Recommendations For Prophylaxis Research Articles

Cutaneous adverse events to systemic anticancer therapies : Hand-foot syndrome and nail changes

Hand-foot syndrome (HFS) and nail changes are frequent adverse events of anticancer therapies. To provide areview of current evidence in HFS and nail disorders associated with medical tumor treatment. Basis is the current German S3guideline "Supportive therapy in oncologic patients" and literature on this topic published since the guideline was finalized. Two variants of HFS are distinguished: achemotherapy-associated and akinase-inhibitor-associated variant. In the first form, painful erythema, blisters and ulceration can occur, also in other areas with ahigh number of sweat glands such as axillary and inguinal regions. Thus, the secretion of toxic substances through sweat glands is aproposed pathogenetic mechanism. For the second form, which results in callus-like painful thickening of the horny layer on areas of mechanic pressure, avascular mechanism is proposed. For prophylaxis of HFS, avoidance of mechanical stress, regular cleaning of predisposed areas, and also urea- and diclofenac-containing ointments are recommended; in case of infusions (taxanes, doxorubicine), cooling of hands and feet during infusion is recommended. In case of manifest HFS, dose reduction or prolongation of intervals of the associated treatment are recommended. Nail changes often develop under therapy with chemotherapeutic agents but also under treatment with agents such as checkpoint inhibitors or under targeted therapy. Different components of the nail unit may be involved such as the nail matrix, nail bed, nail plate, hyponychium, lunula and proximal and lateral nail folds. This work gives insight into the pathophysiology of HFS and nail disorders that develop under systemic oncologic treatments and gives recommendations for prophylaxis and treatment.

Alopecia due to chemotherapeutics, hedgehog inhibitors, targeted antibody therapies and immune checkpoint inhibitors : Pathogenesis, clinical picture, diagnostics and prophylaxis

The incidence and severity of alopecia vary mainly depending on the chemotherapeutic agent used or other drug groups. The pathogenetic characteristics of the different forms of alopecia are reflected in the clinical presentation and, in some cases, in the resulting recommendations for prophylaxis. To provide an overview of the pathogenesis, clinical presentation, diagnosis and prophylaxis of alopecia with chemotherapeutic agents, hedgehog inhibitors, targeted therapies and immune checkpoint inhibitors. Based on the current S3guideline "Supportive therapy", an extensive literature search was carried out. Chemotherapy-induced hair loss (CIA) occurs in up to 65% of cases. Anagen effluvium is observed as early as 1-3weeks after the start of treatment and is reversible in most cases. Alopecia associated with inhibitors of the Sonic Hedgehog signaling pathway (HHIA) such as vismodegib or sonidegib are observed in up to 60% of cases. They are characterized by telogen effluvium. BRAF or immune checkpoint inhibitors lead significantly less frequently to alopecia (BRAFA, CPIA). According to taxane-based chemotherapy protocols, scalp cooling can help to prevent higher-grade CIA. If CIA or other forms of alopecia are expected, early contact with self-help organizations and early prescriptions for wigs should be offered.

Anticoagulation stewardship: Improving adherence to clinical guidelines and reducing overuse of venous thromboembolism prophylaxis in hospitalized medical patients

Adherence to guideline recommendations for venous thromboembolism prophylaxis (VTE) in hospitalized medical patients is suboptimal despite national policies and institutional interventions. The aim of this quality improvement project was to improve adherence to guidelines and decrease the overuse of VTE prophylaxis in order to reduce the institutional cost for heparins. A multidisciplinary anticoagulation stewardship program (ACSP) using the audit and feedback strategy was implemented on the medicine inpatient units at a teaching hospital in Canada. The primary outcome measure was a comparison, pre and post introduction of the ACSP, of the costs per 6-month period for prophylactic dose enoxaparin and unfractionated heparin on the medicine units. The balancing measures were the 90-day VTE rate and major bleeding rate during the hospitalization. Six months after the implementation of the ACSP, the cost was decreased by >50 % without any observed negative impact on patient safety. This study demonstrates the potential for anticoagulation stewardship programs to optimize the use of VTE prophylaxis and reduce the associated costs and risks.

