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Gudiol C, Royo-Cebrecos C, Tebe C, Abdala E, Akova M, Álvarez R, Maestro-de la Calle G, Cano A, Cervera C, Clemente WT, Martín-Dávila P, Freifeld A, Gómez L, Gottlieb T, Gurguí M, Herrera F, Manzur A, Maschmeyer G, Meije Y, Montejo M, Peghin M, Rodríguez-Baño J, Ruiz-Camps I, Sukiennik TC, Carratalà J. Clinical efficacy of β-lactam/β-lactamase inhibitor combinations for the treatment of bloodstream infection due to extended-spectrum β-lactamase-producing Enterobacteriaceae in haematological patients with neutropaenia: a study protocol for a retrospective observational study (BICAR). BMJ Open 2017; 7:e013268. [PMID: 28115333 PMCID: PMC5278288 DOI: 10.1136/bmjopen-2016-013268] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Bloodstream infection (BSI) due to extended-spectrum β-lactamase-producing Gram-negative bacilli (ESBL-GNB) is increasing at an alarming pace worldwide. Although β-lactam/β-lactamase inhibitor (BLBLI) combinations have been suggested as an alternative to carbapenems for the treatment of BSI due to these resistant organisms in the general population, their usefulness for the treatment of BSI due to ESBL-GNB in haematological patients with neutropaenia is yet to be elucidated. The aim of the BICAR study is to compare the efficacy of BLBLI combinations with that of carbapenems for the treatment of BSI due to an ESBL-GNB in this population. METHODS AND ANALYSIS A multinational, multicentre, observational retrospective study. Episodes of BSI due to ESBL-GNB occurring in haematological patients and haematopoietic stem cell transplant recipients with neutropaenia from 1 January 2006 to 31 March 2015 will be analysed. The primary end point will be case-fatality rate within 30 days of onset of BSI. The secondary end points will be 7-day and 14-day case-fatality rates, microbiological failure, colonisation/infection by resistant bacteria, superinfection, intensive care unit admission and development of adverse events. SAMPLE SIZE The number of expected episodes of BSI due to ESBL-GNB in the participant centres will be 260 with a ratio of control to experimental participants of 2. ETHICS AND DISSEMINATION The protocol of the study was approved at the first site by the Research Ethics Committee (REC) of Hospital Universitari de Bellvitge. Approval will be also sought from all relevant RECs. Any formal presentation or publication of data from this study will be considered as a joint publication by the participating investigators and will follow the recommendations of the International Committee of Medical Journal Editors (ICMJE). The study has been endorsed by the European Study Group for Bloodstream Infection and Sepsis (ESGBIS) and the European Study Group for Infections in Compromised Hosts (ESGICH).
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Affiliation(s)
- C Gudiol
- Infectious Diseases Department, Bellvitge University Hospital, IDIBELL, University of Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
- Duran i Reynals Hospital, ICO, L'Hospitalet de Llobregat, Barcelona, Spain
- REIPI (Spanish Network for Research in Infectious Disease), Instituto de Salud Carlos III, Madrid, Spain
| | - C Royo-Cebrecos
- Infectious Diseases Department, Bellvitge University Hospital, IDIBELL, University of Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
- REIPI (Spanish Network for Research in Infectious Disease), Instituto de Salud Carlos III, Madrid, Spain
| | - C Tebe
- Statistics Advisory Service, Institute of Biomedical Research of Bellvitge, Rovira i Virgili University, L'Hospitalet de Llobregat, Barcelona, Spain
| | - E Abdala
- Faculty of Medicine, Instituto do Câncer do Estado de São Paulo, University of São Paulo, Sao Paulo, Brazil
| | - M Akova
- Hacettepe University School of Medicine, Ankara, Turkey
| | - R Álvarez
- Infectious Diseases Research Group, Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine, Institute of Biomedicine of Seville (IBiS), University of Seville/CSIC/University Hospitals Virgen del Rocio and Virgen Macarena, Seville, Spain
