A change for the antibacterial treatment policy to decrease carbapenem consumption at a haematopoietic stem cell transplantation centre.

After experiencing a high rate of carbapenem-resistant Gram-negative bacilli infections in febrile neutropenic patients, a two-stage intervention was introduced in the haematopoietic stem cell transplantation (HSCT) centre. During the first eight months of 2014, carbapenems remained the first choice for the empirical treatment of febrile neutropenia while the use of piperacillin/tazobactam (TZP) was encouraged in patients with stable clinical condition. When blood cultures were reported as negative and the patient was clinically stable the carbapenem/TZP treatment was stopped regardless of continuous fever and neutrophil count. From October 2014, TZP (with prolonged infusion) with or without amikacin replaced carbapenems as the first line therapy of neutropenic fever except for high-risk patients previously known as colonized or infected with extended spectrum beta-lactamase (ESBL) producing Enterobacteriaceae, who presented with severe sepsis, septic shock or nosocomial pneumonia, and recently transferred from the intensive care unit with a high endemicity of multidrug-resistant Gram-negative bacilli. Vancomycin or teicoplanin was used when there was suspicion of septic shock or detection of severe mucositis and central-line associated bacteraemia. The antibacterial therapy was escalated or de-escalated in culture-positive patients according to the antimicrobial susceptibility reports and clinical progress. Daily defined dosages (DDD) per 1000 patient days were calculated for all antibiotics by the hospital pharmacist for each year. A total of 913 admissions with 11,544 patient-days were followed in 2013; and 1,072 admissions with 11,843 patient-days were followed in 2014. The rate of ESBL production in Enterobacteriaceae bacteraemia was as 31.8% in 2013 and 47.3% in 2014. All staphylococci isolated from blood culture were methicillin-resistant for both years. All Enterococcus faecium isolates but one from blood cultures were resistant to ampicillin. The number of the patients who died during hospitalization was 24 in 2013, and 17 patients died in 2014. The DDDs/1000 patient days for imipenem, meropenem, vancomycin, teicoplanin, daptomycin, linezolid, colistin, piperacillin/tazobactam and amikacin in 2013 and 2014 were respectively as follows; 201 vs 19 (p<0.001); 1,578 vs 1,092 (p<0.001); 533 vs 251 (p<0.001); 205 vs 159 (p<0.001); 56 vs 14 (p<0.001); 76 vs 26 (p<0.001); 188 vs 154 (p<0.001); 157 vs 254 (p<0.001); and 5 vs 41 (p<0.001). Our study showed that a febrile neutropenia pathway guided by local epidemiology and international guidelines can reduce the use of antibiotics in haematological cancer or HSCT patients. The sustainability of such an intervention requires strong multidisciplinary cooperation.

Epidemiology and cost implications of candidemia, a 6-year analysis from a developing country.

Surveillance of candidemia is essential to monitor trends in species distribution and change in the incidence and antifungal resistance. In this study, we aimed to investigate prevalence, resistance rates, antifungal utilization and costs. A 6-year retrospective analysis of the data belonging to patients with candidemia hospitalized between 2010 and 2016 was performed. The annual usage of fluconazole and caspofungin and the usage of these antifungals in different units were described in defined daily doses (DDD) per 1000 patient days. In total, 351 patients of candidemia were included. Median age of the patients was 45 (0-88) and 55.1% of them were male. Overall, 48.1% of the candidemia episodes (169/351) were due to C. albicans, followed by C. parapsilosis (25.1%), C. glabrata (11.7%). Length of hospital stay was longer with a median of 20 days among patients with non-albicans candidemia. Presence of a central venous catheter was found to be an associated risk for candidemia caused by non-albicans strains. Annual incidence of candidemia increased from 0.10 to 0.30 cases/1000 patient days. Antifungal use was increased over years correlated with the cost paid for it. The policy against candidemia should be specified by each institution with respect to candidemia prevalence, resistance rates, antifungal use and costs.

A Single Center Experience for Antifungal Prophylaxis in Patients with Acute Myelogenous Leukemia.

We aimed to provide real-life information about the effectivity of different types of primary antifungal prophylaxis (AFP) in patients with acute myeloid leukemia (AML). Records of AML patients who received remission-induction chemotherapy between June 2010 and February 2013 were retrospectively reviewed. A total of 85 AML remission-induction chemotherapy cycles were identified in 80 patients. Fluconazole prophylaxis (FP) was administered in 29 cycles, and posaconazole prophylaxis was given in 56 cycles. Failure in the AFP was observed in 45 (57.9 %) out of 85 cycles. Any type of invasive fungal diseases were detected in 15 (26.8 %) out of 56 cycles receiving posaconazole and 15 (51.7 %) out of 29 cycles receiving fluconazole (p = 0.023). Relapsing or refractory AML, longer duration of neutropenia and FP were more common in patients with AFP failure. Multivariate logistic regression analysis showed that type of AFP (odds ratio (OR) 3.63; 95 % confidence interval (CI) 1.19-11.07), presence of neutropenia longer than 21 days (OR 3.96; 95 % CI 1.36-11.46), and refractory or relapsing AML (OR 6.09; 95 % CI 2.09-17.73) were independent factors associated with failure of AFP. We observed superiority of posaconazole on fluconazole in the prophylaxis of AML patients receiving remission-induction chemotherapy.