Appendix 1:The Questionnaires Translated Into English and Results of This Survey

Appendix 1:The Questionnaires Translated Into English and Results of This Survey

Appendix 1:The questionnaires translated into English and results of this survey

September, 2013

JALSG Supportive Care Committee

【Questionnaireson the management of infection by JALSG】

In principle, we assume the development of neutropenia during remission induction chemotherapy for acute myeloid leukemiathat the duration of neutropenia is predicted to last for more than 10days.

Q1. Please select the situations regarding the therapeutic environment during neutropenia (up to 2 answers are allowed).

Answer choices and results.

1. / Protective environment (private room) / 111
2. / Protective environment (ward) / 44
3. / General private room with portable HEPA filter / 38
4. / General ward with portable HEPA filter / 18
5. / General private room / 7
6. / General ward / 5
7. / Others / 1

Q2.Please select the infection prevention strategies you are using for patients in protective environment(multiple answers are allowed).

Answer choices and results.

1. / Gown technique / 12
2. / Surgical mask / 112
3. / Medical Cap / 9
4. / Sterile gloves / 0
5. / Non-sterile gloves / 23
6. / Alcohol based hand rubs / 129
7. / Handwashing with disinfectants / 18
8. / Others / 11
9. / None of the above / 1

Q3.Please select one answer regarding meals during chemotherapy.

Answer choices and results.

1. / Sterilized food / 12
2. / Heated food(fresh vegetables, natto (fermented soybeans), and food containing lactic acid bacterium are prohibited) / 63
3. / Ordinary diet without raw food (fresh vegetables, natto (fermented soybeans), and food containing lactic acid bacterium are prohibited) / 22
4. / Ordinary diet without raw food (fresh vegetables and natto (fermented soybeans)are prohibited) / 15
5. / Ordinary diet without raw food (natto (fermented soybeans), and food containing lactic acid bacterium are prohibited) / 14
6. / Ordinary diet without raw food (fresh vegetablesand food containing lactic acid bacterium are prohibited) / 1
7. / Ordinary diet without raw food (fresh vegetables are prohibited) / 3
8. / Ordinary diet without raw food (natto (fermented soybeans) is prohibited) / 5
9. / Ordinary diet without raw food (food containing lactic acid bacterium is prohibited) / 5
10. / Others / 3

Q4.Please select the answers regarding antibacterial prophylaxis(multiple answers are allowed).

Answer choices and results.

1. / Non-absorbable polymixin B / 13
2. / Sulfamethoxazole-trimethoprim / 35
3. / Fluoroquinolones / 90
4. / Others / 4
5. / On a case-by-case basis / 9
6. / No antibacterial prophylaxis / 24

Q5. Please select one answer regarding antifungal prophylaxis, describing the most common drug or situation in your institution.

Answer choices and results.

1. / Fluconazole / 68
2. / Micafungin / 3
3. / Caspofungin / 0
4. / Itraconazole capsule / 10
5. / Itraconazole oral solution / 51
6. / Amphotericin B syrup / 0
7. / Others / 3
8. / Combination of the above / 1
9. / No antifungal prophylaxis / 12

Q6. Do you administer sulfamethoxazole-trimethoprim for prophylaxis against pneumocystis pneumoniae? Please select one answer.

Answer choices and results.

1. / In principle, yes / 54
2. / In principle, no / 74
3. / On a case-by-case basis / 12
4. / Others / 1

Q7. Do you perform prophylaxis against herpes simplex virus (ex. oral acyclovir)? Please select one answer.

Answer choices and results.

1. / In principle, yes / 5
2. / In principle, no / 124
3. / On a case-by-case basis / 12
4. / Others / 0

Q8. Please select one answer regarding prophylaxis against tuberculosis.

Answer choices and results.

1. / Performing prophylaxis with Isoniazid in all cases / 1
2. / Prophylactically administer Isoniazid for patients with a history of tuberculosis based on the chest X-ray findings / 21
3. / Prophylactically administer Isoniazid for patients with a history of treatment for tuberculosis / 24
4. / No prophylaxis even in patients with a history of tuberculosis / 8
5. / Prophylactically administer Isoniazid at the discretion of attending physician regardless of the presence or absence of a past history of tuberculosis / 83
6. / Others / 4

Q9. Do you conduct surveillance cultures in afebrile patients? Please select one answer.

Answer choices and results.

1. / Yes / 31
2. / No / 92
3. / On a case-by-case basis / 18
4. / Others / 0

Please answer Q10-11 only if you answered “yes” in Q9.

Q10. What kind of surveillance cultures do you perform? (multiple answers are allowed)

Answer choices and results.

