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Almajid A, Almuyidi S, Alahmadi S, Bohaligah S, Alfaqih L, Alotaibi A, Almarzooq A, Alsarihi A, Alrawi Z, Althaqfan R, Alamoudi R, Albaqami S, Alali AH. ''Myth Busting in Infectious Diseases'': A Comprehensive Review. Cureus 2024; 16:e57238. [PMID: 38686221 PMCID: PMC11056812 DOI: 10.7759/cureus.57238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2024] [Indexed: 05/02/2024] Open
Abstract
Antibiotics have played a pivotal role in modern medicine, drastically reducing mortality rates associated with bacterial infections. Despite their significant contributions, the emergence of antibiotic resistance has become a formidable challenge, necessitating a re-evaluation of antibiotic use practices. The widespread belief in clinical practice that bactericidal antibiotics are inherently superior to bacteriostatic ones lacks consistent support from evidence in randomized controlled trials (RCTs). With the latest evidence, certain infections have demonstrated equal or even superior efficacy with bacteriostatic agents. Furthermore, within clinical practice, there is a tendency to indiscriminately order urine cultures for febrile patients, even in cases where alternative etiologies might be present. Consequently, upon obtaining a positive urine culture result, patients often receive antimicrobial prescriptions despite the absence of clinical indications warranting such treatment. Furthermore, it is a prevailing notion among physicians that extended durations of antibiotic therapy confer potential benefits and mitigate the emergence of antimicrobial resistance. Contrary to this belief, empirical evidence refutes such assertions. This article aims to address common myths and misconceptions within the field of infectious diseases.
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Affiliation(s)
- Ali Almajid
- Internal Medicine, King Fahad Specialist Hospital, Dammam, SAU
| | | | - Shatha Alahmadi
- Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU
| | - Sarah Bohaligah
- Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU
| | | | | | | | - Asmaa Alsarihi
- Applied Medical Sciences, Taibah University, AlMadinah, SAU
| | - Zaina Alrawi
- Medicine, King Abdulaziz University, Jeddah, SAU
| | - Rahaf Althaqfan
- Applied Medical Sciences, King Khalid University, Khamis Mushait, SAU
| | - Rahma Alamoudi
- Medicine, Ibn Sina National College for Medical Studies, Jeddah, SAU
| | | | - Alaa H Alali
- Infectious Diseases, King Saud Medical City, Riyadh, SAU
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Coyle V, Forde C, Adams R, Agus A, Barnes R, Chau I, Clarke M, Doran A, Grayson M, McAuley D, McDowell C, Phair G, Plummer R, Storey D, Thomas A, Wilson R, McMullan R. Early switch from intravenous to oral antibiotic therapy in patients with cancer who have low-risk neutropenic sepsis: the EASI-SWITCH RCT. Health Technol Assess 2024; 28:1-101. [PMID: 38512064 PMCID: PMC11017157 DOI: 10.3310/rgtp7112] [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] [Indexed: 03/22/2024] Open
Abstract
Background Neutropenic sepsis is a common complication of systemic anticancer treatment. There is variation in practice in timing of switch to oral antibiotics after commencement of empirical intravenous antibiotic therapy. Objectives To establish the clinical and cost effectiveness of early switch to oral antibiotics in patients with neutropenic sepsis at low risk of infective complications. Design A randomised, multicentre, open-label, allocation concealed, non-inferiority trial to establish the clinical and cost effectiveness of early oral switch in comparison to standard care. Setting Nineteen UK oncology centres. Participants Patients aged 16 years and over receiving systemic anticancer therapy with fever (≥ 38°C), or symptoms and signs of sepsis, and neutropenia (≤ 1.0 × 109/l) within 24 hours of randomisation, with a Multinational Association for Supportive Care in Cancer score of ≥ 21 and receiving intravenous piperacillin/tazobactam or meropenem for < 24 hours were eligible. Patients with acute leukaemia or stem cell transplant were excluded. Intervention Early switch to oral ciprofloxacin (750 mg twice daily) and co-amoxiclav (625 mg three times daily) within 12-24 hours of starting intravenous antibiotics to complete 5 days treatment in total. Control was standard care, that is, continuation of intravenous antibiotics for at least 48 hours with ongoing treatment at physician discretion. Main outcome measures Treatment failure, a composite measure assessed at day 14 based on the following criteria: fever persistence or recurrence within 72 hours of starting intravenous antibiotics; escalation from protocolised antibiotics; critical care support or death. Results The study was closed early due to under-recruitment with 129 patients recruited; hence, a definitive conclusion regarding non-inferiority cannot be made. Sixty-five patients were randomised to the early switch arm and 64 to the standard care arm with subsequent intention-to-treat and per-protocol analyses including 125 (intervention n = 61 and control n = 64) and 113 (intervention n = 53 and control n = 60) patients, respectively. In the intention-to-treat population the treatment failure rates were 14.1% in the control group and 24.6% in the intervention group, difference = 10.5% (95% confidence interval 0.11 to 0.22). In the per-protocol population the treatment failure rates were 13.3% and 17.7% in control and intervention groups, respectively; difference = 3.7% (95% confidence interval 0.04 to 0.148). Treatment failure predominantly consisted of persistence or recurrence of fever and/or physician-directed escalation from protocolised antibiotics with no critical care admissions or deaths. The median length of stay was shorter in the intervention group and adverse events reported were similar in both groups. Patients, particularly those with care-giving responsibilities, expressed a preference for early switch. However, differences in health-related quality of life and health resource use were small and not statistically significant. Conclusions Non-inferiority for early oral switch could not be proven due to trial under-recruitment. The findings suggest this may be an acceptable treatment strategy for some patients who can adhere to such a treatment regimen and would prefer a potentially reduced duration of hospitalisation while accepting increased risk of treatment failure resulting in re-admission. Further research should explore tools for patient stratification for low-risk de-escalation or ambulatory pathways including use of biomarkers and/or point-of-care rapid microbiological testing as an adjunct to clinical decision-making tools. This could include application to shorter-duration antimicrobial therapy in line with other antimicrobial stewardship studies. Trial registration This trial is registered as ISRCTN84288963. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 13/140/05) and is published in full in Health Technology Assessment; Vol. 28, No. 14. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Vicky Coyle
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Belfast, UK
| | - Caroline Forde
- Patrick G Johnston Centre for Cancer Research, Queen's University Belfast, Belfast, UK
| | - Richard Adams
- Centre for Trials Research - Cancer Division, Cardiff University, Cardiff, UK
| | - Ashley Agus
- Northern Ireland Clinical Trials Unit, Belfast Health and Social Care Trust, Belfast, UK
| | | | - Ian Chau
- Department of Medicine, Royal Marsden Hospital, Surrey, UK
| | - Mike Clarke
- Centre for Public Health, Queens University Belfast, Belfast, UK
| | - Annmarie Doran
- Northern Ireland Clinical Trials Unit, Belfast Health and Social Care Trust, Belfast, UK
| | - Margaret Grayson
- Northern Ireland Cancer Research Consumer Forum, Belfast Health and Social Care Trust, Belfast, UK
| | - Danny McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queens University Belfast, Belfast, UK
| | - Cliona McDowell
- Northern Ireland Clinical Trials Unit, Belfast Health and Social Care Trust, Belfast, UK
| | - Glenn Phair
- Northern Ireland Clinical Trials Unit, Belfast Health and Social Care Trust, Belfast, UK
| | - Ruth Plummer
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Dawn Storey
- The Beatson West of Scotland Cancer Centre, Gartnavel General Hospital, Glasgow, UK
| | - Anne Thomas
- Leicester Cancer Research Centre, University of Leicester, Leicester, UK
| | - Richard Wilson
- Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Ronan McMullan
- Wellcome-Wolfson Institute for Experimental Medicine, Queens University Belfast, Belfast, UK
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Raheja R, Reddy N, Patel T, Kilambi S, Mathew AA, Majeed A. Classification of Chemotherapy-Induced Febrile Neutropenic Episodes Into One of the Three Febrile Neutropenic Syndromes. Cureus 2023; 15:e42843. [PMID: 37664262 PMCID: PMC10472482 DOI: 10.7759/cureus.42843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2023] [Indexed: 09/05/2023] Open
Abstract
Introduction Febrile neutropenia is a commonly encountered medical emergency in patients undergoing cancer treatment and can delay and modify the course of treatment and even lead to dire outcomes, including death. The cause of fever in a post-chemotherapy-induced neutropenic patient can be confusing to treating physicians. A review of the literature demonstrated that blood culture results could determine the cause of febrile neutropenia in only approximately 10% to 25% of patients. The objective of our study was to measure the incidence of positive blood cultures, urine cultures, and other body fluid cultures resulting in chemotherapy-induced neutropenia and further classify fever episodes into three neutropenic fever syndromes, such as microbiologically documented, clinically suspected, or unknown causes of fever, respectively. Methods We conducted a prospective observational study on 399 chemotherapy-induced neutropenic fever episodes with the aim of classifying them into one of the three neutropenic syndromes. We tried to document the cause of the fever in these patients. We also noted the type of cancer treatment regimen they were on and correlated their clinical profile with their body fluid cultures, including blood cultures, urine cultures, and other body fluid cultures. We then categorized each fever episode into one of three neutropenic syndromes. Results We studied 399 febrile neutropenic episodes. We were able to microbiologically document the cause of fever in 39% of the cases, and we obtained growth in 51 out of 399 blood cultures (13%), which was comparable to the available literature, and urine culture showed growth in 62 out of 399 cultures (16%), while other body cultures such as pus culture, bile culture, and bronchioalveolar lavage cultures collectively showed growth in 42 out of 399 episodes (10%). The most common bacteria isolated in both blood and urine cultures were Escherichia coli. Cumulatively, including blood, urine, and body fluid cultures, we were able to classify 39% (155 out of 399 cases) of febrile neutropenic episodes as microbiologically documented. The cause of fever was clinically suspected by means of careful history taking and an extensive physical examination in 31% (125 out of 399) without growth evidence in blood cultures, urine cultures, or any other body fluid culture. The cause of fever remained unknown in 119 cases (30%) of patients and was classified under the unknown cause of fever. Conclusions We conclude by stating that the study of fever in a neutropenic patient should include a thorough history and clinical evaluation of blood, urine, and other body fluid cultures instead of solely relying on blood culture results. We recommend further classifying patients into one of the three neutropenic fever syndromes, such as those that are microbiologically documented, clinically suspected, or unknown. Our blood cultures were able to give us a 13% positivity rate, whereas microbiologically, we were able to isolate an organism likely causing fever in 39% of patients. The cause of fever was suspected clinically in 31% of patients, but we were unsuccessful in microbiologically documenting any culture growth in blood, urine, or any other body fluid culture. The cause of fever remained a mystery and unknown to us without any microbiological or clinical cues in 119 cases (30%) of febrile neutropenic episodes.