Unawareness of partner risk factors thwarts implementation of USPSTF recommendations for HIV pre-exposure prophylaxis in primary care

ABSTRACT The United States Preventive Services Task Force recommends pre-exposure chemoprophylaxis for persons at high risk of HIV exposure. The optimal screening strategy for at-risk individuals in primary care is not known. We evaluated the strategy of universal screening and discussed challenges to the implementation of this recommendation in primary care. Around 430 of 500 (86%) screening surveys were completed. Mutual monogamy was common but monogamous partners with recent negative HIV testing were uncommon. Likewise, among heterosexually active men and women, inconsistent condom use was common. Such individuals would be on guideline for HIV pre-exposure prophylaxis (PrEP) if their partner was at risk for HIV exposure. None of these potentially at-risk individuals met the criteria for PrEP, but 13% lacked knowledge of their partners' sexual and behavioral risk factors, preventing a clear decision on whether PrEP should be used. Our screen identified no individuals who clearly met the guideline criteria for HIV PrEP. We conclude that universal screening for HIV PrEP in primary care is unlikely to be an efficient strategy; targeted screening is likely more appropriate. Moreover, the 2019 guidelines for heterosexually active men and women rely on information that is often unknown to the patient, which makes these guidelines difficult to implement. Future guidelines should address these problems.

Venous Thromboembolism Prophylaxis Prescribing Patterns in Minimally Invasive Gynecologic Surgery After Implementation of Caprini Score Risk Assessment [ID 2683387

INTRODUCTION: Venous thromboembolism (VTE) is a significant cause of postoperative morbidity, mortality, and cost. Although the risk is low in minimally invasive gynecologic surgery, risk-based prophylaxis is recommended. The modifed Caprini score (CS) can assess risk of VTE and inform preoperative and postoperative prophylaxis. We assessed whether formal implementation of the CS in the Department of Minimally Invasive Gynecologic Surgery at a large academic center affected preoperative and postoperative VTE prophylaxis prescribing patterns. METHODS: Institutional review board exemption was obtained. A sample of 356 patients (156 in pre-implementation group and 190 in post-implementation group) undergoing presumed benign minimally invasive hysterectomy or myomectomy between October 2021 and September 2022 was retrospectively analyzed. The primary outcome investigated was adherence to recommended preoperative prophylaxis before and after implementation. Secondary outcomes included incidence of VTE and concern for bleeding. RESULTS: Patient demographics, VTE risk factors, CS, and surgical details were determined to be statistically comparable between the groups. The implementation of CS significantly improved preoperative VTE prophylaxis recommendation adherence from 65.4% to 85.2% (P<.001). This was due to both an increase in indicated pharmacologic prophylaxis, as well as a decrease in nonindicated usage in low-risk patients (from 22.4% to 2.6%). VTE risk was similarly low in both groups, occurring in only one patient from the pre-implementation group. There was no significant difference in estimated blood loss. CONCLUSION: These results suggest that CS use in patients undergoing minimally invasive gynecologic surgery can improve adherence to recommended preoperative prophylaxis for VTE, while decreasing unnecessary overtreatment in low-risk patients.

Cotrimoxazole and targeted antibiotic prophylaxis for transrectal prostate biopsy: a single-center study

PurposeThe recent restriction on the use of fluoroquinolones for prophylaxis by the European Commission has left a gap in clear recommendations for practical antibiotic prophylaxis (PAP) for transrectal prostate biopsy (TRPB). This analysis investigated the viability of cotrimoxazole for PAP in TRPB.MethodsThis analysis included n = 697 patients who underwent TRPB for suspected prostate cancer (PCa). All patients received either empiric PAP with four doses of cotrimoxazole 960 mg or targeted antibiotic prophylaxis in case of a positive rectal or urine screening for multiresistant gram-negatives. Infectious complications after TRPB, microbiological findings, and clinical characteristics were evaluated. A multivariable logistic regression model was calculated to identify variables associated with infectious complications.ResultsOf the cohort, 86% (600/697) received PAP with cotrimoxazole, 1% (8/697) received cotrimoxazole plus an additional antibiotic, 4% (28/697) received amoxicillin + clavulanic acid, 4% (28/697) received fluoroquinolones, and 5% (33/697) received a single shot intravenous antibiotic prophylaxis with meropenem or piperacillin + tazobactam due to multiresistant microbiological findings in either pre-interventional urine culture or rectal swab. Infectious complications occurred in 2.6% (18/697) of patients. Fever was noted in 89% (16/18) of cases. Inpatient treatment was given to 67% (12/18) of affected patients, with 38% (7/18) having positive blood cultures, identifying cotrimoxazole-resistant E. coli strains in six out of seven cases. Multivariable logistic regression analysis revealed no clinically significant variables, including PAP with cotrimoxazole, as independent risk factors for an infectious complication.ConclusionsUsing cotrimoxazole as PAP for TRPB in cases without multiresistant gram-negatives in pre-interventional urine cultures or rectal swabs seems feasible and practical.

