Empiric Therapy of Infections in Hematologic Malignancies: A Prospective, Randomized Trial

Patients with hematologic malignancies were randomly assigned to receive cefuroxime (group A) or tobramycin plus ampicillin (Group B) during 86 febrile episodes. In both regimens carbenicillin was added during neutropenia (71% of all episodes: groups C and D). The most common type of infection was pneumonia (48% alone; 72% with other sites involved), which accounted for a high fatality rate (15%); the highest rate occurred during septicemia with pneumonia (50%). The overall response rate to initial therapy was 63% without significant differences among the four regimens. The worst prognosis was observed in neutropenic patients without granulocyte recovery. When initial and cross-over trials were combined, there were favorable outcomes in 90% of all cases. Cefuroxime alone seems to be as effective as tobramycin plus ampicillin in the treatment of infections in hematologic malignancies. No side effects could be attributed to the cefuroxime-containing regimens.

[Gastrointestinal carriage of Pseudomonas aeruginosa in children residing in chronic care institutes in Jerusalem: high prevalence and high rates of antibiotic resistance]

BACKGROUND

Pseudomonas aeruginosa carriage in the gastrointestinal tract is uncommon in healthy children. Children living in chronic care institutions are often carriers of P. aeruginosa in the respiratory tract, but data is lacking regarding gastrointestinal carriage in these children.

AIMS

To examine the carriage rate of P. aeruginosa in children living in chronic care institutions in Jerusalem and to assess resistance rates of the bacteria to different classes of antibiotics.

METHODS

Rectal swabs were taken from all children residing in two chronic care institutions in Jerusalem: "St. Vincent" and "Aleh". The swabs were examined for presence of Pseudomonas aeruginosa. The authors used disk diffusion technique and E Test to assess resistance for different antibiotics.

RESULTS

Gastrointestinal carriage of P. aeruginosa was detected in 37 out of 125 of the children (30%); 16% of the P. aeruginosa isolates were resistant to carbapenems; 16% were resistant to aminoglycosides, 14% to ureidopenicillins and 11% to quinolones. All isolates were sensitive to ceftazidime and colistin. In 84% of the isolates, the minimal inhibitory concentration (MIC) for meropenem was significantly lower than the MIC for imipenem.

SUMMARY

P. aeruginosa is a common colonizer of the gastrointestinal tract of children living in chronic care institutions. Empiric antibiotic treatment against P. aeruginosa should be considered when treating children with acute gastrointestinal pathologies. Antibiotic resistance, and particularly carbapenem resistance, is common in this population. There is a significant difference between the MICs for imipenem and meropenem. Future studies are needed to understand the clinical significance of this finding.

A case of meningoencephalitis associated with G1P[8] rotavirus infection in a Japanese child

We report the case of a 2-y, 11-month-old boy with G1P[8] rotavirus infection accompanied by acute meningoencephalitis. Substitutions in both the VP4 and VP7 genes were found in the identified strain. A commonly circulating G1P[8] rotavirus with such mutations might be associated with the pathogenesis of CNS complications, including meningoencephalitis.

Latamoxef versus carbenicillin plus gentamicin or carbenicillin plus mecillinam in leukopenic, febrile patients with solid tumors

Sixty-six febrile episodes associated with leukopenia were observed in 56 patients with solid tumors, WBC less than 1.5 X 10(9)/l and temperature greater than or equal to 38.5 degrees C. Stratification to antibiotic treatment regimen was made with regard to prior cis-dichlorodiamineplatinum (cis-platinum) treatment or not. Patients who had received no cis-platinum were randomized between carbenicillin 10 g every 8 h plus gentamicin 80 mg every 8 h or latamoxef 2 g every 8 h (group I). Patients having received cis-platinum were treated with carbenicillin 10 g every 8 h plus mecillinam 800 mg every 8 h or latamoxef 2 g every 8 h (group II). The first dose of latamoxef was preceded by 10 mg of vitamin K i.v. In group I, clinical response was observed in 10 of 19 febrile episodes (52.6%) treated with carbenicillin plus gentamicin and in 10 of 14 (71.4%) treated with latamoxef (p greater than 0.05). In group II, 6 of 14 febrile episodes treated with carbenicillin plus mecillinam responded (42.9%) while 11 of 19 (57.9%) responded to latamoxef (p greater than 0.05). No bleeding due to antibiotic treatment was observed. No statistical difference between standard antibiotic therapy and latamoxef was seen in this subset of patients.

