Adjuvant immunotherapy for locally advanced renal cell carcinoma

INTRODUCTION

Locally advanced renal cell carcinoma (RCC) presents a therapeutic challenge due to 20-40% relapse risk post-nephrectomy. There has been substantial interest in utilizing immunotherapy interrupting the PD-1/PD-L1 axis in the perioperative space, especially in the adjuvant setting, in order to minimize such risk.

AREAS COVERED

We conducted a PubMed search using the terms 'adjuvant' and 'RCC.' We begin by examining landmark studies in the postoperative space for locally advanced RCC, with special emphasis on immunotherapeutic biologics. Important considerations are outlined in an effort to explain the conflicting data on the benefit of adjuvant immunotherapy as well as to adequately assess the magnitude of potential benefit of the recently approved adjuvant pembrolizumab. Relevant contemporary challenges and opportunities as well as future directions of the field are also discussed.

EXPERT OPINION

Systemic immunotherapy with monoclonal antibodies targeting the PD-1/PD-L1 axis likely holds promise, either alone or potentially in combinations, in minimizing recurrence risk for locally advanced RCC. However, emphasis on post-protocol care, robust endpoint selection, and continued work and validation on predictive biomarkers are needed to confidently select those patients that may benefit the most and minimize biologic and financial toxicity.

Development and validation of a prognostic nomogram for overall and disease-specific survival in patients with sarcomatoid urothelial carcinoma

INTRODUCTION

Sarcomatoid urothelial carcinoma (SUC) is a rare and aggressive variant of bladder cancer with limited data guiding prognosis. In this study, we present the first prognostic nomograms in the literature for 3- and 5-year overall survival (OS) and disease-specific survival (DSS), for patients with SUC derived from the surveillance, epidemiology and end results database (SEER).

MATERIALS AND METHODS

Patients with SUC were identified by using the ICD-10 topography codes C67.0-C67.9 (bladder cancer), and the morphologic code 8122 (SUC). Patients were randomly divided into a training cohort (TC) and a validation cohort (VC) (7:3 ratio). Variables significantly associated with OS and DSS were identified with multivariate Cox regression and were used to build the nomograms. Harrel's C-statistic with bootstrap resampling and calibration curves were used for internal (TC) and external (VC) validation. Clinical utility of the nomograms was assessed with the decision curve analysis (DCA). Goodness of fit between the nomograms and the AJCC 8th edition staging system was compared with the likelihood ratio test.

RESULTS

A total of 741 patients with SUC were included (507 TC, 234 VC). No statistically significant differences in baseline characteristics were identified between the 2 cohorts. Sex, SEER stage, radical cystectomy and chemotherapy were common variables for the OS and the DSS nomograms with the addition of age in the former. Optimism-corrected C-statistic for the nomograms was 0.68 and 0.67 for OS and DSS respectively. In comparison, C-statistic for AJCC was 0.59 for OS and 0.60 for DSS (P < 0.001). Calibration curves constructed for the nomograms showed appropriate consistency between predicted and actual survival. The nomograms demonstrated optimal clinical utility in the DCA, outperforming the AJCC staging system, by maintaining a higher clinical net benefits than treat all, treat none and AJCC curves, across threshold probabilities.

CONCLUSION

We present the first prognostic nomograms developed in patients with SUC. Our models demonstrated superior prognostic performance to the AJCC system, by utilizing a set of variables readily available in daily practice and may serve as useful tools for the individualized risk assessment of these patients.

Renal Sarcoma: A Population-Based Study

INTRODUCTION

Renal sarcomas are exceedingly rare and lack a prognostic stage classification. We thus aimed to investigate the contemporary clinicopathologic characteristics and outcomes of renal sarcomas at a national level.

PATIENTS AND METHODS

We utilized the Surveillance, Epidemiology, and End Results database to extract data on patients with renal sarcoma diagnosed between 2004 and 2015. We estimated median, 1-, 3-, and 5-year overall survival (OS) probabilities via Kaplan-Meier curves and used multivariable regression to compare OS between different patient groups.

RESULTS

We identified 365 patients; at diagnosis, 104 patients (28.5%) had stage I disease (T1N0M0), 133 patients (36.4%) patients had stage II disease (T2-4N0M0), and 117 patients (32.1%) patients had stage III disease (any T, N1, or M1). Median survival was 105 months (interquartile range [IQR], 29 - not reached) for stage I disease, 46 months (IQR 14-118 months) for stage II disease, 8 months (IQR 3-28 months) for stage III disease, and 32 months (IQR, 8-116 months) for the entire cohort. Patient age (hazard ratio [HR] for death [per year] 1.02, 95% confidence interval [95% CI] 1.00-1.04), stage (II vs. I: HR 1.71, 95% CI 1.00-2.92; III vs. I: HR 4.93, 95% CI 2.68-9.05), grade (grade 3 vs. grade 1: 3.07, 95% CI 1.18-8.00; grade 4 vs. grade 1: HR 3.66, 95% CI 1.41-9.49), and possessing medical insurance (HR 0.40, 95% CI 0.16-0.94) were independently and significantly associated with OS. Performance of nephrectomy also trended towards independently improving OS (HR 0.23, 95% CI 0.05-1.09).

CONCLUSION

A novel staging classification for renal sarcomas into a 3-stage system based on Tumor Node Metastasis (TNM) criteria produces distinct survival curves, although further studies are needed to robustly assess its validity.

