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Ford CD, Lopansri BK, Hunter BD, Asch J, Hoda D. Multiplexed Gastrointestinal PCR panels for the Evaluation of Diarrhea in HCT Recipients. Transplant Cell Ther 2024:S2666-6367(24)00409-3. [PMID: 38768906 DOI: 10.1016/j.jtct.2024.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 04/24/2024] [Revised: 05/12/2024] [Accepted: 05/14/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND Multiplexed gastrointestinal PCR panels (MGPP) are frequently employed as an aid in the diagnosis and management of diarrhea in HCT recipients. Many issues related to the optimal use of MGPP in HCT patients remain to be clarified. OBJECTIVE To better define MGPP diagnostic and therapeutic stewardship in HCT recipients including indications and benefits of testing, optimal timing, and interpretation of results. STUDY DESIGN We retrieved 463 consecutive MGPP ordered on 651 consecutive first HCT (312 allogeneic, 339 autologous) performed at our institution between June 2015 and June 2023. RESULTS One hundred and sixteen (25%) of the 463 MGPP identified at least one and 12 (3%) more than one diarrheagenic pathogen. A positive result was more likely if the test was ordered within 48 hours of a hospital admission [32/78(41%)] or as an outpatient [46/111(41%)] as compared with evaluation of hospital onset diarrhea [38/274(14%)]. Among the positive results, the most frequent pathogens identified included C. difficile (64%), diarrheagenic E. coli (20%), norovirus (9%), and adenovirus 40/41 (5%). Thirty-eight percent of the positive C. difficile MGPP determinations were associated with a positive test for toxin. Among our allogeneic HCT cohort, 3% of MGPP for hospital onset diarrhea yielded an organism other than C. difficile. Fifty-six percent of positive and 14% of all submitted tests resulted in a change in treatment. For organisms other than C. difficile, only 1% of all tests and 5% of positive tests resulted in initiation of therapy. For patients at risk for acute graft vs. host disease (aGVHD), a positive or negative MGPP result was not predictive for a new diagnosis of aGVHD in proximity to diarrhea onset. CONCLUSIONS MGPP testing is most useful when administered at hospital admission or as an outpatient. Since MGPP is sensitive and does not distinguish between colonization and causes of diarrhea, caution is needed in interpretation of results, especially for toxin negative C. difficile and diarrheagenic gram-negative organisms.
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Affiliation(s)
- Clyde D Ford
- Intermountain Blood and Marrow Transplant Program, LDS Hospital, Salt Lake City, Utah, 84107, USA.
| | - Bert K Lopansri
- Department of Medicine, Division of Infectious Diseases and Clinical Epidemiology, Intermountain Health, Salt Lake City, Utah, 84143, USA; Department of Medicine, Division of Infectious Diseases, University of Utah, Salt Lake City, Utah, 84105, USA
| | - Bradley D Hunter
- Intermountain Blood and Marrow Transplant Program, LDS Hospital, Salt Lake City, Utah, 84107, USA
| | - Julie Asch
- Intermountain Blood and Marrow Transplant Program, LDS Hospital, Salt Lake City, Utah, 84107, USA
| | - Daanish Hoda
- Intermountain Blood and Marrow Transplant Program, LDS Hospital, Salt Lake City, Utah, 84107, USA
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2
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Ford CD, Hoda D, Lopansri BK, Parra M, Sharma P, Asch J. An Algorithm Addressing the Problem of Overdiagnoses of Clostridioides difficile Infections in Hematopoietic Stem-Cell Transplant Recipients: Effects on CDI Rates and Patient Outcomes. Transplant Cell Ther 2023:S2666-6367(23)01242-3. [PMID: 37086852 DOI: 10.1016/j.jtct.2023.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 04/13/2023] [Accepted: 04/16/2023] [Indexed: 04/24/2023]
Abstract
BACKGROUND Diarrhea of other causes and Clostridioides difficile colonization are common in patients hospitalized for hematopoietic stem-cell transplants (HSCT). It has been well recognized that these issues tend to decrease the specificity of stool testing for C. difficile infection (CDI). The best way to address this problem is uncertain. OBJECTIVE In September 2018, we initiated a project with the goal of addressing the apparent problem of overdiagnosis of CDIs in our HSCT population. Using the quality improvement tool Model for Improvement we introduced a C. difficile stool testing and CDI diagnosis algorithm with the aim of decreasing unnecessary inpatient CDI diagnoses and treatments. In this study we examine the effects of the algorithm. STUDY DESIGN We reviewed all HSCT admissions for the 2 years before the algorithm introduction and the 3 years following recording all stool submissions for C. difficile determination and CDI. At the close of the study, we recruited our advanced practice providers (APPs) to review all CDI following algorithm initiation and provide feedback on the ease of use of the algorithm and potential improvements to the overall process. RESULTS Stool submissions for C. difficile determination decreased from 38.0 to 20.6/1000 inpatient days (p=<0.001) and CDI from 5.5 to 2.4/1000 days (p=0.007). Patients admitted for a first allogeneic-HSCT, a first autologous-HSCT, or an HSCT readmission showed similar proportionate reductions. No detrimental effects on length of stay, overall survival, progression free survival, rates of readmission following transplant, incidence of acute graft vs. host disease, or incidence of recurrent CDI were noted following algorithm introduction. A strategy of education, monitoring/feedback, and ease of algorithm access proved effective in inducing provider compliance. APPs rated the algorithm high on ease of use. CONCLUSIONS Use of an algorithm defining criteria for C. difficile testing, diagnosis, and treatment was associated with significantly decreased CDI diagnoses on a HSCT inpatient unit without apparent adverse effects.
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Affiliation(s)
- Clyde D Ford
- Intermountain Blood and Marrow Transplant Program, LDS Hospital, Salt Lake City, Utah 84107 USA.
| | - Daanish Hoda
- Intermountain Blood and Marrow Transplant Program, LDS Hospital, Salt Lake City, Utah 84107 USA
| | - Bert K Lopansri
- Department of Medicine, Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Salt Lake City, Utah 84143 USA; Department of Medicine, Division of Infectious Diseases, University of Utah, Salt Lake City, Utah 84105 USA
| | - Melissa Parra
- Intermountain Blood and Marrow Transplant Program, LDS Hospital, Salt Lake City, Utah 84107 USA
| | - Prashant Sharma
- Intermountain Blood and Marrow Transplant Program, LDS Hospital, Salt Lake City, Utah 84107 USA
| | - Julie Asch
- Intermountain Blood and Marrow Transplant Program, LDS Hospital, Salt Lake City, Utah 84107 USA
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Ford CD, Lopansri BK, Coombs J, Gouw L, Asch J, Hoda D. Extended spectrum cephalosporin resistant enterobacteriaceae carriage and infection in patients admitted with newly-diagnosed acute leukemia. Am J Infect Control 2023; 51:172-177. [PMID: 35644294 DOI: 10.1016/j.ajic.2022.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 03/14/2022] [Revised: 05/22/2022] [Accepted: 05/23/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Current information is limited on the incidence, risk factors, and consequences of extended-spectrum cephalosporin resistant Enterobacteriaceae (ESCRE) carriage in patients undergoing therapy for newly-diagnosed acute leukemia. METHODS We monitored 300 consecutive patients who submitted a first stool within the first week of initial hospitalization for initial and hospital acquired ESCRE carriage. Selected available isolates underwent DNA sequencing for determination of strain typing and resistance genes. RESULTS 19 (6%) patients had ESCRE in their initial stool, and there was continued risk for new acquisition throughout their multiple hospitalizations. Patients with AML had more acquired carriage during their initial hospitalization. Increased hospitalizations and male sex were risk factors for detected acquired ESCRE carriage. ESCRE stool carriage was predictive for ESCRE BSI but not for overall survival. Sequencing revealed that E. coli ESCRE isolates contained primarily ESBL, while Enterobacter spp. and Citrobacter spp. showed primarily AmpC genes. The antibiotic sensitivity patterns for ESCRE BSI isolates reflected these genome findings. DISCUSSION/CONCLUSIONS ESCRE carriage is common in patients with acute leukemia undergoing repeated hospitalizations and increases the risk for ESCRE BSI. ESCRE genera express differing resistance genes which may be predictive for empiric antibiotic efficacy.