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Affiliation(s)
- Ronak Raheja
- Department of Internal Medicine, Kempegowda Institute of Medical Sciences, Bengaluru, IND
| | - Neelesh Reddy
- Department of Medical Oncology, Columbia Asia Referral Hospital Yeshwanthpur, Bangalore, IND
| | - Twinkle Patel
- Department of Internal Medicine, Shri Sathya Sai Medical College and Research Institute, Surat, IND
| | - Srikar Kilambi
- College of Medicine, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
| | - Ashik A Mathew
- Department of Pharmacology and Therapeutics, Manipal Hospitals, Bangalore, IND
| | - Abdul Majeed
- Department of Internal Medicine, Columbia Asia Referral Hospital Yeshwanthpur, Bangalore, IND
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King A, Irvine S, McFadyen A, Isles C. Do we overtreat patients with presumed neutropenic sepsis? Postgrad Med J 2021; 98:825-829. [PMID: 37063037 DOI: 10.1136/postgradmedj-2021-140675] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 09/05/2021] [Indexed: 11/03/2022]
Abstract
PURPOSE Many aspects of the management of neutropenic sepsis remain controversial. These include the choice of empiric antibiotic, the duration of antibiotic therapy and the possibility that very low-risk cases may be managed safely with oral rather than intravenous therapy. STUDY DESIGN Retrospective cohort study conducted in a district general hospital serving a population of 148 000 in south west Scotland. RESULTS Fifty one patients with cancer, whose neutrophil count was less than 1.0×109/L within 21 days of their last chemotherapy, were admitted as a medical emergency in 2019. All received antibiotic because of presumed neutropenic sepsis. A total of 4 patients had positive blood cultures (group 1), 12 patients had a clinical focus of infection but no clear pathogen (group 2), while 35 patients had neither (group 3). Group 3 patients were more likely to have a solid tumour, less likely to be febrile, had shorter time to neutrophil recovery and higher Multinational Association of Supportive Care in Cancer scores, though not all of these comparisons achieved statistical significance. Median intravenous plus oral antibiotic duration in group 3 patients was 9 days with median hospital stay of 7 days, raising the possibility of overtreatment. Retrospectively, 23 (66%) group 3 patients had MASSC Risk Index greater than 21 suggesting they were at low risk of complications. CONCLUSIONS It seems likely that many low-risk neutropenic cancer patients with solid tumours could be managed as effectively and as safely with shorter courses of antibiotic, with oral rather than intravenous antibiotic, as outpatients rather than inpatients and with an overall positive impact on antimicrobial stewardship.
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Affiliation(s)
- Abbey King
- Department of Medicine, Dumfries and Galloway Royal Infirmary, Dumfries, UK
| | - Sharon Irvine
- Department of Microbiology, Dumfries and Galloway Royal Infirmary, Dumfries, UK
| | | | - Chris Isles
- Department of Medicine, Dumfries and Galloway Royal Infirmary, Dumfries, UK
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Monuszko KA, Albright B, Katherine Montes De Oca M, Thao Thi Nguyen N, Havrilesky LJ, Davidson BA. Evaluation of the clinical Index of Stable febrile neutropenia risk stratification system for management of febrile neutropenia in gynecologic oncology patients. Gynecol Oncol Rep 2021; 37:100853. [PMID: 34504931 PMCID: PMC8414105 DOI: 10.1016/j.gore.2021.100853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 08/16/2021] [Accepted: 08/22/2021] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE Scoring systems have been developed to identify low risk patients with febrile neutropenia (FN) who may be candidates for outpatient management. We sought to validate the predictive accuracy of the Clinical Index of Stable Febrile Neutropenia (CISNE) score alone and in conjunction with alternative scoring systems for risk of complications among gynecologic oncology patients. METHODS We conducted a single institution retrospective cohort study of patients admitted to an academic gynecologic oncology service for FN. We examined the performance characteristics (sensitivity, specificity, positive and negative predictive value) of three scoring systems (Multinational Association of Supportive Care in Cancer (MASCC), CISNE cut-off 1 (Low risk = 0), CISNE cut-off 2 (Low risk = <3)), and the combination of MASCC and CISNE to predict complications: inpatient death, ICU admission, hypotension, respiratory/renal failure, mental status change, cardiac failure, bleeding, and arrhythmia. RESULTS Fifty patients were identified for study inclusion. No low-risk CISNE patients died during hospitalization. Fewer CISNE low-risk patients experienced complications compared to high-risk patients, regardless of cut-off. Sensitivity, specificity, positive and negative predictive values of the scoring systems were: CISNE 1-37.1%, 86.7%, 86.7%, 37.1%; CISNE 2-85.7%, 46.7%, 78.9%, 58.3%; MASCC-82.9%, 66.7%, 85.3%, 62.5%; MASCC + CISNE 1-37.1%, 93.3%, 92.9%, 38.9%; MASCC + CISNE 2-80%, 73.3%, 87.5%, 61.1%. CONCLUSIONS The CISNE scoring system is an appropriate tool for the identification of patients with gynecologic cancers and FN who may benefit from close outpatient management. CISNE cut-off 2 performed comparably to the MASCC, but CISNE cut-off 1 had a higher specificity and positive predictive value.