A quantitative analysis of escalating antineoplastic medication price increases

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Background: Established antineoplastic medication prices are overall increasing, yet the yearly trend and additive cost of such increases relative to overall antineoplastic spending is often unclear. Methods: We accessed the yearly reimbursement files from Medicare Part B for parenteral antineoplastic agents (codes J8501-J9999) for the years 2010-2020 and adjusted all values to 2020 USD to account for inflation. We calculated an initial inflation-adjusted price-per-claim for every medication at the time of medication entry to the database and compared that price with the yearly price-per-claim that Medicare reimbursed. For medications whose price had increased beyond the initial inflation-adjusted price, we multiplied the annual differences with the total annual claims of the medication reimbursed in order to calculate the additional cost accrued by Medicare for every affected year. We only included medications with total annual cost >10 million USD/yr in our analysis. Results: Price increases were noted in 70.9% of already established medications annually (median 74.5%, range 52.17-81.48%). This led to an average additional extra cost of 311 million USD (range 156-492 million USD) annually, for a total of 3.1 billion USD over the 10 years of observation. This extra cost represented 4.6-9.3% of the total Medicare Part B spending for antineoplastic medications annually and this percentage rose yearly by a statistically significant 0.43% (95% CI 0.14%-0.73%, P = 0.01; R2 0.59) in absolute terms (Table). Rituximab (1,003 million USD), trastuzumab (421 million USD), and bevacizumab (326 million USD) accumulated the highest extra costs. Conclusions: The majority of established parenteral antineoplastics are affected by escalating price increases beyond the rate of inflation. Year-by-year, these increases occupy a progressively larger part of overall Medicare Part B spending. Since Medicare does not negotiate medication price nor receives rebates but rather relies on average market prices, these increases likely affect other U.S. markets as well.[Table: see text]

Adjuvant immunotherapy for muscle-invasive urothelial carcinoma of the bladder

INTRODUCTION

There are substantial unmet needs with regards to adjuvant therapy for muscle-invasive urothelial carcinoma (UC) of the bladder, including patients with persistent disease histologically following neoadjuvant platinum-based therapy and radical resection, as well as patients who are not eligible for or refuse cytotoxic chemotherapy. As such, increased interest has been developed in advancing the use of systemic immunotherapy in the postoperative setting.

AREAS COVERED

We begin by examining current uses of systemic immunotherapy in the treatment of advanced UC. We also review emerging neoadjuvant data and describe current adjuvant approaches. We then report and analyze data on adjuvant immunotherapy, including the recent randomized trials on adjuvant nivolumab and atezolizumab, and conclude with a discussion on the available evidence and likely directions of the field.

EXPERT OPINION

Systemic immunotherapy can serve to enhance postoperative therapies for muscle-invasive bladder UC, as exemplified by the recent approval of nivolumab. Further research will serve to define optimal immunotherapy timing and combinations with other systemic therapies, as well as identify predictive biomarkers to allow effective tailoring of therapy for each patient.

Cardiovascular mortality in renal cell carcinoma: A population-based study

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Background: Patients with renal cell carcinoma (RCC) often harbor risk factors for cardiovascular disease and may receive anti-VEGF agents, which are associated with cardiovascular toxicity. However, the risk for cardiovascular mortality in this patient population is currently unknown. Methods: Utilizing the SEER database, we identified patients with RCC diagnosed between 2007 (approval of sunitinib) and 2015 and selected patients aged ≥ 45 years. We calculated standardized mortality ratios (SMRs) for cardiovascular mortality (ICD-10 codes I00-I99) by comparing the number of observed deaths in the database to the number of expected deaths in age-matched groups of the US general population drawn from the CDC WONDER database. Multivariable Cox regression was used to identify risk factors for cardiovascular mortality in patients with RCC. Results: We identified 36,576 patients with RCC, of which 33,748 (92.3%) were ≥ 45 years old and among these, 1650 (4.9%) died of cardiovascular diseases. The SMR for cardiovascular mortality was 2.85 (95% CI 2.72-2.99) for all patients, 2.78 (95% CI 2.62-2.95) for males and 2.86 (95% CI 2.64-3.10) for females. Among the various age groups, the SMR was 4.75 (95% CI 3.82-5.84) for patients aged 45-54 years, 3.35 (95% CI 2.93-3.83) for patients aged 55-64 years, 2.75 (95% CI 2.49-3.04) for patients aged 65-74 years, 2.25 (95% CI 2.07-2.45) for patients aged 75-84 years, and 1.47 (95% CI 1.33-1.61) for patients aged > 85 years. In multivariate analysis, advancing age (HR 1.06, 95% CI 1.06-1.07), male sex (HR 1.18, 95% CI 1.05-1.33), black race (HR 1.48, 95% CI 1.27-1.73), stage IV disease (HR 1.21, 95% CI 1.01-1.45), and performance of surgery directed to the primary tumor (HR 0.33, 95% CI 0.29-0.38) were independently associated with cardiovascular mortality. Conclusions: Patients with RCC possess an almost 3-fold greater risk for cardiovascular mortality than the general population and this risk is even more pronounced in middle-aged patients. Aggressive management of modifiable cardiovascular risk factors in this patient population is thus warranted.

