Centers for Disease Control and Prevention, Infectious Disease Society of America, & American Society of Blood and Marrow Transplantation. (2000). Guidelines for preventing opportunistic infections among hematopoietic stem cell transplant recipients. MMWR Recommendations and Reports, 49, 1–125, CE1–CE7.
To summarize the current data and provide comprehensive evidence-based recommendations for the prevention of opportunistic infections in adult and pediatric hematopoietic stem cell transplant (HSCT) recipients.
This was an evidence-based guideline. Evidence was reviewed by multiple professional groups and panels under Centers for Disease Control and Prevention (CDC) guidance.
No results were stated.
This guideline identified infection risks during preengraftment, postengraftment (30–100 days), and late phase (>100 days) for HSCT recipients, associated with immune system defects, device risks, and incidence of specific viral, bacterial, fungal, and mold infectious risks; very specific prevention strategies per treatment phase for allogeneic and autologous HSCT, as well as for both adult and pediatric patients; information on dosage and timing of prophylactic medication, vaccinations, and other specific medical interventions; recommendations for vaccination and behaviors of household members and close contacts; and recommendations for healthcare workers and environmental infection control practices in transplant centers. It identified phase-specific and life-long behavioral prevention, including food preparation, avoiding specific exposures, pet safety, sexual safety, travel safety, water safety, occupational exposures, and general areas to avoid for patients.
Evidence Rating System
A - Strong evidence and substantial clinical benefit (strongly recommended)
B - Strong or moderate evidence, but only limited clinical benefit (generally recommended)
C - Insufficient evidence for efficacy or efficacy does not outweigh possible adverse consequences (optional)
D - Moderate evidence against efficacy or for adverse outcome (generally not recommended)
E- Strong evidence against (never recommended)
I - Evidence from at least one well-executed randomized trial
II - Evidence from at least one well-designed clinical trial without randomization, cohort, or case controlled, time series
III - Evidence from opinions of respected authorities
Recommendations With at Least Optional Recommendation Level
Vaccinations
Other Recommendations
Food-Related
Environmental
Pet Safety
This summary is not intended to provide all content from these guidelines. The reader should refer to the original document for complete information.
Some recommendations are not supported by research data but are provided as best current knowledge in the area.
This was a comprehensive resource, with extensive specific recommendations and identification of the evidence classification of each recommendation. This is an excellent reference for individuals working with HSCT recipients.
Caviggioli, F., Maione, L., Forcellini, D., Klinger, F., & Klinger, M. (2011). Autologous fat graft in postmastectomy pain syndrome. Plastic and Reconstructive Surgery, 128, 349–352.
To assess the clinical effectiveness of lipoaspirate graft in the treatment of postmastectomy pain syndrome
At baseline (prior to autologous fat grafting) and after treatment, pain was measured using a visual analog scale, and analgesic and drug intake were recorded. A nontreatment control group completed the same measures. At one year, measures were repeated in both groups.
The study was a prospective, longitudinal intervention with experimental and control groups.
In the treatment group, there was a decrease in pain (p < 0.0005). The authors noted that 28 of 34 patients stopped their analgesic therapy at 13 months.
More research is needed to determine if autologous fat grafts will benefit women with postmastectomy pain, but this may be a promising area of study.
Cavezzi, A., Paccasassi, S., & Elio, C. (2013). Lymphedema treatment by means of an electro-medical device based on bioresonance and vacuum technology: Clinical and lymphoscintigraphic assessment. International Angiology, 32, 417–423.
To assess the efficacy and safety of a medical device based on electric microcurrents and vacuum mechanism on lower limb lymphedema
Ten daily sessions were performed with an electro-sound wave and vacuum medical device. Lymphoscintigraphy was performed before and after treatments, and an independent observer scored the images. Circumference tape measurement and volumetry were also calculated before and after treatment.
The total limb volumetry decreased from 9,145 cc to 8,714 cc after 10 sessions. There was an 8% reduction in lower limb volumetry. Ankle and midcalf circumference decreased from 27.7 cm to 27.2 cm and 26.2 cm to 25.2 cm, respectively.
