Protected environments and prophylactic antibiotics. A prospective controlled study of their utility in the therapy of acute leukemia

Space disinfection using TiO2 photocatalyst reduces the incidence of febrile neutropenia in cancer patients

Febrile neutropenia (FN) is life-threatening condition, and airborne microorganisms have been identified as one of the potential transmission routes. The objective of this study was to evaluate spatial sterilization using photocatalytic oxidative decomposition reactions which are effective to prevent FN. An air purifier equipped with a platinum-added titanium dioxide photocatalytic and LED light source (LED-TiO2 device) was installed in hospital rooms (per 21.5-35 m3) to investigate changes in FN incidence and airborne microorganism counts. Airborne microorganisms in the hospital rooms matched those responsible for nosocomial infections. The incidence of FN was significantly reduced after installation of the LED-TiO2 device [9/13 vs. 2/12, P-value (P) = 0.015]. The LED-TiO2 device decreased the number of airborne microorganisms in patient-free rooms by approximately 75% after 2 h [P < 0.001]. When patient was in the room, the number of airborne microorganisms increased with medical procedure. However, after 20 min of procedure, the number of airborne microorganisms was approximately 50% lower than without the device room [P = 0.019]. The LED-TiO2 device successfully achieved spatial disinfection of hospital rooms, and reduced the incidence of FN. Spatial disinfection using photocatalysts is considered an effective new infection prevention measure for patients with severe neutropenia undergoing cancer treatment.

[Invasive mechanical ventilation in patients with solid tumor or hematological malignancy]

Invasive mechanical ventilation in onco-hematology patients has become relatively routine, and is now part and parcel of their care pathway. Nevertheless, specific complications and subsequent therapeutic possibilities require discussion. To a greater extent than with regard to other patient populations, cooperation between specialist and ICU physician is mandatory, the objective being to more comprehensively assess a therapeutic project before or during the period of invasive mechanical ventilation. After an overview of recent results concerning ventilated patients in intensive care, this review aims to describe the specific complications and factors associated with mortality in this population.

Fungal infections in hematopoietic stem-cell transplant patients: a review of epidemiology, diagnosis, and management

The advent of bone marrow transplant has opened doors to a different approach and offered a new treatment modality for various hematopoietic stem-cell-related disorders. Since the first bone marrow transplant in 1957, there has been significant progress in managing patients who undergo bone marrow transplants. Plasma-cell disorders, lymphoproliferative disorders, and myelodysplastic syndrome are the most common indications for hematopoietic stem-cell transplant. Despite the advances, invasive fungal infections remain a significant cause of morbidity and mortality in this high-risk population. The overall incidence of invasive fungal infection in patients with hematopoietic stem-cell transplant is around 4%, but the mortality in patients with allogeneic stem-cell transplant is as high as 13% in one study. Type of stem-cell transplant, conditioning regimen, and development of graft-versus-host disease are some of the risk factors that impact the risk and outcomes in patients with invasive fungal infections. Aspergillus and candida remain the two most common organisms causing invasive fungal infections. Molecular diagnostic methods have replaced some traditional methods due to their simplicity of use and rapid turnaround time. Primary prophylaxis has undoubtedly shown to improve outcomes even though breakthrough infection rates remain high. The directed treatment has seen a significant shift from amphotericin B to itraconazole, voriconazole, and echinocandins, which have shown better efficacy and fewer adverse effects. In this comprehensive review, we aim to detail epidemiology, risk factors, diagnosis, and management, including prophylaxis, empiric and directed management of invasive fungal infections in patients with hematopoietic stem-cell transplant.

Rethinking Antimicrobial Prophylaxis in the Transplant Patient in the World of Emerging Resistant Organisms-Where Are We Today?

PURPOSE OF REVIEW

The use of prophylactic antibiotics during the neutropenic period in hematopoietic stem cell transplantation has been the standard of care at most institutions for the past 20 years. We sought to review the benefits and risks of this practice.

RECENT FINDINGS

Emerging data has highlighted the potential costs of antibacterial prophylaxis, from selecting for antibiotic resistance to perturbing the microbiome and contributing to increase risk for Clostridium difficile and perhaps graft-versus-host-disease, conditions which may lead to poorer outcomes. Though in many studies prophylactic antibiotics improved morbidity and mortality outcomes, the potential harms including antibiotic resistance, Clostridium difficile infection, and alterations of the gut microbiome should be considered. Future studies aimed to better risk-stratify patients and limit the use of broad-spectrum antibiotics are warranted.

Effectiveness of antibacterial prophylaxis in children with acute leukemia: A report from a single institution over a 20-year period

BACKGROUND

Infection is the major cause of treatment-related mortality in childhood acute leukemia, mainly due to bacterial translocation across the intestinal mucosa. Only a few studies have reported the impact of different antibacterial prophylaxis treatments on digestive tract flora and infection-related mortality.

PROCEDURES

We performed a retrospective analysis of two different digestive tract decontamination modalities (selective or total digestive decontamination) in a large single-center series of 323 children during the induction treatment of acute leukemia between January 1995 and December 2014. We examined the impact of antibiotic prophylaxis and food regimen (sterile or selected) on the digestive tract flora during the period of antibacterial prophylaxis, on the frequency of bacteremia, and on antibiotic sensitivity.

RESULTS

Only one Gram-negative (Klebsiella pneumonia) translocation occurred in the SDD group. No infection-related death occurred. Extended-spectrum beta-lactamase (ESBL) bacteria were observed in seven of 170 (4%) patients in the SDD group. The faecal-flora total suppression and faecal-flora Gram-negative bacilli suppression was 67 and 77%, respectively, in the TDD group with sterile food, 0 and 58%, respectively, in the SDD group with sterile food, and 6 and 63%, respectively, in the SDD group with selective food.

CONCLUSIONS

This study gives a rationale not to use antibacterial prophylaxis systematically in children who receive induction treatment for acute leukemia; additionally, antibiotics should only be used in case of stool contamination by highly pathogenic bacteria with a high potential of translocation.

