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Tori K, Tansarli GS, Parente DM, Kalligeros M, Ziakas PD, Mylonakis E. The cost-effectiveness of empirical antibiotic treatments for high-risk febrile neutropenic patients: A decision analytic model. Medicine (Baltimore) 2020; 99:e20022. [PMID: 32443305 PMCID: PMC7254453 DOI: 10.1097/md.0000000000020022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Febrile neutropenia has a significant clinical and economic impact on cancer patients. This study evaluates the cost-effectiveness of different current empiric antibiotic treatments. METHODS A decision analytic model was constructed to compare the use of cefepime, meropenem, imipenem/cilastatin, and piperacillin/tazobactam for treatment of high-risk patients. The analysis was performed from the perspective of U.S.-based hospitals. The time horizon was defined to be a single febrile neutropenia episode. Cost-effectiveness was determined by calculating costs and deaths averted. Cost-effectiveness acceptability curves for various willingness-to-pay thresholds (WTP), were used to address the uncertainty in cost-effectiveness. RESULTS The base-case analysis results showed that treatments were equally effective but differed mainly in their cost. In increasing order: treatment with imipenem/cilastatin cost $52,647, cefepime $57,270, piperacillin/tazobactam $57,277, and meropenem $63,778. In the probabilistic analysis, mean costs were $52,554 (CI: $52,242-$52,866) for imipenem/cilastatin, $57,272 (CI: $56,951-$57,593) for cefepime, $57,294 (CI: $56,978-$57,611) for piperacillin/tazobactam, and $63,690 (CI: $63,370-$64,009) for meropenem. Furthermore, with a WTP set at $0 to $50,000, imipenem/cilastatin was cost-effective in 66.2% to 66.3% of simulations compared to all other high-risk options. DISCUSSION Imipenem/cilastatin is a cost-effective strategy and results in considerable health care cost-savings at various WTP thresholds. Cost-effectiveness analyses can be used to differentiate the treatments of febrile neutropenia in high-risk patients.
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Affiliation(s)
- Katerina Tori
- Division of Infectious Diseases, Brown University, Warren Alpert Medical School
| | | | - Diane M. Parente
- Department of Pharmacy, The Miriam Hospital, Providence, Rhode Island, USA
| | - Markos Kalligeros
- Division of Infectious Diseases, Brown University, Warren Alpert Medical School
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Ford CD, Coombs J, Stofer MG, Lopansri BK, Webb BJ, Ostronoff F, Asch J, Hoda D. Decrease in vancomycin-resistant Enterococcus colonization associated with a reduction in carbapenem use as empiric therapy for febrile neutropenia in patients with acute leukemia. Infect Control Hosp Epidemiol 2019; 40:774-9. [PMID: 31046849 DOI: 10.1017/ice.2019.93] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To compare the effects of empiric carbapenems versus cycling cefepime and piperacillin/tazobactam on the rates of vancomycin-resistant Enterococcus (VRE) colonization, bloodstream infections, and outcomes of patients admitted with acute leukemia. DESIGN Retrospective clinical study with VRE molecular strain typing and gastrointestinal microbiome comparison. SETTING A regional referral center for acute leukemia. PATIENTS 342 consecutive patients admitted with newly diagnosed acute leukemia. METHODS In September 2015, we changed our empiric antibiotic of choice for neutropenic fever from a carbapenem to the cycling regimen. We studied 214 consecutive patients during the carbapenem period and 128 during the cycling period. Surveillance for VRE stool colonization was conducted weekly. Representative stool samples were analyzed for VRE MLST types and changes in the composition and diversity of the fecal microbiota. RESULTS The change in empiric antibiotics was associated with a significant decrease in VRE colonization (hazard ratio [HR], 0.35; 95% confidence interval [CI], 0.27-0.66), a switch in the dominant VRE MLST types on the unit, and some modifications in the gastrointestinal microbiome. There were no differences in total gram-positive or gram-negative BSIs. During the carbapenem period, we observed higher absolute numbers of Candida spp and fewer ESBL BSIs, but these did not reach statistical significance. Patients during the carbapenem period had longer lengths of stay and durations of severe neutropenia and 10% higher hospital cost. CONCLUSIONS Carbapenem-sparing empiric antibiotic regimens may have advantages related to VRE ecology, gastrointestinal dysbiosis, duration of neutropenia, cost and length of stay.