The use of a medical device based on bioresonance and vacuum mechanisms appears to be safe and effective at reducing limb volume and lymphoscintigraphy parameters.
This method of limb volume reduction may be effective. However, this was a small study size, and the results of the study require further validation.
Cauwels, R.G., & Martens, L.C. (2011). Low level laser therapy in oral mucositis: A pilot study. European Archives of Paediatric Dentistry, 12, 118–123.
To study the capacity of pain relief and wound healing of low-level laser therapy (LLLT) in chemotherapy-induced oral mucositis in a pediatric population
Children were treated using a GaAIAs diode laser with 830 nm continuous wavelength an output of 150 mW. Laser was applied every 48 hours until complete healing of the lesion occurred.
The study was conducted at a single site in Belgium.
The study used a convenience sample.
Fifty episodes of oral mucositis were included. Pain scores improved after each session with only one exception.
The LLLT appeared to be effective for pain relief in this population.
Castaman, G., Bona, E.D., Schiavotto, C., Trentin, L., D'Emilio, A., & Rodeghiero, F. (1997). Pilot study on the safety and efficacy of desmopressin for the treatment or prevention of bleeding in patients with hematologic malignancies. Haematologica, 82, 584–587.
To determine if desmopressin use is effective to prevent bleeding episodes for patients with thrombocytopenia due to bone marrow failure or idiopathic thrombocytopenic purpura (ITP)
Desmopressin was delivered as 0.4 microgram/kg diluted in 100 mL of NS infused over 30 minutes. Bleeding time was assessed (using standard procedure) before the start of infusion and at one and four hours postinfusion. It is not clear how patients were chosen for inclusion in this study but all had a bleeding event.
All of the patients had a favorable response after one infusion of desmopressin. Bleeding time slowed during infusion and stopped usually within one hour. No nasal packing was required. Patients were able to have scheduled dental procedures, none required platelet transfusions, and no significant side effects were noted from the desmopressin. None of the patients had evidence of disseminated intravascular coagulation.
The findings of this pilot study are interesting to consider for hematologic malignancy groups of patients who receive multiple platelet transfusions and are at risk to become refractory to platelets. Further experimentation is needed to validate the results found here, but on a case-by-case basis, desmopressin infusion could be helpful to decrease bleeding time in thrombocytopenic patients.
At this time, this pilot study does not warrant a change in practice due to its severe limitations of generalizability. There needs to be randomized, clinical trials before a change in practice can be endorsed.
Castagna, L., Bramanti, S., Levis, A., Michieli, M. G., Anastasia, A., Mazza, R., . . . Santoro, A. (2010). Pegfilgrastim versus filgrastim after high-dose chemotherapy and autologous peripheral blood stem cell support. Annals of Oncology, 21, 1482–1485.
To demonstrate that one single fixed dose of pegfilgrastim (PEG) was not inferior compared to daily doses of filgrastim after high-dose chemotherapy (HDC) and autologous peripheral stem cell transplant.
Comparisons between two different granulocyte colony-stimulating factors (G-CSFs) (i.e., PEG and filgrastim) were highlighted in this article. The researcher wanted to reveal that PEG is the same high quality as filgrastim after receiving HDC and peripheral blood stem cells starting from day 1. A single fixed dose of PEG was given 24 hours after stem cell infusion. In the control arm, 5 mcg/kg/day of filgrastim was given from day 1 until absolute neutrophil count (ANC) recovered to greater than .5x 109/l. Each setting followed its own supportive care and prophylaxis guidelines; however, all patients received quinolone prophylaxis.
This was an open-label, randomized study with a noninferiority design.
This study illustrated that the use of a single fixed dose of PEG was not inferior to the use of daily filgrastim. There were no significant differences in measured outcomes between the two groups and no differences in treatment side effects.
PEG can be use alternately to filgrastim as it is only given as one single fixed dose of 6 mg as compared to daily doses of filgrastim. Infection-related outcomes studied were not different between these two treatment approaches.