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Affiliation(s)
- Clyde D Ford
- Intermountain Acute Leukemia Program, LDS Hospital, Salt Lake City, UT.
| | - Bert K Lopansri
- Department of Medicine, Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Salt Lake City, UT; Department of Medicine, Division of Infectious Diseases, University of Utah, Salt Lake City, UT
| | - Jana Coombs
- Department of Medicine, Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Salt Lake City, UT
| | - Launce Gouw
- Intermountain Acute Leukemia Program, LDS Hospital, Salt Lake City, UT
| | - Julie Asch
- Intermountain Acute Leukemia Program, LDS Hospital, Salt Lake City, UT
| | - Daanish Hoda
- Intermountain Acute Leukemia Program, LDS Hospital, Salt Lake City, UT
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Hunter B, Hoda D, Sharma P, Konopa KL, Ostronoff F, Nguyen A, Ford CD. Transmission of ESBL Producing Enterobacteriaceae (ESBLPE) on an Inpatient Unit Dedicated to Hematologic Malignancies and Hematopoietic Stem Cell Transplant (HSCT) and the Value of Surveillance and Contact Isolation. Transplant Cell Ther 2022. [DOI: 10.1016/s2666-6367(22)00648-0] [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: 10/18/2022]
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Webb BJ, Majers J, Healy R, Jones PB, Butler AM, Snow G, Forsyth S, Lopansri BK, Ford CD, Hoda D. Antimicrobial Stewardship in a Hematological Malignancy Unit: Carbapenem Reduction and Decreased Vancomycin-Resistant Enterococcus Infection. Clin Infect Dis 2021; 71:960-967. [PMID: 31751470 DOI: 10.1093/cid/ciz900] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [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: 07/02/2019] [Accepted: 09/10/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Antibiotic stewardship is challenging in hematological malignancy patients. METHODS We performed a quasiexperimental implementation study of 2 antimicrobial stewardship interventions in a hematological malignancy unit: monthly antibiotic cycling for febrile neutropenia that included cefepime (± metronidazole) and piperacillin-tazobactam and a clinical prediction rule to guide anti-vancomycin-resistant Enterococcus faecium (VRE) therapy. We used interrupted time-series analysis to compare antibiotic use and logistic regression in order to adjust observed unit-level changes in resistant infections by background community rates. RESULTS A total of 2434 admissions spanning 3 years pre- and 2 years postimplementation were included. Unadjusted carbapenem and daptomycin use decreased significantly. In interrupted time-series analysis, carbapenem use decreased by -230 days of therapy (DOT)/1000 patient-days (95% confidence interval [CI], -290 to -180; P < .001). Both VRE colonization (odds ratio [OR], 0.64; 95% CI, 0.51 to 0.81; P < .001) and infection (OR, 0.41; 95% CI, 0.2 to 0.9; P = .02) decreased after implementation. This shift may have had a greater effect on daptomycin prescribing (-160 DOT/1000 patient-days; 95% CI, -200 to -120; P < .001) than did the VRE clinical prediction score (-30 DOT/1000 patient-days; 95% CI, -50 to 0; P = .08). Also, 46.2% of Pseudomonas aeruginosa isolates were carbapenem-resistant preimplementation compared with 25.0% postimplementation (P = .32). Unit-level changes in methicillin-resistant Staphylococcus aureus and extended-spectrum beta lactamase (ESBL) incidence were explained by background community-level trends, while changes in AmpC ESBL and VRE appeared to be independent. The program was not associated with increased mortality. CONCLUSIONS An antibiotic cycling-based strategy for febrile neutropenia effectively reduced carbapenem use, which may have resulted in decreased VRE colonization and infection and perhaps, in turn, decreased daptomycin prescribing.
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Affiliation(s)
- Brandon J Webb
- Intermountain Healthcare, Division of Epidemiology and Infectious Disease, Salt Lake City, Utah, USA.,Stanford University, Division of Infectious Diseases and Geographic Medicine, Palo Alto, California, USA
| | - Jacob Majers
- Intermountain Healthcare, LDS Hospital Acute Leukemia/Blood and Marrow Transplant Program, Salt Lake City, Utah, USA
| | - Regan Healy
- Intermountain Healthcare, LDS Hospital Acute Leukemia/Blood and Marrow Transplant Program, Salt Lake City, Utah, USA
| | - Peter Bjorn Jones
- Intermountain Healthcare, Division of Epidemiology and Infectious Disease, Salt Lake City, Utah, USA
| | - Allison M Butler
- Intermountain Healthcare, Statistical Data Center, Salt Lake City, Utah, USA
| | - Greg Snow
- Intermountain Healthcare, Statistical Data Center, Salt Lake City, Utah, USA
| | - Sandra Forsyth
- Intermountain Healthcare, Division of Epidemiology and Infectious Disease, Salt Lake City, Utah, USA
| | - Bert K Lopansri
- Intermountain Healthcare, Division of Epidemiology and Infectious Disease, Salt Lake City, Utah, USA
| | - Clyde D Ford
- Intermountain Healthcare, LDS Hospital Acute Leukemia/Blood and Marrow Transplant Program, Salt Lake City, Utah, USA
| | - Daanish Hoda
- Intermountain Healthcare, LDS Hospital Acute Leukemia/Blood and Marrow Transplant Program, Salt Lake City, Utah, USA
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Ford CD, Lopansri BK, Coombs J, Webb BJ, Asch J, Hoda D. Are Clostridioides difficile infections being overdiagnosed in hematopoietic stem cell transplant recipients? Transpl Infect Dis 2020; 22:e13279. [PMID: 32196881 DOI: 10.1111/tid.13279] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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: 11/25/2019] [Revised: 02/12/2020] [Accepted: 03/08/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND Because both diarrhea due to other causes and gastrointestinal colonization with toxigenic Clostridioides difficile are common in HSCT, there is a possibility of false-positive diagnoses of C difficile infections (CDI). METHODS We estimated the probability of a patient being colonized by toxigenic C difficile by testing non-diarrheal surveillance stools from 223 HSCT recipients and the probability that a specimen submitted for C difficile testing was not CDI by determining the number of clinical tests that returned negative from this cohort. The number of expected false-positive CDI was estimated using these probabilities and compared with observed clinical test results. RESULTS The expected false-positive and the observed numbers of positive clinical results were similar. The 20 patients diagnosed with CDI were also similar to 142 patients with diarrhea and C difficile-negative stools in number of stools on day of testing, associated symptoms, and the recorded number of days to formed stools. C difficile colonization was most commonly detected during the first week and CDI during the second. Retrospective analysis of 837 patients showed that 18 stools were submitted for each diagnosis of CDI. Ribotyping of the surveillance samples showed 17 ribotypes. CONCLUSIONS Although several assumptions could impact the accuracy of our false-positive CDI estimates, it appears that many HSCT recipients diagnosed with CDI may actually represent colonized status and an alternative cause of diarrhea. Diagnostic stewardship, including limiting CDI diagnoses to patients with positive toxin and restricting stool submissions to patients with more severe symptoms, may decrease the number of false-positive diagnoses.
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Affiliation(s)
- Clyde D Ford
- Intermountain Blood and Marrow Transplant Program, LDS Hospital, Salt Lake City, UT, USA
| | - Bert K Lopansri
- Department of Medicine, Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Salt Lake City, UT, USA.,Department of Medicine, Division of Infectious Diseases, University of Utah, Salt Lake City, UT, USA
| | - Jana Coombs
- Department of Medicine, Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Brandon J Webb
- Department of Medicine, Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Salt Lake City, UT, USA.,Department of Medicine, Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, USA
| | - Julie Asch
- Intermountain Blood and Marrow Transplant Program, LDS Hospital, Salt Lake City, UT, USA
| | - Daanish Hoda
- Intermountain Blood and Marrow Transplant Program, LDS Hospital, Salt Lake City, UT, USA
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Webb BJ, Brunner A, Lewis J, Ford CD, Lopansri BK. Repurposing an Old Drug for a New Epidemic: Ursodeoxycholic Acid to Prevent Recurrent Clostridioides difficile Infection. Clin Infect Dis 2020; 68:498-500. [PMID: 30020421 DOI: 10.1093/cid/ciy568] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 07/09/2018] [Indexed: 01/11/2023] Open
Abstract
Recurrent Clostridioides difficile infection (rCDI) may be mediated in part by secondary bile acids. Here we report salvage therapy with ursodeoxycholic acid (UDCA) to prevent rCDI in 16 high-risk patients. Patients on UDCA had a low observed recurrence rate (12.5%). Controlled trials are needed to confirm these observations.