Update on infection control practices in cancer hospitals

Therapies in oncology have evolved rapidly over the last years. At the same pace, supportive care for patients receiving cancer therapy has also evolved, allowing patients to safely receive the newest advances in treatment in both an inpatient and outpatient basis. The recognition of the role of infection control and prevention (ICP) in the outcomes of patients living with cancer has been such that it is now a requirement for hospitals and involves multidisciplinary groups. Some unique aspects of ICP for patients with cancer that have gained momentum over the past few decades include catheter-related infections, multidrug-resistant organisms, community-acquired viral infections, and the impact of the health care environment on the horizontal transmission of organisms. Furthermore, as the potential for infections to cross international borders has increased, alertness for outbreaks or new infections that occur outside the area have become constant. As the future approaches, ICP in immunocompromised hosts will continue to integrate emerging disciplines, such as antibiotic stewardship and the microbiome, and new techniques for environmental cleaning and for controlling the spread of infections, such as whole-genome sequencing. CA Cancer J Clin 2018;000:000-000. © 2018 American Cancer Society.

Management of neutropenic patients in the intensive care unit (NEWBORNS EXCLUDED) recommendations from an expert panel from the French Intensive Care Society (SRLF) with the French Group for Pediatric Intensive Care Emergencies (GFRUP), the French Society of Anesthesia and Intensive Care (SFAR), the French Society of Hematology (SFH), the French Society for Hospital Hygiene (SF2H), and the French Infectious Diseases Society (SPILF)

Neutropenia is defined by either an absolute or functional defect (acute myeloid leukemia or myelodysplastic syndrome) of polymorphonuclear neutrophils and is associated with high risk of specific complications that may require intensive care unit (ICU) admission. Specificities in the management of critically ill neutropenic patients prompted the establishment of guidelines dedicated to intensivists. These recommendations were drawn up by a panel of experts brought together by the French Intensive Care Society in collaboration with the French Group for Pediatric Intensive Care Emergencies, the French Society of Anesthesia and Intensive Care, the French Society of Hematology, the French Society for Hospital Hygiene, and the French Infectious Diseases Society. Literature review and formulation of recommendations were performed using the Grading of Recommendations Assessment, Development and Evaluation system. Each recommendation was then evaluated and rated by each expert using a methodology derived from the RAND/UCLA Appropriateness Method. Six fields are covered by the provided recommendations: (1) ICU admission and prognosis, (2) protective isolation and prophylaxis, (3) management of acute respiratory failure, (4) organ failure and organ support, (5) antibiotic management and source control, and (6) hematological management. Most of the provided recommendations are obtained from low levels of evidence, however, suggesting a need for additional studies. Seven recommendations were, however, associated with high level of evidences and are related to protective isolation, diagnostic workup of acute respiratory failure, medical management, and timing surgery in patients with typhlitis.

Pediatric Bone Marrow Transplantation: Intensive Care Management

Bone marrow transplantation (BMT) has assumed in creasing importance in the treatment of bone marrow failure, hematopoietic malignancies, congenital immuno deficiencies, and solid tumors. Children undergoing BMT are at high risk for infection and hemorrhage dur ing the period of aplasia. In addition, life-threatening complications of circulatory, pulmonary, gastrointesti nal, hepatic, and renal function are common and fre quently require intensive supportive care. This review provides an overview of pediatric BMT that focuses on management problems relevant to intensive care. Thor ough pretransplantation assessment of underlying organ dysfunction is mandatory before undertaking BMT. The complications associated with preconditioning regi mens that use total body irradiation and high doses of ablative chemotherapy are described. Finally, problems involving individual organs are discussed by systems. The challenge of improving the results of BMT in the treatment of childhood malignant and hematopoietic disorders depends, in large part, on successful preven tive measures and good management of complications that occur immediately before and within the first 100 days after transplantation. As BMT is indicated for treat ment of an increasing number of diseases, more patients will require the care of intensivists familiar with trans plantation-related complications.

Failure of the Sterile Air-Flow Component of a Protected Environment Detected by Demonstration of Chaetomium Species Colonization of Four Consecutive Immunosuppressed Occupants

Four bone marrow transplant recipients consecutively occupying the same room on our Oncology-Hematology Special Care Unit (OHSCU) became colonized with Chaetomium species between January and April, 1987. These patients, aged 27 to 43 years, were immunocompromised as a result of intensive chemotherapy, and were consequently at increased risk for development of invasive fungal infection. At the time of Chaetomium colonization, all patients were febrile, two had transient new infiltrates on chest x-ray, and three were receiving amphotericin B therapy. Subsequent environmental cultures revealed Chaetomium contamination of the OHSCU air-handling system, including the HEPA (high-efficiency particulate air) filters in seven of the nine rooms comprising the unit. Because fungal colonization of HEPA filters used to create a “protective environment” for immunocompromised patients can occur and can serve as a source for patient infections, guidelines concerning proper surveillance of these HEPA filters should be established. We suggest that before a new patient enters a “protected” room, the clean side of the HEPA filter should be cultured. If fungi are recovered from that culture, we would recommend changing the filter.

Individuals with hematological malignancies before undergoing chemotherapy present oxidative stress parameters and acute phase proteins correlated with nutritional status

Hematological malignancies present abnormal blood cells that may have altered functions. This study aimed to evaluate nutritional status, acute phase proteins, parameters of cell's functionality, and oxidative stress of patients with hematological malignancies, providing a representation of these variables at diagnosis, comparisons between leukemias and lymphomas and establishing correlations. Nutritional status, C-reactive protein (CRP), albumin, phagocytic capacity and superoxide anion production of mononuclear cells, lipid peroxidation and catalase activity in plasma were evaluated in 16 untreated subjects. Main diagnosis was acute leukemia (n = 9) and median body mass index (BMI) indicated overweight (25.6 kg/m(2)). Median albumin was below (3.2 g/dL) and CRP above (37.45 mg/L) the reference values. Albumin was inversely correlated with BMI (r = -0.53). Most patients were overweight before the beginning of treatment and had a high CRP/albumin ratio, which may indicate a nutrition inflammatory risk. BMI values correlated positively with lipid peroxidation and catalase activity. A strong correlation between catalase activity and lipid peroxidation was found (r = 0.75). Besides the elevated BMI, these patients also have elevated CRP values and unexpected relations between nutritional status and albumin, reinforcing the need for nutritional counseling during the course of chemotherapy, especially considering the correlations between oxidative stress parameters and nutritional status evidenced here.