Quantification of the financial burden of antineoplastic agent price increases

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Background: Antineoplastic medication prices are overall increasing yet this phenomenon is not limited to new medications but can also be observed in already established medications. Methods: We accessed the yearly payment files from Medicare Part B for injectable antineoplastic agents (codes J8501-J9999) for the years 2010-2017 and all costs were adjusted to 2017 USD to adjust for inflation. We then calculated the price-per-dose for every medication and compared that price with the price-per-dose that the medication would have if its initial price was only affected by inflation. We subsequently multiplied the difference with the total doses of the medication administered in order to calculate the additional cost accrued by Medicare from medications whose price had increased more than the inflation rates. Only medications with total annual payments >10 million USD/yr were included in the analysis. Notably, Medicare provides reimbursement based on average U.S. market prices. Results: Price increases were noted on average in 64.5% of already established medications (median 69.6%, range 45.4-74.1%), leading to an average additional extra cost of 243 million USD per year (range 140-330 million USD), for a total of 1.7 billion USD over the 7 years of observation. Rituximab (539 million USD), trastuzumab (221 million USD), and bevacizumab (178 million USD) accrued the highest extra costs. This extra cost represented 4.6-8.9% of the annual total Medicare Part B spending for antineoplastic medications (Table). Conclusions: The majority of already established injectable chemotherapeutics demonstrate price increases that lead to substantial additional financial cost to Medicare and likely other U.S. markets as well. Price increases of Medicare Part B antineoplastic medications with cost >10 million USD/yr. [Table: see text]

Sarcomatoid Renal Cell Carcinoma: Population-Based Study of 879 Patients

BACKGROUND

Sarcomatoid renal cell carcinoma (sRCC) constitutes a rare and aggressive subtype of renal cell carcinoma. We aimed to investigate its clinicopathologic characteristics and outcomes at a national level.

PATIENTS AND METHODS

We accessed the National Cancer Institute's Surveillance, Epidemiology, and End Results database (2010-2015) and extracted data on patients with sRCC. We estimated median, 1-, 3-, and 5-year disease-specific survival (DSS) probabilities after generation of Kaplan-Meier curves and used multivariable regression to evaluate variables associated with nephrectomy and DSS.

RESULTS

A total of 879 patients with sRCC were identified; 60.9% patients had stage IV disease at diagnosis, and the median tumor size was 8.3 cm (interquartile range, 5.5-12 cm). The 5-year DSS were 77.7%, 67.8%, 35.4%, and 3.5% for patients with stage I, II, III, and IV disease at diagnosis, respectively; median DSS was 9 months (interquartile range, 4-42 months) for the entire cohort. Older age (hazard ratio [HR] = 1.01; 95% confidence interval [CI], 1.00-1.02), higher tumor stage (stage III vs. I: HR = 3.81; 95% CI, 2.18-6.67; stage IV vs. I: HR = 9.89; 95% CI, 5.80-16.98), and performance of nephrectomy (HR = 0.53; 95% CI, 0.43-0.66) were found to independently affect DSS.

CONCLUSION

In the largest sRCC cohort to date, we found that most patients present with metastatic disease, and the prognosis for this disease remains extremely poor. Nephrectomy should be considered in all patients with acceptable surgical risk, including cytoreductive nephrectomy in carefully selected patients with metastatic disease.

Outcomes After Surgical Resection Differ by Primary Tumor Location for Metastatic Gastrointestinal Stromal Tumors (GISTs): a Propensity Score Matching Population Study

PURPOSE

Primary tumor location has been identified as an important prognostic factor among patients with gastrointestinal stromal tumors (GISTs). The purpose of this study is to identify how primary tumor location may affect outcomes after resection for patients with metastatic GISTs.

METHODS

Patients with GISTs and distant metastases at diagnosis were identified in the Surveillance Epidemiology and End Results (SEER) database. Patients that underwent surgery were matched to patients that did not undergo surgery using propensity score matching (PSM) analysis.

RESULTS

After PSM, 570 patients were identified (males 334 [58.6%], females 236 [41.4%], age 62 ± 13.9 years). Gastric tumors constituted the majority (325 [57%]), followed by small intestinal (136 [23.9%]), colorectal (19 [3.3%]), and retroperitoneal/peritoneal tumors (23 [4%]). Median follow-up was 25.5 months (95% CI 23-29 months). Undergoing surgery was associated with improved disease-specific survival (DSS) on both univariate (median not reached vs. 51 months, p < 0.001) and multivariate analyses (HR 4.98, 95% CI 2.23-11.12, p < 0.001). A sub-analysis of patients with gastric GISTs showed that undergoing surgery was the only significant factor associated with improved DSS (median not reached vs. 39 months, p < 0.001, HR 2.95, 95% CI 1.92-4.53). In contrast, undergoing surgery was not associated with improved survival for small intestinal, colorectal, or retroperitoneal/peritoneal tumors.

CONCLUSIONS

Surgery for gastric metastatic GISTs is associated with improved survival. No discernible benefit after surgical resection was identified for patients with small intestinal, colorectal, retroperitoneal, or peritoneal metastatic GISTs.

Predictive Nomograms for Synchronous Distant Metastasis in Rectal Cancer

BACKGROUND

Nomograms may be used to quantitatively assess the probability of synchronous distant metastasis. The purpose of this study is to develop predictive nomograms for the presence of synchronous distant metastasis in patients with rectal cancer.

METHODS

A retrospective analysis of the Surveillance Epidemiology and End Results database was performed for cases diagnosed between 2010 and 2014.

RESULTS

Overall, 46,785 patients with rectal cancer (27,773 [59.4%] males, mean age 63.9 ± 13.7 years) were identified, of which 6192 (13.2%) had liver metastasis, 2767 (5.9%) had lung metastasis, and 601 (1.3%) had bone metastasis. Age, sex, race, tumor location, tumor grade, primary tumor size, CEA levels, perineural invasion, T stage, N stage, and liver and lung metastasis were found to be associated with the presence of synchronous distant metastasis and were included in the predictive models. The c-indexes of these models were 0.99 for liver metastasis, 0.99 for lung metastasis, and 1 for bone metastasis.