| | - G Maestro-de la Calle
- Infectious Diseases Unit, Instituto de Investigación Hospital “12 de Octubre” (i+12), “12 de Octubre” University Hospital; School of Medicine, Universidad Complutense, Madrid, Spain
| | - A Cano
- REIPI (Spanish Network for Research in Infectious Disease), Instituto de Salud Carlos III, Madrid, Spain
- Reina Sofía University Hospital-IMIBIC-UCO, Córdoba, Spain
| | - C Cervera
- University Hospital of Alberta, Edmonton, Alberta, Canada
| | - W T Clemente
- Infectious Disease Consultant, Digestive Transplant Service, Hospital das Clínicas, Universidade FederalMinas Gerais, Brazil
| | - P Martín-Dávila
- Infectious Diseases Department, Ramon y Cajal Hospital, Madrid, Spain
| | - A Freifeld
- Infectious Diseases Section, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - L Gómez
- Department of Internal Medicine, University Hospital Mútua de Terrassa, Barcelona, Spain
| | - T Gottlieb
- Department of Microbiology & Infectious Diseases, Concord Hospital, Concord, New South Wales, Australia
| | - M Gurguí
- Infectious Diseases Unit, Hospital de la Santa Creu i Sant Pau and Instituto de Investigación Biomédica Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - F Herrera
- Infectious Diseases Section, Department of Medicine, Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Buenos Aires, Argentina
| | - A Manzur
- Infectious Diseases, Hospital Rawson, San Juan, Argentina
| | - G Maschmeyer
- Department of Hematology, Oncology and Palliative Care, Klinikum Ernst von Bergmann, Academic Teaching Hospital of Charité University Medical School, Berlin, Germany
| | - Y Meije
- REIPI (Spanish Network for Research in Infectious Disease), Instituto de Salud Carlos III, Madrid, Spain
- Infectious Disease Unit, Internal Medicine Department, Barcelona Hospital, SCIAS,Barcelona, Spain
| | - M Montejo
- REIPI (Spanish Network for Research in Infectious Disease), Instituto de Salud Carlos III, Madrid, Spain
- Infectious Diseases Unit, Cruces University Hospital, Bilbao, Spain
| | - M Peghin
- Infectious Diseases Division, Santa Maria Misericordia University Hospital, Udine, Italy
| | - J Rodríguez-Baño
- REIPI (Spanish Network for Research in Infectious Disease), Instituto de Salud Carlos III, Madrid, Spain
- Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine, University Hospitals Virgen Macarena and Virgen del Rocío—IBiS; Department of Medicine, University of Seville, Seville, Spain
| | - I Ruiz-Camps
- REIPI (Spanish Network for Research in Infectious Disease), Instituto de Salud Carlos III, Madrid, Spain
- Infectious Diseases Department, Vall d'Hebrón University Hospital, Barcelona, Spain
| | - T C Sukiennik
- Hospital Santa Casa de Misericórdia de Porto Alegre, Brazil
| | - J Carratalà
- Infectious Diseases Department, Bellvitge University Hospital, IDIBELL, University of Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
- REIPI (Spanish Network for Research in Infectious Disease), Instituto de Salud Carlos III, Madrid, Spain
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Beaird OE, Freifeld A, Ison MG, Lawrence SJ, Theodoropoulos N, Clark NM, Razonable RR, Alangaden G, Miller R, Smith J, Young JAH, Hawkinson D, Pursell K, Kaul DR. Current practices for treatment of respiratory syncytial virus and other non-influenza respiratory viruses in high-risk patient populations: a survey of institutions in the Midwestern Respiratory Virus Collaborative. Transpl Infect Dis 2016; 18:210-5. [PMID: 26923867 PMCID: PMC7169710 DOI: 10.1111/tid.12510] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 09/27/2015] [Accepted: 12/14/2015] [Indexed: 11/30/2022]
Abstract
