Antibiotic treatment of febrile episodes in neutropenic cancer patients. Clinical and economic considerations

Role of urine studies in asymptomatic febrile neutropenic patients presenting to the emergency department

BACKGROUND

The role of urine studies in the detection of urinary tract infection (UTI) in febrile neutropenic patients with urinary symptoms (having a urinary catheter or having a positive urine analysis) is inarguable. However, the evidence is scarce regarding the indication for urine studies in asymptomatic (i.e., without urinary symptoms) patients with febrile neutropenia (FN) presenting to the emergency department (ED). The aim of this study is to evaluate the need for obtaining urine studies in asymptomatic febrile neutropenic patients.

METHODS

This was a retrospective cohort study conducted on adult cancer patients who presented to the ED with FN and had no urinary symptoms. We included all ED presentations of eligible patients between January 2013 and September 2018. Student's t-test and Wilcoxon rank-sum test were used for continuous data, while Chi-square and Fisher's exact tests were used for categorical data. Participants were divided into two groups based on their urine culture (UC) results: negative and positive UCs. Two cut-offs were used for positive UC results: ≥10⁵ cfu/mL and ≥10⁴ cfu/mL.

RESULTS

We included 284 patients in our study. The age of our patient population was 48.5±18.5 years. More than two-thirds (68.7%) of patients had severe neutropenia, while only 3.9% and 9.9% of the patients had positive UCs at ≥10⁵ cfu/mL and ≥10⁴ cfu/mL, respectively. UCs were expectedly positive in most patients with urinalysis (UA) abnormalities. However, 27.3% and 32.1% of patients with positive UCs at ≥10⁵ cfu/mL and ≥10⁴ cfu/mL respectively had a normal UA.

CONCLUSIONS

In our study, the incidence of UTI in adult febrile neutropenic cancer patients who present to the ED without urinary symptoms is low. Consequently, routine urine testing may not be warranted in this population, as it adds unnecessary financial burdens on the patients and delays timely management.

Quality assuring adult anti-microbial guidelines

PURPOSE

Guidelines have been produced in nearly all developed countries to provide cost-effective hospital care. The study's purpose, therefore, was to determine whether a London hospital's anti-microbial guidelines conform to this principle.

DESIGN/METHODOLOGY/APPROACH

The paper's approach was a literature search to determine anti-microbial therapies for certain diseases and comparing outcomes with what hospital guidelines recommend.

FINDINGS

There are significant discrepancies in the hospital anti-microbial guidelines and what is recommended in the literature.

RESEARCH LIMITATIONS/IMPLICATIONS

Local microbial patterns for these diseases were not studied as they were not formally available and these could have had an impact on guidelines recommendations.

PRACTICAL IMPLICATIONS

Local guidelines influence day-to-day hospital clinical practice and their robustness is important. They need to comply with national and/or international guidelines. Deviations from these guidelines need appropriate comments within the documents to highlight their validity. Such an approach would facilitate medical students and junior doctor training who depend on these guidelines for good clinical practice.

ORIGINALITY/VALUE

The study provides an important contribution to developing hospital clinical guidelines.

Bacterial spectrum and antimicrobial susceptibility pattern of bloodstream infections in children with febrile neutropenia: experience of single center in southeast of Turkey

Empirical antimicrobial therapy is usually started in febrile neutropenic patients without having culture results. The aim of this study was to help determine the policies of empirical antibiotic usage in febrile neutropenic children by detecting the antimicrobial susceptibility profile in this group of patients. In this study 811 blood cultures taken from neutropenic children hospitalized at the Department of Oncology of Gaziantep Children Hospital November 2007 and February 2010 were retrospectively evaluated. Blood cultures were routinely collected in aerobic and anaerobic media and incubated using the BACTEC system. Identification and antimicrobial susceptibility testing of the isolates to antimicrobial agents was performed using the Vitek2(®) system according to the recommendations of the Clinical and Laboratory Standards Institute. Of 811 isolates analyzed, 128 (56.4%) were gram positive cocci, 43 (18.9%) were gram negative bacilli and fungi accounted for 56 (24.7%). The main isolated Gram-positive bacteria from blood were coagulase-negative staphylococcus (56.7%), followed by methicillin-resistant Staphylococcus aureus (14.1%). S. aureus and Streptococcus spp. were all susceptible to linezolid, vancomycin and teicoplanin. S aureus was still susceptible to few other antimicrobial agents such as tetracycline (82.4%), chloramphenicol (55.6%). Seven E. faecium, 7 E. fecalis and 1 E. hirae was isolated from blood cultures. Vancomycin resistance was detected in 6 out of 15 (40%) Enterococcus spp. isolates. Among gram-negative bacteria E. coli (30.2%) was followed by Klebsiella pneumoniae (20.9%) and Proteus spp. (18.6%). Imipenem (89.2%), meropenem (86.6%), chloramphenicol (88.9%), amicasin (82.4%) and fosfomycin (81.3%) showed highest susceptibility in vitro activity against all Gram-negative isolates. To know the antimicrobial susceptibility profile of the pathogens frequently isolated from febrile neutropenic children and to consider this profile before starting an empirical antibiotic therapy would help the clinics which have any role in the treatment of these patients to determine the empirical antibiotic usage policies.