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Sipahi OR, Kahraman H, Erdem HA, Yetkin F, Kaya S, Demirdal T, Tunccan OG, Karasahin O, Oruc E, Cag Y, Kurtaran B, Ulug M, Kutlu M, Avci M, Oztoprak N, Arda B, Pullukcu H, Tasbakan M, Yamazhan T, Kandemir O, Dizbay M, Sipahi H, Ulusoy S. Daptomycin vs. glycopeptides in the treatment of febrile neutropenia: results of the Izmir matched cohort study. Infection 2018; 47:259-266. [PMID: 30498901 DOI: 10.1007/s15010-018-1256-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 11/21/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE In this multicentre, retrospective, matched cohort study we aimed to evaluate the outcomes of neutropenic fever cases that were treated with daptomycin or a glycopeptide (vancomycin or teicoplanin). METHODS Data and outcomes of adult (aged > 18-years old) patients with neutropenic fever [(1) without clinical and radiological evidence of pneumonia, (2) who were treated with daptomycin or a glycopeptide (teicoplanin or vancomycin) for any reason and for at least 72 h] were extracted from the hospital databases. Matching was performed with all of the three following criteria: (1) underlying disease, (2) reason for starting daptomycin or glycopeptide (microbiologic evidence vs. microbiologic evidence, clinical infection vs. clinical infection and empirical therapy vs. empirical therapy) and (3) neutropenic status. RESULTS Overall 128 patients [(69/123) (56.1%) in the daptomycin cohort (D) and 59/123 (48%) in the glycopeptide cohort (G)] had a resolution of fever at the end of 72 h antibiotic treatment (p = 0.25). There was no significant difference in cured, improved and (cured + improved) rates between (D) and (G) cohorts as well as fever of unknown origin cases or microbiologically confirmed infections or clinically defined infections subgroups (p > 0.05). There was also no significant difference (p > 0.05), in terms of persistent response in the (D) versus (G) cohorts, CONCLUSIONS: These findings suggest that although not better, daptomycin efficacy is comparable to vancomycin if used as empiric therapy in the treatment of adult febrile neutropenia. We conclude that daptomycin may be used at least as a salvage therapy alternative to glycopeptides in the treatment of adult febrile neutropenia cases. A large, randomized-controlled trial may further consolidate the evidence related to this question.
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Affiliation(s)
- Oguz Resat Sipahi
- Department of Infectious Diseases and Clinical Microbiology, Ege University Faculty of Medicine, Izmir, Turkey
| | - Hasip Kahraman
- Department of Infectious Diseases and Clinical Microbiology, Ege University Faculty of Medicine, Izmir, Turkey.