1. / Stool / 26
2. / Urine / 22
3. / Throat / 27
4. / Sputum if available / 12
5. / Others / 3

Q11. Please select one answer regarding the frequency of surveillance cultures.

Answer choices and results.

1. / Once a week / 14
2. / Twice a week / 1
3. / Only before initiating chemotherapy / 12
4. / On a case-by-case basis / 6

Q12. Please select one answer describing the closest situation regarding the degree of body temperature triggering empirical intravenous antibiotic therapy for neutropenic patients in your institution.

Answer choices and results.

1. / Prophylactically administer intravenous antibiotics even in afebrile patients / 5
2. / Body temperature ≥37.0◦C / 3
3. / Body temperature ≥37.5◦C / 65
4. / Body temperature ≥38.0◦C / 67
5. / Body temperature ≥38.5◦C / 0
6. / On a case-by-case basis / 1
7. / Others / 0

Q13. Please select the examinations you routinely perform before initiating empirical antibiotics for febrile neutropenia (multiple answers are allowed).

Answer choices and results.

1. / Blood culture / 138
2. / Urine culture / 30
3. / Stool culture / 17
4. / Throat culture / 20
5. / Sputum culture if available / 54
6. / Endotoxin / 31
7. / β-D-glucan / 84
8. / Aspergillus galactomannan / 41
9. / PCR based diagnostic test of fungal infection / 0
10. / Chest X-ray / 87
11. / Chest CT / 5
12 / Others / 8

Q14. Please select one answer regarding the number of blood culture sets drawn before initiating empirical antibiotics.

Answer choices and results.

1. / Do not perform blood cultures as the situation now stands / 2
2. / Do not perform blood cultures in some cases / 2
3. / 1 set (one aerobic and anaerobic culture each) / 36
4. / 2 sets on separate occasions at an interval / 3
5. / 2 sets drawn from different sites / 98
6. / Others / 0

Q15. Please select the first-line antibiotics as empirical therapy for febrile neutropenia (up to 2 answers are allowed).

Answer choices and results.

1. / Monotherapy with cephalosporin / 119
2. / Combination of cephalosporin and aminoglycoside / 9
3. / Monotherapy with carbapenem / 41
4. / Combination of carbapenem and aminoglycoside / 1
5. / Monotherapy with antipseudomonal penicillin / 23
6. / Combination of antipseudomonal penicillin and aminoglycoside / 2
7. / Combination of cephalosporin and antipseudomonal penicillin / 0
8. / Combination of cephalosporin, antipseudomonal penicillin and aminoglycoside / 0
9. / Combination of cephalosporin and anti-MRSA antibiotic / 0
10. / Combination of carbapenem and anti-MRSA antibiotic / 0
11. / Combination of cephalosporin, aminoglycoside and anti-MRSA antibiotic / 0
12 / Combination of carbapenem, aminoglycoside and anti-MRSA antibiotic / 0
13. / Others / 0
14. / On a case-by-case basis / 1

Q16. Please select one answer regarding the management for persistent fever. When do you usually change or add antibiotics after initiating empirical antibiotic therapy? It is assumed that patients’ general condition is stable.

Answer choices and results.

1. / Modify antibiotics at 24 hours / 0
2. / Modify antibiotics at 48 hours / 27
3. / Modify antibiotics at 72 hours / 101
4. / Modify antibiotics at 96 hours / 8
5. / No modification if patients’ clinical condition is stable / 5
6. / Others / 0

Q17. Please answer only if you answered modifying antibiotics in Q16. Please select the most common modification.

Answer choices and results.

1. / Add or change between cephalosporin, aminoglycoside and carbapenem antibiotics / 74
2. / Continue the first-line antibiotic and add anti-MRSA antibiotic empirically / 18
3. / Change the first-line to the second-line antibiotic and add anti-MRSA antibiotic empirically / 9
4. / Continue the first-line antibiotic and add antifungal agent empirically / 7
5. / Change the first-line to the second-line antibiotic and add antifungal agent empirically / 26
6. / Continue the first-line antibiotic and add anti-MRSA antibiotic and antifungal agent empirically / 1
7. / Change the first-line to the second-line antibiotics and add anti-MRSA antibiotic and antifungal agent / 2
8. / Others / 3

Q18. Please select one answer regarding the position of anti-MRSA antibiotics.

Answer choices and results.