Background The optimal treatment for respiratory syncytial virus (RSV) infection in adult immunocompromised patients is unknown. We assessed the management of RSV and other non‐influenza respiratory viruses in Midwestern transplant centers. Methods A survey assessing strategies for RSV and other non‐influenza respiratory viral infections was sent to 13 centers. Results Multiplex polymerase chain reaction assay was used for diagnosis in 11/12 centers. Eight of 12 centers used inhaled ribavirin (RBV) in some patient populations. Barriers included cost, safety, lack of evidence, and inconvenience. Six of 12 used intravenous immunoglobulin (IVIG), mostly in combination with RBV. Inhaled RBV was used more than oral, and in the post‐stem cell transplant population, patients with lower respiratory tract infection (LRTI), graft‐versus‐host disease, and more recent transplantation were treated at higher rates. Ten centers had experience with lung transplant patients; all used either oral or inhaled RBV for LRTI, 6/10 treated upper respiratory tract infection (URTI). No center treated non‐lung solid organ transplant (SOT) recipients with URTI; 7/11 would use oral or inhaled RBV in the same group with LRTI. Patients with hematologic malignancy without hematopoietic stem cell transplantation were treated with RBV at a similar frequency to non‐lung SOT recipients. Three of 12 centers, in severe cases, treated parainfluenza and metapneumovirus, and 1/12 treated coronavirus. Conclusions Treatment of RSV in immunocompromised patients varied greatly. While most centers treat LRTI, treatment of URTI was variable. No consensus was found regarding the use of oral versus inhaled RBV, or the use of IVIG. The presence of such heterogeneity demonstrates the need for further studies defining optimal treatment of RSV in immunocompromised hosts.
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Affiliation(s)
- O E Beaird
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - A Freifeld
- Department of Internal Medicine, University of Nebraska, Omaha, Nebraska, USA
| | - M G Ison
- Department of Internal Medicine, Northwestern University, Chicago, Illinois, USA
| | - S J Lawrence
- Department of Internal Medicine, Washington University, St. Louis, Missouri, USA
| | - N Theodoropoulos
- Department of Internal Medicine, The Ohio State University, Columbus, Ohio, USA
| | - N M Clark
- Department of Internal Medicine, Loyola University Medical Center, Maywood, Illinois, USA
| | - R R Razonable
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - G Alangaden
- Department of Internal Medicine, Henry Ford Health System, Detroit, Michigan, USA
| | - R Miller
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa, USA
| | - J Smith
- Department of Internal Medicine, University of Wisconsin, Madison, Wisconsin, USA
| | - J A H Young
- Department of Internal Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - D Hawkinson
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - K Pursell
- Department of Internal Medicine, University of Chicago, Chicago, Illinois, USA
| | - D R Kaul
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
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Neemann K, Eichele DD, Smith PW, Bociek R, Akhtari M, Freifeld A. Fecal microbiota transplantation for fulminant Clostridium difficile infection in an allogeneic stem cell transplant patient. Transpl Infect Dis 2012; 14:E161-5. [PMID: 23121625 DOI: 10.1111/tid.12017] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Revised: 04/29/2012] [Accepted: 07/04/2012] [Indexed: 12/12/2022]
Abstract
We present a case of severe Clostridium difficile infection (CDI) in a non-neutropenic allogeneic hematopoietic stem cell transplant recipient who was treated successfully with fecal microbiota therapy after standard pharmacologic therapy had failed. Following naso-jejunal instillation of donor stool, the patient's symptoms resolved within 48 h. Bowel resection was averted. This is the first case in the literature, to our knowledge, to describe fecal microbiota therapy in a profoundly immunocompromised host with severe CDI. We propose that fecal microbiota therapy be considered as a therapeutic option in immunosuppressed patients with refractory severe CDI.
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Affiliation(s)
- K Neemann
- Infectious Diseases Division, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA.
