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Feasibility of a Hospital-at-Home Program for Autologous Hematopoietic Stem Cell Transplantation. Transplant Cell Ther 2023; 29:111.e1-111.e7. [PMID: 36436783 DOI: 10.1016/j.jtct.2022.11.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 11/03/2022] [Accepted: 11/21/2022] [Indexed: 11/27/2022]
Abstract
The Hospital at Home (HaH) model has been positioned as an appropriate therapeutic strategy for selected patients undergoing autologous hematopoietic stem cell transplantation (ASCT). This care model provides hospital-equivalent care, in terms of both quality and quantity, with medical and nursing staff that go to the patient's home. Here we describe our experience with a full HaH model for patients undergoing ASCT during the phase of aplasia. The patients met the eligibility criteria between January 1997 and December 2019 and were discharged from the hospital and admitted into the HaH-ASCT program on the same day they in which hematopoietic stem cells were infused. A total of 84 patients were included. The median patient age was 54 years (range, 16 to 74 years), and the median duration of participation in the HaH program was 17 days (range, 3 to 86 days). Only 10 of these patients (12%) required hospital readmission to the hematology department, 9 of them due to sepsis and 1 because of family care support claudication. Seventy-two patients (86%) experienced an episode of neutropenic fever during the HAH admission, with a median duration of 2 days (interquartile range [IQR], 1 to 11 days); all were treated with empiric i.v. antimicrobial therapy. Most patients (88%) presented with mucositis (44% with grade 3-4). Parenteral nutrition was administered in 26% of patients for a median of 6 days (IQR, 1 to 12 days). Most patients (94%) required at least 1 blood product transfusion at home. There was no transplantation-related mortality during the HaH-ASCT program or in the patients who were readmitted. With careful selection of patients and a comprehensive and well- experienced multidisciplinary team (doctors, nurses, and auxiliary nurses) in the HaH department and in close collaboration with the hematology department, complete at-home management of ASCT recipients immediately after transplantation is possible. This allows patients undergoing an aggressive procedure such as ASCT to remain in their own familiar environment, providing a better quality of life with a program that has demonstrated to be effective and safe, with a low incidence of complications and no associated mortality.
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Multiple aPDT sessions on periodontitis in rats treated with chemotherapy: histomorphometrical, immunohistochemical, immunological and microbiological analyses. Photodiagnosis Photodyn Ther 2019; 25:92-102. [DOI: 10.1016/j.pdpdt.2018.11.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 10/11/2018] [Accepted: 11/19/2018] [Indexed: 12/12/2022]
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Rambaran KA, Seifert CF. Ciprofloxacin vs. levofloxacin for prophylaxis in recipients of hematopoietic stem cell transplantation. J Oncol Pharm Pract 2018; 25:884-890. [DOI: 10.1177/1078155218787286] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Infection is the most common cause of morbidity and mortality in patients undergoing myleosuppressive therapy with the risk of infection being heightened during the neutropenic phase. Fluoroquinolones are most often utilized as prophylaxis, specifically levofloxacin or ciprofloxacin; however, there is increasing resistance among these agents. The objective of this study is to compare the efficacy of ciprofloxacin and levofloxacin when used prophylactically in hematopoietic stem cell transplantation patients. Study design A retrospective cohort study conducted at a 443-bed tertiary teaching county hospital from 1 January 2005 to 31 September 2016. Methods Patients aged 18–89 who were admitted and received levofloxacin or ciprofloxacin post hematopoietic stem cell transplantation were evaluated. Results The patient population (N = 151) was predominantly male (93 vs. 58) and the median (IQR) age was 57 (20.1) years. There were 108 patients undergoing autologous hematopoietic stem cell transplantation compared to 43 undergoing allogenic hematopoietic stem cell transplantation. Significantly fewer patients who received levofloxacin (11/43, 25.6%) developed neutropenic fever compared to patients who received ciprofloxacin (61/108, 56.5%, p = 0.0006). Also there were significantly more positive blood cultures in the ciprofloxacin group (36/108, 33.3%) compared to the levofloxacin group (4/43, 9.3%); the majority of which were Gram-positive organisms (p = 0.0025). Conclusion Prophylaxis with levofloxacin was associated with a lower incidence of febrile neutropenia and bacteremia when compared to ciprofloxacin in hematopoietic stem cell transplantation patients.