Sensory environment on health-related outcomes of hospital patients

BACKGROUND

Hospital environments have recently received renewed interest, with considerable investments into building and renovating healthcare estates. Understanding the effectiveness of environmental interventions is important for resource utilisation and providing quality care.

OBJECTIVES

To assess the effect of hospital environments on adult patient health-related outcomes.

SEARCH METHODS

We searched: the Cochrane Central Register of Controlled Trials (last searched January 2006); MEDLINE (1902 to December 2006); EMBASE (January 1980 to February 2006); 14 other databases covering health, psychology, and the built environment; reference lists; and organisation websites. This review is currently being updated (MEDLINE last search October 2010), see Studies awaiting classification.

SELECTION CRITERIA

Randomised and non-randomised controlled trials, controlled before-and-after studies, and interrupted times series of environmental interventions in adult hospital patients reporting health-related outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently undertook data extraction and 'Risk of bias' assessment. We contacted authors to obtain missing information. For continuous variables, we calculated a mean difference (MD) or standardized mean difference (SMD), and 95% confidence intervals (CI) for each study. For dichotomous variables, we calculated a risk ratio (RR) with 95% confidence intervals (95% CI). When appropriate, we used a random-effects model of meta-analysis. Heterogeneity was explored qualitatively and quantitatively based on risk of bias, case mix, hospital visit characteristics, and country of study.

MAIN RESULTS

Overall, 102 studies have been included in this review. Interventions explored were: 'positive distracters', to include aromas (two studies), audiovisual distractions (five studies), decoration (one study), and music (85 studies); interventions to reduce environmental stressors through physical changes, to include air quality (three studies), bedroom type (one study), flooring (two studies), furniture and furnishings (one study), lighting (one study), and temperature (one study); and multifaceted interventions (two studies). We did not find any studies meeting the inclusion criteria to evaluate: art, access to nature for example, through hospital gardens, atriums, flowers, and plants, ceilings, interventions to reduce hospital noise, patient controls, technologies, way-finding aids, or the provision of windows. Overall, it appears that music may improve patient-reported outcomes such as anxiety; however, the benefit for physiological outcomes, and medication consumption has less support. There are few studies to support or refute the implementation of physical changes, and except for air quality, the included studies demonstrated that physical changes to the hospital environment at least did no harm.

AUTHORS' CONCLUSIONS

Music may improve patient-reported outcomes in certain circumstances, so support for this relatively inexpensive intervention may be justified. For some environmental interventions, well designed research studies have yet to take place.

Antibiotic prophylaxis for bacterial infections in afebrile neutropenic patients following chemotherapy

BACKGROUND

Bacterial infections are a major cause of morbidity and mortality in patients who are neutropenic following chemotherapy for malignancy. Trials have shown the efficacy of antibiotic prophylaxis in reducing the incidence of bacterial infections but not in reducing mortality rates. Our systematic review from 2006 also showed a reduction in mortality.

OBJECTIVES

This updated review aimed to evaluate whether there is still a benefit of reduction in mortality when compared to placebo or no intervention.

SEARCH METHODS

We searched the Cochrane Cancer Network Register of Trials (2011), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2011), MEDLINE (1966 to March 2011), EMBASE (1980 to March 2011), abstracts of conference proceedings and the references of identified studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs comparing different types of antibiotic prophylaxis with placebo or no intervention, or another antibiotic, to prevent bacterial infections in afebrile neutropenic patients.

DATA COLLECTION AND ANALYSIS

Two authors independently appraised the quality of each trial and extracted data from the included trials. Analyses were performed using RevMan 5.1 software.

MAIN RESULTS

One-hundred and nine trials (involving 13,579 patients) that were conducted between the years 1973 to 2010 met the inclusion criteria. When compared with placebo or no intervention, antibiotic prophylaxis significantly reduced the risk of death from all causes (46 trials, 5635 participants; risk ratio (RR) 0.66, 95% CI 0.55 to 0.79) and the risk of infection-related death (43 trials, 5777 participants; RR 0.61, 95% CI 0.48 to 0.77). The estimated number needed to treat (NNT) to prevent one death was 34 (all-cause mortality) and 48 (infection-related mortality).Prophylaxis also significantly reduced the occurrence of fever (54 trials, 6658 participants; RR 0.80, 95% CI 0.74 to 0.87), clinically documented infection (48 trials, 5758 participants; RR 0.65, 95% CI 0.56 to 0.76), microbiologically documented infection (53 trials, 6383 participants; RR 0.51, 95% CI 0.42 to 0.62) and other indicators of infection.There were no significant differences between quinolone prophylaxis and TMP-SMZ prophylaxis with regard to death from all causes or infection, however, quinolone prophylaxis was associated with fewer side effects leading to discontinuation (seven trials, 850 participants; RR 0.37, 95% CI 0.16 to 0.87) and less resistance to the drugs thereafter (six trials, 366 participants; RR 0.45, 95% CI 0.27 to 0.74).

AUTHORS' CONCLUSIONS

Antibiotic prophylaxis in afebrile neutropenic patients significantly reduced all-cause mortality. In our review, the most significant reduction in mortality was observed in trials assessing prophylaxis with quinolones. The benefits of antibiotic prophylaxis outweighed the harm such as adverse effects and the development of resistance since all-cause mortality was reduced. As most trials in our review were of patients with haematologic cancer, we strongly recommend antibiotic prophylaxis for these patients, preferably with a quinolone. Prophylaxis may also be considered for patients with solid tumours or lymphoma.

The changing face of febrile neutropenia-from monotherapy to moulds to mucositis. Fever and neutropenia: the early years

The importance of neutropenia as a predisposing factor for infection in patients with haematological malignancies was not clearly appreciated until effective therapeutic agents became available. This led to the important advance of administering antibiotics promptly to neutropenic patients when they developed fever, before a diagnosis was established. Although some antibiotics available in the 1960s had activity against many pathogens in vitro, they were ineffective against infections in neutropenic patients. The development of methods to administer white blood cell transfusions along with antibiotics was beneficial to some patients. The development of new antibiotics was of critical importance, such as methicillin for treatment of Staphylococcus aureus and carbenicillin for Pseudomonas aeruginosa. Prevention of infection was attempted, using isolation rooms, air filtration and prophylactic antibiotics. All of these early efforts laid the foundations for the many important current investigations.

