Infections in patients with malignant lymphoma treated with combination chemotherapy

Epidemiology of infections in cancer patients

Although major advances in the care of cancer patients over the past several decades have resulted in improved survival, infectious complications remain a significant cause of morbidity and mortality. To successfully identify, treat, and prevent infections, a comprehensive understanding of risk factors that predispose to infection and of commonly encountered pathogens is necessary. In addition, clinicians must keep abreast of the changing epidemiology of infections in this population. As therapeutic modalities continue to evolve, as established pathogens become increasingly drug resistant, and as new pathogens are discovered, successful management of infections will continue to present challenges in the years to come.

The epidemiology of herpes zoster in patients with newly diagnosed cancer

BACKGROUND

Given the limited literature, we conducted a study to examine the epidemiology of herpes zoster (HZ) among newly diagnosed cancer patients.

METHODS

We identified adult health plan members of Kaiser Permanente Northern California diagnosed with invasive cancer from 2001 to 2005. Electronic health records with inpatient and outpatient diagnoses, laboratory tests, and antiviral medications were used to identify HZ diagnoses from 2001 to 2006. HZ diagnoses and associated complications were confirmed by medical chart review. Treatment with chemotherapy and corticosteroids was used to classify patients by immunosuppression level.

RESULTS

Among 14,670 cancer patients, 424 were diagnosed with HZ during follow-up (median 22 months). The incidence of HZ was 31/1,000 person-year (PY) in patients with hematologic malignancies and 12/1,000 PY in patients with solid tumors. The corresponding 2-year cumulative incidence of HZ was approximately 6% and 2%, respectively. Compared with incidence rates of HZ reported in a general US population, the age- and sex-standardized rates of HZ were 4.8 times higher [95% confidence interval (CI), 4.0-5.6] in patients with hematologic malignancies and 1.9 times higher (95% CI, 1.7-2.1) in those with solid tumors. HZ risk increased with increasing level of immunosuppression. Among HZ cases, 19% with hematologic malignancies and 14% with solid tumors had HZ-associated pain for at least 30 days. The corresponding numbers for nonpain-related complications were 30% and 18%, respectively.

CONCLUSIONS

Cancer patients are at substantially increased risk of HZ and among those with HZ, complications are relatively common.

IMPACT

Better HZ prevention and treatment options for cancer patients are needed.

Circulating neutrophils maintain physiological blood pressure by suppressing bacteria and IFNgamma-dependent iNOS expression in the vasculature of healthy mice

Whether leukocytes exert an influence on vascular function in vivo is not known. Here, genetic and pharmacologic approaches show that the absence of neutrophils leads to acute blood pressure dysregulation. Following neutrophil depletion, systolic blood pressure falls significantly over 3 days (88.0 +/- 3.5 vs 104.0 +/- 2.8 mm Hg, day 3 vs day 0, mean +/- SEM, P < .001), and aortic rings from neutropenic mice do not constrict properly. The constriction defect is corrected using l-nitroarginine-methyl ester (L-NAME) or the specific inducible nitric oxide synthase (iNOS) inhibitor 1400W, while acetylcholine relaxation is normal. iNOS- or IFNgamma-deficient mice are protected from neutropenia-induced hypotension, indicating that iNOS-derived nitric oxide (NO) is responsible and that its induction involves IFNgamma. Oral enrofloxacin partially inhibited hypotension, implicating bacterial products. Roles for cyclooxygenase, complement C5, or endotoxin were excluded, although urinary prostacyclin metabolites were elevated. Neutrophil depletion required complement opsinization, with no evidence for intravascular degranulation. In summary, circulating neutrophils contribute to maintaining physiological tone in the vasculature, at least in part through suppressing early proinflammatory effects of infection. The speed with which hypotension developed provides insight into early changes that occur in the absence of neutrophils and illustrates the importance of constant surveillance of mucosal sites by granulocytes in healthy mice.

Feasibility of withholding antibiotics in selected febrile neutropenic cancer patients

PURPOSE

To investigate the feasibility of withholding antibiotics and early discharge for patients with chemotherapy-induced neutropenia and fever at low risk of bacterial infection by a new risk assessment model.