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Affiliation(s)
- Kerry Anne Rambaran
- Keck Graduate Institute School of Pharmacy, Claremont, CA, USA
- Texas Tech University Health Sciences Center, School of Pharmacy, Lubbock, TX, USA
| | - Charles F Seifert
- Texas Tech University Health Sciences Center, School of Pharmacy, Lubbock, TX, USA
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Freeman B, Brauneis D, Seldin DC, Quillen K, Sloan JM, Renteria AS, Shelton AC, Teschner T, Finn KT, Sanchorawala V. Hospital admissions following outpatient administration of high-dose melphalan and autologous SCT for AL amyloidosis. Bone Marrow Transplant 2014; 49:1345-6. [PMID: 24955784 DOI: 10.1038/bmt.2014.132] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- B Freeman
- Stem Cell Transplantation Program, Section of Hematology/Oncology, Boston Medical Center, Boston, MA, USA
| | - D Brauneis
- Stem Cell Transplantation Program, Section of Hematology/Oncology, Boston Medical Center, Boston, MA, USA
| | - D C Seldin
- Stem Cell Transplantation Program, Section of Hematology/Oncology, Boston Medical Center, Boston, MA, USA
| | - K Quillen
- Stem Cell Transplantation Program, Section of Hematology/Oncology, Boston Medical Center, Boston, MA, USA
| | - J M Sloan
- Stem Cell Transplantation Program, Section of Hematology/Oncology, Boston Medical Center, Boston, MA, USA
| | - A S Renteria
- Stem Cell Transplantation Program, Section of Hematology/Oncology, Boston Medical Center, Boston, MA, USA
| | - A C Shelton
- Stem Cell Transplantation Program, Section of Hematology/Oncology, Boston Medical Center, Boston, MA, USA
| | - T Teschner
- Stem Cell Transplantation Program, Section of Hematology/Oncology, Boston Medical Center, Boston, MA, USA
| | - K T Finn
- Stem Cell Transplantation Program, Section of Hematology/Oncology, Boston Medical Center, Boston, MA, USA
| | - V Sanchorawala
- Stem Cell Transplantation Program, Section of Hematology/Oncology, Boston Medical Center, Boston, MA, USA
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Sohn BS, Yoon DH, Kim S, Lee K, Kang EH, Park JS, Lee DH, Kim SH, Huh J, Suh C. The role of prophylactic antimicrobials during autologous stem cell transplantation: a single-center experience. Eur J Clin Microbiol Infect Dis 2011; 31:1653-61. [DOI: 10.1007/s10096-011-1489-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2011] [Accepted: 11/05/2011] [Indexed: 10/15/2022]
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Eichhorst BF, Busch R, Schweighofer C, Wendtner CM, Emmerich B, Hallek M. Due to low infection rates no routine anti-infective prophylaxis is required in younger patients with chronic lymphocytic leukaemia during fludarabine-based first line therapy. Br J Haematol 2006; 136:63-72. [PMID: 17083342 DOI: 10.1111/j.1365-2141.2006.06382.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The impact of the combination therapy fludarabine plus cyclophosphamide (FC) in comparison with fludarabine alone regarding the incidence and severity of infections among previously untreated patients with chronic lymphocytic leukaemia (CLL) was evaluated within a multicentre phase III study. A total of 375 patients, up to 65 years old, were randomised between fludarabine or FC for first line therapy. No routine anti-infective prophylaxis was provided. A total of 196 infectious episodes, including 33 severe infections, were documented. In the fludarabine arm, 32.9% of the patients developed an infectious complication compared with 39.9% in the FC arm (P = 0.2). No difference was observed in the rate of severe infections (Common Toxicity Criteria grades III and IV) between both treatment arms. Dose reductions were performed more frequently in FC-treated patients. Granulocyte colony-stimulating factor (G-CSF) was administered due to leucopenia in 5% of all patients. A multivariate regression model identified only elevated thymidine kinase, but not the treatment arm, as a statistically independent risk factor for infections. In summary, FC was not associated with a higher rate of infections compared with fludarabine alone. No routine antibiotic or virostatic prophylaxis, or preemptive treatment with G-CSF, is necessary in first line therapy with fludarabine-based regimens in younger patients with CLL, if adequate dose reduction is performed. The combination therapy FC is not associated with a higher rate of infections compared with fludarabine alone. No routine antibiotic or virostatic prophylaxis as well as preemptive treatment with G-CSF is necessary in first line therapy with fludarabine-based regimen in younger patients with CLL, if adequate dose reductions due to cytopenia or previous infections are performed.