The role of nasal carriage in Staphylococcus aureus burn wound colonization

Thermal injury destroys the physical skin barrier that normally prevents invasion of microorganisms. This and concomitant depression of local and systemic host cellular and humoral immune responses are important factors that contribute to colonization and infection of the burn wound. One of the most common burn wound pathogens is Staphylococcus aureus. Staphylococcus aureus is both a human commensal and a frequent cause of infections leading to mild to life-threatening diseases. Despite a variety of infection control measures, for example patient cohorting and contact precaution at burn centres, S. aureus is still frequently encountered in burn wounds. Colonization with S. aureus has been associated with delayed wound healing, increased need for surgical interventions, and prolonged length of stay at burn centres. In this minireview, we focus on S. aureus nasal carriage in relation to S. aureus burn wound colonization and subsequent infection, and its impact on strategies for infection control.

Oral and gastrointestinal candidosis: prophylaxis during immunosuppressive therapy

Patients with acute leukaemia and malignant lymphomas often are severely affected by fungal infections. There is in particular growing concern about disseminated candidosis. Oral, gastrointestinal and systemic candidosis seem to be closely linked. Predisposing factors are damaged mucosal barriers due to chemotherapy, protracted periods of neutropenia, and prolonged use of antibiotics and steroids. Oropharyngeal candidosis is very frequent. This can be prevented or controlled by the application of topical antifungals such as nystatin. The systemic application of antifungals is an alternative for patients who do not respond. Both oral ketoconazole and intravenous amphotericin B have been proven effective. Candida oesophagitis is also an important problem. Oral nystatin suspension can be helpful in mild cases. In others oral ketoconazole and intravenous amphotericin B have to be used. A whole range of measures has to be taken to prevent spread of the disease, i.e. H2-antagonists should be used only if definitely needed. Specific antifungal prophylaxis has also been discussed. Oral amphotericin B seems to be helpful. The azole itraconazole might be especially promising.

Low prevalence of complications in severe neutropenic children with cancer in the unprotected environment of an overnight camp

BACKGROUND

The high risk of infection and other complications in severely neutropenic pediatric oncology patients receiving chemotherapy has led to development of a variety of preventive measures including isolation and diet restrictions. In order to examine the potential impact of these measures, we evaluated the outcomes of such patients attending a recreational summer camp.

METHODS

We collected data on all children who attended an overnight summer camp for children with cancer during the years 1999-2004, and who were either severely neutropenic or at a high-intensity phase of chemotherapy. Outcome measures included fever, bleeding, hospitalization, and clinical or laboratory evidence of infection. The observation period included both, the 2-week camp experience and 30 days post-camp.

RESULTS

The study group was comprised of 34 patients. Although nine (24%) were hospitalized for management of fever and neutropenia, only one patient had clinical or culture-positive evidence of an invasive infectious agent. No bleeding episode was recorded and most patients attended all camp activities.

CONCLUSIONS

Our results support the safety and feasibility of severely neutropenic patients with cancer to attend the non-isolated, non-sterile environment of a summer camp. These findings may be applicable to school and other social settings.

The Effect of the Neutropenic Diet in the Outpatient Setting: A Pilot Study

PURPOSE/OBJECTIVES

To determine whether use of the neutropenic diet in the outpatient setting decreases the number of febrile admissions and positive blood cultures associated with chemotherapy-induced neutropenia.

DESIGN

Descriptive pilot study.

SETTING

Outpatient chemotherapy unit of a medical center in a major metropolitan area.

SAMPLE

Convenience sample of 28 patients aged 33-67 years beginning treatment with 1 of 13 chemotherapy regimens.

METHODS

Twelve-week prospective study beginning on day 1 of chemotherapy cycle 1. Patients received instructions regarding the neutropenic diet before starting chemotherapy. Adherence assessment telephone calls were made at weeks 6 and 12. Hospital admission charts were reviewed at study completion.

MAIN RESEARCH VARIABLES

Adherence with neutropenic diet, number of febrile admissions, and number of positive blood cultures.

FINDINGS

Sixteen patients were compliant with the neutropenic diet, four of which were admitted for neutropenia with gram-negative rods. No significant differences were found in the rates of febrile admissions or positive blood cultures between compliant and noncompliant patients.

CONCLUSIONS

Clinical significance in this pilot study is related to the time required for diet education, content of diet education regarding food restrictions, and difficulty adhering to diet requirements given the multitude of side effects (e.g., nausea, vomiting, mouth sores, diarrhea) of chemotherapy.

IMPLICATIONS FOR NURSING

No clear evidence exists that the neutropenic diet makes a difference in overall rates of infection. Nursing research to compare the neutropenic diet with a less restrictive food safety education-focused diet is needed to guide clinical practice.

Antibiotic prophylaxis for bacterial infections in afebrile neutropenic patients following chemotherapy

BACKGROUND

Bacterial infections are a major cause of morbidity and mortality in neutropenic patients following chemotherapy for malignancy. Trials have shown the efficacy of antibiotic prophylaxis in decreasing the incidence of bacterial infections, but not in reducing mortality rates.

OBJECTIVES

This review aimed to evaluate whether antibiotic prophylaxis in afebrile neutropenic patients reduced mortality when compared to placebo or no intervention.

SEARCH STRATEGY

Electronic searches on The Cochrane Cancer Network Register of Trials (2004), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2004), MEDLINE (1966 to 2004) and EMBASE (1980 to 2004) and abstracts of conference proceedings; references of identified studies; the first author of each included trial was contacted.

SELECTION CRITERIA

RCTs or quasi-RCTs comparing different types of antibiotic prophylaxis with placebo or no intervention, or another antibiotic to prevent bacterial infections in afebrile neutropenic patients.