PATIENTS AND METHODS

Outpatients with febrile neutropenia were allocated to one of three groups by a risk assessment model combining objective clinical parameters and plasma interleukin 8 level. Patients with signs of a bacterial infection and/or abnormal vital signs indicating sepsis were considered high risk. Based on their interleukin-8 level, remaining patients were allocated to low or medium risk for bacterial infection. Medium-risk and high-risk patients received standard antibiotic therapy, whereas low-risk patients did not receive antibiotics and were discharged from hospital after 12 hours of a febrile observation. End points were the feasibility of the treatment protocol.

RESULTS

Of 196 assessable episodes, 76 (39%) were classified as high risk, 84 (43%) as medium risk, and 36 (18%) as low risk. There were no treatment failures in the low-risk group (95% CI, 0% to 10%). Therefore, sensitivity of our risk assessment model was 100% (95% CI, 90% to 100%), the specificity, positive, and negative predictive values were 21%, 13%, and 100%, respectively. Median duration of hospitalization was 3 days in the low-risk group versus 7 days in the medium- and high-risk groups (P < .0001). The incremental costs of the experimental treatment protocol amounted to a saving of 471 (US $572) for every potentially low-risk patient.

CONCLUSION

This risk assessment model appears to identify febrile neutropenic patients at low risk for bacterial infection. Antibiotics can be withheld in well-defined neutropenic patients with fever.

A multicenter, randomized, double blind placebo-controlled trial of amoxicillin/clavulanate for the prophylaxis of fever and infection in neutropenic children with cancer

AIM OF THE STUDY

To evaluate the effectiveness of oral amoxicillin/clavulanate (25 mg/kg every 12 h) for prevention of fever and/or infection in neutropenic children with cancer.

METHODS

Multicenter, prospective, randomized, double blind placebo-controlled trial.

RESULTS

In the intention-to-treat analysis, amoxicillin/clavulanate had a 12% benefit increase in terms of reduction in the incidence of febrile or infectious episodes, compared with placebo [44 of 83 (53%) vs.55 of 84 (65%); 95% confidence interval, -28% to +3%; P = 0.101]. This benefit was also associated with a 30% increase in the probability of failure-free survival at Day 15 (P = 0.138). A logistic regression analysis showed the effect of prophylaxis to be relevant, especially in patients with leukemia or lymphoma and in those not receiving hematopoietic growth factors, with 17 and 15% absolute benefit increases (logistic P = 0.014 and 0.034, respectively). Compliance with oral drugs was good, with very few and nonsevere drug-related adverse events.

CONCLUSIONS

In this study amoxicillin/clavulanate was associated with a detectable clinical effect in the reduction of fever and infection in neutropenic children with cancer, especially those with acute leukemia and not receiving growth factors; the study was not powered to demonstrate a statistically significant effect in the overall patient population.

Fever and neutropenia in cancer patients: the diagnostic role of cytokines in risk assessment strategies

Cancer patients treated with chemotherapy are susceptible to bacterial infections. Therefore, all neutropenic cancer patients with fever receive standard therapy consisting of broad-spectrum antibiotics and hospitalization. However, febrile neutropenia in cancer patients is often due to other causes than bacterial infections. Therefore, standard therapy should be re-evaluated and new treatment strategies for patients with variable risk for bacterial infection should be considered. This paper reviews the changing spectrum of microorganisms and resistance of microorganisms to antibiotics in infection during neutropenia and discusses new strategies for the selection of patients with low-risk for bacterial infection using clinical and biochemical parameters such as acute phase proteins and cytokines. These low-risk patients may be treated with alternative therapies such as oral antibiotics, early discharge from the hospital or outpatient treatment.

Management of fever in neutropenic patients with acute leukemia: current role of ceftazidime plus amikacin as empiric therapy

To evaluate the current role of ceftazidime plus amikacin as empiric therapy in the management of fever in neutropenic patients with acute leukemia, we examined 172 febrile episodes in 106 patients enrolled during 1996-98. The overall success rate (survival of neutropenia, both with and without protocol modification) was 90%: 39% without modification and 51% with modification. We documented a significant difference in documented infections (DI) and fever of undetermined origin (FUO): success without modification was lower in DI and higher in FUO. Failure (death due to documented or presumed infection) was recorded in 10% of all episodes. Episodes with severe neutropenia were treated in 48% of cases without modification and in 41% with modification. No significant difference was observed in the status of underlying disease. 33% of gram-negative bacteria responsible for bloodstream infections were resistant to ceftazidime, of which 21% were multiresistant strains. We conclude that initial chemotherapy with ceftazidime plus amikacin remains a reasonable option for treating febrile and prolonged neutropenia, although patients with DI are likely to require additional or modified treatment. The emergence of resistant strains is an increasingly important issue.