1. / Use anti-MRSA antibiotic empirically as the second-line antibiotic when the response to the first-line antibiotics is not obtained / 31
2. / Use anti-MRSA antibiotic empirically as the third-line antibiotic when the response to the first-line and the second-line antibiotics is not obtained / 52
3. / Start anti-MRSA antibiotic when gram-positive bacteria is identified from cultures and change other drugs if it is not MRSA / 32
4. / Use anti-MRSA antibiotic only for the definitive infection due to MRSA / 1
5. / Use anti-MRSA antibiotic empirically in high-risk cases (MRSA colonization, hypotension, pneumoniae and catheter-related infection) in accordance with IDSA guideline / 26
6. / Others / 1

Q19. Please select one anti-MRSA antibiotic which you most commonly use for bloodstream infection.

Answer choices and results.

1. / Vancomycin / 105
2. / Teicoplanin / 16
3. / Arbekacin / 0
4. / Linezolid / 3
5. / Daptomycin / 10
6. / On a case-by-case basis / 8

Q20. Please select one anti-MRSA antibiotic which you most commonly use for pulmonary infection.

Answer choices and results.

1. / Vancomycin / 103
2. / Teicoplanin / 14
3. / Arbekacin / 0
4. / Linezolid / 12
5. / Daptomycin / 0
6. / On a case-by-case basis / 10

Q21. Please select one anti-MRSA antibiotic which you most commonly use for skin and soft tissue infections.

Answer choices and results.

1. / Vancomycin / 86
2. / Teicoplanin / 12
3. / Arbekacin / 0
4. / Linezolid / 10
5. / Daptomycin / 15
6. / On a case-by-case basis / 17

Q22. Please select one answer regarding the position of intravenous γ-globulin in the management of febrile neutropenia.

Answer choices and results.

1. / Add intravenous γ-globulin to the first-line empirical antibiotics regardless of the amount of serum γ-globulin / 2
2. / Use intravenous γ-globulin regardless of the amount of serum γ-globulin when response to the first-line antibiotics is not obtained / 13
3. / Use intravenous γ-globulin regardless of the amount of serum γ-globulin when response to the second-line or later antibiotics is not obtained / 31
4. / Use intravenous γ-globulin empirically in the cases with hypogammagloblinemia / 13
5. / Use intravenous γ-globulin in the cases with hypogammagloblinemia when response to the first-line antibiotics is not obtained / 13
6. / Use intravenous γ-globulin in the cases with hypogammagloblinemia when response to the second-line or later antibiotics is not obtained / 17
7. / In principal, do not use intravenous γ-globulin / 48
8. / Others / 4

Q23. Please select one answer regarding the antifungal treatment strategies.

Definition of antifungal treatment

Preemptive therapy: Start antifungal therapy based on the results of fungal infection-specific tests such as biomarkers

Empirical therapy: Start antifungal therapy for persistent or recurrent febrile neutropenia under broad-spectrum antibiotic therapy regardless of the results of biomarkers and imaging tests

Presumptive therapy:Start antifungal therapy when there are fungal infection associated symptoms such as persistent or recurrent febrile neutropenia under broad-spectrum antibiotic therapy and also the positivefungal infection specific findings in biomarkers and imaging tests

Targeted therapy: Antifungal therapy for definitive fungal infection

Answer choices and results.

1. / Start preemptive antifungal therapy even when there is no symptom associated with fungal infection. / 35
2. / Start the first-line antibiotics and antifungal agent simultaneously / 1
3. / Use empirical antifungal treatment strategy / 82
4. / Use presumptive antifungal treatment strategy / 21
5. / Start antifungal therapy only as targeted therapy for definitive fungal infection / 0
6. / Others / 0

Q24.Please answer only If you selected No.3 in Q23 (empirical antifungal therapy) and No.9 in Q5 (no antifungal prophylaxis).Which antifungal agent do you most commonly use as empirical antifungal therapy?

Answer choices and results.

1. / Fluconazole / 0
2. / Micafungin / 4
3. / Caspofungin / 0
4. / Voriconazole / 0
5. / Itraconazole / 0
6. / Liposomal amphotericin B / 2
7 / Conventional amphotericin B / 0
8 / Others / 0

Q25. Please answer if you selected No.3 in Q23 (empirical antifungal therapy) and No.1-8 in Q5 (using antifungal prophylaxis).Which antifungal agent do youmost commonly use as empirical antifungal therapy?

Answer choices and results.

1. / Fluconazole / 1
2. / Micafungin / 54
3. / Caspofungin / 7
4. / Voriconazole / 10
5. / Itraconazole / 0
6. / Liposomal amphotericin B / 5
7 / Conventional amphotericin B / 0
8 / Others / 0

Q26.Please answer only If you selected No.3 in Q23 (empirical antifungal therapy) and No.1-8 in Q5 (using antifungal prophylaxis).Which antifungal agent do you most commonly usein the cases with pulmonary infiltrate on chest X-ray?