CONCLUSIONS

Predictive nomograms for the presence of synchronous liver, lung, and bone metastasis were developed and may be used to predict the probability of distant disease in rectal cancer patients.

Conditional survival analysis for patients with intraductal papillary mucinous neoplasms (IPMNs) undergoing curative resection

BACKGROUND

Conditional survival (CS) analysis represents a novel method that may provide more clinically relevant perspectives to cancer management compared to conventional survival analysis. The purpose of this study was to evaluate conditional survival for patients with intraductal papillary mucinous neoplasms (IPMNs) undergoing curative resection.

METHODS

A retrospective search of the Surveillance Epidemiology and End Results (SEER) database was performed. Three-year conditional survival (i.e. probability that a patient will survive an additional 3 years if they have already survived x years) was calculated using the formula 3-CS(x)=OS(x+3)/OS(x), where OS represents overall survival.

RESULTS

Overall, 1303 patients were identified, with mean age of 65.2 ± 12.2 years. 3-CS at 1, 3 and 5 years after diagnosis was 35.8%, 47.5% and 44.7%. Patients with stage III/IV disease demonstrated small differences in 3-CS at 1-3 years after diagnosis compared to patients with stage I/II disease (I/II: 35.1%-46.9%, III/IV: 22.1%-42.3%, d range 0.09-0.28), while their 3-CS was superior at 4-5 years after diagnosis (I/II: 41.5%-45.7%, III/IV: 57.9%-64.7%, d range 0.24-0.47). Differences in 3-CS based on tumor grade displayed a different pattern, with small differences at 1-3 years after diagnosis (well-differentiated (WD)/moderately-differentiated (MD): 34.6%-50%, poorly-differentiated (PD)/undifferentiated (UD): 23.2%-40%, d range 0.18-0.24), before becoming prominent at 4-5 years after diagnosis (WD/MD: 50%-51.7%, PD/UD: 24.1%-30%, d range 0.4-0.55).

CONCLUSIONS

Conditional survival for patients with IPMNs undergoing resection improves over time, especially for patients with high-risk features. This information may be used to provide individualized approaches to surveillance and treatment.

Inappropriate Management of Asymptomatic Patients With Positive Urine Cultures: A Systematic Review and Meta-analysis

BACKGROUND

Mismanagement of asymptomatic patients with positive urine cultures (referred to as asymptomatic bacteriuria [ASB] in the literature) promotes antimicrobial resistance and results in unnecessary antimicrobial-related adverse events and increased health care costs.

METHODS

We conducted a systematic review and meta-analysis of studies that reported on the rate of inappropriate ASB treatment published from 2004 to August 2016. The appropriateness of antimicrobial administration was based on guidelines published by the Infectious Diseases Society of America.

RESULTS

A total of 2142 nonduplicate articles were identified, and among them 30 fulfilled our inclusion criteria. The pooled prevalence of antimicrobial treatment among 4129 cases who did not require treatment was 45% (95% CI, 39-50). Isolation of gram-negative pathogens (odds ratio [OR], 3.58; 95% CI, 2.12-6.06), pyuria (OR, 2.83; 95% CI, 1.9-4.22), nitrite positivity (OR, 3.83; 95% CI, 2.24-6.54), and female sex (OR, 2.11; 95% CI, 1.46-3.06) increased the odds of receiving treatment. The rates of treatment were higher in studies with ≥100 000 cfu/mL cutoff values compared with <10 000 cfu/mL for bacterial growth (P, .011). The implementation of educational and organizational interventions designed to eliminate the overtreatment of ASB resulted in a median absolute risk reduction of 33% (rangeARR, 16-36%, medianRRR, 53%; rangeRRR, 25-80%).

CONCLUSION

The mismanagement of ASB remains extremely frequent. Female sex and the overinterpretation of certain laboratory data (positive nitrites, pyuria, isolation of gram-negative bacteria and cultures with higher microbial count) are associated with overtreatment. Even simple stewardship interventions can be particularly effective, and antimicrobial stewardship programs should focus on the challenge of differentiating true urinary tract infection from ASB.

Trends in incidence and associated risk factors of suicide mortality among breast cancer patients

OBJECTIVE

Breast cancer patients are associated with an increased risk for committing suicide. The purpose of this study was to study the trends in the incidence of suicide mortality and identify pertinent risk factors among patients with breast cancer.

METHODS

A retrospective examination of the Surveillance Epidemiology and End Results database between years 1973 and 2013 was performed.

RESULTS

Overall, 474 128 patients were identified of which 773 had committed suicide. There were no significant differences in the incidence of suicide mortality over the last 3 decades (1984-1993: 0.14%, 1994-2003: 0.16%, 2004-2013: 0.17%, P = 0.173). On logistic regression, younger age (<30 y: OR 6.34, 95% CI: 1.98-20.33, P = 0.002; 30-49 y: OR 10.64, 95% CI: 7.97-14.2, P < 0.001; 50-69 y: OR 4.7, 95% CI: 3.64-6.07, P < 0.001), male sex (OR 4.34, 95% CI: 2.57-7.31, P < 0.001), nonwhite-nonblack race (OR 1.39, 95% CI: 1.01-1.91, P = 0.046), marital status (single: OR 1.35, 95% CI: 1.04-1.76, P = 0.024; separated/divorced/widowed: OR 1.25, 95% CI: 1.01-1.55, P = 0.043), undergoing surgery (OR 2.13, 95% CI: 1.23-3.67, P = 0.007), and short-time elapsed from diagnosis (first year: OR 4.67, 95% CI: 3.39-6.42, P < 0.001; second year: OR 2.35, 95% CI: 1.69-3.27, P < 0.001) were independent risk factors of suicide mortality.

