Comparison of global decolonization efficacy with mupirocin nasal drop and chlorhexidine mouthwash in acute leukemia patients: randomized clinical trial

PURPOSE

Neutropenic fever remains a major complication in acute leukemia. Decolonization is assumed as a promising intervention for eradicating causative agents of infection.

METHODS

In this randomized clinical trial, 96 patients with acute leukemia were assigned randomly to mupirocin nasal drop 2% (n = 32), chlorhexidine mouthwash 0.2% (n = 33), and control group (n = 31). In control group, patients did not receive any medication for decolonization. All patients received treatment for 5 days (2 days prior to chemotherapy until 3 days after chemotherapy). Pharynx and nasal swabs were taken prior to the intervention and at the end of decolonization period in all groups. Antibiotic susceptibility testing was performed by the disc diffusion method in order to identify bacterial isolates.

RESULTS

Bacterial recovery of both nasal and pharynx swabs was observed after global decolonization with mupirocin nasal drop. Decolonization with mupirocin significantly eradicated Coagulase-negative staphylococci (CONS) in both nasal and pharynx swabs (p-value = 0.000). Moreover, mupirocin decreased Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus (MRSA) species. Chlorhexidine mouthwash significantly eradicated CONS in pharynx swabs (p-value = 0.000). In addition, both decolonization strategies decreased both antibiotic use and frequency of fever in leukemic patients.

CONCLUSION

Global decolonization with mupirocin nasal drop not only eradicates both nasal and pharynx microorganisms, but also reduces antibiotic requirement and frequency of fever in patients with acute leukemia. The protocol of the present study was approved on December 2016 (registry number: IRCT20160310026998N6).

An Investigation of Insulin Resistance and Cachexia Relation in Patients with Metastatic Gastrointestinal Malignancies

Background: Insulin resistance has been suggested as one of the known metabolic disorders during cachexia. This study hypothesized that cachexia in cancer patients might be related to insulin resistance as early as cachexia development. Methods: This study was performed on 46 patients with metastatic gastrointestinal cancer. Anthropometric characteristics and biochemical markers were assessed at baseline, second and third month. Insulin resistance was assessed using the homeostasis model assessment-estimated insulin resistance (HOMA IR) method. SFQ-36 questions were used to assess the patients' quality of life at baseline, second and third months. Results: Anthropometric characteristic was significantly associated between pre-cachectic and non-pre-cachectic patients in third month. Cholesterol (P-value = 0.93), albumin (P-value: 0.82), and serum creatinine (P-value = 0.88) in pre-cachectic patients decreased over three months. There was an increasing trend of insulin resistance between pre-cachectic and non-pre-cachectic patients in third month. Cholesterol had an upward trend with a significant relation in cachectic patients [(P-value = 0.00), (P-value = 0.03), (P-value = 0.01)]. We detected a decreasing trend of insulin resistance between cachectic and non-cachectic patients from second to third month (P-value = 0.04). SFQ evaluation had no significant relation with cachectic status. Conclusion: Previous studies showed that the use of NSAIDs, progesterone’s, corticosteroids, COX-2 inhibitors, anabolic agents and drugs targeting inflammatory cytokines may be beneficial for improving of symptoms of cachexia. Significant relation between anthropometric variables with pre-cachexia and cachectic conditions was concluded. Patients' outcome and its relation with insulin resistance demonstrated a significant relation between the cachectic and non-cachectic patients in the third month. We also detected the increased serum cholesterol level in cachectic patients, moreover, higher cholesterol levels in expired cachectic patients than in the living.

Drug Utilization Evaluation of Agents Administered for Prevention and Treatment of Cancer-Related Infections