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Van Schooneveld T, Freifeld A, Lesiak B, Kalil A, Sutton DA, Iwen PC. Paecilomyces lilacinus infection in a liver transplant patient: case report and review of the literature. Transpl Infect Dis 2008; 10:117-22. [PMID: 17605741 DOI: 10.1111/j.1399-3062.2007.00248.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
A 56-year-old male who was 12 months status post liver transplant presented with a 2-month history of painful, erythematous nodules over the right knee. Several biopsies yielded a mold initially phenotypically identified as a Penicillium species, but molecular sequence analysis ultimately determined the identity as Paecilomyces lilacinus. Several courses of oral voriconazole were required for resolution of the infection. A review of the literature revealed that Paecilomyces species are an infrequent cause of disease in transplant patients, with skin and soft tissue infections being the most common presentation. It is important to accurately identify these infections, and polymerase chain reaction assay using universal fungal primers offers a rapid and precise diagnostic approach. Treatment of Paecilomyces infections may require multiple courses of antifungal therapy, often with surgical debridement. We suggest that voriconazole may be a useful treatment alternative to the more traditional therapy with amphotericin B-based agents.
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Affiliation(s)
- T Van Schooneveld
- Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska 68198-5400, USA
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5
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Wood J, Eilers J, DeVetten M, Freifeld A. 421: Improving yield from blood cultures for transplant patients. Biol Blood Marrow Transplant 2007. [DOI: 10.1016/j.bbmt.2007.01.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Saif MW, Leitman SF, Cusack G, Horne M, Freifeld A, Venzon D, PremKumar A, Cowan KH, Gress RE, Zujewski J, Kasten-Sportes C. Thromboembolism following removal of femoral venous apheresis catheters in patients with breast cancer. Ann Oncol 2004; 15:1366-72. [PMID: 15319243 DOI: 10.1093/annonc/mdh347] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Apheresis catheters have simplified collection of peripheral blood stem cells (PBSC), but may be associated with thrombosis of the instrumented vessels. We performed a retrospective analysis to study the prevalence of thromboembolism associated with the use of femoral apheresis catheters in patients with breast cancer. PATIENTS AND METHODS Patients were participants in clinical trials of high-dose chemotherapy with autologous PBSC rescue. They underwent mobilization with either high-dose cyclophosphamide (n = 21) or cyclophosphamide/paclitaxel (n = 64), followed by filgrastim. Double lumen catheters (12 or 13 Fr) were placed in the femoral vein and removed within 12 h of the last apheresis procedure. Apheresis was performed using a continuous flow cell separator and ACD-A anticoagulant. Thromboembolism was diagnosed by either venous ultrasonography or ventilation-perfusion scan. RESULTS Nine of 85 patients (10.6%) undergoing large volume apheresis with use of a femoral catheter developed thromboembolic complications. Pulmonary embolus (PE) was diagnosed in five and femoral vein thrombosis in four patients. Four of the five patients who developed PE were symptomatic; one asymptomatic patient had a pleural-based, wedge-shaped lesion detected on a staging computed tomography scan. The mean number of apheresis procedures was 2.4 (range one to four) and the mean interval between removal of the apheresis catheter and diagnosis of thrombosis was 17.6 days. In contrast, none of 18 patients undergoing apheresis using jugular venous access and none of 54 healthy allogeneic donors undergoing concurrent filgrastim-mobilized PBSC donation (mean 1.7 procedures/donor) using femoral access experienced thromboembolic complications. CONCLUSIONS Thromboembolism following femoral venous catheter placement for PBSC collection in patients with breast cancer may be more common than previously recognized. Healthy PBSC donors are not at the same risk. Onset of symptoms related to thrombosis tended to occur several weeks after catheter removal. This suggests that the physicians not only need to be vigilant during the period of apheresis, but also need to observe patients for thromboembolic complications after the catheter is removed. The long interval between the removal of apheresis catheter and the development of thromboembolism may have a potential impact on prophylactic strategies developed in future, such as the duration of prophylactic anticoagulation. Avoidance of the femoral site in breast cancer patients, and close prospective monitoring after catheter removal, are indicated.
