Bacteraemia caused by non-aeruginosa Pseudomonas species in a cancer centre

Fifty-one episodes of bacteraemia due to Pseudomonas species other than Pseudomonas aeruginosa occurring between 1980 and 1990 in a Belgian cancer centre were reviewed. This corresponded to an incidence of 0.62/1000 admissions, or 1.5% of all bacteraemic episodes. Twenty-nine episodes, each with several positive blood culture sets were considered clinically significant, including six patients belonging to a well-documented outbreak of pseudobacteraemia with Xanthomonas maltophilia and associated with contaminated blood sampling tubes. The respiratory tract was the source in six (20.7%), an infected intravenous catheter in 10 (34.5%) and the source was unknown in seven (24.1%). Seven patients died from infection (24.1%). Twenty-three episodes with a single positive blood culture set were considered clinically not significant, although four of them were considered significant by the Centers for Disease Control (CDC) criteria because of the presence of symptoms and specific antibiotic treatment being administered. None of the patients with a single isolate died from infection despite the fact that 17 of 22 did not receive an effective antimicrobial agent. All isolates were susceptible to co-trimoxazole.

Wound dressing in major head and neck cancer surgery: a prospective randomized study of gauze dressing vs sterile vaseline ointment

A total of 207 patients were randomized in a prospective comparative study of standard gauze dressing vs sterile vaseline ointment. 179 patients were evaluable. All patients received antimicrobial prophylaxis. The two groups (86 standard and 93 vaseline) were comparable as far as age (mean, 57 yr; range, 21-84), genders (155 males/24 females), weight (mean, 66 kg; range, 40-69), type of surgery, previous or concomitant anticancer treatment. Severity of surgery was identical, as was the severity of cancer, in the two groups. Wound infection within 20 days of surgery occurred in 31.2% (29/93) of the vaseline group and 24.4% (21/86) in the standard group (NSS). Bacteremia occurred in three patients from the vaseline group and in four patients from the standard group. Bronchopneumonia occurred in 10 patients from the vaseline group and 14 patients in the standard group. The spectrum of microorganisms recovered was similar in the two groups. The need for antimicrobial treatment (empiric or for documented infections) within 20 days after surgery was 34.4% (32/93) in the vaseline group and 36.0% (31/86) in the standard group. The median delay to infection (range in days) in the vaseline group was 9 (5-15) for wound and 6 (1-12) for bronchopneumonia. For the standard group the corresponding delays were 8 (4-15) and 7 (2-19). Vaseline dressing was not associated with an increased risk of infection as compared to the standard gauze dressing.

Pneumocystis carinii pneumonia in patients with cancer. An increasing incidence

BACKGROUND

The incidence of Pneumocystis carinii pneumonia (PCP) is increasing in patients with cancer. Possible nosocomial transmission from patients with acquired immune deficiency syndrome to those with cancer has been advocated.

METHODS

Retrospectively, 17 patients with cancer were reviewed who had 20 PCP episodes that occurred during a 3-year period (1988-1990).

RESULTS

Twelve patients had a hematologic malignant lesion, and five had a solid tumor as their underlying disease. Cytotoxic and/or immunosuppressive drugs were used in 16 patients (94%). The clinical presentation varied from fulminant to inapparent pneumonia. Clinical improvement and survival after appropriate therapy occurred in 12 patients (70%), whereas the remaining 5 patients died within 4 weeks of trimethoprim-sulfamethoxazole treatment initiation. In two patients, pentamidine was substituted. Complications of treatment occurred in six patients (35%). When survivors were compared with nonsurvivors, there was no difference in mean age, leukocyte counts, arterial oxygen tension, or duration of symptoms before treatment.

CONCLUSIONS

In this series, nosocomial transmission of PCP was unlikely. Prophylaxis after a first episode of PCP should be considered in patients who will remain immunosuppressed.

Pneumocystis carinii pneumonia in patients with cancer. An increasing incidence

BACKGROUND

The incidence of Pneumocystis carinii pneumonia (PCP) is increasing in patients with cancer. Possible nosocomial transmission from patients with acquired immune deficiency syndrome to those with cancer has been advocated.

METHODS

Retrospectively, 17 patients with cancer were reviewed who had 20 PCP episodes that occurred during a 3-year period (1988-1990).