DATA COLLECTION AND ANALYSIS

Two authors independently appraised the quality of each trial and extracted data from the included trials. Relative risks (RR) or average differences, with their 95% confidence intervals (CI) were estimated.

MAIN RESULTS

One hundred trials (10,274 patients) performed between the years 1973 to 2004 met inclusion criteria. Antibiotic prophylaxis significantly decreased the risk for death when compared with placebo or no intervention (RR, 0.66 [95% CI 0.54 to 0.81]). The authors estimated the number needed to treat (NNT) in order to prevent 1 death from all causes as 60 (95% CI 34 to 268). Prophylaxis resulted in a significant decrease in the risk of infection-related death, RR 0.58 (95% CI 0.45 to 0.74) and in the occurrence of fever, RR 0.78 (95% CI 0.75 to 0.82). A reduction in mortality was also evident when the more recently conducted quinolone trials were analysed separately. Quinolone prophylaxis reduced the risk for all-cause mortality, RR 0.52 (95% CI, 0.37 to 0.84).

AUTHORS' CONCLUSIONS

Our review demonstrated that prophylaxis significantly reduced all-cause mortality. The most significant reduction in mortality was observed in trials assessing prophylaxis with quinolones. The benefit demonstrated in our review outweighs harm, such as adverse effects, and development of resistance, since all-cause mortality is reduced. Since most trials in our review were of patients with haematologic cancer, prophylaxis, preferably with a quinolone, should be considered for these patients.

Isolation in the allogeneic transplant environment: how protective is it?

Aggressive infection control measures that include isolating patients within protective hospital environments have become a standard practice during allogeneic stem cell transplantation. A wide range of interventions includes the management of ventilation systems, BMT unit construction and cleaning, isolation and barrier precautions, interactions with health-care workers and visitors, skin and oral care, infection surveillance, and the prevention of specific nosocomial and seasonal infections. However, many of these practices have not been definitively proven to provide patients the intended benefit of decreased infection rates or improved survival. Furthermore, each intervention comes with a financial and social cost. With institutional cost containment efforts and recent trials suggesting that patients may be safely cared for in the outpatient environment after allogeneic transplantation, many widely held practices in managing the transplant environment are being reconsidered. With changing practices, transplant teams are encouraged to review local patterns of infections and associated complications and communicate regularly with infection control committees for guidance on the evolution of isolation needs for the immunosuppressed patient.

Home care versus hospital care of patients with hematological malignancies and chemotherapy-induced cytopenia

BACKGROUND

The purpose of this review study is to examine the accumulating evidence of safety of home care, with regard to infection-related morbidity and mortality, for patients with chemotherapy-induced cytopenia, in light of previous studies on the necessity of protective isolation (PI).

PATIENTS AND METHODS

The existing literature on PI, and home care of cytopenic patients after chemotherapy, published in the English language, based on a Medline search, is reviewed.

RESULTS

The studies published so far on home care versus hospital care are all non-randomized studies and confirm that home care of cytopenic patients is safe, in terms of morbidity and mortality due to infections. On the other hand, the majority of studies on the comparison of PI with standard hospital care conclude that an infection-preventive effect of PI exists. The pooled statistics performed confirmed that such an effect of PI exists regarding the occurrence of severe infections, although no benefit to mortality has been shown.

CONCLUSIONS

Regarding home care, only the results of a prospective, randomized study of sufficient power will enable definitive conclusions to be drawn as to whether home care is equally safe as hospital-based care with PI.

Long-term antifungal prophylaxis in high-risk hematopoietic stem cell transplant recipients

The risks for invasive fungal infections, particularly mould infections such as invasive aspergillosis, among hematopoietic stem cell transplant (HSCT) recipients are linked to the duration and severity of myelosuppression and immunosuppression. Strategies to prevent invasive fungal infections have focused primarily on the use of orally administered azole antifungal agents during the neutropenic period rather than on the more prolonged post-engraftment period. The major limitations of these studies included the heterogeneity among the subjects studied for fungal infection risk factors, the agents administered, the dosing, and duration of prophylaxis. More recent studies have attempted to examine the efficacy of antifungal prophylaxis strategies among allogeneic HSCT recipients to day 100 and beyond. It is clear that a variety of products have efficacy in preventing invasive candidiasis, including imidazole and triazole antifungals, low-dose amphotericin B, and the echinocandin, micafungin; however, only the extended spectrum azole, itraconazole, has been shown to impact the incidence of proven invasive aspergillosis. Other extended spectrum azole antifungal agents, voriconazole and posaconazole, are being studied as long-term prophylaxis in high-risk HSCT recipients. While clinical trials have suggested that a duration of prophylaxis against moulds of six months or more may be required, it remains unclear if this is required in all cases. The prophylactic efficacy over time may be linked to the degree of immunosuppression as measured by markers such as the numbers of circulating CD4 T lymphocytes. Concerns about selection for resistant moulds among long-term recipients of these drugs are emerging. The cumulative experience to date suggests that long-term antifungal chemoprophylaxis is feasible and effective when applied in defined circumstances. The concerns about treatment-related toxicities, resistance, and costs are valid.

Reduced stem cell mobilization in mice receiving antibiotic modulation of the intestinal flora: involvement of endotoxins as cofactors in mobilization