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Affiliation(s)
- Brandon J Webb
- Intermountain Healthcare, Division of Epidemiology and Infectious Diseases, Salt Lake City, Utah.,Stanford University, Division of Infectious Diseases and Geographic Medicine, Palo Alto, California
| | - Ali Brunner
- Intermountain Acute Leukemia/Blood and Marrow Transplant Program, LDS Hospital
| | - Julia Lewis
- University of Utah, Division of Infectious Diseases, Salt Lake City
| | - Clyde D Ford
- Intermountain Acute Leukemia/Blood and Marrow Transplant Program, LDS Hospital
| | - Bert K Lopansri
- Intermountain Healthcare, Division of Epidemiology and Infectious Diseases, Salt Lake City, Utah.,University of Utah, Division of Infectious Diseases, Salt Lake City
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Kator S, Zurko J, Webb BJ, Balatico MA, Clayton F, Palmer CA, Konopa K, Motyckova G, Ford CD, Ostronoff F. Disseminated toxoplasmosis and haemophagocytic lymphohistiocytosis following chimeric antigen receptor T-cell therapy. Br J Haematol 2020; 189:e4-e6. [PMID: 31958891 DOI: 10.1111/bjh.16402] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Sarah Kator
- Department of Pharmacy, Intermountain LDS Hospital, Salt Lake City, UT, USA
| | - Jessica Zurko
- Department of Infectious Disease, University of Utah, Salt Lake City, UT, USA
| | - Brandon J Webb
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Salt Lake City, UT, USA.,Division of Infectious Diseases and Geographic Medicine, Stanford University, Palo Alto, CA, USA
| | | | - Frederic Clayton
- Department of Pathology, University of Utah, Salt Lake City, UT, USA
| | - Cheryl A Palmer
- Department of Pathology, University of Utah, Salt Lake City, UT, USA
| | - Kelly Konopa
- Intermountain Blood and Marrow Transplant and Acute Leukemia Program, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Gabriela Motyckova
- Intermountain Blood and Marrow Transplant and Acute Leukemia Program, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Clyde D Ford
- Intermountain Blood and Marrow Transplant and Acute Leukemia Program, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Fabiana Ostronoff
- Intermountain Blood and Marrow Transplant and Acute Leukemia Program, Intermountain Healthcare, Salt Lake City, UT, USA
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Ford CD, Lopansri BK, Coombs J, Webb BJ, Nguyen A, Asch J, Hoda D. Clostridioides difficile colonization and infection in patients admitted for a first autologous transplantation: Incidence, risk factors, and patient outcomes. Clin Transplant 2019; 33:e13712. [PMID: 31532030 DOI: 10.1111/ctr.13712] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [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: 07/22/2019] [Revised: 09/09/2019] [Accepted: 09/13/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND More data are needed regarding the incidence, risk factors, and outcomes for Clostridioides difficile infection (CDI) and colonization in patients undergoing an autologous hematopoietic stem cell transplantation (AHSCT). METHODS We studied 472 consecutive patients admitted for a first AHSCT and conducted a prospective C difficile stool surveillance and ribotyping analysis in a subset of 94 patients. RESULTS Clostridioides difficile infection was diagnosed in 7% of patients for an incidence of 3.4 CDI/1000 inpatient days, recurrent/reinfection CDI was rare. CDI was increased in patients who were colonized on admission, had required a recent pre-admission inpatient stay for fever and/or serious infection, or received empiric therapy with a carbapenem or extended-spectrum penicillin. CDI was associated with a longer length of stay and higher hospital costs. Twelve of 94 patients (13%) were found to have colonization on admission; CDI was diagnosed in 27% of these vs 1% in those with initial negative stools. Colonization in the hospital for those negative on admission was infrequent. C difficile ribotyping showed a predominance of 014/020. CONCLUSIONS Clostridioides difficile infection is a significant infection in patients receiving a first AHSCT. The risk factors identified may be useful in designing preventive interventions.
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Affiliation(s)
- Clyde D Ford
- Intermountain Blood and Marrow Transplant Program, LDS Hospital, Salt Lake City, UT, USA
| | - Bert K Lopansri
- Department of Medicine, Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Salt Lake City, UT, USA.,Department of Medicine, Division of Infectious Diseases, University of Utah, Salt Lake City, UT, USA
| | - Jana Coombs
- Department of Medicine, Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Brandon J Webb
- Department of Medicine, Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Salt Lake City, UT, USA.,Department of Medicine, Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, USA
| | - Andy Nguyen
- Intermountain Blood and Marrow Transplant Program, LDS Hospital, Salt Lake City, UT, USA
| | - Julie Asch
- Intermountain Blood and Marrow Transplant Program, LDS Hospital, Salt Lake City, UT, USA
| | - Daanish Hoda
- Intermountain Blood and Marrow Transplant Program, LDS Hospital, Salt Lake City, UT, USA
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Jensen RR, Healy RM, Ford CD, Child B, Majers J, Draper B, Hasan Y, Hoda D. Amlodipine and calcineurin inhibitor‐induced nephrotoxicity following allogeneic hematopoietic stem cell transplant. Clin Transplant 2019; 33:e13633. [DOI: 10.1111/ctr.13633] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 06/03/2019] [Accepted: 06/05/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Ryan R. Jensen
- Intermountain Healthcare Acute Leukemia, Blood and Marrow Transplant Program LDS Hospital Salt Lake City Utah
- Department of Pharmacy LDS Hospital Salt Lake City Utah
| | - Regan M. Healy
- Intermountain Healthcare Acute Leukemia, Blood and Marrow Transplant Program LDS Hospital Salt Lake City Utah
- Department of Pharmacy LDS Hospital Salt Lake City Utah
| | - Clyde D. Ford
- Intermountain Healthcare Acute Leukemia, Blood and Marrow Transplant Program LDS Hospital Salt Lake City Utah
| | - Berrie Child
- Intermountain Healthcare Acute Leukemia, Blood and Marrow Transplant Program LDS Hospital Salt Lake City Utah
- Department of Pharmacy LDS Hospital Salt Lake City Utah
| | - Jacob Majers
- Intermountain Healthcare Acute Leukemia, Blood and Marrow Transplant Program LDS Hospital Salt Lake City Utah
- Department of Pharmacy LDS Hospital Salt Lake City Utah
| | - Brent Draper
- Intermountain Healthcare Acute Leukemia, Blood and Marrow Transplant Program LDS Hospital Salt Lake City Utah
- Department of Pharmacy LDS Hospital Salt Lake City Utah
| | - Yousef Hasan
- Royal College of Surgeons in Ireland Dublin Ireland
| | - Daanish Hoda
- Intermountain Healthcare Acute Leukemia, Blood and Marrow Transplant Program LDS Hospital Salt Lake City Utah
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11
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Ford CD, Lopansri BK, Webb BJ, Coombs J, Gouw L, Asch J, Hoda D. Clostridioides difficile colonization and infection in patients with newly diagnosed acute leukemia: Incidence, risk factors, and patient outcomes. Am J Infect Control 2019; 47:394-399. [PMID: 30471971 DOI: 10.1016/j.ajic.2018.09.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 09/25/2018] [Accepted: 09/25/2018] [Indexed: 01/15/2023]
Abstract
BACKGROUND The frequency, risk factors, and outcomes for Clostridioides difficile infection (CDI) in patients with newly diagnosed acute leukemia (AL) admitted for induction therapy are unclear. METHODS We studied 509 consecutive patients with AL admitted between 2006 and 2017 and conducted a prospective C difficile surveillance and ribotyping analysis in a subset of these. RESULTS The incidence of CDI was 2.2/1,000 inpatient days during induction, and CDI was rare after discharge. CDI was highest in patients with acute myelogenous leukemia. A hospitalization shortly before admission and administration of a greater number of antibiotics increased the risk for CDI. No single class of antibiotics conveyed an increased risk. All cases were successfully treated, and CDI was not associated with an increase in length of stay, costs, or mortality. In a subgroup analysis, 16% of patients with acute myelogenous leukemia and 4% with other leukemia types were colonized on admission. Colonization was associated with a higher risk of CDI. Ribotyping of available isolates showed 27 different strain types with 014/020 and 027 being the most frequent. CONCLUSIONS The number of antibiotics administered are a major risk factor for CDI in patients with AL. However, CDI appears to have minimal clinical impact in this population.