Infections in acute myeloid leukemia: an analysis of 382 febrile episodes

Neutropenic fever is an important cause of morbidity and mortality during therapy of acute myeloid leukemia (AML). We retrospectively analyzed 382 febrile episodes encountered during induction and consolidation chemotherapy to determine the potential etiology, microbiologic spectrum, response/resistance to antibiotics and outcome. Between May, 2001 and December, 2006, 95 patients with de novo non-M3 AML received remission induction chemotherapy followed by consolidation in those who achieved complete remission. Patients median age was 28 years, ranging from 2 to 61 years, 26 patients were ≤15 years of age. There were 57 males and 38 females. Febrile neutropenia was defined as per international guidelines. A total of 382 febrile episodes were recorded; neutropenic 347 (induction phase 172, consolidation phase 175) and non-neutropenic 35 (induction 16, consolidation 19). Clinical, microbiological and radiological evidence of infection could be identified in 64% of the febrile episodes (74% during induction, 52% during consolidation). Pulmonary infections were most common, both during induction and consolidation phase. Microbiologically gram-negative infections predominated. There were 60 possible/probable/definite episodes of fungal infection. Six cases of tuberculosis (pulmonary 5 and spine 1) and 3 cases of malaria (including one case of cerebral malaria) were also identified. Nineteen patients died (17 during induction, 2 during consolidation); 17 deaths were infection related, 12/17 possibly due to fungal infections. We suggest that evaluation of antibacterial resistance patterns in an institution must be done routinely in order to choose empiric antibiotics therapy. Careful selection of antibiotics and early institution of antifungal therapy besides considering alternative diagnosis peculiar to the region (e.g. tuberculosis, malaria) may help in reducing morbidity and mortality during AML therapy.

Infections in childhood acute lymphoblastic leukemia: an analysis of 222 febrile neutropenic episodes

A retrospective analysis was performed on febrile neutropenic episodes in patients with acute lymphoblastic leukemia (ALL) from 1992 to 2002. There were 222 febrile neutropenic episodes in 266 ALL patients with documented ANC < 500/mm(3). Of the 222 episodes, 98 (44%) had documented focus of infection; the rest were fever without focus. There were 274 different sites of infection in the 98 episodes of documented focus of infection; pulmonary infections were the commonest site of infection (27.3%) followed by HEENT (22.9%). Of 69 bacterial isolates, gram-negative bacteria (n = 46, 67%) were twice as common as gram-positive bacteria (n = 23, 33%). Most common site of isolation for gram-negative bacteria was blood (50%) followed by urine (32.6%). Blood (78.3%) was predominant site of isolation of gram-positive bacteria followed by HEENT (8.7%). Escherichia coli (45.7%) was the commonest gram-negative isolate, while Staphylococcus aureus (39%) was the commonest gram-positive bacterial isolate. There were a total of 22 fungal isolates, the majority from urine (n = 12) and HEENT (n = 9). Of the 22 fungal isolates, 19 were detected in induction phase of chemotherapy. A total of 95/222 (42.8%) febrile neutropenic episodes improved with first-line antibiotic therapy, while modification was required in 127 episodes (57.2%). Antifungal therapy was used in 86 episodes (38.7%). There were a total of 13 deaths, 6 each during induction and intensification/consolidation phases, while 1 died during maintenance phase. Of the 13 deaths, 10 had pneumonia, 8 had bacteremia, and 7 had fungal infection. The current study stresses the importance of frequent reviewing of type, frequency, severity, and outcome of infection complications over the years to detect changing epidemiological patterns. The majority of fungal infections were detected during induction chemotherapy, which highlights the need to consider this type of infection in the evaluation of patients.

Mississippi mud no more: cost-effectiveness of pharmacokinetic dosage adjustment of vancomycin to prevent nephrotoxicity

OBJECTIVE

To determine the cost-effectiveness of pharmacokinetic dosage adjustment of vancomycin to prevent nephrotoxicity. An analysis was performed for subpopulations of patients receiving nephrotoxic agents (aminoglycosides, amphotericin, and acyclovir), those in the intensive care unit, and those on the oncology service.

