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Karim N, Kabir A, Islam M, Biswas AR, Wasim M, Alam M, Chowdhury N, Islam MN, Tabassum T, Hasan MJ. Use of cefepime, meropenem, or piperacillin/tazobactam as initial treatment for febrile neutropenia in patients with hematological malignancy — a real-life experience. THE EGYPTIAN JOURNAL OF INTERNAL MEDICINE 2022. [DOI: 10.1186/s43162-022-00154-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Antimicrobials like fourth-generation cephalosporins, carbapenems, or β-lactams are widely used in treatment of febrile neutropenia (FN). The present study aimed to compare the efficacy of cefepime, meropenem, and piperacillin/tazobactam as initial treatment for chemo-induced FN in patients with hematological malignancy.
Methods
This was an observational study conducted in the Department of Hematology of Dhaka Medical College Hospital from July 2020 to June 2021 including 99 adult FN patients with hematological malignancy who were randomized equally to three treatment arms to receive cefepime, meropenem, or piperacillin/tazobactam as an empirical antibiotic. Response to therapy was defined as improvement in symptoms (e.g., defervescence) or in laboratory values including neutrophil counts on day 3 and day 7 after the initiation of the therapy. Chi-square test and Fisher’s exact test were used to compare the efficacy of the treatment regimens.
Results
Response rate to initial treatment with different antibiotic regimens was similar without any statistically significant difference (60.6%, 63.6%, and 51.5% on day 3 and 63.6%, 75.8%, and 66.7% on day 7 for cefepime, meropenem, and piperacillin/tazobactam, respectively, p-value > 0.05) irrespective of underlying diagnosis, the severity of neutropenia, and cause of fever.
Conclusion
Initial therapy with cefepime, meropenem, or piperacillin/tazobactam is safe and equally effective in chemo-induced FN in patients with hematological malignancy. This finding may be considered in clinical practice for optimum therapeutic outcomes.
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Deveci B, Kublashvili G, Yilmaz S, Özcan B, Korkmaz HF, Gürsoy O, Toptaş T, Döşemeci L, Saba R. Investigation of typhlitis in bone marrow transplant patients in a stem cell transplant unit. Medicine (Baltimore) 2022; 101:e30104. [PMID: 36042636 PMCID: PMC9410587 DOI: 10.1097/md.0000000000030104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Typhlitis is a special type of enterocolitis that specifically develops in immunosuppressive patients with hematological malignancies. Typhlitis is a common consideration after bone marrow transplantation due to high-dose chemotherapy that is used in conditioning regimens those contain high-dose cytotoxic chemotherapeutic agents. Although there are several studies about typhlitis during chemotherapy or in leukemia patients, there is not enough data evaluating its relationship between stem cell transplant in adults. Therefore, the current study aimed to analyze the possible causes that may lead to the development of typhlitis in hematopoietic stem cell recipient patients. This retrospective study included 210 adult patients who underwent bone marrow transplantation between January 2017 and December 2019. Pediatric patients (patients younger than 18 years of age) were excluded. Patients' data were evaluated to determine their effects on typhlitis and the mortality risk of the patients with typhlitis. The analysis of the variables was performed using the IBM SPSS Statistics for Windows version 26 (IBM Corp., Armonk, NY).Variables were analyzed at a 95% confidence level and a P value <0.05 was considered significant. Typhlitis developed in 23 (10.9%) transplant patients. Male sex, length of hospital stay, presence of febrile neutropenia, antibiotic and antifungal use, need for switching antibiotics, duration of neutropenia, diarrhea and antibiotic use in days were risk factors for development of typhlitis. It was observed that 100-days mortality was higher in typhlitis group reaching to a statistical significance (P < .05). In multiple logistic regression analysis, presence of mucositis and additional source of infection were determined as independent risk factors for the development of typhlitis in bone marrow transplant patients. This study provides valuable information for bone marrow transplant patients through an analysis of risk factors for the development of typhlitis. According to our results, mucositis and additional bacterial infections were found as risk factors for typhlitis therefore it would be beneficial for clinicians to consider these factors in patient follow-up. However, due to the retrospective nature of our study, prospective studies are needed to investigate risk factors and optimum treatment methods for typhlitis.
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Affiliation(s)
- Burak Deveci
- Department of Hematology and Stem Cell Transplant Unit, Medstar Antalya Hospital Antalya, Turkey
| | - George Kublashvili
- Department of Hematology and Stem Cell Transplant Unit, Medstar Antalya Hospital Antalya, Turkey
| | - Saim Yilmaz
- Department of Radiology Varisson Radiology Center, Antalya, Turkey
| | - Bariş Özcan
- Department of Surgery, Medstar Antalya Hospital Antalya, Turkey
| | - Halil Fatih Korkmaz
- Department of Anesthesiology and Reanimation Medstar Antalya Hospital, Antalya, Turkey
| | - Olcay Gürsoy
- Department of Anesthesiology and Reanimation Medstar Antalya Hospital, Antalya, Turkey
| | - Tayfur Toptaş
- Department of Hematology, Marmara University School of Medicine, Istanbul, Turkey
| | - Levent Döşemeci
- Department of Anesthesiology and Reanimation Medstar Antalya Hospital, Antalya, Turkey
| | - Rabin Saba
- Department of Dentistry, Antalya Bilim University, Antalya, Turkey
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Ackerman M, Frost A, Stanford K. Abdominal pain and fever in a patient with human immunodeficiency virus: a case report. Int J Emerg Med 2022; 15:35. [PMID: 35941531 PMCID: PMC9361662 DOI: 10.1186/s12245-022-00439-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 07/09/2022] [Indexed: 11/10/2022] Open
Abstract
Background Neutropenic enterocolitis (NE), or typhlitis, a condition typically associated with severe neutropenia in the setting of chemotherapy, is highly morbid (50–100%) and benefits from early diagnosis. It has been associated with neutropenia in the setting of human immunodeficiency virus (HIV) but has not been described in a patient with HIV who was not neutropenic on presentation. We present the case of a patient with HIV who was not neutropenic on presentation but found to have NE. Case presentation A 27-year-old male with a history of HIV on antiretroviral therapy and epilepsy presented with concern for breakthrough seizure. The patient revealed he was having non-bloody, non-bilious emesis and diarrhea for 3 days. Initial labs were white blood cell count 3.9 × 109/L, absolute neutrophil count (ANC) 3.14 × 109/L, CD4 count 290 cells/mm3, and undetectable viral load. A computed tomography (CT) scan of the abdomen/pelvis with contrast revealed wall thickening of the cecum and proximal ascending colon (Fig. 1), suggestive of NE. The patient was started on cefepime and metronidazole but switched to piperacillin/tazobactam after he became leukopenic/neutropenic. Conclusions Neutropenic enterocolitis, typically presenting with fever, abdominal pain, and hematochezia, can be difficult to identify, particularly in patients without a history of malignancy. However, it should be considered in patients with HIV presenting with these symptoms, even with a normal ANC and CD4 count above 200 cells/mm3. Prompt diagnosis can be made with CT, and early initiation of broad-spectrum antibiotics greatly reduces the risk of morbidity/mortality.
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Affiliation(s)
- Max Ackerman
- University of Chicago Pritzker School of Medicine, 924 E 57th St #104, Chicago, IL, 60637, USA.
| | - Arian Frost
- Department of Medicine, Section of Emergency Medicine, University of Chicago, 5841 S Maryland Ave, Chicago, IL, 60637, USA
| | - Kimberly Stanford
- Department of Medicine, Section of Emergency Medicine, University of Chicago, 5841 S Maryland Ave, Chicago, IL, 60637, USA
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Belmoufid N, Daghri S, Driouich S, Nadi A, Bouanani N. Neutropenic Enterocolitis as a Complication of Autologous Stem Cell Transplant in Patients With Multiple Myeloma: A Case Series. Cureus 2022; 14:e24475. [PMID: 35651414 PMCID: PMC9135047 DOI: 10.7759/cureus.24475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2022] [Indexed: 11/05/2022] Open
Abstract
Neutropenic enterocolitis (NE) is a rare but severe complication occurring in neutropenic patients undergoing intensive chemotherapy. Mortality is high, so early diagnosis is required to start urgent medical or surgical treatment. Data analysis of the development of NE after hematopoietic stem cell transplantation remains scarce. The aim of this case series is to discuss five out of 100 patients receiving autologous stem cell transplants (ASCTs) for multiple myeloma complicated with NE between 2016 and 2020 in the hematology department of the Cheikh Khalifa International University Hospital, Casablanca, Morocco. The patients were diagnosed with IgA and IgG multiple myeloma and aged between 58 to 64 years. They received induction therapy with four cycles of a triplet regimen including a proteasome inhibitor, an immunomodulatory drug, and corticosteroids, allowing a complete remission. Intensification was based on ASCT with melphalan at 200 mg/m2. The period of aplasia was marked by the sudden appearance of NE, diagnosed based on clinical, biological, and imaging criteria. Treatment included antibiotherapy and supportive care. We report no complications in our cases, nor the need for surgical care. Therefore, we consider that early diagnosis and treatment allowed a good evolution in our case series. The management of NE must be multidisciplinary associating hematologists, gastroenterologists, radiologists, and biologists. More studies and trials are needed to establish specific diagnostic criteria and better treatment options.