Epidemiology of infectious complications in cancer patients

Patients with underlying malignancies are at risk for a wide array of infectious diseases that cause significant morbidity and mortality. To develop a clear etiologic understanding of the infectious agents involved first requires a knowledge of the factors that predispose to infection. Neutropenia is clearly the single most important risk factor for infection in the cancer patient. However, a variety of both host and treatment-associated factors act together to predispose these patients to opportunistic infections. Approaching the individual malignancies with a knowledge of the underlying risk factors helps logically guide diagnosis and therapy. The astute clinician must also be aware of new and emerging infections in this patient population. As new pathogens are discovered and established pathogens become increasingly drug resistant, they will continue to present challenges for physicians caring for these patients in the years ahead.

An approach to the design and implementation of clinical trials of empirical antibiotic therapy in febrile and neutropenic cancer patients

The results of many clinical trials on empirical therapy in febrile, neutropenic cancer patients cannot be readily transferred to the clinical practice, because the methodology is often flawed and definitions, study endpoints and eligibility criteria differ from trial to trial. This article critically reviews some issues related to the design and implementation of randomised clinical trials of empirical antibiotic therapy in cancer patients. Within the definition of phase III clinical trials, two approaches co-exist, based on the trial's specific aims: the "explanatory" approach and the "pragmatic" approach. The usual "explicit" aim of clinical trials of empirical therapy in febrile, neutropenic patients has been that of comparing the "efficacy" of two regimens. However, this term has been more often used with reference to the antibacterial activity of the regimen under study (explanatory aim) than to indicate the practical benefits it draws to the overall patient population treated for fever and neutropenia (pragmatic aim). These two meanings are often taken as perfectly interchangeable, while, conversely, they are completely distinct (though not independent) treatment effects. Most trials conducted in this patient population in recent years are explanatory trials, though not explicitly so, but their results have been widely applied to clinical practice, as they were pragmatic trials. In an explanatory trial the appropriate endpoint is success or failure (defined by clinical and laboratory data) among those patients affected with the specific infection for which the study drug is being given, while in pragmatic trials survival is probably the more appropriate outcome variable, since they are designed to assess the practical benefits that the overall population of febrile and neutropenic patients can obtain from the new empirical treatment. Unfortunately, survival is not a practical study endpoint for the difficulty in assessing the cause of death in this patient population and, especially, for the need for very large sample sizes, which might render the implementation problematic even for large, multicentre groups. Both types of trials need an intention to treat analysis, but this is especially crucial for pragmatic trials, which should not differentiate those cases in which success was obtained through multiple treatment modifications from those who did not require any treatment change. Obviously, this implies that no conclusion should be drawn about the antibacterial activity of the study drugs and that the number of treatment modifications should be taken into account in the interpretation of the results, especially for quality of life and cost evaluations. Information related to fever and signs of infection, age, underlying disease, neutropenia and concomitant administration of other antibiotics are crucial entry criteria that need to be clearly discussed and defined. Finally, the evaluation of toxicity is problematic in this patient population, due to the existence of a number of toxigenic factors, including the underlying disease, the type of infectious complication, the administration of chemotherapy and radiotherapy and the use of parental nutrition. All these effects tend to overlap, thus impairing the investigator's ability to detect specific drug-related side-effects.

Oral infection as a reason for febrile episodes in lymphoma patients receiving cytostatic drugs

56 patients receiving chemotherapy for non-Hodgkin lymphoma or Hodgkin's disease with curative intent were monitored for up to one year after initiation of treatment. During chemotherapy (mean duration 5.2 months), 26 of the patients (46%) suffered from 38 febrile episodes. In only 16 instances was an extraoral cause for the septicaemia found. However, severe dental infection, reflected in an elevated radiological index for the jaws, was found more frequently in patients suffering febrile episodes than in those without (P = 0.02). Moderate to severe gingival inflammation was observed during 22 (58%) of episodes. During 71% of the episodes various pathological findings were also recorded in the oral mucosa. No source of infection other than an oral one was found in 42% of the patients. Our results emphasise the importance of oral foci as the possible infection source in patients receiving intensive chemotherapy.

