Infections in cancer patients

Axillary lesions in patients with acute leukemia: evaluation of a preventive program

Axillary skin lesions can cause significant morbidity in patients with acute nonlymphocytic leukemia. The incidence in relation to the level of circulating granulocytes and the microbiology of 15 such lesions among 150 patients over a three year period were determined. Lesions occurred predominantly during periods of profound granulocytopenia (0-499 cells/microliter). Gram-negative bacilli were the most common pathogens isolated from these lesions. The initiation of a supervised preventive program for 84 patients over 19 months which includes the regular swabbing of each axilla with povidone-iodine cotton sticks in addition to measures to avoid skin trauma has virtually eliminated inflammatory axillary lesions in this high risk patient population.

Randomized trial of empiric antibiotic therapy with ticarcillin in combination with gentamicin, amikacin or netilmicin in febrile patients with granulocytopenia and cancer

A randomized trial of ticarcillin plus gentamicin (group 1), ticarcillin plus amikacin (group 2) and ticarcillin plus netilmicin (group 3) as empiric antibiotic therapy in patients with granulocytopenia and cancer was carried out at the Baltimore Cancer Research Center. The response rate for all infections was 97 per cent in group 1, 91 per cent in group 2 and 95 per cent in group 3. Patients with bacteremias showed improvement in 93 per cent (group 1), 78 per cent (group 2) and 82 per cent (group 3) of cases. All failures were among patients with gram-negative bacteremias. Both antibiotic susceptibility of the bacteremic organism and granulocyte recovery correlated with patient improvement. Nephrotoxicity and ototoxicity were rare and were not significantly different in three groups of patients. Therefore, ticarcillin plus gentamicin, ticarcillin plus amikacin and ticarcillin plus netilmicin appear to be equally efficacious and minimally toxic in this patient population. Excellent over-all results can be expected with these combinations provided the etiologic agent is susceptible.

Managing infections in immunosuppressed patients

Various infections are associated with depressed host defenses. Systemic antibiotic therapy is not useful prophylactically but should be instituted immediately in patients with known bacterial infections and in febrile patients with neutropenia. Meticulous patient care and attention to collection and evaluation of microbiologic data are the keys to early detection of infection. Nonbacterial opportunistic infections should be considered in patients with prolonged fever or fever and pulmonary infiltrates. Some ancillary measures, such as patient isolation and reconstitution of the immune system, may help in prevention or treatment of infections in immunosuppressed patients.

Infection in acute leukemia patients receiving oral nonabsorable antibiotics

During a 20-month period all acute nonlymphocytic patients (87 patient trials) receiving cytotoxic chemotherapy were placed on an oral nonabsorbable antibiotic regimen consisting of gentamicin, vancomycin, and nystatin in addition to an intensive program of infection prevention aimed at reducing exogenously acquired and body-surface potential pathogens. Although side effects of anorexia, diarrhea, and nausea were common, gentamicin-vancomycin-nystatin was ingested 80% of the study time. Microbial growth in gingival and rectal cultures was substantially reduced. The incidence of bacteremias and other serious infections was low. Pseudomonas aeruginosa, other gram-negative bacilli, and Candida species caused few infections along the alimentary canal, whereas infections of the skin (especially Staphylococcus aureus) were not reduced compared with those occurring in former years. A total of the 104 acquired gram-negative bacilli were gentamicin resistant; 5 subsequently caused infection. Thus, despite certain definite drawbacks, the use of oral nonabsorbable antibiotics to suppress alimentary tract microbial flora in combination with other infection prevention techniques in granulocytopenic cancer patients has proven feasible and tolerable and has been associated with a low order of life-threatening infections.

Comparison of serum bactericidal activity among three antimicrobial combinations

Three antimicrobial combinations, ticarcillin plus cephalothin (T+C), ticarcillin plus gentamicin (T+G), and cephalothin plus gentamicin (C+G), were administered to 105 febrile granulocytopenic cancer patients at the Baltimore Cancer Research Center as part of a multi-institutional prospective randomized antibiotic trial. The sera from 32 of these patients (T+C-10 patients, T+G-10 patients, and C+G-12 patients) obtained 1 h post-antibiotic administration were examined for bactericidal activity against 11 strains each of the most common pathogens infecting the granulocytopenic host: Pseudomonas aeruginosa, Klebsiella pneumoniae, Escherichia coli, and Staphylococcus aureus. Each of the three antibiotic regimens produced a high degree of bactericidal activity in these sera against S. aureus and E. coli. P. aeruginosa was equally, although poorly, killed by sera containing ticarcillin (T+G, T+C), whereas C+G produced no measurable serocidal activity (P < 0.05). Sera with C+G killed K. pneumoniae more effectively than T+G; T+C produced the least killing effect of the three regimens against this organism (P < 0.05). The bactericidal activity of the serum from these 32 patients supplements the overall clinical results of the multi-institutional antibiotic trial and suggests that T+G is a useful initial regimen for empiric therapy of febrile episodes in granulocytopenic cancer patients.