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Fernández-Avilés F, Carreras E, Urbano-Ispizua A, Rovira M, Martínez C, Gaya A, Granell M, Ramiro L, Gallego C, Hernando A, Segura S, García L, González M, Valverde M, Montserrat E. Case-Control Comparison of At-Home to Total Hospital Care for Autologous Stem-Cell Transplantation for Hematologic Malignancies. J Clin Oncol 2006; 24:4855-61. [PMID: 17001069 DOI: 10.1200/jco.2006.06.4238] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose One of the most significant limitations of at-home autologous stem-cell transplantation (ASCT) is the necessity for hospital readmission. We developed an at-home ASCT program in which prophylactic ceftriaxone and treatment of febrile neutropenia with piperacillin and tazobactam was introduced to minimize the readmission rate. Patients and Methods Between November 2000 and February 2005, 178 consecutive patients underwent ASCT for a hematologic malignancy. Of these, 50 patients fulfilled the requirements for at-home ASCT. Results were compared with those observed in a control group of 50 patients individually matched to the group of patients treated at home for age, sex, diagnosis, stage of disease, conditioning, and source of stem cells. Results Febrile neutropenia occurred in fewer patients in the at-home group as compared with the hospitalized group (76% v 96%: P = .008), and duration of fever was also shorter in the at-home group (median, 2 and 6 days, respectively; range, 1 to 11 and 1 to 20 days, respectively; P = .00003). Hospital readmission in the at-home group was required in only four cases (8%). This resulted in a reduction of 18.6 days of hospitalization per patient. Likewise, total median charges were approximately half in the at-home group as compared with the in-hospital group (3,345 € v 6,250 €, respectively; P < .00001). Conclusion Results of at-home ASCT with prophylactic administration of ceftriaxone and domiciliary treatment of febrile neutropenia with piperacillin and tazobactam are highly satisfactory and significantly cheaper compared with those obtained with conventional in-hospital ASCT.
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Affiliation(s)
- Francesc Fernández-Avilés
- Department of Hematology, Institute of Hematology and Oncology, IDIBAPS, Postgraduate School of Hematology Farreras Valentí, Hospital Clínic of Barcelona, University of Barcelona, Barcelona, Spain.
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Solano C, Gutierrez A, Martinez F, Gimeno C, Gómez C, Muñoz I, Faus F, Goterris R, Farga A, Navarro D. Prophylaxis of early bacterial infections after autologous peripheral blood stem cell transplantation (PBSCT): a matched-pair study comparing oral fluoroquinolones and intravenous piperacillin-tazobactam. Bone Marrow Transplant 2005; 36:59-65. [PMID: 15908979 DOI: 10.1038/sj.bmt.1705005] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The safety and efficacy of early bacterial prophylaxis with piperacillin-tazobactam were prospectively evaluated in 51 autologous peripheral blood stem cell transplantation (PBSCT) recipients. The results were compared with those obtained in 51 control patients receiving oral fluoroquinolones in a retrospective matched-pair control study. Overall, 76% of the study group and 98% of the control group developed at least one febrile episode during neutropenia (P=0.002). Time from neutropenia to the first febrile episode (FFE) was significantly longer in the study group than in the control group (P=0.04). Once a febrile episode appeared, the duration of fever was significantly longer in cases than in controls (median of 5 and 2 days respectively, P<0.001), and led to a more frequent use of empirical amphotericin B (AmB), not statistically significant (P=0.13). However, the total time of antibiotic administration was significantly greater in the control than in the study group (P=0.05). The duration of AmB treatment shows a trend toward a longer duration in the control than in study group (P=0.2). Overall, 86% of the Gram-positive bacteremia and 85% of the Gram-negative bacteria were susceptible to the tested antibiotics. Our study suggests that a subgroup of patients could benefit from prophylaxis with piperacillin-tazobactam without increasing toxicity or bacterial resistance.