Open lung biopsy in patients with non-Hodgkin's lymphoma and pulmonary infiltrates

Patients with non-Hodgkin's lymphoma (NHL) are at increased risk for pulmonary infection with opportunistic pathogens associated with diminished cell mediated immunity. Open lung biopsy (OLB) frequently is recommended for diagnosis of pulmonary infiltrates in patients with NHL, but its usefulness for patient management and outcome has not been evaluated for patients with NHL. We reviewed the results of 20 consecutive OLB in 19 patients with previously diagnosed non-Hodgkin's lymphoma at Stanford University Medical Center during a nine-year period. Fifteen patients had known active lymphoma at time of OLB, and no patient had granulocytopenia. Ten of the 20 OLBs yielded specific diagnoses. A greater proportion of patients with stage I or II disease had specific diagnoses than patients with more advanced NHL. Five of 14 patients considered to have had a life threatening illness at the time of OLB had specific diagnoses from OLB vs five of six patients considered clinically stable. Chest roentgenograms that had discrete masses or nodules correlated with ability to establish a specific diagnosis by OLB. For patients in whom the results of OLB were nonspecific, management appeared unaffected by the OLB. The OLB in NHL appeared most useful for detecting recurrent NHL in clinically stable patients with discrete nodules or masses on chest roentgenogram. Pneumocystis pneumonia was the only infection identified by OLB.

Open lung biopsy in patients with Hodgkin's disease and pulmonary infiltrates

Although open lung biopsy (OLB) is frequently employed for diagnosis of pulmonary lesions in patients with Hodgkin's disease, the actual efficacy of the procedure in establishing a diagnosis in these patients, and its effect on their treatment and clinical outcome, have not been evaluated. We reviewed the results of OLB in 41 patients with previously diagnosed Hodgkin's disease (17 with stage II disease, 10 with stage III, and 14 with stage IV) who had pulmonary opacification on chest roentgenogram. Nineteen (46%) diagnoses were specific and 22 nonspecific. The most common specific diagnosis was Hodgkin's disease (12 patients); the others were Pneumocystis carinii pneumonia (3), solitary fungal granuloma (2), cytomegalovirus pneumonia (1), and primary lung adenocarcinoma (1). Specific diagnoses were made in 11 (69%) of 16 patients with discrete nodules or masses but in only eight (32%) of the 25 patients with non-nodular radiographic opacification. Eleven (58%) of 19 patients who were asymptomatic or had had symptoms for longer than 4 wk had specific diagnoses, compared to one of six patients (17%) symptomatic for 1 wk or less. Survival of hospitalization correlated more with stage of Hodgkin's disease than with specific diagnosis. However, treatment was changed after biopsy in 22 (54%) of the patients. The results suggest that OLB can be helpful in the management of patients with Hodgkin's disease and pulmonary infiltrates, both in establishing a diagnosis and in assisting the patients' management. OLB appears to be more helpful in patients with Hodgkin's disease than in patients with acute nonlymphocytic leukemia or the acquired immunodeficiency syndrome and pulmonary infiltrates.