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Crowther MR, Ford CD, Lian B, Mitchell Q. A COMPARISON OF CUSTODIAL AND NON-CUSTODIAL RURAL AFRICAN AMERICAN GRANDPARENTS ON EMOTIONAL HEALTH AND WELL-BEING. Innov Aging 2018. [DOI: 10.1093/geroni/igy023.2260] [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: 11/12/2022] Open
Affiliation(s)
- M R Crowther
- The University of Alabama, Tuscaloosa, Alabama, United States
| | - C D Ford
- The University of Alabama Tuscaloosa,AL
| | - B Lian
- Mercer University Macon, GA
| | - Q Mitchell
- The University of Alabama Tuscaloosa, AL
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13
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Jensen RR, Healy R, Ford CD, Hoda D, Majers J, Draper B, Child B, Petersen FB. Amlodipine and Calcineurin Inhibitor Induced Nephrotoxicity Following Allogeneic Hematopoietic Stem Cell Transplant. Biol Blood Marrow Transplant 2018. [DOI: 10.1016/j.bbmt.2017.12.769] [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: 10/18/2022]
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14
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Ford CD, Hoda D, Asch J, Webb B, Lopansri B, Petersen FB. Clostridium Difficile Colonization and Infection in Patients Receiving Hematopoietic Stem-Cell Transplants. Biol Blood Marrow Transplant 2018. [DOI: 10.1016/j.bbmt.2017.12.466] [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: 10/18/2022]
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Ford CD, Lopansri BK, Gazdik MA, Webb B, Snow GL, Hoda D, Adams B, Petersen FB. Room contamination, patient colonization pressure, and the risk of vancomycin-resistant Enterococcus colonization on a unit dedicated to the treatment of hematologic malignancies and hematopoietic stem cell transplantation. Am J Infect Control 2016; 44:1110-1115. [PMID: 27287734 DOI: 10.1016/j.ajic.2016.03.044] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Revised: 03/29/2016] [Accepted: 03/30/2016] [Indexed: 12/23/2022]
Abstract
BACKGROUND Contaminated surfaces and colonization pressure are risk factors for vancomycin-resistant Enterococcus (VRE) colonization in intensive care units (ICUs). Whether these apply to modern units dedicated to the care of hematologic malignancies and hematopoietic stem cell transplant (HSCT) procedures is unknown. METHODS We reviewed the records of 780 consecutive admissions for acute leukemia, autologous HSCT, or allogeneic HSCT in which the patient was at risk for hospital-acquired VRE and underwent weekly surveillance. We also obtained staff and room cultures, observed staff behavior, and performed VRE molecular strain typing on selected isolates. RESULTS The overall rate of VRE colonization was 11.4 cases/1,000 patient days. Cultures of room surfaces revealed VRE isolates in 10% of terminally cleaned rooms. A prior VRE-colonized room occupant did not increase risk, and paired isolates from 20 patients and prior occupants were indistinguishable on molecular typing in only 1 pair. VRE colonization pressure was significantly associated with acquisition. Cultures of unit personnel and shared equipment were negative except for weighing scales. Observation of unit clinical personnel showed high compliance for hand sanitation and but less so for gowns. Conversely, ancillary staff showed poor compliance. CONCLUSIONS Transmission of VRE from room surfaces seems to be an infrequent event. Encouraging adherence to surveillance, disinfection, and contact isolation protocols may decrease VRE colonization rates.
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Affiliation(s)
- Clyde D Ford
- Intermountain Acute Leukemia and Blood and Marrow Transplant Program, LDS Hospital, Salt Lake City, UT; Division of Infectious Diseases, LDS Hospital, Salt Lake City, UT.
| | - Bert K Lopansri
- Division of Infectious Diseases, LDS Hospital, Salt Lake City, UT; Division of Infectious Diseases, University of Utah, Salt Lake City, UT
| | | | - Brandon Webb
- Division of Infectious Diseases, LDS Hospital, Salt Lake City, UT; Division of Infectious Diseases, University of Utah, Salt Lake City, UT
| | - Gregory L Snow
- Statistical Data Center, LDS Hospital, Salt Lake City, UT
| | - Daanish Hoda
- Intermountain Acute Leukemia and Blood and Marrow Transplant Program, LDS Hospital, Salt Lake City, UT
| | - Barbara Adams
- Intermountain Acute Leukemia and Blood and Marrow Transplant Program, LDS Hospital, Salt Lake City, UT
| | - Finn Bo Petersen
- Intermountain Acute Leukemia and Blood and Marrow Transplant Program, LDS Hospital, Salt Lake City, UT
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Webb BJ, Brunner A, Ford CD, Gazdik MA, Petersen FB, Hoda D. Fecal microbiota transplantation for recurrent Clostridium difficile infection in hematopoietic stem cell transplant recipients. Transpl Infect Dis 2016; 18:628-33. [PMID: 27214585 DOI: 10.1111/tid.12550] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [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: 01/08/2016] [Revised: 03/16/2016] [Accepted: 03/27/2016] [Indexed: 12/12/2022]
Abstract
Recurrent Clostridium difficile infection (CDI) is a consequence of intestinal dysbiosis and is particularly common following hematopoietic stem cell transplantation (HSCT). Fecal microbiota transplantation (FMT) is an effective method of treating CDI by correcting intestinal dysbiosis by passive transfer of healthy donor microflora. FMT has not been widely used in immunocompromised patients, including HSCT recipients, owing to concern for donor-derived infection. Here, we describe initial results of an FMT program for CDI at a US HSCT center. Seven HSCT recipients underwent FMT between February 2015 and February 2016. Mean time post HSCT was 635 days (25-75 interquartile range [IQR] 38-791). Five of the patients (71.4%) were on immunosuppressive therapy at FMT; 4 had required long-term suppressive oral vancomycin therapy because of immediate recurrence after antibiotic cessation. Stool donors underwent comprehensive health and behavioral screening and laboratory testing of serum and stool for 32 potential pathogens. FMT was administered via the naso-jejunal route in 6 of the 7 patients. Mean follow-up was 265 days (IQR 51-288). Minor post-FMT adverse effects included self-limited bloating and urgency. One patient was suspected of having post-FMT small intestinal bacterial overgrowth. No serious adverse events were noted and all-cause mortality was 0%. Six of 7 (85.7%) patients had no recurrence; 1 patient recurred at day 156 post FMT after taking an oral antibiotic and required repeat FMT, after which no recurrence has occurred. Diarrhea was improved in all patients and 1 patient with gastrointestinal graft-versus-host disease was able to taper off systemic immunosuppression after FMT. With careful donor selection and laboratory screening, FMT appears to be a safe and effective therapy for CDI in HSCT patients and may confer additional benefits. Larger studies are necessary to confirm safety and efficacy and explore other possible effects.
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Affiliation(s)
- B J Webb
- Division of Epidemiology and Infectious Diseases, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - A Brunner
- Intermountain Acute Leukemia/Blood and Marrow Transplant Program, LDS Hospital, Salt Lake City, Utah, USA
| | - C D Ford
- Intermountain Acute Leukemia/Blood and Marrow Transplant Program, LDS Hospital, Salt Lake City, Utah, USA
| | - M A Gazdik
- Division of Epidemiology and Infectious Diseases, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - F B Petersen
- Intermountain Acute Leukemia/Blood and Marrow Transplant Program, LDS Hospital, Salt Lake City, Utah, USA
| | - D Hoda
- Intermountain Acute Leukemia/Blood and Marrow Transplant Program, LDS Hospital, Salt Lake City, Utah, USA
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17
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Ford CD, Lopansri BK, Gazdik MA, Snow GL, Webb BJ, Konopa KL, Petersen FB. The clinical impact of vancomycin-resistant Enterococcus colonization and bloodstream infection in patients undergoing autologous transplantation. Transpl Infect Dis 2015; 17:688-94. [PMID: 26256692 DOI: 10.1111/tid.12433] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Revised: 07/16/2015] [Accepted: 07/20/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Although several studies have documented adverse outcomes for vancomycin-resistant Enterococcus (VRE) colonization and infection in allogeneic hematopoietic stem cell transplantation (allo-HSCT) recipients, data are inadequate for patients undergoing autologous (auto-)HSCT. METHODS We conducted a retrospective cohort study of 300 consecutive patients receiving an auto-HSCT between 2006 and 2014. Patients had stool cultures for VRE on admission and weekly during hospitalization. RESULTS Thirty-six percent of patients had VRE gastrointestinal (GI) colonization and 3% developed a VRE bloodstream infection (BSI), all of whom were colonized. VRE strain typing of BSI isolates showed that some patients shared identical patterns. Rates of colonization and BSI in colonized patients were similar to simultaneous patients undergoing allo-HSCT, except that the latter had a higher rate of colonization at admission. A diagnosis of lymphoma was associated with an increased risk of colonization. VRE BSI was associated with longer lengths of stay and possibly higher costs, but no decrease in overall survival, and colonized patients had no VRE infections during the year following discharge. Repeat stool cultures in patients subsequently undergoing allo-HSCT suggested that most, if not all, VRE-positive auto-HSCT patients lose their detectable GI colonization within a few months of discharge. CONCLUSION VRE colonization is frequent but carries a low risk for infection in patients undergoing auto-HSCT. However, these patients can serve as reservoirs for transmission to higher risk patients. Moreover, patients may remain colonized if proceeding to an allo-HSCT shortly after auto-HSCT, potentially increasing the risk of the allogeneic procedure.
