures were compared to those of 16S rRNA gene NGS. RESULTS Nineteen (32%) subjects had positive blood cultures, of which 13 yielded gram-negative bacilli, 5 gram-positive cocci, and 1 both gram-negative bacilli and gram-positive cocci. 16S rRNA gene NGS findings were concordant in 11. For the remaining 8, 16S rRNA gene NGS results yielded discordant detections (n = 5) or were negative (n = 3). Interestingly, Clostridium species were additionally detected by 16S rRNA gene NGS in 3 of the 6 subjects with gastrointestinal sources of gram-negative bacteremia and none of the 3 subjects with urinary sources of gram-negative bacteremia. In the 41 remaining subjects, 16S rRNA gene NGS detected at least 1 potentially pathogenic organism in 17. In 15, the detected microorganism clinically correlated with the patient's syndrome. In 17 subjects with a clinically defined infectious syndrome, neither test was positive; in the remaining 7 subjects, a noninfectious cause of clinical presentation was identified. CONCLUSIONS 16S rRNA gene NGS may be useful for detecting bacteria in plasma of septic patients. In some cases of gram-negative sepsis, it may be possible to pinpoint a gastrointestinal or urinary source of sepsis based on the profile of bacteria detected in plasma.
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Affiliation(s)
- Madiha Fida
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Division of Clinical Microbiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthew J Wolf
- Division of Clinical Microbiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ahmed Hamdi
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Prakhar Vijayvargiya
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Division of Infectious Diseases, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississipi, USA
| | - Zerelda Esquer Garrigos
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Division of Infectious Diseases, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississipi, USA
| | - Sarwat Khalil
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Department of Infectious Diseases and International Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Matthew J Thoendel
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Robin Patel
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Division of Clinical Microbiology, Mayo Clinic, Rochester, Minnesota, USA
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Wang Y, Du Z, Chen Y, Liu Y, Yang Z. Meta-analysis: combination of meropenem vs ceftazidime and amikacin for empirical treatment of cancer patients with febrile neutropenia. Medicine (Baltimore) 2021; 100:e24883. [PMID: 33663117 PMCID: PMC7909104 DOI: 10.1097/md.0000000000024883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 12/09/2020] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Meropenem monotherapy vs ceftazidime plus amikacin have been approved for use against febrile neutropenia. To assess the effectiveness and safety of them for empirical treatment of cancer patients with febrile neutropenia, we conducted a meta-analysis of randomized controlled trial. METHODS Randomized controlled trials on ceftazidime plus amikacin, or/and monotherapy with meropenem for the treatment of cancer patients with febrile neutropenia were identified by searching Cochrane Library, PubMed, Science Direct, Wiley Online, Science Citation Index, Google (scholar), National Center for Biotechnology Information, and China National Knowledge Infrastructure. Data on interventions, participants' characteristics and the outcomes of therapy, were extracted for statistical analysis. Seven trials fulfilled the inclusion criteria. RESULT The treatment with ceftazidime plus amikacin was more effective than meropenem (OR = 1.17; 95% CI 0.93-1.46; 1270 participants). However, the treatment effects of the 2 therapy methods were almost parallel in adults (OR = 1.15; 95% CI 0.91-1.46; 1130 participants older than 16). Drug-related adverse effects afflicted more patients treated with ceftazidime plus amikacin (OR = 0.78; 95% CI 0.52-1.15; 1445 participants). The common responses were nausea, diarrhea, rash, and increased in serum glutamic oxaloacetic transaminase, serum glutamic pyruvic transaminase and bilirubin. CONCLUSION Ceftazidime plus amikacin should be the first choice for empirical treatment of cancer patients with febrile neutropenia, and meropenem may be chosen as a last defense against pathogenic bacteria.
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Affiliation(s)
- Ying Wang
- Department of Pharmacology, Medical College and Affiliated Hospital of Hebei University of Engineering
| | - Zhichao Du
- Department of Pharmacology, Medical College and Affiliated Hospital of Hebei University of Engineering
| | | | | | - Zhitang Yang
- Department of Neurology, Affiliated Hospital of Hebei University of Engineering, Handan, Hebei, PR China
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Kayal S, Madasamy P, Pattnaik J. Commentary on Cefepime versus Cefoperazone/Sulbactam in Combination with Amikacin as Empirical Antibiotic Therapy in Febrile Neutropenia. Indian J Med Paediatr Oncol 2020. [DOI: 10.4103/ijmpo.ijmpo_237_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Smita Kayal
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Ponraj Madasamy
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Jogamaya Pattnaik
- Department of Medical Oncology, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India
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Kuriyama K, Koyama Y, Tsuto K, Tokuhira N, Nagata H, Muramatsu A, Oshiro M, Hirakawa Y, Iwai T, Uchiyama H. Gastric lymphoma complicated by phlegmonous gastritis and Guillain-Barré syndrome: A case report. Medicine (Baltimore) 2020; 99:e20030. [PMID: 32358382 PMCID: PMC7440357 DOI: 10.1097/md.0000000000020030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Complications such as severe infection may occur during the chemotherapy of malignant lymphoma. Phlegmonous gastritis (PG) is a rare acute bacterial infection associated with high mortality, requiring early diagnosis, and prompt management. In addition, Guillain-Barré syndrome (GBS) occasionally requires early treatment and intensive care management due to the occurrence of severe neuropathy and respiratory failure. PATIENT CONCERNS A 70-year-old male was diagnosed with primary gastric diffuse large B-cell lymphoma (DLBCL) after the detection of several polypoid tumors with ulcers. The patient underwent chemotherapy for DLBCL and exhibited adverse effects (i.e., fever, vomiting, epigastric pain, and neutropenia). Computed tomography indicated widespread thickening in the gastric wall. Furthermore, approximately 2 weeks later, the patient presented with gradual symmetric lower extremity weakness and respiratory failure due to paralysis of the respiratory muscle. DIAGNOSES DLBCL was diagnosed through a gastric tumor biopsy. On the basis of the computed tomography findings, a culture of gastric juice, nerve conduction studies, and clinical symptoms, this case of gastric lymphoma was complicated with PG and GBS. INTERVENTIONS The patient was treated with antimicrobial therapy and administration of granulocyte colony-stimulating factor for PG, and with intravenous immunoglobulin and intensive care management for GBS. OUTCOMES Despite the aggressive progress of the condition, the patient improved without relapse of DLBCL. CONCLUSION PG was regarded as a precedent infection of GBS. In this article, we present the first reported case of gastric lymphoma complicated with PG and GBS.
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Affiliation(s)
| | | | | | - Natsuko Tokuhira
- Department of Anesthesiology, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
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Tori K, Tansarli GS, Parente DM, Kalligeros M, Ziakas PD, Mylonakis E. The cost-effectiveness of empirical antibiotic treatments for high-risk febrile neutropenic patients: A decision analytic model. Medicine (Baltimore) 2020; 99:e20022. [PMID: 32443305 PMCID: PMC7254453 DOI: 10.1097/md.0000000000020022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Febrile neutropenia has a significant clinical and economic impact on cancer patients. This study evaluates the cost-effectiveness of different current empiric antibiotic treatments. METHODS A decision analytic model was constructed to compare the use of cefepime, meropenem, imipenem/cilastatin, and piperacillin/tazobactam for treatment of high-risk patients. The analysis was performed from the perspective of U.S.-based hospitals. The time horizon was defined to be a single febrile neutropenia episode. Cost-effectiveness was determined by calculating costs and deaths averted. Cost-effectiveness acceptability curves for various willingness-to-pay thresholds (WTP), were used to address the uncertainty in cost-effectiveness. RESULTS The base-case analysis results showed that treatments were equally effective but differed mainly in their cost. In increasing order: treatment with imipenem/cilastatin cost $52,647, cefepime $57,270, piperacillin/tazobactam $57,277, and meropenem $63,778. In the probabilistic analysis, mean costs were $52,554 (CI: $52,242-$52,866) for imipenem/cilastatin, $57,272 (CI: $56,951-$57,593) for cefepime, $57,294 (CI: $56,978-$57,611) for piperacillin/tazobactam, and $63,690 (CI: $63,370-$64,009) for meropenem. Furthermore, with a WTP set at $0 to $50,000, imipenem/cilastatin was cost-effective in 66.2% to 66.3% of simulations compared to all other high-risk options. DISCUSSION Imipenem/cilastatin is a cost-effective strategy and results in considerable health care cost-savings at various WTP thresholds. Cost-effectiveness analyses can be used to differentiate the treatments of febrile neutropenia in high-risk patients.