| | - Huseyin Aytac Erdem
- Department of Infectious Diseases and Clinical Microbiology, Ege University Faculty of Medicine, Izmir, Turkey
| | - Funda Yetkin
- Department of Infectious Diseases and Clinical Microbiology, Inonu University Faculty of Medicine, Malatya, Turkey
| | - Selcuk Kaya
- Department of Infectious Diseases and Clinical Microbiology, Karadeniz Technical University Faculty of Medicine, Trabzon, Turkey
| | - Tuna Demirdal
- Department of Infectious Diseases and Clinical Microbiology, Katip Celebi University Faculty of Medicine, Izmir, Turkey
| | - Ozlem Guzel Tunccan
- Department of Infectious Diseases and Clinical Microbiology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Omer Karasahin
- Department of Infectious Diseases and Clinical Microbiology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Ebru Oruc
- Department of Infectious Diseases and Clinical Microbiology, Baskent University Faculty of Medicine, Adana, Turkey
| | - Yasemin Cag
- Department of Infectious Diseases and Clinical Microbiology, Dr. Lütfi Kirdar Training and Research Hospital, Istanbul, Turkey
| | - Behice Kurtaran
- Department of Infectious Diseases and Clinical Microbiology, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Mehmet Ulug
- Infectious Diseases Clinic, Eskisehir Private Umit Hospital, Eskisehir, Turkey
| | - Murat Kutlu
- Department of Infectious Diseases and Clinical Microbiology, Pamukkale University Faculty of Medicine, Denizli, Turkey
| | - Meltem Avci
- Infectious Disease and Clinical Microbiology Clinic, İzmir Bozyaka Training and Research Hospital, Izmir, Turkey
| | - Nefise Oztoprak
- Department of Infectious Diseases and Clinical Microbiology Clinic, Antalya Training and Research Hospital, Antalya, Turkey
| | - Bilgin Arda
- Department of Infectious Diseases and Clinical Microbiology, Ege University Faculty of Medicine, Izmir, Turkey
| | - Husnu Pullukcu
- Department of Infectious Diseases and Clinical Microbiology, Ege University Faculty of Medicine, Izmir, Turkey
| | - Meltem Tasbakan
- Department of Infectious Diseases and Clinical Microbiology, Ege University Faculty of Medicine, Izmir, Turkey
| | - Tansu Yamazhan
- Department of Infectious Diseases and Clinical Microbiology, Ege University Faculty of Medicine, Izmir, Turkey
| | - Ozlem Kandemir
- Department of Clinical Microbiology and Infectious Diseases, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Murat Dizbay
- Department of Infectious Diseases and Clinical Microbiology, Gazi University Faculty of Medicine, Ankara, Turkey
| | | | - Sercan Ulusoy
- Department of Infectious Diseases and Clinical Microbiology, Ege University Faculty of Medicine, Izmir, Turkey
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Khoo AL, Zhao YJ, Teng M, Ying D, Jin J, Chee YL, Poon LM, Lim SE, Koh LP, Chng WJ, Lim BP, Hsu LY, Chai LYA. Evaluation of a risk-guided strategy for empirical carbapenem use in febrile neutropenia. Int J Antimicrob Agents 2018; 52:350-357. [PMID: 29751120 DOI: 10.1016/j.ijantimicag.2018.04.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 04/18/2018] [Accepted: 04/29/2018] [Indexed: 11/28/2022]
Abstract
Febrile neutropenia (FN) is associated with substantial morbidity and necessitates empirical broad-spectrum antimicrobial treatment. In this prospective cohort study, a risk-guided management strategy for FN using empirical piperacillin/tazobactam (TZP) or a carbapenem was evaluated. The analysis involved 723 FN episodes in hospitalised adult patients, including those with severe sepsis or prior infection/colonisation with extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae. Propensity score matching analysis was used to adjust for baseline differences between treatment groups and produced 267 matched pairs. The primary outcome was all-cause mortality. Secondary outcomes were the incidences of drug-resistant Gram-negative (including ESBL-producing) and Gram-positive bacterial isolates and of invasive pulmonary aspergillosis (IPA) and their associated mortality. There was no difference in mortality between empirical carbapenem and TZP [18/267 (6.7%) vs. 14/267 (5.2%); P = 0.466]. Higher incidences of drug-resistant Gram-negative isolates [77/267 (28.8%) vs. 26/267 (9.7%); P < 0.001], including ESBL-producing bacteria [57/267 (21.3%) vs. 16/267 (6.0%); P < 0.001], were observed in carbapenem-treated episodes where its use lowered mortality. Mortality rates for ESBL-positive infections were 5.3% (3/57) and 25.0% (4/16) (P = 0.037) and for drug-resistant Gram-negative infections were 6.5% (5/77) and 23.1% (6/26) (P = 0.018) in carbapenem- and TZP-treated episodes, respectively. More IPA was observed with carbapenem use [16/267 (6.0%) vs. 6/267 (2.2%); P = 0.029]. Antifungal prophylaxis reduced the risk of death (odds ratio = 0.39, 95% confidence interval 0.17-0.87; P = 0.017). Risk-guided carbapenem prescribing in FN correctly identified cases prone to drug-resistant Gram-negative infections and reduced the mortality in these episodes.
