Low-dose alemtuzumab for GvHD prevention followed by prophylactic donor lymphocyte infusions in high-risk leukemia

We analyzed the use of low-dose alemtuzumab in a cohort of 158 consecutive patients who underwent allogeneic PBSC transplantation. Patients with high-risk acute leukemia were prospectively screened for prophylactic donor lymphocyte infusion (pDLI). Lymphocytes were administered repeatedly at low and non-escalating doses (0.5-1 × 10⁶/kg). Low-dose alemtuzumab was effective in prevention of acute GvHD after sibling or well-matched unrelated transplantation, whereas a more intensified approach was needed after mismatched transplantation. The cumulative incidence of chronic moderate/severe chronic-GvHD (cGvHD) was 15.6%. In total, 63 high-risk leukemia patients were eligible for pDLI. Only 1 out of the 39 pDLI recipients relapsed as compared with 7 out of the 24 recipients, who did not receive pDLI due to logistical hurdles. In multivariate analysis, the use of adjuvant lymphocyte therapy was significantly associated with reduced incidence of relapse and improved disease-free survival. In summary, low-dose alemtuzumab confers to a low cGvHD incidence and the administration of pDLIs in this context is very likely to reduce relapse risk in high risk leukemia patients. This is translated in an estimated 5-year probability of GvHD-free and relapse-free survival of 43.3% for the 136 leukemia patients.

Variation in paediatric hospital antibiotic guidelines in Europe

OBJECTIVE

To assess the availability and source of guidelines for common infections in European paediatric hospitals and determine their content and characteristics.

DESIGN

Participating hospitals completed an online questionnaire on the availability and characteristics of antibiotic prescribing guidelines and on empirical antibiotic treatment including duration of therapy for 5 common infection syndromes: respiratory tract, urinary tract, skin and soft tissue, osteoarticular and sepsis in neonates and children.

RESULTS

84 hospitals from 19 European countries participated in the survey of which 74 confirmed the existence of guidelines. Complete guidelines (existing guidelines for all requested infection syndromes) were reported by 20% of hospitals and the majority (71%) used a range of different sources. Guidelines most commonly available were those for urinary tract infection (UTI) (74%), neonatal sepsis (71%) and sepsis in children (65%). Penicillin and amoxicillin were the antibiotics most commonly recommended for respiratory tract infections (RTIs) (up to 76%), cephalosporin for UTI (up to 50%) and for skin and soft tissue infection (SSTI) and bone infection (20% and 30%, respectively). Antistaphylococcal penicillins were recommended for SSTIs and bone infections in 43% and 36%, respectively. Recommendations for neonatal sepsis included 20 different antibiotic combinations. Duration of therapy guidelines was mostly available for RTI and UTI (82%). A third of hospitals with guidelines for sepsis provided recommendations for length of therapy.

CONCLUSIONS

Comprehensive antibiotic guideline recommendations are generally lacking from European paediatric hospitals. We documented multiple antibiotics and combinations for most infections. Considerable improvement in the quality of guidelines and their evidence base is required, linking empirical therapy to resistance rates.

Impact of the Gen-Probe Amplified MTD® Test on tuberculosis diagnosis in children

OBJECTIVE

To evaluate the performance of the Gen-Probe Amplified MTD® Test (AMTD) for childhood tuberculosis (TB) diagnosis compared to conventional culture.

DESIGN

We retrospectively studied 121 childhood cases (73 males; median age 7 years, range 1-16). Pulmonary samples (104/152, 68%) included gastric aspirates (n = 53), induced sputum samples (n = 43), bronchial aspirates and bronchoalveolar lavage (n = 8). Extra-pulmonary samples (48/152, 32%) included lymph nodes (n = 34) and other sterile fluids (n = 14). Specimens were examined using acid-fast bacilli (AFB) microscopy, AMTD and bacterial culture using BACTEC™ MGIT™ 960 and Löwenstein-Jensen (LJ) media.