Background: Due to the critical role of antibiotics and increasing trend of resistance in developing countries, comprehensive methods of antibiotic use is necessary to limit the threat of resistant microorganisms. In this study we compare antibiotics consumption by Defined Daily Dose (DDD) per 100 bed-days in Shahid Ghazi hospitals during three months in Tabriz, Iran. Methods: This is a retrospective study, which enrolled patients with malignancy who admitted to Shahid Ghazi hospital from January till March 2016. From all, 58 patients diagnosed with malignancy and received antibiotics for prophylaxis and/or treatment. For the purpose of Drug Utilization Evaluation (DUE) all antibiotics, antifungals and antiviruses consumption for any reason (prophylaxis, empiric therapy, targeted therapy) were recorded. Data on administered medications such as indication, duration, and dose were compared according to the guidelines of the NCCN 2.2016. The accuracy of antibiotics consumption was assessing by NCCN (2.2016) guideline. Anatomical Therapeutic Chemical (ATC) code J01 was explained as defined daily doses per 100 bed- days (DDD/100) according to the ATC/DDD classification. The amount of consumption was assessed with DDD per 100 bed-days in three months. Results: from 56 patients, 46 of them had hematologic malignancy and 10 of them had solid tumors. The indication of antibiotics and antifungal prophylaxis were wrong in 19.6% of indications. The prophylaxis dosage of antibiotics, antifungal, antiviral and PCP were wrong in 8.8%, 41.7%, 80% and 50%, respectively. The prophylaxis duration of antibiotics, antifungal, antiviral and PCP were wrong in 69.4%, 61.2%, 80% and 100% respectively. The dose adjustment of antibiotics with GFR and renal status of patients, in 8 of 9 patients (88.88%) who received meropenem, and in 9 of 23 patients (39.13%) who received imipenem, were not applicable according standard guidelines. The total consumption of systemic antibiotics in Ghazi Hospital during 3 months was 5091 (Table 7). From all patients 75% of them received antibiotics according to the ATC/DDD classification System. Conclusion: Specific strategies should be employed in infection control development and engage rational antibiotic utilization in order to reduce future resistant strains and increase anti-microbial efficacy.

Isolation and identification of nontuberculous mycobacteria from specimens of lower respiratory tract of transplanted patients based on the evaluation of 16SrRNA gene

BACKGROUND

Nontuberculous mycobacteria are pervasive microorganisms and are often present as saprophytes in humans, animals, and the environment. Today, these bacteria are known as the most important environmental opportunists and, in the last decades, infections by nontuberculous mycobacteria have multiplied, due to increased immunodeficiency (cancer, transplant recipients, HIV).

STUDY DESIGN

This study aimed to investigate the infections by nontuberculous mycobacteria in transplanted patients.

METHODS

The study was performed on 57 samples from respiratory secretions of transplant recipients taken by standard methods. Nontuberculous mycobacteria were identified by culture method and molecular identities of clinical isolates were investigated by PCR amplification using 16SrRNA gene and sequence analysis and Blast of the sequences. Demographic data were evaluated by Spss software.

RESULTS

The prevalence of nontuberculous mycobacteria in transplant patients was 22.8%, the age of patients was between 23 and 52 years. The most common involvement of nontuberculous mycobacteria in our transplanted individuals were 6 strains of M avium-intracellulare Complex (42.87%), followed by 2 strains of M marinum (14.29%) and 1 strain each (7.14%) of M xenopi, M chelonae, M intracellulare, M kansasii, M simiae. At the conclusion of the tests, one final strain was identified as M tuberculosis (7.14%).

CONCLUSION

The prevalence of nontuberculous mycobacteria indicates their importance in the fate of these patients. The identification of nontuberculous mycobacteria is a neglected part of microbiology laboratories, due to the lack of sufficient facilities and the risk associated with their culture. Therefore developing routine methods for the identification of these infections appears to be critical, especially in hospitals with the transplantation ward.

Reliability Evaluation of Fluorescence In Situ Hybridization (FISH) and G-Banding on Bone Marrow and Peripheral Blood Cells in Chronic Myelogenous Leukemia Patients

Chronic myeloid leukemia (CML) is a myeloproliferative disease. The cytogenetic hallmark of CML is Philadelphia (Ph) chromosome. This study aimed to diagnose suspected CML patients, to monitor CML patients under therapy using cytogenetic and fluorescence in situ hybridization (FISH) techniques to analyze their bone marrow (BM) and peripheral blood (PB) samples, and finally to compare their obtained results for both specimens. This study was conducted during one-year period (2012-2013). The participants were recruited from the Hematology and Oncology Clinic of Shahid Gazi (Emam Reza) Hospital of Tabriz University of Medical Sciences, Tabriz, East Azerbaijan Province, Iran. We analyzed 90 samples from 60 suspected CML patients (30 BM and 60 PB samples). All samples were analyzed using G-banding, 5 samples using dual fusion FISH (DF-FISH) probes, as well as 30 samples using both FISH and G-banding. Among the 90 analyzed samples of 60 patients, 25 (41.66%) were Ph+ using karyotyping, whereas five cases were not analyzable, so FISH was applied and the results confirmed that only two individuals were BCR-ABL+. In the comparison between 25 BM and 25 PB samples using karyotyping, 15 (60%) and 10 (40%) were ph+, respectively. The comparison of FISH and karyotyping on 30 samples showed that 9 (30%) and 8 (26.66%) were Ph+, respectively, and only 18.18% of Ph+ patients showed atypical patterns. In the comparison between BM-cytogenetic and PB- interphase-FISH (I-FISH), BM-cytogenetic was more reliable than PB-I-FISH in detecting Ph. Our data demonstrate that FISH analysis is a rapid, reliable and sensitive technique. The comparison between BM and PB showed that PB can not be replaced by BM, even in detecting by FISH.