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Affiliation(s)
- M W Saif
- National Cancer Institute and Clinical Center, National Institutes of Health, Bethesda, MD, USA.
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Freifeld A, McNabb J, Anderson J, Ullrich FA. Low-risk patients with fever and neutropenia during chemotherapy: Current clinical practice patterns. J Clin Oncol 2004. [DOI: 10.1200/jco.2004.22.90140.8089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- A. Freifeld
- University of Nebraska Medical Center, Omaha, NE
| | - J. McNabb
- University of Nebraska Medical Center, Omaha, NE
| | - J. Anderson
- University of Nebraska Medical Center, Omaha, NE
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Guarner J, Shieh WJ, Dawson J, Subbarao K, Shaw M, Ferebee T, Morken T, Nolte KB, Freifeld A, Cox N, Zaki SR. Immunohistochemical and in situ hybridization studies of influenza A virus infection in human lungs. Am J Clin Pathol 2000; 114:227-33. [PMID: 10941338 DOI: 10.1309/hv74-n24t-2k2c-3e8q] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Influenza viruses are responsible for acute febrile respiratory disease. When deaths occur, definitive diagnosis requires viral isolation because no characteristic viral inclusions are seen. We examined the distribution of influenza A virus in tissues from 8 patients with fatal infection using 2 immunohistochemical assays (monoclonal antibodies to nucleoprotein [NP] and hemagglutinin [HA]) and 2 in situ hybridization (ISH) assays (digoxigenin-labeled probes that hybridized to HA and NP genes). Five patients had prominent bronchitis; by immunohistochemical assay, influenza A staining was present focally in the epithelium of larger bronchi (intact and detached necrotic cells) and in rare interstitial cells. The anti-NP antibody stained primarily cell nuclei, and the anti-HA antibody stained mainly the cytoplasm. In 4 of these cases, nucleic acids (ISH) were identified in the same areas. Three patients had lymphohistiocytic alveolitis and showed no immunohistochemical or ISH staining. Both techniques were useful for detection of influenza virus antigens and nucleic acids in formalin-fixed paraffin-embedded tissues and can enable further understanding of fatal influenza A virus infections in humans.
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Affiliation(s)
- J Guarner
- Division of Viral and Rickettsial Diseases, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA
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Freifeld A, Marchigiani D, Walsh T, Chanock S, Lewis L, Hiemenz J, Hiemenz S, Hicks JE, Gill V, Steinberg SM, Pizzo PA. A double-blind comparison of empirical oral and intravenous antibiotic therapy for low-risk febrile patients with neutropenia during cancer chemotherapy. N Engl J Med 1999; 341:305-11. [PMID: 10423464 DOI: 10.1056/nejm199907293410501] [Citation(s) in RCA: 305] [Impact Index Per Article: 12.2] [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] [Indexed: 01/09/2023]
Abstract
BACKGROUND Among patients with fever and neutropenia during chemotherapy for cancer who have a low risk of complications, oral administration of empirical broad-spectrum antibiotics may be an acceptable alternative to intravenous treatment. METHODS We conducted a randomized, double-blind, placebo-controlled study of patients (age, 5 to 74 years) who had fever and neutropenia during chemotherapy for cancer. Neutropenia was expected to be present for no more than 10 days in these patients, and they had to have no other underlying conditions. Patients were assigned to receive either oral ciprofloxacin plus amoxicillin-clavulanate or intravenous ceftazidime. They were hospitalized until fever and neutropenia resolved. RESULTS A total of 116 episodes were included in each group (84 patients in the oral-therapy group and 79 patients in the intravenous-therapy group). The mean neutrophil counts at admission were 81 per cubic millimeter and 84 per cubic millimeter, respectively; the mean duration of neutropenia was 3.4 and 3.8 days, respectively. Treatment was successful without the need for modifications in 71 percent of episodes in the oral-therapy group and 67 percent of episodes in the intravenous-therapy group (difference between groups, 3 percent; 95 percent confidence interval, -8 percent to 15 percent; P=0.48). Treatment was considered to have failed because of the need for modifications in the regimen in 13 percent and 32 percent of episodes, respectively (P<0.001) and because of the patient's inability to tolerate the regimen in 16 percent and 1 percent of episodes, respectively (P<0.001). There were no deaths. The incidence of intolerance of the oral antibiotics was 16 percent, as compared with 8 percent for placebo (P=0.07). CONCLUSIONS In hospitalized low-risk patients who have fever and neutropenia during cancer chemotherapy, empirical therapy with oral ciprofloxacin and amoxicillin-clavulanate is safe and effective.