Diagnosis of pulmonary infections in immunocompromised patients

In an immunocompromised patient with fever and pulmonary infiltrates, it frequently is difficult to decide which invasive procedure, if any, to use to obtain a definitive diagnosis. Because most lung infiltrates in immunosuppressed patients are caused by bacteria and sputum usually is readily available for examination, empiric therapy with potent, safe, broad spectrum, antibacterial drugs often is successful. Invasive procedures that prove a diagnosis may result in substantive changes in therapy in perhaps as few as 10 to 20 per cent of patients, and the procedure itself may harm the patient. In a unique study in which patients with acute pneumonitis without neutropenia were randomized to either empiric antibiotic treatment or treatment based on results of open lung biopsy, patients with open lung biopsy had a worse outcome, possibly related to morbidity of open lung biopsy. Furthermore, no diagnoses were provided by open lung biopsy that were not treated by the empiric regimen. A missed treatable disease may be tragic, however. A thoughtful clinician must evaluate each patient with careful consideration of the history in light of the underlying disease and its treatment, rapidity of clinical course, physical examination, and laboratory data, particularly the chest radiograph, sputum examination, and bleeding parameters. Fiberoptic bronchoscopy with washings and brushings is very safe; the addition of transbronchial biopsy adds diagnostic power at the price of some complications. Bronchoalveolar lavage is a very promising technique that probably will find widespread use. However, none of the foregoing techniques is completely sensitive. When no diagnosis is established and bronchoscopy studies are negative, open lung biopsy must be considered, especially when the chest radiograph or computed tomography scan suggests focal disease or lymphadenopathy. Needle aspiration can be used, particularly if local experience is favorable and lung disease is peripheral. When evaluating a procedure, local experience must be considered rather than reliance on published diagnostic yields and complication rates. New diagnostic and therapeutic developments may change decision analysis in the near future. At present, cultures for viruses and fungi and serologic techniques have little application at most medical centers, and decisions on data from invasive procedures pivot on interpretation of histology and smears. Development of assays for antigen (for example, Aspergillus) and rapid culture techniques (for example, cytomegalovirus and the shell vial method), coupled with new, effective antimicrobials, may demand maximum effort for a definitive diagnosis in every patient.

Mortality-associated factors in infected lymphoma patients

Three hundred eighty-eight medical records of patients with lymphoma seen between 1971 and 1980 were analyzed for factors related to infection-associated mortality. Infection occurred in 100 patients (36 Hodgkin's lymphoma [HL], and 64 non-Hodgkin's lymphoma [NHL]). The overall mortality with infection was 17% (6 of 36) for HL and 52% (33 of 64) for NHL. In patients with NHL mortality correlated with infection in the respiratory tract (P less than or equal to 0.0001), blood (P less than or equal to 0.003), and multiple sites (P less than or equal to 0.0004) and with the following factors: granulocytopenia (P less than or equal to 0.05), thrombocytopenia (P less than or equal to 0.035), and cytotoxic therapy (P less than or equal to 0.034). Patients with HL showed a positive correlation only with staphylococcal infections (P less than or equal to 0.001) and monocytopenia (P less than or equal to 0.01). The above data may be used to generate a risk factor profile of patients at greater risk of mortality associated with such infections. Advance knowledge of such a profile may assist in the clinical management of these high-risk patients.

Bacteremia and fungemia in patients with neoplastic disease

This study reviewed 431 episodes of septicemia occurring in 356 patients with cancer at Memorial Sloan-Kettering Cancer Center during 1982. The most frequent organisms causing 273 episodes in 239 non-neutropenic patients were Escherichia coli (20 percent), Staphylococcus aureus (13 percent), polymicrobic (12 percent), Pseudomonas species (8 percent), Klebsiella species (7 percent), Candida species (7 percent), Bacteroides species (6 percent), Enterobacter species (4 percent), and Clostridium species (4 percent). The overall mortality was 31 percent (21 percent with adequate therapy; 50 percent with inadequate therapy). The most frequent organisms causing 158 episodes in 117 neutropenic patients were polymicrobic (21 percent), E. coli (16 percent), Klebsiella species (15 percent), Pseudomonas species (8 percent), Candida species (6 percent), S. aureus (6 percent), Streptococcus faecalis (5 percent), S. epidermidis (4 percent), and Corynebacterium CDC-JK (3 percent). The overall mortality was 52 percent (36 percent with adequate therapy; 88 percent with inadequate therapy). Since a review a decade ago, the spectrum of organisms changed in that the gram-positive organisms, S. faecalis, S. epidermidis, and C. CDC-JK, emerged as important pathogens. Neutropenic patients had a high incidence (42 percent) of septicemia due to multiple organisms, occurring concurrently or sequentially. The overall mortality of these patients was exceptionally high (80 percent). In contrast, the overall mortality of neutropenic patients with single-organism septicemia was comparable to that of non-neutropenic patients with single-organism septicemia (37 percent versus 29 percent).