120 Venous Thromboembolism Prophylaxis in Burn Patients

Abstract Introduction Venous thromboembolism (VTE) is extensively studied in trauma patients, but burn patients require special consideration due to their unique pathophysiology and management strategies. Currently, there are no specific prophylaxis recommendations to help mitigate VTE in burn patients. Methods The US National Trauma Data Bank (NTDB) was analyzed to identify patients with burn encounters from 2017-2021 using ICD-10 event codes. Our primary outcome measure was incidence of VTE, which included deep venous thrombosis and pulmonary embolism. Secondary outcome measures included need for blood transfusion and need to return to the operating room due to hemorrhage from skin/soft tissues/extremities. Multivariable regressions were conducted to evaluate the relationship between various VTE prophylaxis types and timing of VTE prophylaxis and VTE incidence while controlling for age, sex, %TBSA and inhalation injury. Results A total of 326,614 patients with burn injuries were identified in the NTDB during the study period, of whom 5,604 (1.7%) had a VTE event during their hospital admission. The majority of patients did not receive VTE prophylaxis (54.1%). Of those that did, the most commonly used VTE prophylaxis was LMWH (37.9%), followed by unfractionated heparin (4.1%). When controlling for age, sex, inhalation injury, and %TBSA, unfractionated heparin and LMWH were significantly associated with an increased risk of VTE (heparin: OR=1.8 95% CI 1.3-2.5, p < .001; LMWH: OR=1.5 95% CI 1.2-1.8, p < .001). Longer time to VTE prophylaxis was significantly associated with increased odds of VTE when controlling for the same covariates (OR=1.04 95% CI 1.03=1.07, p < .001). Neither VTE prophylaxis type nor timing of VTE prophylaxis administration was significantly associated with an increased need for blood transfusion. Heparin was the only VTE prophylaxis type significantly associated with increased odds of returning to the OR for a bleeding-related complication (p < .001). Conclusions A majority of burn patients in the NTDB did not receive VTE chemoprophylaxis, and counterintuitively, patients who received VTE chemoprophylaxis had higher rates of VTE than patients who did not, despite controlling for known VTE risk factors. In patients who did get chemoprophylaxis, unfractionated heparin is associated with a higher rate of VTE and surgical bleeding complications when compared with LMWH. Delayed initiation of VTE prophylaxis correlates with a higher likelihood of VTE occurrence. These findings underscore the importance of better studying and developing specialized VTE prevention guidelines for burn patients to enhance their care and outcomes. Applicability of Research to Practice Prompt initiation of VTE prophylaxis is essential to reduce the risk of VTE among burn patients, highlighting the importance of timely interventions. Developing specialized VTE prevention guidelines for this population can enhance their care and outcomes.

ВАКЦИНАЦИЯ ДЕТЕЙ С ВРОЖДЕННЫМИ ДЕФЕКТАМИ ИММУНИТЕТА: СОВРЕМЕННЫЕ ПРЕДСТАВЛЕНИЯ О БЕЗОПАСНОСТИ И ЭФФЕКТИВНОСТИ

Primary immunodeficiencies (PIDs) or inborn errors of immunity (IEIs) are a heterogeneous group of genetically-determined diseases that are divided into ten groups according to modern classification. The high heterogeneity in clinical manifestations and pathogenetic mechanisms as well as wide use of immunoglobulin replacement therapy, various immunosuppressant and anti-inflammatory drugs make it difficult to decide on the safety and efficacy of vaccination for patients with IEIs. There are no universally accepted recommendations for vaccine prophylaxis among patients with IEIs both in Russia and Worldwide due to the lack of controlled clinical trials available. Authors have attempted summarizing the bibliographical sources available on the safety and efficacy of vaccine prophylaxis in individuals with different forms of IEIs considering the Authors’ own opinion raising the importance of controlled clinical trials.

