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Antibiotics Help Infection Linked To Chemotherapy

Breaking News - September 2005 - Week 2

(Sep 14, 2005)

Healthcare in  the News

-- Since bacterial infections can be a common side effect of chemotherapy treatment, researchers asked if it would make sense to use antibiotics to prevent those infections. Results of the studies were reported in the New England Journal of Medicine (NEJM).

Picture of a prescription pad and a pill bottle

Both studies found some benefit to using antibiotics to prevent infections in people receiving chemotherapy, but the studies' researchers and other experts point out that the benefit may be too small when compared to the cost of the medications and the risk of developing antibiotic resistance.

"These studies are well designed and suggest that a number of bad outcomes, such as fevers, infections, and hospitalizations, could be reduced [with prophylactic use of levofloxacin], but that reduction comes at a cost in terms of actual dollars, in terms of side effects, and in terms of the possibility of developing antibiotic resistance," says Dr. Len Lichtenfeld, deputy chief medical officer for the American Cancer Society.

Chemotherapy Affects Healthy Cells

Infections sometimes occur during and after chemotherapy treatment because the same medications that kill cancer cells can also affect healthy cells. Infection-fighting white blood cells are often depleted by chemotherapy, especially white blood cells called neutrophils.

When chemotherapy or radiation therapy reduces the numbers of neutrophils significantly, a condition called neutropenia develops. Patients with neutropenia are at increased risk of infection, according to National Cancer Institute experts.

In the US, physicians routinely treat patients undergoing chemotherapy with granulocyte colony-stimulating factor (G-CSF), a therapy that helps stimulate the growth of white blood cells, explains Dr. Bruce Raphael, a hematologist/oncologist at the New York University Cancer Institute in New York City.

But, whether or not using preventive antibiotic therapy would further reduce the rate of infections, hospitalizations, and deaths was still an open question, Dr. Lichtenfeld says.

One recent study estimated that the routine prophylactic use of antibiotics for chemotherapy patients may already be as high as 45 percent.

In the first of two studies in this week's NEJM, researchers in Italy compared the use of levofloxacin (Levaquin®) to a placebo (inactive substance) in 760 people diagnosed with chemotherapy-induced neutropenia. In the study, 384 people received 500 milligrams of levofloxacin daily from the start of chemotherapy until their neutropenia disappeared.

According to a team led by Dr. Giampaolo Bucaneve of Policlinico Monteluce, Perugia, 85 percent of those on the placebo developed a fever - indicating a possible infection - while just 65 percent of those taking levofloxacin did. There was no statistically significant improvement in patient death rates, however.

"These researchers concentrated on a group of patients we know develop neutropenia, sometimes for weeks at a time," says Dr. Raphael. "The questions you have to ask are, could they reduce the number of infections? Yes, they did, but at what cost? Are you inducing resistant bugs?"

The second study, this time led by Dr. Michael Cullen of University Hospital Birmingham Cancer Centre in the United Kingdom, included patients who were not as sick as those in the first study, meaning that they needed lower doses of chemotherapy to treat their disease. And, as the dose of chemotherapy dropped, so, too, did their risk for neutropenia.

This study included 1,565 cancer patients randomly assigned to receive placebo treatment or treatment with 500 milligrams of levofloxacin for seven days, at a period where they were thought to be at high risk for neutropenia.

During the first cycle of chemotherapy, 7.9 percent of those on the placebo developed fever compared to just 3.5 percent of those taking levofloxacin. Hospitalizations for infection occurred in 15.7 percent of those receiving levofloxacin compared to 21.6 percent of those on placebo, the researchers report.

There were four infection-related deaths in each of the two groups, according to the study.

"Here, they're treating a huge number of patients with antibiotics to prevent a small number of infections," Dr. Raphael notes. "The rate of infection was only about 8 percent for placebo. They did reduce the number of infections by as much as 50 percent [with levofloxacin], but many people took the drug and didn't need it."