Symposium on infectious complications of neoplastic disease (Part I). Introduction and epidemiology

An approach to infections in cancer patients is outlined that divides such infections into those due to underlying disease, those related to underlying disease plus therapy, and those related to therapy alone. The incidence of such infections in each of the categories is discussed, together with a general outline of patterns and trends in regard to involved microorganisms. Several specific areas discussed include: problems of superinfection with newer antimicrobial agents; the current inadequacy of diagnostic techniques; the potential for early treatment with monoclonal antibodies; the potential for augmenting one or more host defenses prior to sundering other defenses during antitumor chemotherapy; the potential value of a variety of nutrients that either may be depleted or might be of benefit in enhancing host defense mechanisms.

Randomized controlled trial comparing trimethoprim/sulfamethoxazole and trimethoprim for infection prophylaxis in hospitalized granulocytopenic patients

The clinical and microbiologic efficacy of trimethoprim alone and trimethoprim/sulfamethoxazole for infection prevention was evaluated in 75 patients during 92 episodes of granulocytopenia. Ultimately, 60 patients were evaluable during 77 episodes of granulocytopenia, 36 episodes in the trimethoprim group and 41 episodes in the trimethoprim/sulfamethoxazole group. The incidence of infection was higher in the trimethoprim group (50 percent) than in the trimethoprim/sulfamethoxazole group (39 percent), but this did not reach statistical significance. Trimethoprim did not appear to be as protective as trimethoprim/sulfamethoxazole when the granulocyte count was less than 100/mm3. In patients receiving trimethoprim/sulfamethoxazole, aerobic gram-negative bacilli cleared from fecal surveillance cultures more often and new aerobic gram-negative bacilli were acquired less often than in those receiving trimethoprim alone (p less than 0.05). More myelosuppression was observed among patients receiving trimethoprim/sulfamethoxazole (p less than 0.001). These observations suggest that trimethoprim alone may not be optimal for preventing colonization and infection in granulocytopenic patients and that combination with other agents may be necessary to increase the spectrum of activity. Trimethoprim/sulfamethoxazole itself may predispose toward an increased risk of infection by prolonging myelosuppression.

Herpes zoster in patients with carcinoma of the lung

Herpes zoster was observed in only four of 250 (1.6 percent) patients with small cell carcinoma of the lung, who were treated in a prospective, combined modality therapy trial. Induction chemotherapy in this study consisted of six courses of cyclophosphamide, doxorubicin, and vincristine (CAV), followed by intrathoracic and cranial irradiation. Those with extensive disease also received single doses of upper half-body irradiation. Patients did not receive maintenance chemotherapy (CAV2 protocol). This contrasted with our previous study (CAV1 protocol), which consisted of three courses of the same induction chemotherapy, the same intrathoracic irradiation, but with one year of oral maintenance chemotherapy. During the CAV1 regimen, we observed that herpes zoster developed in 13 of 161 (8.1 percent) patients in association with their therapy. A retrospective analysis of 6,576 patients with lung cancer revealed that herpes zoster developed in 58 (0.9 percent). This complication developed in 10 of 622 (1.6 percent) patients with small cell carcinoma of the lung, as compared to 48 of 5,954 (0.8 percent) patients with non-small cell carcinoma of the lung. The risk of development of herpes zoster in the CAV1 group was significantly greater than the historical group (p = 0.007) and was also greater than the CAV2 group (p = 0.031). However, there was no significant difference between the historical group and the CAV2 group. Attempts to explain the differences in the rate of herpes zoster in our three studies and those in the literature suggest that the duration of therapy, the type of chemotherapy used, and the improving survival rate may be important contributing factors to this complication in patients aggressively treated for small cell carcinoma of the lung. The literature and our own studies suggest that procarbazine is the most likely chemotherapeutic agent predisposing to this complication.

Causes of death in patients with non-Hodgkin's lymphoma

The causes of death and postmortem findings in patients treated for non-Hodgkin's lymphoma at a single institution over a 13-year period were reviewed. Postmortem examination (70% of the entire sample) revealed evidence of lymphoma in 67 of 80 patients. The most frequent extranodal sites of involvement were the respiratory tract, bone marrow, liver, kidney, and gastrointestinal tract in that order. The most common cause of death was infection (33% of cases). Predisposing factors for infection included the underlying disease, (i.e., lymphomatous infiltration of organ systems) and granulocytopenia secondary to combination chemotherapy. Other causes of death included hemorrhage and respiratory failure secondary to lymphomatous infiltration of the lung. Despite advances in therapy and supportive care of patients with non-Hodgkin's lymphoma, many patients still die of this disease or of sequelae related to its treatment.