CONCLUSIONS

There have been no identifiable improvements in preventing suicide mortality in the United States. Younger age, male sex, race, marital status, and undergoing surgery are independent risk factors for committing suicide, especially in the first year after diagnosis.

Urinary tract infections caused by ESBL-producing Enterobacteriaceae in renal transplant recipients: A systematic review and meta-analysis

BACKGROUND

Urinary tract infections (UTIs) are the most common infectious complications among renal transplant recipients (RTR). UTIs caused by extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae (ESBL-PE) have been associated with inferior clinical outcomes and increased financial burden.

METHODS

We performed a systematic review and meta-analysis by searching through the PubMed and EMBASE databases (to May 20, 2016) and identifying studies that reported data on the number of RTR who developed an ESBL-PE UTI.

RESULTS

Our analysis included seven studies, out of 357 non-duplicate articles, that provided data on 2824 patients. Among them, 10% (95% confidence interval [CI] 4%-17%) developed an ESBL-PE UTI over their follow-up periods. The proportion of RTR affected by an ESBL-PE UTI was 2% in North America (95% CI 1%-3%), 5% in Europe (95% CI 4%-6%), 17% in South America (95% CI 10%-27%), and 33% in Asia (95% CI 27%-41%). In addition, patients affected with an ESBL-PE UTI were 2.75-times (95% CI 1.97-3.83) more likely to suffer a recurrent UTI.

CONCLUSIONS

Based on a limited number of studies, one in 10 RTR will develop a UTI caused by an ESBL-PE, and these patients face an almost 3 times greater risk of recurrence. A more rigorous monitoring of RTR, both during and after resolution of their infection, should be evaluated in order to reduce the incidence and the clinical impact of these resistant infections.

The salivary microbiome is consistent between subjects and resistant to impacts of short-term hospitalization

In recent years, a growing amount of research has begun to focus on the oral microbiome due to its links with health and systemic disease. The oral microbiome has numerous advantages that make it particularly useful for clinical studies, including non-invasive collection, temporal stability, and lower complexity relative to other niches, such as the gut. Despite recent discoveries made in this area, it is unknown how the oral microbiome responds to short-term hospitalization. Previous studies have demonstrated that the gut microbiome is extremely sensitive to short-term hospitalization and that these changes are associated with significant morbidity and mortality. Here, we present a comprehensive pipeline for reliable bedside collection, sequencing, and analysis of the human salivary microbiome. We also develop a novel oral-specific mock community for pipeline validation. Using our methodology, we analyzed the salivary microbiomes of patients before and during hospitalization or azithromycin treatment to profile impacts on this community. Our findings indicate that azithromycin alters the diversity and taxonomic composition of the salivary microbiome; however, we also found that short-term hospitalization does not impact the richness or structure of this community, suggesting that the oral cavity may be less susceptible to dysbiosis during short-term hospitalization.

Bloodstream infections due to extended-spectrum β-lactamase-producing Enterobacteriaceae among patients with malignancy: a systematic review and meta-analysis

Extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-PE) are an increasing cause of resistant infections among patients with malignancy. This study sought to estimate the prevalence of bloodstream infections (BSIs) caused by ESBL-PE in this population and to examine regional and temporal differences. The PubMed and EMBASE databases (to 30 April 2016) were searched to identify studies reporting ESBL-PE BSI rates among patients with malignancies. Of 593 non-duplicate reports, 22 studies providing data on 5650 BSI cases satisfied the inclusion criteria. Among all BSIs the pooled prevalence of ESBL-PE was 11% (95% CI 8-15%) and among Gram-negative BSIs it was 21% (95% CI 16-27%). Among patients with haematological malignancies, the pooled ESBL-PE prevalence was 11% (95% CI 8-15%), whereas no studies providing specific data on patients with solid tumours were identified. Stratifying per geographic region, the pooled prevalence was 7% each in Europe (95% CI 5-11%), the Eastern Mediterranean region (95% CI 4-11%) and South America (95% CI 2-14%), 10% in the Western Pacific region (95% CI 4-19%) and 30% in Southeast Asia (95% CI 18-44%). Importantly, there was a 7.1% annual increase in the ESBL-PE incidence (P = 0.004). Overall, ca. 1 in 10 BSIs in patients with malignancy is caused by ESBL-PE and in some areas this rate can be as high as 1 in 3 cases. Additionally, the incidence of these resistant infections is rising. These findings should be considered when selecting empirical antimicrobial therapy and should prompt strict adherence to antimicrobial stewardship.

Colonization and infection with extended-spectrum beta-lactamase producing Enterobacteriaceae in patients with malignancy

INTRODUCTION

Extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) constitute a global threat and are prevalent in both nosocomial and community settings. These pathogens have been associated with delays in initiation of appropriate antimicrobial therapy and worse clinical outcomes. Patients with solid or hematologic malignancy represent a high-risk population for both colonization and infection with ESBL-PE. Areas covered: A description of the microbiology and epidemiology of the ESBL-PE is presented. Also, we explore studies on ESBL-PE colonization and infection, and examine areas where future research is needed. Expert commentary: ESBL-PE constitute an increasing threat to patients with malignancy. Unfortunately, substantial geographic variations as well as knowledge gaps in certain regions of the world limit our ability to reach conclusions that are valid globally. Furthermore, there is limited evidence regarding the optimal ways to prevent and manage infections caused by ESBL-PE. Research is urgently needed to elucidate these areas and allow the institution of appropriate infection control and antimicrobial stewardship policies and recommendations.