Use of a single dose of PEG rather than daily injections of filgrastim may be a useful alternative for these types of patients in order to avoid multiple injections. Findings of this study were limited by sample size, study design issues, and the fact that other prophylactic treatment was not consistent throughout the sample. Further research in this area will be helpful to confirm differences in the relative equivalency of these two approaches.
Castagna, L., Benhamou, E., Pedraza, E., Luboinski, M., Forni, M., Brandes, I., … Dietrich, P.-Y. (2001). Prevention of mucositis in bone marrow transplantation: A double blind randomised controlled trial of sucralfate. Annals of Oncology, 12, 953–955.
To compare placebo to sucralfate for prevention of mucositis in high-dose chemotherapy and bone marrow transplant (BMT)
Treatment was started one day before the regimen. Patients received one 2 g dose pack every three hours during the day and once during the night if awakened for a maximum of 7 per 24 hours until bone marrow (BM) recovery or end of mucositis.
The study reported on 102 patients hospitalized for allogeneic or autologous BMT.
The study was conducted between April 1991 and November 1993.
This was a prospective, randomized, double-blind study.
Patients were examined twice weekly by two physicians only, recorded prospectively, according to adapted Oral and Maxillofacial Surgeon (OMS) criteria for grafted patients.
Cassileth, B.R., Van Zee, K.J., Yeung, K.S., Coleton, M.I., Cohen, S., Chan, Y.H., … Hudis, C.A. (2013). Acupuncture in the treatment of upper-limb lymphedema: Results of a pilot study. Cancer, 119, 2455–2461.
To evaluate the safety and potential efficacy of acupuncture in the treatment of arm lymphedema in women with breast cancer-related lymphedema
Each patient was given acupuncture treatment twice weekly for four weeks. Treatments lasted 30 minutes, as 14 needles were inserted at apecific points determined on the basis of history and consensus of experienced acupuncturists. Arm circumference was measured before and after each treatment.
This was a single-site, outpatient study conducted at Memorial Sloan-Kettering Cancer Center in New York.
This study has clinical applicability for late effects and survivorship.
This was a prospective trial.
Findings suggest that acupuncture can be safely provided to patients with arm lymphedema. However, the benefit is unclear because of study design limitations and the fact that the mean change in lymphedema was very small.
This study provides insufficient evidence to support efficacy of acupuncture for lymphedema management.
Cassileth, B.R., Van Zee, K.J., Chan, Y., Coleton, M.I., Hudis, C.A., Cohen, S., . . . Vickers, A.J. (2011). A safety and efficacy pilot study of acupuncture for the treatment of chronic lymphoedema. Acupuncture in Medicine: Journal of the British Medical Acupuncture Society, 29(3),170–172.
To evaluate the safety and effectiveness of acupuncture in women diagnosed with chronic lymphedema
Women with chronic lymphedema after breast cancer surgery received acupuncture twice a week for four weeks using Acupoint prescription, chosen by consensus from members of the Memorial Sloan Kettering Cancer Center Integrative Medicine Service certified acupuncturists.
The study took place at the Integrative Medicine Service and Department of Epidemiology and Biostatistics at the Memorial Sloan-Kettering Cancer Center in New York.
The study has clinical applicability for late effects and survivorship.
The study used a prospective pilot design.
After nine subjects were treated, four women demonstrated a 30% reduction in limb volume after four weeks of treatment, with no significant adverse events occurring. Some patients did experience minor toxicities, such as slight bruising or minor pain at acupuncture site shortly after treatment.
The pilot study suggests that acupuncture for women with arm lymphedema may be practical and was not associated with significant adverse effects. Further research in this area to establish safety and begin to evaluate effectiveness is planned.
Additional robust randomized controlled trials are needed to evaluate the use of acupuncture for the treatment of lymphedema.
Cassileth, B.R., & Vickers, A.J. (2004). Massage therapy for symptom control: Outcome study at a major cancer center. Journal of Pain and Symptom Management, 28, 244–249.
Promising results warrant a controlled trial.