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Tan XN, Yew CY, Ragg SJ, Harrup RA, Johnston AM. Outpatient autologous stem cell transplantation in Royal Hobart Hospital, Tasmania: a single-centre, retrospective review in the Australian setting. Intern Med J 2021; 52:1242-1250. [PMID: 33949777 DOI: 10.1111/imj.15334] [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] [Received: 09/14/2020] [Revised: 03/14/2021] [Accepted: 04/17/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Several international centres have published their experiences with outpatient autologous stem cell transplantation (ASCT) as treatment of haematological malignancies. AIM In this single-centre retrospective review, we aim to examine the outcomes of outpatient autograft and review healthcare resource utilization in the pre-cytopenic period. METHODS Patients undergoing ASCT in Royal Hobart Hospital, Tasmania between 2008 and 2018 had their records reviewed and key outcomes data collected based upon whether they received inpatient/outpatient ASCT. An outpatient ASCT was defined as conditioning as an outpatient; patients could then be managed with an elective admission during the cytopenic period or admission only when clinically indicated. RESULTS Of 231 ASCTs performed, 135 (58%) were as outpatients ASCTs: 59 used carmustine-etoposide-cytarabine-melphalan-conditioning for lymphoma (BEAM-ASCT) and 76 used high dose melphalan for myeloma and amyloidosis (MEL-ASCT). Approximately one-third of patients undergoing outpatient ASCT were admitted electively during nadir period; the majority of patients required minimal interventions prior to this time. The most common causes for unplanned hospitalization (which occurred in 71 of the 89 planned outpatient transplants, 80%) were febrile neutropenia (39%) and mucositis (35%). Age was the only risk factor identified to increase risk of requiring unplanned hospitalization. Use of oral antibiotic prophylaxis reduced febrile neutropenia rates amongst melphalan-outpatient-ASCT. Outpatient-ASCTs led to significantly reduced inpatient bed-days and overall cost (approximately AUD $13000- $16,000) compared with inpatient autografts, with no significant differences in engraftment, rates of febrile neutropenia, intensive care admissions or mortality. CONCLUSION Outpatient autografts may save healthcare resources without compromising patient outcomes. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Xuan Ni Tan
- Sir Charles Gairdner Hospital, Western Australia & University of Western Australia
| | - Chang Yang Yew
- Armadale Health Service, Western Australia & candidate in Master of Biostatistics, University of Sydney
| | - Scott J Ragg
- Royal Hobart Hospital, Tasmania & University of Tasmania
| | | | - Anna M Johnston
- Clinical Haematologist and Director of Haematology and Statewide Bone Marrow Transplant Service, Royal Hobart Hospital, Tasmania & University of Tasmania
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Fouad ER, Morsy AM, Kamel HEM, Ali AM. Neutropenic enterocolitis in pediatric leukemia patients treated with intensive chemotherapy in Upper Egypt. Pediatr Investig 2020; 4:5-10. [PMID: 32851335 PMCID: PMC7331293 DOI: 10.1002/ped4.12174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 01/14/2020] [Indexed: 12/20/2022] Open
Abstract
IMPORTANCE In low resource countries, there has been scarcity of research on the risk factors associated with neutropenic enterocolitis, a serious complication that commonly develops during treatment of cancer patients. OBJECTIVE To identify the pattern of intestinal complications in pediatric leukemia patients treated with intensive chemotherapy, including those with neutropenic enterocolitis; to assess the outcome; and to evaluate the risk factors associated with the mortality in these patients. METHODS During the period from June 2015 to December 2016, a prospective study was carried out on pediatric patients diagnosed with acute leukemia who received induction/or re-induction phases of chemotherapy at South Egypt Cancer Institute. Patients with documented episodes of intestinal complications were included in the study. Recovery or death from an episode of intestinal complication was utilized as the primary outcome measure for the study. Using univariable and multivariable methods, potential risk factors associated with mortality were delineated by logistic regression analysis, both for the entire intestinal complications episodes as a whole and for those episodes of neutropenic enterocolitis only. RESULTS Out of 88 documented episodes of intestinal complications from 77 patients; 58 episodes were identified as neutropenic enterocolitis from 47 patients. In those patients who were having episodes of neutropenic enterocolitis, the presence of abdominal tenderness (OR 4.529, 95%CI 1.062-19.317, P = 0.041); a longer duration of neutropenia (OR 1.215, 95%CI 1.030-1.434, P = 0.021); and hemodynamic instability (OR 17.023, 95%CI 4.095-70.772, P < 0.001), were found to be independently associated with worse outcome. INTERPRETATION In Upper Egypt, the use of intensive systemic chemotherapy during the induction phase of acute leukemia was found to be associated with potentially lethal intestinal complications. A high index of clinical suspicion is warranted.
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Affiliation(s)
- Ereen Refaat Fouad
- Department of Pediatric OncologySouth Egypt Cancer InstituteAssiut UniversityAssiutEgypt
| | - Ahmed Mohammed Morsy
- Department of Pediatric OncologySouth Egypt Cancer InstituteAssiut UniversityAssiutEgypt
| | | | - Amany Mohamed Ali
- Department of Pediatric OncologySouth Egypt Cancer InstituteAssiut UniversityAssiutEgypt
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7
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Modi D, Jang H, Kim S, Surapaneni M, Sankar K, Deol A, Ayash L, Bhutani D, Lum LG, Ratanatharathorn V, Manasa R, Mellert K, Chandrasekar P, Uberti JP. Fluoroquinolone prophylaxis in autologous hematopoietic stem cell transplant recipients. Support Care Cancer 2017; 25:2593-2601. [PMID: 28365897 DOI: 10.1007/s00520-017-3670-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 03/14/2017] [Indexed: 11/26/2022]
Abstract
PURPOSE Although fluoroquinolone prophylaxis is frequently utilized in autologous hematopoietic stem cell transplant (AHSCT) patients, its impact on morbidity and mortality is uncertain. This study investigates the role of quinolone prophylaxis after AHSCT in recent years. METHODS We conducted a retrospective review of 291 consecutive adult patients who underwent AHSCT for malignant disorders, between June 2013 and January 2015. Outcomes were compared between patients who received norfloxacin prophylaxis and those who did not. The endpoints were mortality during prophylaxis and at 100 days after transplant, frequency of ICU admissions, and incidence and type of bacteremia. RESULTS Of 291 patients, 252 patients received norfloxacin prophylaxis and 39 patients did not. The mortality during prophylaxis and at 100 days as well as the median number of days of hospitalization following AHSCT did not differ between the two groups. No differences were noted in the frequency of ICU admission, incidence of septic shock, and duration of ICU stay. Patients who did not receive prophylaxis had a significantly higher rate of neutropenic fever (97%) than patients who received prophylaxis (77%) (p = 0.005). The patients with prophylaxis demonstrated a significantly higher rate of gram-positive bacteremia as compared to those without prophylaxis (p = 0.002). Frequency of Clostridium difficile infection was similar during and post-prophylaxis. More antibiotic use was noted among patients without prophylaxis [97%; median 9 (range, 5-24) days] compared to patients with prophylaxis [79%; median 7 (range, 3-36) days, p = 0.04]. CONCLUSION Although fluoroquinolone prophylaxis reduced the incidence of neutropenic fever and antibiotic use in AHSCT, it did not alter mortality or morbidity.
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Affiliation(s)
- Dipenkumar Modi
- Department of Hematology-Oncology, Karmanos Cancer Institute/Wayne State University, 4100 John R, HW04H0, Detroit, MI, 48201, USA.