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Affiliation(s)
- Katerina Tori
- Division of Infectious Diseases, Brown University, Warren Alpert Medical School
| | | | - Diane M. Parente
- Department of Pharmacy, The Miriam Hospital, Providence, Rhode Island, USA
| | - Markos Kalligeros
- Division of Infectious Diseases, Brown University, Warren Alpert Medical School
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Oyake T, Takemasa-Fujisawa Y, Sugawara N, Mine T, Tsukushi Y, Hanamura I, Fujishima Y, Aoki Y, Kowata S, Ito S, Ishida Y. Doripenem versus meropenem as first-line empiric therapy of febrile neutropenia in patients with acute leukemia: a prospective, randomized study. Ann Hematol 2019; 98:1209-1216. [PMID: 30824955 DOI: 10.1007/s00277-019-03634-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 02/03/2019] [Indexed: 10/27/2022]
Abstract
Febrile neutropenia is often observed in patients with hematologic malignancies, especially in those with acute leukemia. Meropenem has potent and broad antibacterial activity against gram-positive and gram-negative bacteria, and is recommended as first-line empiric therapy for febrile neutropenia. In contrast, the safety and efficacy of doripenem in patients with febrile neutropenia and hematologic malignancies is limited. In this randomized, prospective, cooperative, open-label trial, we compared doripenem (1.0 g every 8 h) to meropenem (1.0 g every 8 h) as first-line empiric antibacterial treatment of febrile neutropenia. To evaluate efficacy and safety, 133 hospitalized patients with acute leukemia or high-risk myelodysplastic syndrome, who developed febrile neutropenia during or after chemotherapy, were randomized to each drug. Resolution of fever within 3 to 5 days without treatment modification (i.e., the primary endpoint) did not significantly differ between the doripenem and meropenem groups (60.0% vs. 45.6%, respectively; P = 0.136). However, resolution of fever within 7 days of treatment was significantly higher in the doripenem group than in the meropenem group (78.4% vs. 60.2%, respectively; P = 0.037). Similar rates of adverse events (grades 1-2) were observed in both groups. Thus, we conclude that both drugs are safe and well-tolerated for the treatment of febrile neutropenia in patients with acute leukemia or high-risk myelodysplastic syndrome, and that the clinical efficacy of doripenem is noninferior to that of meropenem. UMIN Clinical Trial Registry number: 000006124.
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Affiliation(s)
- Tatsuo Oyake
- Division of Hematology and Oncology, Department of Internal Medicine, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka City, Iwate, 020-8505, Japan.
| | - Yuka Takemasa-Fujisawa
- Division of Hematology and Oncology, Department of Internal Medicine, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka City, Iwate, 020-8505, Japan
| | - Norifumi Sugawara
- Division of Hematology, Department of Internal Medicine, Iwate Prefectural Chubu Hospital, Kitakami, Japan
| | - Takahiro Mine
- Division of Hematology, Department of Internal Medicine, Morioka Red Cross Hospital, Morioka, Japan
| | - Yasuhiko Tsukushi
- Division of Hematology, Department of Internal Medicine, Hachinohe Red Cross Hospital, Hachinohe, Japan
| | - Ichiro Hanamura
- Division of Hematology, Department of Internal Medicine, Aichi Medical University School of Medicine, Nagoya, Japan
| | - Yukiteru Fujishima
- Division of Hematology and Oncology, Department of Internal Medicine, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka City, Iwate, 020-8505, Japan
| | - Yusei Aoki
- Division of Hematology and Oncology, Department of Internal Medicine, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka City, Iwate, 020-8505, Japan
| | - Shugo Kowata
- Division of Hematology and Oncology, Department of Internal Medicine, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka City, Iwate, 020-8505, Japan
| | - Shigeki Ito
- Department of Clinical Oncology, Iwate Medical University School of Medicine, Morioka, Japan
| | - Yoji Ishida
- Division of Hematology and Oncology, Department of Internal Medicine, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka City, Iwate, 020-8505, Japan
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Klemencic S, Perkins J. Diagnosis and Management of Oncologic Emergencies. West J Emerg Med 2019; 20:316-322. [PMID: 30881552 PMCID: PMC6404710 DOI: 10.5811/westjem.2018.12.37335] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 12/13/2018] [Accepted: 12/13/2018] [Indexed: 02/06/2023] Open
Abstract
Oncologic emergencies may be seen in any emergency department and will become more frequent as our population ages and more patients receive chemotherapy. Life-saving interventions are available for certain oncologic emergencies if the diagnosis is made in a timely fashion. In this article we will cover neutropenic fever, tumor lysis syndrome, hypercalcemia of malignancy, and hyperviscosity syndrome. After reading this article the reader should be much more confident in the diagnosis, evaluation, and management of these oncologic emergencies.
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Affiliation(s)
- Sarah Klemencic
- Virginia Tech Carilion School of Medicine, Department of Emergency Medicine, Roanoke, Virginia
| | - Jack Perkins
- Virginia Tech Carilion School of Medicine, Department of Emergency Medicine, Roanoke, Virginia
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10
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Anoshirvani AA, Zarinfar N, Rafiee M, Zamani Z. Effect of Combination Therapy of Ceftazidime/Amikacin and Monotherapy with Imipenem on the Treatment of Fever and Neutropenia in Patients with Cancers. Open Access Maced J Med Sci 2018; 6:1423-1430. [PMID: 30159069 PMCID: PMC6108819 DOI: 10.3889/oamjms.2018.310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 07/23/2018] [Accepted: 07/26/2018] [Indexed: 11/10/2022] Open
Abstract
AIM: This study aimed to compare the effect of Imipenem monotherapy and combination therapy with Ceftazidime/Amikacin in febrile episodes in neutropenic cancer patients. MATERIALS AND METHODS: In this double-blind randomised trial, 122 adult patients with cancer, neutropenia and fever who were treated by chemotherapy were gathered by simple sampling method and were divided randomly to two equal Imipenem (IP) and Ceftazidime/Amikacin (CA) groups. 500 mg of Imipenem was administered every 6 hours IP group and 2 g of Ceftazidimeplus 15 mg/kg/day in 2 equally divided doses of Amikacin was administered in the CA group. The treatment was continued for 72 hours in both groups. Data were analysed with SPSS19. RESULTS: There was a significant difference between the mean temperatures of three days in each group (P < 0.001). There was no significant difference between the two groups regarding microbial response to antibiotics. There was no significant difference between 19 patients of IP and 13 patients of CA groups regarding bacteriologically documented infection (P = 0.3). CONCLUSION: Unmodified therapy by Imipenem is as effective as combinational therapy by Ceftazidime/Amikacin in clinically and bacteriologically documented infection.
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Affiliation(s)
- Ali Arash Anoshirvani
- Department of Hematology and Medical Oncology, Arak University of Medical Sciences, Arak, Iran
| | - Nader Zarinfar
- Department of Infectious Disease, Arak University of Medical Sciences, Arak, Iran
| | - Mohammad Rafiee
- Department of Statistics and Epidemiology, Arak University of Medical Sciences, Arak, Iran
| | - Zahra Zamani
- Department of Internal Medicine, Arak University of Medical Sciences, Arak, Iran
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11
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Ponraj M, Dubashi B, Harish BH, Kayal S, Cyriac SL, Pattnaik J, Ranjith K, Pillai US, Jadhav N, Matta KK, Singh J, Jaffa E, Prakash B. Cefepime vs. cefoperazone/sulbactam in combination with amikacin as empirical antibiotic therapy in febrile neutropenia. Support Care Cancer 2018; 26:3899-3908. [DOI: 10.1007/s00520-018-4260-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 05/06/2018] [Indexed: 01/06/2023]
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12
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Lambregts MMC, Warreman EB, Bernards AT, Veelken H, von dem Borne PA, Dekkers OM, Visser LG, de Boer MG. Distribution and clinical determinants of time-to-positivity of blood cultures in patients with neutropenia. Eur J Haematol 2017; 100:206-214. [PMID: 29171916 DOI: 10.1111/ejh.13001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2017] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Blood cultures (BCs) are essential in the evaluation of neutropenic fever. Modern BC systems have significantly reduced the time-to-positivity (TTP) of BC. This study explores the probability of bacteraemia when BCs have remained negative for different periods of time. METHODS All adult patients with neutropenia and bacteraemia were included (January 2012-February 2016). Predictive clinical factors for short (≤16 hours) and long (>24 hours) TTP were determined. The residual probability of bacteraemia was estimated for the scenario of negative BC 24 hours after collection. RESULTS The cohort consisted of 154 patients, accounting for 190 episodes of bacteraemia. Median age of 61 years, 60.5% were male. In 123 (64.7%) episodes, BC yielded a single Gram-positive micro-organism and in 49 (25.8%) a Gram-negative micro-organism (median TTP 16.7, 14.5 hours respectively, P < .01). TTP was ≤24 hours in 91.6% of episodes. Central line-associated bacteraemia was associated with long TTP. The probability of bacteraemia if BC had remained negative for 24 hours was 1%-3%. CONCLUSIONS The expected TTP offers guidance in the management of patients with neutropenia and suspected bacteraemia. The knowledge of negative BC can support a change in working diagnosis, and impact clinical decisions as soon as 24 hours after BC collection.