Colonization with extended-spectrum beta-lactamase-producing Enterobacteriaceae in solid organ transplantation: A meta-analysis and review

BACKGROUND

Extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E) may cause severe infections, often preceded by ESBL-E gastrointestinal (GI) colonization.

METHODS

We conducted a review of the literature, investigating the prevalence of ESBL-E GI colonization in solid organ transplant (SOT) patients and the risk for subsequent ESBL-E infection. We searched the PubMed and EMBASE databases (to April 1, 2016) looking for studies that contained data on ESBL-E colonization among transplant patients.

RESULTS

Of 341 non-duplicate citations, four studies reporting data on 1089 patients fulfilled our inclusion criteria. Among them, the pooled prevalence for ESBL-E colonization was 18% (95% confidence interval [CI] 5%-36%). Stratifying by transplant type, we identified an ESBL-E colonization rate of 17% (95% CI 3%-39%) among liver transplant recipients and 24% (single report) among kidney transplant recipients.

CONCLUSIONS

Among SOT patients, approximately one in five patients is colonized with ESBL-E, although this finding may be skewed by reporting bias from centers with high ESBL-E prevalence. ESBL-E screening in SOT patients should be considered and evaluated in future studies.

The Dose-Dependent Efficacy of Cefepime in the Empiric Management of Febrile Neutropenia: A Systematic Review and Meta-Analysis

BACKGROUND

Despite reports questioning its efficacy, cefepime remains a first-line option in febrile neutropenia. We aimed to re-evaluate the role of cefepime in this setting.

METHODS

We searched the PubMed and EMBASE databases to identify randomized comparisons of (1) cefepime vs alternative monotherapy or (2) cefepime plus aminoglycoside vs alternative monotherapy plus aminoglycoside, published until November 28, 2016.

RESULTS

Thirty-two trials, reporting on 5724 patients, were included. Clinical efficacy was similar between study arms (P = .698), but overall mortality was greater among cefepime-treated patients (risk ratio [RR] = 1.321; 95% confidence interval [CI], 1.035-1.686; P = .025). Also of note, this effect seemed to stem from trials using low-dose (2 grams/12 hours, 100 mg/kg per day) cefepime monotherapy (RR = 1.682; 95% CI, 1.038-2.727; P = .035). Cefepime was also associated with increased mortality compared with carbapenems (RR = 1.668; 95% CI, 1.089-2.555; P = .019), a finding possibly influenced by cefepime dose, because carbapenems were compared with low-dose cefepime monotherapy in 5 of 9 trials. Treatment failure in clinically documented infections was also more frequent with cefepime (RR = 1.143; 95% CI, 1.004-1.300; P = .043). Toxicity-related treatment discontinuation was more common among patients that received high-dose cefepime (P = .026), whereas low-dose cefepime monotherapy resulted in fewer adverse events, compared with alternative monotherapy (P = .009).

CONCLUSIONS

Cefepime demonstrated increased mortality compared with carbapenems, reduced efficacy in clinically documented infections, and higher rates of toxicity-related treatment discontinuation. The impact of cefepime dosing on these outcomes is important, because low-dose regimens were associated with lower toxicity at the expense of higher mortality.

Comparison Between Carbapenems and β-Lactam/β-Lactamase Inhibitors in the Treatment for Bloodstream Infections Caused by Extended-Spectrum β-Lactamase-Producing Enterobacteriaceae: A Systematic Review and Meta-Analysis

Background

Carbapenems are widely used for the management of bloodstream infections (BSIs) caused by extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-PE). However, the wide use of carbapenems has been associated with carbapenem-resistant Enterobacteriaceae development.

Methods

We searched the PubMed and Scopus databases (last search date was on June 1, 2016) looking for studies that reported mortality in adult patients with ESBL-PE BSIs that were treated with carbapenems or β-lactam/β-lactamase inhibitors (BL/BLIs).

Results

Fourteen studies reported mortality data in adult patients with ESBL-PE BSI that were treated with carbapenems or BL/BLIs. Among them, 13 studies reported extractable data on empiric therapy, with no statistically significant difference in mortality of patients with ESBL-PE BSI that were treated empirically with carbapenems (22.1%; 121 of 547), compared with those that received empiric BL/BLIs (20.5%; 109 of 531; relative risk [RR], 1.05; 95% confidence interval [CI], 0.83–1.37; I² = 20.7%; P = .241). In addition, 7 studies reported data on definitive therapy. In total, 767 patients (79.3%) received carbapenems and 199 patients (20.6%) received BL/BLIs as definitive therapy, and there was again no statistically significant difference (RR, 0.62; 95% CI, 0.25–1.52; I² = 84.6%; P < .001). Regarding specific pathogens, the use of empiric BL/BLIs in patients with BSI due to ESBL-Escherichia coli was not associated with a statistically significant difference in mortality (RR, 1.014; 95% CI, 0.491–2.095; I² = 62.5%; P = .046), compared with the use of empiric carbapenems.

Conclusions

These data do not support the wide use of carbapenems as empiric therapy, and BL/BLIs might be effective agents for initial/empiric therapy for patients with BSI caused by likely ESBL-PE, and especially ESBL-E coli.

The Impact of Shortages on Medication Prices: Implications for Shortage Prevention

BACKGROUND

Medication shortages are frequent and have clinical and financial ramifications; however, their effect on drug prices remains unknown.

OBJECTIVE

To examine price progression of medications affected by a shortage.