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Affiliation(s)
- C D Ford
- Intermountain Acute Leukemia and Blood and Marrow Transplant Program, LDS Hospital, Salt Lake City, Utah, USA
| | - B K Lopansri
- Division of Infectious Diseases, LDS Hospital, Salt Lake City, Utah, USA.,Division of Infectious Diseases, The University of Utah, Salt Lake City, Utah, USA
| | - M A Gazdik
- Division of Infectious Diseases, LDS Hospital, Salt Lake City, Utah, USA
| | - G L Snow
- Statistical Data Center, LDS Hospital, Salt Lake City, Utah, USA
| | - B J Webb
- Division of Infectious Diseases, LDS Hospital, Salt Lake City, Utah, USA.,Division of Infectious Diseases, The University of Utah, Salt Lake City, Utah, USA
| | - K L Konopa
- Intermountain Acute Leukemia and Blood and Marrow Transplant Program, LDS Hospital, Salt Lake City, Utah, USA
| | - F B Petersen
- Intermountain Acute Leukemia and Blood and Marrow Transplant Program, LDS Hospital, Salt Lake City, Utah, USA
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Haydoura S, Wallentine J, Lopansri B, Ford CD, Saad D, Burke JP. Disseminated histoplasmosis in allogeneic bone marrow transplant: a diagnosis not to be missed. Transpl Infect Dis 2014; 16:822-6. [PMID: 24981307 DOI: 10.1111/tid.12261] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [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: 12/03/2013] [Revised: 03/27/2014] [Accepted: 04/01/2014] [Indexed: 11/26/2022]
Abstract
Immunosuppressed patients are at highest risk for disseminated histoplasmosis, but only a few cases have been reported in hematopoietic stem cell transplant recipients. We report a case of disseminated histoplasmosis in an allogeneic bone marrow transplant recipient residing in a non-endemic area. Diagnosis was first suspected based on a peripheral blood smear.
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Affiliation(s)
- S Haydoura
- Divisions of Infectious Disease, LDS Hospital/Intermountain Healthcare and University of Utah, Salt Lake City, Utah, USA
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Abstract
PURPOSE Medication errors (MEs) have been a significant problem resulting in excessive patient morbidity and cost, especially for cancer chemotherapeutic agents. Although some progress has been made, ME measurement methods and prevention strategies remain important areas of research. METHODS During a 2-year period (2003-2004), we conducted a prospective study on the oncology ward of a large community hospital, with the goals of (1) complete nurse reporting of observed medication administration errors (MAEs), (2) classifying observed MAEs, and (3) formulating improvement strategies. We also conducted a retrospective review of a randomly chosen sample of 200 chemotherapy orders to assess the appropriateness of ordering, dispensing, and administration. RESULTS Our nurses reported 141 MAEs during the study period, for a reported rate of 0.04% of medication administrations. Twenty-one percent of these were order writing and transcribing errors, 38% were nurse or pharmacy dispensing errors, and 41% were nurse administration errors. Only three MAEs resulted in adverse drug events. Nurses were less likely to report MAEs that they felt were innocuous, especially late-arriving medications from the pharmacy. A retrospective review of 200 chemotherapy administrations found only one clear MAE, a miscalculated dose that should have been intercepted. CONCLUSIONS Significant reported MAE rates on our ward (0.04% of drug administrations and 0.03 MAEs/patient admission) appear to be relatively low due to application of current safety guidelines. An emphasis on studying MAEs at individual institutions is likely to result in meaningful process changes, improved efficiency of MAE reporting, and other benefits.
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Affiliation(s)
- Clyde D Ford
- Intermountain Blood and Marrow Transplant Program and Departments of Nursing, Pharmacy, and Medicine, LDS Hospital, Salt Lake City, UT
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21
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Abstract
We report 2 patients with aggressive non-Hodgkin lymphoma who had positive restaging PET scans limited to the spleen and no significant uptake in nodal areas of previously known disease. Examination of the resected spleens from both patients revealed extensive inflammation surrounding necrotic tumor with no evidence of viable lymphoma or active infection. It is suggested that close observation of such patients for evidence of progressive disease may be considered as opposed to immediate intervention.
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MESH Headings
- Antibodies, Monoclonal
- Antibodies, Monoclonal, Murine-Derived
- Antineoplastic Combined Chemotherapy Protocols/administration & dosage
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Biopsy
- Burkitt Lymphoma/diagnostic imaging
- Burkitt Lymphoma/drug therapy
- Burkitt Lymphoma/pathology
- Carboplatin
- Cyclophosphamide
- Dexamethasone
- Disease Progression
- Doxorubicin
- Etoposide
- False Positive Reactions
- Humans
- Ifosfamide
- Laparoscopy
- Lymphoma, B-Cell/diagnostic imaging
- Lymphoma, B-Cell/drug therapy
- Lymphoma, B-Cell/pathology
- Lymphoma, Large B-Cell, Diffuse/diagnostic imaging
- Lymphoma, Large B-Cell, Diffuse/drug therapy
- Lymphoma, Large B-Cell, Diffuse/pathology
- Lymphoma, Non-Hodgkin/diagnostic imaging
- Lymphoma, Non-Hodgkin/drug therapy
- Lymphoma, Non-Hodgkin/pathology
- Male
- Middle Aged
- Necrosis
- Neoplasm Staging/methods
- Positron-Emission Tomography
- Prednisone
- Remission Induction
- Rituximab
- Salvage Therapy
- Spleen/diagnostic imaging
- Splenectomy
- Tomography, X-Ray Computed
- Unnecessary Procedures
- Vincristine
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Affiliation(s)
- Clyde D Ford
- Department of Medicine, LDS Hospital, Salt Lake City, Utah 84143, USA.
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Ford CD, Greenwood J, Anderson J, Snow G, Petersen FB. CD34+ cell adhesion molecule profiles differ between patients mobilized with granulocyte-colony-stimulating factor alone and chemotherapy followed by granulocyte-colony-stimulating factor. Transfusion 2006; 46:193-8. [PMID: 16441594 DOI: 10.1111/j.1537-2995.2006.00717.x] [Citation(s) in RCA: 12] [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] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND High-dose therapy with autologous peripheral blood progenitor cell support is widely utilized but requires successful CD34+ cell mobilization and collection. Chemotherapy plus growth factors appear to mobilize more CD34+ cells than growth factors alone. Because alterations in expression of adhesion molecules are important in the trafficking of hematopoietic progenitors, the possibility was explored that the mechanism of this superior mobilization may be greater down regulation of adhesion molecules. STUDY DESIGN AND METHODS The expression of eight adhesion molecules (CD11a, b, and c; 15s; 49d and e; 54; and 62L) on the collected CD34+ cells from 15 patients undergoing mobilization with chemotherapy plus granulocyte-colony-stimulating factor (G-CSF) was compared with those of 14 concomitant patients receiving G-CSF alone. RESULTS Patients receiving chemotherapy plus G-CSF mobilized more CD34+ cells and did not differ in prior chemotherapy or radiation. There were no significant differences in the percentage of CD34+ cells expressing any of the adhesion molecules examined between the two groups. The chemotherapy plus G-CSF-mobilized cells consistently showed higher expression intensity, and this showed significance or a strong trend for CD11a and c, CD15s, and CD54. Despite these higher expression levels, there were no differences in engraftment kinetics. CONCLUSIONS CD34+ cells mobilized by chemotherapy plus growth factors appear to have higher intensities of expression of several adhesion molecules. The significance of this observation will require further study.
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Affiliation(s)
- Clyde D Ford
- Utah Blood and Marrow Transplant Program, LDS Hospital, Salt Lake City, Utah 84143, USA.
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23
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Strait KA, Warnick CT, Ford CD, Dabbas B, Hammond EH, Ilstrup SJ. Histone deacetylase inhibitors induce G2-checkpoint arrest and apoptosis in cisplatinum-resistant ovarian cancer cells associated with overexpression of the Bcl-2–related protein Bad. Mol Cancer Ther 2005; 4:603-11. [PMID: 15827334 DOI: 10.1158/1535-7163.mct-04-0107] [Citation(s) in RCA: 43] [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: 11/16/2022]
Abstract
Trichostatin A produces predominantly G(1) cell-cycle blockade and differentiation of the cisplatinum-sensitive A2780 ovarian cancer cell line. Given the propensity of ovarian tumors to become resistant to cisplatinum, often leading to cross-resistance to other agents, we have extended these observations by examining how the emergence of resistant phenotypes in A2780 cells affects the actions of histone deacetylase (HDAC) inhibitors. Trichostatin A exposure (100 ng/mL, 24 hours) induced ultrastructural differentiation of the "intrinsically" cisplatinum-resistant A2780-9M subline, with the reappearance of intercellular junctions and lumina containing primitive microvilli. Similar trichostatin A exposure in the acquired resistance A2780CP cells produced minimal differentiation consisting of occasional weak intercellular junctions. Independent of the differences in trichostatin A-induced differentiation, in both resistant sublines trichostatin A produced a similar reduction in cell viability, by >90%, within 5 days of treatment. Diminished viability in both A2780-9M and CP cells was associated with the absence of cell cycle arrest in G1, resulting in predominant G2-checkpoint arrest accompanied by a 10- to 20-fold increase in Annexin V binding and the reemergence of apoptosis. Similar cell cycle arrests and apoptosis were also observed using other HDAC inhibitors and in other resistant ovarian cancer cell lines (OVCAR-3 and SK-OV-3). Trichostatin A-induced apoptosis in resistant cells is in sharp contrast to its effects on the parental cisplatinum-sensitive A2780 and normal MRC-5 fibroblast cell lines (predominant cycle arrest in G1 with no detectable apoptosis). Western immunoblot analysis indicated trichostatin A triggers apoptosis in resistant ovarian cancer cells via p53-independent activation of the intrinsic "mitochondrial" pathway, commensurate with induction of the Bcl-2-related protein Bad. These results suggest cisplatinum resistance alters the effects of HDAC inhibition through a shift in cell cycle arrest from the G1 to the G2 checkpoint and reactivation of the intrinsic mitochondrial apoptotic cascade.
