Internal Medicine Journal最新文献

Since the publication of the Australian consensus guidelines in 2011, the routine use of prophylactic antibiotics in patients with neutropenia has remained controversial, because of concern that the risks of promoting antimicrobial resistance outweighed the level of evidence that their use reduced mortality. Populations at risk have changed over this period and now include a multitude of new cancer therapies, such as targeted cancer therapies and immunotherapies. Emerging understanding about the importance and role of the microbiome in defining treatment response and patterns of antibiotic resistance has also expanded. In addition, the management of neutropenic fever has improved significantly through the development and routine implementation of sepsis pathways. These updated consensus guidelines review recent evidence for the use of antibacterial prophylaxis in adults and children receiving cancer therapies associated with neutropenia. Recommendations presented in these guidelines were based on evaluating current evidence for the benefits and harms of antibacterial prophylaxis while considering the current Australian and New Zealand healthcare setting. In most circumstances, the potential harm of antibiotic resistance, adverse effects of antibiotics and disruption to the microbiome, outweighed the benefit of reducing the incidence of infection, without a benefit in mortality.

Neutropenic fever is a common complication of haematology and oncology treatments and is associated with a significant risk of morbidity and mortality. Few studies report patients' and carers' understanding of neutropenic fever, including risk reduction, recognition and optimal management. This guideline aims to improve communication around prevention, recognition and management strategies for neutropenic fever in patients receiving cancer treatment. Medical specialists, allied health physicians, other key stakeholders, parents and carers, and patient consumers collaborated to develop guidelines for patients and carers on neutropenic fever. This addition to the 2024 Australasian Consensus Guidelines for the Management of Neutropenic Fever in Patients with Cancer is the first directed at healthcare workers treating paediatric and adult patients at risk of neutropenic fever.

Background: Neutropenic fever (NF) is a common complication of systemic anti-cancer therapy requiring prompt management. A previous 2009 Australian survey of NF clinical practices identified evidence-practice gaps that informed the 2011 Australian Consensus Guidelines for the Management of Neutropenic Fever in Adult Cancer Patients. The emergence of novel cancer therapies and evidence for risk-stratified NF treatment warrant re-evaluation of current approaches to management.

Aims: To describe current clinical practices in Australia and New Zealand in adult NF management, compare results to the 2009 survey, and identify areas for improvement.

Methods: An electronic survey was distributed to haematology, oncology, and infectious diseases clinicians across Australia and New Zealand between June and August 2023. Survey domains included risk stratification, empiric treatment, use of prophylaxis, and management of patients colonised with multidrug-resistant organisms. Descriptive analyses compared responses between specialties and to 2009 data.

Results: A total of 132 clinician responses were received. Improvements were observed in the appropriateness of empiric treatment of NF with a reduction in the use of dual therapy and prescribing of antibacterial prophylaxis. However, knowledge of risk stratification and utilisation of ambulatory care for low-risk NF remained low. Heterogeneity in empiric antibiotic duration and management of patients colonised with multi-drug resistant organisms was observed. Infectious diseases involvement remained widespread but decreased among the medical oncology cohort between 2009 and 2023.

Conclusions: While practices have evolved, critical gaps in risk assessment, appropriateness for early discharge, and antimicrobial stewardship remain. Investments in infrastructure, education and multidisciplinary collaboration are essential to improve the uptake of ambulatory care models for NF. The updated consensus guidelines have addressed ambulatory care, antimicrobial duration and empiric management of those colonised with resistant organisms.

In the context of significant advances in the literature, this chapter of the 2024 Australasian Consensus Guidelines for the Management of Neutropenic Fever in Patients with Cancer addresses the management of patients beyond the first 72 h, focusing on high-risk patients. A writing group - including adult and paediatric representatives across infectious diseases, microbiology, haematology, transplant and oncology across Australia and New Zealand, as well as across craft groups, including medicine, nursing and pharmacy - was developed to produce and address key management questions, overseen by a steering committee that included consumer representation. This chapter follows on from the Initial Empiric Management chapter and it complements the Ambulatory Care chapter, which is dedicated to low-risk patients. Using an extensive review of the literature, these guidelines provide consensus recommendations with evidence grading on topics including investigation of persistent and recurrent fever, common causes of non-infection-related fever and antibiotic rationalisation options, such as cessation, de-escalation and targeted therapy.