Impaired antibody responses to a pneumococcal polysaccharide vaccine in patients with non-Hodgkin's lymphoma in remission

Eight patients with non-Hodgkin's lymphoma who have been in complete clinical remission for the mean of 23.3 months were evaluated for their antibody responses to a pneumococcal vaccine. The results were correlated with lymphocyte subpopulations, serum immunoglobulin levels, and in vitro mitogenic responses to phytohemagglutinin, concanavalin and pokeweed mitogen. Two patients with normal antibody responses had immunoglobulin levels and mitogenesis within the range of controls. Impaired antibody responses in the remaining six patients were correlated either with marked depressed mitogenesis to phytohemagglutinin or with low levels of IgA. Impaired humoral immune responses seem to persist in these patients even after several months of sustained clinical remission.

Infections in children with malignant disease in Argentina

During six-month period, 102 consecutive episodes of fever in 68 children (ranging from 1 month to 14 years of age) with malignant diseases were prospectively evaluated. Sixty-five had acute lymphoblastic leukemia, nine had acute myeloblastic leukemia, nine had malignant lymphoma (four Hodgkin and five non-Hodgkin), five had chronic myeloid leukemia, four had rhabdomyosarcoma, three had CNS tumors, two had neuroblastoma, one had Wilms, and four had other malignant tumors. Forty cases (39.2%) showed severe neutropenia (500 neutrophil/m3) during the episode. S. aureus, E. coli, and S. pyogenes were in 53% of the 75 microbiologic isolates. Twenty-two percent of the viral studies were positive. Mycologic studies were all negative, except one case with C. Albicans. Pneumonia (33 cases), cellulitis (15 cases), pharyngitis (12 cases), and varicella (11 cases) were the most common final diagnosis. Seventy-one percent of the episodes were etiologically documented (by bacterial isolate, characteristic serology, and/or typical clinic picture); 19% of the febrile episodes were probable infections, and 10% were fever of uncertain cause. Ninety percent of the cases responded well to therapy, and mortality of this series was 7%. Gentamicin, Carbenicillin, and Methicilin were the more common antibiotics employed. We conclude that in our population 1) infection is a frequent cause of morbidity in children with malignant diseases; 2) the most common cause of the febrile episodes is bacterial infection; 3) S. aureus, E. coli and S. pyrogenes are the most frequent bacterial isolates, and P. aeruginosa is infrequent; 4)viral infections are relatively frequent in this group of children; and 5) with adequate management, the mortality is low.

Effect of antineoplastic drugs on human leukocyte-mediated cytotoxicity against herpes simplex virus infected cells

We evaluated the effect of five antineoplastic drugs on the ability of human leukocytes to destroy herpes simplex virus (HSV) infected target cells in the presence of antibody (antibody-dependent cellular cytotoxicity) and in its absence (natural killer cytotoxicity). Leukocytes from healthy volunteers were separated into macrophages, polymorphonuclear leukocytes, and lymphocytes. Adriamycin, cyclophosphamide, prednisone, procarbazine, and vincristine, at various concentrations and incubation periods, were tested for their effects on the natural killer and antibody dependent cellular cytotoxicity of macrophages, lymphocytes, and polymorphonuclear lymphocytes in a 51Cr release microcytotoxicity assay against HSV-infected cells. All drugs at therapeutic concentrations inhibited natural killer and antibody dependent cellular cytotoxicity; an exception was cyclophosphamide, which did not inhibit the natural killer cytoxicity of lymphocytes. The antibody dependent cellular cytotoxicity of macrophages and polymorphonuclear leukocytes appeared to be more than that of lymphocytes. The results of short incubation (2 hours) of the drug with either effector cells or target cells, followed by drug removal, suggests that the drug effect occurred early and predominantly at the effector cell level. Antineoplastic drugs had an inhibitory effect on natural killer and antibody dependent cellular cytotoxicity against HSV-infected cells. This inhibitory action may partially explain the increased susceptibility of patients receiving chemotherapy to developing viral infections.

