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Khedr RA, Ali E, Elshafei ZA, Ahmed El-Mahallawy H, Ezz Eldeen N. Cost-Effectiveness of Oral Levofloxacin Versus Amoxicillin-Clavulanate/Ciprofloxacin for Outpatient Management of Low-Risk Febrile Neutropenia in Children With Cancer in Egypt. JCO Glob Oncol 2025; 11:e2400182. [PMID: 40267379 DOI: 10.1200/go.24.00182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 12/12/2024] [Accepted: 02/20/2025] [Indexed: 04/25/2025] Open
Abstract
PURPOSE Febrile neutropenia (FN) is a common cancer complication in children. A growing body of evidence suggests that home-based care with oral antibiotics is safe and effective in carefully selected children with low-risk (LR) FN. This study aimed to assess the efficacy and safety of oral levofloxacin versus oral amoxicillin-clavulanate/ciprofloxacin in the management of LR-FN in children with cancer over a time horizon of 7 days from the National Cancer Institute (NCI) perspective. PATIENTS AND METHODS This is a randomized controlled study conducted at the NCI from December 2021 to September 2022, including children and adolescents age between 3 and 18 years who presented to the emergency room with LR-FN criteria with the exclusion of patients younger than 3 years and patients with Down syndrome. One hundred LR-FN episodes were enrolled in each arm. Patient demographics, microbiologic data, and outcomes were collected at different time points. A decision analytic model was created to compare the two treatment strategies. The outcome measures included quality-adjusted FN episodes, costs, and incremental cost-effectiveness ratios. RESULTS Levofloxacin was a safe and effective treatment option for LR-FN. It proved to be the dominant strategy against amoxicillin-clavulanate/ciprofloxacin with an incremental quality-adjusted life-year (QALY) of 0.0001 and a lower cost of 62.4996 Egyptian pounds (EGPs) in the treatment of home-based LR-FN with a willingness to pay a threshold of 77,520 EGPs per QALY (1 gross domestic product/capita). CONCLUSION For the treatment of FN in pediatric patients with cancer, levofloxacin offers a cost-saving option with improved survival benefits over a 7-day time horizon from the NCI perspective. These findings will help health care decisions regarding the allocation of health care system resources to improve supportive care for patients with LR-FN.
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Affiliation(s)
- Reham Abdelaziz Khedr
- Pediatric Oncology, National Cancer Institute, Cairo University, Cairo, Egypt
- Children's Cancer Hospital of Egypt, Cairo, Egypt
| | - Ebtehal Ali
- Pediatric Oncology, National Cancer Institute, Cairo University, Cairo, Egypt
| | | | | | - Nashwa Ezz Eldeen
- Pediatric Oncology, National Cancer Institute, Cairo University, Cairo, Egypt
- Children's Cancer Hospital of Egypt, Cairo, Egypt
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Ulusan M, Bireller S, Ertugrul B, Kasarci G, Atas MN, Aydemir L, Ergen A, Cakmakoglu B. What if amoxicillin/clavulanic acid reduces the cisplatin anticancer impact on oral cancer treatment? JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2023; 124:101502. [PMID: 37192700 DOI: 10.1016/j.jormas.2023.101502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 05/13/2023] [Indexed: 05/18/2023]
Abstract
Antibiotics-chemotherapeutics combination have become on the table for many cancer treatments. For this reason, we thought that further progress and development of studies to support chemotherapeutic approaches with the use of antibiotics may be beneficial in the clinical field. Cell lines (SCC-15, HTB-41, and MRC-5) were treated with 5-100 μM/ml concentrations of cisplatin (cisp) and amoxicillin/clavulanic acid (amx/cla) with combination (amx/cla-cisp) and alone in three different incubation periods. The all-cells viability was examined with WST-1 and apoptotic activity of the drugs were investigated via cell death ELISA assay kit. The cytotoxic impact of the 100 μM amx/cla-cisp combination was found to be reduced by up to 21.8%, which was significant given that the cytotoxic effect of only cisplatin therapy was 86.1%. Because our findings demonstrated that solo amx/cla therapy have almost no impact on proliferation or death, we focused on the amx/cla-cisp combination effect. It was found that the amx/cla-cisp combination has reduced the apoptotic fragment when comparing with the solely cisp-treated cells. Due to amx/cla-cisp combination on both cells but significantly on SCC-15 recovered the sole cisplatin effect, we believe that there might be a second thought when prescribing antibiotics while treating cancer patients. Not only the antibiotic's type but also the cancer type might interact to lessen the chemotherapeutic agent's impact which is clinically a dilemma to focus on.