Plus, Dr. Raphael points out that G-CSF was not given as prophylaxis in this study to boost white cell counts, as is commonly done in the US.

Experts Say Find Those Most In Need

In an accompanying editorial, Dr. Lindsey Baden, the deputy editor of the NEJM writes, "[These studies] provide evidence of the significant benefit of levofloxacin prophylaxis, but the price of this benefit may be high."

Because of the added risk of antibiotic resistance, Dr. Baden suggests that a more targeted approach might be warranted. Drs. Lichtenfeld and Raphael concur.

"If it works, why not concentrate on those who most likely need it - people who have been shown to have a low white blood cell count during the first cycle, people who are older, people who have bone marrow involvement?" says Dr. Raphael. "In these groups, this approach appears to be very reasonable."

He adds that patients would also need to be monitored to ensure that antibiotic resistance was not developing.

The bottom line? "I don't see a need to treat every patient who has chemotherapy with antibiotics," says Dr. Raphael.

Dr. Lichtenfeld adds that cancer patients should know that this is an option - and discuss with their physician whether or not it is a good choice for them.

Always consult your physician for more information.

For more information on health and wellness, please visit health information modules on this Web site.

Preventing Infection During Chemotherapy

Many chemotherapy drugs can damage the bone marrow, where blood cells are made. White blood cells are the cells that fight many types of infections, which means that chemotherapy can leave you at risk for infection.

The bacteria that cause most infections are normally found on your skin and in your mouth, intestines, and genital tract. Sometimes, the source of an infection is unknown.

Infections can happen to people even when they are very careful. Individuals who are fighting infections are sometimes given a medication to boost their white blood cell count after chemotherapy.

The National Cancer Institute (NCI) advises the following ways to avoid infection:

  • Wash your hands often during the day. Be sure to wash them before you eat, after you use the bathroom, and after touching animals.
  • Clean your rectal area gently but thoroughly after each bowel movement. Ask your physician or nurse for advice if the area becomes irritated or if you have hemorrhoids. Also, check with your physician before using enemas or suppositories.
  • Stay away from people who have illnesses you can catch, such as a cold, the flu, measles, or chicken pox.
  • Try to avoid crowds. For example, go shopping or to the movies when the stores or theaters are least likely to be busy.
  • Stay away from children who recently have received "live virus" vaccines such as chicken pox and oral polio, since they may be contagious to people with a low blood cell count. Call your physician or local health department if you have any questions.
  • Do not cut or tear the cuticles of your nails.
  • Be careful not to cut or nick yourself when using scissors, needles, or knives.
  • Maintain good mouth care.
  • Do not squeeze or scratch pimples.
  • Take a warm (not hot) bath, shower, or sponge bath every day. Pat your skin dry using a light touch. Do not rub too hard.
  • Use lotion or oil to soften and heal your skin if it becomes dry and cracked.
  • Clean cuts and scrapes right away and daily until healed with warm water, soap, and an antiseptic.
  • Avoid contact with animal litter boxes and waste, bird cages, and fish tanks.
  • Avoid standing water, for example, bird baths, flower vases, or humidifiers.
  • Wear protective gloves when gardening or cleaning up after others, especially small children.
  • Do not get any immunizations, such as flu or pneumonia shots, without checking with your physician first.
  • Do not eat raw fish, seafood, meat, or eggs.
  • Use an electric shaver instead of a razor to prevent breaks or cuts in your skin.

The NCI says to call your physician right away if you have any of these symptoms:

  • Fever over 100° F or 38° C.
  • Chills, especially shaking chills
  • Sweating
  • Loose bowel movements
  • Frequent urgency to urinate or a burning feeling when you urinate
  • A severe cough or sore throat
  • Unusual vaginal discharge or itching
  • Redness, swelling, or tenderness, especially around a wound, sore, ostomy, pimple, rectal area, or catheter site
  • Sinus pain or pressure
  • Earaches, headaches, or stiff neck
  • Blisters on the lips or skin
  • Mouth sores

Always consult your physician for a diagnosis.

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