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Affiliation(s)
- Ai Leng Khoo
- Pharmacy and Therapeutics Office, Group Health Informatics, National Healthcare Group, Singapore
| | - Ying Jiao Zhao
- Pharmacy and Therapeutics Office, Group Health Informatics, National Healthcare Group, Singapore
| | - Monica Teng
- Pharmacy and Therapeutics Office, Group Health Informatics, National Healthcare Group, Singapore
| | - Ding Ying
- Department of Infectious Diseases, Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, Singapore
| | - Jing Jin
- Children's Minnesota Research Institute, Children's Hospitals and Clinics of Minnesota, Minneapolis-Saint Paul, MN, USA
| | - Yen Lin Chee
- Department of Haematology-Oncology, National University Cancer Institute, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Li Mei Poon
- Department of Haematology-Oncology, National University Cancer Institute, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Siew Eng Lim
- Department of Haematology-Oncology, National University Cancer Institute, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Liang Piu Koh
- Department of Haematology-Oncology, National University Cancer Institute, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Wee Joo Chng
- Department of Haematology-Oncology, National University Cancer Institute, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Boon Peng Lim
- Pharmacy and Therapeutics Office, Group Health Informatics, National Healthcare Group, Singapore
| | - Li Yang Hsu
- Department of Infectious Diseases, Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Louis Yi Ann Chai
- Department of Haematology-Oncology, National University Cancer Institute, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Infectious Diseases, University Medicine Cluster, National University Health System, Singapore.
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Sano H, Kobayashi R, Suzuki D, Hori D, Kishimoto K, Kobayashi K. A prospective randomized trial comparing piperacillin/tazobactam with meropenem as empirical antibiotic treatment of febrile neutropenic children and adolescents with hematologic and malignant disorders. Pediatr Blood Cancer 2017; 64. [PMID: 27873451 DOI: 10.1002/pbc.26360] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 10/17/2016] [Indexed: 11/12/2022]
Abstract
BACKGROUND This randomized prospective study was designed to assess whether piperacillin/tazobactam (PIPC/TAZ) is as effective as meropenem (MEPM) as a first-line antibiotic treatment for febrile neutropenia (FN). PROCEDURE FN episodes were randomly assigned to receive either PIPC/TAZ (337.5 mg/kg per day in three doses, 1-hr DIV, maximum 13.5 g per day) or MEPM (120 mg/kg per day in three doses, 1-hr DIV, maximum 3 g per day). Clinical responses were evaluated 120 hr after the DIV. RESULTS A total of 434 febrile episodes in 105 patients (42 females and 63 males) with a median age of 8 years (range 0-25) were included in this trial. Blood cultures were positive in 47 out of the 434 episodes (10.8%). Regarding responses to the treatment, success rates between the PIPC/TAZ and MEPM groups were similar (62.4 vs. 65.9%, P = 0.484), even if patients were restricted to those with bacteremia (26.1 vs 37.5%, P = 0.534). Mortality rates did not significantly differ between the two groups (0.8 vs. 0%, P = 0.500). CONCLUSION Both PIPC/TAZ and MEPM appeared to be equally efficacious and safe. Carbapenems are now broadly used to treat FN; however, this may increase the prevalence of drug-resistant bacteria. In this regard, the treatment using PIPC/TAZ for FN is more beneficial.