Answer choices and results.

1. / Fluconazole / 0
2. / Micafungin / 15
3. / Caspofungin / 1
4. / Voriconazole / 33
5. / Itraconazole / 1
6. / Liposomal amphotericin B / 32
7 / Conventional amphotericin B / 1
8 / Others / 0

Q27. Which antifungal agent do you most commonly use as the initial therapy for candidemia?

Answer choices and results.

1. / Fluconazole / 20
2. / Micafungin / 84
3. / Caspofungin / 5
4. / Voriconazole / 7
5. / Itraconazole / 0
6. / Liposomal amphotericin B / 19
7 / Conventional amphotericin B / 2
8 / Others / 1

Q28. Which antifungal agent do you most commonly use as the targeted therapy for candidemia due to Candida albicans?

Answer choices and results.

1. / Fluconazole / 52
2. / Micafungin / 62
3. / Caspofungin / 2
4. / Voriconazole / 2
5. / Itraconazole / 0
6. / Liposomal amphotericin B / 17
7 / Conventional amphotericin B / 1
8 / Others / 1

Q29. Which antifungal agent do you most commonly use as the targeted therapy for candidemia due to Candida glabrata?

Answer choices and results.

1. / Fluconazole / 1
2. / Micafungin / 82
3. / Caspofungin / 6
4. / Voriconazole / 12
5. / Itraconazole / 1
6. / Liposomal amphotericin B / 28
7 / Conventional amphotericin B / 1
8 / Others / 3

Q30. Which antifungal agent do you most commonly use as the targeted therapy for candidemia due to Candida parapsilosis?

Answer choices and results.

1. / Fluconazole / 20
2. / Micafungin / 29
3. / Caspofungin / 1
4. / Voriconazole / 24
5. / Itraconazole / 2
6. / Liposomal amphotericin B / 57
7 / Conventional amphotericin B / 1
8 / Others / 4

Q31. Which antifungal agent do you most commonly use as the targeted therapy for invasive pulmonary aspergillosis?

Answer choices and results.

1. / Fluconazole / 0
2. / Micafungin / 1
3. / Caspofungin / 0
4. / Voriconazole / 93
5. / Itraconazole / 2
6. / Liposomal amphotericin B / 42
7 / Conventional amphotericin B / 0
8 / Others / 1

Q32. Do you perform antifungal susceptibility testing in the cases with fungemia?

Answer choices and results.

1. / Routinely perform antifungal susceptibility testing / 47
2. / Occasionally perform antifungal susceptibility testing / 34
3. / Rarely perform antifungal susceptibility testing / 58

Q33. Please select the frequency of β-D-glucan monitoring.

Answer choices and results.

1. / Twice a week / 7
2. / Once a week / 84
3. / Once every two weeks / 19
4. / On a case-by-case basis / 28
5. / Others / 0
6. / Do not perform β-D-glucan monitoring / 1

Q34. Please select the site and the cut off value ofβ-D-glucan testing (in-house or outsourcing for the site and 20pg/ml or 11pg/ml for the cut off value)

Answer choices and results.

1. / In-house / 72
2. / Outsourcing / 60
3. / 20 pg/ml / 54
4. / 11 pg/ml / 58
5. / Do not grasp the information / 1
6. / Others / 3

Q35. Please evaluate the usefulness of β-D-glucan screening based on the experiences in your institution (multiple answers are allowed).

Answer choices and results.

1. / High sensitivity for candidiasis / 40
2. / High sensitivity for aspergillosis / 8
3. / High sensitivity as a screening test for fungal infections / 52
4. / Low sensitivity for candidiasis / 2
5. / Low sensitivity for aspergillosis / 25
6. / Low sensitivity as a screening test for fungal infections / 39
7. / High specificity as a screening test for fungal infections / 18
8. / Low specificity as a screening test for fungal infections / 30
9. / Others / 3

Q36. Please select the frequency of aspergillus galactomannan monitoring.

Answer choices and results.

1. / More than once a week / 2
2. / Once a week / 54
3. / Once every two weeks / 15
4. / On a case-by-case basis / 60
5. / Others / 5
6. / Do not perform aspergillus galactomannan monitoring / 5

Q37. Please evaluate the usefulness of aspergillus galactomannan for the diagnosis of invasive aspergillosis based on the experiences in your institution (please answer for sensitivity and specificity).

Answer choices and results.

1. / High sensitivity / 50
2. / Low sensitivity / 33
3. / High specificity / 57
4. / Low specificity / 31
5. / Cannot be determined / 28

Q38. Please select the frequency of monitoring by PCR based diagnostic test of fungal infection.