Delayed hemolytic transfusion reaction with multiple alloantibody (Anti S, N, K) and a monospecific autoanti-JK(b) in intermediate β-thalassemia patient in Tabriz

It appears that delayed hemolytic transfusion reactions may occur several days after the administration of donor red cells is true even though they have been shown to be compatible in cross match tests by the antiglobulin technique. A specific case was observed in our center, which confirms the fact. The patient was a 37-year-old male suffering from intermediate β-thalassemia. He had a history of two previous transfusions, with unknown transfusion reaction. In the last transfusion, laboratory data showed: Hb 7.8 g/dL and Hematocrit (Hct) 24.2%. The patient received two units of cross matched, compatible concentrated red blood cells (RBCs). After eight days a severe reaction was observed with clinical evidence of tachycardia, fatigue, fever, back pain, chest discomfort, jaundice, nausea and anorexia. Accordingly delayed hemolytic transfusion reaction was suspected, and anti-RBC antibodies were tested. Laboratory tests revealed the presence of three alloantibodies: Anti-N, anti-S, anti-K, and a monospecific autoanti-JK(b).

Successful management of total knee replacement in a high responder hemophilia patient with a history of inhibitor

The development of inhibitors against administered clotting factors may render replacement therapy ineffective for some hemophilia patients. Such patients are therefore at the highest risk of developing arthropathy. Elective orthopedic surgery (EOS) in hemophilic patients having such inhibitors remains a rare, expensive, and difficult surgery, whose management represents a significant challenge. We report the case of a 35-year-old man with a severe form of hemophilia A (factor VIII < 1%), who was suffering from repetitive spontaneous hemarthrosis, especially in his knee joints that had consequently become more susceptible to bleeding. The patient had a history of high levels of factor VIII inhibitor (> 5.0 Bethesda Unit [BU]/ml) as shown by the factor VIII inhibitor assay; therefore, we began treatment with factor VIIa for his mild-to-moderate bleeding (90 µg/kg intravenous bolus injections). The interval between injections varied with the severity of the hemorrhage in each bleeding episode. The inhibitor level reduced to 3.1 BU/ml after three months, to 1.6 BU/ml after six months, and disappeared completely after one year of treatment. We administered factor VIII at a dose of 50 IU/kg every eight hours during the first three post-operative days, then continued administration with a dose of 40 IU/kg every 12 hours for another four days, and observed a very good response to treatment with no bleeding. Recombinant activated factor VII (rFVIIa) is not an inhibitor-removal strategy, but an inhibitor-bypassing product. However, in our patient, the treatment of mild-to-moderate bleeding with short-term use of rFVIIa and no exposure to factor VIII caused a gradual reduction in the inhibitor level over a period of 1 year.

Evaluation of Copper, Zinc, Cu/Zn, and VEGF in Patients with AML in Iran

BACKGROUND

Copper and zinc are the elements with numerous physiological activities. Copper (Cu) has an important role in angiogenesis and acts by increasing Vascular Endothelial Growth Factor (VEGF). Serum levels of copper will be increased in cancer incidence, progression and recurrence. The aim of this study was to measure blood levels of copper, zinc, and the ratio of Cu /Zn, as well as VEGF levels before and after treatment of acute myeloid leukemia.

METHODS

Thirty patients who were recently diagnosed with Acute Myeloblastic Leukemia (AML) in Shahid Ghazi Tabatabai oncology hospital enrolled in this clinical trial. On the first day, blood samples were taken for copper, zinc, and VEGF assay and flowcytometry. Treatment protocol was (7×3) regimen. Blood samples were collected for evaluation of copper, zinc, and VEGF. They were sent to Biochemistry Laboratory in medicine faculty for analysis.

RESULTS

Amongst 30 AML patients, 14 (46.7%) were female and 16 (53.3%) were male. Patients of various ages ranged from 16 to 53 years, with a median age of 9.1±9.35 years. The mean serum level of copper, zinc, and mean Cu/Zn ratio before and after treatment showed significant difference (p<0.05) There was also significant difference between the mean VEGF level before and after treatment (p<0.05).

CONCLUSION

This study reveals that there is no significant relationship between copper, zinc serum levels, their ratio, and VEGF in AML patients. We hypothesize that increased serum copper is associated with increase of VEGF levels which can indicate the impact of copper in malignancies including AML.