| | - Hyejeong Jang
- Biostatistics Core, Karmanos Cancer Institute, Department of Oncology, Wayne State University, Detroit, MI, 48201, USA
| | - Seongho Kim
- Biostatistics Core, Karmanos Cancer Institute, Department of Oncology, Wayne State University, Detroit, MI, 48201, USA
| | - Malini Surapaneni
- Department of Internal Medicine, 3990 John R, 5904 5Hudson, Detroit, MI, 48201, USA
| | - Kamya Sankar
- Wayne State School of Medicine, 320 E Canfield Ave; Suite 315, Detroit, MI, 48201, USA
| | - Abhinav Deol
- Department of Oncology, Blood and Marrow Stem Cell Transplant Program, Karmanos Cancer Institute/Wayne State University, 4100 John R, 4 HW04H0, Detroit, MI, 48201, USA
| | - Lois Ayash
- Department of Oncology, Blood and Marrow Stem Cell Transplant Program, Karmanos Cancer Institute/Wayne State University, 4100 John R, 4 HW04H0, Detroit, MI, 48201, USA
| | - Divaya Bhutani
- Department of Oncology, Blood and Marrow Stem Cell Transplant Program, Karmanos Cancer Institute/Wayne State University, 4100 John R, 4 HW04H0, Detroit, MI, 48201, USA
| | - Lawrence G Lum
- Division of Hematology/Oncology, University of Virginia Cancer Center, West Complex, Rm 7191, 1300 Jefferson Park Avenue, Charlottesville, VA, USA
| | - Voravit Ratanatharathorn
- Department of Oncology, Blood and Marrow Stem Cell Transplant Program, Karmanos Cancer Institute/Wayne State University, 4100 John R, 4 HW04H0, Detroit, MI, 48201, USA
| | - Richard Manasa
- Clinical Trials Office Bone Marrow Transplant, Karmanos Cancer Institute, 4100 John R, WN10SC, Detroit, MI, 48201, USA
| | - Kendra Mellert
- Clinical Trials Office Bone Marrow Transplant, Karmanos Cancer Institute, 4100 John R, WN10SC, Detroit, MI, 48201, USA
| | | | - Joseph P Uberti
- Department of Oncology, Blood and Marrow Stem Cell Transplant Program, Karmanos Cancer Institute/Wayne State University, 4100 John R, 4 HW04H0, Detroit, MI, 48201, USA
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8
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Bacteremia during neutropenic episodes in children undergoing hematopoietic stem cell transplantation with ciprofloxacin and penicillin prophylaxis. Int J Hematol 2016; 105:213-220. [PMID: 27771837 DOI: 10.1007/s12185-016-2113-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 10/11/2016] [Accepted: 10/18/2016] [Indexed: 10/20/2022]
Abstract
Bacteremia during neutropenic episodes is a cause of morbidity and mortality in patients undergoing hematopoietic stem cell transplantation (HSCT). We have used oral ciprofloxacin and penicillin V, from the start of the conditioning regimen until engraftment, for the prophylaxis of bacterial infection. The objective of this study was to retrospectively analyze the prevalence of and risk factors for breakthrough bacteremia during neutropenic episodes in autologous and allogeneic HSCT patients. There were 215 patients enrolled, with a median age of 8.32 years (range 0.51-21.64 years) between 2002 and 2014. The common underlying diseases were thalassemia and acute leukemia. Bacteremia was documented in 33 patients (15.3 %), with 39 microorganisms isolated. Escherichia coli (28.2 %) and Streptococcus viridans (12.8 %) were the most commonly isolated Gram-negative and Gram-positive bacteria, respectively. Multidrug resistant strains were found in 32 and 14.3 % of Gram-negative and Gram-positive bacteria, respectively. Risk factors for bacteremia were receiving anti-thymocyte globulin (ATG) [odds ratio (OR) 2.44, 95 % confidence interval (CI) 1.06-5.65, P = 0.037] and umbilical cord blood as a stem cell graft (OR 6.60, 95 % CI 1.04-41.83, P = 0.045). In conclusion, the prevalence of bacteremia was 15.3 % and the use of ATG and cord blood were risk factors for bacteremia during neutropenic episodes.
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Prevalence and recurrence rate of perianal abscess--a population-based study, Sweden 1997-2009. Int J Colorectal Dis 2016; 31:669-73. [PMID: 26768004 DOI: 10.1007/s00384-015-2500-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/31/2015] [Indexed: 02/04/2023]
Abstract
INTRODUCTION The aim of this study was to assess the impact of diabetes mellitus, Crohn's disease, HIV/aids, and obesity on the prevalence and readmission rate of perianal abscess. METHODS The study cohort was based on the Swedish National Patient Register and included all patients treated for perianal abscess in Sweden 1997-2009. The prevalence and risk for readmission were assessed in association with four comorbidity diagnoses: diabetes mellitus, Crohn's disease, HIV, and/or AIDS and obesity. RESULTS A total of 18,877 patients were admitted during the study period including 11,138 men and 4557 women (2.4:1). Crohn's disease, diabetes, and obesity were associated with a significantly higher prevalence of perianal abscess than an age- and gender-matched background population (p < 0.05). In univariate analysis, neither age nor gender had any significant impact on the risk for readmission. In a multivariate Cox proportional hazard analysis, Crohns disease was the only significant risk factor for readmission of perianal abscess. CONCLUSION Crohn's disease, diabetes, and obesity increase the risk for perianal abscess. Of these, Crohn's and HIV has an impact on readmission. The pathogenesis and the influence of diabetes and obesity need further research if we are to understand why these diseases increase the risk for perianal abscess but not its recurrence.
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Hematopoietic Cell Transplantation in Patients with Medication-Related Osteonecrosis of the Jaws. Biol Blood Marrow Transplant 2016; 22:344-348. [DOI: 10.1016/j.bbmt.2015.08.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Accepted: 08/12/2015] [Indexed: 01/04/2023]
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11
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Incidence, risk factors, and outcome of bacteremia following autologous hematopoietic stem cell transplantation in 720 adult patients. Ann Hematol 2013; 93:299-307. [DOI: 10.1007/s00277-013-1872-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Accepted: 08/01/2013] [Indexed: 01/31/2023]
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12
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Fernandes LLD, Torres SR, Garnica M, de Souza Gonçalves L, Junior AS, de Vasconcellos ÁC, Cavalcanti W, Maiolino A, de Barros Torres MCM. Oral status of patients submitted to autologous hematopoietic stem cell transplantation. Support Care Cancer 2013; 22:15-21. [DOI: 10.1007/s00520-013-1940-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2012] [Accepted: 08/05/2013] [Indexed: 10/26/2022]
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13
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Prospective randomized study of cefepime, panipenem, or meropenem monotherapy for patients with hematological disorders and febrile neutropenia. J Infect Chemother 2013; 19:103-11. [DOI: 10.1007/s10156-012-0466-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2011] [Accepted: 08/08/2012] [Indexed: 12/20/2022]
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14
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Nesher L, Rolston KVI. Neutropenic enterocolitis, a growing concern in the era of widespread use of aggressive chemotherapy. Clin Infect Dis 2012. [PMID: 23196957 DOI: 10.1093/cid/cis998] [Citation(s) in RCA: 119] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Neutropenic enterocolitis (NEC) is a life-threatening disease with substantial morbidity and mortality, seen primarily in patients with hematologic malignancies. The frequency of NEC has increased with the widespread use of chemotherapeutic agents such as the taxanes, which cause severe gastrointestinal mucositis. Neutropenic patients with fever and abdominal symptoms (cramping, pain, distention, diarrhea, GI bleeding), should undergo evaluation of the abdomen for bowel wall thickening of >4 mm, the hallmark of NEC. Clostridium difficile infection should be ruled out, as well as other etiologies such as graft-versus-host disease. Complications include bacteremia, which is often polymicrobial, hemorrhage, and bowel wall perforation/abscess formation. Management includes bowel rest, correction of cytopathies and coagulopathies, and broad spectrum antibiotics and antifungal agents. Surgical intervention may be necessary to manage complications such as hemorrhage and perforation and should be delayed, if possible, until recovery from neutropenia.
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Affiliation(s)
- Lior Nesher
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
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15
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Sherief LM, Beshir MR, Kamal NM, Gohar MK, Gohar GK. Diarrhea in neutropenic children with cancer: An Egyptian center experience, with emphasis on neutropenic enterocolitis. Indian J Med Paediatr Oncol 2012; 33:95-101. [PMID: 22988351 PMCID: PMC3439797 DOI: 10.4103/0971-5851.99742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background: Diarrhea is a frequent complication in children with cancer who received intensive chemotheraputic regimens. It may be caused by several factors, neutropenic enterocolitis (NE) being the most serious. Aim: To study diarrhea in neutropenic cancer patients in the pediatric age group, with its underlying etiologies and risk factors, especially the bacterial causes, with special concern on NE. Materials and Methods: This study was carried out at the Pediatric Hematology and Oncology Units, Zagazig University Hospitals, Egypt, from January 2009 to September 2010. All children with malignant diseases who are ≤12 years of age were included. Patients who were neutropenic (<500/ mm3) on admission or who became neutropenic during their stay in the hospital were monitored regularly (daily) for diarrhea. Neutropenic cancer patients with diarrhea were grouped into two groups: Group 1, with NE, and group 2, with neutropenic diarrhea rather than NE. On the first day of diarrhea, patients were subjected to complete blood count, blood cultures, stool microscopy and culture. Abdominal ultrasonography was carried out within 3 days of diarrhea. Results: A total of 200 children ≤12 years old, suffering from different malignancies, with a total of 180 neutropenic episodes were followed. Diarrhea was observed in 100 episodes (55.5%). NE constituted 16% of these diarrheal episodes. All patients with NE had significantly more severe neutropenia, and this was of longer duration than the other group. All patients with NE were febrile, with 100% positive blood culture. Stool analysis diagnosed giardiasis in 4.8% of the non-NE patients and in none of the NE patients, while stool culture was positive in 75% of the NE patients compared with 40.5% of the other group. Conclusions: Diarrhea is a common complication in neutropenic cancer children. Gram negative bacteria and Candida are the most incriminated pathogens. Duration and severity of neutropenia carry a great risk for the development of NE.