[Anti-Pseudomonas aerosol therapy in cystic fibrosis: improvement with tobramycin]

Aerosol delivery of antibiotics offers the potential to achieve high antibiotic concentrations at the site of infection while reducing the risk of systemic untoward effects because of minimal resorption into the bloodstream. We reviewed knowledge acquired in this field over the two latter decades. While the earliest data were obtained with gentamycin, the most conclusive evidence presently regards aminoglycosides and colistin. Aerosol delivery of tobramycin was recently improved with the development of a new formulation for inhalation. Coupled with an adequate nebulization system, intermittent treatment with tobramycin for inhalation has been evaluated in randomized placebo-controlled studies. These studies have demonstrated a significant improvement of respiratory function.

Pseudomonas aeruginosa ventilator-associated pneumonia: comparison of episodes due to piperacillin-resistant versus piperacillin-susceptible organisms

We sought to determine the epidemiological characteristics of patients in an intensive care unit (ICU) who developed ventilator-associated pneumonia (VAP) caused by piperacillin-resistant Pseudomonas aeruginosa (PRPA; n=34) or piperacillin-susceptible P. aeruginosa (PSPA; n=101). According to univariate analysis, the factors associated with the development of PRPA VAP were presence of an underlying fatal medical condition, immunocompromised status, longer previous hospital stay, less-severe illness at the time of ICU admission, duration of mechanical ventilation before onset of VAP, number of classes of antibiotic received, and previous exposure to imipenem or fluoroquinolone. Multivariate logistic regression analysis identified the following significant independent factors: presence of an underlying fatal medical condition (odds ratio [OR], 5.6), previous fluoroquinolone use (OR, 4.6), and initial disease severity (OR, 0.8). We concluded that the clinical characteristics of patients who develop PRPA VAP differ from those of patients who develop PSPA VAP. Restricted fluoroquinolone use is the sole independent risk factor for PRPA VAP that is open to medical intervention.

Empirical antimicrobial therapy in pediatric patients with neutropenia and fever. Risk factors for treatment failure

BACKGROUND

The use of combinations of antibiotics has been the cornerstone of therapy for febrile patients with cancer and severe neutropenia. Each empirical regimen should be selected according to the epidemiology and susceptibility patterns in each center. We describe here the experience with empirical antimicrobial treatments in pediatric patients with cancer, fever and severe neutropenia, and identify the risk factors associated with treatment failure.

METHODS

This is a prospective study including 145 patients with cancer, and 171 episodes of neutropenia and fever. Blood cultures were taken before initiating empirical treatment: a) carbenicillin (400 mg/kg/day) plus amikacin (21 mg/kg/day) (Cb/ak), and b) ceftazidime (100 mg/kg/day), plus amikacin at the same dosage (Cz/ak).

RESULTS

The overall response rate was 54.9% and 56.3% for Cb/ak and Cz/ak, respectively. Fifty-seven episodes (33.3%) were microbiologically documented, gram-positive isolated in 38% and gram-negative in 49%. Risk factors associated significantly with treatment failure were acute myelocytic leukemia (AML) (RR 2.59, CI 95% 1.42-4.7, p = 0.003); bacteriological identification (RR = 4.41, CI 95% 2.21-8.8, p < 0.001), and the presence of two or more sites of infection (RR = 2.89, CI 95% 1.03-8.11, p = 0.03).

CONCLUSIONS

The rates of response are similar to the combinations used in the hospital (Cb/ak, Cz/ak). The risk factors associated with treatment failure were AML diagnosis, bacteriological identification, and the presence of two or more sites of infection.