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Affiliation(s)
- Murat Ulusan
- Department of Otolaryngology, Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Sinem Bireller
- Department of Biochemistry, Faculty of Pharmacy, Acıbadem Mehmet Ali Aydınlar University, Istanbul, Turkey
| | - Baris Ertugrul
- Department of Molecular Medicine, Aziz Sancar Institute of Experimental Medicine, Istanbul University, Istanbul, Turkey; Graduate School of Health Sciences, Istanbul University, Istanbul, Turkey
| | - Goksu Kasarci
- Department of Molecular Medicine, Aziz Sancar Institute of Experimental Medicine, Istanbul University, Istanbul, Turkey; Graduate School of Health Sciences, Istanbul University, Istanbul, Turkey
| | - Merve Nur Atas
- Department of Molecular Medicine, Aziz Sancar Institute of Experimental Medicine, Istanbul University, Istanbul, Turkey; Graduate School of Health Sciences, Istanbul University, Istanbul, Turkey
| | - Levent Aydemir
- Department of Otolaryngology, Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Arzu Ergen
- Department of Molecular Medicine, Aziz Sancar Institute of Experimental Medicine, Istanbul University, Istanbul, Turkey
| | - Bedia Cakmakoglu
- Department of Molecular Medicine, Aziz Sancar Institute of Experimental Medicine, Istanbul University, Istanbul, Turkey.
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Danielsen AS, Franconeri L, Page S, Myhre AE, Tornes RA, Kacelnik O, Bjørnholt JV. Clinical outcomes of antimicrobial resistance in cancer patients: a systematic review of multivariable models. BMC Infect Dis 2023; 23:247. [PMID: 37072711 PMCID: PMC10114324 DOI: 10.1186/s12879-023-08182-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 03/17/2023] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND Infections are major causes of disease in cancer patients and pose a major obstacle to the success of cancer care. The global rise of antimicrobial resistance threatens to make these obstacles even greater and hinder continuing progress in cancer care. To prevent and handle such infections, better models of clinical outcomes building on current knowledge are needed. This internally funded systematic review (PROSPERO registration: CRD42021282769) aimed to review multivariable models of resistant infections/colonisations and corresponding mortality, what risk factors have been investigated, and with what methodological approaches. METHODS We employed two broad searches of antimicrobial resistance in cancer patients, using terms associated with antimicrobial resistance, in MEDLINE and Embase through Ovid, in addition to Cinahl through EBSCOhost and Web of Science Core Collection. Primary, observational studies in English from January 2015 to November 2021 on human cancer patients that explicitly modelled infection/colonisation or mortality associated with antimicrobial resistance in a multivariable model were included. We extracted data on the study populations and their malignancies, risk factors, microbial aetiology, and methods for variable selection, and assessed the risk of bias using the NHLBI Study Quality Assessment Tools. RESULTS Two searches yielded a total of 27,151 unique records, of which 144 studies were included after screening and reading. Of the outcomes studied, mortality was the most common (68/144, 47%). Forty-five per cent (65/144) of the studies focused on haemato-oncological patients, and 27% (39/144) studied several bacteria or fungi. Studies included a median of 200 patients and 46 events. One-hundred-and-three (72%) studies used a p-value-based variable selection. Studies included a median of seven variables in the final (and largest) model, which yielded a median of 7 events per variable. An in-depth example of vancomycin-resistant enterococci was reported. CONCLUSIONS We found the current research to be heterogeneous in the approaches to studying this topic. Methodological choices resulting in very diverse models made it difficult or even impossible to draw statistical inferences and summarise what risk factors were of clinical relevance. The development and adherence to more standardised protocols that build on existing literature are urgent.
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Affiliation(s)
- Anders Skyrud Danielsen
- Department of Microbiology, Oslo University Hospital, Oslo, Norway.
