Over the last twenty years there has been a startling increase in the incidence of invasive fungal infection in Bone Marrow Transplant patients (BMT). This is primarily due to medical advances which have introduced intensive chemotherapies and immuno-suppressive drugs, resulting in increased numbers of severely ill and immuno-compromised hospitalised patients. A retrospective audit conducted recently, looked at whether the United Kingdom Children’s Cancer Group (UKCCSG) Fungal Management Strategy was adhered to. Looking at 100 paediatric patients aged 10months to 19 years who received Bone Marrow Transplants during June 2000 to December 2002; we identified whether they received prophylactic and empirical fungal therapy as outlined by the protocol and if not, what the reasons were for detracting from the protocol. Data collected included primary diagnosis; type of transplantation; myeloablative regimen; time to engraftment; antifungal used, when changed and reasons for change and survival at day +100. The audit outlined that most patients were initially assigned the wrong risk status but once corrected they followed the protocol appropriately. The main problems highlighted were intolerance to oral Itraconazole which led to patients automatically being changed to Intravenous (IV) AmBisome, even if only one dose was refused. A solution needed to be found and perhaps introducing nasogastric tubes would overcome inappropriate usage of IV therapy. NG tubes are not currently used within our unit but introducing them would impact on other therapies such as enteral feeds over total parenteral nutrition. Introducing this change to practice is not without its problems: Would the medical and nursing staff be receptive to introducing NG tubing? How would we train staff in the passing and care of NG tubes? What support is available for nauseated patients? Would there be reduced costs? Are there any benefits to patients? By highlighting the use of, and adherence to the policy, alongside implementing training for all staff, adherence problems will be addressed. Staff will become competent in the care of NG tubes and the issue of oral therapy versus IV therapy would not arise. Possible benefits to patients include shorter admissions and reduced possible side effects related to prolonged use of IV antifungals. This practice change would facilitate the appropriate use of IV AmBisome in accordance with the UKCCSG fungal management guidelines.
Full conference title:
30th Annual Meeting of the European Group for Blood and Marrow Transplantation
- EBMT 2004