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Affiliation(s)
- C Solano
- Department of Haematology and Medical Oncology, University Clinic Hospital, School of Medicine, University of Valencia, Valencia, Spain.
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West F, Mitchell SA. Evidence-based guidelines for the management of neutropenia following outpatient hematopoietic stem cell transplantation. Clin J Oncol Nurs 2005; 8:601-13. [PMID: 15637955 DOI: 10.1188/04.cjon.601-613] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Hematopoietic stem cell transplantation (HSCT) involves the transfer of stem cells to establish hematopoiesis in patients who have received myeloablative chemotherapy with or without whole body irradiation. Following high-dose therapy and HSCT, all patients experience a period of neutropenia. Outpatient care delivery models place expanded responsibilities on patients and their families for the management of this treatment side effect. Proactive management of neutropenia is critical to decrease the depth and duration of neutropenia following HSCT, limit exposure to opportunistic and nosocomial pathogens, and ensure prompt intervention should febrile neutropenia or infection develop. Patient and family education, psychosocial support, and coordination of care are key nursing responsibilities.
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Affiliation(s)
- Fran West
- Cancer Center Methodist University Hospital, Memphis, TN, USA.
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Abstract
This article reviews clinical trials of outpatient management of fever and neutropenia in pediatric cancer patients. The syndrome of fever and neutropenia is discussed, and strategies of identifying patients at low risk for complex or fatal infections are described. A number of clinical trials in a wide range of clinical settings and countries have demonstrated that low risk pediatric cancer patients with fever and neutropenia can be prospectively identified and safely treated as outpatients. In addition outpatient management has been shown to be less costly than conventional intravenous therapy in hospitalized patients. Oral fluoroquinolones, including ciprofloxacin, have been used as a component of therapy in several trials because of their ease of administration and their activity against the majority of pathogenic bacteria causing illness in this group. The article also discusses the role of antibiotic prophylaxis of fever and neutropenia in certain high risk settings, such as hematopoietic stem cell transplantation. In selected high risk patients, prophylactic use of limited spectrum fluoroquinolones such as ciprofloxacin may reduce the incidence of Gram-negative bacteremias. Use of fluoroquinolone therapy as prophylaxis, however, is controversial because of concerns about an emergence of resistant organisms. Prudent use of fluoroquinolones as therapy and prophylaxis is essential to prolonging the benefits of this class of compounds.
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Affiliation(s)
- Craig A Mullen
- Golisano Children's Hospital at Strong, University of Rochester Medical Center, NY 14642, USA.
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11
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Cruciani M, Malena M, Bosco O, Nardi S, Serpelloni G, Mengoli C. Reappraisal With Meta-Analysis of the Addition of Gram-Positive Prophylaxis to Fluoroquinolone in Neutropenic Patients. J Clin Oncol 2003; 21:4127-37. [PMID: 14615441 DOI: 10.1200/jco.2003.01.234] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Purpose: Past reports and meta-analyses indicate that fluoroquinolones are highly effective in preventing Gram-negative infections in neutropenic cancer patients, but offer inadequate coverage for Gram-positive infections. We evaluated by meta-analysis the efficacy of the addition of antimicrobial agents with enhanced Gram-positive activity to prophylaxis with quinolones. Materials and Methods: Randomized trials comparing fluoroquinolones alone (ciprofloxacin, ofloxacin, pefloxacin, or norfloxacin) with fluoroquinolone in combination with Gram-positive prophylaxis (rifampin, vancomycin, amoxicillin, roxithromycin, or penicillin) were retrieved. We pooled relative risks (RRs) using a fixed-effects model. Results: Nine trials (1,202 patients) published between 1993 and 2000 meet inclusion criteria. Compared with fluoroquinolone alone, Gram-positive prophylaxis reduced total bacteremic episodes (RR, 1.54; 95% CI, 1.26 to 1.88), streptococcal infections (RR, 2.20; 95% CI, 1.44 to 3.37), coagulase-negative staphylococcal infections (RR, 1.46; 95% CI, 1.04 to 2.04), and rate of febrile patients (RR 1.08; 95% CI, 1.00 to 1.16). Occurrence of clinically documented infections, unexplained fever, and infectious mortality was similar in the two groups. The addition of Gram-positive prophylaxis, however, significantly increased side effects (RR, 0.46; 95% CI, 0.28 to 0.76). Rifampin use resulted in a higher incidence of undesirable effects. Conclusion: Considering the lack of cut-clear benefit on some parameters of morbidity and mortality, routine use of Gram-positive prophylaxis is not advisable. This strategy, however, should be particularly valuable in subgroups of patients at high risk of streptococcal infection (eg, those with severe and prolonged neutropenia or mucositis, and those receiving cytarabine). Problems of tolerability and the potential for the emergence of resistant microorganisms should be considered when prescribing prophylaxis with enhanced Gram-positive activity to neutropenic patients.