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Affiliation(s)
- Merel M C Lambregts
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
| | - Eva B Warreman
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
| | - Alexandra T Bernards
- Department of Microbiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Hendrik Veelken
- Department of Haematology, Leiden University Medical Center, Leiden, The Netherlands
| | - Peter A von dem Borne
- Department of Haematology, Leiden University Medical Center, Leiden, The Netherlands
| | - Olaf M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Leo G Visser
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
| | - Mark G de Boer
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
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13
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Marchetti O, Tissot F, Calandra T. Infections in the Cancer Patient. Infect Dis (Lond) 2017. [DOI: 10.1016/b978-0-7020-6285-8.00079-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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14
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Nakane T, Tamura K, Hino M, Tamaki T, Yoshida I, Fukushima T, Tatsumi Y, Nakagawa Y, Hatanaka K, Takahashi T, Akiyama N, Tanimoto M, Ohyashiki K, Urabe A, Masaoka T, Kanamaru A. Cefozopran, meropenem, or imipenem-cilastatin compared with cefepime as empirical therapy in febrile neutropenic adult patients: A multicenter prospective randomized trial. J Infect Chemother 2015; 21:16-22. [PMID: 25239059 DOI: 10.1016/j.jiac.2014.08.026] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2014] [Revised: 08/19/2014] [Accepted: 08/20/2014] [Indexed: 10/24/2022]
Abstract
We conducted an open-label, randomized study to evaluate the clinical efficacy of cefozopran, meropenem or imipenem-cilastatin using cefepime as a control in febrile neutropenia (FN) patients. Three hundred and seventy-six patients received cefepime, cefozopran, meropenem or imipenem-cilastatinas initial therapy for FN. The primary endpoint was the non-inferiority of response rates including modification at day 7 in cefozopran, meropenem or imipenem-cilastatin patients compared with cefepime in the per-protocol population (delta = 10%). The response rates for cefozopran, meropenem and imipenem-cilastatin were not significantly different compared with cefepime (cefozopran: 54/90 (60%), meropenem: 60/92 (65%), and IPM/CS: 63/88 (72%) versus cefepime: 56/85 (66%) (p = 0.44, 1.0 and 0.51, respectively)), and the differences in treatment success for cefozopran, meropenem and imipenem-cilastatin compared with cefepime were -5.9% (95% confidence interval (CI): -20.1-8.4), -0.7% (95% CI: -14.6-13.3), and 5.7% (95% CI: -8.1-19.4), respectively. The same tendency was seen in the modified intention-to-treat population. Based on the evaluation of initial drug efficacy performed on days 3-5, there was no significant difference between the four drugs. In the subgroup with an absolute neutrophil count ≤ 100 × 10(6)/L for longer than seven days, there was significantly better efficacy in the carbapenem arm compared to 4th generation beta-lactams (52% versus 27% at days 3-5, p = 0.006, and 76% versus 48% at day 7, p = 0.002). Our results suggest that the effects of these four drugs as empiric therapy were virtually the same for adult FN patients, although non-inferiority was shown only in imipenem-cilastatin compared with cefepime (clinical trial number: UMIN000000462).
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Affiliation(s)
- Takahiko Nakane
- Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan.
| | - Kazuo Tamura
- Department of Oncology, Hematology, and Infectious Diseases, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Masayuki Hino
- Hematology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | | | - Isao Yoshida
- Hematologic Oncology, Shikoku Cancer Center, Ehime, Japan
| | | | - Youichi Tatsumi
- Department of Hematology, Rheumatology, and Nephrology, Kinki University School of Medicine, Osaka, Japan
| | - Yasuaki Nakagawa
- Department of Hematology, Japanese Red Cross Medical Center, Japan
| | - Kazuo Hatanaka
- Department of Hematology/Oncology, Wakayama Medical University, Wakayama, Japan
| | - Tsutomu Takahashi
- Department of Oncology/Hematology, Shimane University Hospital, Shimane, Japan
| | - Nobu Akiyama
- Department of Internal Medicine, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Mitsune Tanimoto
- Department of Hematology, Okayama University School of Medicine, Okayama, Japan
| | - Kazuma Ohyashiki
- First Department of Internal Medicine, Tokyo Medical University, Tokyo, Japan
| | | | - Toru Masaoka
- Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
| | - Akihisa Kanamaru
- Department of Internal Medicine, Kinki University School of Medicine, Osaka, Japan
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15
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Association between early peak temperature and mortality in neutropenic sepsis. Ann Hematol 2014; 94:857-64. [DOI: 10.1007/s00277-014-2273-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 12/02/2014] [Indexed: 10/24/2022]
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16
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Efficacy of an Alternative Dosing Strategy of Meropenem in the Treatment of High-Risk Febrile Neutropenia in Adult Subjects. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2014. [DOI: 10.1097/ipc.0000000000000141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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17
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Napier EB. Ceftazidime for neutropenic fevers: is it still an appropriate choice? J Adv Pract Oncol 2014; 4:394-401. [PMID: 25032019 PMCID: PMC4093453 DOI: 10.6004/jadpro.2013.4.6.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Infection continues to rank as a primary cause of treatment-related mortality in patients with cancer. For patients with neutropenic fevers, immediate empiric treatment with antibiotics is standard care. However, which specific antibiotic is best for initial treatment of high-risk patients has been much debated without consensus. Many major health centers use intravenous ceftazidime as first-line therapy for these patients. Yet updates to guidelines published by the Infectious Diseases Society of America and the National Comprehensive Cancer Network suggest that ceftazidime may no longer be an optimal choice. This article reviews the literature regarding ceftazidime therapy for the treatment of high-risk neutropenic patients with fevers. This critical analysis of existing research reveals significant pharmacologic, physiologic, social, and financial implications, and recommendations for further studies are made.
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18
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Goulenok T, Fantin B. Antimicrobial treatment of febrile neutropenia: pharmacokinetic-pharmacodynamic considerations. Clin Pharmacokinet 2014; 52:869-83. [PMID: 23807657 DOI: 10.1007/s40262-013-0086-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Patients with cancer or hematologic diseases are particularly at risk of infection leading to high morbidity, mortality and costs. Extensive data show that optimization of the administration of antimicrobials according to their pharmacokinetic and pharmacodynamic parameters improves clinical outcome. Evidence is growing that when pharmacokinetic and pharmacodynamic parameters are used to target not only clinical cure but also eradication, the selection resistance is also contained. This is of particular importance in patients with neutropenia in whom increasing rates of drug-resistant Gram-negative bacteria have been reported, particularly Pseudomonas aeruginosa. Based on experimental and clinical studies, pharmacokinetic and pharmacodynamic parameters are discussed in this review for each antibiotic used in febrile neutropenia in order to help physicians improve dosing and optimization of antimicrobial agents.