RESULTS

Twelve patients had a hematologic malignant lesion, and five had a solid tumor as their underlying disease. Cytotoxic and/or immunosuppressive drugs were used in 16 patients (94%). The clinical presentation varied from fulminant to inapparent pneumonia. Clinical improvement and survival after appropriate therapy occurred in 12 patients (70%), whereas the remaining 5 patients died within 4 weeks of trimethoprim-sulfamethoxazole treatment initiation. In two patients, pentamidine was substituted. Complications of treatment occurred in six patients (35%). When survivors were compared with nonsurvivors, there was no difference in mean age, leukocyte counts, arterial oxygen tension, or duration of symptoms before treatment.

CONCLUSIONS

In this series, nosocomial transmission of PCP was unlikely. Prophylaxis after a first episode of PCP should be considered in patients who will remain immunosuppressed.

Antimicrobial prophylaxis for major head and neck surgery in cancer patients: sulbactam-ampicillin versus clindamycin-amikacin

A total of 99 patients with head and neck cancer who were to undergo surgery were randomized in a prospective comparative study of sulbactam-ampicillin (1:2 ratio; four doses of 3 g of ampicillin and 1.5 g of sulbactam intravenously [i.v.] every 6 h) versus clindamycin (four doses of 600 mg i.v. every 6 h)-amikacin (two doses of 500 mg i.v. every 12 h) as prophylaxis starting at the induction of anesthesia. The two groups of evaluable patients (43 in the clindamycin-amikacin treatment group and 42 in the sulbactam-ampicillin treatment group) were comparable as far as age (mean, 57 years; range, 21 to 84 years), sex ratio (71 males, 28 females), weight (mean, 66 kg; range, 40 to 69 kg), indication for surgery (first surgery, 48 patients; recurrence, 37 patients), previous anticancer treatment (surgery, radiation therapy, chemotherapy), type of surgery, and stage of cancer. The overall infection rate (wound, bacteremia, and bronchopneumonia) within 20 days after surgery was 20 patients in each group. Wound infections occurred in 14 (33%) sulbactam-ampicillin-treated patients and 9 (21%) clindamycin-amikacin-treated patients (P = 0.19; not significant). The rates of bacteremia were 2 and 4%, respectively. The rates of bronchopneumonia were 14.3 and 23.2%, respectively (P was not significant). Most infections were polymicrobial, but strict anaerobes were recovered only from patients who received sulbactam-ampicillin. Antimicrobial treatment was required within 20 days after surgery for 42% of the sulbactam-ampicillin-treated patients and 44% of the clindamycin-amikacin-treated patients. By comparison with previous studies, we observed a decreased efficacy of antimicrobial prophylaxis in patients with head and neck cancer undergoing surgery because of the increased proportion of patients who were at very high risk for infection (extensive excision and plastic reconstruction in patients with recurrent stage III and IV cancers) and because of the longer duration of surgery.

Streptococcal and enterococcal bacteremia in patients with cancer

Eighty-two episodes of bacteremia due to streptococci (including the genus Enterococcus) in 78 patients hospitalized at Institut Jules Bordet between 1986 and 1988 were reviewed. The incidence ranged from 5.5 to 7.6 per 1,000 admissions (16% of all bacteremias). Enterococcus faecalis, Streptococcus sanguis, and Streptococcus mitis were the most prevalent isolates, followed by Streptococcus angionosus, Streptococcus salivarius, and large colony-forming beta-hemolytic species (A, B, C, and G). Twenty-one episodes were polymicrobial. One-half of the patients had solid tumors, and one-half had hematologic malignancies. Forty-two patients were neutropenic (less than 1,000 polymorphonuclear neutrophils/microL). Only 15 episodes were acquired outside the hospital, and 11 episodes were breakthrough bacteremias. Twenty patients died within 1 month of the onset of streptococcal bacteremia. Five patients, two of whom were neutropenic, had fatal adult respiratory distress syndrome. The source of bacteremia remained undetermined in 35.4% of the episodes; the oral mucous membrane and the gastrointestinal tract were the most frequently recognized associated sites of infection. No unexpected antimicrobial resistance was observed except in two penicillin-resistant strains, one S. mitis and one E. faecium. No relation between peak or trough serum bactericidal titers and outcome could be demonstrated.