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Affiliation(s)
- Mario Cruciani
- Center of Preventive Medicine/HIV Outpatient Clinic, Verona, Italy.
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Von Bültzingslöwen I, Adlerberth I, Wold AE, Dahlén G, Jontell M. Oral and intestinal microflora in 5-fluorouracil treated rats, translocation to cervical and mesenteric lymph nodes and effects of probiotic bacteria. ORAL MICROBIOLOGY AND IMMUNOLOGY 2003; 18:278-84. [PMID: 12930518 DOI: 10.1034/j.1399-302x.2003.00075.x] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Serious systemic infections may occur during cancer chemotherapy due to disturbances in the oropharyngeal and gastrointestinal microflora, impaired mucosal barrier functions and immunosuppression. Bacteria may spread from the gastrointestinal tract to the regional lymph nodes. The routes for bacterial spread from the oral cavity are less well known. In the present study we investigated changes in the oral and intestinal microfloras in rats given 50 mg/kg 5-fluorouracil (5-FU) i.v. for 6 days. Bacterial dissemination to the lymph nodes draining the oral cavity and the lymph nodes draining the gastrointestinal tract was examined. Effects of adding the probiotic strain Lactobacillus plantarum 299v in the drinking water to the rats were measured. 5-FU treatment caused an increase in the number of facultative and strictly anaerobic bacteria in biopsies from the oral cavity and an increase in the number of facultative anaerobes in the large intestine. The proportion of facultative gram-negative rods increased in both the oral cavity and intestine. Bacteria translocated to both the cervical and mesenteric lymph nodes in untreated animals and increased in numbers after 5-FU treatment due to an increase in the number of facultative gram-negative rods. Treatment with L. plantarum 299v improved food intake and body weight in 5-FU-treated rats. It also reduced the 5-FU-induced raise in the total numbers of facultative anaerobes in the intestine, but did not reduce translocation and did not prevent diarrhea. This study reinforces the oral cavity, along with the gastrointestinal tract, as a source for bacterial dissemination. The use of probiotic bacteria may reduce some side effects of 5-FU treatment.
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Affiliation(s)
- I Von Bültzingslöwen
- Department of Endodontology and Oral Diagnosis, The Sahlgrenska Academy, Göteborg University, Göteborg, Sweden.
