Surveillance on meticillin-sensitive Staphylococcus aureus colonization and infection in a neonatal intensive care unit

BACKGROUND

Meticillin-sensitive Staphylococcus aureus (MSSA) infection is a significant health concern in neonatal intensive care units (NICUs). Bacterial colonization increases the risk of subsequent infection, leading to morbidity and mortality.

AIM

To report the findings of a retrospective cohort study on the surveillance of MSSA colonization and infection in NICU patients.

METHODS

The weekly microbial surveillance results for MSSA colonization in the throat, nose, anus, and groin, as well as invasive and non-invasive MSSA infections, were analysed from November 2020 to June 2022. The MSSA infection and colonization risk were compared after adjustment for confounders by stepwise logistic regression analysis.

FINDINGS

Three hundred and eighty-three neonates were screened; 42.8% (N=164) were MSSA colonized. Significant risk factors for MSSA colonization were length of stay, vaginal delivery and extreme low gestational age <28 weeks (ELGAN) (all P<0.05). The surveillance detected 38 (9.9%) mild MSSA infections and 11 (2.9%) invasive MSSA infections. Neonatal colonization with MSSA is a major risk factor for MSSA infection overall (29.3% in colonized/infected vs 70.7% colonized/not-infected and 0.5% in not-colonized/infected vs 99.5% in not-colonized/not-infected infants) and invasive MSSA infections (6.1% in colonized/infected vs 93.9% in colonized/not-infected and 0.5% in non-colonized/infected vs 99.5% not-colonized/not-infected infants). Also, extreme low birth weight (<1000 g), ELGAN and invasive ventilation were significant risk factors for MSSA infections (all, P<0.05).

CONCLUSIONS

The link between postnatal MSSA colonization and subsequent MSSA infection offers possibilities for prevention. Additional research is needed to explore the association between vaginal birth and the pathogenesis of neonatal MSSA colonization.

Cosmetic Results and Side Effects of Accelerated Partial-Breast Irradiation Versus Whole-Breast Irradiation for Low-Risk Invasive Carcinoma of the Breast: The Randomized Phase III IRMA Trial

PURPOSE

The results in terms of side effects vary among the published accelerated partial-breast irradiation (APBI) studies. Here, we report the 5-year results for cosmetic outcomes and toxicity of the IRMA trial.

METHODS

We ran this randomized phase III trial in 35 centers. Women with stage I-IIA breast cancer treated with breast-conserving surgery, age ≥ 49 years, were randomly assigned 1:1 to receive either whole-breast irradiation (WBI) or external beam radiation therapy APBI (38.5 Gy/10 fraction twice daily). Patients and investigators were not masked to treatment allocation. The primary end point was ipsilateral breast tumor recurrence. We hereby present the analysis of the secondary outcomes, cosmesis, and normal tissue toxicity. All side effects were graded with the Radiation Therapy Oncology Group/European Organisation for Research and Treatment of Cancer Radiation Morbidity Scoring Schema. Analysis was performed with both intention-to-treat and as-treated approaches.

RESULTS

Between March 2007 and March 2019, 3,309 patients were randomly assigned to 1,657 WBI and 1,652 APBI; 3,225 patients comprised the intention-to-treat population (1,623 WBI and 1,602 APBI). At a median follow-up of 5.6 (interquartile range, 4.0-8.4) years, adverse cosmesis in the APBI patients was higher than that in the WBI patients at 3 years (12.7% v 9.2%; P = .009) and at 5 years (14% v 9.8%; P = .012). Late soft tissue toxicity (grade ≥ 3: 2.8% APBI v 1% WBI, P < .0001) and late bone toxicity (grade ≥ 3: 1.1% APBI v 0% WBI, P < .0001) were significantly higher in the APBI arm. There were no significant differences in late skin and lung toxicities.

CONCLUSION

External beam radiation therapy-APBI with a twice-daily IRMA schedule was associated with increased rates of late moderate soft tissue and bone toxicities, with a slight decrease in patient-reported cosmetic outcomes at 5 years when compared with WBI, although overall toxicity was in an acceptable range.

Side Effects 15 Years after Lymph Node Irradiation in Breast Cancer: Randomized EORTC Trial 22922/10925

BACKGROUND

Uncertainty about the benefit/risk ratio of regional lymph node irradiation led to varying clinical protocols. We investigated long-term late side effects after internal mammary and medial supraclavicular (IM-MS) lymph node irradiation to improve shared decision-making.

METHODS

The multicentre EORTC trial (ClinicalTrials.gov, NCT00002851) randomized stage I-III breast cancer patients with involved axillary nodes and/or a medially located primary tumor. We analyzed late side effects, both longitudinally at every follow-up and cross-sectionally at 5-year intervals. All statistical tests were 2-sided.