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Affiliation(s)
- Kevin A Strait
- Department of Medicine, Laboratory for Molecular Oncology, LDS Hospital, Salt Lake City, Utah 84143, USA.
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24
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Abstract
BACKGROUND Alterations in expression of adhesion molecules are important in the trafficking of hematopoietic progenitors and probably in the mobilization process. Relatively little and conflicting data are currently available on the differences in expression between good and poor mobilizing patients. STUDY DESIGN AND METHODS In this study, the expression of eight adhesion molecules on the collected CD34+ cells from 36 patients undergoing mobilization was determined. RESULTS Good mobilizing patients, defined as those who collected their target in one apheresis procedure, had significantly fewer cells that expressed CD11a (LFA-1) and CD54 (ICAM-1) and borderline fewer that expressed CD11c, CD49d (VLA-4), and CD49d (VLA-5). No differences were detected in CD11b (Mac-1), CD15s (sLe(x)), or CD62L (L-selectin). Linear regression analysis identified number of prior chemotherapy courses and expression of CD11a (LFA-1) as independent predictive factors for mobilization efficiency. Good and poor mobilizing patients had approximately the same number of total CD34+ cells collected and little difference in times to engraftment. CONCLUSIONS CD11a (LFA-1) expression inversely correlates with mobilization efficiency. Elucidation of the mechanism(s) underlying these observations will require further study.
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Affiliation(s)
- Clyde D Ford
- Utah Blood and Marrow Transplant Program and the Department of Pathology, LDS Hospital and the University of Utah, Salt Lake City, Utah 84143, USA.
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25
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Ford CD, Asch J, Pulsipher M, Petersen FB. Successful reduced-intensity allogeneic transplantation utilizing a fludarabine-based preparative regimen in a patient with chronic lymphocytic leukaemia and a history of fludarabine-associated autoimmune haemolytic anaemia. Br J Haematol 2004; 126:623-4. [PMID: 15287959 DOI: 10.1111/j.1365-2141.2004.05088.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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26
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Abstract
A number of studies have suggested that prior chemotherapy correlates negatively with the efficiency of hematopoietic stem cell mobilization. However, little data exist with regard to the relative effects of the specific chemotherapeutic drug classes. We retrospectively reviewed the records of 201 consecutive patients with nonmyeloid malignancies undergoing CD34+ cell mobilization with chemotherapy+granulocyte colony-stimulating factor (G-CSF). The number of prior chemotherapy courses correlated negatively with the peripheral CD34+ cell concentration (pCD34) on the first day of collection (P<0.001). No significant correlation was found for age, gender, tumor primary, mobilization chemotherapy regimen, disease status, marrow involvement, prior radiation therapy, or dose and timing of G-CSF administration. When the number of courses of individual classes of chemotherapeutic agents was correlated with pCD34, only exposures to platinum compounds (P=0.001) and alkylating agents (P=0.01) were found to be independent negative predictive factors for pCD34. Within classes, DNA crosslinking agents and etoposide appeared possibly more damaging than DNA methylating agents and doxorubicin, respectively. None of the drug classes showed evidence of recovery. We conclude that exposure to chemotherapy, especially platinum compounds and alkylating agents, should be minimized prior to mobilization.
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Affiliation(s)
- C D Ford
- Utah Blood and Bone Marrow Transplantation Program, LDS Hospital and University of Utah, Salt Lake City 84143, USA.
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Warnick CT, Dabbas B, Ilstrup SJ, Ford CD, Strait KA. Cell type-dependent regulation of hMLH1 promoter activity is influenced by the presence of multiple redundant elements. Mol Cancer Res 2003; 1:610-8. [PMID: 12805408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Abstract
Immunohistochemical analysis confirmed the presence of MLH1 protein in A2780 ovarian cancer cells and its absence in this same cell line on acquired resistance to cisplatinum (A2780/CP). Transfection of a -1781-bp hMLH1 promoter construct into either A2780 or A2780/CP cells produced similar (30-fold) induction of luciferase, an indication that the transcriptional machinery for hMLH1 expression remains intact. hMLH1-luciferase activity was also unaffected by re-expression of hMLH1 following treatment of A2780/CP cells with the methylase inhibitor 2'-deoxy-5-azacytidine. Serial 5'-deletion studies of the hMLH1 promoter region in ovarian cancer cells localized transcriptional enhancers to a region (-250 to -151 bp) that excludes the previously identified CCAAT element (-282) active in HeLa cells. When these same deletion constructs were transfected into HeLa cells, deletion of the CCAAT-containing region caused a significant loss of promoter activity, an indication of cell-specific use of enhancer elements. Finally, a series of internal deletion and linker mutation studies of the -250 to -151 bp ovarian enhancer region revealed that the hMLH1 promoter contains multiple redundant enhancer elements capable of independent promoter activation and may explain the association of this region with methylation silencing of hMLH1.
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Affiliation(s)
- C Terry Warnick
- Department of Medicine and Pathology, LDS Hospital, Salt Lake City, UT 84143, USA
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28
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Ford CD, Chan KJ, Reilly WF, Petersen FB. An evaluation of predictive factors for CD34+ cell harvest yields from patients mobilized with chemotherapy and growth factors. Transfusion 2003; 43:622-5. [PMID: 12702184 DOI: 10.1046/j.1537-2995.2003.00376.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.4] [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: 11/20/2022]
Abstract
BACKGROUND Accurately predicting the outcomes of peripheral blood stem cell harvests is important because unproductive collections are expensive and subject the donor to unnecessary toxicity. STUDY DESIGN AND METHODS Predictive factors for stem cell mobilization and collection by a retrospective review of 104 consecutive donors were evaluated. RESULTS Of several previously suggested measures, the peripheral CD34+ cell concentration on the day of harvest (pCD34DH) correlated best with total numbers of CD34+ collected (r = 0.88). This was followed by the pCD34 on the day before harvest (pCD34Day -1) (r = 0.74). The peripheral WBC count on the day of harvest (pWBC) was inferior (r = 0.39). When ratios of potential predictive factors divided by the previous day's value were examined, pWBC ratio was found to be a significant independent predictive factor for cells collected (r = 0.45). Furthermore, the predictive value of both the pCD34Day -1 and the pWBC can be improved by combining with the pWBC ratio. To examine whether the chosen collection starting days were optimal, serial pCD34 obtained daily during the harvest procedures was examined. Poorly mobilizing donors, who required several days of collection, did not reach maximal harvest yields until the fourth collection day. CONCLUSIONS pCD34DH is the optimal predictive factor for harvest yields. If pCD34DH is not available, pCD34Day -1 or pWBC combined with the pWBC ratio may offer the best prediction of harvest outcomes. The best harvest yields on poorly mobilizing donors occur 3 to 4 days after the usual collection starting times.
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Affiliation(s)
- C D Ford
- Blood and Bone Marrow Transplant Program, LDS Hospital, Eighth Avenue and C Street, Salt Lake City, UT 84143, USA.
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29
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Strait KA, Dabbas B, Hammond EH, Warnick CT, Iistrup SJ, Ford CD. Cell cycle blockade and differentiation of ovarian cancer cells by the histone deacetylase inhibitor trichostatin A are associated with changes in p21, Rb, and Id proteins. Mol Cancer Ther 2002; 1:1181-90. [PMID: 12479699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2023]
Abstract
Inhibitors of histone deacetylase activity are emerging as a potentially important new class of anticancer agents. In the current studies, exposing A2780 ovarian cancer cells to the histone deacetylase inhibitor trichostatin A (TSA) produced a marked change in cellular morphology, proliferation, and differentiation. Within 24 h of TSA treatment, there was a morphological transformation of the cells, with increased cytoplasm, a more epithelial-like columnar appearance, and the emergence of distinct cellular boundaries. Commensurate with the morphological transformation, TSA also inhibited cell proliferation; cells treated with TSA for 72 h increased to 110% of the initial cell numbers versus control cell numbers of 622%, with a corresponding reduction in mitotic activity and a flow cytometry S-phase fraction of 3.9% in TSA-treated cells versus 28.8% for control. TSA also induced epithelial-like differentiation with increased cytokeratin expression from 2% of controls to 22-25% of TSA-treated cells and the reappearance of intercellular plasma membrane junctions and primitive microvilli. Immunocytochemical analyses indicate the molecular mechanism underlying the actions of TSA on A2780 cell cycle progression and differentiation involves reexpression of the CDK inhibitor p21. Elevated levels of p21, in TSA-treated cells, were associated with a reduction in the phosphorylation of the cell cycle regulator retinoblastoma protein (Rb). TSA also caused a decrease in the helix-loop-helix inhibitor of differentiation/DNA binding protein Id1, with no change in Id2 levels. In conclusion, the observed TSA-induced changes in p21, Rb, and Id1 are consistent with cell cycle senescence and differentiation of A2780 ovarian cancer cells.