Answer choices and results.

1. / More than once a week / 0
2. / Once a week / 1
3. / Once every two weeks / 0
4. / On a case-by-case basis / 41
5. / Others / 0
6. / Do not perform PCR based diagnostic test of fungal infection / 99

Q39. Please answer only if you selected conducting PCR based diagnostic test in Q38 and are using GeniQ aspergillus®. Please evaluate the usefulness of it based on the experiences in your institution (choosing one answer is required).

Answer choices and results.

1. / High sensitivity / 3
2. / Low sensitivity / 0
3. / High specificity / 2
4. / Low specificity / 0
5. / Cannot be determined / 7

Q40. How do you use granulocyte-colony stimulating factor during remission induction chemotherapy for acute myeloid leukemia? We assumed that blast cells in the peripheral blood have disappeared. Please select one answer.

Answer choices and results.

1. / Use it for neutropenia prophylactically before the development of fever / 3
2. / Use it for febrile neutropenia in addition to empirical antibiotics / 7
3. / Use it if response to empirical antibiotics is not obtained / 15
4. / Use it for clinically documented infection / 14
5. / Use it for microbiologically documented infection / 9
6. / Use it when you judge the condition as life-threatening / 69
7 / Do not use it in principal / 18
8 / On a case-by-case basis / 6
9. / Others / 0

Q41. How do you use granulocyte-colony stimulating factor during consolidation chemotherapy with high-dose cytarabine for acute myeloid leukemia? Please select one answer.

Answer choices and results.

1. / Use it for neutropenia prophylactically before the development of fever / 24
2. / Use it for febrile neutropenia in addition to empirical antibiotics / 13
3. / Use it if response to empirical antibiotics is not obtained / 19
4. / Use it for clinically documented infection / 12
5. / Use it for microbiologically documented infection / 10
6. / Use it when you judge the condition as life-threatening / 45
7 / Do not use it in principal / 9
8 / On a case-by-case basis / 5
9. / Others / 2

Q42. How do you use granulocyte-colony stimulating factor during consolidation chemotherapy with standard-dose cytarabine for acute myeloid leukemia? Please select one answer.

Answer choices and results.

1. / Use it for neutropenia prophylactically before the development of fever / 14
2. / Use it for febrile neutropenia in addition to empirical antibiotics / 12
3. / Use it if response to empirical antibiotics is not obtained / 18
4. / Use it for clinically documented infection / 15
5. / Use it for microbiologically documented infection / 9
6. / Use it when you judge the condition as life-threatening / 56
7 / Do not use it in principal / 8
8 / On a case-by-case basis / 8
9. / Others / 1

Q43. How do you use granulocyte-colony stimulating factor during remission induction chemotherapy for acute lymphoblastic leukemia? Please select one answer.

Answer choices and results.

1. / Use it for neutropenia prophylactically before the development of fever / 76
2. / Use it for febrile neutropenia in addition to empirical antibiotics / 15
3. / Use it if response to empirical antibiotics is not obtained / 13
4. / Use it for clinically documented infection / 1
5. / Use it for microbiologically documented infection / 2
6. / Use it when you judge the condition as life-threatening / 2
7. / Start it after finishing chemotherapy / 22
8 / Do not use it in principal / 2
9 / On a case-by-case basis / 2
10. / Others / 3

Q44. How do you use granulocyte-colony stimulating factor during consolidation chemotherapy for acute lymphoblastic leukemia? Please select one answer.

Answer choices and results.

1. / Use it for neutropenia prophylactically before the development of fever / 79
2. / Use it for febrile neutropenia in addition to empirical antibiotics / 16
3. / Use it if response to empirical antibiotics is not obtained / 12
4. / Use it for clinically documented infection / 1
5. / Use it for microbiologically documented infection / 3
6. / Use it when you judge the condition as life-threatening / 1
7. / Start it after finishing chemotherapy / 21
8 / Do not use it in principal / 0
9 / On a case-by-case basis / 3
10. / Others / 3

Q45. Please select the guidelines you commonly refer to (up to two answers are allowed).

Answer choices and results.

1. / IDSA guideline / 45
2. / Japanese guideline published in 2004 / 52
3. / FN guideline published in 2012 by the Japanese Society of Medical Oncology / 89
4. / The JAID (Japanese Association for Infectious Diseases ) / JSC (Japanese Society of Chemotherapy) guide to clinical management of infectious diseases 2011 / 7
5. / The Sanford Guide to Antimicrobial Therapy / 28
6. / Others / 1

Q46.How many patients underwent initial induction remission chemotherapy for newly diagnosed acute leukemia for 1 year in 2012 in your institution?