METHODS

Decision analysis was used to model the cost-effectiveness of pharmacokinetic dosage adjustment of vancomycin. The reference case was determined, in part, by a retrospective review of 200 patients randomly selected from our clinical pharmacology consultation service. Patients were aged 18 years or older and had received intravenous vancomycin for at least 48 hours, with at least two--one peak and one trough--vancomycin serum concentrations obtained during therapy. Results of published clinical trials were used to determine the probability of vancomycin-induced nephrotoxicity.

RESULTS

The mean cost of treating nephrotoxicity was 11,233 dollars at our institution. The mean cost for all patients was 25,166 dollars (sensitivity analysis 15,000-27,500 dollars)/nephrotoxic episode prevented. The subgroup analysis revealed a cost of 8,363 dollars (sensitivity analysis 4,368-10,500 dollars)/nephrotoxic episode prevented in intensive care patients, 5,000 dollars (sensitivity analysis 1,687-13,250 dollars ) in oncology patients, and a dominant strategy showing a cost savings of 5,564 dollars (sensitivity analysis 2,724-12,428 dollars) in those receiving concomitant nephrotoxins.

CONCLUSION

Although pharmacokinetic monitoring and dosage adjustment are effective methods for reducing the toxicity of many drugs, controversy exists regarding the necessity of such monitoring with vancomycin. Evaluation by decision analysis over a range of assumptions, varying probabilities, and costs reveals that pharmacokinetic monitoring and vancomycin dosage adjustment to prevent nephrotoxicity are not cost-effective for all patients. However, such dosage adjustment demonstrates cost-effectiveness for patients receiving concomitant nephrotoxins, intensive care patients, and probably oncology patients.

Outpatient therapy for febrile neutropenia: clinical and economic implications

Although febrile episodes in neutropenic patients remain a potentially life-threatening complication of anticancer chemotherapy, considerable progress has been achieved in understanding this issue. Febrile neutropenic patients represent a heterogeneous population that displays a very variable risk for serious medical complications. It has also been ascertained that in low-risk patients, the standard of care can be safely and effectively shifted from traditional hospital-based, parenteral, empiric, broad-spectrum antibacterial therapy to outpatient treatment, even for the entire duration of the febrile episode. Furthermore, in the last years some risk assessment models have been developed to identify, at the onset of febrile episodes, low-risk neutropenic patients who are most likely to have a favourable outcome (and who can effectively and safely be treated on an outpatient basis). With respect to traditional hospital-based therapy, the outpatient treatment of low-risk patients is associated with several advantages, including a conspicuous cost saving. Some strategies for inpatient therapy, such as switching from intravenous to oral antibacterials and early discharge, can allow some cost containment; however, the most substantial decrease in costs can be obtained by using outpatient treatment over the entire febrile episode, especially by using oral antibacterials. In spite of the considerable number of clinical studies published over the past 20 years, only limited pharmacoeconomic data on this issue are available. Future comparative studies between outpatient and inpatient treatment of febrile neutropenia, in addition to clinical outcomes (e.g. survival, time to clinical response), should therefore include the following: (i) a detailed analysis of total costs, specifying the setting of outpatient treatment and the method of administration of antimicrobial agents (home nursing, self administration or treatment at infusion centres or at a low-care unit of the hospital); (ii) cost of inpatient treatment if outpatient therapy fails; and (iii) out-of-pocket expenses incurred by the patients.

A randomized prospective multicentre trial of cefpirome versus piperacillin-tazobactam in febrile neutropenia

Fever is frequently the only clinical sign of infection in patients with chemo-induced neutropenia. In this setting, empirical administration of broad spectrum antibiotics must be rapid. The aim of this work was to compare, for the first time, cefpirome (CPO) and piperacillin-tazobactam (PT) in a large randomized trial. Two hundred-eight febrile neutropenic episodes (FNE) (> or = 38.5 degrees C and ANC < or = 0.5 giga/l) were treated by randomization, as first line therapy, using either CPO 2 g x 2/day (105 cases) or PT 4 g x 3/day (103 cases), alone (CPO: 15/PT: 15), or plus aminoglycoside (165 cases, CPO: 82/PT: 83) or quinolone (CPO: 2/PT: 2). There were 131 men and 77 women aged between 17 and 83 years (median: 49) who received chemotherapy (n = 160) or allogeneic (n = 10) or autologous (n = 38) stem cell transplantations. Underlying diseases were: acute leukemia (n = 131), lymphoma (n = 33), myeloma (n = 16), solid tumor (n = 8), myeloproliferative disorder (n = 9), chronic lymphoid leukemia (n = 5), aplastic anemia (n = 3), myelodysplasia (n = 3). Distribution of age, neutropenia duration (median: 17 days), underlying disease, and protocol therapy duration (median: 11 days) was comparable in both arms. A microbiologically documented infection (MDI) was evidenced in 57 cases (27%). Bacteria were isolated from blood cultures in 54 cases (Gram positive: 32 cases). Their in vitro susceptibility rates to CPO and PT were not different. Two days after antibiotics initiation, clinical (fever disappearance) and microbiological (culture negativation) success rates (SR) were 62% for CPO versus 61% for PT and 50% versus 55% respectively in case of MDI (p = 0.89). Two deaths and 77 failures were registered. At the end of protocol, SR (no antibiotic change/absence of superinfection) was 59% with CPO versus 50% with PT (p = 0.27) and 53% versus 40% respectively in the 151 cases with neutropenia > or = 10 days (p = 0.17). The occurrence of side effects was similar in both arms. In our hands, the efficacy of CPO and PT was comparable for treating FNE.