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Affiliation(s)
- Laila M Sherief
- Department of Pediatrics, Pediatric Hematology and Oncology Units, Faculty of Medicine, Zagazig University, Egypt
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Gil L, Poplawski D, Mol A, Nowicki A, Schneider A, Komarnicki M. Neutropenic enterocolitis after high-dose chemotherapy and autologous stem cell transplantation: incidence, risk factors, and outcome. Transpl Infect Dis 2012; 15:1-7. [DOI: 10.1111/j.1399-3062.2012.00777.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Revised: 03/26/2012] [Accepted: 04/03/2012] [Indexed: 11/28/2022]
Affiliation(s)
- L. Gil
- Department of Hematology; Poznan University of Medical Sciences; Poznan; Poland
| | - D. Poplawski
- Department of Radiology; Poznan University of Medical Sciences; Poznan; Poland
| | - A. Mol
- Department of Microbiology; Poznan University of Medical Sciences; Poznan; Poland
| | - A. Nowicki
- Department of Hematology; Poznan University of Medical Sciences; Poznan; Poland
| | - A. Schneider
- Department of Microbiology; Poznan University of Medical Sciences; Poznan; Poland
| | - M. Komarnicki
- Department of Hematology; Poznan University of Medical Sciences; Poznan; Poland
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17
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Antimicrobial therapy of febrile complications after high-dose chemotherapy and autologous hematopoietic stem cell transplantation--guidelines of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Oncology (DGHO). Ann Hematol 2012; 91:1161-74. [PMID: 22638755 DOI: 10.1007/s00277-012-1456-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2011] [Accepted: 03/16/2012] [Indexed: 01/29/2023]
Abstract
More than 18,000 autolgous transplantation were performed in Europe in the year 2009. It as a routine procedure in experienced centres. Even if there is a low mortality rate, infections are a major issue after transplantation, occurring in more than 60 % of the patients. In this review we discuss all aspects of infections after autologous stem transplantation, including epidemiology, diagnostics, therapeutic algorithms, prophylaxis and supportive therapy.
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Abstract
Rac GTPases form part of the family of Rho small GTPases. Rac GTPases, like other Rho family GTPases, are key molecular switches controlling the transduction of external signals to cytoplasmic and nuclear effectors. The development of genetic and pharmacological tools has allowed a more precise definition of the specific roles of Rac GTPases in hematopoietic stem cells (HSCs). Our current knowledge has enabled dissection of their specific and redundant roles. Rac GTPases are now known to be crucial in the response of HSCs to the hematopoietic microenvironment cues. This review will briefly summarize the known HSC functions that are regulated by Rac GTPases, focusing on adhesion, migration, retention, proliferation, and survival, and how Rac relates to the physiological functions of HSC. The development of small molecule inhibitors with the ability to interfere with Rac GTPase activation offers new therapeutic strategies to manipulate the function of HSC in vivo and ex vivo.
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Affiliation(s)
- J A Cancelas
- Hoxworth Blood Center, University of Cincinnati Academic Health Center, and Stem Cell Program, Division of Experimental Hematology and Cancer Biology, Cincinnati Children's Hospital Medical Center, University of Cincinnati Medical Center, Cincinnati, Ohio, 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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Abstract
The most common complaints among patients with cancer who present to the emergency department are related to the gastrointestinal system, and 40% of these patients complain of abdominal pain. These presentations can stem from the underlying malignancy itself, treatment directed toward the disease, or the full range of pathologies present in a healthy population. Immunosuppression may blunt many of the findings one expects in a healthy population of patients, thus rendering the clinical exam less reliable in many patients with cancer. Moreover, the degree of immunosuppression shapes both the types of pathologies the clinician should consider and the rate at which the disease may progress. Understanding the limitations of physical examination, pathophysiology of disease, and the methods by which these diagnoses are established is of critical importance in this population. This article focuses specifically on patients with cancer who present with an acute abdomen, and it discusses how a concurrent malignancy can shape the differential diagnosis in these cases.
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Affiliation(s)
- Jonathan S Ilgen
- Department of Emergency Medicine, Oregon Health & Science University, CDW-EM, Portland, OR 97239, USA.
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21
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Bow EJ. Invasive Fungal Infection in Haematopoietic Stem Cell Transplant Recipients: Epidemiology from the Transplant Physician’s Viewpoint. Mycopathologia 2009; 168:283-97. [DOI: 10.1007/s11046-009-9196-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2008] [Accepted: 03/18/2009] [Indexed: 01/07/2023]
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22
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de la Rubia J, Montesinos P, Martino R, Jarque I, Rovira M, Vázquez L, López J, Batlle M, de la Cámara R, Juliá A, Lahuerta JJ, Debén G, Díaz J, García R, Sanz MA. Imipenem/Cilastatin with or without Glycopeptide as Initial Antibiotic Therapy for Recipients of Autologous Stem Cell Transplantation: Results of a Spanish Multicenter Study. Biol Blood Marrow Transplant 2009; 15:512-6. [DOI: 10.1016/j.bbmt.2008.12.505] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2008] [Accepted: 12/22/2008] [Indexed: 10/21/2022]
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23
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Jimeno A, Arcediano A, Bazares S, Amador ML, González-Cortijo L, Ciruelos E, Robles L, Castellano D, Paz-Ares L, Lumbreras C, Hornedo J, Cortés-Funes H. Randomized study of cefepime versus ceftazidime plus amikacin in patients with solid tumors treated with high dose chemotherapy (HDC) and peripheral blood stem cell support (PBSCS) with febrile neutropenia. Clin Transl Oncol 2009; 8:889-95. [PMID: 17169762 DOI: 10.1007/s12094-006-0152-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE This randomized clinical trial evaluated the efficacy and safety of monotherapy with cefepime for patients with solid tumors treated with high dose chemotherapy (HDC) and peripheral blood stem cell support (PBSCS) with febrile neutropenia. SUBJECTS Patients with solid tumors treated with HDC and PBSCS, that developed fever and neutropenia (absolute neutrophil count < 500 cells/microL) were eligible, and randomly assigned to receive ceftazidime plus amikacin or cefepime. RESULTS Fifty-one episodes were randomized, and all were evaluable (27 received ceftazidime plus amikacin arm, and 24 cefepime). Major efficacy endpoints did not show significant differences, with success rates of 44.4% and 54.2% (p = 0.481) for the combination arm and the monotherapy arm, respectively. The proportion of patients that became afebrile in the first 24 hours was significantly higher in the cefepime group (41.7% vs 11.1%, respectively; p = 0.012). However, due to its premature closure and small sample size, this study lacks the adequate power to definitely address this question. CONCLUSIONS Cefepime monotherapy appeared to have an equivalent efficacy and safety as empiric treatment in febrile neutropenia episodes in a highrisk population compared with ceftazidime and amikacin. Nevertheless, this study is not adequately powered to answer this question. Given the small number of patients randomized and the single-center nature of this study, these results must be cautiously interpreted.
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Affiliation(s)
- A Jimeno
- Department of Medical Oncology, University Hospital 12 de Octubre, Madrid, Spain.
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24
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Erikçi AA, Öztürk A, Özyurt M, Tekgündüz AE, Karagöz B, Bilgi O, Bilekli F. FEBRIL NEUTROPENIA ETIOLOGY IN A HEMATOLOGY DEPARTMENT. ELECTRONIC JOURNAL OF GENERAL MEDICINE 2008. [DOI: 10.29333/ejgm/82612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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25
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Increased risk for invasive aspergillosis in patients with lymphoproliferative diseases after autologous hematopoietic SCT. Bone Marrow Transplant 2008; 43:121-6. [DOI: 10.1038/bmt.2008.303] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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26
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Lee SY, Lin JH, Lai CT, Chang KS, Shih SC. Acute Abdomen in Post-chemotherapy Acute Monoblastic Leukemia. INT J GERONTOL 2007. [DOI: 10.1016/s1873-9598(08)70041-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Puig N, de la Rubia J, Jarque I, Salavert M, Montesinos P, Sanz J, Martín G, Sanz G, Cantero S, Lorenzo I, Sanz MA. A study of incidence and characteristics of infections in 476 patients from a single center undergoing autologous blood stem cell transplantation. Int J Hematol 2007; 86:186-92. [PMID: 17875536 DOI: 10.1532/ijh97.e0633] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Infectious complications are a major cause of morbidity and mortality in patients who undergo autologous stem cell transplantation (ASCT). We examined 476 patients with hematologic malignancies (401) or solid tumors (75) who underwent ASCT between February 1990 and May 2005. Anti-infectious prophylaxis consisted of different combinations of ciprofloxacin, cotrimoxazole, fluconazole, aerosolized amphotericin B, acyclovir, and intravenous immunoglobulins. Overall, 454 patients (95%) developed fever in the first 60 days after ASCT. In the majority of patients, initial antibiotic therapy consisted of broad-spectrum beta-lactamic with or without amikacin. A glycopeptide was administered as initial therapy in 86 cases. Overall, there were 132 (29%) clinically documented infections (37 pneumonias), 79 (17%) microbiologically documented infections (65 bacteremias), and 243 (54%) fevers of unknown origin. Coagulase-negative staphylococci (18, 25%) and E coli (18, 25%) were the organisms most frequently isolated. The pattern of infection did not change throughout the study except for a significantly higher incidence of bacteremia due to gram-positive bacteria in the first 5 years of the study. Infection-related mortality was 5% (21 cases), with pneumonia the most frequent cause of death. ASCT should be considered a low-risk procedure, although new therapeutic approaches for patients developing severe respiratory infections are still needed.