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Affiliation(s)
- Hirozumi Sano
- Department of Pediatrics, Sapporo Hokuyu Hospital, Shiroishi-ku, Sapporo, Japan
| | - Ryoji Kobayashi
- Department of Pediatrics, Sapporo Hokuyu Hospital, Shiroishi-ku, Sapporo, Japan
| | - Daisuke Suzuki
- Department of Pediatrics, Sapporo Hokuyu Hospital, Shiroishi-ku, Sapporo, Japan
| | - Daiki Hori
- Department of Pediatrics, Sapporo Hokuyu Hospital, Shiroishi-ku, Sapporo, Japan
| | - Kenji Kishimoto
- Department of Pediatrics, Sapporo Hokuyu Hospital, Shiroishi-ku, Sapporo, Japan
| | - Kunihiko Kobayashi
- Department of Pediatrics, Sapporo Hokuyu Hospital, Shiroishi-ku, Sapporo, Japan
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Aamir M, Abrol P, Sharma D, Punia H. A clinical evaluation of efficacy and safety of cefepime monotherapy versus piperacillin-tazobactam in patients of paediatric age group with febrile neutropenia in a tertiary care centre of north India. Trop Doct 2015; 46:142-8. [DOI: 10.1177/0049475515617571] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Objective To evaluate clinically the efficacy and safety in northern India of cefepime monotherapy versus piperacillin-tazobactam in patients of paediatric age group with febrile neutropenia. Material and Methods Children aged ≤18 years admitted febrile with chemotherapy-induced neutropenia were randomised into two groups comprising 20 cases in each group viz. CEF (receiving cefepime only) and PIP-TAZO (receiving piperacillin-tazobactam). Based on clinical and laboratory tests, patients were classified into: microbiologically documented infections (MDI); clinically documented infections (CDI); and unexplained fever (UF). They were assessed for clinical signs and symptoms as well as laboratory parameters at the time of enrolment and subsequently on days 3 and 7. Results Incidence of MDI, CDI and UF were 22.5%, 47.5% and 30%, respectively. The mean duration of neutropenia (in days) was 5.45 ± 2.1 in the PIP-TAZO group and 5.5 ± 1.5 in the CEF group ( P = 0.305). The success rate defined as clearing infection effectively and improvement of neutropenia was comparable ( P = 0.705). There was a mortality rate of 20% in the PIP-TAZO group as compared to 10% in the CEF group. Conclusion We conclude that cefepime monotherapy and piperacillin-tazobactam are equally efficacious and safe in treating patients with febrile neutropenia. Empirical monotherapy with cefepime would prevent an unnecessary extra economic burden as well as avoiding the serious adverse or toxic effects of multi-drug regimes, especially in low- and middle-income countries.
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Affiliation(s)
- Mohammad Aamir
- Department of Paediatrics, PGIMS, Rohtak, Haryana, India
| | - Pankaj Abrol
- Senior Professor and Head, Department of Paediatrics, SHKM Medical College, Mewat, Haryana India
| | - Deepak Sharma
- Department of Neonatology, Fernandez Hospital, Hyderabad, India
| | - Harish Punia
- Department of Paediatrics, PGIMS, Rohtak, Haryana, India
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Sezgin G, Acipayam C, Ozkan A, Bayram I, Tanyeli A. Meropenem versus piperacillin-tazobactam as empiric therapy for febrile neutropenia in pediatric oncology patients. Asian Pac J Cancer Prev 2015; 15:4549-53. [PMID: 24969883 DOI: 10.7314/apjcp.2014.15.11.4549] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Infection is a serious cause of mortality in febrile neutropenia of pediatric cancer patients. Recently, monotherapy has replaced the combination therapy in empirical treatment of febrile neutropenia. Since there has been no reported trial comparing the efficacy of meropenem and piperacillin-tazobactam (PIP/ TAZ) monotherapies, the present retrospective study was conducted to compare safety and efficacy in febrile neutropenic children with cancer. MATERIALS AND METHODS Charts of febrile, neutropenic children hospitalized at our center between March 2008 and April 2011 for hemato-oncological malignancies were reviewed. Patients received PIP/TAZ 360 mg/kg/day or meropenem 60 mg/kg/day intravenously in three divided doses. Duration of fever and neutropenia, absolute neutrophil count, modification, and success rate were compared between the two groups. Resolution of fever without antibiotic change was defined as success and resolution of fever with antibiotic change or death of a patient was defined as failure. Modification was defined as changing the empirical antimicrobial agent during a febrile episode. RESULTS Two hundred eighty four febrile neutropenic episodes were documented in 136 patients with a median age of 5 years. In 198 episodes meropenem and in 86 episodes PIP/ TAZ were used. Duration of fever and neutropenia, neutrophil count, sex, and primary disease were not different between two groups. Success rates and modification rate between two groups showed no significant differences (p>0.05). Overall success rate in the meropenem and PIP/TAZ groups were 92.4% and 91.9% respectively. No serious adverse effects occurred in either of the groups. CONCLUSIONS Meropenem and PIP/TAZ monotherapy are equally safe and effective in the initial treatment of febrile neutropenia in children with cancer.
