Empiric antimicrobial therapy for febrile granulocytopenic cancer patients. Lessons from four EORTC trials

Role of glycopeptides as part of initial empirical treatment of febrile neutropenic patients: a meta-analysis of randomised controlled trials

We did a meta-analysis of randomised controlled trials studying glycopeptides as part of the initial empirical treatment of febrile neutropenic patients with a beta-lactam and with or without an aminoglycoside. 14 randomised controlled trials that studied 2413 patients were included in the analysis. A better outcome regarding treatment success, without modification of the initial regimen, was accomplished with the inclusion of a glycopeptide in the empirical therapy; this better outcome applied to the full set of studied patients (OR=1.63, 95% CI 1.17-2.28), as well as in three important subsets of patients--those with microbiologically documented infections (2.03, 1.39-2.97), patients with bacteraemia (1.80, 1.23-2.63), and patients with severe neutropenia, defined as a white blood cell count below 100 cells/microL (2.24, 1.15-4.39). However, mortality was not different in the compared groups (0.67, 0.42-1.05). Overall treatment success was not different if a glycopeptide was added to the antimicrobial regimen in the case of continuation of fever 72 hours or more after the start of treatment (1.02, 0.68-1.52). Also, the inclusion of a glycopeptide in the empirical regimen did not lead to a difference regarding time to defervesence. Adverse effects (4.98, 2.91-8.55), including nephrotoxicity (2.10, 1.12-3.95), were more common in the group receiving a glycopeptide as part of the empirical treatment. In conclusion, our meta-analysis suggests that there are good reasons why glycopeptides should not be routinely used as part of the initial empirical treatment of febrile neutropenic patients.

Safety and Potential of Drug Interactions of Caspofungin and Voriconazole in Multimorbid Patients

Due to their broad antimycotic spectrum and the relatively low rate of side effects, the two antifungals caspofungin and voriconazole are considered as attractive therapeutic alternatives to amphotericin B. However, treatment of severe mycotic infections in patients taking co-medication is associated with the risk of severe adverse drug interactions. The risk of such interactions is increased if voriconazole and, much less pronounced caspofungin, are co-administered with drugs which have an inducing or inhibiting effect on the CYP 450 system, primarily on the isoenzymes CYP2C19, CYP2C9 and CYP3A4. This review provides a comprehensive overview on the potential drug interactions of caspofungin and voriconazole in multimorbid patients.

Empirical antifungal therapy

The number of fungal infections is increasing, particularly in patients with cancer, and represent a major problem given the relatively poor response rates, especially for aspergillosis, and the high cost. Empirical therapy has become an accepted practice as delay in instituting therapy is clearly associated with increased morbidity and mortality. In terms of efficacy for the management of persistent febrile neutropenic patients, there is no convincing evidence that conventional amphotericin B (ampho B) is inferior to any other agent; the lipid formulations of ampho B provide similar efficacy with lower toxicity but at a much higher cost. Fluconazole is equivalent to ampho B, provided patients at high risk of aspergillus infections are excluded. Itraconazole and voriconazole, as empirical therapies, are equivalent to conventional ampho B and liposomal ampho B, respectively; toxicity is definitely lower and voriconazole is more effective at preventing breakthrough fungal infections.

Temporary interruption of ceftazidime continuous infusion without reduction of activity: a computer-assisted simulation

Continuous infusion (CI) of ceftazidime has been demonstrated to add clinical advantages in the treatment of infection of neutropenic cancer patients, especially in the presence of gram-negative bacteremia. However, this particular administration route is not always feasible in this particular clinical setting because of the patient's need of additional care or drug administration. The aim of this study was to evaluate, through a computer-assisted simulation, the modifications of drug concentration in presence of a single or repeated 2-hour interruptions of CI ceftazidime in critically ill patients. Our analysis shows that a loading dose of 20 mg/kg, followed by a CI of 100/mg/kg/die, should be able to maintain efficacious plasma concentrations in all subjects, even when it is interrupted for a 2-hour period every 8 hours. Plasma concentrations after interruption should not fall below 8 microg/mL and for about 65-80% of time should reach levels equal to 5 times the MIC of the infecting pathogen. A 2-hour interruption of CI ceftazidime up to 3 times a day is likely to represent a safe and efficacious administration regimen that may enhance the management of the treatment of infectious complications in critically ill patients such as neutropenic cancer patients.

Prophylaxis with ofloxacin in patients with cancer and neutropenia

The suppression of potentially pathogenic microorganisms using prophylactic antibacterial treatment could eventually protect the patient from infection. Oral absorbable and non-absorbable antibacterial agents have been used with variable results. In the present study, 47 patients with cancer and neutropenia received oral ofloxacin 200 mg twice daily prophylactically. All patients were previously treated with antineoplastic chemotherapy. Septicemia developed in ten patients (21%). The number of infections was higher in patients with a level of granulocytopenia under 0.5 x 10(9)/1. Infection was caused in almost all patients by gram-positive organisms. Prophylaxis with ofloxacin provided efficacious protection against gram-negative bacteria and was well tolerated.

Use of quinolones in the immunocompromised host

Immune deficiency generally leads to infections. Cancer chemotherapy, medical interventions and various investigational procedures are important factors in the development of infection. In recent decades, there has been a major change in most cancer centers in the etiology of bacterial infections occurring in the immunocompromised host, most infections now being caused by gram-positive organisms. This might be partly due to prophylactic use of agents effective against gram-negative bacteria. The quinolones are now widely used in the treatment of serious infections of the immunocompromised patient. Prophylaxis with quinolones is also practised in cancer centers.