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Affiliation(s)
- Tiphaine Goulenok
- Internal Medicine Department, Beaujon Hospital, APHP and University Paris Diderot, Sorbonne Paris Cité, Paris, France
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19
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Cannon JP, Lee TA, Clark NM, Setlak P, Grim SA. The risk of seizures among the carbapenems: a meta-analysis. J Antimicrob Chemother 2014; 69:2043-55. [PMID: 24744302 DOI: 10.1093/jac/dku111] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES A consensus exists among clinicians that imipenem/cilastatin is the most epileptogenic carbapenem, despite inconsistencies in the literature. METHODS We conducted a meta-analysis of all randomized controlled trials comparing carbapenems with each other or with non-carbapenem antibiotics to assess the risk of seizures for imipenem, meropenem, ertapenem and doripenem. RESULTS In the risk difference (RD) analysis, there were increased patients with seizure (2 per 1000 persons, 95% CI 0.001, 0.004) among recipients of carbapenems versus non-carbapenem antibiotics. This difference was largely attributed to imipenem as its use was associated with an additional 4 patients per 1000 with seizure (95% CI 0.002, 0.007) compared with non-carbapenem antibiotics, whereas none of the other carbapenems was associated with increased seizure. Similarly, in the pooled OR analysis, carbapenems were associated with a significant increase in the risk of seizures relative to non-carbapenem comparator antibiotics (OR 1.87, 95% CI 1.35, 2.59). The ORs for risk of seizures from imipenem, meropenem, ertapenem and doripenem compared with other antibiotics were 3.50 (95% CI 2.23, 5.49), 1.04 (95% CI 0.61, 1.77), 1.32 (95% CI 0.22, 7.74) and 0.44 (95% CI 0.13, 1.53), respectively. In studies directly comparing imipenem and meropenem, there was no difference in epileptogenicity in either RD or pooled OR analyses. CONCLUSIONS The absolute risk of seizures with carbapenems was low, albeit higher than with non-carbapenem antibiotics. Although imipenem was more epileptogenic than non-carbapenem antibiotics, there was no statistically significant difference in the imipenem versus meropenem head-to-head comparison.
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Affiliation(s)
- Joan P Cannon
- Pharmacy Services, Hines VA Hospital, Hines, IL, USA
| | - Todd A Lee
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - Nina M Clark
- Department of Medicine, Division of Infectious Diseases, Loyola University Chicago, Maywood, IL, USA
| | | | - Shellee A Grim
- Department of Medicine, Division of Infectious Diseases, Loyola University Chicago, Maywood, IL, USA Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
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20
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Abstract
Neutropenia remains the predominant predisposing factor for infection in most cancer patients. Bacterial and fungal infections are common in this setting. Not all neutropenic patients have the same risk of developing severe infection or serious medical complications. Although all patients with neutropenia and fever should receive prompt, empiric antibiotic therapy, low-risk patients can be effectively managed without hospitalization-often with the administration of oral antibiotics. Other patients need hospital-based therapy. The emergence of resistant microorganisms has become a significant problem in neutropenic patients. Frequent epidemiologic surveys to detect the emergence of resistant organisms are recommended. Antibiotic stewardship and Infection Control Programs are important tools in combating resistant organisms.
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Affiliation(s)
- Kenneth V I Rolston
- Department of Infectious Diseases, Infection Control, and Employee Health, V.T. MD Anderson Cancer Center, 1515 Holcombe BLVD, Houston, TX, 77030, USA,
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21
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Abstract
BACKGROUND Meropenem is an effective β-lactam antibiotic that is frequently used to treat serious infections in both intensive care unit (ICU) and febrile neutropenic hematology/oncology (Hem/Onc) patients. Studies suggest that to be effective, meropenem concentrations must be maintained above the inhibitory concentrations for the majority of a dosing interval. However, the pharmacokinetics (PK) of meropenem seem to differ in critically ill patients compared with healthy or less ill subjects used to select labeled dosing regimens. OBJECTIVES This study was designed to investigate meropenem PK in critically ill patients and to see how often standard dosing regimens produced adequate plasma concentrations. A secondary objective was to investigate how achieved concentrations were related to outcomes (morbidity and mortality) in these patients. METHODS Meropenem plasma concentrations over time were measured using a high pressure liquid chromatography assay in febrile Hem/Onc and ICU patients who were treated with standard meropenem dosing schedules. Outcomes such as fever control and survival were assessed in these patients and compared with individual meropenem PK data and with recommended target concentrations. RESULTS A total of 25 subjects including 10 febrile Hem/Onc and 15 ICU patients with a variety of serious illnesses and baseline renal function were studied. Mean peak concentrations were less variable than were pre-dose concentrations. Post peak and trough concentrations were often below recommended minimum inhibitory concentrations. Both clearance and volumes of distribution were greater than reported in less ill subjects, only in part explained by increased renal clearance. Therefore, serum concentrations often did not exceed recommended concentration targets even for moderately sensitive organisms. Inadequate concentrations were especially common in the mostly ill, febrile neutropenic Hem/Onc subjects and seemed to explain at least some therapeutic failures. Conversely, drug accumulation occurred in ICU subjects with decreased renal function. CONCLUSIONS Standard meropenem dosing regimens were inadequate in many critically ill febrile, neutropenic Hem/Onc, and septic ICU patients. These data suggest a role for meropenem concentration monitoring in such patients.
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Abstract
Neutropenic fever sepsis syndromes are common among patients with cancer who are receiving intensive cytotoxic systemic therapy. Recognition of the syndromes and timely initial antibacterial therapy is critical for survival and treatment success. Outcomes are linked to myeloid reconstitution and recovery from neutropenia, control of active comorbidities, and appropriate treatment of the infections that underlie the sepsis syndrome. Hematologists and oncologists must be clear about the prognosis and treatment goals to work effectively with critical care physicians toward the best outcomes for patients with cancer who develop neutropenic sepsis syndromes.
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Affiliation(s)
- Eric J Bow
- Department of Medical Microbiology and Infectious Diseases, The University of Manitoba, Winnipeg, Manitoba R3T 2N2, Canada.
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23
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Bloodstream infections in adult patients with cancer: clinical features and pathogenic significance of Staphylococcus aureus bacteremia. Support Care Cancer 2011; 20:2371-8. [DOI: 10.1007/s00520-011-1353-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2011] [Accepted: 12/12/2011] [Indexed: 10/14/2022]
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24
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Paul M, Yahav D, Bivas A, Fraser A, Leibovici L. Cochrane Review: Anti-pseudomonal beta-lactams for the initial, empirical, treatment of febrile neutropenia: comparison of beta-lactams. ACTA ACUST UNITED AC 2011. [DOI: 10.1002/ebch.879] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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25
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VAN VLIET M, POTTING C, STURM P, DONNELLY J, BLIJLEVENS N. How prompt is prompt in daily practice? Earlier initiation of empirical antibacterial therapy for the febrile neutropenic patient. Eur J Cancer Care (Engl) 2011; 20:679-85. [DOI: 10.1111/j.1365-2354.2011.01264.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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26
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Legrand M, Max A, Schlemmer B, Azoulay E, Gachot B. The strategy of antibiotic use in critically ill neutropenic patients. Ann Intensive Care 2011; 1:22. [PMID: 21906359 PMCID: PMC3224396 DOI: 10.1186/2110-5820-1-22] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2011] [Accepted: 06/15/2011] [Indexed: 11/12/2022] Open
Abstract
Suspicion of sepsis in neutropenic patients requires immediate antimicrobial treatment. The initial regimen in critically ill patients should cover both Gram-positive and Gram-negative pathogens, including Pseudomonas aeruginosa. However, the risk of selecting multidrug-resistant pathogens should be considered when using broad-spectrum antibiotics for a prolonged period of time. The choice of the first-line empirical drugs should take into account the underlying malignancy, local bacterial ecology, clinical presentation and severity of acute illness. This review provides an up-to-date guide that will assist physicians in choosing the best strategy regarding the use of antibiotics in neutropenic patients, with a special focus on critically ill patients, based on the above-mentioned considerations and on the most recent international guidelines and literature.
