Bacteremic infection and malnutrition in patients with solid tumors: investigation of host defense mechanisms

Education needed to improve antimicrobial use during end-of-life care of older adults with advanced cancer: A cross-sectional survey

BACKGROUND

Antimicrobial use during end-of-life care of older adults with advanced cancer is prevalent. Factors influencing the decision to prescribe antimicrobials during end-of-life care are not well defined.

AIM

To evaluate factors influencing medicine subspecialists to prescribe intravenous and oral antimicrobials during end-of-life care of older adults with advanced cancer to guide an educational intervention.

DESIGN

18-item single-center cross-sectional survey.

SETTING/PARTICIPANTS

Inpatient medicine subspecialists in 2018.

RESULTS

Of 186 subspecialists surveyed, 67 (36%) responded. Most considered withholding antimicrobials at the time of clinical deterioration during hospitalization (n = 54/67, 81%), viewed the initiation of additional intravenous antimicrobials as escalation of care (n = 44/67, 66%), and believed decision-making should involve patients or surrogates and providers (n = 64/67, 96%). Fifty-one percent (n = 30/59) of respondents who conducted advance care planning did not discuss antimicrobials. Barriers to discussing end-of-life antimicrobials included the potential to overwhelm patients or families, challenges of withdrawing antimicrobials, and insufficient training.

CONCLUSIONS

Although the initiation of additional intravenous antimicrobials was viewed as escalation of care, antimicrobials were not routinely discussed during advance care planning. Educational interventions that promote recognition of antimicrobial-associated adverse events, incorporate antimicrobial use into advance care plans, and offer communication simulation training around the role of antimicrobials during end-of-life care are warranted.

Increased Length of Stay Associated With Antibiotic Use in Older Adults With Advanced Cancer Transitioned to Comfort Measures

BACKGROUND

Antibiotic use may increase hospital length of stay (LOS) among older patients with advanced cancer who are transitioned to comfort measures.

METHODS

We studied a cohort of patients with advanced cancer aged ≥65 years who were transitioned to comfort measures during admission from July 1, 2014, through November 30, 2016. We evaluated the association between antibiotic exposure and LOS using a Poisson regression model adjusted for age, gender, cancer type, comorbidities, infection, and intensive care unit admission.

RESULTS

Among 461 patients with advanced cancer, median age was 74 years (range: 65-99), 49.0% (n = 226) were female, and 20.6% (n = 95) had liquid tumors. Overall, 82.9% (n = 382) received ≥1 antibiotic and 64.6% (n = 298) had ≥1 infection diagnosis during hospitalization. Infection diagnoses commonly included sepsis (35%, n = 161/461), pneumonia (25%, n = 117/461), and urinary tract infection (14%, n = 66/461). Among those receiving antibiotics, the most common choices included vancomycin (79%, n = 300/382), cephalosporins (63%, n = 241/382), and penicillins (45%, n = 172/382). In a multivariable Poisson regression model, LOS was 34% longer (count ratio = 1.34, [95% confidence interval: 1.20-1.51]) among those exposed versus unexposed to antibiotics.

CONCLUSIONS

Antibiotic use among patients with advanced cancer who are transitioned to comfort measures is associated with longer LOS. These data illustrate the importance of tradeoffs associated with antibiotic use, such as unintended increased LOS, when striving for goal-concordant care near the end of life.

Defective Function of Granulocytes in Patients with Cancer

Mobilization of granulocytes into a serum-filled chamber, histochemical nitroblue tetrazolium (NBT) reduction tests, and phagocytosis were performed in 11 patients with solid tumors treated with surgical excision and chemotherapy and in 22 untreated or surgically treated patients. The results revealed a decreased mobilization (p < 0.001) and an impaired capability of neutrophils to reduce NBT after stimulation (p < 0.05) in both groups of patients. The decrease in the values in the stimulated reduction of NBT was more pronounced in untreated patients than in treated ones. At the same time the phagocytic activity of neutrophils on Candida albicans, which was decreased (p < 0.01) in untreated patients, was normal in those who had been treated with chemotherapy. There were no distinctive correlations between circulating immune complexes and granulocyte function. We propose that this newly demostrated defect in neutrophil mobilization and low median C. albicans-stimulated NBT reduction contributes more in the evolution of the tumor than in the pathogenesis of infections and that chemotherapy seems to restore a better granulocyte function.

Effects of malnutrition on oxidative burst functions and infection episodes in children with acute lymphoblastic leukemia

INTRODUCTION

The aim of this study was to determine the effect of malnutrition on oxidative burst functions (OBF) of neutrophils in children with acute lymphoblastic leukemia (ALL).

MATERIALS AND METHODS

Twenty-eight patients with ALL and thirty healthy controls were enrolled to the study. Thirteen patients with ALL were found to have malnutrition. While neutrophil OBF of ALL patients without malnutrition were studied both before induction chemotherapy and 3 months after, the same functions in ALL patients with malnutrition were studied both before induction chemotherapy and when the nutritional status improved. Control group were studied at admission and 3 months later.

