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  • Measure Summary
  • NQMC:008562
  • Apr 2012

Infection control after hematopoietic cell transplantation (HCT): percentage of patients who were expected to be neutropenic for 7 or more days during HCT and were prescribed antibacterial prophylaxis with a fluoroquinolone.

Proposed infection control after HCT measure set: questionnaire, patient selection, measures with specifications, glossary. Arlington Heights (IL): American Society for Blood and Marrow Transplantation; 20 p.

This is the current release of the measure.

The measure developer reaffirmed the currency of this measure in February 2017.

Primary Measure Domain

Clinical Quality Measures: Process

Secondary Measure Domain

Does not apply to this measure

Description

This measure is used to assess the percentage of patients greater than or equal to 18 years of age who were expected to be neutropenic for 7 or more days during hematopoietic cell transplantation (HCT) and were prescribed antibacterial prophylaxis with a fluoroquinolone.

Rationale

In the past decade, modifications in hematopoietic cell transplantation (HCT) management and supportive care have resulted in changes in recommendations for the prevention of infection in HCT patients. These changes are fueled by new antimicrobial agents, increased knowledge of immune reconstitution, and expanded conditioning regimens and patient populations eligible for HCT. Despite these advances, infection is reported as the primary cause of death in 8% of autologous HCT patients and 17% to 20% of allogeneic HCT recipients.

Support (verbatim) from guidelines: Antibacterial prophylaxis with a fluoroquinolone (i.e., levofloxacin) to prevent bacterial infections should be strongly considered for adult HCT patients with anticipated neutropenic periods of 7 days or more. Antibacterial prophylaxis is generally started at the time of stem cell infusion and continued until recovery from neutropenia or initiation of empirical antibacterial therapy for fever during neutropenia. The prophylaxis should not be continued after recovery from neutropenia. Local epidemiological data should be carefully considered before applying fluoroquinolone prophylaxis, and once it is applied, the emergence of resistance in bacterial pathogens should be monitored closely because of increasing quinolone resistance worldwide among Gram-negative bacteria (e.g., Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa) and staphylococci; plasmid-mediated quinolone resistance in Enterobacteriaceae that is closely related to the beta lactamases that inactivate third-generation cephalosporins; and quinolone-related development of a hypervirulent strain of Clostridium difficile.

Note on pediatrics: Because of lack of data, there are currently no antimicrobial prophylactic regimens that can be recommended for children. Some experts use levofloxacin for pediatric antibacterial prophylaxis.

Statement (verbatim) from guidelines on gap: Significant changes in the field of HCT since the publication of the original guidelines necessitated this update. These changes include new antimicrobial agents, broader use of reduced-intensity conditioning (RIC), the increasing age of HCT recipients, and more frequent use of alternative donor stem cell sources such as haploidentical donors and umbilical cord blood. Furthermore, as with any field of medicine, published studies continue to add to the evidence regarding supportive medical care. Despite—or perhaps because of—these changes, infections still occur with increased frequency or severity among HCT recipients as a patient population.

Statement from the American Society for Blood and Marrow Transplantation (ASBMT) Task Force on gap: Fluoroquinolone for bacterial infection prophylaxis is new to the 2009 guidelines from the prior 2000 guidelines. For this reason, we believe there is a significant gap in adoption of this therapy.

Evidence for Rationale

 Pasquini MC, Wang Z.  Current use and outcome of hematopoietic stem cell transplantation: CIBMTR summary slides.  2012.

Blahova J, Kralikova K, Krcmery V Sr, Babalova M, Menkyna R, Glosova L, Knotkova H, Liskova A, Molokacova M, Vaculikova A, Bruckmayerova D, Rovny I. Four years of monitoring antibiotic resistance in microorganisms from bacteremic patients. J Chemother. 2007 Dec;19(6):665-9. PubMed External Web Site Policy

Bonadio M, Morelli G, Mori S, Riccioni R, Papineschi F, Petrini M. Fluoroquinolone resistance in hematopoietic stem cell transplant recipients with infectious complications. Biomed Pharmacother. 2005 Oct;59(9):511-6. PubMed External Web Site Policy

Bucaneve G, Castagnola E, Viscoli C, Leibovici L, Menichetti F. Quinolone prophylaxis for bacterial infections in afebrile high risk neutropenic patients. Eur J Cancer. 2007;(Suppl 5):5-12.