Since endotoxins are potent inducers of stem cell mobilization, we hypothesized that their presence in the gut may play a role in cytokine-induced mobilization. To address this possibility we added ciprofloxacin and polymyxin B to the drinking water of Balb/c mice mobilized with either interleukin-8 (IL-8), granulocyte colony-stimulating factor (G-CSF), or flt3 ligand (FL). The yield of colony-forming units (CFUs) was significantly reduced in all mice treated with these antibiotics when compared with controls (IL-8: 192 +/- 61 vs 290 +/- 64, P <.05; G-CSF: 1925 +/- 1216 vs 3371 +/- 1214, P <.05; FL: 562 +/- 213 vs 1068 +/- 528, P <.05). Treatment with ciprofloxacin eliminated only aerobic Gram-negative bacteria from the feces without effect on mobilization. Polymyxin B treatment did not result in decontamination but significantly reduced the number of mobilized hematopoietic progenitor cells (HPCs) most likely due to the endotoxin binding capacity of polymyxin B. More than 90% of the gastrointestinal flora consists of anaerobic bacteria. Elimination of the anaerobic flora by metronidazol led to a significantly reduced number of mobilized HPCs when compared with controls (IL-8: 55 +/- 66 vs 538 +/- 216, P <.05). Germ-free OF1 mice showed a significantly reduced mobilization compared with their wild-type controls (IL-8 controls: 378 +/- 182, IL-8 germ free: 157 +/- 53, P <.05). Finally, we performed reconstitution experiments adding Escherichia coli-derived endotoxins to the drinking water of decontaminated mice. This resulted in partial restoration of the IL-8-induced mobilization (67 +/- 28 vs 190 +/- 98.1, P <.01). Our results indicate that endotoxins serve as cofactors in cytokine-induced mobilization. Modification of the endotoxin content by antibiotic treatment may affect the yield of cytokine-induced mobilization.

Is there still an indication for nursing patients with prolonged neutropenia in protective isolation? An evidence-based nursing and medical study of 4 years experience for nursing patients with neutropenia without isolation

Patients with severe neutropenia due to high-dose chemotherapy and/or total-body irradiation are at risk of serious infections and are frequently nursed in strict protective isolation. This is a costly procedure and results in a psychological burden for the patient and its significance has been debated for a long time. The introduction of very potent systemic antibiotics, antibiotic prophylaxis, haematopoietic growth factors and peripheral stem cell transplantation might have decreased the need for it. We performed a systematic literature review and conducted a medical/nursing guideline study. In the literature we searched especially for prospective randomised studies. Only six were found, these were prospective randomised studies and contradicted each other on the usefulness of protective isolation. In an initiative aimed at promoting evidence-based care, we conducted a combined medical and nursing guideline study consisting of three parts: (1) inventory of (inter) national guidelines; (2) analysis of potential sources of infection; and (3) follow-up study post-implementation of new guidelines.

RESULTS

(1) The practices in different centres in Europe appeared to vary widely. (2) Micro-organisms spread easily, especially if hands are not adequately dried. Isolation does not prevent this. Based on these findings we decided to stop protective isolation. This change of policy was combined with a campaign for optimal hygiene and introduction of hand alcohol. (3) We monitored the incidence of febrile neutropenia, infections and use of systemic antibiotics and antifungals in a 3-year period without protective isolation and compared this with the findings in the preceding 3 years with isolation. No significant differences in infections and mortality were found. We concluded that abandoning protective isolation combined with increased hygienic measures in nursing of patients with severe neutropenia does not increase the risk of infections, but improves the quality of care and patient satisfaction and reduces costs.

The neutropenic diet: what's the evidence?

Despite improved survival of children with cancer, opportunistic infections remain a significant cause of morbidity and mortality in this population. Several interventions have been tried to decrease the incidence of infection by reducing patients' exposure to bacteria during neutropenia. The neutropenic diet is one such intervention that was intended to limit the introduction of bacteria into the host's gastrointestinal tract. The only studies evaluating this diet have used this strategy in combination with multiple other interventions, and the independent effect of this diet remains unknown. More research about the neutropenic diet is needed to establish its effectiveness in clinical practice.

Antifungal prophylaxis for severely neutropenic chemotherapy recipients: a meta analysis of randomized-controlled clinical trials

BACKGROUND

The overall clinical efficacy of the azoles antifungal agents and low-dose intravenous amphotericin B for antifungal chemoprophylaxis in patients with malignant disease who have severe neutropenia remains unclear.

METHODS

Randomized-controlled trials of azoles (fluconazole, itraconazole, ketoconazole, and miconazole) or intravenous amphotericin B formulations compared with placebo/no treatment or polyene-based controls in severely neutropenic chemotherapy recipients were evaluated using meta-analytical techniques.

RESULTS

Thirty-eight trials that included 7014 patients (study agents, 3515 patients; control patients, 3499 patients) were analyzed. Overall, there were reductions in the use of parenteral antifungal therapy (prophylaxis success: odds ratio [OR], 0.57; 95% confidence interval [95% CI], 0.48-0.68; relative risk reduction [RRR], 19%; number requiring treatment for this outcome [NNT], 10 patients), superficial fungal infection (OR, 0.29; 95% CI, 0.20-0.43; RRR, 61%; NNT, 12 patients), invasive fungal infection (OR, 0.44; 95% CI, 0.35-0.55; RRR, 56%; NNT, 22 patients), and fungal infection-related mortality (OR, 0.58; 95% CI, 0.41-0.82; RRR, 47%; NNT, 52 patients). Invasive aspergillosis was unaffected (OR, 1.03; 95% CI, 0.62-1.44). Although overall mortality was not reduced (OR, 0.87; 95% CI, 0.74-1.03), subgroup analyses showed reduced mortality in studies of patients who had prolonged neutropenia (OR, 0.72; 95% CI, 0.55-0.95) or who underwent hematopoietic stem cell transplantation (HSCT) (OR, 0.77; 95% CI, 0.59-0.99). The multivariate metaregression analyses identified HSCT, prolonged neutropenia, acute leukemia with prolonged neutropenia, and higher azole dose as predictors of treatment effect.

CONCLUSIONS

Antifungal prophylaxis reduced morbidity, as evidenced by reductions in the use of parenteral antifungal therapy, superficial fungal infection, and invasive fungal infection, as well as reducing fungal infection-related mortality. These effects were most pronounced in patients with malignant disease who had prolonged neutropenia and HSCT recipients.