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Affiliation(s)
- Gulay Sezgin
- Division of Pediatric Oncology and BMT Unit, Cukurova University Medical School, Adana, Turkey E-mail :
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Shiber S, Yahav D, Avni T, Leibovici L, Paul M. β-Lactam/β-lactamase inhibitors versus carbapenems for the treatment of sepsis: systematic review and meta-analysis of randomized controlled trials. J Antimicrob Chemother 2014; 70:41-7. [PMID: 25261419 DOI: 10.1093/jac/dku351] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Data on the relative efficacy of β-lactam/β-lactamase inhibitors (BL/BLIs) versus carbapenems are scant. METHODS This is a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing any BL/BLI versus any carbapenem for the treatment of sepsis. The primary outcome was all-cause mortality. A broad search was conducted with no restrictions on language, publication status or date. Two reviewers independently applied the inclusion criteria and extracted the data. Assessment of risk of bias was performed using the domain-based approach. Subgroup analyses were used to investigate heterogeneity and focus on patient groups more likely to harbour ESBL-positive bacteria. Risk ratios (RRs) with 95% CIs were calculated and pooled. RESULTS Thirty-one RCTs were included. There was no difference between BL/BLIs and carbapenems in terms of mortality (RR 0.98, 95% CI 0.79-1.20), without heterogeneity. No differences were observed with regard to clinical or microbiological failure and bacterial superinfections. The results were not affected by risk of bias. No differences were detected in the subgroups of patients with nosocomial infections, Gram-negative infections and neutropenic fever. Adverse events requiring discontinuation were more common with BL/BLIs, on account of an increased incidence of diarrhoea. However, Clostridium difficile-associated diarrhoea (RR 0.29, 95% CI 0.10-0.87) was more frequent with carbapenems and seizures were more frequent with imipenem (RR 0.21, 95% CI 0.05-0.93). CONCLUSIONS No differences in efficacy between BL/BLIs and carbapenems exist in RCTs including patient populations with a certain, albeit unknown, rate of ESBL-positive bacteria causing infections.
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Affiliation(s)
- Shachaf Shiber
- Emergency Department, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Dafna Yahav
- Unit of Infectious Diseases, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel Sackler Faculty of Medicine, Tel-Aviv University, Ramat Aviv, Israel
| | - Tomer Avni
- Medicine E, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Leonard Leibovici
- Sackler Faculty of Medicine, Tel-Aviv University, Ramat Aviv, Israel Medicine E, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Mical Paul
- Sackler Faculty of Medicine, Tel-Aviv University, Ramat Aviv, Israel Unit of Infectious Diseases, Rambam Health Care Center, Haifa, Israel
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Affiliation(s)
- Natasha Ali
- Department of Pathology and Microbiology/OncologyThe Aga Khan University, Karachi, Pakistan
| | - Muhammad Baqir
- Department of Emergency MedicineThe Aga Khan University, Karachi, Pakistan
| | - Aasma Hamid
- Department of Pharmacy ServicesThe Aga Khan University, Karachi, Pakistan
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Sipahi OR, Arda B, Nazli-Zeka A, Pullukcu H, Tasbakan M, Yamazhan T, Ozkoren-Calik S, Sipahi H, Ulusoy S. Piperacillin/tazobactam vs. cefoperazone/sulbactam in adult low-risk febrile neutropenia cases. Int J Clin Pract 2014; 68:230-5. [PMID: 24372736 DOI: 10.1111/ijcp.12279] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Accepted: 08/08/2013] [Indexed: 11/30/2022] Open
Abstract