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Affiliation(s)
- Matthieu Legrand
- Department of Anesthesiology and Critical Care, Lariboisière Hospital, Assistance Publique - Hopitaux de Paris, University of Paris 7 Denis Diderot, 2 rue Ambroise-Paré, 75475 Paris, Cedex 10, France
- Medical Intensive Care Unit, AP-HP, Saint-Louis Hospital, 1 rue Claude Vellefaux, Assistance Publique - Hopitaux de Paris, University of Paris 7 Denis Diderot, 75010, Paris, France
| | - Adeline Max
- Medical Intensive Care Unit, AP-HP, Saint-Louis Hospital, 1 rue Claude Vellefaux, Assistance Publique - Hopitaux de Paris, University of Paris 7 Denis Diderot, 75010, Paris, France
| | - Benoît Schlemmer
- Medical Intensive Care Unit, AP-HP, Saint-Louis Hospital, 1 rue Claude Vellefaux, Assistance Publique - Hopitaux de Paris, University of Paris 7 Denis Diderot, 75010, Paris, France
| | - Elie Azoulay
- Medical Intensive Care Unit, AP-HP, Saint-Louis Hospital, 1 rue Claude Vellefaux, Assistance Publique - Hopitaux de Paris, University of Paris 7 Denis Diderot, 75010, Paris, France
| | - Bertrand Gachot
- Department of Intensive Care and Infectious Diseases, Institut Gustave Roussy, 39, rue Camille Desmoulins, 94805 Villejuif cedex, France
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27
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Lee DG, Kim SH, Kim SY, Kim CJ, Park WB, Song YG, Choi JH. Evidence-based guidelines for empirical therapy of neutropenic fever in Korea. Korean J Intern Med 2011; 26:220-52. [PMID: 21716917 PMCID: PMC3110859 DOI: 10.3904/kjim.2011.26.2.220] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Neutrophils play an important role in immunological function. Neutropenic patients are vulnerable to infection, and except fever is present, inflammatory reactions are scarce in many cases. Additionally, because infections can worsen rapidly, early evaluation and treatments are especially important in febrile neutropenic patients. In cases in which febrile neutropenia is anticipated due to anticancer chemotherapy, antibiotic prophylaxis can be used, based on the risk of infection. Antifungal prophylaxis may also be considered if long-term neutropenia or mucosal damage is expected. When fever is observed in patients suspected to have neutropenia, an adequate physical examination and blood and sputum cultures should be performed. Initial antibiotics should be chosen by considering the risk of complications following the infection; if the risk is low, oral antibiotics can be used. For initial intravenous antibiotics, monotherapy with a broad-spectrum antibiotic or combination therapy with two antibiotics is recommended. At 3-5 days after beginning the initial antibiotic therapy, the condition of the patient is assessed again to determine whether the fever has subsided or symptoms have worsened. If the patient's condition has improved, intravenous antibiotics can be replaced with oral antibiotics; if the condition has deteriorated, a change of antibiotics or addition of antifungal agents should be considered. If the causative microorganism is identified, initial antimicrobial or antifungal agents should be changed accordingly. When the cause is not detected, the initial agents should continue to be used until the neutrophil count recovers.
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Affiliation(s)
- Dong-Gun Lee
- National Evidence-based Healthcare Collaborating Agency, Seoul, Korea.
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28
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Freifeld AG, Bow EJ, Sepkowitz KA, Boeckh MJ, Ito JI, Mullen CA, Raad II, Rolston KV, Young JAH, Wingard JR. Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the infectious diseases society of america. Clin Infect Dis 2011; 52:e56-93. [PMID: 21258094 DOI: 10.1093/cid/cir073] [Citation(s) in RCA: 1812] [Impact Index Per Article: 139.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
This document updates and expands the initial Infectious Diseases Society of America (IDSA) Fever and Neutropenia Guideline that was published in 1997 and first updated in 2002. It is intended as a guide for the use of antimicrobial agents in managing patients with cancer who experience chemotherapy-induced fever and neutropenia. Recent advances in antimicrobial drug development and technology, clinical trial results, and extensive clinical experience have informed the approaches and recommendations herein. Because the previous iteration of this guideline in 2002, we have a developed a clearer definition of which populations of patients with cancer may benefit most from antibiotic, antifungal, and antiviral prophylaxis. Furthermore, categorizing neutropenic patients as being at high risk or low risk for infection according to presenting signs and symptoms, underlying cancer, type of therapy, and medical comorbidities has become essential to the treatment algorithm. Risk stratification is a recommended starting point for managing patients with fever and neutropenia. In addition, earlier detection of invasive fungal infections has led to debate regarding optimal use of empirical or preemptive antifungal therapy, although algorithms are still evolving. What has not changed is the indication for immediate empirical antibiotic therapy. It remains true that all patients who present with fever and neutropenia should be treated swiftly and broadly with antibiotics to treat both gram-positive and gram-negative pathogens. Finally, we note that all Panel members are from institutions in the United States or Canada; thus, these guidelines were developed in the context of North American practices. Some recommendations may not be as applicable outside of North America, in areas where differences in available antibiotics, in the predominant pathogens, and/or in health care-associated economic conditions exist. Regardless of venue, clinical vigilance and immediate treatment are the universal keys to managing neutropenic patients with fever and/or infection.
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Affiliation(s)
- Alison G Freifeld
- Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
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29
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Freifeld AG, Bow EJ, Sepkowitz KA, Boeckh MJ, Ito JI, Mullen CA, Raad II, Rolston KV, Young JAH, Wingard JR. Executive Summary: Clinical Practice Guideline for the Use of Antimicrobial Agents in Neutropenic Patients with Cancer: 2010 Update by the Infectious Diseases Society of America. Clin Infect Dis 2011; 52:427-31. [DOI: 10.1093/cid/ciq147] [Citation(s) in RCA: 508] [Impact Index Per Article: 39.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Abstract
This document updates and expands the initial Infectious Diseases Society of America (IDSA) Fever and Neutropenia Guideline that was published in 1997 and first updated in 2002. It is intended as a guide for the use of antimicrobial agents in managing patients with cancer who experience chemotherapy-induced fever and neutropenia.
Recent advances in antimicrobial drug development and technology, clinical trial results, and extensive clinical experience have informed the approaches and recommendations herein. Because the previous iteration of this guideline in 2002, we have a developed a clearer definition of which populations of patients with cancer may benefit most from antibiotic, antifungal, and antiviral prophylaxis. Furthermore, categorizing neutropenic patients as being at high risk or low risk for infection according to presenting signs and symptoms, underlying cancer, type of therapy, and medical comorbidities has become essential to the treatment algorithm. Risk stratification is a recommended starting point for managing patients with fever and neutropenia. In addition, earlier detection of invasive fungal infections has led to debate regarding optimal use of empirical or preemptive antifungal therapy, although algorithms are still evolving.
What has not changed is the indication for immediate empirical antibiotic therapy. It remains true that all patients who present with fever and neutropenia should be treated swiftly and broadly with antibiotics to treat both gram-positive and gram-negative pathogens.
Finally, we note that all Panel members are from institutions in the United States or Canada; thus, these guidelines were developed in the context of North American practices. Some recommendations may not be as applicable outside of North America, in areas where differences in available antibiotics, in the predominant pathogens, and/or in health care–associated economic conditions exist. Regardless of venue, clinical vigilance and immediate treatment are the universal keys to managing neutropenic patients with fever and/or infection.