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Kroschinsky F, Wichmann G, Bornhauser M, Ordemann R, Schuler U, Ehninger G, Hanel M. Efficacy and tolerability of prophylactic treatment with intravenous piperacillin/tazobactam in patients undergoing hematopoietic stem cell transplantation. Transpl Infect Dis 2002; 4:132-6. [PMID: 12421457 DOI: 10.1034/j.1399-3062.2002.t01-1-01014.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Infections remain a major cause of morbidity and mortality in patients undergoing autologous or allogeneic hematopoietic stem cell transplantation (HSCT). About 80% of patients experience fever during aplasia and early engraftment despite oral antibacterial chemoprophylaxis. METHODS In a pilot study, 50 patients undergoing autologous or allogeneic HSCT received a prophylactic antibacterial treatment with intravenous piperacillin/tazobactam beginning on day of stem cell or bone marrow transfusion. They were analyzed retrospectively for frequencies of fever of unknown origin (FUO), documented infection, bacteremia and death because of infection. Furthermore, data from microbiological monitoring and tolerability were evaluated. RESULTS Among 28 autologous transplanted patients, 10 (36%) developed fever more than 38.5 degrees C; 9/10 FUO, 1/28 pulmonary infiltrates. Eighteen patients (64%) remained without any symptom of infection. In the allogeneic group (n = 22), there were eight patients (36%) with FUO, and five patients (23%) with documented infections (pneumonia 2, enteritis 1, pyelonephritis 1, Escherichia coli bacteremia 1). In nine patients (41%), escalation of antimicrobial treatment was not necessary. The majority of detected microbes in cultures of throat and nose secretions, blood, urine and stool were gram-positive bacteria (77.8%), among them Staphylococcus epidermidis (23.5%), streptococci (group A, B, C; 21.0%) and enterococci (10.6%). Incidence of gram-negative bacteria and fungi was similar with 11.8% and 10.4%, respectively. The most frequent gram-negative strains were Escherichia coli (6.5%) and Pseudomonas aeruginosa (1.7%). There was no severe toxicity or hypersensitivity. CONCLUSION Compared to oral decontamination and chemoprophylaxis, an intravenous prophylactic regimen as described above could be an effective and well-tolerated approach in prevention of bacterial infections and related complications, with a higher acceptance in recipients of bone marrow or stems cell grafts. Further evaluation in comparison with fluoroquinolone prophylaxis regarding efficacy, development of resistances as well as cost-benefit analyses is warranted.
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Affiliation(s)
- F Kroschinsky
- Medical Department I (Hematology/Oncology), University Hospital, Fetscherstrasse 74, D-01307 Dresden, Germany.
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Chandrasekar PH, Abraham OC, Klein J, Alangaden G, Chalasani G, Cassells L, Dansey R, Abella S, Karanes C, Peters W, Baynes R. Low infectious morbidity after intensive chemotherapy and autologous peripheral blood progenitor cell transplantation in the outpatient setting for women with breast cancer. Clin Infect Dis 2001; 32:546-51. [PMID: 11181116 DOI: 10.1086/318715] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2000] [Revised: 07/05/2000] [Indexed: 11/03/2022] Open
Abstract
Autologous peripheral blood progenitor cell (PBPC) transplantation is increasingly employed in the outpatient setting, yet data on early complications following PBPC transplantation are scant. We evaluated 105 women with high-risk primary or metastatic breast cancer who were treated at a single institution during 1996--1997. The mean duration of neutropenia (absolute neutrophil count, <500 cells/mm(3)) was 7.5 days. Twenty-nine percent of women remained afebrile throughout the neutropenic period. Of the remaining 71%, most (64 of 75) had fever of unknown origin. Infections, mostly of mild severity, occurred in 34% of women; these infections included bacteremia due to gram-positive organisms, catheter site infection, cellulitis, pneumonia, oral candidiasis, herpes simplex virus infection, and vaginitis. Fifty percent of PBPC transplant recipients required hospital admission, usually because of persistent fever; the mean duration of hospitalization was 3 days. No deaths or serious adverse events occurred. Such reduced infectious morbidity may be a consequence of minimal oral and/or gastrointestinal mucositis associated with the conditioning regimen and broad-spectrum antimicrobial prophylaxis used for this patient population.
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Affiliation(s)
- P H Chandrasekar
- Division of Infectious Diseases, Department of Internal Medicine, Barbara Ann Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI 48201, USA.