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Affiliation(s)
- A Freifeld
- National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
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Walsh TJ, Yeldandi V, McEvoy M, Gonzalez C, Chanock S, Freifeld A, Seibel NI, Whitcomb PO, Jarosinski P, Boswell G, Bekersky I, Alak A, Buell D, Barret J, Wilson W. Safety, tolerance, and pharmacokinetics of a small unilamellar liposomal formulation of amphotericin B (AmBisome) in neutropenic patients. Antimicrob Agents Chemother 1998; 42:2391-8. [PMID: 9736569 PMCID: PMC105839 DOI: 10.1128/aac.42.9.2391] [Citation(s) in RCA: 121] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/1997] [Accepted: 05/03/1998] [Indexed: 11/20/2022] Open
Abstract
The safety, tolerance, and pharmacokinetics of a small unilamellar liposomal formulation of amphotericin B (AmBisome) administered for empirical antifungal therapy were evaluated for 36 persistently febrile neutropenic adults receiving cancer chemotherapy and bone marrow transplantation. The protocol was an open-label, sequential-dose-escalation, multidose pharmacokinetic study which enrolled a total of 8 to 12 patients in each of the four dosage cohorts. Each cohort received daily doses of either 1.0, 2.5, 5.0, or 7.5 mg of amphotericin B in the form of AmBisome/kg of body weight. The study population consisted of patients between the ages of 13 and 80 years with neutropenia (absolute neutrophil count, <500/mm3) who were eligible to receive empirical antifungal therapy. Patients were monitored for safety and tolerance by frequent laboratory examinations and the monitoring of infusion-related reactions. Efficacy was assessed by monitoring for the development of invasive fungal infection. The pharmacokinetic parameters of AmBisome were measured as those of amphotericin B by high-performance liquid chromatography. Noncompartmental methods were used to calculate pharmacokinetic parameters. AmBisome administered as a 1-h infusion in this population was well tolerated and was seldom associated with infusion-related toxicity. Infusion-related side effects occurred in 15 (5%) of all 331 infusions, and only two patients (5%) required premedication. Serum creatinine, potassium, and magnesium levels were not significantly changed from baseline in any of the dosage cohorts, and there was no net increase in serum transaminase levels. AmBisome followed a nonlinear dosage relationship that was consistent with reticuloendothelial uptake and redistribution. There were no breakthrough fungal infections during empirical therapy with AmBisome. AmBisome administered to febrile neutropenic patients in this study was well tolerated, was seldom associated with infusion-related toxicity, was characterized by nonlinear saturation kinetics, and was effective in preventing breakthrough fungal infections.
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Affiliation(s)
- T J Walsh
- Pediatric Oncology Branch, National Institutes of Health, Bethesda, Maryland, USA.
