Use of antibacterial prophylaxis for patients with neutropenia. Australian Consensus Guidelines 2011 Steering Committee.

The use of oral prophylactic antibiotics in patients with neutropenia is controversial and not recommended by this group because of a lack of evidence showing a reduction in mortality and concerns that such practice promotes antimicrobial resistance. Recent evidence has demonstrated non-significant but consistent, improvement in all-cause mortality when fluoroquinolones (FQs) are used as primary prophylaxis. However, the consensus was that this evidence was not strong enough to recommend prophylaxis. The evidence base for FQ prophylaxis is presented alongside current consensus opinion to guide the appropriate and judicious use of these agents. Due consideration is given to patient risk, as it pertains to specific patient populations, as well as the net effect on selective pressure from antibiotics if FQ prophylaxis is routinely used in a target population. The potential costs and consequences of emerging FQ resistance, particularly among Escherichia coli, Clostridium difficile and Gram-positive organisms, are considered. As FQ prophylaxis has been advocated in some chemotherapy protocols, specific regard is given to whether FQ prophylaxis should be used to support these regimens. The group also provides recommendations for monitoring and surveillance of emerging resistance in those centres that have adopted FQ prophylaxis.

Optimizing antifungal drug dosing and monitoring to avoid toxicity and improve outcomes in patients with haematological disorders.

Antifungal prophylaxis, empirical therapy and treatment of established fungal infections in the haematology population may be associated with significant toxicity or drug interactions leading to sub-therapeutic antifungal drug concentrations and poorer clinical outcomes. These risks may be minimised by clinical assessment, laboratory monitoring of biochemical or haematological indices, avoidance of particular drug combinations and dose modification in certain circumstances. Specific measures, such as the optimal timing of oral drug administration in relation to meals, use of pre-hydration and electrolyte supplementation may also be required. For certain agents, therapeutic drug monitoring (TDM) is warranted where non-compliance, non-linear pharmacokinetics, a narrow therapeutic window, suspected drug interaction or unexpected toxicity are encountered. Pharmacokinetics and pharmacodynamics of clinical relevance to the haematology population are discussed for the azole, polyene and echinocandin classes of antifungal agents. The evidence supporting an association between TDM and enhanced treatment outcomes is presented for individual antifungal drugs, and recommendations for clinical practice are provided. Further randomised study of newer antifungal agents, such as posaconazole, is required to explore the potential for improved clinical outcomes in association with TDM.

Effects of aquatic therapy on joint flexibility and functional ability in subjects with rheumatic disease.

Currently, there is a deficit of objective data showing the efficacy of aquatic exercise therapy in improving function in individuals with rheumatic disease. The purpose of this study was to quantify the effectiveness of aquatic therapy in changing joint motion, functional status, assistance, pain, and difficulty in 13 subjects with rheumatic disease. Active joint motion and Functional Status Index scores of assistance, pain, and difficulty were taken prior to and following 8 weeks of aquatic therapy. Multivariate analysis of variance, analysis of covariance procedure controlling for pain, and a Pearson correlation between active joint motion and Functional Status Index changes and between assistance, pain, and difficulty scores of the Functional Status Index were conducted. Results showed a significant difference between the pre and post means of active joint motion, Functional Status Index, pain, and difficulty (p < .05); a significant, negative relationship between pain and active joint motion of select joints; and positive correlations between assistance and pain, assistance and difficulty, and pain and difficulty. The decreased pain and difficulty experienced in performing daily tasks contributed significantly (94%) to the overall increased functional status and active joint motion for select joints. These findings support aquatic therapy as an effective means of increasing joint flexibility and functional ability while reducing pain and difficulty with daily tasks.