RESULTS

Between 1996 and 2004, 46 departments from 13 countries accrued 4004 patients. Median follow-up was 15.7 years. Longitudinal follow-up data showed cumulative incidence rates at 15 years of 2.9% (95% confidence interval [CI] = 2.2%-3.8%) vs. 5.7% (95% CI = 4.7%-6.9%) (P<.001) for lung fibrosis, of 1.1% (95% CI = 0.7%-1.7%) vs. 1.9% (95% CI = 1.3%-2.6%) (P=.07) for cardiac fibrosis, and of 9.4% (95% CI = 8.0%-10.8%) vs. 11.1% (95% CI = 9.6%-12.7%) (P=.04) for any cardiac disease, when treated without or with IM-MS lymph node irradiation. There was no evidence for differences between left- and right-sided breast cancer (Wald chi-square test of treatment by breast side interaction, P=.33 and P=.35, for cardiac fibrosis and for any cardiac disease, respectively). The cumulative incidence probabilities of cross-sectionally reported side effects with a score of 2 or greater at 15 years were 0.1% (95% CI = 0.0%-0.5%) vs. 0.8% (95% CI = 0.4%-1.4%) for pulmonary (P=.02), 1.8% (95% CI = 1.1%-2.8%) vs. 2.6% (95% CI = 1.8%-3.7%) for cardiac (P=.15), and 0.0% (95% CI not evaluated) vs. 0.1% (95% CI = 0.0%-0.4%) for oesophageal (P=.16), respectively. No difference was observed in the incidence of second malignancies, contralateral breast cancer or cardiovascular deaths.

CONCLUSIONS

The incidence of late pulmonary side effects was statistically significantly higher after IM-MS lymph node irradiation, as were some of the cardiac events, without a difference between left- and right-sided treatments. Absolute rates and differences were very low, without increased non-breast cancer related mortality, even before introducing heart-sparing techniques.

Short Androgen Suppression and Radiation Dose Escalation in Prostate Cancer: 12-Year Results of EORTC Trial 22991 in Patients With Localized Intermediate-Risk Disease

PURPOSE

The European Organisation for Research and Treatment of Cancer (EORTC) trial 22991 (NCT00021450) showed that 6 months of concomitant and adjuvant androgen suppression (AS) improves event- (EFS, Phoenix) and clinical disease-free survival (DFS) of intermediate- and high-risk localized prostatic carcinoma, treated by external-beam radiotherapy (EBRT) at 70-78 Gy. We report the long-term results in intermediate-risk patients treated with 74 or 78 Gy EBRT, as per current guidelines.

PATIENT AND METHODS

Of 819 patients randomly assigned between EBRT or EBRT plus AS started on day 1 of EBRT, 481 entered with intermediate risk (International Union Against Cancer TNM 1997 cT1b-c or T2a with prostate-specific antigen (PSA) ≥ 10 ng/mL or Gleason ≤ 7 and PSA ≤ 20 ng/mL, N0M0) and had EBRT planned at 74 (342 patients, 71.1%) or 78 Gy (139 patients, 28.9%). We report the trial primary end point EFS, DFS, distant metastasis-free survival (DMFS), and overall survival (OS) by intention-to-treat stratified by EBRT dose at two-sided α = 5%.

RESULTS

At a median follow-up of 12.2 years, 92 of 245 patients and 132 of 236 had EFS events in the EBRT plus AS and EBRT arm, respectively, mostly PSA relapse (48.7%) or death (45.1%). EBRT plus AS improved EFS and DFS (hazard ratio [HR] = 0.53; CI, 0.41 to 0.70; P < .001 and HR = 0.67; CI, 0.49 to 0.90; P = .008). At 10 years, DMFS was 79.3% (CI, 73.4 to 84.0) with EBRT plus AS and 72.7% (CI, 66.2 to 78.2) with EBRT (HR = 0.74; CI, 0.53 to 1.02; P = .065). With 140 deaths (EBRT plus AS: 64; EBRT: 76), 10-year OS was 80.0% (CI, 74.1 to 84.7) with EBRT plus AS and 74.3% (CI, 67.8 to 79.7) with EBRT, but not statistically significantly different (HR = 0.74; CI, 0.53 to 1.04; P = .082).

CONCLUSION

Six months of concomitant and adjuvant AS statistically significantly improves EFS and DFS in intermediate-risk prostatic carcinoma, treated by irradiation at 74 or 78 Gy. The effects on OS and DMFS did not reach statistical significance.

Internal mammary and medial supraclavicular lymph node chain irradiation in stage I-III breast cancer (EORTC 22922/10925): 15-year results of a randomised, phase 3 trial

BACKGROUND

10-year results from several studies showed improved disease-free survival and distant metastasis-free survival, reduced breast cancer-related mortality, and variable effects on overall survival with the addition of partial or comprehensive regional lymph node irradiation after surgery in patients with breast cancer. We present the scheduled 15-year analysis of the European Organisation for Research and Treatment of Cancer (EORTC) 22922/10925 trial, which aims to investigate the impact on overall survival of elective internal mammary and medial supraclavicular (IM-MS) irradiation.