Nosocomial Pneumonia is Not Prevented by Protective Contact Isolation in the Surgical Intensive Care Unit

Nosocomial pneumonia (NP) is the leading cause of death from hospital-acquired infection in intubated surgical intensive care unit (SICU) patients. To determine whether protective contact isolation would lower the incidence of NP in intubated patients we performed a prospective, randomized, and controlled study in two SICUs in a tertiary medical center. Over a period of 15 months two identical ten-bed SICUs alternated for 3-month periods between protective contact isolation (isolation group) and standard “universal precautions” (control group). In the isolation group all personnel and visitors donned disposable gowns and nonsterile gloves before entering an intubated patient's room; handwashing was required before entry and on leaving the room. In the control group caregivers utilized only “standard precautions” including handwashing and nonsterile gloves for intubated patients. Respiratory cultures were obtained 48 hours after SICU admission and every 48 hours thereafter until extubation, transfer to floor care, or death. Airway colonization (AC) occurred in 72.7 per cent of isolated patients and 69.0 per cent of control patients ( P = 0.61). The incidence of NP was significantly higher in the isolation group (36.4%) compared with the control group (19.5%) ( P = 0.02). There was no statistically significant difference between groups in days from SICU admission to AC, days to NP, and mortality. We conclude that protective contact isolation with gowns, gloves, and handwashing is not superior to gloves and handwashing alone in the prevention of AC and NP in SICU patients and may in fact be detrimental.

Infections following hematopoietic stem cell transplantation

Numerous advances have been made in the management of infection in HSCT recipients. With increasing knowledge the authors are able to prevent several serious infections from occurring, and reduce the severity of infections once they occur. Despite these advances, several previously unrecognized pathogens have emerged and pose risks to this population. Ongoing surveillance and reporting of atypical infections are warranted. Transplant and infectious disease clinicians alike must be vigilant to the shifts in infectious syndromes as a consequence of various prophylaxis and preemptive strategies, and be ready to modify empiric strategies to meet the changing microbiologic milieu. As we increase our understanding of the HSCT process, and use the immune system rather than relying on high-dose chemotherapy, the authors are likely to reduce toxicities and improve patient outcomes.

Rifampin does not improve the efficacy of quinolone antibacterial prophylaxis in neutropenic cancer patients: results of a randomized clinical trial

PURPOSE

To determine whether the addition of rifampin to a quinolone-based antibacterial prophylactic regimen in patients undergoing high-dose chemotherapy (HDC) with peripheral-blood stem-cell transplantation (PBSCT) decreases the incidence of neutropenia and fever, Gram-positive bacteremia, and infection-related morbidity.

PATIENTS AND METHODS

Patients with solid tumors undergoing HDC with PBSCT were randomized to receive prophylactic antibiotics with either ciprofloxacin 500 mg orally every 8 hours or the same ciprofloxacin regimen with rifampin 300 mg orally every 12 hours. Prophylaxis was started 48 hours before stem-cell reinfusion. Patients were monitored to document the occurrence of neutropenia and fever, incidence and cause of bacterial infection, time to onset and duration of fever, requirement for intravenous antimicrobials, and length of hospital admission.

RESULTS

Sixty-five patients were randomized to receive ciprofloxacin and 65 to receive ciprofloxacin plus rifampin, and from these groups, 62 and 61 were assessable, respectively. The proportion of patients who developed neutropenia and fever was 87% in the group treated with ciprofloxacin and 78% in the group treated with ciprofloxacin and rifampin (P =.25). Although there was a trend toward a reduction in the overall incidence of bacteremia (12 v 4 patients), and Gram-positive bacteremia (8 v 2 patients) with the addition of rifampin, none of these comparisons was statistically significant (P =.05 and P =.09, respectively).

CONCLUSION

The results of this study, which demonstrate that rifampin does not improve ciprofloxacin antibacterial prophylaxis in cancer patients undergoing HDC with PBSCT support but that it does increase the occurrence of undesirable side effects, do not support the routine use of rifampin in this setting.

Reflections on gut decontamination in hematology

In Europe, but decontamination (GD) is largely used in the prophylaxis of bacterial infections in departments of oncohematology treating neutropenic patients, in particular those patients subject to profound (absolute neutrophil count (ANC) <100/mm3) and prolonged (>10 days) neutropenia, such as patients undergoing bone marrow allografting or induction chemotherapy for acute leukemia. Initially, treatment was in the form of non-absorbable antibiotics, but this has been partially superseded by quinolone-containing regimens, in particular in the centers participating in EORTC trials. In the last two EORTC trials comparing different regimens for the treatment of febrile neutropenia, 57-73% of the patients were receiving GD. A French epidemiologic study, performed prospectively and consecutively in 36 oncohematology centers, has recently shown that 45% of febrile neutropenic patients receive digestive decontamination (DD) at the onset of their first febrile episode. The value of GD has been the subject of much controversy. Numerous trials, some of which were controlled, were performed in neutropenic patients in the 1980s, prior to trials of GD in intensive care units, but did not lead to a consensus in the medical community of the value of GD. Moreover, GD is not, or is infrequently, used in the USA. Apart from trials involving the quinolones, very few studies have been published during the last 10 years. Despite this, policies have not changed greatly in the various centers. The CLIOH group has gathered the opinions of experts invited to a multidisciplinary meeting that took place in Paris in October 1996. The text that follows summarizes the reflections arising from this forum. It should be noted that this meeting was not designed to be a consensus conference, but rather to re-examine the correlation between the data in the literature and actual clinical practice and to highlight the main problems posed by DD in current oncohematology. The experts were separated into three working groups, each of which has drafted a report which appears in the text below.

Fluconazole versus itraconazole for the prevention of fungal infections in haemato-oncology

AIMS

To compare the efficacy of and tolerance to oral fluconazole and intraconazole in preventing fungal infection in neutropenic patients with haematological malignancies.

PATIENTS

213 consecutive, afebrile adult patients treated with or without autologous stem cell transplantation for haematological malignancies.

METHODS

A randomised, double blind, single centre study. Patients were randomly assigned to receive fluconazole 50 mg or itraconazole 100 mg, both twice daily in identical capsules. An intention to treat analysis was performed on 202 patients, 101 in each group.

RESULTS

Microbiologically documented systemic fungal infections occurred in four patients in each group. Clinical fungal infection was thought to be present in seven recipients of fluconazole and four of itraconazole. In all 202 patients, 29 proceeded to intravenous amphotericin (amphotericin B), 16 in the fluconazole group and 13 in the itraconazole group. Superficial fungal infection was seen only in three non-compliant patients in the fluconazole group. All these infections were oral. No major differences were noted in the isolates of fungi in mouth washes and fecal samples. Overall mortality was 8.9% (18 deaths; seven in the fluconazole group, 11 in the itraconazole group). Mortality from microbiologically and clinically documented fungal infection was 4.5% (nine deaths; three in the fluconazole group, six in the itraconazole group). Median time to suspected or proven fungal infection was 16 days in both groups. None of these comparisons reached statistical significance (p < 0.05). No major clinical toxicity was noted and compliance was excellent.