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Affiliation(s)
- Kevin A Strait
- Department of Medicine, Cancer Research Laboratory, LDS Hospital, Salt Lake City, Utah 84143, USA.
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Abstract
Optimal collections of mobilized CD34+ cells are important in terms of both patient toxicity and cost. The factors that determine CD34+ collection efficiency (CD34eff) of cell separators have not been well studied. In addition, because several cell separators are available, the type of collection device may also be a significant variable. Previous studies comparing the Baxter-Fenwal CS3000 and the COBE Spectra have not yielded consistent conclusions. Therefore, we retrospectively analyzed the collection outcomes of 163 consecutive donors with a peripheral CD34+ cell concentration (pCD34) of > or =5 cells/microl on the first collection that had been harvested on one or the other device. The CS3000 was found to yield a significantly higher CD34eff (50% vs. 39%, P = 0.006). However, donors were not balanced for several prognostic factors, which may contribute to CD34eff including mobilization with G-CSF vs. chemotherapy+G-CSF, average flow rate, and total volume of peripheral blood processed. When appropriate variables were included in a stepwise multiple variable analysis, cell separator type emerged as a significant independent predictive factor for CD34eff (P = 0.018). Our data indicates that the CS3000 will, on average, show a higher absolute CDeff of 8%. Furthermore, since the two devices differ in mechanism, prognostic factors may also differ. Comparisons suggest that peripheral blood WBC and hematocrit may be more important predictors for the CS3000.
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Affiliation(s)
- C D Ford
- Utah Blood and Marrow Transplant Program, LDS Hospital, Eighth Avenue and C Street, Salt Lake City, UT 84143, USA.
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31
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Ford CD, Greenwood J, Strupp A, Lehman CM. Change in CD34+ cell concentration during peripheral blood progenitor cell collection: effects on collection efficiency and efficacy. Transfusion 2002; 42:904-11. [PMID: 12375664 DOI: 10.1046/j.1537-2995.2002.00131.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [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: 11/20/2022]
Abstract
BACKGROUND An understanding of factors affecting CD34+ cell collection efficacy is essential to minimize donor toxicity and cost. STUDY DESIGN AND METHODS Peripheral blood CD34+ cell (CD34) measurements were determined at various intervals before, during, and after automated cell collection (Cobe Spectra 6.0). The serial mean of multiple, intraprocedural CD34 levels was calculated for each procedure as an estimate of the mean, inlet-line CD34 level. RESULTS The CD34+ concentration fell a mean of 30 percent in the first 30 to 70 minutes of collection. The degree of decline was inversely correlated with donor blood volume (BV), but was not due to hemodilution. The mean of the CD34 level before and after collection slightly overestimated the serial mean CD34 level. Cell yields, normalized for the CD34 level before collection, were higher from donors with larger BVs. CONCLUSIONS The CD34 concentration rapidly decreased to a relative equilibrium level during the collection procedure. The degree of decrease in the CD34 level inversely correlated with the BV of the donor and was consistent with cell pooling in the collection set. The higher equilibrium CD34 levels in donors with larger BVs resulted in increased collection of CD34+ cells, and therefore, large-volume apheresis should be most efficient in these donors.
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Affiliation(s)
- Clyde D Ford
- Utah Blood and Bone Marrow Transplant Program, LDS Hospital, Salt Lake City 84143, USA.
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Warnick CT, Dabbas B, Ford CD, Strait KA. Identification of a p53 Response Element in the Promoter Region of the hMSH2 Gene Required for Expression in A2780 Ovarian Cancer Cells. J Biol Chem 2001; 276:27363-70. [PMID: 11350971 DOI: 10.1074/jbc.m103088200] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.6] [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: 11/06/2022] Open
Abstract
Defects in the human MSH2 mismatch repair system have been implicated in cellular mutagenesis, tumorigenesis, and chemotherapeutic resistance. The current studies characterized the 5' upstream proximal promoter region of the hMSH2 gene using transient transfection of A2780 ovarian cancer cells. Serial deletions of a 1.88-kb fragment of the proximal promoter region of the hMSH2 gene revealed that promoter activity was restricted to the first -281 bp. Targeted deletions within this -281 bp region coupled with specific sequence mutagenesis identified a response element for the p53 tumor suppressor protein located between -242 and -222 bp. The -242 hMSH2 p53 element is configured as a direct tandem repeat palindrome with 80% homology to the p53 consensus binding sequence. Co-transfection of an hMSH2 reporter and p53 expression vector into the p53-null cell line SK-OV-3 produced 10-fold enhanced transcription, which was lost when the -242 to -222 p53 binding site was mutated. These results clearly demonstrate the presence of a previously unidentified p53 response element in the hMSH2 proximal promoter. Its location at -242 bp upstream of the start site of transcription is distinct from two previously reported p53 sites at -447 and -416, which transactivate in Saos-2 cells (Scherer, S. J., Maier, S. M., Seifert, M., Hanselmann, R. G., Zang, K. D., Muller-Hermelink, H. K., Angel, P., Welter, C., and Schartl, M. (2000) J. Biol. Chem. 275, 37469-37473). Finally, in sharp contrast to their activity in Saos-2 cells, deletion of the -447 and -416 sites in A2780 cells had no effect on hMSH2 promoter activity. Thus, it appears that p53 regulates hMSH2 expression through multiple cell type-specific DNA response elements.
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Affiliation(s)
- C T Warnick
- Departments of Medicine and Pathology, Cancer Research Laboratory, LDS Hospital, Salt Lake City, Utah 84143, USA
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Abstract
BACKGROUND The yield of CD34-positive cells obtained from an apheresis procedure is determined, in part, by the efficiency of collection. Optimization of the efficiency of CD34-positive peripheral blood cell collection requires identification of predictive factors. STUDY DESIGN AND METHODS Demographic, stem cell collection, mobilization, and disease-related measures from autologous and allogeneic donors undergoing 252 progenitor cell apheresis procedures were retrospectively reviewed. Statistical relationships between CD34 collection efficiency and the various measures were determined by correlation and multiple linear regression analysis. RESULTS CD34 collection efficiency inversely correlated with the peripheral white cell count, hematocrit, and serum albumin concentration (R2 = 0.29). White cell count was the single best predictor of CD34 efficiency (R2 = 0.19). Donor groups with cytopenias (patients vs. normal donors; increased cycles of prior chemotherapy; bone marrow involvement; chemotherapy plus growth factor mobilization) had higher collection efficiencies. Only 29 percent of the variability in the data could be attributed to white cell count, hematocrit, and albumin concentration. The majority of the remaining variability was due to unexplained differences between donors. CONCLUSION CD34 collection efficiencies show considerable variation. Higher peripheral white cell counts, hematocrits, and/or albumin concentrations result in decreased CD34 collection efficiency, but most of the variability in the data is not accounted for by these three factors.
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Affiliation(s)
- C D Ford
- Blood and Bone Marrow Transplant Program, LDS Hospital, Salt Lake City, Utah, USA
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Ford CD, Reilly W, Wood J, Classen DC, Burke JP. Oral antimicrobial prophylaxis in bone marrow transplant recipients: randomized trial of ciprofloxacin versus ciprofloxacin-vancomycin. Antimicrob Agents Chemother 1998; 42:1402-5. [PMID: 9624484 PMCID: PMC105612 DOI: 10.1128/aac.42.6.1402] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [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: 02/07/2023] Open
Abstract
The optimal oral antimicrobial prophylactic regimen for bone marrow transplant recipients remains to be elucidated. We randomized 84 patients to receive either oral ciprofloxacin or ciprofloxacin plus vancomycin at hospital admission. Patients were monitored for bacteremias and clinical parameters, and stool and throat swab surveillance cultures were performed. The addition of vancomycin resulted in a significant decrease in the frequency of patients with surveillance cultures positive for coagulase-negative staphylococci (stool cultures, 44 versus 23%; throat swab cultures, 37 versus 19%) and alpha-hemolytic streptococci (throat swab cultures, 90 versus 60%). The frequencies of positivity for Candida spp. and gram-negative organisms on surveillance cultures were comparable. Despite these results, no differences in the incidences of bacteremias (12 of 41 versus 12 of 43 patients) or clinical parameters such as number of days to first fever, total number of febrile days, length of stay, and number of transfusions could be demonstrated. Because of a lack of efficacy of vancomycin and emerging problems with vancomycin-resistant isolates, vancomycin should not be used in oral antimicrobial prophylaxis regimens.