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Affiliation(s)
- Alison G. Freifeld
- Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Eric J. Bow
- Departments of Medical Microbiology and Internal Medicine, the University of Manitoba, and Infection Control Services, Cancer Care Manitoba, Winnipeg, Manitoba, Canada
| | - Kent A. Sepkowitz
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York
| | - Michael J. Boeckh
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research, Seattle, Washington
| | - James I. Ito
- Division of Infectious Diseases, City of Hope National Medical Center, Duarte, California
| | - Craig A. Mullen
- Department of Pediatrics, University of Rochester Medical Center, Rochester, New York
| | - Issam I. Raad
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Kenneth V. Rolston
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas M.D. Anderson Cancer Center, Houston, Texas
| | - Jo-Anne H. Young
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - John R. Wingard
- Division of Hematology/Oncology, University of Florida, Gainesville, Florida
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30
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Lee DG, Kim SH, Kim SY, Kim CJ, Min CK, Park WB, Park YJ, Song YG, Jang JS, Jang JH, Jin JY, Choi JH. Evidence-based Guidelines for Empirical Therapy of Neutropenic Fever in Korea. Infect Chemother 2011. [DOI: 10.3947/ic.2011.43.4.285] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Dong-Gun Lee
- National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sung-Han Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Soo Young Kim
- Department of Family Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Chung-Jong Kim
- National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Chang-Ki Min
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Wan Beom Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Yeon-Joon Park
- Department of Laboratory Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Young Goo Song
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Joung-Soon Jang
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Jun Ho Jang
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong Youl Jin
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jung-Hyun Choi
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
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31
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Management of Gram-Positive Bacterial Disease: Staphylococcus aureus, Streptococcal, Pneumococcal and Enterococcal Infections. PRINCIPLES AND PRACTICE OF CANCER INFECTIOUS DISEASES 2011. [PMCID: PMC7120901 DOI: 10.1007/978-1-60761-644-3_35] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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32
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Paul M, Yahav D, Bivas A, Fraser A, Leibovici L. Anti-pseudomonal beta-lactams for the initial, empirical, treatment of febrile neutropenia: comparison of beta-lactams. Cochrane Database Syst Rev 2010; 2015:CD005197. [PMID: 21069685 PMCID: PMC9022089 DOI: 10.1002/14651858.cd005197.pub3] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Several beta-lactams are recommended as single agents for the treatment of febrile neutropenia. OBJECTIVES To compare the effectiveness of different anti-pseudomonal beta-lactams as single agents in the treatment of febrile neutropenia. To compare the development of bacterial resistance, bacterial and fungal superinfections during or following treatment with the different beta-lactams. SEARCH STRATEGY We searched the Cochane Register of Controlled Trials (CENTRAL), Issue 3, 2010. MEDLINE, EMBASE, LILACS, FDA drug applications, conference proceedings and ongoing clinical trial databases up to August 2010. References of included studies were scanned. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing an antipseudomonal beta-lactam to another antipseudomonal beta-lactam antibiotic, both given alone or with the addition of the same glycopeptide to both study arms, for the initial treatment of fever and neutropenia among cancer patients. DATA COLLECTION AND ANALYSIS Two review authors applied inclusion criteria and extracted the data independently. Missing data were sought. Risk ratios (RR) were calculated with 95% confidence intervals (CI), and pooled using the fixed effect model. The primary outcome was all-cause mortality. Risk of bias was assessed using a domain-based evaluation and its effect of results was assessed through sensitivity analyses. MAIN RESULTS Forty-four trials were included. The antibiotics assessed were cefepime, ceftazidime, piperacillin-tazobactam, imipenem and meropenem. Adequate allocation concealment and generation were reported in about half of the trials and only two trials were double-blinded. The risk for all-cause mortality was significantly higher with cefepime compared to other beta-lactams (RR 1.39, 95% CI 1.04 to 1.86, 21 trials, 3471 participants), without heterogeneity and with higher RRs in trials at low risk for bias. There were no differences in secondary outcomes but for a non-significantly higher rate of bacterial superinfections with cefepime. Mortality was significantly lower with piperacillin-tazobactam compared to other antibiotics (RR 0.56, 95% CI 0.34 to 0.92, 8 trials, 1314 participants), without heterogeneity. Carbapenems resulted in similar all-cause mortality and a lower rate of clinical failure and antibiotic modifications as compared to other antibiotics, but a higher rate of diarrhea caused by Clostridium difficile. AUTHORS' CONCLUSIONS Current evidence supports the use of piperacillin-tazobactam in locations where antibiotic resistance profiles do not mandate empirical use of carbapenems. Carbapenems result in a higher rate of antibiotic-associated and Clostridium difficile-associated diarrhea. There is a high level of evidence that all-cause mortality is higher with cefepime compared to other beta-lactams and it should not be used as monotherapy for patients with febrile neutropenia.
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Affiliation(s)
- Mical Paul
- Infectious Diseases Unit, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel, 49100
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Chong Y, Yakushiji H, Ito Y, Kamimura T. Cefepime-resistant Gram-negative bacteremia in febrile neutropenic patients with hematological malignancies. Int J Infect Dis 2010; 14 Suppl 3:e171-5. [DOI: 10.1016/j.ijid.2010.01.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2009] [Revised: 11/18/2009] [Accepted: 01/15/2010] [Indexed: 10/19/2022] Open
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Hirata Y, Yokote T, Kobayashi K, Nakayama S, Oka S, Miyoshi T, Akioka T, Hiraoka N, Iwaki K, Takayama A, Nishimura Y, Makino J, Takubo T, Tsuji M, Hanafusa T. Antifungal prophylaxis with micafungin in neutropenic patients with hematological malignancies. Leuk Lymphoma 2010; 51:853-9. [DOI: 10.3109/10428191003682726] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Marchetti O, Calandra T. Infections in the neutropenic cancer patient. Infect Dis (Lond) 2010. [DOI: 10.1016/b978-0-323-04579-7.00073-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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Bow EJ. Neutropenic fever syndromes in patients undergoing cytotoxic therapy for acute leukemia and myelodysplastic syndromes. Semin Hematol 2009; 46:259-68. [PMID: 19549578 DOI: 10.1053/j.seminhematol.2009.03.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Fever represents the major surrogate of infection in neutropenic cancer patients. A number of neutropenic fever syndromes have been recognized, the causes and significance of which will vary depending upon the clinical context. First neutropenic fever syndromes are typically of bacterial origin, the character of which may be influenced by whether antibacterial chemoprophylaxis has been administered. Persistent neutropenic fevers are documented during the empirical systemic antibacterial therapy for the first neutropenic fever, the cause of which is likely outside the spectrum of activity of the initial therapy. Recrudescent neutropenic fevers, defined by the appearance of a new fever after defervescence of the first fever, are often a function of invasive fungal infection or gram-positive infections outside the spectrum of the initial empirical antibacterial regimen. The myeloid reconstitution syndrome occurs in parallel with neutrophil recovery from aplasia and may not necessarily represent new infection. Recognition of these patterns can help the clinician make better clinical judgments and management plans.
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Affiliation(s)
- E J Bow
- Sections of Hematology/Oncology and Infectious Diseases, Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
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Abstract
Inadequate initial antimicrobial treatment in serious infections leads to increased mortality. Achieving adequate treatment is increasingly difficult because of the increasing prevalence of multidrug-resistant (MDR) pathogens. The carbapenems are potent, broad-spectrum antibiotics that have been shown to be safe and efficacious therapies in the treatment of serious infections. This review is intended to compare the 4 major members of the carbapenem class, which include imipenem, meropenem, ertapenem, and doripenem, with other widely used antimicrobial agents in the intensive care unit (ICU). The carbapenems are potent, broad-spectrum antibiotics that have been shown to be safe and efficacious therapies in the treatment of serious infections. They provide better gram-negative coverage than other beta-lactams and are stable against extended-spectrum beta-lactamases and AmpC beta-lactamases, making them effective in the treatment of many MDR bacteria. The newly approved carbapenem, doripenem, may help preserve the utility of the carbapenem class.
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Affiliation(s)
- Robert P Baughman
- Department of Internal Medicine, University of Cincinnati Medical Center, Cincinnati, Ohio 45267, USA.
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Williams KJ. The changing face of febrile neutropenia-from monotherapy to moulds to mucositis. Why monotherapy? J Antimicrob Chemother 2009; 63 Suppl 1:i18-20. [PMID: 19372175 DOI: 10.1093/jac/dkp077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
This is an account of the history of the early days of monotherapy of infections in neutropenic patients with haematological malignancies. A chance encounter with Ben de Pauw led to his introduction to clinical drug development research, introduced him to Peter Donnelly who was studying ceftazidime at the Hammersmith Hospital in London and led to a series of collaborative studies at the start of a distinguished research career. This paper is dedicated to Ben de Pauw and also to the memory of my mentor, Roy Foord, who had the vision to go against his initial cautious instinct and allow me to convince him of the merits of these studies when combinations including aminoglycosides were standard. These initial studies also contributed to the concept of initial empirical monotherapy with re-appraisal at 48-72 h.
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Affiliation(s)
- Keith J Williams
- KW Drug Developments Ltd, Nightingale House, 5 Maplewood Road, Wilmslow, Cheshire SK9 2RY, UK.
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de la Rubia J, Montesinos P, Martino R, Jarque I, Rovira M, Vázquez L, López J, Batlle M, de la Cámara R, Juliá A, Lahuerta JJ, Debén G, Díaz J, García R, Sanz MA. Imipenem/Cilastatin with or without Glycopeptide as Initial Antibiotic Therapy for Recipients of Autologous Stem Cell Transplantation: Results of a Spanish Multicenter Study. Biol Blood Marrow Transplant 2009; 15:512-6. [DOI: 10.1016/j.bbmt.2008.12.505] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2008] [Accepted: 12/22/2008] [Indexed: 10/21/2022]
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Abe M, Kamijo T, Matsuzawa S, Miki J, Nakazawa Y, Sakashita K, Okabe T, Honda T, Mitsuyama JI, Koike K. High incidence of meropenem resistance among alpha-hemolytic streptococci in children with cancer. Pediatr Int 2009; 51:103-6. [PMID: 19371287 DOI: 10.1111/j.1442-200x.2008.02663.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Infections caused by antibiotics-resistant Gram-positive bacteria have been reported from many pediatric hematology-oncology centers. METHODS The susceptibility profiles to meropenem, piperacillin, and vancomycin among oral flora isolates of alpha-hemolytic streptococci (AHS) obtained from six children with cancer who received several empirical therapies (ET) against febrile neutropenia, were investigated. RESULTS Meropenem minimum inhibitory concentration (MIC) of AHS isolated from ET patients was 2.167 +/- 0.258 microg/mL (mean +/- SD), which was significantly higher than the MIC of AHS isolated from control groups. Intriguingly, AHS isolated approximately 6 months after hospital discharge indicated recovery of susceptibility to meropenem. CONCLUSIONS AHS isolates from neutropenic children with cancer should be checked for antibiotic susceptibility, even against carbapenems.