CONCLUSIONS

In neutropenic patients treated for haematological malignancies with or without autologous stem cell transplantation, fluconazole and itraconazole in low doses result in a similar low frequency of fungal disease. Fluconazole may be the preferable drug because of the smaller number of capsules and lack of need for timing relative to meals.

Prevention of infection in immunocompromised hosts

The prevention of infection in patients with cancer has changed tremendously over the last decade, but remains in evolution. Despite many clinical trials examining the role of antibacterial, antifungal, and antiviral prophylaxis, there is still discussion among physicians about not only which patients require prophylaxis, but also the optimal regimen. Nevertheless, many of these regimens offer the hope to prevent infection in patients with underlying neoplastic diseases. There is no therapy that is uniformly effective in all settings. This is generally due to the severity of the defects in host defenses and the virulence of the microorganism. Hopefully, the future will hold many new therapeutic options to help prevent infection in patients with cancer.

Prevention of infection in children with acute leukaemia. No major difference between total and selective bowel decontamination

To evaluate the effect of total bowel decontamination (TD) and selective bowel decontamination (SD) in a non-protective environment clinical and laboratory data of children treated for acute leukaemia between 1983 and 1991 were analysed retrospectively. From 1983 until 1989 34 patients [18 acute non-lymphoblastic leukaemia (ANLL) patients, 16 acute lymphoblastic leukaemia (ALL) patients] received TD and 31 patients (8 ANLL patients, 23 ALL patients) received SD from 1987 until 1991. TD consisted of colistin sulphate, neomycin, cephaloridine and amphotericin B orally as well as Orabase and sterilized food, while the patients were nursed in a single room. SD consisted of oral colistin sulphate, neomycin and amphotericin B. Those patients with ANLL were nursed in a single room; patients with ALL were nursed in a single room during remission induction therapy only. All patients except those with ANLL receiving TD received Pneumocystis carinii pneumonia prophylaxis with cotrimoxazole. Because the two groups were heterogeneous for diagnosis and chemotherapy the occurrence of fever (central body temperature at least 38.5 degrees C) and major infections (septicaemia of infections of the deep tissues or organs) were registered during periods of neutropenia (neutrophilic granulocytes < or = 500/mm3 for at least 8 days). Patients on TD had 55 periods of neutropenia, patients on SD 80. Patients on TD had 89.1 periods of fever/100 periods of neutropenia whereas patients on SD had 56.3. Also patients on TD had 27.3 major infections/100 periods of neutropenia whereas patients on SD had 11.3. Major infections predominantly consisted of septicaemia caused by gram-positive bacteria. We conclude that, in this study, TD in a non-protective environment does not offer better protection against major infections that SD in patients with ALL or ANLL.

Influence of a changed care environment on bacterial colonization of burn wounds

This study investigated the influence of a conditioned care environment per se on bacterial colonization of burn wounds. Two cohorts of burn patients were treated in the successive years 1992 and 1993, the first group in a (permanent) purpose-designed unit and the second in wards of traditional 'open' design, during renovation of the unit. Patients who were admitted to the permanent and temporary units numbered 224 and 231 respectively, the groups being similar in features that generally influence the course and outcome of burn injuries. The principles and practice of treatment by the burn care team remained the same in both years. No significant difference in wound colonization rates was found between the two groups. We conclude that while the other known advantages of managing burn patients in purpose-designed units remain valid, a conditioned care environment per se does not influence bacterial colonization rates of burn wounds.

Protective isolation: who needs it?

Infection continues to be a major cause of morbidity and mortality in neutropenic patients following chemotherapy or bone marrow transplantation (BMT). Concerted efforts have been made to protect these patients from infection during the neutropenic period. Elaborate protocols to protect the patient from both intrinsic and extrinsic pathogens have been devised, ranging from simple single room isolation to laminar air flow units (LAFs), in association with varying degrees of antibiotic decontamination of the digestive tract. Comparative rates of infection using these techniques have varied in different studies, and their use has been somewhat controversial. More recently, prophylactic quinolone administration to neutropenic patients has significantly decreased the incidence of both Gram-negative septicaemia and pyrexial episodes, probably superseding any advantages which may have been conferred by previous regimens. LAFs with high efficiency particulate air filtration still appear to be the best means of protection against aspergillosis, but are expensive and would not be available for the majority of neutropenic patients. They should probably be allocated to patients who are most at risk; BMT recipients or others who may be expected to have a prolonged neutropenic period.

Selective decontamination in neutropenic patients

It is well known that severe neutropenia, as usually seen in patients with acute leukaemia, aplastic anaemia or secondary to aggressive chemotherapy, predisposes to infections with Gram-negative enteric bacilli,Pseudomonas aeruginosa, Staphylococcus aureus, and to fungal infections. Infection with anaerobes, in contrast, is rare in patients with haematologic malignancy [1]. The spectrum of bacterial pathogens in this patient population has recently broadened, and now includes coagulase-negative staphylococci, viridans group streptococci, and, occasionally, coryneforms and other rather unusual opportunistic organisms. All these microorganisms originate either from the patient's own microflora, especially from the digestive tract, or from the hospital environment after having colonized the patient during the hospital stay [2]. Studies have shown that the incidence of fever during periods of severe neutropenia approaches 100%, and most of these fever episodes actually represent bacterial infection. For more than 20 years, methods for the prevention of bacterial and fungal infections have been under investigation in patients with profound neutropenia. These included decontamination trails, oral or systemic antimicrobial prophylaxis, strict reverse isolation and maintenance of germ-free conditions [3–8], prophylactic granulocyte transfusions [9], and, more recently, the application of haemopoietic growth factors [10, 11]. The method which remains the most widely used is oral antimicrobial prophylaxis, especially with agents for so-called selective decontamination of the intestinal tract.