Candidemia in immunocompromised patients

This study reviews data on patients with fungemia and confirms the high prevalence (50%) of infections caused by non-albicans species of Candida. Fungemia due to C. albicans or Torulopsis glabrata occurred significantly more often in patients with a solid tumor, while fungemia due to Candida tropicalis or Candida krusei was significantly more common in patients with hematologic malignancy (P = .001). For 31% of patients, only a single blood culture was positive for yeasts, and the prognosis for these patients was not significantly different than that for patients with three or more positive blood cultures (P = 1), including those who had C. albicans fungemia. The overall mortality rate was 41.8%, which is much lower than that previously reported in studies of patients with cancer. No significant difference was observed between patients treated with amphotericin B and those treated with fluconazole in this retrospective analysis. Although no significant difference was observed in the mortality rate among patients who had fungemia with or without neutropenia, the incidence of disseminated candidiasis was significantly higher among neutropenic patients (P = .03).

Fungal infections in cancer patients: an international autopsy survey

In an attempt to estimate the frequency of fungal infections among cancer patients, a survey of autopsy examinations was conducted in multiple institutions in Europe, Japan and Canada. Fungal infections were identified most often in leukemic patients and transplant recipients (25% each). Fifty-eight percent of fungal infections were caused by Candida spp. and 30% by Aspergillus spp. There was considerable variability in the frequency of fungal infections in different countries. Nevertheless, this study clearly demonstrates that fungal infections represent a common complication in cancer patients, especially in patients with leukemia.

Invasive infections due to Candida krusei: report of ten cases of fungemia that include three cases of endophthalmitis

Candida krusei has become an increasingly important invasive pathogen, particularly in immunocompromised patients. Previous experimental and clinical experience suggest that C. krusei has a low propensity for hematogenously infecting the eye. We report 10 cases of fungemia due to C. krusei at our institutions, including three cases of endophthalmitis due to C. krusei. Fungemia was associated with nodular skin lesions in all seven patients with neutropenia and occurred despite administration of antifungal prophylaxis or empirical therapy. None of the patients apparently died as a direct result of C. krusei fungemia. Treatment with amphotericin B resulted in resolution of endophthalmitis, although one patient required vitrectomy. Early institution of aggressive therapy with amphotericin B may alter the course and improve the prognosis of C. krusei infection, particularly in immunocompromised patients.

Efficacy of amphotericin B encapsulated in liposomes (AmBisome) in the treatment of invasive fungal infections in immunocompromised patients

One hundred and twenty-six patients were treated for 137 episodes of fungal infection with liposomal amphotericin B (AmBisome) at 43 investigational centres. Among the patients were 72 with malignancies, 17 organ transplant recipients, 20 patients with immunological disorders and 17 others. AmBisome treatment was instituted after toxicity from previous amphotericin B treatment in 49 cases, nephrotoxicity or renal insufficiency in 40 and failure of previous antifungal treatment in 41. One hundred and eight episodes were clinically evaluable; among these 52 were caused by Candida spp. and 34 by Aspergillus spp. Ninety-nine patients were treated for at least eight days with a maximum dose of 0.7-5 mg/kg/day. Among 64 cases with proven invasive fungal infection 58% were cured. Fungi were eradicated in 35 of 54 (65%) mycologically evaluable cases. The cumulative dose was 3.2 +/- 3.2 (mean +/- S.D.) in cases where fungi were eradicated in comparison with 3.3 +/- 2.3 g in cases where fungi persisted. The eradication rate was 83% for Candida spp. compared with 41% for Aspergillus spp. (P less than 0.01). Among 24 cases with presumptive invasive fungal infections 14 (58%) were cured. Candida spp. were eradicated in seven of ten of these cases. Among 11 cases with superficial fungal infections eight were cured and three improved. Candida spp. were eradicated in four of five patients. It is concluded that AmBisome is an effective antifungal agent in a majority of patients with invasive or superficial fungal infections.

Liposomal amphotericin B (AmBisome): safety data from a phase II/III clinical trial

AmBisome is a commercially available preparation of amphotericin B incorporated in small unilamellar liposomes. The analysis of safety data provided in a multicentre compassionate phase II/III study evaluating 133 episodes of therapy with AmBisome in patients with severe underlying disease is very encouraging. Rapid (30-60 min) administration of a high daily dose of AmBisome is feasible without the well known side effects observed with the conventional formulation of amphotericin B (Fungizone). Although eleven of 71 patients with initially normal serum creatinine concentrations showed increased values after AmBisome therapy, 17 patients among 50 with initially high creatinine concentrations recovered normal renal function during AmBisome treatment. Hypokalaemia was observed in 24 episodes of treatment (18%). Increases in serum glutamyl oxaloacetic transaminase and alkaline phosphatase were also quite common in this selected population with severe underlying disease and the contribution of AmBisome to these changes is difficult to establish. AmBisome appears a safe alternative to conventional amphotericin B, and its efficacy should be further investigated.