These guidelines provide updated recommendations on ambulatory care for low-risk neutropenic fever in adult and paediatric patients. National and international data support the clinical, economic and psychosocial benefits of risk stratification, and home-based or reduced intensity treatment of neutropenic fever. Benefits include shortened in-hospital length of stay, reduced healthcare costs, early intravenous to oral switch and improved patient and caregiver quality of life. Since publication of the 2011 Australian consensus guidelines, additional adult and paediatric neutropenic fever clinical decision rules have been derived and validated. These rules assist clinicians in stratifying patients into lower or higher risk of serious infection. For adult patients the Multinational Association of Supportive Care in Cancer and the Clinical Index of Stable Febrile Neutropenia scores are recommended, whereas for paediatric patients the AUS rule has been prospectively derived and validated in the Australian setting. These rules are recommended as part of a structured low-risk neutropenic fever care pathway that incorporates additional disease-level, treatment-level and patient-level safety net criteria. Key infrastructure requirements for cost-effective and safe hospital-based ambulatory neutropenic fever care are discussed, as are recommended oral antimicrobial regimens and criteria for re-admission. Biomarkers and the use of new and wearable technologies are currently not routinely recommended as part of risk stratification or monitoring. Gaps in the literature are summarised and are anticipated to be the focus of future updates to these guidelines.

This is the introductory chapter to the 2024 Australasian Consensus Guidelines for the Management of Neutropenic Fever in Patients with Cancer, an update of the Australian consensus guidelines published in 2011. These guidelines reflect the new treatment paradigms for cancer care (such as immunotherapy, bispecific antibodies, oral targeted therapies and CAR T) given the changing risks of neutropenic fever and sepsis, the emerging challenges of antimicrobial resistance and the new models of care for managing neutropenic fever. The scope of these guidelines has been broadened to include paediatrics for the first time. Further, chapters are dedicated to antimicrobial stewardship and infection prevention, and consumer engagement and education. Recognising the longstanding challenges about decision-making in the setting of recurrent or persistent neutropenic fever, a new chapter provides guidance about antimicrobial management and investigations. This current chapter introduces the rationale for these guidelines, defines key terms used, including risk assessment, provides an overview of the key principles suitable for a systems approach to the prevention and management of infections in neutropenic patients with cancer, defines the target audience and scope of each chapter, and helps readers navigate the guidelines. We also outline the approach to guideline development, review and feedback.

This chapter aims to provide an updated framework for whole-of-hospital neutropenic fever management, outlining best-practice principles to guide the integration of antimicrobial stewardship, infection prevention, microbiology, pharmacy and nursing within the multidisciplinary care of patients with neutropenic fever. A comprehensive literature search was performed using PUBMED, prioritising randomised controlled trials and notable observational studies since 2011. Hospital antimicrobial stewardship programmes can significantly improve neutropenic fever care through personalised approaches and decision support tools which consider individual risk profiles, colonisation status and infection history to guide precise empiric therapy decisions. Key aspects include pre-chemotherapy antibiotic allergy assessments, appropriate use of cephalosporins in certain allergy cases, and specialised evaluation for severe reactions. The microbiology laboratory plays a crucial role in pathogen diagnosis and surveillance for drug resistance including formulation of antibiograms. Infection prevention and control measures, including adherence to national standards and local protocols, are critical in reducing hospital-acquired infections. Optimised antimicrobial dosing should be implemented, considering patient-specific factors and utilising therapeutic drug monitoring. Advanced practice nurses can significantly contribute to patient experience through direct management and education. The management of NF requires a cohesive hospital-wide strategy that goes beyond the actions of individual clinicians and draws on the collective expertise of various disciplines. These guidelines underscore the importance of a structured systems approach.

The prevalence of immune-mediated inflammatory diseases (IMIDs) is rising, associated with increasing disease burden and healthcare expenditure. Medical therapy is the major driver of healthcare costs associated with IMIDs, owing to the need for lifelong therapy. However, many patients exhaust medical options, highlighting the need for new therapies with novel mechanisms of action. Recently, a highly effective class of medical therapy gained registration for use in Australia for IMIDs but was unsuccessful in attaining Pharmaceutical Benefits Scheme reimbursement. There is a growing need to reevaluate the reimbursement process for medicines in Australia, aiming to balance access to new therapies with prudent health-economic policy.