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Affiliation(s)
- Karen A. Monuszko
- Duke University School of Medicine, Durham, NC, 27710, United States
| | - Benjamin Albright
- Division of Gynecologic Oncology, Duke Cancer Institute, Durham, NC, 27710, United States
| | | | | | - Laura J. Havrilesky
- Division of Gynecologic Oncology, Duke Cancer Institute, Durham, NC, 27710, United States
| | - Brittany A. Davidson
- Division of Gynecologic Oncology, Duke Cancer Institute, Durham, NC, 27710, United States
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Morgan JE, Phillips B, Haeusler GM, Chisholm JC. Optimising Antimicrobial Selection and Duration in the Treatment of Febrile Neutropenia in Children. Infect Drug Resist 2021; 14:1283-1293. [PMID: 33833534 PMCID: PMC8019605 DOI: 10.2147/idr.s238567] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 02/11/2021] [Indexed: 12/13/2022] Open
Abstract
Febrile neutropenia (FN) is a frequent complication of cancer treatment in children. Owing to the potential for overwhelming bacterial sepsis, the recognition and management of FN requires rapid implementation of evidenced-based management protocols. Treatment paradigms have progressed from hospitalisation with broad spectrum antibiotics for all patients, through to risk adapted approaches to management. Such risk adapted approaches aim to provide safe care through incorporating antimicrobial stewardship (AMS) principles such as implementation of comprehensive clinical pathways incorporating de-escalation strategies with the imperative to reduce hospital stay and antibiotic exposure where possible in order to improve patient experience, reduce costs and diminish the risk of nosocomial infection. This review summarises the principles of risk stratification in FN, the current key considerations for optimising empiric antimicrobial selection including knowledge of antimicrobial resistance patterns and emerging technologies for rapid diagnosis of specific infections and summarises existing evidence on time to treatment, investigations required and duration of treatment. To aid treating physicians we suggest the key features based on current evidence that should be part of any FN management guideline and highlight areas for future research. The focus is on treatment of bacterial infections although fungal and viral infections are also important in this patient group.
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Affiliation(s)
- Jessica E Morgan
- Centre for Reviews and Dissemination, University of York, Heslington, YO10 5DD, UK.,Department of Paediatric Oncology, Leeds Teaching Hospitals NHS Trust, Leeds, LS1 3EX, UK
| | - Bob Phillips
- Centre for Reviews and Dissemination, University of York, Heslington, YO10 5DD, UK.,Department of Paediatric Oncology, Leeds Teaching Hospitals NHS Trust, Leeds, LS1 3EX, UK
| | - Gabrielle M Haeusler
- NHMRC National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, 3010, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, 3010, Australia.,Infection Diseases Unit, Department of General Medicine, Royal Children's Hospital, Parkville, Victoria, 3168, Australia.,Murdoch Children's Research Institute, Parkville, Victoria, 3052, Australia
| | - Julia C Chisholm
- Royal Marsden Hospital and Institute of Cancer Research, Sutton, SM2 5PT, UK
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Implementation of pharmacist-managed early switch from intravenous to oral therapy using electronic identification at a tertiary academic hospital. Saudi Pharm J 2021; 29:324-336. [PMID: 33994827 PMCID: PMC8093584 DOI: 10.1016/j.jsps.2021.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 03/06/2021] [Indexed: 11/20/2022] Open
Abstract
Overutilization of intravenous (IV) medications can result in drug shortages, which is one of the major health care crisis, in addition to increasing costs, length of hospital stays (LOS) and the associated complications. We hypothesized that IV therapy was overused at our hospital where oral (PO) was applicable, and that the implementation of IV-PO protocol could result in a cost-effective practice. Hence, we aimed at assessing impact and outcomes of implementing such a protocol. A single center, prospective quasi-interventional study conducted at tertiary academic hospital. A protocol was implemented targeting 17 medications, with educational sessions to medical staff during a 5-month phase. IV orders of 48 h or more, among adult patients at medical or surgical wards with no contraindication to PO route were eligible. Once eligible, pharmacists send interventions using hospital's computerized order entry system, and physicians' responses were monitored on daily basis. Efficacy was estimated by percentage of switch recommendations that resulted in effective switch to PO medication. Cost-minimization analysis was used for course cost between the control phase and intervention phase. Length of hospital stay (LOS), readmissions within 90 days and in-hospital mortality were analyzed as secondary outcomes. During intervention phase, 781 patients had at least one IV order switched to PO. Gastric acid-reducing agents (GARAs) accounted for the most IV prescriptions (50.4%), followed by antibiotics (39.6%). Pharmacists carried out 2677 interventions to which switch recommendations were issued in 1185 (44.3%). Primary switch recommendations (N = 677) led to effective switch in 60.7% cases. These included per protocol switch (8.9%), switch to another PO (2.5%), spontaneous switch by physician (17.6%) and IV discontinuation (31.8%). The overall efficacy was estimated as 62.8%. The intervention was associated with reduced IV consumption from 4,574-18,597 vials in control phase to 3,654-15,546 vials in intervention phase, which resulted in overall cost saving of 50,960.8 SAR ($13,589.5), with an average monthly cost saving of 10,192.2 SAR ($2,717.9). Pharmacist-managed early switch from IV-PO therapy, with physicians' education, showed significant reduction in IV medication use in our hospital. By reducing unnecessary IV use, this strategy enabled considerable cost savings, besides the potential advantages of convenience and safety.
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Tew M, Forster D, Teh BW, Dalziel K. National cost savings from an ambulatory program for low-risk febrile neutropenia patients in Australia. AUST HEALTH REV 2020; 43:549-555. [PMID: 31526466 DOI: 10.1071/ah19061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 05/28/2019] [Indexed: 11/23/2022]
Abstract
Objective The management of low-risk febrile neutropenia (FN) patients through ambulatory programs has demonstrated comparative safety and effectiveness to in-patient strategies. However, there is limited evidence of benefits of changing practice, particularly on a national scale. The aim of this study was to estimate costs and benefits of the program over a 10-year time horizon. Methods A comparative cost analysis from a health system perspective was performed, comparing costs and length of stay (LOS) of patients enrolled in an ambulatory program to a historical cohort who did not receive the program. Generalised linear models were used for analysis and bootstrapped to account for uncertainty. National data of identified FN admissions were used to inform future projections, with varying proportions of low-risk patients and eligibility for the ambulatory program. Results The overall LOS for patients in ambulatory cohort was 1.9 days shorter (95% confidence interval (CI) 1.0-2.8 days), a 50% reduction in in-patient bed-days. Although patients in the ambulatory cohort incurred additional costs due to care received outside hospital (mean (± s.d.) A$828.03 ± 124.30), the mean total cost incurred remained substantially lower than that of the historical cohort (A$2979 lower; 95% CI A$772-5391). On a national scale, this could translate into A$62.7 million in costs averted and 41347 bed-days saved over 10 years if the low-risk prediction rate and eligibility for ambulatory programs remained at currently observed rates. Conclusions The wider implementation of a safe and effective ambulatory program to manage low-risk FN patients can result in significant return-on-investment for the healthcare system by eliminating avoidable costs due to unnecessary lengthy hospital admissions. What is known about the topic? There is strong evidence demonstrating out-patient treatment of low-risk FN patients to be an effective and cost-effective strategy compared with continued in-patient hospitalisation. What does this paper add? This study demonstrates the sustainability of the ambulatory program in ensuring cost benefits and in-patient beds through real-life implementation data. It also provides evidence of the substantial cost and bed-days potentially averted when the cost savings and difference in LOS are estimated on a national scale over a 10-year time horizon. What are the implications for practitioners? The management of low-risk FN patients through ambulatory or out-patient programs is a safe and effective approach. There is strong evidence demonstrating the likely cost savings and considerable bed-days saved, which can be reallocated to meet other medical demands.
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Affiliation(s)
- Michelle Tew
- Centre for Health Policy, Melbourne School of Population and Global Health, 207 Bouverie Street, Carlton, Vic. 3053, Australia. ; ; and National Centre for Infections in Cancer, Peter MacCallum Cancer Institute, 305 Grattan Street, Melbourne, Vic. 3000, Australia. ; and Corresponding author.