AIM The aim of this study was to compare the efficacy of piperacillin/tazobactam (P/T) and cefoperazone/sulbactam (C/S) in the empirical treatment of adult neutropenic fever. METHODS Data and outcomes of low-risk adult cases with neutropenic fever and treated with P/T (4.5 g q6h) or C/S (2 g q8h) between 2005 and 2011 June were extracted from our database. Risk evaluation was made according to criteria of Multinational Association for Supportive Care in Cancer (MASCC) and a score of ≥ 21 was considered as low risk. Data were collected prospectively by daily visits and evaluated retrospectively. Primary outcome was - fever defervescence at 72 h in combination with success without modification (referring to episodes where the patient recovered from fever with disappearance of signs of infection without modification to initial empirical treatment). All-cause mortality referred to death resulting from a documented or presumed infection or unidentified reason during the treatment and 30-day follow-up period. RESULTS A total of 172 patients (113 cases P/T and 59 cases C/S) fulfilled the study inclusion criteria. Persistent response in P/T arm was 73.5%, whereas it was 64.5% in C/S arm (p > 0.05). Rates of any modification were also similar in both treatment arms. All-cause mortality during the treatment and 30-day follow-up period was not significantly different (P/T: 4/113 vs. C/S: 2/59, p > 0.05). There was no severe adverse effect requiring antibiotic cessation in both cohorts. CONCLUSION In conclusion, our data suggest that C/S may be a safe alternative to P/T in the empirical treatment of adult low-risk febrile neutropenia cases.
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Affiliation(s)
- O R Sipahi
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Ege University, Izmir, Turkey
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Roohullah A, Moniwa A, Wood C, Humble M, Balm M, Carter J, Weinkove R. Imipenem versus piperacillin/tazobactam for empiric treatment of neutropenic fever in adults. Intern Med J 2013; 43:1151-4. [DOI: 10.1111/imj.12226] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Accepted: 06/17/2013] [Indexed: 11/29/2022]
Affiliation(s)
- A. Roohullah
- Wellington Blood and Cancer Centre; Capital and Coast District Health Board; Wellington New Zealand
| | - A. Moniwa
- Wellington Blood and Cancer Centre; Capital and Coast District Health Board; Wellington New Zealand
| | - C. Wood
- Wellington Blood and Cancer Centre; Capital and Coast District Health Board; Wellington New Zealand
- Malaghan Institute of Medical Research; Wellington New Zealand
| | - M. Humble
- Department of Pathology and Molecular Medicine; University of Otago Wellington; Wellington New Zealand
- Microbiology Laboratory; Capital and Coast District Health Board; Wellington New Zealand
| | - M. Balm
- Microbiology Laboratory; Capital and Coast District Health Board; Wellington New Zealand
| | - J. Carter
- Wellington Blood and Cancer Centre; Capital and Coast District Health Board; Wellington New Zealand
- Department of Pathology and Molecular Medicine; University of Otago Wellington; Wellington New Zealand
| | - R. Weinkove
- Wellington Blood and Cancer Centre; Capital and Coast District Health Board; Wellington New Zealand
- Department of Pathology and Molecular Medicine; University of Otago Wellington; Wellington New Zealand
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Abstract
Consensus guidelines recommend antimicrobial stewardship in all hospitals with the following goals in mind: appropriate and judicious use of antimicrobial agents leading to increased drug safety, reduced antimicrobial utilization, reduction in the development and selection of resistant organisms, cost containment, and improved patient outcomes. Patients with cancer, especially those with hematologic malignancies and neutropenia, develop serious infections often and receive antimicrobial therapy frequently. Consequently, there is considerable opportunity to practice antimicrobial stewardship in this population. Several antimicrobial stewardship strategies such as antimicrobial restriction, cycling, prospective audit and feedback, and de-escalation have been evaluated in patients with cancer. The primary focus has been on the prevention and treatment of bacterial infections in febrile neutropenic patients. These efforts should be expanded to include fungal, viral, and other infections.