Current trends for venous thromboembolic prophylaxis for hip arthroscopy: a modified Delphi and nominal group technique consensus study

ABSTRACT The overall risk of venous thromboembolism (VTE) after hip arthroscopy (HA) is reported to range from 0.2% to 9.5%, but a clear set of recommendations for VTE prophylaxis in HA patients remains scarce. The aim is to survey high-volume hip arthroscopists about their current trends regarding VTE prophylaxis use. A combination of two consensus group methods was used in this study: nominal group technique (NGT) and modified Delphi. A preliminary questionnaire was prepared, and rounds of discussion were completed between NGT members. The final version of the survey was administered to 35 high-volume hip surgeons. Delegates’ mean volume of annual hip arthroscopic surgery was 109. Approximately 22% of their patients are revision HA procedures. A total of 91.4% of delegates use chemoprophylaxis, 28.6% use sequential compression devices and 91.4% believed that chemoprophylaxis is necessary for more prolonged and complex procedures (strong consensus). Aspirin was the choice for all participants, and the duration was 2–3 weeks (31.4%), 1 month (65.7%) and 2–3 months (2.9%). History of VTE, hypercoagulable status, and malignancy were considered risk factors. No consensus was achieved for the discontinuation of oral contraceptive and smoking preoperatively. However, the optimal length of VTE prophylaxis is unclear. A total of 97.1% of the experts responded that they administer aspirin between 2 and 4 weeks. High-volume arthroscopic surgeons do consider VTE prophylaxis to be important and warranted in the postoperative setting. Aspirin is the mainstay of chemoprophylaxis, although the appropriate duration is unknown.

Screening and treatment of latent tuberculosis in patients with solid tumors and systemic cancer therapy.

Tuberculosis is one of the infectious diseases with greater morbidity and mortality worldwide. Cancer causes an important immunosuppression with increased risk of infections. There is an enlarged bidirectional incidence between tuberculosis and cancer, mainly due to latent tuberculosis. There is great discrepancy between recommendations for screening and prophylaxis of latent tuberculosis in patients with solid tumors and systemic cancer therapy among different medical societies and guidelines. Most infectious diseases guidelines recommend it, while most oncology guidelines do not. Patients with solid tumours generally have a limited life expectancy and a state of intermittent immunosuppression, resulting in a lower risk of tuberculosis reactivation than other riskypopulations. There is a lack of prospective and retrospective studies analysing the benefit of screening and prophylaxis in this population. The first step is to study the incidence of active tuberculosis in this population to estimate the real magnitude of the problem.

Strategic infection prevention after genetically modified hematopoietic stem cell therapies: recommendations from the International Society for Cell & Gene Therapy Stem Cell Engineering Committee

There is lack of guidance for immune monitoring and infection prevention after administration of ex vivo genetically modified hematopoietic stem cell therapies (GMHSCT). We reviewed current infection prevention practices as reported by providers experienced with GMHSCTs across North America and Europe, and assessed potential immunologic compromise associated with the therapeutic process of GMHSCTs described to date. Based on these assessments, and with consensus from members of the International Society for Cell & Gene Therapy (ISCT) Stem Cell Engineering Committee, we propose risk-adapted recommendations for immune monitoring, infection surveillance and prophylaxis, and revaccination after receipt of GMHSCTs. Disease-specific and GMHSCT-specific considerations should guide decision making for each therapy.

Current management of SARS-CoV-2 infection in solid organ transplant recipients: Experience derived from an ESGICH-ESOT survey.

