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Marx AH, Nowicki DN, Carlson RB, Schultz KM, Sickbert-Bennett E, Weber DJ. Bacille Calmette-Guérin preparation and intravesical administration to patients with bladder cancer: Risks to healthcare personnel and patients, and mitigation strategies. Infect Control Hosp Epidemiol 2024; 45:520-525. [PMID: 38073548 DOI: 10.1017/ice.2023.259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Abstract
Intravesical Bacillus Calmette-Guérin (BCG) is a standard therapy for non-muscle-invasive bladder cancer used in urology clinics and inpatient settings. We present a review of infection risks to patients receiving intravesical BCG, healthcare personnel who prepare and administer BCG, and other patients treated in facilities where BCG is prepared and administered. Knowledge of these risks and relevant regulations informs appropriate infection prevention measures.
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Affiliation(s)
- Ashley H Marx
- Department of Pharmacy, University of North Carolina Medical Center; University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Diana N Nowicki
- Department of Pharmacy, University of North Carolina Medical Center; University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Rebecca B Carlson
- University of North Carolina Health Sciences Library, Chapel Hill, North Carolina
| | - Katherine M Schultz
- Department of Infection Prevention, UNC Medical Center; Chapel Hill, North Carolina
| | - Emily Sickbert-Bennett
- Department of Infection Prevention, UNC Medical Center; Chapel Hill, North Carolina
- Department of Epidemiology, University of North Carolina School of Public Health; Division of Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - David J Weber
- Department of Infection Prevention, UNC Medical Center; Chapel Hill, North Carolina
- Department of Epidemiology, University of North Carolina School of Public Health; Division of Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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Rahman ZA, Hidayatullah F, Lim J, Hakim L. A systematic review and meta-analysis of intraarterial chemotherapy for non muscle invasive bladder cancer: Promising alternative therapy in high tuberculosis burden countries. Arch Ital Urol Androl 2024; 96:12154. [PMID: 38363237 DOI: 10.4081/aiua.2024.12154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 01/04/2024] [Indexed: 02/17/2024] Open
Abstract
INTRODUCTION Local therapies for high risk non-muscle-invasive bladder cancer (NMIBC) such as intravesical chemotherapy (IVC) have shown a high rate of progression and recurrence. Intravesical Bacillus Calmette-Guérin (BCG) for local therapies has been shown to reduce progression and recurrence in patient with NMIBC. However, its potential role is limited in high burden countries for tuberculosis (TB) due to its low specificity that can cause wrong diagnosis or false positive in patients with clinically diagnosed tuberculosis. BCG vaccine that has to be given for most people in tuberculosis endemic countries will induce trained immunity that could reduce the effectivity of intravesical BCG for NMIBC. Moreover, intravesical BCG is contraindicated in patient with or previous tuberculosis. The potential clinical benefit of intraarterial chemotherapy (IAC) in delaying the recurrence and progression of high-risk NMIBC have been investigated with promising results. We aimed to conduct a meta-analysis to evaluate the potential anti-tumor effect of IAC in NMIBC. METHODS We conducted a comprehensive search of published articles in Cochrane Library, Pubmed, and Science-Direct to identify relevant randomized controlled trials (RCTs) and observational studies comparing IAC alone or combined with IVC versus IVC/BCG alone in NMIBC. The protocol of preferred reporting items for systematic review and meta-analysis (PRISMA) was applied to this study. RESULTS Four RCTs and 4 cohort observational studies were eligible in this study and 5 studies were included in meta-analysis. The risk ratio of tumor recurrence was reduced by 35% (RR = 0.65; 95% CI 0.49-0.87; p = 0.004) in IAC plus IVC, while recurrence-free survival (RFS) was prolonged by 45% (HR: 0.55; 95% CI, 0.44-0.69; p < 0.001). The risk of tumor progression was reduced by 45% (RR = 0.55; 95% CI 0.41-0.75; p = 0.002) and tumor progression-free survival (PFS) was also prolonged by 53% (HR: 0.47; 95% CI, 0.34-0.65; p<0.001). Some RCT's had high or unclear risk of bias, meanwhile 4 included cohort studies had overall low risk of bias, therefore the pooled results need to be interpreted cautiously. Subgroup analysis revealed that the heterogeneity outcome of tumour recurrence might be attributed to the difference in NMIBC stages and grades. CONCLUSIONS The IAC alone or combined with IVC following bladder tumor resection may lower the risk of tumor recurrence and progression. These findings highlight the importance of further multi institutional randomized controlled trials with bigger sample size using a standardized IAC protocol to validate the current results.