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Affiliation(s)
- Frank P Tverdek
- Department of Pharmacy Clinical Programs, The University of Texas M.D. Anderson Cancer Center, Houston, Texas 77030, USA
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13
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Laupland KB, Fisman DN. A new paradigm for clinical trials in antibiotherapy? Can J Infect Dis Med Microbiol 2011; 22:39-42. [PMID: 22654923 DOI: 10.1155/2011/412857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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14
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Paul M, Yahav D, Bivas A, Fraser A, Leibovici L. Cochrane Review: Anti-pseudomonal beta-lactams for the initial, empirical, treatment of febrile neutropenia: comparison of beta-lactams. ACTA ACUST UNITED AC 2011. [DOI: 10.1002/ebch.879] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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15
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Paul M, Yahav D, Bivas A, Fraser A, Leibovici L. Anti-pseudomonal beta-lactams for the initial, empirical, treatment of febrile neutropenia: comparison of beta-lactams. Cochrane Database Syst Rev 2010; 2015:CD005197. [PMID: 21069685 PMCID: PMC9022089 DOI: 10.1002/14651858.cd005197.pub3] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Several beta-lactams are recommended as single agents for the treatment of febrile neutropenia. OBJECTIVES To compare the effectiveness of different anti-pseudomonal beta-lactams as single agents in the treatment of febrile neutropenia. To compare the development of bacterial resistance, bacterial and fungal superinfections during or following treatment with the different beta-lactams. SEARCH STRATEGY We searched the Cochane Register of Controlled Trials (CENTRAL), Issue 3, 2010. MEDLINE, EMBASE, LILACS, FDA drug applications, conference proceedings and ongoing clinical trial databases up to August 2010. References of included studies were scanned. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing an antipseudomonal beta-lactam to another antipseudomonal beta-lactam antibiotic, both given alone or with the addition of the same glycopeptide to both study arms, for the initial treatment of fever and neutropenia among cancer patients. DATA COLLECTION AND ANALYSIS Two review authors applied inclusion criteria and extracted the data independently. Missing data were sought. Risk ratios (RR) were calculated with 95% confidence intervals (CI), and pooled using the fixed effect model. The primary outcome was all-cause mortality. Risk of bias was assessed using a domain-based evaluation and its effect of results was assessed through sensitivity analyses. MAIN RESULTS Forty-four trials were included. The antibiotics assessed were cefepime, ceftazidime, piperacillin-tazobactam, imipenem and meropenem. Adequate allocation concealment and generation were reported in about half of the trials and only two trials were double-blinded. The risk for all-cause mortality was significantly higher with cefepime compared to other beta-lactams (RR 1.39, 95% CI 1.04 to 1.86, 21 trials, 3471 participants), without heterogeneity and with higher RRs in trials at low risk for bias. There were no differences in secondary outcomes but for a non-significantly higher rate of bacterial superinfections with cefepime. Mortality was significantly lower with piperacillin-tazobactam compared to other antibiotics (RR 0.56, 95% CI 0.34 to 0.92, 8 trials, 1314 participants), without heterogeneity. Carbapenems resulted in similar all-cause mortality and a lower rate of clinical failure and antibiotic modifications as compared to other antibiotics, but a higher rate of diarrhea caused by Clostridium difficile. AUTHORS' CONCLUSIONS Current evidence supports the use of piperacillin-tazobactam in locations where antibiotic resistance profiles do not mandate empirical use of carbapenems. Carbapenems result in a higher rate of antibiotic-associated and Clostridium difficile-associated diarrhea. There is a high level of evidence that all-cause mortality is higher with cefepime compared to other beta-lactams and it should not be used as monotherapy for patients with febrile neutropenia.
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Affiliation(s)
- Mical Paul
- Infectious Diseases Unit, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel, 49100
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