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Affiliation(s)
- Masako Abe
- Department of Pediatrics, Shinshu University School of Medicine, Japan
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Toltzis P, Dul M, O'Riordan MA, Melnick D, Lo M, Blumer J. Meropenem use and colonization by antibiotic-resistant Gram-negative bacilli in a pediatric intensive care unit. Pediatr Crit Care Med 2009; 10:49-54. [PMID: 19057450 DOI: 10.1097/pcc.0b013e318193691a] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The carbapenems are broad-spectrum beta-lactam antibiotics with activity against most organisms encountered in the pediatric intensive care unit (PICU). In anticipation of their increased use in critically ill children, we measured the effect of sustained meropenem use on the pattern of Gram-negative bacillus colonization in patients admitted to a tertiary care PICU. DESIGN : Prospective preintervention/postintervention comparison. SETTING Medical/surgical PICU. PATIENTS Consecutive PICU admissions over 2.5 yrs. INTERVENTIONS After a 6-mo baseline period, all children with serious infections admitted to the PICU during the subsequent 2 yrs were administered meropenem. The incidence of colonization by Gram-negative bacilli resistant to one of a battery of broad-spectrum parenteral agents, and by organisms resistant specifically to meropenem, during the baseline period was compared with the period of preferred meropenem use. RESULTS During the period of preferred meropenem use, the amount of meropenem used increased >seven-fold, whereas the use of other advanced generation beta-lactams was reduced by nearly 80%. The mean prevalence of colonization by antibiotic-resistant bacilli in general was not statistically altered during the period of meropenem preference (7.3 organisms/100 patient-days, vs. 9.4 organisms/100 patient-days at baseline, p < 0.09). The prevalence of colonization by Gram-negative organisms resistant specifically to meropenem was 0.61 organisms/100 patient-days during the baseline period vs. 1.04 organisms/100 patient-days during the period of meropenem preference (p < 0.30). The incidence of nosocomial infections did not change, and the prevalence of nosocomial infections caused by meropenem-resistant organisms was always <1% of all admissions during the period of meropenem preference. CONCLUSION There was no statistically detectable effect on the prevalence of colonization by Gram-negative organisms resistant to one or more classes of broad-spectrum parenteral antibiotics, or to colonization by organisms resistant specifically to meropenem, when meropenem was the preferred antibiotic in a PICU.
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Affiliation(s)
- Philip Toltzis
- Rainbow Babies and Children's Hospital/Case Western Reserve University School of Medicine, Cleveland, OH, USA.
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Acute Myelogenous Leukemia and Febrile Neutropenia. MANAGING INFECTIONS IN PATIENTS WITH HEMATOLOGICAL MALIGNANCIES 2009. [PMCID: PMC7121946 DOI: 10.1007/978-1-59745-415-5_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Aggressive chemotherapy has a deleterious effect on all components of the defense system of the human body. The resulting neutropenia as well as injury to the pulmonary and gastrointestinal mucosa allow pathogenic micro-organisms easy access to the body. The symptoms of an incipient infection are usually subtle and limited to unexplained fever due to the absence of granulocytes. This is the reason why prompt administration of antimicrobial agents while waiting for the results of the blood cultures, the so-called empirical approach, became an undisputed standard of care. Gram-negative pathogens remain the principal concern because their virulence accounts for serious morbidity and a high early mortality rate. Three basic intravenous antibiotic regimens have evolved: initial therapy with a single antipseudomonal β-lactam, the so-called monotherapy; a combination of two drugs: a β-lactam with an aminoglycoside, a second β-lactam or a quinolone; and, thirdly, a glycopeptide in addition to β-lactam monotherapy or combination. As there is no single consistently superior empirical regimen, one should consider the local antibiotic susceptibility of bacterial isolates in the selection of the initial antibiotic regimen. Not all febrile neutropenic patients carry the same risk as those with fever only generally respond rapidly, whereas those with a clinically or microbiologically documented infection show a much slower reaction and less favorable response rate. Once an empirical antibiotic therapy has been started, the patient must be monitored continuously for nonresponse, emergence of secondary infections, adverse effects, and the development of drug-resistant organisms. The averageduration of fever in serious infections in eventually successfully treated neutropenic patients is 4–5 days. Adaptations of an antibiotic regimen in a patient who is clearly not responding is relatively straightforward when a micro-organism has been isolated; the results of the cultures, supplemented by susceptibility testing, will assist in selecting the proper antibiotics. The management of febrile patients with pulmonary infiltrates is complex. Bronchoscopy and a high resolution computer-assisted tomographic scan represent the cornerstones of all diagnostic procedures, supplemented by serological tests for relevant viral pathogens and for aspergillosis. Fungi have been found to be responsible for two thirds of all superinfections that may surface during broad-spectrum antibiotic treatment of neutropenic patients. Antibiotic treatment is usually continued for a minimum of 7 days or until culture results indicate that the causative organism has been eradicated and the patient is free of major signs and symptoms. If a persistently neutropenic patient has no complaints and displays no evidence of infection, early watchful cessation of antibiotic therapy or a change to the oral regimen should be considered.
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Baldwin CM, Lyseng-Williamson KA, Keam SJ. Meropenem: a review of its use in the treatment of serious bacterial infections. Drugs 2008; 68:803-38. [PMID: 18416587 DOI: 10.2165/00003495-200868060-00006] [Citation(s) in RCA: 125] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Meropenem (Merrem, Meronem) is a broad-spectrum antibacterial agent of the carbapenem family, indicated as empirical therapy prior to the identification of causative organisms, or for disease caused by single or multiple susceptible bacteria in both adults and children with a broad range of serious infections. Meropenem is approved for use in complicated intra-abdominal infection (cIAI), complicated skin and skin structure infection (cSSSI) and bacterial meningitis (in paediatric patients aged > or = 3 months) in the US, and in most other countries for nosocomial pneumonia, cIAI, septicaemia, febrile neutropenia, cSSSI, bacterial meningitis, complicated urinary tract infection (UTI), obstetric and gynaecological infections, in cystic fibrosis patients with pulmonary exacerbations, and for the treatment of severe community-acquired pneumonia (CAP). Meropenem has a broad spectrum of in vitro activity against Gram-positive and Gram-negative pathogens, including extended-spectrum beta-lactamase (ESBL)- and AmpC-producing Enterobacteriaceae. It has similar efficacy to comparator antibacterial agents, including: imipenem/cilastatin in cIAI, cSSSI, febrile neutropenia, complicated UTI, obstetric or gynaecological infections and severe CAP; clindamycin plus tobramycin or gentamicin in cIAI or obstetric/gynaecological infections; cefotaxime plus metronidazole in cIAI; cefepime and ceftazidime plus amikacin in septicaemia or febrile neutropenia; and ceftazidime, clarithromycin plus ceftriaxone or amikacin in severe CAP. Meropenem has also shown similar efficacy to cefotaxime in paediatric and adult patients with bacterial meningitis, and to ceftazidime when both agents were administered with or without tobramycin in patients with cystic fibrosis experiencing acute pulmonary exacerbations. Meropenem showed greater efficacy than ceftazidime or piperacillin/tazobactam in febrile neutropenia, and greater efficacy than ceftazidime plus amikacin or tobramycin in patients with nosocomial pneumonia. Meropenem is well tolerated and has the advantage of being suitable for administration as an intravenous bolus or infusion. Its low propensity for inducing seizures means that it is suitable for treating bacterial meningitis and is the only carbapenem approved in this indication. Thus, meropenem continues to be an important option for the empirical treatment of serious bacterial infections in hospitalized patients.
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Affiliation(s)
- Claudine M Baldwin
- Wolters Kluwer Health/Adis, 41 Centorian Drive, Private Bag 65901, Mairangi Bay, North Shore 0754, Auckland, New Zealand.