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Affiliation(s)
- Noemí Puig
- Hematology Service, University Hospital La Fe, Valencia, Spain
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28
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Maschmeyer G, Haas A, Cornely OA. Invasive aspergillosis: epidemiology, diagnosis and management in immunocompromised patients. Drugs 2007; 67:1567-601. [PMID: 17661528 DOI: 10.2165/00003495-200767110-00004] [Citation(s) in RCA: 279] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Morbidity and mortality caused by invasive Aspergillus infections are increasing. This is because of the higher number of patients with malignancies treated with intensive immunosuppressive therapy regimens as well as their improved survival from formerly fatal bacterial infections, and the rising number of patients undergoing allogeneic haematopoietic stem cell or organ transplantation. Early initiation of effective systemic antifungal treatment is essential for a successful clinical outcome in these patients; however, clinical clues for diagnosis are sparse and early microbiological proof of invasive aspergillosis (IA) is rare. Clinical diagnosis is based on pulmonary CT scan findings and non-culture based diagnostic techniques such as galactomannan or DNA detection in blood or bronchoalveolar lavage samples. Most promising outcomes can be expected in patients at high risk for aspergillosis in whom antifungal treatment has been started pre-emptively, backed up by laboratory and imaging findings. The gold standard of systemic antifungal treatment is voriconazole, which has been proven to be significantly superior to conventional amphotericin B and has led to a profound improvement of survival rates in patients with cerebral aspergillosis. Liposomal amphotericin B at standard dosages appears to be a suitable alternative for primary treatment, while caspofungin, amphotericin B lipid complex or posaconazole have shown partial or complete response in patients who had been refractory to or intolerant of primary antifungal therapy. Combination therapy with two antifungal compounds may be a promising future strategy for first-line treatment. Lung resection helps to prevent fatal haemorrhage in single patients with pulmonary lesions located in close proximity to larger blood vessels, but is primarily considered for reducing the risk of relapse during subsequent periods of severe immunosuppression. Strict reverse isolation appears to reduce the incidence of aspergillosis in allogeneic stem cell transplant recipients and patients with acute myeloid leukaemia undergoing aggressive anticancer therapy. Well designed, prospective randomised studies on infection control measures effective to prevent aspergillosis are lacking. Prophylactic systemic antifungal treatment with posaconazole significantly improves survival and reduces IA in acute myeloid leukaemia patients and reduces aspergillosis incidence rates in patients with intermediate-to-severe graft-versus-host reaction emerging after allogeneic haematopoietic stem cell transplantation. Voriconazole prophylaxis may be suitable for prevention of IA as well; however, the results of large clinical trials are still awaited.
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Affiliation(s)
- Georg Maschmeyer
- Department of Internal Medicine, Hematology and Oncology, Klinikum Ernst von Bergmann, Potsdam, Germany.
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29
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Gil L, Styczynski J, Komarnicki M. Infectious complication in 314 patients after high-dose therapy and autologous hematopoietic stem cell transplantation: risk factors analysis and outcome. Infection 2007; 35:421-7. [PMID: 17926001 DOI: 10.1007/s15010-007-6350-2] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2006] [Accepted: 06/27/2007] [Indexed: 01/01/2023]
Abstract
BACKGROUND Infectious complications occur in most of the patients receiving high-dose therapy (HDT) and autologous hematopoietic stem cell transplantation (HSCT). The objective of the study was to analyze of the type and incidence of infectious complications during neutropenia after HDT and autologous HSCT with respect to risk factors related to stem cell transplant setting in patients treated for hematological malignancies in a single center. PATIENTS AND METHODS A total number of 314 patients diagnosed for Hodgkin's disease (HD), non-Hodgkin's lymphoma (NHL), acute myeloid leukemia (AML), multiple myeloma (MM) or acute lymphoblastic leukemia (ALL) were included in the study. Analysis of risk factors and outcome of infections after HDT and autologous HSCT was performed. RESULTS Infectious complications during neutropenia after HDT occurred in 92.3% patients. Microbiologically documented infections (MDI) accounted for 38.9% of febrile episodes, clinically documented infections (CDI) for 9.3%, and fever of unknown origin (FUO) for 51.7% cases. Median time to defervescence with antibiotic therapy was seven days for FUO and nine days for documented infections (p < 0.001). Duration of infection correlated with the length of very severe neutropenia (p < 0.001). Response to first-line antibiotic therapy was seen in 34% patients. Infections were fatal in 12 (3.8%) patients. The highest probability of infection was observed for ALL and AML patients, especially these conditioned with total body irradiation (TBI). CONCLUSION Patients at high risk of infection after autologous HSCT were identified as those with acute leukemia and those after conditioning with TBI, all with prolonged neutropenia. We suggest that newer prophylactic strategies should be administered to these groups of patients.
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Affiliation(s)
- L Gil
- Department of Hematology, University of Medical Sciences, ul. Szamarzewskiego 84, 60-569, Poznan, Poland.
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30
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Rolston KVI, Bodey GP, Safdar A. Polymicrobial Infection in Patients with Cancer: An Underappreciated and Underreported Entity. Clin Infect Dis 2007; 45:228-33. [PMID: 17578784 DOI: 10.1086/518873] [Citation(s) in RCA: 113] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2007] [Accepted: 03/24/2007] [Indexed: 12/30/2022] Open
Abstract
Polymicrobial infections account for ~15% of infections in immunocompromised patients with cancer. However, limited information exists regarding the spectrum and microbiology of these infections, even in severely neutropenic patients. Most studies describe only monomicrobial bloodstream infections in detail, and information regarding polymicrobial infections and nonbacteremic infections is often incomplete or not provided at all. The current lack of well-established definitions for various infections in the immunocompromised host, including pneumonia, neutropenic enterocolitis, and polymicrobial infections, probably plays an important role in the paucity of published information. In this review, we briefly describe the limited information available regarding polymicrobial infections in patients with cancer and address the need for establishing consensus definitions for site-specific polymicrobial infections in neutropenic and nonneutropenic patients. We anticipate that, as factual information regarding such infections becomes available, a more comprehensive understanding of the true scope and impact of these infections will emerge, leading to appropriate modifications in the diagnostic work-up and in the therapeutic approaches used in treating these patients.
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Affiliation(s)
- Kenneth V I Rolston
- The University of Texas, M. D. Anderson Cancer Center, Houston, TX 77030, USA
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31
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Aksoy DY, Tanriover MD, Uzun O, Zarakolu P, Ercis S, Ergüven S, Oto A, Kerimoglu U, Hayran M, Abbasoglu O. Diarrhea in neutropenic patients: a prospective cohort study with emphasis on neutropenic enterocolitis. Ann Oncol 2006; 18:183-189. [PMID: 17023562 DOI: 10.1093/annonc/mdl337] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Although diarrhea is a frequent complication in neutropenic patients, its true incidence, risk factors and clinical course have not been investigated prospectively. PATIENTS AND METHODS The study was carried out at Hacettepe University Hospital for Adults and involved patients over 16 years of age. Patients with malignant diseases who were neutropenic on admission or who became neutropenic during their stay in the wards between January 2001 and February 2003 were included. They were monitored daily until discharge, exitus, or recovery from neutropenia-whichever occurred earlier-to monitor the presence of diarrhea and other infections. RESULTS A total of 317 neutropenic episodes in 215 patients were followed. Diarrhea was observed in 18.6% episodes, and the incidence of NEC was 3.5%. The etiology in 27% episodes of diarrhea could not be identified. The use of anthracyclines and mitoxantrone increased the incidence of diarrhea. Prior use of penicillin derivatives plus beta-lactam inhibitors and N-imidazoline derivatives was associated with decreased incidence of diarrhea. CONCLUSIONS Diarrhea is a common complication in neutropenic patients. Not only specific conditions like NEC, but also nonspecific diseases like parasitosis may be the cause of diarrhea in this patient population.
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Affiliation(s)
| | | | - O Uzun
- Section of Infectious Diseases, Department of Medicine
| | - P Zarakolu
- Section of Infectious Diseases, Department of Medicine
| | - S Ercis
- Department of Microbiology and Clinical Microbiology, Faculty of Medicine, Hacettepe University, Sihhiye, Ankara 06100, Turkey
| | - S Ergüven
- Department of Microbiology and Clinical Microbiology, Faculty of Medicine, Hacettepe University, Sihhiye, Ankara 06100, Turkey
| | - A Oto
- Department of Radiology, University of Texas, Medical Branch at Galveston, Galveston, Texas
| | | | - M Hayran
- Department of Preventive Oncology, Institute of Oncology
| | - O Abbasoglu
- Department of General Surgery, Faculty of Medicine, Hacettepe University, Sihhiye, Ankara 06100, Turkey
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32
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Tuma R, Almyroudis N, Sohn S, Panageas K, Rice R, Galinkin D, Blain M, Montefusco M, Pamer E, Nimer S, Kewalramani T. The serum IL-12:IL-6 ratio reliably distinguishes infectious from non-infectious causes of fever during autologous stem cell transplantation. Cytotherapy 2006; 8:327-34. [PMID: 16923608 DOI: 10.1080/14653240600845237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Fever during neutropenia and after neutrophil engraftment (post-engraftment fever) occurs commonly during autologous transplantation (ASCT), but infections are infrequently identified. Tests that reliably exclude infection may reduce the cost and toxicity of unnecessary diagnostic testing and empiric treatment. We assessed whether serum levels of inflammatory cytokines could distinguish infectious from non-infectious causes of fever in patients undergoing ASCT. METHODS Serum levels of IL-1beta, IL-2, IL-6, IL-8, IL-10, IL-12(p70), TNF-alpha and IFN-gamma were measured by sandwich ELISA at multiple pre-determined times and at the onset of the first fever during neutropenia and after neutrophil engraftment in patients with hematologic malignancies undergoing ASCT. Standard clinical criteria were used to assess for the presence of infection. RESULTS Seventy-two febrile episodes occurred in 54 of 65 enrolled patients; 29 (40%) of the episodes occurred after neutrophil engraftment. Infections were identified as the cause of 28% and 24% of the neutropenic and post-engraftment febrile episodes, respectively. The level of IL-12 decreased and that of IL-6 increased significantly during fever because of infection, such that the IL-12:IL-6 ratio accurately excluded infection. The area under the ROC curve for the IL-12:IL-6 ratio was 0.88 (95% CI 0.79-0.97). The sensitivity, specificity, positive predictive and negative predictive values associated with a cut-off ratio of 4.1 were 95%, 75%, 60%, and 97%, respectively. DISCUSSION The IL-12:IL-6 ratio effectively discriminates infectious from non-infectious causes of fever during ASCT. It may be useful in assessing the probability of infection in patients with post-engraftment fever.