Antibiotic resistance in bacterial urinary tract infections, 1991 to 1997

This study assessed changing patterns of antibiotic resistance in Escherichia coli urinary tract infections at a university student health center during three periods: the first 6 months each of 1991, 1994, and 1997. Urine culture and sensitivity results were taken from available medical records of female patients having urine cultures during the three periods (1991, n = 739; 1994, n = 938; 1997, n = 863); age and ethnicity were also noted. In E. coli isolates (the majority of positive cultures), resistance to four antibiotics changed significantly: ampicillin (30% to 45% to 39%), carbenicillin (29% to 42% to 39%), tetracycline (29% to 40% to 23%), and trimethoprim/sulfamethoxazole (15% to 32% to 15%). The results raise questions regarding the future clinical reliability of several commonly used antibiotics in the treatment of urinary tract infection.

Randomized trial comparing oral ciprofloxacin plus penicillin V with amikacin plus carbenicillin or ceftazidime for empirical treatment of febrile neutropenic cancer patients

Aminoglycoside-containing combination therapy has been the standard empirical approach for febrile neutropenic cancer patients. With the advent of the broad-spectrum oral fluoroquinolones, it is now possible to evaluate an initial empirical alternative therapy. A prospective randomized study was conducted comparing oral ciprofloxacin plus penicillin V (group A) with amikacin plus carbenicillin or ceftazidime (group B). Main criteria for eligibility were febrile patients with solid tumor or nonlymphoblastic lymphoma, a Zubrod PS equal to 1 or 2, no diarrhea, mucositis, or long-term central venous catheter. A total of 108 consecutive neutropenic febrile episodes were randomized (5 exclusions); 55 episodes were assigned to group A and 48 to group B. Most febrile episodes were of unknown origin. There were 10 microbiologically documented episodes with two cases of bacteremia. Both regimens were well tolerated. Oral regimen was substantially cheaper than parenteral regimen. Treatment success without regimen modification was 94.5% for group A and 93.8% for group B (p = .86; CI -0.08-0.10). Oral therapy with ciprofloxacin and penicillin V is a safe alternative to standard parenteral therapy in this low-risk group of neutropenic patients, with unquestionable cost containment.

The treatment of acute myeloid leukemia in Brazil: progress and obstacles

BACKGROUND

Substantial progress has been made in the treatment of acute myeloid leukemia in the last two decades. We wanted to evaluate the outcome of intensive chemotherapy and the influence of recent therapy changes in underprivileged patients treated in a large urban public university hospital.

METHODS

The records of all patients treated for acute myeloid leukemia from 1980 to 1993 were analyzed.

RESULTS

109 patients were identified; 41 did not receive any treatment for the leukemia because of infectious and/or hemorrhagic complications of advanced disease. Median survival in this group was 4 days. The other 68 patients received one of two induction protocols: TAD from 1980 to 1985 (n = 23) and ara-C plus daunorubicin from 1985 to 1992 (n = 45). The complete remission rate was 56%, disease-free survival 24% and overall survival 15% at 13 years. Overall survival was better for patients treated with ara-C plus daunorubicin than with TAD (19% versus 8%, p = 0.01). This is attributed to a reduction in infection mortality after ceftazidime and amikacin replaced cephalotin, carbenicillin and amikacin as the antibiotic regimen.

CONCLUSIONS

The most effective intervention in our population would probably be an improvement in the primary health care system, so that earlier diagnosis could allow the treatment of a larger fraction of patients.

Management of an infected urachal cyst during pregnancy

An infected urachal cyst complicating a pregnancy is extremely rare, but is considered to present a high risk to both the mother and the fetus. We treated a patient with an infected urachal cyst diagnosed at 29 weeks of gestation. A healthy infant was delivered by cesarean section at 37 weeks of gestation. The patient underwent excision of the unruptured cyst 37 days later. This is the first reported case of an infected urachal cyst complicating a pregnancy, that was diagnosed before rupture and was managed without serious sequelae for either the mother or the fetus. The diagnosis and management of the infected urachal cyst complicating the pregnancy is discussed.