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Abstract
BACKGROUND Empiric antibiotic therapy has become a standard of care for the febrile neutropenic patient. Many clinical trials over the previous three decades have demonstrated that a variety of antibiotic combinations and more recently potent antibiotic monotherapies may preserve the patient through the critical time of fever and neutropenia. Recently attempts have been made to identify "low risk" patients who may not require traditional, intensive, hospitalized intravenous antimicrobial therapy. Therefore the need for new treatment alternatives for the febrile neutropenic pediatric cancer patient in particular revolves around the desire for less complex regimens, agents with minimal toxicity and expense and the option of an oral formulation for outpatient management. OBJECTIVE Fluoroquinolones, especially ciprofloxacin and ofloxacin, are examined in this paper as potential oral alternatives for managing the low risk neutropenic pediatric cancer patient population. Attention must be paid to their antibacterial spectra, however, and in some cases fluoroquinolones should be combined with a second agent for additional Gram-positive coverage. RESULTS Several studies, including one ongoing trial at the National Cancer Institute, have shown the potential benefits of oral fluoroquinolone therapy among low risk febrile neutropenic patients. Joint complaints in children after ciprofloxacin therapy in the National Cancer Institute trial thus far have been minimal, reversible and felt to be unrelated to ciprofloxacin treatment. CONCLUSION The use of outpatient therapy, such as the fluoroquinolones, to manage febrile neutropenic episodes must be approached with caution and should be undertaken only in selected low risk patients.
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Affiliation(s)
- A Freifeld
- Infectious Diseases Section, National Cancer Institutes of Health, Bethesda, MD 20892, USA
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12
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Beekmann SE, Engler HD, Collins AS, Canosa J, Henderson DK, Freifeld A. Rapid identification of respiratory viruses: impact on isolation practices and transmission among immunocompromised pediatric patients. Infect Control Hosp Epidemiol 1996; 17:581-6. [PMID: 8880230 DOI: 10.1086/647389] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine whether empiric isolation of patients with acute respiratory virus infection symptoms could be discontinued when preliminary shell vial cultures were negative, and the impact of this approach on hospital resources. DESIGN In 1993, we retrospectively reviewed respiratory virus test results from 1992 to 1993 and extended data collection prospectively through the 1993 to 1994 season. The rapid test and 48-hour shell vial results were compared to a standard of rapid test plus 5-day shell vial culture results to determine the sensitivity and specificity of these "preliminary" results. SETTING A 400-bed tertiary referral research hospital. PATIENTS Patients from any inpatient unit or clinic with acute respiratory virus infection symptoms who had a specimen submitted for respiratory virus culture. Patients were placed on empiric respiratory isolation pending culture results. RESULTS The overall sensitivity of the combined rapid and 48-hour culture results in adults and children was 97%. All 15 pediatric patients with respiratory syncytial virus infection who had specimens submitted on first suspicion of respiratory virus infection were positive by rapid test. Culture results were positive within 48 hours for 100% of patients with influenza A (15 patients), influenza B (6), and parainfluenza (18) viruses. Of 59 pediatric inpatients who were isolated empirically awaiting 5-day culture results, 31 (52%) ultimately were determined to be culture negative. CONCLUSIONS Empiric isolation of symptomatic children can be discontinued at 48 hours when both the rapid test and the early culture results are negative. Our institution would have saved 93 days of unnecessary isolation over 2 years had such a policy been in place.
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Affiliation(s)
- S E Beekmann
- Hospital Epidemiology Service, National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892, USA
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13
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Rolston KV, Rubenstein EB, Freifeld A. Early Empiric Antibiotic Therapy for Febrile Neutropenia Patients at Low Risk. Cancer Control 1996; 3:366-374. [PMID: 10765229 DOI: 10.1177/107327489600300411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Affiliation(s)
- KV Rolston
- The University of Texas M. D. Anderson Cancer Center, Houston 77030, USA
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Abstract
Although it is apparent that certain patients with febrile neutropenic episodes can benefit from outpatient antibiotic therapy, not all low-risk patients are treated in this fashion. There are barriers, real and perceived, to implementing this approach for patients, health care providers, and caregivers. Table 3 summarizes the advantages and disadvantages of ambulatory management of febrile neutropenic patients. For many patients and physicians, outpatient oral antibiotics may be preferred, whereas for others a more conservative approach might be needed in order to feel comfortable with treating this population on an outpatient basis. In this situation, patients can be treated in a stepwise fashion as shown in Table 4. These alternatives allow physicians and patients options to discuss when planning treatment strategies for febrile neutropenia.