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Affiliation(s)
- Ra Tuma
- Infectious Disease Service, Memorial Sloan-Kettering Cancer Center, New York, New York 10121, USA
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33
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Cancelas JA, Jansen M, Williams DA. The role of chemokine activation of Rac GTPases in hematopoietic stem cell marrow homing, retention, and peripheral mobilization. Exp Hematol 2006; 34:976-85. [PMID: 16863904 DOI: 10.1016/j.exphem.2006.03.016] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2006] [Indexed: 01/13/2023]
Abstract
Signaling downstream from the chemokine receptor CXCR4, the tyrosine kinase receptor c-kit and beta1-integrins has been shown to be crucial in the regulation of migration, homing, and engraftment of hematopoietic stem cells and progenitors. Each of these receptors signal through Rac-type Rho guanosine triphosphatases (GTPases). Rac GTPases play a major role in the organization of the actin cytoskeleton and also in the control of gene expression and the activation of proliferation and survival pathways. Here we review the specific roles of the members of the Rac subfamily of the Rho GTPase family in regulating the intracellular signaling of hematopoietic cells responsible for regulation of homing, marrow retention, and peripheral mobilization.
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Affiliation(s)
- Jose A Cancelas
- Division of Experimental Hematology, Cincinnati Children's Research Foundation, Cincinnati, Ohio 45215, USA
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34
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Sandherr M, Einsele H, Hebart H, Kahl C, Kern W, Kiehl M, Massenkeil G, Penack O, Schiel X, Schuettrumpf S, Ullmann AJ, Cornely OA. Antiviral prophylaxis in patients with haematological malignancies and solid tumours: Guidelines of the Infectious Diseases Working Party (AGIHO) of the German Society for Hematology and Oncology (DGHO). Ann Oncol 2006; 17:1051-9. [PMID: 16410361 DOI: 10.1093/annonc/mdj132] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Morbidity and mortality in patients with malignancies are increased by viral infections. These mostly are reactivations of asymptomatic latent infections. They primarily concern clinical entities associated with the reactivation of herpes viruses, such as varicella zoster virus (VZV) and cytomegalovirus (CMV). Respiratory tract infections caused by influenza, parainfluenza or respiratory syncytial virus (RSV) are less common. Since reactivation of latent infections has major clinical impact, antiviral prophylaxis is an attractive approach for patients expecting immunosuppression. The main risk factor for clinically relevant reactivation is profound disruption of cellular immune response. Duration and severity of chemotherapy induced neutropenia are of lesser importance. The risk of viral complications rises significantly in the presence of sustained suppression of T-cell function, e.g. in recipients of allogeneic stem cell transplants or of alemtuzumab (Campath-1H) antibody therapy. The objective of this guideline is to review the basis of prophylactic strategies and to provide recommendations for clinicians treating patients with haematological malignancies and solid tumors.
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Affiliation(s)
- M Sandherr
- Medizinische Klinik, Klinikum Augsburg, Germany.
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35
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Frère P, Pereira M, Fillet G, Beguin Y. Infections after CD34-selected or unmanipulated autologous hematopoietic stem cell transplantation. Eur J Haematol 2006; 76:102-8. [PMID: 16405430 DOI: 10.1111/j.1600-0609.2005.00569.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Immune reconstitution may be delayed after CD34-selected compared with unmanipulated autologous peripheral blood stem cell transplantation (PBSCT), resulting in a theoretically increased risk of infections. In a case-control matched study we compared the incidence of infection in 25 recipients of CD34-selected PBSC (CD34 group) and 75 recipients of unmanipulated PBSC (PBSC group) transplants. The population included 52 males and 48 females suffering from non-Hodgkin's lymphoma (n = 32), Hodgkin's disease (n = 8), multiple myeloma (n = 40) or breast cancer (n = 20). Neutrophil engraftment was comparable in the two groups. The actuarial incidence of infection was similar in the two groups (56% vs. 49% at day 30, and 70% vs. 64% at 1 yr respectively). The proportion of patients with 1, 2 or 3 infections, the number of infectious event per patient (1.32 vs. 1.04; NS), the number of infections before day 15 or 30, between days 31 and 100 or after day 100, the risk of varicella-zoster virus or cytomegalovirus infection or disease, or the use of antibiotic or antifungal therapy, were not increased in the CD34 compared with the PBSC group. The main agents responsible for infection were bacteria, particularly gram-positive cocci, in both groups. Bacteremia accounted for 33% of all infectious events in the CD34 group vs. 16% in the PBSC group (P < 0.05). Fungal infections were rare. In conclusion, our results do not support the notion that CD34-selection of the graft is associated with an increased rate of infection after autologous PBSC transplantation. The role of extended infection prophylaxis should be evaluated.
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Affiliation(s)
- Pascale Frère
- Division of Hematology, Department of Medicine, University of Liège, Liège, Belgium
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36
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George B, Mathews V, Viswabandya A, Srivastava A, Chandy M. Infections in children undergoing allogeneic bone marrow transplantation in India. Pediatr Transplant 2006; 10:48-54. [PMID: 16499587 DOI: 10.1111/j.1399-3046.2005.00397.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
We studied the clinical profile of infections among 221 pediatric patients who underwent 230 allogeneic transplants between 1986 and June 2004. All patients developed febrile neutropenia. There were 283 documented infections, which included bacterial (36.9%), viral (45.7%), fungal (11.1%) and other infections (6.3%) including tuberculosis. Bacterial and fungal infections were more common in the first 30 days following BMT, while viral infections were more common >30 days after BMT. Bacterial pathogens were predominantly gram-negative organisms (72.7%), when compared with gram-positive organisms (27.3%). Common gram-negative organisms included NFGNB, Pseudomonas, Escherichia coli and Klebsiella while coagulase negative Staphylococci was the main gram-positive organism. Bacteremia (61.2%) was the main source positive cultures and was mainly because of gram-negative organisms (81%), predominantly NFGNB and Pseudomonas. Exactly 103/221(43.7%) transplants had 128 documented viral infections commonly because of Cytomegalovirus, Herpes group of viruses and transfusion related hepatitis. Thirty of 221 (13.5%) of transplants had 30 documented fungal infections with the majority being because of aspergillus (90%). Tuberculosis was seen in 1.7% of transplants while catheter infections were seen in 21 patients (9.1%). Infection related mortality was seen in 12% predominantly because of CMV or fungal infections. A sub group analysis (pre-1998 vs. post-1998) revealed higher incidences of gram-negative infections, bacteremia and bacterial infection related mortality in the pre-1998 era when compared with the recent times. The profile and mortality of infections in this series from India is not significantly different from reports from the West.
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Affiliation(s)
- Biju George
- Department of Haematology, Christian Medical College, Vellore, Tamil Nadu, India.
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Koo DH, Ko OB, Kim S, Lee DH, Kim SW, Suh C. Prospective Randomized Comparative Observations of Infectious Complications with or without Antimicrobial Prophylaxis, during Autologous Stem Cell Transplantation. THE KOREAN JOURNAL OF HEMATOLOGY 2006. [DOI: 10.5045/kjh.2006.41.4.282] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Dong Hoe Koo
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ock Bae Ko
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Shin Kim
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dae Ho Lee
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang We Kim
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Cheolwon Suh
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Reich G, Cornely OA, Sandherr M, Kubin T, Krause S, Einsele H, Thiel E, Bellaire T, Dörken B, Maschmeyer G. Empirical antimicrobial monotherapy in patients after high-dose chemotherapy and autologous stem cell transplantation: a randomised, multicentre trial. Br J Haematol 2005; 130:265-70. [PMID: 16029455 DOI: 10.1111/j.1365-2141.2005.05608.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
We report on 232 patients undergoing autologous haematopoietic stem cell transplantation (ASCT) entered into a multicentre, randomised trial comparing the efficacy and tolerability of meropenem (MPM) with that of piperacillin/tazobactam (P/T) as empirical antimicrobial first-line therapy for febrile neutropenia. In 27.6% of patients in the MPM group and 22.4% in the P/T group, therapy was initially supplemented with a glycopeptide for venous catheter infection or bacteraemia because of coagulase-negative staphylococci. Complete response rate after 72 h was 63.8% in the MPM group and 49.6% in the P/T group (P = 0.034). Overall complete response rate after treatment modification was 94.0% in the MPM group and 93.1% in the P/T group. Median time to defervescence was 2 d in the MPM group and 3 d in the P/T group. The most frequently isolated pathogens were Gram-positive cocci. Treatment was well tolerated in both groups. One patient (0.4%) died from infection. Empirical first-line therapy with MPM as well as with P/T is safe and effective in febrile episodes emerging after ASCT. Higher response rates to primary treatment can be achieved with MPM.