Aeromonas species in septicemia: laboratory characteristics and clinical observations

We retrospectively analyzed clinical and epidemiological data on and laboratory characteristics of 53 cases of aeromonas septicemia. Only four Aeromonas genomospecies (species defined by DNA relatedness) were associated with the 53 cases, with Aeromonas hydrophila (sensu stricto) predominating (47%). Nearly 60% of all Aeromonas isolates from blood fell into one of four somatic groups: serogroups O:11, O:16, O:18, and O:34. Unlike Aeromonas-associated gastroenteritis, septicemia did not peak in frequency during the warmer months but rather was most common in January through March, when approximately 40% of cases occurred. In vitro tests of the pathogenicity of 20 selected blood isolates of Aeromonas indicated that resistance to complement-mediated lysis, elevated levels of protease and hemolysin activity, and the ability to elaborate siderophores correlated with higher virulence. Species and serogroup designations also correlated with the degree of virulence. Susceptibility studies of 50 strains indicated that A. hydrophila was the most drug-resistant species and that Aeromonas veronii was the most susceptible. Susceptibility to first- and second-generation cephalosporins and carbenicillin was species-associated.

[Sensitivity of pathogens of post-ventilation pneumonia in newborns to antibacterial drugs]

The majority of the enteric bacteria and aerobic and anaerobic cocci causing postventilation pneumonia in newborns were susceptible to gentamicin, carbenicillin, ampicillin and cephalosporins. The strains of Pseudomonas aeruginosa were mainly susceptible to gentamicin and carbenicillin. Bacteroides were susceptible to metronidazole, ceftazidime and lincomycin. 70.8 per cent of the causative agents of the pneumonia were polyresistant to at least 6 antibiotics.

[The characteristics of lysozyme and carbenicillin action on the clinico-immunological status of patients with chronic bronchitis]

Clinical, laboratory and immunological methods used to study 68 patients with chronic bronchitis revealed a normalizing effect of intratracheal administration of lyzozyme and its combinations with carbenicillin on the indices of cellular and humoral links of immunity. Treatment tactics is discussed.

Randomised comparison of oral ofloxacin alone with combination of parenteral antibiotics in neutropenic febrile patients

Prompt treatment with empirical antibiotics in neutropenic febrile patients reduces morbidity and mortality. Most patients have been treated with parenteral combination antibiotics, but newer antibiotics with broad-spectrum bactericidal activity have made monotherapy feasible. Ofloxacin, a broad-spectrum fluoroquinolone, has the additional advantage that bactericidal concentrations can be achieved with oral administration. We have compared ofloxacin as an oral single agent with standard parenteral combination antibiotics for the management of neutropenic febrile patients in a prospective, randomised trial. Patients with severe neutropenia (absolute neutrophil count less than or equal to 0.5 x 10(9)/l), fever above 38 degrees C, and ability to take drugs by mouth were eligible for the study. After initial investigations, 60 patients were randomly assigned to oral ofloxacin 400 mg twice daily and 62 to parenteral combination antibiotic therapy (amikacin 15 mg/kg daily, plus, at various times in the trial, carbenicillin, cloxacillin, or piperacillin). Patients were examined 72 h and 7 days after the start of treatment and when neutropenia resolved. 24 (40%) ofloxacin-treated and 26 (42%) combination-treated patients had pyrexia of unknown origin (PUO). In both treatment groups, the treatment success rate was higher for such patients than for those with clinically or microbiologically documented infections (92% vs 67% [p less than 0.05] for ofloxacin; 85% vs 64% for combination). There were no significant differences in success rates of ofloxacin and combination treatment for these subgroups or overall (77% vs 73%). Patients with neutropenia for less than 1 week had better responses to both treatments than patients with longer-lasting neutropenia. There were 4 (7%) deaths in the ofloxacin group and 6 (10%) in the combination group. Both regimens were well tolerated. We conclude that oral single-agent ofloxacin is as effective as parenteral combination antibiotic therapy in neutropenic febrile patients, especially those expected to have short durations of neutropenia.