METHODS

EORTC 22922/10925, a randomised, phase 3 trial done across 46 radiation oncology departments from 13 countries, included women up to 75 years of age with unilateral, histologically confirmed, stage I-III breast adenocarcinoma with involved axillary nodes or a central or medially located primary tumour. Surgery consisted of mastectomy or breast-conserving surgery and axillary staging. Patients were randomly assigned (1:1) centrally using minimisation to receive IM-MS irradiation at 50 Gy in 25 fractions (IM-MS irradiation group) or no IM-MS irradiation (control group). Stratification was done for institution, menopausal status, site of the primary tumour within the breast, type of breast and axillary surgery, and pathological T and N stage. Patients and investigators were not masked to treatment allocation. The primary endpoint was overall survival analysed according to the intention-to-treat principle. Secondary endpoints were disease-free survival, distant metastasis-free survival, breast cancer mortality, any breast cancer recurrence, and cause of death. Follow-up is ongoing for 20 years after randomisation. This study is registered with ClinicalTrials.gov, NCT00002851.

FINDINGS

Between Aug 5, 1996, and Jan 13, 2004, we enrolled 4004 patients, of whom 2002 were randomly assigned to the IM-MS irradiation group and 2002 to the no IM-MS irradiation group. At a median follow-up of 15·7 years (IQR 14·0-17·6), 554 (27·7%) patients in the IM-MS irradiation group and 569 (28·4%) patients in the control group had died. Overall survival was 73·1% (95% CI 71·0-75·2) in the IM-MS irradiation group and 70·9% (68·6-72·9) in the control group (HR 0·95 [95% CI 0·84-1·06], p=0·36). Any breast cancer recurrence (24·5% [95% CI 22·5-26·6] vs 27·1% [25·1-29·2]; HR 0·87 [95% CI 0·77-0·98], p=0·024) and breast cancer mortality (16·0% [14·3-17·7] vs 19·8% [18·0-21·7]; 0·81 [0·70-0·94], p=0·0055) were lower in the IM-MS irradiation group than in the control group. No significant differences in the IM-MS irradiation group versus the control group were seen for disease-free survival (60·8% [95% CI 58·4-63·2] vs 59·9% [57·5-62·2]; HR 0·93 [95% CI 0·84-1·03], p=0·18), or distant metastasis-free survival (70·0% [67·7-72·2] vs 68·2% [65·9-70·3]; 0·93 [0·83-1·04], p=0·18). Causes of death between groups were similar.

INTERPRETATION

The 15-year results show a significant reduction of breast cancer mortality and any breast cancer recurrence by IM-MS irradiation in stage I-III breast cancer. However, this is not converted to improved overall survival.

FUNDING

US National Cancer Institute, Ligue Nationale contre le Cancer, and KWF Kankerbestrijding.

No long-term effects of hormonal therapy preceding brachytherapy on urinary function and health-related quality of life among prostate cancer patients

OBJECTIVES

To prospectively investigate the influence of 3-month neoadjuvant hormonal therapy (NHT) before brachytherapy (BT) for low-risk prostate cancer (PCa) on urinary function and health-related quality of life (HRQL).

METHODS

Between 2003 and 2008, 300 patients with PCa were treated with BT using (125)I stranded seeds, of whom 86 received 3-month NHT to downsize the prostate before treatment. Urinary complaints were measured on all occasions with the International Prostate Symptom Score (n = 134) and European Organization for Research and Treatment of Cancer-Quality of Life Questionnaire PR25 (EORTC-QLQ-PR25 questionnaire; n = 118) and HRQL with the EORTC-QLQ-C30 (n = 120) questionnaire.

RESULTS

Post-BT, urinary function became worse over the first 6 weeks and then improved steadily, but did not return to baseline levels at 1 year. At baseline, the NHT group reported worse urinary function compared with the non-NHT group (P < .01). However, the post-BT improvement of urinary function was better in the NHT group at 3 months (P < .05). Global HRQL, physical, role and social functioning decreased over the first 3 months (P < .05) post-BT but returned to baseline levels within 1 year. Emotional function steadily improved over the 1-year follow-up period (P < .001). The NHT group reported better global HRQL, social and emotional functioning 1 year post-BT compared with baseline (P < 05). All results were adjusted for comorbidity. This is a single-center study with a follow-up of 1 year, thereby potentially limiting the general applicability of the results.

CONCLUSIONS

Three months of NHT before BT might positively influence urinary function and HRQL up to 1 year post-BT. Therefore, PCa patients should not be dissuaded from considering NHT followed by BT because of prostate size.