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Affiliation(s)
- Zakaria Aulia Rahman
- Department of Urology, Faculty of Medicine, Universitas Airlangga; Dr. Soetomo General-Academic Hospital, Surabaya, East Java.
| | - Furqan Hidayatullah
- Department of Urology, Faculty of Medicine, Universitas Airlangga; Dr. Soetomo General-Academic Hospital, Surabaya, East Java.
| | - Jasmine Lim
- Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur.
| | - Lukman Hakim
- Department of Urology, Faculty of Medicine, Universitas Airlangga; Universitas Airlangga Teaching Hospital, Surabaya, East Java.
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Shibutani K, Ishikawa K, Mori N. Uncommon but Clinically Significant: Bacillus Calmette-Guerin (BCG) Infection of the Urinary Tract and its Impact on Quality of Life. AMERICAN JOURNAL OF CASE REPORTS 2023; 24:e940375. [PMID: 37537854 PMCID: PMC10405347 DOI: 10.12659/ajcr.940375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 06/30/2023] [Accepted: 06/08/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND The intravesical administration of bacillus Calmette-Guerin (BCG), an attenuated live strain of Mycobacterium bovis, is an immunotherapy given for superficial bladder cancer and is generally well tolerated and widely used. However, BCG sometimes causes local infections, such as cystitis and prostatitis or systemic infection. Because BCG infection is a rare complication of intravesical BCG instillation, the combination of an anti-tuberculous regimen and its duration of are unknown. CASE REPORT We describe 2 cases of BCG infection localized to the urinary tract. Case 1 was a 77-year-old man with BCG infection of the bladder and prostate. Combination therapy of anti-tuberculous agents with isoniazid, rifampicin, and ethambutol did not improve his symptoms, and his quality of life was significantly impaired from the symptoms of BCG infection; therefore, he underwent total resection of the bladder and prostate. Case 2 was an 84-year-old man with BCG infection of the bilateral ureter and bladder. It took 15 months for his symptoms to improve, but combination therapy with isoniazid, rifabutin, and ethambutol improved his condition completely. CONCLUSIONS Although BCG infection of the urinary tract is a rare complication, it is clinically important because it directly affects the quality of life of patients and requires a longer duration of treatment, depending on the symptoms. Tissue cultures are also difficult to culture, making a definitive diagnosis challenging. If the symptoms of BCG infection are not controlled, surgery can be necessary even if it is not a complication of a vital organ.
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Tregidgo L, Hammond R, Bramley A, Davis M, Morshed A, Patel A, Pradhan A, D'Cruz R, Lipman M. Delayed-onset disseminated BCG disease causing a multi-system illness with fatal mycotic aortic aneurysm. CLINICAL INFECTION IN PRACTICE 2022. [DOI: 10.1016/j.clinpr.2022.100216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
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Oliveira AA, Morais J, Ribeiro J, Gouveia PF. Systemic infection following intravesical therapy with BCG. BMJ Case Rep 2021; 14:e243641. [PMID: 34753717 PMCID: PMC8578936 DOI: 10.1136/bcr-2021-243641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2021] [Indexed: 11/03/2022] Open
Abstract
Immunotherapy with BCG is an effective and widely used treatment for non-muscle-invasive bladder cancer. BCG sepsis is a rare but life-threatening and frequently not a straightforward complication of this treatment; in cases with a high index of suspicion, anti-bacillary treatment should not wait for laboratory confirmation and be instituted immediately. We report a severe case of BCG sepsis, in which timely diagnosis and initiation of antituberculosis agents enabled a full recovery.
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Affiliation(s)
| | - Joana Morais
- Department of Internal Medicine, Hospital de Braga, Braga, Portugal
| | - Jorge Ribeiro
- Department of Urology, Hospital de Braga, Braga, Portugal
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Disseminated M. bovis Infection and Vertebral Osteomyelitis following Immunotherapy for Bladder Cancer. Case Rep Infect Dis 2021; 2020:6676163. [PMID: 33457027 PMCID: PMC7785387 DOI: 10.1155/2020/6676163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 12/12/2020] [Accepted: 12/18/2020] [Indexed: 11/18/2022] Open
Abstract
The use of BCG in immunotherapy for bladder cancer has been in practice for over 40 years. However, uncommon, serious complications can occur with the therapy. Here, we present a case of vertebral osteomyelitis secondary to dissemination of BCG following immunotherapy, an exceedingly rare presentation of an already rare complication.