Solid organ transplant (SOT) recipients have a poorer SARS-CoV-2 vaccine response and higher risk for COVID-19-associated complications. However, there is no consensus on the current management of COVID-19 and data on persistent COVID-19 rates in SOT recipients are lacking. An electronic survey concerning the management of COVID-19 in SOT recipients was distributed among all members of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group for Infections in Compromised Hosts (ESGICH) and of the European Society for Organ Transplantation (ESOT). Four major sections were covered: prevention, early COVID-19, late COVID-19, and persistent COVID-19. We developed a structured questionnaire including eight multiple-choice questions with branching logic in case of positive answers and three open-ended questions related to clinical practice. Questions were asked separately for lung and non-lung transplantation. Thirty-two physicians from 24 different centers participated. Most answers (n = 30) were provided by European physicians. Thirty of 32 (93.75%) physicians managed non-lung transplant recipients and 12 of 32 (33.3%) lung transplant recipients. There was a huge variability in practice regarding the treatment of COVID-19, and particularly noticeable when considering lung and non-lung transplant recipients. Main discordances included the use of nirmatrelvir alone or in combination therapy for early COVID-19, the use of immunomodulatory drugs other than steroids for late COVID-19, and the need for treating asymptomatic viral shedding in persistent COVID-19. There was more similarity in terms of prophylaxis recommendations. Despite a low number of respondents, this survey shows that there are many differences on how experts manage SARS-CoV-2 infections in SOT recipients.

Practical Management of Adverse Events Associated With FGFR Inhibitors for Cholangiocarcinoma for the Advanced Practice Provider

Cholangiocarcinoma is a cancer of the bile duct frequently diagnosed at a late stage with a poor prognosis. Selective fibroblast growth factor receptor (FGFR) inhibitors have demonstrated efficacy in the treatment of cholangiocarcinoma with FGFR2 fusions or rearrangements, but are associated with hyperphosphatemia, fatigue, and ocular, dermatologic, and gastrointestinal adverse events (AEs). Treatment adherence and patient outcomes can be improved by anticipating and effectively managing the AEs associated with FGFR inhibitors and providing appropriate intervention and patient education. The multidisciplinary care team for patients with cholangiocarcinoma can involve optometrists and advanced practice providers, including nurse practitioners, physician assistants, pharmacists. This review provides practical insights for advanced practice providers on the management of these common AEs associated with selective FGFR inhibitors in the real-world setting, focusing on pemigatinib and futibatinib. Impacts of renal or hepatic impairment, drug–drug interactions, and drug–food interactions are discussed. Also presented are practical recommendations for prophylaxis and supportive care measures, and resources for health-care professionals and patients.

(046) An Approach to the Thoughtful Selection of Antimicrobial Prophylaxis for Inflatable Penile Prosthesis Surgery

Abstract Introduction There is a growing body of evidence questioning the efficacy of the antibiotic prophylaxis regimens recommended by the American Urological Association (AUA) Best Practice Statement (BPS) for IPP surgery. However, since publication of the BPS the use gentamicin and vancomycin use has increased substantially. This is potentially due to a lack of other specific prophylaxis recommendations making it difficult for surgeons to know which agents to select. Objective We sought to create a simple process to enable surgeons to select an individualized prophylaxis regimen which accounts for local antibiotic resistance patterns. Methods We retrospectively collected IPP infection history from 3 surgeons from 3 different regions of the United States between 2016 and 2021. Local hospital antibiograms were obtained for each surgeons’ institution. Each surgeons IPP infection history was crossed with the resistance patterns on the local antibiograms to identify prophylactic antimicrobial regimens providing the highest level of coverage. Results The organisms causing implant infections for each surgeon during the inclusion period are reported in Table 1. Vancomycin and fluconazole provided excellent Gram-positive and fungal coverage for all surgeons, however Gram-negative coverage varied. Surgeon A had a history of ESBL-producing E. Coli and no infections from Pseudomonas sp. Gentamicin and tobramycin have poor coverage of ESBL-producing E. coli (61% and 52% respectively). However, pipercillin/tazobactam covers 92% of ESBL-producing E. coli. The only Gram-negative organism that pipercillin/tazobactam has worse coverage of than the aminoglycosides is Pseudomonas (gentamicin-92%, tobramycin-96%, pipercilin/tazobactam-80%); however, Surgeon A had no history of Pseudomonas infections. Therefore, the greatest level of coverage can be obtained with vancomycin, pipercillin/tazobactam, and fluconazole. All of Surgeon B’s infections were caused by non-ESBL producing E. coli. Gentamicin, tobramycin, and pipercillin/tazobactam all have excellent coverage of E. coli (95%, 94%, and 95% respectively). Comparing these agents to other common pathogens shows superior coverage of tobramycin over gentamicin and pipercillin/tazobactom for Pseudomonas. The highest level of coverage for Surgeon B can be obtained with vancomycin, tobramycin, and fluconazole. Surgeon C’s infection history has a predominance of Klebsiella sp., but also includes Pseudomonas. Both gentamicin and tobramycin have excellent coverage (>95%) of these Gram-negative organisms. The highest level of coverage can be obtained with vancomycin, an aminoglycoside, and fluconazole. Conclusions The use of local antibiograms and infection history is a simple strategy to tailor prophylaxis regimens to resistance patterns. We found a different regimen to be superior at each institution. Surgeon B’s experience demonstrates that all aminoglycosides may not be equal when factoring in local resistance patterns. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast, Cynosure, Antares Pharma, Clarus Pharmaceuticals, Acerus Pharma, Boston Scientific.