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.
| | - Léa Franconeri
- Department of Infection Control and Preparedness, Norwegian Institute of Public Health, Oslo, Norway
- ECDC Fellowship Programme, Field Epidemiology Path (EPIET), European Centre for Disease Prevention and Control, (ECDC), Stockholm, Sweden
| | - Samantha Page
- Department of Infection Control and Preparedness, Norwegian Institute of Public Health, Oslo, Norway
| | | | - Ragnhild Agathe Tornes
- The Library for the Healthcare Administration, Norwegian Institute of Public Health, Oslo, Norway
| | - Oliver Kacelnik
- Department of Infection Control and Preparedness, Norwegian Institute of Public Health, Oslo, Norway
| | - Jørgen Vildershøj Bjørnholt
- Department of Microbiology, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
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Model for Evaluating Antimicrobial Therapy To Prevent Life-Threatening Bacterial Infections following Exposure to a Medically Significant Radiation Dose. Antimicrob Agents Chemother 2022; 66:e0054622. [PMID: 36154387 DOI: 10.1128/aac.00546-22] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
More evidence is needed to support recommendations for medical management of acute radiation syndrome (ARS) and associated infections resulting from a radiological/nuclear event. While current guidelines recommend the administration of antibiotics to chemotherapy patients with febrile neutropenia, the clinical benefit is unclear for acute radiation injury patients. A well-characterized nonhuman primate (NHP) model of hematopoietic ARS was developed that incorporates supportive care postirradiation. This model evaluated the efficacy of myeloid growth factors within 24 to 48 h after total body irradiation (TBI). However, in this model, NHPs continued to develop life-threatening bacterial infections, even when granulocyte colony-stimulating factor or granulocyte-macrophage colony-stimulating factor was administered in combination with antibiotic monotherapy. In this study, we evaluated the efficacy of combination antibiotic therapies administered to NHPs following 7.4-Gy TBI to understand the occurrence of bacterial infection in NHPs with hematopoietic ARS. We compared enrofloxacin-linezolid, enrofloxacin-cefepime, and enrofloxacin-ertapenem to enrofloxacin monotherapy. The primary endpoint was 60-day postirradiation mortality, with secondary endpoints of overall survival time, incidence of bacterial infection, and bacteriologic culture with antimicrobial susceptibility testing. We observed that enrofloxacin-ertapenem significantly increased survival compared to enrofloxacin monotherapy. Bacteria isolated from nonsurviving macaques with systemic bacterial infections exhibited uniform resistance to enrofloxacin and variable resistance to beta-lactam antibiotics, linezolid, gentamicin, and azithromycin. Multidrug antibiotic resistance was observed in Enterococcus spp. and Escherichia coli. We conclude that antibiotic combination therapies appear to be more effective than monotherapy alone but acknowledge that more work is needed to identify an optimal antimicrobial therapy.
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Anderson K, Bradford N, Edwards R, Nicholson J, Lockwood L, Clark JE. Improving management of fever in neutropenic children with cancer across multiple sites. Eur J Cancer Care (Engl) 2021; 30:e13413. [PMID: 33511731 DOI: 10.1111/ecc.13413] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 10/28/2020] [Accepted: 01/06/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of a clinical pathway in achieving antibiotic administration in less than 60 minutes for children with cancer, presenting with fever and neutropenia. Secondary objectives were to determine association between time to antibiotics (TTA) and other variables including fever duration, location of care and intravenous access types. METHODS Following introduction of the clinical pathway, we collected prospective data about management of all cases that did and did not use the pathway across multiple sites over 16 months. A follow-up audit was conducted after 12 months. RESULTS We evaluated a total of 453 presentations. Use of the clinical pathway was significantly associated with achieving TTA in less than 60 minutes (RR 0.69, 95% CI 0.56-0.85, p = <0.001). Despite varying use of the pathway over time, the median time to antibiotics was achieved in both the initial study period (57 minutes) and sustained at follow-up (60 minutes). TTA was also associated with types of intravenous access device and location of care and with length of stay. We did not find any association between TTA and any other variables. CONCLUSION Clinical pathways improve fever management in this patient cohort. Ongoing education and auditing to identify factors which impact processes of care are necessary.
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Affiliation(s)
- Katrina Anderson
- Oncology Services Group, Queensland Children's Hospital, South Brisbane, Qld, Australia
| | - Natalie Bradford
- Cancer and Palliative Care Outcomes Centre and Centre for Children's Health Research, Queensland University of Technology, South Brisbane, Qld, Australia
| | - Rachel Edwards
- Oncology Services Group, Queensland Children's Hospital, South Brisbane, Qld, Australia
| | - Jessica Nicholson
- Oncology Services Group, Queensland Children's Hospital, South Brisbane, Qld, Australia
| | - Liane Lockwood
- Oncology Services Group, Queensland Children's Hospital, South Brisbane, Qld, Australia
| | - Julia E Clark
- Infection Management and Prevention Service, Queensland Children's Hospital, South Brisbane, Qld, Australia.,School of Clinical Medicine, University of Queensland, Brisbane, Australia
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