| | - Daniel Forster
- Centre for Health Policy, Melbourne School of Population and Global Health, 207 Bouverie Street, Carlton, Vic. 3053, Australia. ;
| | - Benjamin W Teh
- National Centre for Infections in Cancer, Peter MacCallum Cancer Institute, 305 Grattan Street, Melbourne, Vic. 3000, Australia. ; and Department of Infectious Diseases, Peter MacCallum Cancer Institute, 305 Grattan Street, Melbourne, Vic. 3000, Australia; and Sir Peter MacCallum Department of Oncology, Peter MacCallum Cancer Institute, 305 Grattan Street, Melbourne, Vic. 3000, Australia
| | - Kim Dalziel
- Centre for Health Policy, Melbourne School of Population and Global Health, 207 Bouverie Street, Carlton, Vic. 3053, Australia. ;
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Epstein–Barr Virus Infection Related to Low White Blood Cell Count in Cancer Patients Receiving Chemotherapy in Al-Najaf Governorate/Iraq. JOURNAL OF PURE AND APPLIED MICROBIOLOGY 2020. [DOI: 10.22207/jpam.14.2.59] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Forde C, McMullan R, Clarke M, Wilson RH, Plummer R, Grayson M, McDowell C, Agus A, Doran A, McAuley DF, Thomas AL, Barnes RA, Adams R, Chau I, Coyle V. Early switch from intravenous to oral antibiotic therapy in patients with cancer who have low-risk neutropenic sepsis (the EASI-SWITCH trial): study protocol for a randomised controlled trial. Trials 2020; 21:431. [PMID: 32460818 PMCID: PMC7251886 DOI: 10.1186/s13063-020-04241-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 03/10/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Neutropenic sepsis remains a common treatment complication for patients receiving systemic anti-cancer treatment. The UK National Institute for Health and Care Excellence have not recommended switching from empirical intravenous antibiotics to oral antibiotics within 48 h for patients assessed as low risk for septic complications because of uncertainty about whether this would achieve comparable outcomes to using intravenous antibiotics for longer. The UK National Institute for Health Research funded the EASI-SWITCH trial to tackle this uncertainty. METHODS The trial is a pragmatic, randomised, non-inferiority trial that aims to establish the clinical and cost-effectiveness of early switching from intravenous to oral antibiotics in cancer patients with low-risk neutropenic sepsis. Patients ≥ 16 years, receiving systemic anti-cancer treatment (acute leukaemics/stem cell transplants excluded), with a temperature of > 38 °C, neutrophil count ≤ 1.0 × 109/L, MASCC (Multinational Association of Supportive Care in Cancer) score ≥ 21 and receiving IV piperacillin/tazobactam or meropenem for less than 24 h are eligible to participate. Patients are randomised 1:1 either (i) to switch to oral ciprofloxacin and co-amoxiclav within 12-24 h of commencing intravenous antibiotics, completing at least 5 days total antibiotics (intervention), or (ii) to continue intravenous antibiotics for at least 48 h, with ongoing antibiotics being continued at the physician's discretion (control). Patients are discharged home when their physician deems it appropriate. The primary outcome measure is a composite of treatment failures as assessed at day 14. The criteria for treatment failure include fever persistence or recurrence 72 h after starting intravenous antibiotics, escalation from protocolised antibiotics, hospital readmission related to infection/antibiotics, critical care support or death. Based on a 15% treatment failure rate in the control group and a 15% non-inferiority margin, the recruitment target is 230 patients. DISCUSSION If the trial demonstrates non-inferiority of early switching to oral antibiotics, with potential benefits for patient quality of life and resource savings, this finding will have significant implications for the routine clinical management of those with low-risk neutropenic sepsis. TRIAL REGISTRATION ISRCTN: 84288963. Registered on the 1 July 2015. https://doi.org/10.1186/ISRCTN84288963. EudraCT: 2015-002830-35.
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Affiliation(s)
- Caroline Forde
- Centre for Cancer Research and Cell Biology, Queen’s University Belfast, Lisburn Road, Belfast, BT9 7AE UK
| | - Ronan McMullan
- Centre for Experimental Medicine, Queen’s University Belfast, Belfast, UK
| | - Mike Clarke
- Northern Ireland Methodology Hub, Queen’s University Belfast, Belfast, UK
- Northern Ireland Clinical Trials Unit, Belfast Health and Social Care Trust, Belfast, UK
| | | | - Ruth Plummer
- Northern Institute for Cancer Research, Newcastle University, Newcastle, UK
| | | | - Cliona McDowell
- Northern Ireland Clinical Trials Unit, Belfast Health and Social Care Trust, Belfast, UK
| | - Ashley Agus
- Northern Ireland Clinical Trials Unit, Belfast Health and Social Care Trust, Belfast, UK
| | - Annmarie Doran
- Northern Ireland Clinical Trials Unit, Belfast Health and Social Care Trust, Belfast, UK
| | - Danny F. McAuley
- The Wellcome Wolfson Institute for Experimental Medicine, Queens University Belfast, Belfast, UK
| | | | | | - Richard Adams
- Cardiff University and Velindre NHS Trust, Cardiff, UK
| | - Ian Chau
- The Royal Marsden NHS Foundation Trust, London, UK
| | - Vicky Coyle
- Centre for Cancer Research and Cell Biology, Queen’s University Belfast, Lisburn Road, Belfast, BT9 7AE UK
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11
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Boutayeb S, El Ghissassi I, Mrabti H, Errihani H. How to Manage Febrile Neutropenia During the COVID Pandemic? Oncologist 2020; 25:e1251. [PMID: 32399999 DOI: 10.1634/theoncologist.2020-0285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 04/20/2020] [Indexed: 01/12/2023] Open
Abstract
This letter to the editor reflects on the recently published article about management of cancer patients during the COVID-19 pandemic by Al-Shamsi et al., specifically as regards the management of febrile neutropenia in the context of the pandemic.
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Affiliation(s)
- Saber Boutayeb
- Medical Oncology Department, National Institute of Oncology, Mohammed V University, Rabat, Morocco
| | - Ibrahim El Ghissassi
- Medical Oncology Department, National Institute of Oncology, Mohammed V University, Rabat, Morocco
| | - Hind Mrabti
- Medical Oncology Department, National Institute of Oncology, Mohammed V University, Rabat, Morocco
| | - Hassan Errihani
- Medical Oncology Department, National Institute of Oncology, Mohammed V University, Rabat, Morocco
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Tori K, Tansarli GS, Parente DM, Kalligeros M, Ziakas PD, Mylonakis E. The cost-effectiveness of empirical antibiotic treatments for high-risk febrile neutropenic patients: A decision analytic model. Medicine (Baltimore) 2020; 99:e20022. [PMID: 32443305 PMCID: PMC7254453 DOI: 10.1097/md.0000000000020022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Febrile neutropenia has a significant clinical and economic impact on cancer patients. This study evaluates the cost-effectiveness of different current empiric antibiotic treatments. METHODS A decision analytic model was constructed to compare the use of cefepime, meropenem, imipenem/cilastatin, and piperacillin/tazobactam for treatment of high-risk patients. The analysis was performed from the perspective of U.S.-based hospitals. The time horizon was defined to be a single febrile neutropenia episode. Cost-effectiveness was determined by calculating costs and deaths averted. Cost-effectiveness acceptability curves for various willingness-to-pay thresholds (WTP), were used to address the uncertainty in cost-effectiveness. RESULTS The base-case analysis results showed that treatments were equally effective but differed mainly in their cost. In increasing order: treatment with imipenem/cilastatin cost $52,647, cefepime $57,270, piperacillin/tazobactam $57,277, and meropenem $63,778. In the probabilistic analysis, mean costs were $52,554 (CI: $52,242-$52,866) for imipenem/cilastatin, $57,272 (CI: $56,951-$57,593) for cefepime, $57,294 (CI: $56,978-$57,611) for piperacillin/tazobactam, and $63,690 (CI: $63,370-$64,009) for meropenem. Furthermore, with a WTP set at $0 to $50,000, imipenem/cilastatin was cost-effective in 66.2% to 66.3% of simulations compared to all other high-risk options. DISCUSSION Imipenem/cilastatin is a cost-effective strategy and results in considerable health care cost-savings at various WTP thresholds. Cost-effectiveness analyses can be used to differentiate the treatments of febrile neutropenia in high-risk patients.