Pharmacotherapy in the heart transplant recipient: A primer for nurse clinicians and pharmacists.

Heart transplantation (HT) is the definitive treatment for eligible patients with end-stage heart disease. A major complication of HT is allograft rejection which can lead to graft dysfunction and death. The guiding principle of chronic immunosuppression therapy is to prevent rejection of the transplanted organ while avoiding oversuppression of the immune system, which can cause opportunistic infections and malignancy. The purpose of this review is to describe immunosuppressive management of the HT recipient-including agent-specific pharmacology and pharmacokinetics, outcomes data, adverse effects, clinical considerations, and recent guideline updates. We will also provide recommendations for medical prophylaxis of immunosuppressed patients based on the most recent clinical guidelines. Additionally, we highlight the importance of medical therapy adherence and the effect of social determinants of health on the long-term management of HT. HT recipients are a complex and high-risk population. The objective of this review is to describe basic pharmacotherapy in HT and implications for nurses and pharmacists.

Are changes in antibiotic prophylaxis recommendations responsible for an increased risk of cefazolin allergy?

BackgroundThe first line of prevention of surgical site infection relies on the timely administration of antibiotic prophylaxis. First- and second-generation cephalosporins are the most recommended antibiotics in elective surgery. The incidence of cefazolin allergy has increased worldwide over the years. The sensitization mechanism of cefazolin is currently unknown, and data supporting cross-reactivity between penicillins and cephalosporins are lacking. Sensitization could occur through previous exposure either to cefazolin or to structurally related chemical agents. The objective of this study was to evaluate sensitization agents towards cefazolin. MethodsThe OpenBabel chemoinformatics toolbox was used to search for similarities between cefazolin and other molecules in an extensive drug database. Using the pholcodine-rocuronium similarity score as a threshold, we selected drugs with the most similar structure to that of cefazolin. Exposure to those drugs and cefazolin was assessed in a cohort of patients with skin test-proven cefazolin allergy at a specialized allergy centre via a self-administered anonymous questionnaire. ResultsUsing the pholcodine-rocuronium similarity score as a threshold (score≥0.7), 42 molecules were found to be similar to cefazolin (all cephalosporins). Only 8 were marketed in France. None of the 14 cefazolin-allergic patients who answered the questionnaire (65% female, median age 56 years) reported exposure to any identified antibiotics. In contrast, 11 (78%) had at least one previous surgery requiring cefazolin before the index case. ConclusionDirect previous cefazolin exposure was identified in 78% of cefazolin-allergic patients. Cefazolin started to take a central place in antibiotic prophylaxis after 2010, when cefamandole usage decreased drastically. Changes in antibiotic prophylaxis over the past 14 years in France could have been the turning point for the increased incidence of cefazolin allergy.

Improving the safety of CAR-T-cell therapy: The risk and prevention of viral infection for patients with relapsed or refractory B-cell lymphoma undergoing CAR-T-cell therapy.

Chimeric antigen receptor (CAR) T-cell therapy, an innovative immunotherapeutic against relapsed/refractory B-cell lymphoma, faces challenges due to frequent viral infections. Despite this, a comprehensive review addressing risk assessment, surveillance, and treatment management is notably absent. This review elucidates immune response compromises during viral infections in CAR-T recipients, collates susceptibility risk factors, and deliberates on preventive strategies. In the post-pandemic era, marked by the Omicron variant, new and severe threats to CAR-T therapy emerge, necessitating exploration of preventive and treatment measures for COVID-19. Overall, the review provides recommendations for viral infection prophylaxis and management, enhancing CAR-T product safety and recipient survival.

