Invasive fungal infections: epidemiology and analysis of antifungal prescriptions in onco-haematology.

WHAT IS KNOWN AND OBJECTIVE: Invasive fungal infections (IFI) are associated with high rates of morbidity and mortality, particularly in onco-haematology patients. We aimed to study the epidemiology of IFI in neutropenic patients and estimate the economic impact of treatment of those infections. METHODS: All patients hospitalized in onco-haematology, and treated with antifungal agents, in 2005 were investigated. Four features were studied: the diagnosis for each patient, the antifungal drugs used, the thoracic densitometry reports and the sero-mycological data. Infectious episodes were stratified according to the EORTC 2008 classification criteria (10). RESULTS AND DISCUSSION: Of the 1130 patients surveyed, 192 patients received systemic antifungal agents. Of these 46% had acute leukaemia, 29% bone-marrow allografts, 7% lymphoma and 18% other malignant haemopathies. Using the EORTC 2008 criteria (10), there were 8 proved IFI (3 aspergillosis, 3 candidosis and 2 other IFI), 17 probable IFI (11 aspergillosis, 6 candidosis) and 16 possible aspergillosis. The incidence of IFI was 2·1%. Eighty patients (41·7%) had received prophylaxis: 56 with fluconazole and 24 with voriconazole. Treatment was most often empirical (n = 127, 66·1%). Combination of two antifungals was used in 17 cases. The mean duration of prophylactic, empirical, proved/probable aspergillosis-directed, candidaemia-directed and combination treatment was 19, 19, 46, 32 and 27 days, respectively. The cost of antifungal treatment in 2005 reached almost 2,000,000 €, including 427,000 € for documented infections (proved and probable), 1,246,000 € for empirical treatment and 58,300 € for prophylaxis. WHAT IS NEW AND CONCLUSION: The incidence of IFI is low but the pharmacoeconomic impact is extremely high. Improved strategies are required to reduce the frequency and duration of empirical treatment without compromising beneficial outcome.

[Economic evaluation of at home subcutaneous and intravenous immunoglobulin substitution]. / Etude comparative du coût du traitement à domicile des immunoglobulines intraveineuses ou sous-cutanées à visée substitutive.

BACKGROUND: Intravenous (IV) and subcutaneous (SC) immunoglobulin (Ig) administration is a safe and an efficacious treatment in patients with IgG deficiency. Home administration of IV Ig and SC Ig has recently been approved in France. Most of the patients treated in hospital ask for home treatment. Some patients prefer monthly IV administration, others weekly SC administration. MATERIAL AND METHODS: We evaluated in details the cost of both of these practices. We currently use electric pumps for both IV and SC administration which are fixed to the patient giving complete freedom and mobility. RESULTS: For 20 g administrated per 4 week, the total cost of home treatment is 1,518 euro with SC Ig and 1,033 euro with IV Ig. For 40 g administrated per 4 week, the total cost of home treatment is 2,507 euro to 2,729 euro with SC Ig and 2,034 euro with IV Ig. The difference is mainly explained by the cost of renting the electric pumps and by the cost of furniture for SC administration. The choice of home Ig substitution must be given to all patient receiving treatment in hospital. CONCLUSIONS: Home IV and home SC perfusions are two possible options each different with there own advantages and disadvantages. The cost of each procedure must be known by the medical staff.

[Management of aspergillosis in immunocompromised patients. Recommendations of Lille University Hospital--4th version--November 2004]. / Prise en charge diagnostique et thérapeutique des infections à Aspergillus sp. chez le patient immunodéprimé. Recommandations du CHRU de Lille--version 4--novembre 2004.

Invasive aspergillosis is a severe complication in immunocompromised patients. The arrival of new antifungal agents motivated the redaction of guidelines, regularly updated, by a Lille University hospital multidisciplinary task force. These guidelines assess diagnostic and therapeutic issues. The main recommended diagnosis tool is the chest CT scan, ordered at the smallest suspicion and, also, measure of the blood and broncho alveolar lavage fluid galactomannan. Treatment guidelines assess prophylaxis, empirical and documented therapy. Primary prophylaxis is warranted in only two cases, pulmonary graft or stem cell transplant in patients with chronic GVH and receiving corticosteroids. Empirical therapy should use one of the available amphotericin B formulations, chosen according to the patient history. Caspofungin is another choice. Documented therapy, depending on presentation, can be a single drug or a combination. First line therapy for single drug is i.v. voriconazole. Lipid formulations of amphotericin B are another choice. A combination therapy can be used as a first line treatment, for multiple lesions, or as salvage therapy. It must include caspofungin, associated with liposomal amphotericin B or voriconazole. A tight cooperation with thoracic surgeons is recommended.