Prophylactic antibiotics, air quality control and barrier isolation combined reduce mortality

December 19, 2008

A combination of prophylactic antibiotics, barrier isolation and air quality control measures substantially reduces the risk of death in high-risk cancer patients who are immunocompromised due to chemotherapy or stem cell transplantation. This reduction is 40% at 30 days post-treatment. But it is the antibiotic administration that is needed to show the effect on mortality - without this, the effect diminishes. The issues are discussed in a Review published early Online and in the February edition of Lancet Infectious Diseases, written by Dr Mical Paul, Unit of Infectious Diseases, Rabin Medical Center and Sackler Faculty of Medicine, Tel-Aviv University, Israel, and colleagues.

Infections constitute a frequent complication of cancer treatment due to its resultant effect on the immune system. Such infections are the most common preventable cause of death in these patients. Yet application of infection control measures for cancer patients vary widely between hospitals and countries. Available measures range from simple interventions such as hand hygiene, use of barriers (gloves, gown, and mask), and provision of low-bacterial or sterile food, to complicated engineering control measures involving ventilation and air-quality technologies that aim to minimise the risk of acquiring environmental fungal infections. These interventions represent a substantial cost to health-care systems. Furthermore, not all cancer patients are the same -- cancer patients differ in their risk for infection, with patients undergoing allogenic haematopoietic stem-cell transplantation (HSCT) and those with acute leukaemia at highest risk. The authors say: "In an era of rising antimicrobial resistance, we might need to increase our reliance on infection prevention and control."

In addition to the 40% reduction in all-cause mortality (ACM) at 30 days for the high-risk patients mentioned above, the authors also found there was still a 14% ACM reduction at the longest follow-up of three years. Improved survival could be shown only when antibiotic and anti-fungal prophylaxis were used in conjunction with air quality or barrier isolation. The authors say: "On the basis of the evidence presented, the effect of protective isolation, including control of air quality, barrier isolation, and antibiotic/antifungal prophylaxis, can be estimated at a risk reduction of 40% in 30-day all-cause mortality. These results apply similarly to patients after allogeneic or autologous HSCT and for patients treated for acute leukaemia, but not for lower-risk patients. Since prophylaxis has the highest effect within this multifaceted intervention, efforts should be directed at administering effective prophylaxis. We could not show an independent contribution of barrier precautions. However, they might be more important in the present day, given the high rates of resistant pathogens in hospitals. Barrier precautions might increase the efficacy of prophylaxis and allow better empirical treatment by reducing cross-transmission of resistant nosocomial pathogens."

The authors also analysed 11 non-randomised prospective studies which assesses inpatient versus outpatient management following HSCT transplantation. All cause mortality was found to be 28% lower in outpatients. The authors conclude: "The safety and potential benefit of outpatient management in observational studies calls for the assessment of outpatient versus inpatient management of HSCT in randomised controlled trials."
-end-
Dr Mical Paul, Unit of Infectious Diseases, Rabin Medical Center and Sackler Faculty of Medicine, Tel-Aviv University, Israel T) +972-3-9377512 E) pil1pel@zahav.net.il

For full Review, see: http://press.thelancet.com/TLIDbarrierfinal.pdf

Lancet

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