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Affiliation(s)
- Gernot Reich
- Department of Haematology, Oncology and Tumour Immunology, Charité University Hospital, Campus Buch, Lindenberger Weg, Berlin, Germany.
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Gorschlüter M, Mey U, Strehl J, Ziske C, Schepke M, Schmidt-Wolf IGH, Sauerbruch T, Glasmacher A. Neutropenic enterocolitis in adults: systematic analysis of evidence quality. Eur J Haematol 2005; 75:1-13. [PMID: 15946304 DOI: 10.1111/j.1600-0609.2005.00442.x] [Citation(s) in RCA: 162] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Neutropenic enterocolitis is a life-threatening complication occurring most frequently after intensive chemotherapy in acute leukaemias. The literature is heterogeneous and a systematic review is lacking. METHODS Following a systematic search we categorised all relevant reports according to their quality and extracted evidence to answer the questions: Which diagnostic criteria are appropriate? What is the incidence of neutropenic enterocolitis? Are there good quality studies supporting specific interventions: Which empiric antimicrobial therapy is recommendable? Is neutropenic enterocolitis without surgical emergency complications an indication for bowel resection? RESULTS We found and analysed 145 articles of these reports: 64 were reports of single cases, 30 papers reported of two or three cases, 13 were narrative reviews, 34 were retrospective case series of more than three cases and four were prospective diagnostic studies. There were no prospective trials or case control studies on the therapy of neutropenic enterocolitis. There was no consensus on diagnostic criteria. We discuss the difficulty to define diagnostic criteria without having a disease definition. Histology is mostly not available in the living patients. We suggest applying a combination of clinical and radiological criteria: fever, abdominal pain and any bowel wall thickening >4 mm detected by ultrasonography (US) or computed tomography. We calculated a pooled incidence rate from 21 studies of 5.3% (266/5058; 95% CI: 4.7%-5.9%) in patients hospitalised for haematological malignancies, for high-dose chemotherapy in solid tumours or for aplastic anaemia. CONCLUSIONS This systematic review provides diagnostic criteria for neutropenic enterocolitis, presents a quantitative synthesis on its incidence and discusses its treatment recommendations. Prospective studies are clearly warranted.
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Affiliation(s)
- Marcus Gorschlüter
- Department of Internal Medicine I, University of Bonn, Sigmund-Freud-Strasse 25, 53105 Bonn, Germany.
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Kern WV, Klose K, Jellen-Ritter AS, Oethinger M, Bohnert J, Kern P, Reuter S, von Baum H, Marre R. Fluoroquinolone resistance of Escherichia coli at a cancer center: epidemiologic evolution and effects of discontinuing prophylactic fluoroquinolone use in neutropenic patients with leukemia. Eur J Clin Microbiol Infect Dis 2005; 24:111-8. [PMID: 15714332 DOI: 10.1007/s10096-005-1278-x] [Citation(s) in RCA: 115] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The aim of the present study was to investigate the epidemiologic evolution of fluoroquinolone resistance of E. coli clinical isolates from patients admitted to a hematology-oncology service where fluoroquinolone prophylaxis during neutropenia was recommended as the standard of care for many years but was then discontinued in a trial conducted in patients with acute leukemia. Fluoroquinolones had been shown to decrease the incidence of gram-negative bacteremia in cancer patients with neutropenia, yet it was thought that the emergence of resistance in Escherichia coli and other gram-negative bacteria may have caused a progressive lack of efficacy of fluoroquinolone prophylaxis. Epidemiologic surveillance of fluoroquinolone resistance of E. coli clinical isolates at our cancer center since 1992 showed a continuing influx of new clones not previously observed in the population of cancer patients, an increase in the number of cancer patients per year colonized and/or infected by fluoroquinolone-resistant E. coli (1992-1994, 10-16 patients; 1995-1997, 24-27 patients), and a resistance rate of >50% among E. coli bloodstream isolates of hematology-oncology patients. A 6-month fluoroquinolone prophylaxis discontinuation intervention trial in 1998 suggested that despite increasing resistance among E. coli isolates, fluoroquinolone prophylaxis in acute leukemia patients was still effective in the prevention of gram-negative bacteremia (incidence rates, 8% during the pre-intervention period vs. 20% after discontinuation; p<0.01). The resumption of fluoroquinolone prophylaxis in acute leukemia patients thereafter decreased the incidence of gram-negative bacteremia to the pre-intervention level (9%; p=0.03), while the proportion of in vitro fluoroquinolone resistance in E. coli bacteremia isolates again increased (from 15% during the intervention period to >50% in the post-intervention period). Relative rates of resistance thus were a poor indicator of the potential clinical benefits associated with fluoroquinolone prophylaxis in cancer patients.
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Affiliation(s)
- W V Kern
- Center for Infectious Diseases and Travel Medicine, Department of Medicine, University Hospital, Hugstetter Strasse 55, 79106 Freiburg, Germany.
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Machatschek J, Duda J, Matthay K, Cowan M, Horn B. Immune reconstitution, infectious complications and post transplant supportive care measures after autologous blood and marrow transplantation in children. Bone Marrow Transplant 2003; 32:687-93. [PMID: 13130316 DOI: 10.1038/sj.bmt.1704196] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
We retrospectively analyzed data on T- and B-cell reconstitution and infectious complications in 58 children undergoing ABMT, in order to evaluate post-transplant supportive care measures used during the study period. Normalization of T-cell number and lymphocyte proliferative responses to phytohemagglutinin (PHA) and alloantigen (MLC) occurred in two-thirds of children by 6 months post transplant. Normal IgM levels developed in 75% of children by 6 months post transplant. A total of 34 children (59%) developed 39 episodes of infection between neutrophil engraftment and 1 year post transplant. The most common infections included bacteremia, varicella-zoster virus infection and pneumonia, which represented 46, 23 and 9% of infections, respectively. All patients with bacteremia had a central venous catheter in place at the time of infection. Most infections (77%) developed by 6 months post transplant. In this small patient cohort, time to normalization of tests of T- and B-cell function was not significantly different between patients with and without infection. Earlier removal of an indwelling central venous catheter may decrease the risk of bacteremia post transplant. Post-transplant supportive care measures may be discontinued at 6 months post ABMT in most children, as the risk of infection decreases after that time.
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Fujii K, Aoyama M, Shinagawa K, Matsuo K, Takenaka K, Ikeda K, Kojima K, Ishimaru F, Kiura K, Ueoka H, Niiya K, Tanimoto M, Harada M. Risk of neutropenic fever and early infectious complications after autologous peripheral blood stem cell transplantation for malignant diseases. Int J Hematol 2002; 76:186-91. [PMID: 12215019 DOI: 10.1007/bf02982583] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Autologous peripheral blood stem cell transplantation (auto-PBSCT) has facilitated high-dose chemotherapy for the treatment of various types of malignancy, but the factors affecting the treatment outcome have not been well defined. We evaluated patients who underwent auto-PBSCT (46 patients with hematological malignancies and 39 with solid tumors) to elucidate the risks of background factors, including age, in association with infectious complications. In contrast to former reports, faster engraftment did not influence the incidence of documented infection or neutropenic fever, whereas high age (age > or = 50 years old) and delayed platelet recovery (> or = 18 days) were demonstrated to be positively involved. The odds ratio (OR) for documented infection in elderly patients was 4.94 (95% confidence interval, 1.22-15.8). Another risk factor of infection was the HD-ICE regimen (ifosfamide, carboplatin, etoposide) given to patients with solid tumors (OR, 8.00; 95% confidence interval, 1.61-39.7). In conclusion, we found that elderly patients and patients on the HD-ICE regimen have a higher risk of infectious complications even after auto-PBSCT. Although the clinical indications for auto-PBSCT can be extended to elderly patients, thorough precautions should be taken against infectious complications during the pre-engraftment phase.
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Affiliation(s)
- Keiko Fujii
- Second Department of Internal Medicine, Okayama University Medical School, Japan
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Stoiser B, Kofler J, Staudinger T, Georgopoulos A, Lugauer S, Guggenbichler JP, Burgmann H, Frass M. Contamination of central venous catheters in immunocompromised patients: a comparison between two different types of central venous catheters. J Hosp Infect 2002; 50:202-6. [PMID: 11886196 DOI: 10.1053/jhin.2001.1095] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Catheters impregnated with silver have been proposed as a means of reducing catheter-related infection. We therefore performed a prospective randomized study to compare a new silver-impregnated central venous catheter (CVC) with a commercially available CVC in a cohort of immunocompromised patients. We studied 157 patients of whom 97 could be analysed. The median indwelling time in the study group (SC) was 10.5 days and 11 days in the control group (CC). The incidence of contamination in the SC group was 15.6 vs 24.6 in the CC group referring to 1000 catheter days. In both groups, we found 6% of catheter-related infections according to the definitions of a published scoring system. The differences between the two groups were not significant. We conclude that the SC decrease the incidence of catheter contamination and may have a positive effect on the reduction of CVC-related infections.