Bucaneve G, Micozzi A, Menichetti F, Martino P, Dionisi MS, Martinelli G, Allione B, D'Antonio D, Buelli M, Nosari AM, Cilloni D, Zuffa E, Cantaffa R, Specchia G, Amadori S, Fabbiano F, Deliliers GL, Lauria F, Foa R, Del Favero A, Gruppo Italiano Malattie Ematologiche dell'Adulto (GIMEMA) Infection Program. Levofloxacin to prevent bacterial infection in patients with cancer and neutropenia. N Engl J Med. 2005 Sep 8;353(10):977-87. PubMed External Web Site Policy

Cruciani M, Malena M, Bosco O, Nardi S, Serpelloni G, Mengoli C. Reappraisal with meta-analysis of the addition of Gram-positive prophylaxis to fluoroquinolone in neutropenic patients. J Clin Oncol. 2003 Nov 15;21(22):4127-37. PubMed External Web Site Policy

Cruciani M, Rampazzo R, Malena M, Lazzarini L, Todeschini G, Messori A, Concia E. Prophylaxis with fluoroquinolones for bacterial infections in neutropenic patients: a meta-analysis. Clin Infect Dis. 1996 Oct;23(4):795-805. PubMed External Web Site Policy

Engels EA, Lau J, Barza M. Efficacy of quinolone prophylaxis in neutropenic cancer patients: a meta-analysis. J Clin Oncol. 1998 Mar;16(3):1179-87. PubMed External Web Site Policy

Gafter-Gvili A, Fraser A, Paul M, Leibovici L. Meta-analysis: antibiotic prophylaxis reduces mortality in neutropenic patients. Ann Intern Med. 2005 Jun 21;142(12 Pt 1):979-95. PubMed External Web Site Policy

Kirby JT, Fritsche TR, Jones RN. Influence of patient age on the frequency of occurrence and antimicrobial resistance patterns of isolates from hematology/oncology patients. Diagn Microbiol Infect Dis. 2006 Sep;56(1):75-82. PubMed External Web Site Policy

Loo VG, Poirier L, Miller MA, Oughton M, Libman MD, Michaud S, Bourgault AM, Nguyen T, Frenette C, Kelly M, Vibien A, Brassard P, Fenn S, Dewar K, Hudson TJ, Horn R, Rene P, Monczak Y, Dascal A. A predominantly clonal multi-institutional outbreak of Clostridium difficile-associated diarrhea with high morbidity and mortality. N Engl J Med. 2005 Dec 8;353(23):2442-9. PubMed External Web Site Policy

MacDougall C, Powell JP, Johnson CK, Edmond MB, Polk RE. Hospital and community fluoroquinolone use and resistance in Staphylococcus aureus and Escherichia coli in 17 US hospitals. Clin Infect Dis. 2005 Aug 15;41(4):435-40. PubMed External Web Site Policy

Oktem IM, Gulay Z, Bicmen M, Gur D, HITIT Project Study Group. qnrA prevalence in extended-spectrum beta-lactamase-positive Enterobacteriaceae isolates from Turkey. Jpn J Infect Dis. 2008 Jan;61(1):13-7. PubMed External Web Site Policy

Poirel L, Cattoir V, Nordmann P. Is plasmid-mediated quinolone resistance a clinically significant problem. Clin Microbiol Infect. 2008 Apr;14(4):295-7. PubMed External Web Site Policy

Proposed infection control after HCT measure set: questionnaire, patient selection, measures with specifications, glossary. Arlington Heights (IL): American Society for Blood and Marrow Transplantation; 20 p.

Robicsek A, Jacoby GA, Hooper DC. The worldwide emergence of plasmid-mediated quinolone resistance. Lancet Infect Dis. 2006 Oct;6(10):629-40. [77 references] PubMed External Web Site Policy

The European Antimicrobial Resistance Surveillance System (EARSS). Annual report 2006. 2008.

Tomblyn M, Chiller T, Einsele H, Gress R, Sepkowitz K, Storek J, Wingard JR, Young JA, Boeckh MJ, Center for International Blood and Marrow Research, National Marrow Donor program, European Blood and Marrow Transplant Group, American Society of Blood and Marrow Transplantation, Canadian Blood and Marrow Transplant Group, Infectious Diseases Society of America, Society for Healthcare Epidemiology of America, Association of Medical Microbiology and Infectious Disease Canada, Centers for Disease Control and Prevention. Guidelines for preventing infectious complications among hematopoietic cell transplantation recipients: a global perspective. Biol Blood Marrow Transplant. 2009 Oct;15(10):1143-238. PubMed External Web Site Policy

van de Wetering MD, de Witte MA, Kremer LC, Offringa M, Scholten RJ, Caron HN. Efficacy of oral prophylactic antibiotics in neutropenic afebrile oncology patients: a systematic review of randomised controlled trials. Eur J Cancer. 2005 Jul;41(10):1372-82. [44 references] PubMed External Web Site Policy

Primary Health Components

Hematopoietic cell transplantation (HCT); neutropenia; antibacterial prophylaxis; fluoroquinolone

Denominator Description

The number of patients in your selection having hematopoietic cell transplantation (HCT) AND expected to be neutropenic for 7 or more days (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

The number of patients in your selection having hematopoietic cell transplantation (HCT) AND expected to be neutropenic for 7 or more days AND were prescribed fluoroquinolone (see the related "Numerator Inclusions/Exclusions" field)

Type of Evidence Supporting the Criterion of Quality for the Measure

  • A clinical practice guideline or other peer-reviewed synthesis of the clinical research evidence
  • A formal consensus procedure, involving experts in relevant clinical, methodological, public health and organizational sciences
  • A systematic review of the clinical research literature (e.g., Cochrane Review)
  • One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal

Additional Information Supporting Need for the Measure

Unspecified

Extent of Measure Testing

The Infection Control (IC) measure set was developed by the American Society for Blood and Marrow Transplantation (ASBMT) using a rigorous methodology (adapted from the American Medical Association's Physician Consortium for Performance Improvement [AMA-PCPI] and including field testing) and adapted for use in Practice Improvement Modules (PIMs) by the American Board of Internal Medicine (ABIM).

