Work

Outpatient Foscarnet Administration Incorporating Home Infusions Is Feasible Greatly Enhancing the Care of Hematopoietic Stem Cell Transplant Recipients

Year: 2017

Type: article

Abstract: Introduction: Cytomegalovirus (CMV) infection continues to be a major cause of morbidity and mortality in patients (pts) receiving hematopoietic stem cell transplantations (HSCT). Foscarnet (FCN) is a well-established therapy for CMV viremia and disease and frequently FCN must be given due to inadequate myelopoiesis prohibiting ganciclovir/valgancyclovir. Due to the potentially dangerous FCN toxicities with the need for aggressive repletion of multiple electrolytes and high volume hydration, FCN induction has previously been limited to inpatient administration for 2 or even 3 weeks. To decrease the need for hospitalization, a home FCN infusion initiative was started 7/2015 at our center. Selected pts that could come to clinic daily for AM dosing were eligible. Our objective was to assess the feasibility of q12 hour FCN induction incorporating PM outpatient home infusions. The primary outcome was success as measured by the number of outpatient days of q12 hour FCN induction incorporating home infusions. Complications related to home therapy that resulted in admission were also measured. Methods: Pts received their AM dose in the clinic with fluids and electrolytes as needed per electrolyte (Ca, K, Mg) and creatinine results. Repletion was additionally supplemented by oral calcium as needed. Upon completion, a registered nurse (RN) connected 2 CADD pumps: one for the PM dose, the other for post-FCN hydration admixed with a standard electrolyte formulation (2gm calcium, 40 mEq potassium, 1gm magnesium). The first CADD pump was programmed to start FCN 12 hours after the first dose and to run over 2 hours. The second was programmed to start immediately after the FCN to run over 6-8 hrs. The RN educated pts or caregivers how to self disconnect their central line from the CADD pumps upon infusion completion. Results: Seven patients received PM dose home infusion of induction FCN from 7/2015-9/2016. Median per pt and total numbers of outpatient treatment days were 13 (9-23) and 101 days respectively. Six pts were transitioned to maintenance FCN. After count recovery, one pt was switched to induction ganciclovir after initiating induction FCN in order to reduce clinic visits. One pt was admitted during treatment for possible bacterial pneumonia and Enterobacter bacteremia, and upon discharge the pt resumed home induction FCN. There were no adverse events associated with electrolyte repletion. Conclusions: We concluded that administration of induction dose FCN in the outpatient setting incorporating PM home infusion is safe and feasible in allo transplant recipients. This strategy resulted in significant reduction of inpatient hospitalization days greatly reducing cost and increasing pt satisfaction. To ensure safety, this approach, however, is limited to pts/caregivers who can reliably manipulate central lines as an outpatient.

Source: Transplantation and Cellular Therapy

DOI: 10.1016/j.bbmt.2016.12.363