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Affiliation(s)
- K V Rolston
- Ambulatory and Supportive Care Oncology Research Program, University of Texas M.D. Anderson Cancer Center, Houston, USA
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Roilides E, Paschalides P, Freifeld A, Pizzo PA. Suppression of polymorphonuclear leukocyte bactericidal activity by suramin. Antimicrob Agents Chemother 1993; 37:495-500. [PMID: 7681657 PMCID: PMC187698 DOI: 10.1128/aac.37.3.495] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Suramin is a polyanionic compound with potent antineoplastic properties. Because polymorphonuclear leukocytes (PMNs) are a crucial component of host defenses against bacteria and fungi, the effects of suramin on PMN function were studied in vitro. PMNs from healthy donors were incubated with concentrations of suramin of 1 to 1,000 micrograms/ml (within and exceeding the therapeutic range) for 30 min, and PMN functional parameters were subsequently assessed. Suramin had no effect on viability, chemotaxis to N-formylmethionyl leucyl phenylalanine, phagocytosis of Candida albicans, or superoxide anion production in response to phorbol myristate acetate and formylmethionyl leucyl phenylalanine. Fungicidal activity against C. albicans blastoconidia was unaffected at a suramin concentration of < 500 micrograms/ml, whereas at higher concentrations a slight suppression was observed (P = 0.04). Bactericidal activity against Staphylococcus aureus was significantly suppressed by concentrations of > or = 100 micrograms/ml (P < 0.01). Phagocytosis of S. aureus was also significantly impaired at > or = 10 micrograms/ml (P < 0.05). The presence of 10% human serum during pretreatment did not abrogate the suramin-induced suppression of bactericidal activity. Treatment of PMNs with granulocyte colony-stimulating factor (4,000 U/ml) for 30 min prior to the addition of suramin (250 micrograms/ml) improved the bactericidal defect (P = 0.02). The PMN functional impairment may be related to increased susceptibility to bacterial infections, and granulocyte colony-stimulating factor may improve the defect.
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Affiliation(s)
- E Roilides
- Infectious Diseases Section, National Cancer Institute, Bethesda, Maryland 20892
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Affiliation(s)
- P A Pizzo
- Pediatric Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892
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Affiliation(s)
- P A Pizzo
- Pediatric Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892
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Straus SE, Ostrove JM, Inchauspé G, Felser JM, Freifeld A, Croen KD, Sawyer MH. NIH conference. Varicella-zoster virus infections. Biology, natural history, treatment, and prevention. Ann Intern Med 1988; 108:221-37. [PMID: 2829675 DOI: 10.7326/0003-4819-108-2-221] [Citation(s) in RCA: 284] [Impact Index Per Article: 7.9] [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] [Indexed: 01/02/2023] Open
Abstract
During the last 10 years, there have been major advances in the understanding of varicella-zoster virus and the diseases it causes. The molecular biology of the virus is being unraveled with the aid of new molecular technologies. Varicella, usually a benign manifestation of primary infection, and zoster, a result of reactivation of latent virus, can cause considerable morbidity in patients with immune impairment. Antiviral drugs, especially acyclovir, ameliorate severe infections but still have little role in the treatment of most normal patients with varicella or zoster. Varicella can be prevented when necessary by patient isolation and passive prophylaxis with varicella-zoster immune globulin. An experimental live vaccine also prevents varicella, but problems regarding its virulence for immunosuppressed patients and the durability of the protective response are still being addressed.
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Affiliation(s)
- S E Straus
- National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, Maryland
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