Prospective randomized evaluation of ciprofloxacin versus piperacillin plus amikacin for empiric antibiotic therapy of febrile granulocytopenic cancer patients with lymphomas and solid tumors. The European Organization for Research on Treatment of Cancer International Antimicrobial Therapy Cooperative Group

Empiric therapy for febrile granulocytopenic patients is mandatory, but whether monotherapy is a safe alternative and whether fluoroquinolones are useful agents for this indication are still controversial issues. The use of monotherapy with intravenous ciprofloxacin (200 to 300 mg every 12 h) was evaluated against combined therapy with piperacillin plus amikacin in febrile granulocytopenic patients with solid tumor or lymphoma. The study was discontinued prematurely because patients treated with ciprofloxacin had a significantly lower overall success rate than patients treated with piperacillin plus amikacin (31 of 48 patients [65%] versus 48 of 53 patients [91%], P = 0.002). Patients with gram-positive coccal bacteremia had a particularly poor outcome: therapy failed for six of eight patients (75%) treated with ciprofloxacin, while therapy failed for none of four patients treated with piperacillin plus amikacin. Death from primary infection during initially randomized protocol therapy occurred in 7 of 48 patients (14.5%) treated with ciprofloxacin and in 3 of 53 (6%) treated with piperacillin plus amikacin. This study does not support the use of this dose of intravenous ciprofloxacin as empiric monotherapy for fever in granulocytopenic patients.

Empirical antimicrobial therapy with a single daily dose of ceftriaxone plus amikacin in febrile granulocytopenic patients: a pilot study

The optimal management of fever in granulocytopenic patients remains controversial. This pilot study investigated the potential value of single daily doses of amikacin administered empirically with ceftriaxone in febrile granulocytopenic patients. None of the patients died as a result of infection or toxicity from the prescribed regimen. Serum concentrations failed to show drug accumulation. Modifications of empirical antimicrobial therapy were made at a similar rate to other conventional regimens. Vancomycin seemed to increase the incidence of nephrotoxicity. Overall, this pilot study suggests that empirical therapy with single daily doses of amikacin plus ceftriaxone is safe and effective and should be further investigated in a larger number of patients.

Pharmacodynamic parameters and toxicity of netilmicin (6 milligrams/kilogram/day) given once daily or in three divided doses to cancer patients with urinary tract infection

The pharmacologic parameters and toxicity of netilmicin (6 mg/kg/day) given once daily (qd) or thrice daily (tid) for the treatment of urinary tract infections were studied in a randomized prospective study of 60 cancer patients. The overall efficacy was 96%. Nephrotoxicity, assessed by the measure of urinary excretion of phospholipids, was lower for the patients receiving the qd regimen than for those receiving the tid regimen. Elevation of serum creatinine (20% over baseline) occurred in one patient receiving the qd regimen and in three receiving the tid regimen. Cochleotoxicity, assessed by pure-tone audiometry (250 to 18,000 Hz) occurred in one patient receiving the qd regimen and none receiving the tid regimen. Concentrations in sera were measured on days 1 and 5. No significant accumulation was observed in either group. Median serum bactericidal titers, expressed as reciprocal values (percentage of the sera with a titer greater than or equal to 8), were measured against 25 test organisms in samples collected 6 h after the administration of netilmicin and were, for the qd group, 16 (82%) against members of the family Enterobacteriaceae and less than 2 (8%) against Pseudomonas aeruginosa, and for the tid group, 4 (57%) against members of the Enterobacteriaceae and less than 2 (0%) against P. aeruginosa. The rate of killing in serum was rapid (2 to 3 log in 2 h against P. aeruginosa; 3 to 5 log in 2 h against members of the Enterobacteriaceae) and correlated with the sampling time and hence the concentration in serum of netilmicin. The duration of the postantibiotic effect in serum depended also on the strain and the sampling time of the serum.