Microbiological findings in febrile neutropenia

BACKGROUND

This study was carried out to assess the isolation rate of bacterial and fungal causative agents in Mexican neutropenic adults with hematological neoplasia.

METHODS

A prospective observational survey involving 120 consecutive episodes of febrile neutropenia during 1 year was carried out. These episodes were observed in 630 patients discharged with diagnoses of leukemia or lymphoma, or after bone-marrow transplantation.

RESULTS

At least one pathogen was isolated in 42 of 120 episodes (35%), and was present in 39 patients with acute myeloid leukemia (AML) (43%), acute lymphoblastic leukemia (ALL) (23%), and in patients who underwent bone-marrow transplantation (20%). Primary bacteremia was the most frequent cause of fever (24 episodes, 57%), followed by intravascular device-related infections (5 episodes, 17%), and soft-tissue infections (5 episodes, 15%). Escherichia coli (33%) was the most frequently isolated agent of primary bacteremia, followed by coagulase-negative Staphylococcus (29%), and Klebsiella oxytoca (16%). Fungal infection was responsible for five events (4%): two episodes of pneumonia (Penicillium marneffei and Aspergillus fumigatus, one event each); two cases of fungemia, one due to Candida tropicalis and one to Rhodotorula gluttinis, and one cryptococcal meningitis event.

CONCLUSIONS

The isolation rate, approximately 30%, was in accordance with previous reports; similar percentages of Gram-positive and Gram-negative isolates were found. A remarkably low rate of viridans group streptococci and fungal agents was observed, despite the fact that neutropenia is the main risk factor for infection due to these agents. Studies reporting local microbiological findings are necessary because they support an antibiotic choice for prophylaxis or therapy more accurately than reports from other areas.

Sepsis

OBJECTIVES

To review infection and sepsis in patients with cancer and to provide an overview of controversies and research-based practices of infectious complications and management strategies.

DATA SOURCES

Research studies, review articles, web sites, and consensus documents.

CONCLUSIONS

Traditional assumptions about infection and its optimal management are redefined by research regarding transfusion and catheter-related infections, prophylactic antibiotic administration, use of growth factors, and antimicrobial therapy regimens.

IMPLICATIONS FOR NURSING PRACTICE

Infection is still the most common source of morbidity and mortality among cancer patients. The importance of recognizing high-risk patients, implementing infection prevention practices, and prompt intervention for infection symptoms has been established.

[Febrile neutropenia: practical aspects]

BACKGROUND

Infections are a major cause of mortality in neutropenic patients. They require long hospital stays and highly expensive therapeutic measures. In this review we discuss the practical and pharmaco-economic aspects of the management of febrile neutropenia.

PREVENTION AND THERAPY

Prevention of fever of unknown origin (FUO) demands hygienic and antimicrobiotic measures. First-line antibiotic therapy consists of an aminoglycoside combined with an ureidopenicillin or a 3rd-generation cephalosporin. Double beta-lactam antibiotic combinations are equally effective and less toxic, but more expensive. Monotherapy with carbapenems, ceftazidime, or cefepime appear to offer comparable efficacy. Lung infiltrates require immediate treatment with amphotericin B. If the initial therapeutic regime fails, a carbapenem plus a glycopeptide antibiotic and a parenteral antimycotic drug should be applied after 3 to 4 days. The prophylactic or interventional administration of hematopoietic growth factors is only indicated in special high-risk situations.

CONCLUSIONS

Using the described therapeutic procedure, the response rate exceeds 90%. Consistent, step-wise escalating administration of antibiotics is essential. More evaluation is needed to determine whether selected patients with febrile neutropenia can be treated on an outpatient basis.