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Widows MR, Jacobsen PB, Fields KK. Relation of psychological vulnerability factors to posttraumatic stress disorder symptomatology in bone marrow transplant recipients. Psychosom Med 2000; 62:873-82. [PMID: 11139008 DOI: 10.1097/00006842-200011000-00018] [Citation(s) in RCA: 105] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Prior research suggests that the diagnosis and treatment of cancer can result in the development of symptoms of posttraumatic stress disorder (PTSD). Based on Lazarus and Folkman's model of stress, the current study examined whether trauma appraisals, coping, social support, and social constraint were associated with the severity of PTSD symptoms in cancer patients who had undergone bone marrow transplantation (BMT). METHODS Participants were 23 males and 79 females treated with BMT an average of 20 months previously (range = 3-62 months). Past and current psychiatric diagnoses were assessed through a structured clinical interview. PTSD symptomatology and other psychological variables were assessed using standardized self-report measures. RESULTS Results indicated that 5% of participants met diagnostic criteria for current PTSD. Participants reported an average of three to four symptoms of PTSD (range = 0-16). Univariate analyses confirmed predictions that increased PTSD symptomatology would be associated with more negative appraisals of the BMT experience, greater use of avoidance-based coping strategies, lower levels of social support, and greater social constraint (p < .05). Regression analyses indicated that each of these variables accounted for significant (p < .05) variability in PTSD symptomatology above and beyond relevant demographic and medical variables. CONCLUSIONS Results of the present study confirm and extend prior research regarding the prevalence of PTSD and PTSD symptoms among patients treated for cancer. In addition, the study identified a set of theoretically derived psychological characteristics that seem to place patients at risk for greater PTSD symptomatology after BMT.
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Affiliation(s)
- M R Widows
- Department of Psychology, University of South Florida, Tampa, USA
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Gomez-Martin C, Solá C, Hornedo J, Perea S, Lumbreras C, Valentí V, Arcediano A, Rodriguez M, Salazar R, Cortés-Funes H, Hidalgo M. Rifampin does not improve the efficacy of quinolone antibacterial prophylaxis in neutropenic cancer patients: results of a randomized clinical trial. J Clin Oncol 2000; 18:2126-34. [PMID: 10811678 DOI: 10.1200/jco.2000.18.10.2126] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To determine whether the addition of rifampin to a quinolone-based antibacterial prophylactic regimen in patients undergoing high-dose chemotherapy (HDC) with peripheral-blood stem-cell transplantation (PBSCT) decreases the incidence of neutropenia and fever, Gram-positive bacteremia, and infection-related morbidity. PATIENTS AND METHODS Patients with solid tumors undergoing HDC with PBSCT were randomized to receive prophylactic antibiotics with either ciprofloxacin 500 mg orally every 8 hours or the same ciprofloxacin regimen with rifampin 300 mg orally every 12 hours. Prophylaxis was started 48 hours before stem-cell reinfusion. Patients were monitored to document the occurrence of neutropenia and fever, incidence and cause of bacterial infection, time to onset and duration of fever, requirement for intravenous antimicrobials, and length of hospital admission. RESULTS Sixty-five patients were randomized to receive ciprofloxacin and 65 to receive ciprofloxacin plus rifampin, and from these groups, 62 and 61 were assessable, respectively. The proportion of patients who developed neutropenia and fever was 87% in the group treated with ciprofloxacin and 78% in the group treated with ciprofloxacin and rifampin (P =.25). Although there was a trend toward a reduction in the overall incidence of bacteremia (12 v 4 patients), and Gram-positive bacteremia (8 v 2 patients) with the addition of rifampin, none of these comparisons was statistically significant (P =.05 and P =.09, respectively). CONCLUSION The results of this study, which demonstrate that rifampin does not improve ciprofloxacin antibacterial prophylaxis in cancer patients undergoing HDC with PBSCT support but that it does increase the occurrence of undesirable side effects, do not support the routine use of rifampin in this setting.
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Affiliation(s)
- C Gomez-Martin
- Division of Medical Oncology, Microbiology, and Infectious Disease, Hospital Universitario "12 de Octubre," Madrid, Spain
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17
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Kerr KG. The prophylaxis of bacterial infections in neutropenic patients. J Antimicrob Chemother 1999; 44:587-91. [PMID: 10552973 DOI: 10.1093/jac/44.5.587] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- K G Kerr
- Department of Microbiology, University of Leeds, Leeds LS2 9JT, UK
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18
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Abstract
Therapeutic approaches in the practice of haematology/oncology are increasing in complexity. Agents such as the purine analogues and monoclonal antibodies may introduce a new spectrum of infection as a consequence of prolonged/profound lymphoid suppression. The use of high dose therapy with stem cells support is increasing rapidly in clinical practice. Allogeneic transplantation is associated with prolonged immunosuppression and a high potential for transplant-related mortality from infection. This has led to intense interest in strategies aimed at improved prophylaxis and treatment of infective complications. This review aims to summarize recent advances in haematological practice and the effect this has had on opportunistic infections.