Liver disease complicating the management of acute leukemia during remission

Eight adults who developed persisting liver function abnormalities during remission from acute leukemia (6 acute nonlymphoblastic leukemia and 2 acute lymphoblastic leukemia) are reported. These patients constituted 20% of the adults with acute leukemia attaining remission over the time period studied. Although we were unable to be absolutely certain of the etiology of the liver dysfunction, the following findings characterize the problem: 1) onset following red blood cell and platelet transfusions in all cases; 2) minimal symptoms and signs except for transient episodes of jaundice; 3) fluctuating, but often marked, increases in liver transaminases; 4) no other consistent laboratory abnormalities; 5) liver biopsies showing varying degrees of inflammation; 6) a consistent decrease in transaminase levels following pulse chemotherapy; 7) absence of progression of abnormalities during the observation period. This group of patients did not have a worse prognosis than patients with normal liver function. We feel that it is important to recognize this entity and to not withhold antileukemic therapy.

Clinical pharmacology of mezlocillin

Mezlocillin is a new broad-spectrum semisynthetic penicillin that has shown encouraging in vitro activity against the infecting organisms most likely to cause mortality and morbidity in cancer patients receiving chemotherapy. The serum clearances and urine recoveries of mezlocillin, ampicillin, and carbenicillin were compared after the intravenous administration of single 3-g doses. The peak mean serum concentrations of mezlocillin and carbenicillin were 269 and 278 mug/ml, respectively, whereas the peak ampicillin level was lower at 167 mug/ml. The terminal half-life of mezlocillin, 66 min, was not significantly different from those of ampicillin and carbencillin (63 and 77 min, respectively). Recoveries of mezlocillin, ampicillin, and carbenicillin from urine over 6-h periods after drug dosage were 45, 61, and 80%, respectively. A further study in 11 cancer patients examined serum maintenance levels of mezlocillin when 3-g doses were given intravenously every 4 h for at least 7 consecutive days. After 3 days of therapy, the mean serum concentrations were maintained above 50 mug/ml. Although therapeutic efficacy was not an objective of this study, all of three documented bacterial infections were cured, and no serious toxicity was encountered.

Nonbacterial thrombotic endocarditis in cancer patients: comparison of characteristics of patients with and without concomitant disseminated intravascular coagulation

Thirty-one cases with malignant neoplasm and nonbacterial thrombotic endocarditis (NBTE) were studied. A threefold increase in the incidence of NBTE over the five-year period ending in 1976 was noticed. Seventy-one percent of patients with NBTE had concomitant disseminated intravascular coagulation (DIC). Adenocarcinomas of the lung or ovary were the most common tumors (48%), followed by hematologic malignancies (25%). Five patients had acute leukemia, two of whom had received bone marrow transplantation. Sudden changes in the status of cardiovascular and central nervous systems were the most common manifestations of NBTE and its complications. The possible predisposing factors included disseminated malignant neoplasms and infection with gram-negative bacilli. Identification of high-risk patients and early administration of preventive measures including anticoagulation might decrease the morbidity and mortality related to NBTE.

Ticarcillin in combination with cephalothin or gentamicin as empiric antibiotic therapy in granulocytopenic cancer patients

Ticarcillin was used in combination with either cephalothin or gentamicin as initial empiric antibiotic therapy for 127 patient trials of suspected infection in granulocytopenic cancer patients. Bacteremia was present in 20%, nonbacteremic microbiologically documented infections in 21%, clinically documented infections in 23%, and possible infections in 5%; infection was doubtful in 31%. Although Staphylococcus aureus was the most common single organism isolated (23%), gram-negative bacilli accounted for 54% of all pathogens. Both antibiotic regimens were highly efficacious, with complete resolution in 46% of bacteremias, 88% of nonbacteremic microbiologically documented infections, and 95% of clinically documented infections. Among bacteremias, 8 of 9 caused by S. aureus but only 4 of 15 (27%) caused by gram-negative bacilli were completely resolved with these antibiotic combinations. Reasons for nonresponse in bacteremias were persistent granulocytopenia, mixed infection and, in two patients, antibiotic-resistant organisms. Toxicities other than hypokalemia were minimal. Although the rate of further infections was high overall (18/127), only one occurred among the 39 patients with <4 days of antibiotic therapy. Ticarcillin in combination with either cephalothin or gentamicin was effective as initial empiric therapy of suspected infection in granulocytopenic cancer patients.