Adverse reactions to prolonged treatment with high doses of carbenicillin and ureidopenicillins

Charts were reviewed for 63 patients whose chronic pseudomonas osteomyelitis was treated with high doses of extended-spectrum penicillins for prolonged periods. The incidence of untoward drug reactions was significantly higher than expected. Carbenicillin evoked adverse reactions in 22.8% of patients. However, most of these reactions were mild, and a change of drug was required in only 5.7% of cases. No adverse drug reactions were observed with cumulative doses of less than 750 g. In contrast to carbenicillin, the ureidopenicillins were associated with adverse reactions in 67.7% of patients; most reactions were moderate to severe in intensity; a cumulative dose of greater than 250 g produced adverse reactions; and discontinuation or change of therapy was required in 51.6% of cases. The main adverse reactions to both carbenicillin and the ureidopenicillins included rash, drug fever, leukopenia, eosinophilia, thrombocytopenia, and hepatic damage.

The efficacy of norfloxacin in the treatment of chronic bacterial prostatitis refractory to trimethoprim-sulfamethoxazole and/or carbenicillin

We treated 15 men who had chronic bacterial prostatitis refractory to trimethoprim-sulfamethoxazole and/or carbenicillin with 400 mg. norfloxacin twice daily for 28 days. All pathogens were susceptible to norfloxacin and absent in prostatic fluid cultures obtained during therapy. One patient had negative post-therapy prostatic fluid cultures but was lost to followup at 1 month. Of the 14 patients followed for at least 6 months 9 (64%) were cured of the original infection, including 6 who have remained uninfected and have had negative prostatic secretion and urine cultures for at least 2 years (1), 1 year (2) or 6 months (3). In 3 patients urinary tract infections recurred with new pathogens at 6, 560 and 820 days after post-therapy negative prostatic fluid cultures. Bacterial prostatitis with the original pathogen recurred in 5 patients within 2 months of completing therapy. The bacteria remained susceptible to norfloxacin but could not be eradicated with 30 to 90 days of additional norfloxacin therapy. Cures were achieved in 9 of 12 patients with Escherichia coli, none of 2 with Pseudomonas prostatitis and 3 of 5 with prostatic calculi. No patient experienced significant adverse effects. The data suggest that norfloxacin is effective and safe for the treatment of refractory chronic bacterial prostatitis.

Ofloxacin in the management of complicated urinary tract infections, including prostatitis

Studies of ofloxacin pharmacokinetics and pathogen susceptibilities suggested that this new fluoroquinolone might be particularly well suited to the treatment of urinary tract infections and prostatitis. Compared with carbenicillin and trimethoprim/sulfamethoxazole in separate studies of complicated urinary tract infection, ofloxacin achieved a significantly higher rate (p = 0.048) of microbiologic cures and more clinical cures than carbenicillin, while essentially matching the efficacy of the trimethoprim/sulfamethoxazole combination. Most common organisms were Pseudomonas aeruginosa in the first study and Escherichia coli in the second. In preliminary data from the prostatitis study comparing ofloxacin 300 mg given twice daily with carbenicillin 764 mg given every six hours, microbiologic cure rates were 100 percent with both medications. However, clinical cure rates were significantly higher (p = 0.048) with ofloxacin. Throughout these trials, ofloxacin has shown excellent safety and tolerability, with a lower incidence of nausea and diarrhea than with carbenicillin, and less nausea and rash than with trimethoprim/sulfamethoxazole. In all treatment groups, clinically significant laboratory abnormalities were uncommon and unrelated to the medications. Overall, these studies indicate that in complicated urinary tract infection the efficacy of ofloxacin is comparable with that of trimethoprim/sulfamethoxazole and superior to that of carbenicillin. In chronic bacterial prostatitis, results to date suggest that ofloxacin may be more effective clinically and as effective microbiologically as carbenicillin.

Achromobacter xylosoxidans corneal ulcer in a therapeutic soft contact lens wearer

Achromobacter xylosoxidans is an opportunistic organism that is usually seen in immunocompromised or immunosuppressed patients. It is an aerobic gram-negative rod, often confused with other more commonly seen gram-negative bacteria such as Pseudomonas aeruginosa. The organism is usually sensitive to extended spectrum penicillins such as carbenicillin and usually resistant to aminoglycosides and first generation cephalosporins. We wish to describe a corneal ulcer from A. xylosoxidans that developed in a patient wearing a therapeutic soft contact lens. The patient did not have a preexisting microbial keratitis and was not receiving corticosteroid therapy.