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Affiliation(s)
- M Potter
- Department of Haematology, Royal Free Hospital, London, UK
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19
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Westermann AM, Holtkamp MM, Linthorst GA, van Leeuwen L, Willemse EJ, van Dijk WC, Nooijen WJ, Baars JW, Schornagel JH, Rodenhuis S. At home management of aplastic phase following high-dose chemotherapy with stem-cell rescue for hematological and non-hematological malignancies. Ann Oncol 1999; 10:511-7. [PMID: 10415999 DOI: 10.1023/a:1026427724108] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND After high-dose chemotherapy with autologous stem-cell support long hospital stays in the aplastic phase are expensive, lead to increased risk of hospital infections and to increasing pressure on available hospital beds. We developed a home care regimen that allows patients to be at home for most of the aplastic period, without daily hospital visits. PATIENTS AND METHODS Between October 1995 and December 1997, transfer of supportive care to the home setting took place in three phases for patients undergoing high-dose chemotherapy with stem-cell transplant for malignant lymphoma (one course of BEAM), breast cancer or germ-cell cancer (three courses of tCTC). In the inpatient cohort, the supportive care designed for at home use was administered in the hospital until neutrophile recovery to 0.5 x 10(9)/l. In the second, outpatient cohort, patients were discharged the day after stem-cell reinfusion but the supportive care was delivered daily in hospital. The third, home care cohort, consisted of patients who were discharged the day after stemcell reinfusion, after which specialized home care professionals delivered all supportive care including transfusions and parenteral antibiotics at home, with once weekly check-up in hospital by the transplant physician. RESULTS Forty-two patients were treated with 81 cycles of high-dose chemotherapy (11, 18 and 13 patients and 17, 40 and 24 courses in the inpatient, outpatient and home care cohorts respectively). Inpatients were hospitalized in the aplastic phase for a median of 14 days. Patients in the outpatient cohort were at home in the aplastic phase for a median of six days (with a median of six days in hospital), and in the home care cohort for a median of 10 days (with a median of 1.5 days in hospital). Unscheduled readmissions and hospital visits were frequent in the outpatient and home care cohorts, mostly due to fever, central indwelling catheter malfunctioning or chemotherapy-related toxicity. However, patients could usually be discharged again after observation and treatment. No infectious deaths or unexpected emergencies occurred in the outpatient or home care cohort. Neither was there any suggestion of an increased number of fevers, infections, or other complications. CONCLUSIONS At home management in the aplastic phase after high-dose chemotherapy and stemcell transplant by community-based professionals is feasible without signs of increased toxicity or infections.
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Affiliation(s)
- A M Westermann
- Department of Medical Oncology, Antoni van Leeuwenhoekhuis/The Netherlands Cancer Institute, Amsterdam, The Netherlands.
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20
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Abstract
Mucositis may be a painful, debilitating, dose-limiting side-effect of both chemotherapy and radiotherapy for which there is no widely accepted prophylaxis or effective treatment. The basis of management is pain relief, prevention of dehydration and adequate nutrition. When tested vigorously, most antiseptic mouthwashes and anti-ulcer agents are ineffective. Simple mechanical cleansing by saline is the most effective traditional measure. A variety of new agents are effective. Granulocyte macrophage colony-stimulating factor (GM-CSF) and granulocyte colony-stimulating factor (G-CSF) act outwith the haemopoeitic system and can reduce mucositis, but the best schedule, dosage and method of administration is not known or which is the best growth factor to prevent this side-effect. A placebo-controlled randomized trial of antibiotic pastilles has shown a significant reduction in mucositis and weight loss during radiotherapy for head and neck cancer. Another method to reduce radiation effects in normal tissue is to stimulate cells to divide before radiotherapy by silver nitrate or interleukin 1. These methods may be particularly effective when given along with hyperfractionated radiation treatment such as CHART.
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Affiliation(s)
- R P Symonds
- Beatson Oncology Centre, Western Infirmary, Glasgow, UK
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