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Affiliation(s)
- Katerina Tori
- Division of Infectious Diseases, Brown University, Warren Alpert Medical School
| | | | - Diane M. Parente
- Department of Pharmacy, The Miriam Hospital, Providence, Rhode Island, USA
| | - Markos Kalligeros
- Division of Infectious Diseases, Brown University, Warren Alpert Medical School
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Rivas‐Ruiz R, Villasis‐Keever M, Miranda‐Novales G, Castelán‐Martínez OD, Rivas‐Contreras S. Outpatient treatment for people with cancer who develop a low-risk febrile neutropaenic event. Cochrane Database Syst Rev 2019; 3:CD009031. [PMID: 30887505 PMCID: PMC6423292 DOI: 10.1002/14651858.cd009031.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND People with febrile neutropaenia are usually treated in a hospital setting. Recently, treatment with oral antibiotics has been proven to be as effective as intravenous therapy. However, the efficacy and safety of outpatient treatment have not been fully evaluated. OBJECTIVES To compare the efficacy (treatment failure and mortality) and safety (adverse events of antimicrobials) of outpatient treatment compared with inpatient treatment in people with cancer who have low-risk febrile neutropaenia. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 11) in the Cochrane Library, MEDLINE via Ovid (from 1948 to November week 4, 2018), Embase via Ovid (from 1980 to 2018, week 48) and trial registries (National Cancer Institute, MetaRegister of Controlled Trials, Medical Research Council Clinical Trial Directory). We handsearched all references of included studies and major reviews. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing outpatient with inpatient treatment for people with cancer who develop febrile neutropaenia. The outpatient group included those who started treatment as an inpatient and completed the antibiotic course at home (sequential) as well as those who started treatment at home. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial eligibility, methodological quality, and extracted data. Primary outcome measures were: treatment failure and mortality; secondary outcome measures considered were: duration of fever, adverse drug reactions to antimicrobial treatment, duration of neutropaenia, duration of hospitalisation, duration of antimicrobial treatment, and quality of life (QoL). We estimated risk ratios (RRs) with 95% confidence intervals (CIs) for dichotomous data; we calculated weighted mean differences for continuous data. Random-effects meta-analyses and sensitivity analyses were conducted. MAIN RESULTS We included ten RCTs, six in adults (628 participants) and four in children (366 participants). We found no clear evidence of a difference in treatment failure between the outpatient and inpatient groups, either in adults (RR 1.23, 95% CI 0.82 to 1.85, I2 0%; six studies; moderate-certainty evidence) or children (RR 1.04, 95% CI 0.55 to 1.99, I2 0%; four studies; moderate-certainty evidence). For mortality, we also found no clear evidence of a difference either in studies in adults (RR 1.04, 95% CI 0.29 to 3.71; six studies; 628 participants; moderate-certainty evidence) or in children (RR 0.63, 95% CI 0.15 to 2.70; three studies; 329 participants; moderate-certainty evidence).According to the type of intervention (early discharge or exclusively outpatient), meta-analysis of treatment failure in four RCTs in adults with early discharge (RR 1.48, 95% CI 0.74 to 2.95; P = 0.26, I2 0%; 364 participants; moderate-certainty evidence) was similar to the results of the exclusively outpatient meta-analysis (RR 1.15, 95% CI 0.62 to 2.13; P = 0.65, I2 19%; two studies; 264 participants; moderate-certainty evidence).Regarding the secondary outcome measures, we found no clear evidence of a difference between outpatient and inpatient groups in duration of fever (adults: mean difference (MD) 0.2, 95% CI -0.36 to 0.76, 1 study, 169 participants; low-certainty evidence) (children: MD -0.6, 95% CI -0.84 to 0.71, 3 studies, 305 participants; low-certainty evidence) and in duration of neutropaenia (adults: MD 0.1, 95% CI -0.59 to 0.79, 1 study, 169 participants; low-certainty evidence) (children: MD -0.65, 95% CI -0.1.86 to 0.55, 2 studies, 268 participants; moderate-certainty evidence). With regard to adverse drug reactions, although there was greater frequency in the outpatient group, we found no clear evidence of a difference when compared to the inpatient group, either in adult participants (RR 8.39, 95% CI 0.38 to 187.15; three studies; 375 participants; low-certainty evidence) or children (RR 1.90, 95% CI 0.61 to 5.98; two studies; 156 participants; low-certainty evidence).Four studies compared the hospitalisation time and found that the mean number of days of hospital stay was lower in the outpatient treated group by 1.64 days in adults (MD -1.64, 95% CI -2.22 to -1.06; 3 studies, 251 participants; low-certainty evidence) and by 3.9 days in children (MD -3.90, 95% CI -5.37 to -2.43; 1 study, 119 participants; low-certainty evidence). In the 3 RCTs of children in which days of antimicrobial treatment were analysed, we found no difference between outpatient and inpatient groups (MD -0.07, 95% CI -1.26 to 1.12; 305 participants; low-certainty evidence).We identified two studies that measured QoL: one in adults and one in children. QoL was slightly better in the outpatient group than in the inpatient group in both studies, but there was no consistency in the domains included. AUTHORS' CONCLUSIONS Outpatient treatment for low-risk febrile neutropaenia in people with cancer probably makes little or no difference to treatment failure and mortality compared with the standard hospital (inpatient) treatment and may reduce time that patients need to be treated in hospital.
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Affiliation(s)
- Rodolfo Rivas‐Ruiz
- Insitiuto Mexicano del Seguro Social, Centro Medico Nacional Siglo XXICentro de adiestramiento en Investigación ClínicaHospital de Pediatria del CMN SXXIAvenida Cuauhtemoc #330Mexico CityMexico
| | - Miguel Villasis‐Keever
- Instituto Mexicano del Seguro SocialClinical Epidemiology Research UnitMexico CityDFMexicoCP 06470
| | | | - Osvaldo D Castelán‐Martínez
- Universidad Nacional Autónoma de MéxicoFacultad de Estudios Superiores ZaragozaBatalla 5 de mayo s/n esquina Fuerte de LoretoCol. Ejercito de Oriente, Iztapalapa, C.P. 09230Mexico CityMexico
| | - Silvia Rivas‐Contreras
- Instituto de Salud del Estado de MexicoCentro de Atención Primaria a la Salud TlalmanalcoAvenida Mirador No. 40TlamanalcoMexico56700
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14
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Stern A, Carrara E, Bitterman R, Yahav D, Leibovici L, Paul M. Early discontinuation of antibiotics for febrile neutropenia versus continuation until neutropenia resolution in people with cancer. Cochrane Database Syst Rev 2019; 1:CD012184. [PMID: 30605229 PMCID: PMC6353178 DOI: 10.1002/14651858.cd012184.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND People with cancer with febrile neutropenia are at risk of severe infections and mortality and are thus treated empirically with broad-spectrum antibiotic therapy. However, the recommended duration of antibiotic therapy differs across guidelines. OBJECTIVES To assess the safety of protocol-guided discontinuation of antibiotics regardless of neutrophil count, compared to continuation of antibiotics until neutropenia resolution in people with cancer with fever and neutropenia, in terms of mortality and morbidity. To assess the emergence of resistant bacteria in people with cancer treated with short courses of antibiotic therapy compared with people with cancer treated until resolution of neutropenia. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 10) in the Cochrane Library, MEDLINE, Embase, and LILACS up to 1 October 2018. We searched the metaRegister of Controlled Trials and the US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov for ongoing and unpublished trials. We reviewed the references of all identified studies for additional trials and handsearched conference proceedings of international infectious diseases and oncology and haematology conferences. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared a short antibiotic therapy course in which discontinuation of antibiotics was guided by protocols regardless of the neutrophil count to a long course in which antibiotics were continued until neutropenia resolution in people with cancer with febrile neutropenia. The primary outcome was 30-day or end of follow-up all-cause mortality. DATA COLLECTION AND ANALYSIS Two review authors independently reviewed all studies for eligibility, extracted data, and assessed risk of bias for all included trials. We calculated risk ratios (RRs) with 95% confidence intervals (CIs) whenever possible. For dichotomous outcomes with zero events in both arms of the trials, we conducted meta-analysis of risk differences (RDs) as well. For continuous outcomes, we extracted means with standard deviations (SD) from the studies and computed mean difference (MD) and 95% CI. If no substantial clinical heterogeneity was found, trials were pooled using the Mantel-Haenszel fixed-effect model. MAIN RESULTS We included eight RCTs comprising a total of 662 distinct febrile neutropenia episodes. The studies included adults and children, and had variable design and criteria for discontinuation of antibiotics in both study arms. All included studies but two were performed before the year 2000. All studies included people with cancer with fever of unknown origin and excluded people with microbiological documented infections.We found no significant difference between the short-antibiotic therapy arm and the long-antibiotic therapy arm for all-cause mortality (RR 1.38, 95% CI 0.73 to 2.62; RD 0.02, 95% CI -0.02 to 0.05; low-certainty evidence). We downgraded the certainty of the evidence to low due to imprecision and high risk of selection bias. The number of fever days was significantly lower for people in the short-antibiotic treatment arm compared to the long-antibiotic treatment arm (mean difference -0.64, 95% CI -0.96 to -0.32; I² = 30%). In all studies, total antibiotic days were fewer in the intervention arm by three to seven days compared to the long antibiotic therapy. We found no significant differences in the rates of clinical failure (RR 1.23, 95% CI 0.85 to 1.77; very low-certainty evidence). We downgraded the certainty of the evidence for clinical failure due to variable and inconsistent definitions of clinical failure across studies, possible selection bias, and wide confidence intervals. There was no significant difference in the incidence of bacteraemia occurring after randomisation (RR 1.56, 95% CI 0.91 to 2.66; very low-certainty evidence), while the incidence of any documented infections was significantly higher in the short-antibiotic therapy arm (RR 1.67, 95% CI 1.08 to 2.57). There was no significant difference in the incidence of invasive fungal infections (RR 0.86, 95% CI 0.32 to 2.31) and development of antibiotic resistance (RR 1.49, 95% CI 0.62 to 3.61). The data on hospital stay were too sparse to permit any meaningful conclusions. AUTHORS' CONCLUSIONS We could make no strong conclusions on the safety of antibiotic discontinuation before neutropenia resolution among people with cancer with febrile neutropenia based on the existing evidence and its low certainty. Results of microbiological outcomes favouring long antibiotic therapy may be misleading due to lower culture positivity rates under antibiotic therapy and not true differences in infection rates. Well-designed, adequately powered RCTs are required that address this issue in the era of rising antibiotic resistance.