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Narvskaya O, Starkova D, Levi D, Alexandrova N, Molchanov V, Chernyaeva E, Vyazovaya A, Mushkin A, Zhuravlev V, Solovieva N, Vishnevskiy B, Mokrousov I. First insight into the whole-genome sequence variations in Mycobacterium bovis BCG-1 (Russia) vaccine seed lots and their progeny clinical isolates from children with BCG-induced adverse events. BMC Genomics 2020; 21:567. [PMID: 32811436 PMCID: PMC7437937 DOI: 10.1186/s12864-020-06973-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 08/05/2020] [Indexed: 02/08/2023] Open
Abstract
Background The only licensed live Bacille Calmette-Guérin (BCG) vaccine used to prevent severe childhood tuberculosis comprises genetically divergent strains with variable protective efficacy and rates of BCG-induced adverse events. The whole-genome sequencing (WGS) allowed evaluating the genome stability of BCG strains and the impact of spontaneous heterogeneity in seed and commercial lots on the efficacy of BCG-vaccines in different countries. Our study aimed to assess sequence variations and their putative effects on genes and protein functions in the BCG-1 (Russia) seed lots compared to their progeny isolates available from immunocompetent children with BCG-induced disease (mainly, osteitis). Results Based on the WGS data, we analyzed the links between seed lots 361, 367, and 368 used for vaccine manufacture in Russia in different periods, and their nine progeny isolates recovered from immunocompetent children with BCG-induced disease. The complete catalog of variants in genes relative to the reference genome (GenBank: CP013741) included 4 synonymous and 8 nonsynonymous single nucleotide polymorphisms, and 3 frameshift deletions. Seed lot 361 shared variants with 2 of 6 descendant isolates that had higher proportions of such polymorphisms in several genes, including ppsC, eccD5, and eccA5 involved in metabolism and cell wall processes and reportedly associated with virulence in mycobacteria. One isolate preserved variants of its parent seed lot 361 without gain of further changes in the sequence profile within 14 years. Conclusions The background genomic information allowed us for the first time to follow the BCG diversity starting from the freeze-dried seed lots to descendant clinical isolates. Sequence variations in several genes of seed lot 361 did not alter the genomic stability and viability of the vaccine and appeared accumulated in isolates during the survival in the human organism. The impact of the observed variations in the context of association with the development of BCG-induced disease should be evaluated in parallel with the immune status and host genetics. Comparative genomic studies of BCG seed lots and their descendant clinical isolates represent a beneficial approach to better understand the molecular bases of efficacy and adverse events during the long-term survival of BCG in the host organism.
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Affiliation(s)
- Olga Narvskaya
- Laboratory of Molecular Epidemiology and Evolutionary Genetics, St. Petersburg Pasteur Institute, St. Petersburg, 197101, Russia. .,St. Petersburg Research Institute of Phthisiopulmonology, St. Petersburg, 191036, Russia.
| | - Daria Starkova
- Laboratory of Molecular Epidemiology and Evolutionary Genetics, St. Petersburg Pasteur Institute, St. Petersburg, 197101, Russia
| | - Diana Levi
- Scientific Center for Expert Evaluation of Medical Products, Moscow, 127051, Russia
| | - Natalia Alexandrova
- Scientific Center for Expert Evaluation of Medical Products, Moscow, 127051, Russia
| | - Vladimir Molchanov
- Laboratory of Molecular Epidemiology and Evolutionary Genetics, St. Petersburg Pasteur Institute, St. Petersburg, 197101, Russia. .,Present address: Van Andel Institute, Grand Rapids, MI, 49503-2518, USA.
| | | | - Anna Vyazovaya
- Laboratory of Molecular Epidemiology and Evolutionary Genetics, St. Petersburg Pasteur Institute, St. Petersburg, 197101, Russia
| | - Alexander Mushkin
- St. Petersburg Research Institute of Phthisiopulmonology, St. Petersburg, 191036, Russia
| | - Viacheslav Zhuravlev
- St. Petersburg Research Institute of Phthisiopulmonology, St. Petersburg, 191036, Russia
| | - Natalia Solovieva
- St. Petersburg Research Institute of Phthisiopulmonology, St. Petersburg, 191036, Russia
| | - Boris Vishnevskiy
- St. Petersburg Research Institute of Phthisiopulmonology, St. Petersburg, 191036, Russia
| | - Igor Mokrousov
- Laboratory of Molecular Epidemiology and Evolutionary Genetics, St. Petersburg Pasteur Institute, St. Petersburg, 197101, Russia
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