METHODS

We collected prices of medications covered under Medicare Part B, reflective of general market prices, and data on clinically relevant shortages for the period 2005-16. We used linear mixed-effects models to examine the price growth of affected medications.

RESULTS

Shortage medications demonstrated a quarterly price growth of -0.5 % (95 % confidence interval [CI] -1.6, 0.6) in the period preceding a shortage, 4.3 % (95 % CI 3.6, 4.5) during a shortage, and 4.1 % (95 % CI 2.6, 5.5) in the post-shortage period. Medications not affected by a shortage had a quarterly price growth of 0.2 % (95 % CI -0.3, 0.6).

CONCLUSIONS

Medication shortages are associated with price increases, and these increases are likely reactive to the low profitability of the affected medications and thus, proactive collaboration between the US Food and Drug Administration and industry can serve to identify low-profit drugs and evaluate measures to ensure continued production.

Vancomycin-resistant enterococci colonisation, risk factors and risk for infection among hospitalised paediatric patients: a systematic review and meta-analysis

The objective of this study was to estimate the rate and significance of colonisation with vancomycin-resistant enterococci (VRE) among hospitalised children. The PubMed and EMBASE databases were systematically searched (last accessed on 29 May 2016) to identify studies evaluating VRE colonisation of the gastrointestinal tract of hospitalised children in non-outbreak periods. Of 945 non-duplicate citations, 19 studies enrolling 20 234 children were included. The overall and paediatric intensive care unit (PICU) rate of VRE colonisation were both 5% [95% confidence interval (CI) 3-8% overall and 95% CI 2-9% in the PICU] but was 23% in haematology/oncology units (95% CI 18-29%). Studies that were exclusively performed in haematology/oncology units reported significantly higher rates compared with all other studies in the univariate and multivariate analyses (P = 0.001). Previous vancomycin [risk ratio (RR) = 4.34, 95% CI 2.77-6.82] or ceftazidime (RR = 4.15, 95% CI 2.69-6.40) use was a risk factor for VRE colonisation. Importantly, VRE colonisation increased the risk of subsequent VRE infection (RR = 8.75, 95% CI 3.19-23.97). In conclusion, a high rate of VRE colonisation was found among hospitalised children in institutions that performed targeted screening. Importantly, colonised children were almost 9 times more likely to develop subsequent VRE infection. Judicious use of specific antibiotics along with intensification of infection control measures should be considered in high-prevalence institutions. Also, the high incidence of VRE colonisation among children with haematological/oncological diseases identifies a high-risk population.

The Attributable Burden of Clostridium difficile Infection to Long-Term Care Facilities Stay: A Clinical Study

BACKGROUND

Advanced age, history of hospitalization, and antibiotic consumption are associated with the pathogenesis of Clostridium difficile infection (CDI). Long-term care facilities (LTCFs) represent a setting where CDI has been increasingly reported. We aimed to estimate the actual attributable burden of CDI to LTCF stay and determine the characteristics of the disease epidemiology in this setting.

DESIGN

IRB-approved retrospective cohort study.

SETTING

LTCF and community.

PARTICIPANTS

One thousand seven hundred and sixty-one patients.

MEASUREMENTS/RESULTS

The prevalence of CDI among LTCF residents was 22.4%, whereas the prevalence of CDI among community residents was 6.7% (P < .001). The prevalence of CDI among LTCF residents was significantly higher in both the 18-64 (P < .001) and the ≥65 age groups (P < .010). Measures of hospital exposure and antibiotic consumption between LTCF and community residents prior to CDI diagnosis were non-significant. A strict matching (1:2) between LTCF and community residents adjusting for age, total number of hospital admissions and antibiotic consumption showed that the odds of CDI for an LTCF resident were 6.89 times larger than the odds for a community resident (OR = 6.89, 95%, 4.67-10.17). For an LTCF resident with CDI, the odds of manifesting severe disease were 3.25 times larger than the odds for a community resident with CDI (OR = 3.25, 95%, 1.81-5.86). LTCF residents were more frequently hospitalized (P = .002) required longer hospital stays for their CDI management (P = .03) and had more recurrent CDI cases than community residents (P = .04).

CONCLUSIONS

Our study highlights the increased burden of CDI among LTCF residents independently of age, antibiotic, and hospitalization background. Severe CDI disease and recurrences are more frequent in LTCFs.

Prevalence of ESBL-Producing Enterobacteriaceae in Pediatric Bloodstream Infections: A Systematic Review and Meta-Analysis

Background

Pediatric bloodstream infections (BSIs) with Extended-Spectrum Beta-Lactamase- producing Enterobacteriaceae (ESBL-PE) are associated with worse clinical outcomes. We aimed to estimate the prevalence of and the mortality associated with ESBL-PE in this patient population.

Methods

A systematic review and meta-analysis using PubMed and EMBASE and included studies reporting the prevalence of ESBL-PE among confirmed BSIs in patients <19 years old.

Results

Twenty three (out of 1,718 non-duplicate reports) studies that provided data on 3,381 pediatric BSIs from 1996 to 2013 were included. The prevalence of ESBL-PE was 9% [95%CI (6, 13)] with an annual increase of 3.2% (P = 0.04). The prevalence was 11% [95%CI (6, 17)] among neonates, compared to 5% [95%CI (0, 14)] among children older than 28 days. The pooled prevalence was 15% in Africa [95%CI (8, 23)], 12% in South America [95%CI (5, 23)], 11% in India [95%CI (7, 17)], 7% in the rest of Asia [95%CI (0, 22)], 4% in Europe [95%CI (1, 7)] and 0% in Oceania [95%CI (0, 3)]. Importantly, the mortality in neonates with BSI due to ESBL-PE was 36% [95%CI (22, 51)], compared to 18% [95%CI (15, 22)] among all other neonates with BSI and this difference was statistically significant (P = 0.01).