Variation in clinical practice guideline recommendations for medication use in pregnancy in Australia: A systematic review

AbstractBackgroundMedication use in pregnancy is common; however, it is unknown if clinical practice guideline (CPG) prescribing recommendations referred to in Australia at the state, national and international level are consistent.AimsThis systematic review aimed to: (1) identify sources of CPGs that inform prescribing during pregnancy in Australia; (2) assess CPG quality; and (3) evaluate variation within CPG recommendations for medication use in three common conditions in pregnancy: prophylactic antibiotics following premature rupture of membranes (PROM) at term, antidepressants in pregnancy and metformin in gestational diabetes mellitus (GDM).Materials and MethodsA literature search was conducted across PubMed, Scopus and EMBASE databases. Grey literature was identified through publicly available Australian policy statements. Prescribing recommendations for prophylactic antibiotics following PROM at term, antidepressants in pregnancy and metformin in GDM, were compared at the state, national and international levels. CPG quality was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument.ResultsWe identified 39 CPG sources that inform prescribing during pregnancy in Australia. CPG quality varied between resources. There was minor variation in recommendations for antibiotic prophylaxis in PROM at term. Recommendations regarding metformin use in GDM were also variable, with CPGs either recommending its use as a first‐line agent when lifestyle modifications are not effective or when insulin therapy is not practicable. Recommendations for antidepressant use were consistent across CPGs analysed.ConclusionMultiple CPGs exist to inform prescribing during pregnancy in Australia, with variation present within CPG quality and recommendations. These findings offer insight into potential sources of variation in maternal and neonatal health outcomes.

Infections in children following chimeric antigen receptor T-cell therapy for B-cell acute lymphoblastic leukemia.

CD19-directed chimeric antigen receptor T-cell (CAR-T) therapy is transforming care for pediatric patients with relapsed or refractory B-cell acute lymphoblastic leukemia (B-ALL). There are limited pediatric-specific data concerning the infection risks associated with CD19 CAR-T therapy and the adequacy of current antimicrobial prophylaxis guidelines for these patients. We describe the antimicrobial prophylaxis used and the types of infectious occurring in the first 100 days following CAR-T therapy for relapsed or refractory B-cell ALL in children and adolescents (≤18 years) at our centre. Twenty-seven patients received their first CAR-T infusion (CTI) during the study period. Almost all patients (96%) had a comprehensive Infectious Diseases review prior to CTI, which informed a personalised prophylaxis or fever/sepsis plan in six (22%). Overall, six (22%) patients had one or more infections during the study period including five (19%, 0.9 per 100 days-at-risk) from days 0-30 and three (n = 20, 15%, 0.6 per 100 days-at-risk) from days 31-100. Bacterial blood stream infections were the most common type of infection encountered during both time periods, and one patient had probable pulmonary aspergillosis. There were no infection-related deaths. Our study contributes important information on the spectrum of infections encountered in pediatric patients with B-ALL post CAR-T therapy. Overall, the burden of infectious complications post CAR-T therapy in our cohort is lower than previously reported in the literature. Results suggest that our prophylaxis recommendations are effective in this population.

Infective Endocarditis Antibiotic Prophylaxis: Review of the Evidence and Guidelines.

The question of antibiotic prophylaxis and its role in prevention of infective endocarditis (IE) remains controversial, with differing recommendations from international societies. The aim of this review was to compare and contrast current recommendations on antibiotic prophylaxis for IE by the American Heart Association (AHA), the European Society of Cardiology (ESC), and the National Institute for Health and Care Excellence (NICE) and highlight the evidence supporting these recommendations. International guidelines for administration of antibiotic prophylaxis for prevention of IE are largely unchanged since 2009. Studies on the impact of the more restrictive antibiotic prophylaxis recommendations are conflicting, with several studies suggesting lack of adherence to current guidance from the ESC (2015), NICE (2016), and AHA (2021). The question of antibiotic prophylaxis in patients with IE remains controversial, with differing recommendations from international societies. Despite the change in guidelines more than 15years ago, lack of adherence to current guidelines persists. Due to the lack of high-quality evidence and the conflicting results from observational studies along with the lack of randomized clinical trials, the question of whether to recommend antibiotic prophylaxis or not in certain patient populations remains unanswered and remains largely based on expert consensus opinion.