RESULTS

A clinical diagnosis of TB was made in 50/121 (41%) children (43/50 pulmonary disease). AFB microscopy was positive in 6%; Mycobacterium tuberculosis was recovered by culture from 16/50 (32%) and AMTD was positive in 29/50 (58%). AMTD sensitivity, specificity, positive predictive value and negative predictive value compared to culture were respectively 100%, 85%, 50% and 100%. For pulmonary vs. extra-pulmonary disease, the performance of AMTD compared to culture was respectively 100%, 77%, 46% and 100% vs. 100%, 97.5%, 75% and 100%.

CONCLUSIONS

Nucleic acid amplification tests are more sensitive and very specific methods for the rapid detection of M. tuberculosis. The AMTD technique increases TB detection in children compared to conventional culture.

Changes in clinical indications for community antibiotic prescribing for children in the UK from 1996 to 2006: will the new NICE prescribing guidance on upper respiratory tract infections just be ignored?

OBJECTIVE

To analyse changes in clinical indications for community antibiotic prescribing for children in the UK between 1996 and 2006 and relate these findings to the new NICE guidelines for the treatment of upper respiratory tract infections in children.

STUDY DESIGN

Retrospective cohort study.

METHOD

The IMS Health Mediplus database was used to obtain annual antibiotic prescribing rates and associated clinical indications in 0-18-year-old patients between 1 January 1996 and 31 December 2006 in the UK.

RESULTS

Antibiotic prescribing declined by 24% between 1996 and 2000 but increased again by 10% during 2003-2006. Respiratory tract infection was the most common indication for which an antibiotic was prescribed, followed by "abnormal signs and symptoms", ear and skin infections. Antibiotic prescriptions for respiratory tract infections have decreased by 31% (p<0.01) mainly because of reduced prescribing for lower respiratory tract infections (56% decline, p<0.001) and specific upper respiratory tract infections including tonsillitis/pharyngitis (48% decline, p<0.001) and otitis (46% decline, p<0.001). Prescribing for non-specific upper respiratory tract infection increased fourfold (p<0.001). Prescribing for "abnormal signs and symptoms" increased significantly since 2001 (40% increase, p<0.001).

CONCLUSION

There has been a marked decrease in community antibiotic prescribing linked to lower respiratory tract infection, tonsillitis, pharyngitis and otitis. Overall prescribing is now increasing again but is associated with non-specific upper respiratory tract infection diagnoses. General practitioners may be avoiding using diagnoses where formal guidance suggests antibiotic prescribing is not indicated. The new NICE guidance on upper respiratory tract infections is at risk of being ignored.

The impact of Greece's childhood tuberculosis screening programme on the epidemiological indexes in the greater Athens area

SETTING

A hospital referral centre for childhood tuberculosis in Athens.

OBJECTIVE

To evaluate the effectiveness of the screening programme implemented for childhood tuberculosis, through its impact on the epidemiological index.

DESIGN

In Greece, tuberculosis has been systematically screened for in children since 1991 using the tuberculin skin test. The epidemiological and clinical profiles of all tuberculous children who attended the TB clinic were compared. The children were divided into those who attended in 1982-1990 and those who did so in 1991-1999.

RESULTS

A total of 1122 TB patients were screened. In the second period there was an increase in numbers of immigrant children (3% vs. 28%, P = 0.0001), the rate of extra-pulmonary TB decreased (16% vs. 7.6%, P = 0.0001), patients identified by the screening programme increased (19% vs. 57%, P = 0.0001) and the number of symptomatic children fell (51% vs. 16%, P = 0.0001). The proportion of children who failed to attend for regular follow-up was lower during the second period (20% vs. 7%, P = 0.0001).

CONCLUSIONS

Our study suggests that the screening programme applied in Greece during the last decade has contributed to the early identification of tuberculosis, and the limitation of symptomatic patients and extrapulmonary TB cases.