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Affiliation(s)
- Anat Stern
- Rambam Health Care CampusDivision of Infectious DiseasesHa‐aliya 8 StHaifaIsrael33705
| | - Elena Carrara
- Policlinico San Matteo HospitalInfectious DiseasesUniversity of PaviaPaviaLombardyItaly27100
| | - Roni Bitterman
- Rambam Health Care CampusDivision of Infectious DiseasesHa‐aliya 8 StHaifaIsrael33705
| | - Dafna Yahav
- Beilinson Hospital, Rabin Medical CenterDepartment of Medicine E39 Jabotinski StreetPetah TikvaIsrael49100
| | - Leonard Leibovici
- Beilinson Hospital, Rabin Medical CenterDepartment of Medicine E39 Jabotinski StreetPetah TikvaIsrael49100
| | - Mical Paul
- Rambam Health Care CampusDivision of Infectious DiseasesHa‐aliya 8 StHaifaIsrael33705
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15
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Moon H, Choi YJ, Sim SH. Validation of the Clinical Index of Stable Febrile Neutropenia (CISNE) model in febrile neutropenia patients visiting the emergency department. Can it guide emergency physicians to a reasonable decision on outpatient vs. inpatient treatment? PLoS One 2018; 13:e0210019. [PMID: 30596803 PMCID: PMC6312365 DOI: 10.1371/journal.pone.0210019] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 12/14/2018] [Indexed: 11/23/2022] Open
Abstract
Advances in oncology have enabled physicians to treat low-risk febrile neutropenia (FN) in outpatient settings. This study was aimed to explore the usefulness of the CISNE model and identify better triage in the emergency setting. This is a retrospective cohort study on 400 adult FN patients presenting to the Emergency Department of National Cancer Center, Korea from January 2010 to December 2016. All had been treated with cytotoxic chemotherapy for solid tumors in the previous 30 days. The primary outcome was the frequency of any serious complications during the duration of illness. Apparently stable patients numbered 299 (74.8%) of 400, and the remainder comprised clinically unstable patients. The stable patients fell into three cohorts according to the risk scores: CISNE I (low risk), 56 patients (18.7%); CISNE II (intermediate), 124 (41.5%) and CISNE III (high), 119 (39.8%). The primary outcome occurred in 10.7%, 19.4% and 33.6%, respectively, according to the cohort. Compared with the Multinational Association of Supportive Care in Cancer Risk Index Score (MASCC RIS), CISNE I stratum had significantly lower sensitivity (0.22 vs. 0.95 of MASCC low risk) but higher specificity (0.91 vs. 0.17) to predict zero occurrence of the primary outcome. The CISNE model was useful for identifying low-risk FN patients for outpatient treatment. The combination of the CISNE and MASCC RIS may help emergency physicians cope with FN more confidently.
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Affiliation(s)
- Hae Moon
- Department of Internal Medicine, National Cancer Center, Goyang, Gyeonggi-do, Republic of Korea
| | - Young Ju Choi
- Infectious Diseases Clinic, National Cancer Center, Goyang, Gyeonggi-do, Republic of Korea
| | - Sung Hoon Sim
- Center for Breast Cancer, National Cancer Center, Goyang, Gyeonggi-do, Republic of Korea
- Translational Cancer Research Branch, Division of Cancer Biology, Research Institute, National Cancer Center, Goyang, Gyeonggi-do, Republic of Korea
- * E-mail:
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16
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A cohort study on protocol-based nurse-led out-patient management of post-chemotherapy low-risk febrile neutropenia. Support Care Cancer 2018; 26:3039-3045. [PMID: 29556814 DOI: 10.1007/s00520-018-4157-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 03/12/2018] [Indexed: 10/17/2022]
Abstract
PURPOSE International guidelines adopt risk stratification approach to manage patients with low-risk febrile neutropenia patients. We developed this out-patient program using shared-care model with professional input and patient empowerment, so as to reduce patients' psychological burden from hospitalization and to improve the cost-effectiveness of management. METHOD This is a prospective cohort study to compare the efficacy and safeness of the out-patient program when compared with traditional in-patient care. Patients with solid tumors, developed febrile neutropenia with Multinational Association of Supportive Care in Cancer score of at least 21, and good performance status were included. After initial assessment and the first dose of oral antibiotics, patients were observed in the ambulatory center. Stable patients were discharged home after 4 h of observation and nurse counseling. Patients' condition and clinical progress were regularly reviewed by specialist nurses within the following week by telephone and nurse clinic follow-up. The primary objective of the study is success rate, which defined as the resolution of fever and infection, without hospitalization or any change in antibiotics. RESULTS From September 2014 to December 2016, a total of 38 patients were enrolled. Majority were female with breast cancer (97%). Two patients required hospitalization due to persistent fever. The success rate of the out-patient program was not significantly different from the historical in-patient cohort (94.9 versus 97.4%, p = 0.053). No mortality was observed. Patients' compliance to the program was 100%, to telephone follow-up, nurse clinic visits, and daily temperature record. CONCLUSION Out-patient management of patients with low-risk febrile neutropenia is effective and safe through implementation of a structured protocol with joint inputs and engagement from clinicians, oncology nurses, and patients.
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17
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Mathew JL. Does Routine Antibiotic Therapy Benefit Children With Severe Acute Malnutrition?: Evidence-based Medicine Viewpoint. Indian Pediatr 2017; 53:329-32. [PMID: 27156547 DOI: 10.1007/s13312-016-0846-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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18
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Goldman JL, Richardson T, Newland JG, Lee B, Gerber JS, Hall M, Kronman M, Hersh AL. Outpatient Parenteral Antimicrobial Therapy in Pediatric Medicaid Enrollees. J Pediatric Infect Dis Soc 2017; 6:65-71. [PMID: 26803327 PMCID: PMC5907854 DOI: 10.1093/jpids/piv106] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 12/14/2015] [Indexed: 11/12/2022]
Abstract
BACKGROUND Outpatient parenteral antimicrobial therapy (OPAT) is overused in cases where highly bioavailable oral alternatives would be equally effective. However, the scope of OPAT use for children nationwide is poorly understood. Our objective was to characterize OPAT use and clinical outcomes for a large population of pediatric Medicaid enrollees treated with OPAT. METHODS We analyzed the Truven MarketScan Medicaid claims database between 2009 and 2012. An OPAT episode was identified by capturing children with claims data indicating home infusion therapy for an intravenous antimicrobial. We characterized OPAT use by describing patient demographics, diagnoses, and antimicrobials prescribed. We categorized an antimicrobial as highly bioavailable if ≥80% systemic exposure was expected from the peroral dose. We also determined the percentage of OPAT recipients in whom a follow-up healthcare encounter occurred during the OPAT episode in either the emergency department or as a hospital admission. We reviewed the primary diagnoses associated with these healthcare encounters to determine whether it was related to OPAT. RESULTS We identified 3433 OPAT episodes in 2687 patients. A total of 4774 antimicrobials were prescribed during these episodes. Ceftriaxone and vancomycin were the most commonly prescribed antimicrobials. Highly bioavailable antimicrobials accounted for 34% of antimicrobials used for OPAT. An emergency department visit or hospital admission occurred during 38% of OPAT episodes, among which 61% were OPAT-related. CONCLUSIONS The high rate of medical encounters associated with OPAT in this cohort and the common prescribing of highly bioavailable antimicrobials underscore the opportunities for antimicrobial stewardship of pediatric OPAT.