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Senn L, Robinson JO, Schmidt S, Knaup M, Asahi N, Satomura S, Matsuura S, Duvoisin B, Bille J, Calandra T, Marchetti O. 1,3- -D-Glucan Antigenemia for Early Diagnosis of Invasive Fungal Infections in Neutropenic Patients with Acute Leukemia. Clin Infect Dis 2008; 46:878-85. [DOI: 10.1086/527382] [Citation(s) in RCA: 229] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Antoniadou A, Giamarellou H. Fever of Unknown Origin in Febrile Leukopenia. Infect Dis Clin North Am 2007; 21:1055-90, x. [DOI: 10.1016/j.idc.2007.08.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Cometta A, Marchetti O, Calandra T. Empirical use of anti-Gram-positive antibiotics in febrile neutropaenic cancer patients with acute leukaemia. EJC Suppl 2007. [DOI: 10.1016/j.ejcsup.2007.06.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Velasco E, Byington R, Martins CAS, Schirmer M, Dias LMC, Gonçalves VMSC. Comparative study of clinical characteristics of neutropenic and non-neutropenic adult cancer patients with bloodstream infections. Eur J Clin Microbiol Infect Dis 2007; 25:1-7. [PMID: 16424972 DOI: 10.1007/s10096-005-0077-8] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
A total of 399 consecutive episodes of bloodstream infections in adult patients with haematologic malignancies and solid tumours were evaluated prospectively over a 26-month period, with the aim of determining the clinical characteristics and the microbiological profile of the patients relative to neutrophil count. The overall 30-day mortality rate was 32% (35% in non-neutropenic patients vs. 26% in neutropenic patients, p=0.05). Main diagnoses were solid tumours (33%) and lymphoma (29%). Most of the episodes of bloodstream infection (58%) occurred in non-neutropenic patients. Acute leukaemia and bone marrow transplantation predominated in the neutropenic group. Non-neutropenic patients tended to be older and to have a higher frequency of solid tumours and advanced or uncontrolled diseases. Indwelling central venous catheters were present in 51% of the episodes, with a predominance of long-term catheters in neutropenic haematologic patients. Concomitant infections were observed more frequently in non-neutropenic patients. There were 1,040 noninfectious comorbid conditions, most of which were present in non-neutropenic patients. The causative pathogens were predominantly gram-negative bacilli (56%). Escherichia coli and Klebsiella pneumoniae were isolated more frequently from neutropenic patients, while Staphylococcus aureus and Acinetobacter spp. were more frequent in non-neutropenic patients. Seventy-four percent of the episodes of candidaemia occurred in patients with central venous catheters, with non-albicans strains predominating. The results of this study highlight the heterogeneity of cancer patients with bloodstream infections and the value of stratifying risk factors and aetiologic agents according to neutrophil count.
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Affiliation(s)
- E Velasco
- Rua General Glicério 486/1002, Cep 22245-120, Rio de Janeiro, Brazil.
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Zhanel GG, Wiebe R, Dilay L, Thomson K, Rubinstein E, Hoban DJ, Noreddin AM, Karlowsky JA. Comparative Review of the Carbapenems. Drugs 2007; 67:1027-52. [PMID: 17488146 DOI: 10.2165/00003495-200767070-00006] [Citation(s) in RCA: 365] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
The carbapenems are beta-lactam antimicrobial agents with an exceptionally broad spectrum of activity. Older carbapenems, such as imipenem, were often susceptible to degradation by the enzyme dehydropeptidase-1 (DHP-1) located in renal tubules and required co-administration with a DHP-1 inhibitor such as cilastatin. Later additions to the class such as meropenem, ertapenem and doripenem demonstrated increased stability to DHP-1 and are administered without a DHP-1 inhibitor. Like all beta-lactam antimicrobial agents, carbapenems act by inhibiting bacterial cell wall synthesis by binding to and inactivating penicillin-binding proteins (PBPs). Carbapenems are stable to most beta-lactamases including AmpC beta-lactamases and extended-spectrum beta-lactamases. Resistance to carbapenems develops when bacteria acquire or develop structural changes within their PBPs, when they acquire metallo-beta-lactamases that are capable of rapidly degrading carbapenems, or when changes in membrane permeability arise as a result of loss of specific outer membrane porins. Carbapenems (imipenem, meropenem, doripenem) possess broad-spectrum in vitro activity, which includes activity against many Gram-positive, Gram-negative and anaerobic bacteria; carbapenems lack activity against Enterococcus faecium, methicillin-resistant Staphylococcus aureus and Stenotrophomonas maltophilia. Compared with imipenem, meropenem and doripenem, the spectrum of activity of ertapenem is more limited primarily because it lacks activity against Pseudomonas aeruginosa and Enterococcus spp. Imipenem, meropenem and doripenem have in vivo half lives of approximately 1 hour, while ertapenem has a half-life of approximately 4 hours making it suitable for once-daily administration. As with other beta-lactam antimicrobial agents, the most important pharmacodynamic parameter predicting in vivo efficacy is the time that the plasma drug concentration is maintained above the minimum inhibitory concentration (T>MIC). Imipenem/cilastatin and meropenem have been studied in comparative clinical trials establishing their efficacy in the treatment of a variety of infections including complicated intra-abdominal infections, skin and skin structure infections, community-acquired pneumonia, nosocomial pneumonia, complicated urinary tract infections, meningitis (meropenem only) and febrile neutropenia. The current role for imipenem/cilastatin and meropenem in therapy remains for use in moderate to severe nosocomial and polymicrobial infections. The unique antimicrobial spectrum and pharmacokinetic properties of ertapenem make it more suited to treatment of community-acquired infections and outpatient intravenous antimicrobial therapy than for the treatment of nosocomial infections. Doripenem is a promising new carbapenem with similar properties to those of meropenem, although it appears to have more potent in vitro activity against P. aeruginosa than meropenem. Clinical trials are required to establish the efficacy and safety of doripenem in moderate to severe infections, including nosocomial infections.
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Affiliation(s)
- George G Zhanel
- Department of Medical Microbiology, Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
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Bow EJ, Rotstein C, Noskin GA, Laverdiere M, Schwarer AP, Segal BH, Seymour JF, Szer J, Sanche S. A randomized, open-label, multicenter comparative study of the efficacy and safety of piperacillin-tazobactam and cefepime for the empirical treatment of febrile neutropenic episodes in patients with hematologic malignancies. Clin Infect Dis 2006; 43:447-59. [PMID: 16838234 DOI: 10.1086/505393] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2006] [Accepted: 04/17/2006] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND The empirical treatment of febrile, neutropenic patients with cancer requires antibacterial regimens active against both gram-positive and gram-negative pathogens. This study was performed to demonstrate the noninferiority of monotherapy with piperacillin-tazobactam, compared with cefepime. METHODS We conducted a randomized-controlled, open-label, multicenter clinical trial among high-risk patients from 34 university-affiliated tertiary care medical centers in the United States, Canada, and Australia who were undergoing treatment for leukemia or hematopoietic stem cell transplantation and were hospitalized for empirical treatment of febrile neutropenic episodes. Patients received piperacillin-tazobactam (4.5 g every 6 h) or cefepime (2 g every 8 h) intravenously. The primary outcome was success (defined by defervescence without treatment modification) at 72 h of treatment, end of treatment, and test of cure in the modified intent-to-treat analysis. Secondary outcomes included time to defervescence, microbiological efficacy, the additional use of glycopeptide antibiotics, emergence of resistant bacteria, and safety. RESULTS For 528 subjects (265 received piperacillin-tazobactam and 263 received cefepime), success rates were 57.7% and 48.3%, respectively (P = .04) at the 72-h time point, 39.6% and 31.6% (P = .06) at end of treatment, and 26.8% and 20.5% (P = .11) at the test-of-cure visit. The analyses demonstrated noninferiority for piperacillin-tazobactam at all time points (P< or = .0001). Treatment with piperacillin-tazobactam was independently associated with treatment success in multivariate analysis (odds ratio, 1.65; 95% confidence interval, 1.04-2.64; P = .035). Both regimens were well tolerated. CONCLUSIONS This study demonstrates the noninferiority and safety of piperacillin-tazobactam monotherapy, compared with cefepime, for the empirical treatment of high-risk febrile neutropenic patients with cancer.
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Affiliation(s)
- E J Bow
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
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