[Standards, Options, and Recommendations for the management of brief neutropenias. Fedération Nationale des Centres de Lutte Contre le Cancer]. / Standards, Options et Recommandations pour la prise en charge des neutropénies courtes.

CONTEXT: The "Standards, Options and Recommendations" (SOR), initiated in 1993, is a collaborative project between the Federation of the French Cancer Centres (FNCLCC), the 20 French Cancer Centres and specialists from French Public Universities, General Hospitals and Private Clinics. The main objective is the development of clinical practice guidelines to improve the quality of health care and outcomes for cancer patients. The methodology is based on literature review and critical appraisal by a multidisciplinary experts group, with feedback from specialists in cancer care delivery. OBJECTIVE: To develop a clinical practice guideline for the management of neutropenic cancer patients (excluding prolonged neutropenia). METHODS: Data have been identified by literature search using Medline and Current Contents (up to February 1997) and personal reference lists. The main end points considered were mortality, morbidity, risk factors, fever, source of infection, microbiological documentation, incidence and length of hospital stays, quality of life, efficacy of treatment, safety and costs. Once the guideline was defined, the document was submitted to 48 reviewers for peer review and to the medical committees of the 20 French Cancer Centres for review and agreement. RESULTS: The key recommendations are: 1) before receiving cytotoxic chemotherapy, patients must be informed of potential risks and precautions to observe; 2) non-febrile neutropenic patients can be followed at home (except specific context); antibiotic prophylaxis is not recommended; 3) initial empirical antibiotic therapy for febrile patients is mandatory, whether associated beta-lactam and aminoglycoside, or monotherapy with a broad-spectrum beta-lactam (except in case of septic shock or pneumopathy). A glycopeptide can be added in case of overt catheter-related or cutaneous infection, in case of microbiologically documented infection with a oxacillin-resistant Gram positive bacteria, or in case of persistent fever in a clinically deteriorating patient; 4) at the present time, there is insufficient evidence to recommend the management of febrile neutropenic patients at home. We recommend participation in studies to identify predicting factors of low-risk patients and to assess the feasibility and safety of early discharge and home therapy.

Microbial contamination of enteral feeding tubes occurring during nutritional treatment.

Enteral nutrition is an effective treatment for catabolic patients with normal intestinal absorption. However, tube-fed patients are at risk from superinfection. Our study is the first to evaluate in vivo the microbial contamination of solutions staying in the nasogastric tube of cancer patients receiving nutritional preparations. After daily feeding, the tube was rinsed with nonsterile tap water. Tap water staying overnight in the tube was considered as tube-rinsing solution. Microbial burden of nutritional preparations was determined on the fifth day of enteral nutrition, from opening the first container and throughout feeding. The next day, a sample of the tube-rinsing solution was cultured. All bacterial species were identified and antibiotic susceptibility pattern was assessed. Thirty-one cancer patients were included, 12 on the hospital's preparations and 19 on commercial feeding. Seven of the hospital--and none of the commercial--preparations were contaminated. Among the 48 samples collected during feeding, 16 were contaminated, including 10 hospital and 6 commercial preparations. All the 31 tube-rinsing solutions were contaminated and 102 strains cultured. Their median concentration was 10(6) colony-forming units/mL (range 10-10(10)). The strains were 48 Enterobacteriaceae, 20 group D streptococci, 9 Candida albicans, 9 Pseudomonas aeruginosa, and 16 others. Multiple antibiotic resistance was present in 12 of the 102 strains. Lower resistance was present in 33. The predominant microorganism of the tube-rinsing solution caused a bacterial colonization for three febrile patients. In conclusion, the feeding tube is an important reservoir for multiple antibiotic-resistant bacteria.

Candida albicans--adriamycin interactions: ultrastructural and spectrofluorometric study of whole yeasts and spheroplasts.

The occurrence of candidiasis in cancer patients who undergo chemotherapy requires the interrelation of Candida albicans and the antimitotic drug Adriamycin (ADM) which is well known as an intercalating agent. The whole yeasts were not affected by 2 h of contact with the drug at 10(-4) M neither for their growth curve nor for their ultrastructure, despite the presence of free ADM on their surface. Spheroplasts displayed a delay in their growth and exhibited altered nucleoli with segregation of their granular and fibrillar components. The modified emission spectrum of ADM, determined by spectrofluorometry, corresponded neither to the free ADM nor to the DNA-bound drug, but it could be related to a metabolite of the drug. The cell wall appeared to be one of the main sites for ADM resistance of Candida albicans in vitro.