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Affiliation(s)
- Jennifer L. Goldman
- Children's Mercy Hospitals and Clinics, Kansas City, Missouri,University of Missouri-Kansas City
| | | | - Jason G. Newland
- Children's Mercy Hospitals and Clinics, Kansas City, Missouri,University of Missouri-Kansas City
| | - Brian Lee
- Children's Mercy Hospitals and Clinics, Kansas City, Missouri,University of Missouri-Kansas City
| | | | - Matt Hall
- Children's Hospital Association, Overland Park, Kansas
| | | | - Adam L. Hersh
- University of Utah School of Medicine, Salt Lake City
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A nomogram for predicting complications in patients with solid tumours and seemingly stable febrile neutropenia. Br J Cancer 2016; 114:1191-8. [PMID: 27187687 PMCID: PMC4891503 DOI: 10.1038/bjc.2016.118] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 03/18/2016] [Accepted: 04/08/2016] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND We sought to develop and externally validate a nomogram and web-based calculator to individually predict the development of serious complications in seemingly stable adult patients with solid tumours and episodes of febrile neutropenia (FN). PATIENTS AND METHODS The data from the FINITE study (n=1133) and University of Salamanca Hospital (USH) FN registry (n=296) were used to develop and validate this tool. The main eligibility criterion was the presence of apparent clinical stability, defined as events without acute organ dysfunction, abnormal vital signs, or major infections. Discriminatory ability was measured as the concordance index and stratification into risk groups. RESULTS The rate of infection-related complications in the FINITE and USH series was 13.4% and 18.6%, respectively. The nomogram used the following covariates: Eastern Cooperative Group (ECOG) Performance Status ⩾2, chronic obstructive pulmonary disease, chronic cardiovascular disease, mucositis of grade ⩾2 (National Cancer Institute Common Toxicity Criteria), monocytes <200/mm(3), and stress-induced hyperglycaemia. The nomogram predictions appeared to be well calibrated in both data sets (Hosmer-Lemeshow test, P>0.1). The concordance index was 0.855 and 0.831 in each series. Risk group stratification revealed a significant distinction in the proportion of complications. With a ⩾116-point cutoff, the nomogram yielded the following prognostic indices in the USH registry validation series: 66% sensitivity, 83% specificity, 3.88 positive likelihood ratio, 48% positive predictive value, and 91% negative predictive value. CONCLUSIONS We have developed and externally validated a nomogram and web calculator to predict serious complications that can potentially impact decision-making in patients with seemingly stable FN.
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Stern A, Carrara E, Yahav D, Leibovici L, Paul M. Early discontinuation of antibiotics for febrile neutropenia versus continuation until neutropenia resolution. Hippokratia 2016. [DOI: 10.1002/14651858.cd012184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Anat Stern
- Rambam Health Care Campus; Division of Infectious Diseases; Ha-aliya 8 St Haifa Israel 33705
| | - Elena Carrara
- Policlinico San Matteo Hospital; Infectious Diseases; University of Pavia Pavia Lombardy Italy 27100
| | - Dafna Yahav
- Beilinson Hospital, Rabin Medical Center; Department of Medicine E; 39 Jabotinski Street Petah Tikva Israel 49100
| | - Leonard Leibovici
- Beilinson Hospital, Rabin Medical Center; Department of Medicine E; 39 Jabotinski Street Petah Tikva Israel 49100
| | - Mical Paul
- Rambam Health Care Campus; Division of Infectious Diseases; Ha-aliya 8 St Haifa Israel 33705
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21
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Richter ME, Neugebauer S, Engelmann F, Hagel S, Ludewig K, La Rosée P, Sayer HG, Hochhaus A, von Lilienfeld-Toal M, Bretschneider T, Pausch C, Engel C, Brunkhorst FM, Kiehntopf M. Biomarker candidates for the detection of an infectious etiology of febrile neutropenia. Infection 2015; 44:175-86. [PMID: 26275448 DOI: 10.1007/s15010-015-0830-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 07/31/2015] [Indexed: 01/01/2023]
Abstract
PURPOSE Infections and subsequent septicemia are major complications in neutropenic patients with hematological malignancies. Here, we identify biomarker candidates for the early detection of an infectious origin, and monitoring of febrile neutropenia (FN). METHODS Proteome, metabolome, and conventional biomarkers from 20 patients with febrile neutropenia without proven infection (FNPI) were compared to 28 patients with proven infection, including 17 patients with bacteremia. RESULTS Three peptides (mass to charge ratio 1017.4-1057.3; p-values 0.011-0.024), six proteins (mass to charge ratio 6881-17,215; p-values 0.002-0.004), and six phosphatidylcholines (p-values 0.007-0.037) were identified that differed in FNPI patients compared to patients with infection or bacteremia. Seven of these marker candidates discriminated FNPI from infection at fever onset with higher sensitivity and specificity (ROC-AUC 0.688-0.824) than conventional biomarkers i.e., procalcitonin, C-reactive protein, or interleukin-6 (ROC-AUC 0.535-0.672). In a post hoc analysis, monitoring the time course of four lysophosphatidylcholines, threonine, and tryptophan allowed for discrimination of patients with or without resolution of FN (ROC-AUC 0.648-0.919) with higher accuracy compared to conventional markers (ROC-AUC 0.514-0.871). CONCLUSIONS Twenty-one promising biomarker candidates for the early detection of an infectious origin or for monitoring the course of FN were found which might overcome known shortcomings of conventional markers.
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Affiliation(s)
- Martin E Richter
- Institut für Klinische Chemie und Laboratoriumsdiagnostik, Universitätsklinikum Jena, Erlanger Allee 101, 07747, Jena, Germany.,Integriertes Forschungs- und Behandlungszentrum Sepsis und Sepsisfolgen (CSCC), Universitätsklinikum Jena, Erlanger Allee 101, 07747, Jena, Germany
| | - Sophie Neugebauer
- Institut für Klinische Chemie und Laboratoriumsdiagnostik, Universitätsklinikum Jena, Erlanger Allee 101, 07747, Jena, Germany.,Integriertes Forschungs- und Behandlungszentrum Sepsis und Sepsisfolgen (CSCC), Universitätsklinikum Jena, Erlanger Allee 101, 07747, Jena, Germany
| | - Falco Engelmann
- Institut für Klinische Chemie und Laboratoriumsdiagnostik, Universitätsklinikum Jena, Erlanger Allee 101, 07747, Jena, Germany
| | - Stefan Hagel
- Integriertes Forschungs- und Behandlungszentrum Sepsis und Sepsisfolgen (CSCC), Universitätsklinikum Jena, Erlanger Allee 101, 07747, Jena, Germany.,Zentrum für Infektionsmedizin und Krankenhaushygiene, Universitätsklinikum Jena, Erlanger Allee 101, 07747, Jena, Germany.,Klinik für Innere Medizin IV (Gastroenterologie, Hepatologie, Infektiologie), Universitätsklinikum Jena, Erlanger Allee 101, 07747, Jena, Germany
| | - Katrin Ludewig
- Integriertes Forschungs- und Behandlungszentrum Sepsis und Sepsisfolgen (CSCC), Universitätsklinikum Jena, Erlanger Allee 101, 07747, Jena, Germany
| | - Paul La Rosée
- Integriertes Forschungs- und Behandlungszentrum Sepsis und Sepsisfolgen (CSCC), Universitätsklinikum Jena, Erlanger Allee 101, 07747, Jena, Germany.,Klinik für Innere Medizin II, Abt. Hämatologie und Intern. Onkologie, Universitätsklinikum Jena, Erlanger Allee 101, 07747, Jena, Germany
| | - Herbert G Sayer
- Integriertes Forschungs- und Behandlungszentrum Sepsis und Sepsisfolgen (CSCC), Universitätsklinikum Jena, Erlanger Allee 101, 07747, Jena, Germany.,Klinik für Innere Medizin II, Abt. Hämatologie und Intern. Onkologie, Universitätsklinikum Jena, Erlanger Allee 101, 07747, Jena, Germany.,4. Medizinische Klinik (Hämatologie und internistische Onkologie, Hämostaseologie), HELIOS Klinikum Erfurt, Nordhäuser Straße 74, 99089, Erfurt, Germany
| | - Andreas Hochhaus
- Integriertes Forschungs- und Behandlungszentrum Sepsis und Sepsisfolgen (CSCC), Universitätsklinikum Jena, Erlanger Allee 101, 07747, Jena, Germany.,Klinik für Innere Medizin II, Abt. Hämatologie und Intern. Onkologie, Universitätsklinikum Jena, Erlanger Allee 101, 07747, Jena, Germany
| | - Marie von Lilienfeld-Toal
- Integriertes Forschungs- und Behandlungszentrum Sepsis und Sepsisfolgen (CSCC), Universitätsklinikum Jena, Erlanger Allee 101, 07747, Jena, Germany.,Klinik für Innere Medizin II, Abt. Hämatologie und Intern. Onkologie, Universitätsklinikum Jena, Erlanger Allee 101, 07747, Jena, Germany
| | - Tom Bretschneider
- Leibniz Institut für Naturstoff-Forschung und Infektionsbiologie, Hans-Knöll-Institut, Adolf-Reichwein-Straße 23, 07745, Jena, Germany
| | - Christine Pausch
- Integriertes Forschungs- und Behandlungszentrum Sepsis und Sepsisfolgen (CSCC), Universitätsklinikum Jena, Erlanger Allee 101, 07747, Jena, Germany.,Institut für Medizinische Informatik, Statistik und Epidemiologie, Universität Leipzig, Härtelstraße 16-18, 04107, Leipzig, Germany
| | - Christoph Engel
- Institut für Medizinische Informatik, Statistik und Epidemiologie, Universität Leipzig, Härtelstraße 16-18, 04107, Leipzig, Germany
| | - Frank M Brunkhorst
- Zentrum für Klinische Studien, Universitätsklinikum Jena, Salvador-Allende-Platz 27, 07747, Jena, Germany
| | - Michael Kiehntopf
- Institut für Klinische Chemie und Laboratoriumsdiagnostik, Universitätsklinikum Jena, Erlanger Allee 101, 07747, Jena, Germany. .,Integriertes Forschungs- und Behandlungszentrum Sepsis und Sepsisfolgen (CSCC), Universitätsklinikum Jena, Erlanger Allee 101, 07747, Jena, Germany.