Evidence for Extent of Measure Testing

Joseph TL. (Executive Director, American Society for Blood and Marrow Transplantation). Personal communication. 2013 Jan 21.  1 p.

State of Use

Current routine use

Current Use

Certification

Internal quality improvement

Measurement Setting

Ambulatory/Office-based Care

Hospital Inpatient

Hospital Outpatient

Intensive Care Units

Professionals Involved in Delivery of Health Services

Physicians

Least Aggregated Level of Services Delivery Addressed

Clinical Practice or Public Health Sites

Statement of Acceptable Minimum Sample Size

Specified

Target Population Age

Age greater than or equal to 18 years

Target Population Gender

Either male or female

National Quality Strategy Aim

Better Care

National Quality Strategy Priority

Making Care Safer
Prevention and Treatment of Leading Causes of Mortality

IOM Care Need

Living with Illness

IOM Domain

Effectiveness

Safety

Case Finding Period

12 months

Denominator Sampling Frame

Patients associated with provider

Denominator (Index) Event or Characteristic

Clinical Condition

Encounter

Therapeutic Intervention

Denominator Time Window

Does not apply to this measure

Denominator Inclusions/Exclusions

Inclusions
The number of patients in your selection having hematopoietic cell transplantation (HCT) AND expected to be neutropenic for 7 or more days

Note: Patients can be included in the chart abstraction if:

  • They have been seen by the practice within the past 12 months; and
  • Management decisions regarding care are made primarily by providers in the practice.

Select at least 25 of your patients who have had HCT. Refer to the original measure documentation for administrative codes.

Exclusions
Patients less than 18 years old

Exclusions/Exceptions

Patient factors addressed

Numerator Inclusions/Exclusions

Inclusions
The number of patients in your selection having hematopoietic cell transplantation (HCT) AND expected to be neutropenic for 7 or more days AND were prescribed fluoroquinolone

Note: This requires documentation in the patient's medical record that fluoroquinolone therapy was prescribed as described in the guidelines (see the original measure documentation for details).

Exclusions
None

Numerator Search Strategy

Fixed time period or point in time

Data Source

Administrative clinical data

Paper medical record

Type of Health State

Does not apply to this measure

Instruments Used and/or Associated with the Measure

Unspecified

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Rate/Proportion

Interpretation of Score

Desired value is a higher score

Allowance for Patient or Population Factors

Unspecified

Standard of Comparison

Internal time comparison

Original Title

Patients who were expected to be neutropenic for 7 or more days during HCT and were prescribed antibacterial prophylaxis with a fluoroquinolone.

Measure Collection Name

Infection Control after Hematopoietic Cell Transplantation Measure Set

Submitter

American Society for Blood and Marrow Transplantation - Professional Association

Developer

American Society for Blood and Marrow Transplantation - Professional Association

Funding Source(s)

American Society for Blood and Marrow Transplantation

Composition of the Group that Developed the Measure

The American Society for Blood and Marrow Transplantation (ASBMT) Education Practice Improvement Modules Task Force:

  • Linda Burns, MD (chair)
  • Stephan A Grupp, MD, PhD
  • Mark B Juckett, MD
  • Vivek Roy, MD
  • Edward Agura, MD
  • Miguel-Angel Perales, MD
  • Thomas Joseph, MPS, CAE, ASBMT Executive Director
  • Sue Frechette, BSN, MBA Consultant

Financial Disclosures/Other Potential Conflicts of Interest

Conflicts, if any, are disclosed in accordance with the American Society for Blood and Marrow Transplantation (ASBMT) conflict of interest policy.

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2012 Apr

Measure Maintenance

Unspecified

Date of Next Anticipated Revision

Unspecified

Measure Status

This is the current release of the measure.

The measure developer reaffirmed the currency of this measure in February 2017.

Source(s)

Proposed infection control after HCT measure set: questionnaire, patient selection, measures with specifications, glossary. Arlington Heights (IL): American Society for Blood and Marrow Transplantation; 20 p.

Measure Availability

Source not available electronically.

For more information, contact the American Society for Blood and Marrow Transplantation (ASBMT) at 85 W. Algonquin Road, Suite 550, Arlington Heights, IL 60005; Phone: 847-427-0224; Fax: 847-427-9656; Web site: www.asbmt.org External Web Site Policy; E-mail: mail@asbmt.org.

NQMC Status

This NQMC summary was completed by ECRI Institute on September 24, 2013. The information was verified by the measure developer on October 25, 2013.

The information was reaffirmed by the measure developer on February 8, 2017.

Copyright Statement

This NQMC summary is based on the original measure, which is subject to the measure developer's copyright restrictions.

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