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Affiliation(s)
- C D Ford
- Department of Medicine, LDS Hospital, Salt Lake City, Utah 84143, USA.
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Abstract
BACKGROUND Perioperative blood transfusion has been reported to cause a variety of immunosuppressive effects, including increased rates of malignancy recurrence. The effect of perioperative transfusion on second malignancy risk has not previously been investigated. STUDY DESIGN AND METHODS Second malignancy risk was evaluated in 1053 patients previously operated upon for colon cancer, and these findings are related to perioperative transfusion history. RESULTS Transfusion history did not relate to the probability of a patient's remaining free of second malignancy. CONCLUSION An increased risk of total or second malignancies (with the possible exception of lung cancer) was not associated with transfusion.
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Affiliation(s)
- C D Ford
- Tumor Registry, LDS Hospital, Salt Lake City, Utah
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Ford CD, VanMoorleghem G, Menlove RL. Blood transfusions and postoperative wound infection. Surgery 1993; 113:603-7. [PMID: 8506516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Several studies have suggested an association between blood transfusions and infection in surgical patients. However, previous reports have not documented the relationship of transfusion to specific infection sites and have not adequately explored the importance of timing and type of blood product. METHODS We reviewed the records of all patients undergoing operation for colon cancer at a large community hospital during the years 1974 to 1987. Data on hospital wound and other infections, wound infection risk factors, and type and timing of transfusions were analyzed. RESULTS Increased wound infection rates were associated with administration of both whole blood and packed red blood cells. However, multivariate analysis suggested that only the administration of packed red cells after operation independently predicted wound infections. Other independent variables were the presence of a colostomy and/or drain. A highly predictive model for wound infection was constructed with these three variables. CONCLUSIONS Blood transfusions, especially with packed red cells, after operation are an independent risk factor for wound infection.
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Affiliation(s)
- C D Ford
- LDS Hospital, Salt Lake City, Utah 84143
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Wozniak AJ, Samson MK, Shah NT, Crawford ED, Ford CD, Altman SJ, Stephens RL, Natale RB, Bouroncle BA, Blumenstein BA. A randomized trial of cisplatin, vinblastine, and bleomycin versus vinblastine, cisplatin, and etoposide in the treatment of advanced germ cell tumors of the testis: a Southwest Oncology Group study. J Clin Oncol 1991; 9:70-6. [PMID: 1702148 DOI: 10.1200/jco.1991.9.1.70] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
This is a Southwest Oncology Group (SWOG) prospective randomized trial of cisplatin, vinblastine, and bleomycin (PVB) versus vinblastine, cisplatin, and etoposide (VP-16) (VPV) in the treatment of advanced germ cell tumors of the testis. The study objective was to determine what effect the replacement of bleomycin with VP-16 has on complete response (CR), survival, and drug toxicity. One hundred sixty-nine patients were registered and randomized. Of these patients, 160 were assessable for response. All had histologically confirmed disseminated germ cell neoplasms of testicular origin. Forty-six had minimal metastatic disease, and 114 had maximal disease. Seventy-seven were randomized to PVB and 83 to VPV chemotherapy. There was no significant difference in pretreatment characteristics between the two arms with regard to tumor burden, histologic type, and overall performance status. Patients received four courses of induction chemotherapy, either PVB (cisplatin 120 mg/m2 day 3, vinblastine 12 mg/m2 day 1, bleomycin 15 U/m2 twice per week) or VPV (vinblastine 8 mg/m2 day 1, cisplatin 120 mg/m2 day 3, VP-16 50 mg/m2 days 2 to 5). Chemotherapy was given every 3 weeks. Cytoreductive surgery was done postinduction if a chemotherapy CR was not achieved. There was no difference in the percentage of patients achieving a disease-free status between PVB (77%) and VPV (73%). The mean leukocyte nadir was similar for both treatments, but the mean platelet nadir was significantly lower (P = .003) in the VPV arm. All bleomycin-related toxicities (pulmonary, mucositis, skin) were avoided in the VPV arm. We conclude that bleomycin can be replaced in first-line therapy for advanced germ cell tumors without sacrificing efficacy and with the advantage of avoiding unnecessary drug toxicity.
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Affiliation(s)
- A J Wozniak
- Wayne State University Medical Center, Detroit, MI
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Classen DC, Burke JP, Ford CD, Evershed S, Aloia MR, Wilfahrt JK, Elliott JA. Streptococcus mitis sepsis in bone marrow transplant patients receiving oral antimicrobial prophylaxis. Am J Med 1990; 89:441-6. [PMID: 2171333 DOI: 10.1016/0002-9343(90)90373-l] [Citation(s) in RCA: 69] [Impact Index Per Article: 2.0] [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: 12/30/2022]
Abstract
PURPOSE Streptococcal infection has increasingly become a problem in neutropenic patients. We report on an outbreak of Streptococcus mitis sepsis in six bone marrow transplant patients receiving oral antimicrobial prophylaxis. PATIENTS AND METHODS We performed an epidemiologic study of all patients in our bone marrow transplant program from 1986 to 1988. The hospital and microbiology records for all patients were reviewed. All bone marrow patients were treated according to specified protocols, including an oral prophylactic antimicrobial regimen that was changed in late 1987 from vancomycin/polymyxin/tobramycin to norfloxacin. Identification, susceptibility testing, and whole cell protein analysis of streptococcal isolates were performed at the Reference and Antimicrobial Investigations Laboratories at the Centers for Disease Control. RESULTS We detected six cases of S. mitis sepsis among 21 patients undergoing bone marrow transplantation. No other concurrent pathogen was isolated from any patient at the time of the S. mitis bacteremia. Bacteremia developed within 72 hours of transplant in five of six patients and was associated with severe mucositis in four patients. An environmental study failed to reveal any common source for the outbreak, and whole cell protein analysis of all six S. mitis isolates revealed each to be distinct. Of 12 patients receiving oral vancomycin/polymyxin/tobramycin, one developed S. mitis bacteremia, versus five of nine patients receiving norfloxacin (p less than 0.03). CONCLUSION We believe S. mitis bacteremia is a potential complication of bone marrow transplantation and is associated with antimicrobial prophylaxis with norfloxacin, especially in the setting of mucositis.
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Affiliation(s)
- D C Classen
- Division of Infectious Disease, LDS Hospital, Salt Lake City, Utah 84143
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Abstract
We report a case of post-lumbar-puncture headache successfully treated with intravenous caffeine sodium benzoate. The patient presented to the emergency department with a severe headache three days after a myelogram of the lumbar region. Caffeine sodium benzoate (500 mg) in 1 liter of fluid (D5LR) intravenously over one and a half hours was administered. The patient reported complete resolution of symptoms and no recurrence of headache. Caffeine sodium benzoate is a simple treatment of post-lumbar-puncture headaches. It should be considered as a safe alternative to an epidural blood patch for the treatment of post-lumbar-puncture headaches.
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Affiliation(s)
- C D Ford
- Emergency Department, Memorial Hospital of Laramie County, Cheyenne, Wyoming
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Ford CD, Warnick CT, Sheets S, Quist R, Stevens LE. Blood transfusions lower natural killer cell activity. Transplant Proc 1987; 19:1456-7. [PMID: 3274353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- C D Ford
- Department of Medicine, LDS Hospital, Salt Lake City, UT 84143
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Ford CD. Reflections on Ohio's malpractice climate. Ohio State Med J 1984; 80:303-8. [PMID: 6717882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Abstract
The observations that limited neonatal diethylstilbesterol (DES) exposure in mice produces persistent natural killing defects and that natural killer (NK) cells have an origin early in gestation suggested the possibility that NK abnormalities may exist in in utero DES-exposed women. However, when compared to controls, these women showed slightly higher NK activity with no evidence of stimulation by accessory mononuclear cells. Altered natural killing cannot be invoked in this population as a contributing factor to increased cancer risk.
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Ford CD. Taking charge. Interview by Carol Wright Mullinax. Ohio State Med J 1982; 78:695-6. [PMID: 7155498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Ford CD. Breaking new ground. Questions and answers about OSMA's new Group Professional Liability Plan. Ohio State Med J 1982; 78:599-601. [PMID: 7145294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Ford CD. Facing the free riders. Ohio State Med J 1979; 75:755, 758-60. [PMID: 523051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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