Objective: To review the published literature assessing adherence rates to antifungal guidelines and reasons for nonadherence in the adult malignant hematology inpatient setting. Data sources: The databases Embase, MEDLINE, and PubMed (from data inception to May 2019) were searched using the terms hematology, oncology, antifungal, guidelines, adherence, and stewardship with the search limited to adult human subjects and published in English. This yielded 123 articles. From this list, studies that were published in peer-reviewed journals were extracted, leaving 10 citations that met the final inclusion criteria. Study Selection and Data Extraction: Ten studies were selected assessing adherence to consensus antifungal guidelines in the malignant hematology setting. These included studies investigating the introduction of antifungal stewardship programs in tertiary hospitals. Data Synthesis: Although the studies were heterogeneous, all focused on appropriateness of antifungal therapy in the inpatient setting. Adherence to antifungal guidelines for optimal antifungal prophylaxis and treatment was low in most studies, with rates of inappropriate antifungal therapy ranging from 25% to 70% of fungal prescriptions. Relevance to Patient Care and Clinical Practice: Adherence rates with guidelines for antifungal therapy are low in the hematology inpatient setting. This may affect infection rates influencing morbidity and mortality in this high-risk population. Conclusion: Given the prevalence of invasive fungal infections in malignant hematology inpatients, suboptimal adherence with antifungal guidelines is concerning. This demands a focus on education, antifungal stewardship, and updating guidelines to meet real-world scenarios. Adherence with antifungal guidelines in the outpatient hematology setting is unknown and requires further research.
Background: Immunotherapy for metastatic melanoma has improved response rates and progression-free survival significantly compared to traditional chemotherapy. However, our understanding of their unique side-effect profile remains limited given the novelty of these treatments. Unlike traditional cytotoxic chemotherapy, immunotherapy is often associated with autoimmune-related toxicities, including colitis, thyroiditis, pneumonitis or hepatitis. However, autoimmune endocrinopathies are much less well described. These experiences are concerning as the use of these agents is becoming more widespread in other cancer subtypes and they require very different approaches in regard to toxicity management. We report a case of pembrolizumab-induced auto-immune diabetes and hepatitis in a patient undergoing treatment for metastatic melanoma. Clinical details: A 79-year-old Caucasian man was referred by his general practitioner to the emergency department with hyperglycaemia and elevated liver function tests on a background of recurrent metastatic melanoma on pembrolizumab treatment. The patient had a long history of hypertension but no other significant past medical history. The patient did not have a personal or family history of diabetes or autoimmune disease. Outcomes: The patient was treated with a basal-bolus insulin regimen for his new-onset diabetes and a reducing dose of prednisolone for hepatitis. Conclusion: New emerging immunotherapy treatments are changing the outcomes of patients with metastatic melanoma; however, their side effect profile differs from traditional chemotherapeutic agents and has not been fully explored. Healthcare professionals and patients should be aware that autoimmune side effects, such as diabetes and hepatitis, do occur in the context of these new treatments.
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