Septicaemia in patients with haematological malignant disease

Of 565 patients with haematological malignant disease who were seen between January, 1976, and July, 1978, 66 patients (11.7%) developed 77 episodes of septicaemia, 37 of which proved fatal. The highest prevalence of septicaemia occurred in patients with acute granulocytic leukemia (16 of 42 patients, nine deaths) and acute monocytic leukaemia (four of eight patients, two deaths). The prevalence of septicaemia in patients with multiple myeloma was also high (eight of 41 patients), due in five of these patients to Streptococcus pneumoniae. Factors associated with septicaemia, and the prevalence of the various pathogens isolated, are discussed.

Measurement of drug dosage intensity in MVPP therapy in Hodgkin's disease

The dose of combination chemotherapy in Hodgkin's disease is commonly calculated from a formula based on the body surface area. A method is described for measuring the intensity of combination chemotherapy actually received compared to the calculated planned dose. The technique is applied to 56 patients receiving mustine, vinblastine, procarbazine and prednisolone, but would also be suitable for other cytotoxic regimens. The planned dosage intensity had to be significantly reduced in over half of the patients because of marrow toxicity. Splenectomized patients received a higher dose intensity than those in whom the procedure was not performed.

Current concepts of bacteremia in children with malignancies

One hundred fifteen episodes of bacteremia occurred among 2790 children with malignancies hospitalized during a 45-month period. The mean age was 9.3 years with a male predilection (62%). A greater (p less than .025) number of children over 10 years of age died with bacteremia when compared to younger children. The majority of episodes occurred in children with leukemia (56%); however, once bacteremia developed, a significantly (p less than .05) greater number of children with lymphoma died when compared to children with other malignancies. Absolute polymorphonuclear leukocyte counts were greater in survivors (p less than .025) than in children who died. Thirty-seven different microorganisms were isolated with E. coli, S. Aureus, P. aeruginosa, and K. pneumoniae accounting for 50% of the episodes. Anaerobes were isolated from blood of 12 (10%) children. Twelve children had polymicrobial bacteremia and 14 had recurrent bacteremia which occurred during antibiotic therapy. Mortality (78%) in these children was significantly (p less than .001) greater then in children from whom one microorganism was isolated (47%). Interesting aspects include the resurgence of S. aureus, failure of development of meningitis in children with bacteremia, and unchanged antibiotic susceptibility since the last review of bacteremia in this institution. Polymicrobial and recurrent bacteremia necessitate obtaining simultaneous and sequential blood cultures to facilitate administration of appropriate antimicrobial therapy until bone marrow function improves.

Effect of chemotherapeutic agents on metabolic and bactericidal activity of polymorphonuclear leukocytes

Blood was obtained on 36 occasions from 12 healthy adult volunteers and the polymorphonuclear leukocytes (PMNL) were separated. PMNL hexose monophosphate shunt activity of whole blood and ability of separated cells to phagocytize and kill E. coli were evaluated when the PMNL were incubated with normal pooled sera and sera containing therapeutic concentrations of either 15 cancer chemotherapeutic drugs singly and in combination or 9 antibiotics. Resting and stimulated HMPS activity was significantly (p less than 0.025 to p less than 0.001) decreased by cyclophosphamide, carmustine (BCNU), high dose prednisone (pred), vinblastine (vinbl) and vincristine (vinc) and significantly (p less than 0.025 to p less than 0.01) increased by combinations of vinc-pred, vinc-predasparaginase, 6-mercaptopurine (6MP)-methotrexate (Mtx) and 6MP-Mtx-pred when compared to controls. No significant differences in HMPS activity of PMNL were found when exposed to various antimicrobial agents singly or in combination. The killing of E. coli by PMNL was significantly (p less than 0.001) decreased when exposed to BCNU, high concentration pred or combinations of 6MP-Mtx-pred, 6MP-Mtx and vinc-vinbl-pred but not when exposed to other chemotherapeutic agents. This study shows a disparity in results obtained when evaluating PMNL function by HMPS activity and bactericidal assay. In addition, a functional impairment in PMNL exposed to various antimetabolites occurred at a time when they exhibited normal morphology.