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Affiliation(s)
- B Stoiser
- Department of Internal Medicine I (Division of Infectious Diseases and Chemotherapy), University of Vienna, Austria.
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Toor AA, van Burik JA, Weisdorf DJ. Infections during mobilizing chemotherapy and following autologous stem cell transplantation. Bone Marrow Transplant 2001; 28:1129-34. [PMID: 11803354 DOI: 10.1038/sj.bmt.1703307] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2000] [Accepted: 05/28/2001] [Indexed: 11/10/2022]
Abstract
Autologous peripheral blood stem cells (PBSC), for transplantation following high-dose chemotherapy, are collected using regimens containing cytokines with or without chemotherapy. The added period of neutropenia prior to stem cell transplantation (SCT) in patients receiving chemotherapy mobilization may increase the risk of infections following transplantation. We studied the incidence of culture-positive infections in 107 consecutive patients who were divided into three groups, according to whether they experienced extended neutropenia during chemotherapy for stem cell mobilization as well as post autotransplant. All the patients received antibiotic prophylaxis and hematopoietic growth factors during neutropenia. The total duration of pre-transplant neutropenia differed among the three mobilization schemes (growth factors alone; one cycle; or two cycles of chemotherapy plus growth factor for mobilization) at 0, 6 and 18 days, respectively (median). However the post-autograft time to myeloid engraftment was similar at 10 days (median). The incidence of culture-proven infections in all three groups was similar. Using fluconazole for yeast prophylaxis, 40% patients developed gastrointestinal colonization with yeast, and the majority of speciated isolates were Candida glabrata. Bacteremia developed in 22% and 9% of patients with S. epidermidis and Gram-negative organisms, respectively, while 11% developed C. difficile-associated diarrhea. In conclusion, treatment using none, one or two cycles of mobilizing chemotherapy pre-transplant does not influence the overall incidence of infections among autologous SCT recipients. However, although post-transplant neutropenia is brief, infections remain a significant cause of morbidity.
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Affiliation(s)
- A A Toor
- Blood and Marrow Transplant Program, Department of Medicine, University of Minnesota, 420 Delaware Street SE, Minneapolis, MN 55455, USA
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45
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Razonable RR, Patel R, Wilhelm MP, Gertz MA, Litzow MR, Inwards DJ, Dearani JA, Edwards BS, McGregor CG. Fatal disseminated aspergillosis following sequential heart and stem cell transplantation for systemic amyloidosis. Am J Transplant 2001; 1:93-5. [PMID: 12095046 DOI: 10.1034/j.1600-6143.2001.010117.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Infectious complications are a major cause of morbidity and mortality in transplant recipients. We describe a case of fatal disseminated aspergillosis immediately following autologous peripheral stem cell reconstitution in a patient who had undergone orthotopic heart transplantation for systemic amyloidosis. The case described suggests that the infectious risks in patients undergoing these sequential procedures may be distinct from those occurring in patients undergoing either procedure independently. Potential prophylactic and therapeutic interventions are discussed. Since this experimental and evolving approach for the management of systemic amyloidosis is potentially applicable to a limited number of patients, multicenter collaboration may be needed to further define the infectious risks in this unique subset of transplant recipients.
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Affiliation(s)
- R R Razonable
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN 55905, USA
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Abstract
The last decade has been remarkable for the dramatic increase in the prevalence of serious fungal infections in patients with haematological disorders and neutropenic cancer patients. The mortality rate of deep-seated infection has been in excess of 90% and there is no doubt that this is one of the greatest challenges currently facing haematologists and oncologists. The development of the lipid-based drugs - liposomal amphotericin (AmBisome(R)), amphotericin B lipid complex, ABLC (Abelcet(R)), amphotericin B colloidal dispersion, Amphocil (ABCD(R)), has meant that doses of amphotericin B can be safely escalated for the first time whilst the problems of nephrotoxicity, infusion related reactions (including chills, rigors, fevers and hypoxia) can be reduced. These toxicities are variably reduced with AmBisome more than Abelcet and more than Amphocil and there is little information from randomised trials other than for AmBisome. AmBisome used in the setting of persistent fever and neutropenia not responding after 3-4 days of intravenous antibiotics, is associated with less breakthrough systemic fungal infections. There is also much less need for premedication, including steroids, compared with amphotericin B and Abelcet. The use of intermittent doses of Ambisome given prophylactically is now being explored. A new and exciting era of antifungal therapy is opening up with new compounds, such as itraconazole voriconazole, posaconazole and echinocandins, being investigated and for the first time, we also have options for combination therapy and prophylaxis.
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Affiliation(s)
- I M Hann
- Department of Haematology, Camelia Botnar Laboratories, Level II, Great Ormond Street Children's Hospital, London WC1N 3JH, UK.
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47
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Reich G, Mapara MY, Reichardt P, Dörken B, Maschmeyer G. Infectious complications after high-dose chemotherapy and autologous stem cell transplantation: comparison between patients with lymphoma or multiple myeloma and patients with solid tumors. Bone Marrow Transplant 2001; 27:525-9. [PMID: 11313687 DOI: 10.1038/sj.bmt.1702822] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2000] [Accepted: 12/14/2000] [Indexed: 11/09/2022]
Abstract
From November 1994 to May 1998, 117 patients (66 with solid tumor, 36 with lymphoma, 14 with multiple myeloma, one with acute leukemia) underwent 178 cycles of high-dose chemotherapy and autologous stem cell transplantation (ASCT) at our institution. We retrospectively analyzed the infectious complications that occurred after ASCT. Median duration of neutropenia (granulocyte count <0.5 x 10(9)/l ) was 8 days, the overall incidence of fever requiring antimicrobial treatment was 63%. 35.4% of patients had fever of unknown orign (FUO), whereas primary bacteremia occurred in 21.3%, pneumonia in 3.4% and severe skin infection in 1.1% of patients. Invasive fungal infections occurred in three, and enterocolitis in one patient. Infection was fatal in three patients (2.6%), in each case due to septic shock. The most frequently isolated pathogens were Gram-positive cocci. Median time to defervescence with antimicrobial therapy was 4 days (6 days in patients with bacteremia or other severe infection, and 3 days in patients with FUO). First-line antimicrobial therapy was successful in 65% of patients with FUO and 30.6% of patients with documented infections. With respect to the incidence, type and clinical course of infection, no significant differences between patients with lymphoma or multiple myeloma and those with solid tumors were detected.
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Affiliation(s)
- G Reich
- Charité University Hospital, Campus Berlin-Buch, Robert-Rössle-Klinik, Department of Hematology, Oncology and Tumor Immunology, Humboldt University of Berlin, 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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Prentice HG, Kibbler CC, Prentice AG. Towards a targeted, risk-based, antifungal strategy in neutropenic patients. Br J Haematol 2000; 110:273-84. [PMID: 10971382 DOI: 10.1046/j.1365-2141.2000.02014.x] [Citation(s) in RCA: 139] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- H G Prentice
- Department of Haematology, Royal Free and University College Medical School, Royal Free Campus and Hospital, London, UK.
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50
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Toh HC, McAfee SL, Sackstein R, Multani P, Cox BF, Garcia-Carbonero R, Colby C, Spitzer TR. High-dose cyclophosphamide + carboplatin and interleukin-2 (IL-2) activated autologous stem cell transplantation followed by maintenance IL-2 therapy in metastatic breast carcinoma - a phase II study. Bone Marrow Transplant 2000; 25:19-24. [PMID: 10654009 DOI: 10.1038/sj.bmt.1702091] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
While high-dose chemotherapy and stem cell transplantation is associated with higher complete response rates than conventional chemotherapy in patients with metastatic breast cancer (MBC), its role in conferring a survival advantage is unproven. We report the results of a prospective phase II trial of 33 patients accrued between 1996 to 1998 with chemosensitive MBC, who received cyclophosphamide (Cy) 2000 mg/m2/day and carboplatin (Cb) 600 mg/m2/day for 3 consecutive days, followed by infusion of peripheral blood stem cells cultured in IL-2 for 24 h on day 0 as adoptive immunotherapy. Low-dose interleukin-2 (IL-2) was administered from day 0 to +4 and/or +7 to +11, +14 to +18, +21 to +25, then 5 days per month for 11 months to augment a graft-versus-tumor effect. The results of this study were compared to those of a historical control group treated with an identical high-dose Cb + Cy regimen with SCT but without IL-2 treatment. Only gastrointestinal (GI) toxicity was more frequent in the IL-2 cohort (P = 0.0031). At a median follow-up of 18.6 months, the median progression-free survival (PFS) is 9 months (2.4-40) and the median OS has not been reached yet. The Kaplan-Meier estimated 2 year PFS is 35%, compared with 17% in the control arm (P = 0.73), and the estimated 2 year OS is 78%, compared with 61% in the control arm (P = 0.22). Multivariate analysis showed that ER status was an independent predictor for OS and PFS, and less chemotherapy prior to HDCSCT predicted for a better PFS. These results show that augmenting HDC with IL-2 activated SCT is well-tolerated. Whether a therapeutic advantage is achievable in patients with MBC remains to be determined. Bone Marrow Transplantation (2000) 25, 19-24.
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Affiliation(s)
- H C Toh
- Bone Marrow Transplant Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
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