Conclusions

In the pediatric population, the prevalence of BSI due to ESBL-PE is significant and is associated with increased mortality in neonates. Further studies are warranted to establish a high-risk group and the evaluation of preventive measures, such as antibiotic stewardship programs and infection control measures, in this population is urgently needed.

Colonization With Vancomycin-Resistant Enterococci and Risk for Bloodstream Infection Among Patients With Malignancy: A Systematic Review and Meta-Analysis

Background

Vancomycin-resistant enterococci (VRE) cause severe infections among patients with malignancy, and these infections are usually preceded by gastrointestinal colonization.

Methods

We searched the PubMed and EMBASE databases (up to May 26, 2016) to identify studies that reported data on VRE gastrointestinal colonization among patients with solid or hematologic malignancy.

Results

Thirty-four studies, reporting data on 8391 patients with malignancy, were included in our analysis. The pooled prevalence of VRE colonization in this population was 20% (95% confidence interval [CI], 14%–26%). Among patients with hematologic malignancy, 24% (95% CI, 16%–34%) were colonized with VRE, whereas no studies reported data solely on patients with solid malignancy. Patients with acute leukemia were at higher risk for VRE colonization (risk ratio [RR] = 1.95; 95% CI, 1.17–3.26). Vancomycin use or hospitalization within 3 months were associated with increased colonization risk (RR = 1.92, 95% CI = 1.06–3.45 and RR = 4.68, 95% CI = 1.66–13.21, respectively). Among the different geographic regions, VRE colonization rate was 21% in North America (95% CI, 13%–31%), 20% in Europe (95% CI, 9%–34%), 23% in Asia (95% CI, 13%–38%), and 4% in Oceania (95% CI, 2%–6%). More importantly, colonized patients were 24.15 (95% CI, 10.27–56.79) times more likely to develop a bloodstream infection due to VRE than noncolonized patients.

Conclusions

A substantial VRE colonization burden exists among patients with malignancy, and colonization greatly increases the risk for subsequent VRE bloodstream infection. Adherence to antimicrobial stewardship is needed, and a re-evaluation of the use of vancomycin as empiric therapy in this patient population may be warranted.

Colonisation with extended-spectrum β-lactamase-producing Enterobacteriaceae and risk for infection among patients with solid or haematological malignancy: a systematic review and meta-analysis

Cancer patients are vulnerable to infections, including those with extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-PE), and most of these infections are associated with colonisation of the gastrointestinal tract. The aim of this study was to estimate the prevalence of gastrointestinal colonisation with ESBL-PE cancer populations and to determine the risk for subsequent bloodstream infection (BSI) with these pathogens. PubMed and EMBASE databases were searched from 1 January 1991 to 1 March 2016 to identify studies regarding ESBL-PE colonisation among patients with malignancies. Ten studies (out of 561 non-duplicate articles) were included, providing data on 2211 patients. The pooled prevalence of ESBL-PE colonisation was 19% [95% confidence interval (CI) 8-32%]. Stratifying per region, the pooled prevalence in Europe was 15% (95% CI 10-21%), whereas in Asia the pooled prevalence was 31% (95% CI 4-69%). In addition, the pooled prevalence was 15% (95% CI 7-24%) among patients with haematological malignancy, whereas no studies were identified that included solely patients with solid tumours. Notably, cancer patients with ESBL-PE colonisation were 12.98 times (95% CI 3.91-43.06) more likely to develop a BSI with ESBL-PE during their hospitalisation compared with non-colonised patients. We found that, overall, one in five patients with cancer is colonised with ESBL-PE and the incidence can be as high as one in three in Asia. This is important because colonisation was associated with an almost 13 times higher risk for developing BSI with ESBL-PE. Screening measures should be evaluated to identify their clinical benefit in patients with malignancy.

Prevalence of ESBL-producing Enterobacteriaceae in paediatric urinary tract infections: A systematic review and meta-analysis

OBJECTIVES

We aimed to evaluate the prevalence of paediatric urinary tract infections (UTIs) caused by extended spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE), identify predisposing factors and examine their effect on the length of hospital stay (LOS).

METHODS

For this systematic review and meta-analysis, we searched the PubMed and EMBASE databases for studies that provide data on the rate of ESBL-PE among paediatric UTIs.

RESULTS

Out of 1828 non-duplicate citations, 16 studies reporting a total of 7374 cases of UTI were included. The prevalence of ESBL-PE was 14% [(95%CI 8, 21)]. Vesicoureteral reflux (VUR) [OR = 2.79, (95%CI 1.39, 5.58)], history of UTI [OR = 2.89 (95%CI 1.78, 4.68)] and recent antibiotic use [OR = 3.92, (95%CI 1.76, 8.7)] were identified as risk factors. The LOS was significantly longer among children infected with ESBL-PE, compared to those infected with other uropathogens. [SMD = 0.88, (95%CI 0.40, 1.35)].

CONCLUSIONS

In the paediatric population, 1 out of 7 UTIs are caused by ESBL-PE. Patients with VUR, previous UTI or recent antibiotic use constitute a high risk group and these pathogens are associated with increased LOS. The significant incidence of ESBL-PE in this population should be taken into consideration in the development of empiric treatment protocols and antibiotic stewardship programmes, especially in high-prevalence areas.