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22
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Mueller EL, Walkovich KJ, Mody R, Gebremariam A, Davis MM. Hospital discharges for fever and neutropenia in pediatric cancer patients: United States, 2009. BMC Cancer 2015; 15:388. [PMID: 25957578 PMCID: PMC4494157 DOI: 10.1186/s12885-015-1413-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 05/01/2015] [Indexed: 01/08/2023] Open
Abstract
Background Fever and neutropenia (FN) is a common complication of pediatric cancer treatment, but hospital utilization patterns for this condition are not well described. Methods Data were analyzed from the Kids’ Inpatient Database (KID), an all-payer US hospital database, for 2009. Pediatric FN patients were identified using: age ≤19 years, urgent or emergent admit type, non-transferred, and a combination of ICD-9-CM codes for fever and neutropenia. Sampling weights were used to permit national inferences. Results Pediatric cancer patients accounted for 1.5 % of pediatric hospital discharges in 2009 (n = 110,967), with 10.1 % of cancer-related discharges meeting FN criteria (n = 11,261). Two-fifths of FN discharges had a “short length of stay” (SLOS) of ≤3 days, which accounted for approximately $65.5 million in hospital charges. Upper respiratory infection (6.0 %) and acute otitis media (AOM) (3.7 %) were the most common infections associated with SLOS. Factors significantly associated with SLOS included living in the Midwest region (OR = 1.65, 1.22–2.24) or West region (OR 1.54, 1.11–2.14) versus Northeast, having a diagnosis of AOM (OR = 1.39, 1.03–1.87) or viral infection (OR = 1.63, 1.18–2.25) versus those without those comorbidities, and having a soft tissue sarcoma (OR = 1.47, 1.05–2.04), Hodgkin lymphoma (OR = 2.33, 1.62–3.35), or an ovarian/testicular tumor (OR = 1.76, 1.05–2.95) compared with patients without these diagnoses. Conclusion FN represents a common precipitant for hospitalizations among pediatric cancer patients. SLOS admissions are rarely associated with serious infections, but contribute substantially to the burden of hospitalization for pediatric FN.
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Affiliation(s)
- Emily L Mueller
- Section of Pediatric Hematology Oncology, Department of Pediatrics, Indiana University School of Medicine, 410 West 10th Street, Suite 4099C, Indianapolis, IN, 46202, USA. .,Pediatric and Adolescent Comparative Effectiveness Research, Indiana University, Indianapolis, IN, 46202, USA.
| | - Kelly J Walkovich
- Division of Pediatric Hematology Oncology, Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Rajen Mody
- Division of Pediatric Hematology Oncology, Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Achamyeleh Gebremariam
- Child Health Evaluation and Research (CHEAR) Unit, Division of General Pediatrics, Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Matthew M Davis
- Child Health Evaluation and Research (CHEAR) Unit, Division of General Pediatrics, Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, 48109, USA.,Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, 48109, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, 48109, USA.,Gerald R. Ford School of Public Policy, University of Michigan, Ann Arbor, MI, 48109, USA
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23
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Abstract
Philip Bejon and colleagues reflect on the widespread belief in the superiority of intravenous antibiotics.
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Affiliation(s)
- Ho Kwong Li
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, United Kingdom
| | - Ambrose Agweyu
- Kenya Medical Research Institute Wellcome Trust Research Programme, Nairobi, Kenya
| | - Mike English
- Kenya Medical Research Institute Wellcome Trust Research Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Philip Bejon
- Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, United Kingdom
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Kenya Medical Research Institute Wellcome Trust Research Programme, Kilifi, Kenya
- * E-mail:
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24
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Fontanella C, Bolzonello S, Lederer B, Aprile G. Management of breast cancer patients with chemotherapy-induced neutropenia or febrile neutropenia. ACTA ACUST UNITED AC 2014; 9:239-45. [PMID: 25404882 DOI: 10.1159/000366466] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Chemotherapy-induced neutropenia (CIN) is a common toxicity caused by the administration of anticancer drugs. This side effect is associated with life-threatening infections and may alter the chemotherapy schedule, thus impacting on early and long-term outcomes. Elderly breast cancer patients with impaired health status or advanced disease as well as patients undergoing dose-dense anthracycline/taxane- or docetaxel-based regimens have the highest risk of CIN. A careful assessment of the baseline risk for CIN allows the selection of patients who need primary prophylaxis with granulocyte colony-stimulating factor (G-CSF) and/or antimicrobial agents. Neutropenic cancer patients may develop febrile neutropenia and CIN-related severe medical complications. Specific risk assessment scores, along with comprehensive clinical evaluation, are able to define a group of febrile patients with low risk for complications who can be safely treated as outpatients. Conversely, patients with higher risk of severe complications should be hospitalized and should receive intravenous antibiotic therapy with or without G-CSF.
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Affiliation(s)
- Caterina Fontanella
- Department of Oncology, University Hospital of Udine, Italy ; German Breast Group, Neu-Isenburg, Germany
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25
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Morgan JE, Stewart L, Phillips RS. Protocol for a systematic review of reductions in therapy for children with low-risk febrile neutropenia. Syst Rev 2014; 3:119. [PMID: 25336249 PMCID: PMC4234526 DOI: 10.1186/2046-4053-3-119] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Accepted: 10/02/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Febrile neutropenia is a common complication of therapy in children with cancer. Some patients are at low risk of complications, and research has considered reduction in therapy for these patients. A previous systematic review broadly considered whether outpatient treatment and oral antibiotics were safe in this context and concluded that this was likely to be the case. Since that review, there has been further research in this area. Therefore, we aim to provide a more robust answer to these questions and to additionally explore whether the exact timing of discharge, including entirely outpatient treatment, has an impact on outcomes. METHODS/DESIGN The search will cover MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, CDSR, CENTRAL, LILACS, HTA and DARE. A full search strategy is provided. Key conference proceedings and reference lists of included papers will be hand searched. Prominent authors/clinicians in the field will be contacted. We will include randomised and quasi-randomised controlled trials along with prospective single-arm studies that examine the location of therapy and/or the route of administration of antibiotics in children or young adults (aged less than 18 years) who attend paediatric services with fever and neutropenia due to treatment for cancer and are assessed to be at low risk of medical complications. Studies will be screened and data extracted by one researcher and independently checked by a second. All studies will be critically appraised using tools appropriate to the study design. Data from randomised controlled trials (RCTs) will be combined to provide comparative estimates of treatment failure, safety and adequacy. Information from quasi-randomised trials and single-arm studies will provide further data on the safety and adequacy of regimes. Random effects meta-analysis will be used to combine studies. A detailed analysis plan, including assessment of heterogeneity and publication bias, is provided. DISCUSSION This study will aim to specifically define the features of a low-risk strategy that will maintain levels of safety and adequacy equivalent to those of traditional treatments. This will both inform the development of services and provide patients and families with data to help them make an informed decision about care. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42014005817.
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Affiliation(s)
- Jessica E Morgan
- Centre for Reviews and Dissemination, University of York, York, UK.
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