RESULTS

The OBF of ALL patients with and without malnutrition before induction chemotherapy were found to be significantly lower than the control group (P = 0.009), whereas the OBF were found to be similar in both patient groups with ALL (P = 0.27). The median infection episode rate and the duration of antibiotics therapy during the study period were similar in both patient groups with ALL. The repeated OBF of both patient groups with ALL were shown to increase to similar values with the control group in the third month of chemotherapy (P = 0.002). The median infection episode rate during the first month of chemotherapy was shown to decrease significantly during the third month of chemotherapy in both patient with ALL groups (P < 0.001).

CONCLUSIONS

We have not been able to demonstrate an overt effect of malnutrition on OBF. However, our results still need to be verified via further larger scaled studies of OBF in leukemic children with and without malnutrition.

Microbiology and management of infected solid tumours

Infection has been recognized as one of the major obstacles to the successful management of patients with malignant tumours. Aerobic and anaerobic bacteria of endogenous source are a major cause of infections in the necrotic tumour, especially when they occur in proximity to a site where these bacteria reside as part of the normal flora. Although surgical removal or evacuation of the purulent fluid is preferred, this is not always feasible in a patient with a malignant tumour. Antimicrobial therapy against potential bacterial pathogens is often the sole therapy or is used along with surgical drainage or removal of the infected area. This review describes the microbiology and management of infection in necrotic tumours.

Underlying Disorders and Their Impact on the Host Response to Infection

Underlying disorders, especially those that chronically impair immune host response (e.g., cancers and hematologic malignancies) but also those that acutely impair this response (e.g., major surgery and multiple trauma), increase the incidence of infection and alter the outcome of patients with sepsis. As a part of innate immunity, inflammatory and coagulation responses are lower in patients with underlying disorders than in patients without such disorders, whereas the need for vasopressors and mechanical ventilation is more frequent. Although these patients are older, age-related defects do not appear to be responsible for this lower response, because innate immunity is usually up-regulated in the elderly. Innate immunity seems to be negligibly affected by the direct consequences of underlying disorders, but underlying disorder-related chronic organ insufficiency certainly participates in the observed organ dysfunction, overestimating the infectious insult by itself. Although innate immunity seems not to be actually blunted in patients with underlying disorders, the underlying disorder itself contributes to the severity of the physiological response to sepsis, thereby resulting in a worse outcome.

Recovery of uncommon bacteria from blood: association with neoplastic disease

Table 6 is a summary of the organisms discussed with a listing of the environmental source, the endogenous source, the predisposing factors including neoplasms, and the postulated mechanisms by which the organism can gain access to the circulation. The evidence considered indicates that the entrance of one of these microorganisms into the bloodstream of a human being depends on the presence of multiplicity of predisposing factors. In the majority of cases of bacteremia due to one of these unusual organisms, two or more predisposing factors are present. Certain predisposing factors, such as cancer chemotherapy or intravenous catheterization, often provide a barrier break, while others, such as liver disease, may render the host immune system less capable of clearing organisms from the circulation. For organisms such as Campy-lobacter, Listeria, and Salmonella spp., attributes that allow the invasion of a healthy host are present and seem to be enhanced by the simultaneous presence of a predisposing condition, such as liver disease, in the host. Although somewhat fragmentary, a number of individual case reports describe bacteremia due to one of these organisms occurring weeks to years after surgery and after other therapeutic measures had effected a supposed cure of a cancer. It may be speculated that cancer patients, even after a cure, are still susceptible to bloodstream invasion by one of the aforementioned organisms by virtue of the presence of one or more predisposing metabolic, physiologic, or immunologic factors, even though these factors may be cryptic. The predominance of hematologic malignancies among cases of bacteremia due to these unusual organisms is also apparent. Although, as pointed out by Keusch (169), the reduction in the performance of immune function in hematologic malignancies compared with solid tumors is likely to be responsible, other associations of certain organisms with specific neoplasms warrant further examination. The frequency of bloodstream infections of Salmonella typhimurium and Capno-cytophaga canimorsus in Hodgkin's disease patients seems likely due to a particular mechanism which infection by these species is favored. The specific nature of these mechanisms remains to be determined. The recovery of any unusual bacterium from blood should warrant a careful consideration of the possibility of underlying disease, especially cancer. Microbiologists should advise clinicians of the unusual nature of the identified organism and provide the counsel that certain neoplastic processes, often accompanied by neutropenia, render the human host susceptible to invasion by almost any bacterium. The recovery of such organisms as C. septicum or S. bovis should prompt the clinician to aggressively seek to identify an occult neoplasm if one has not yet been diagnosed.

Nutritional support of children with neoplastic diseases

There are numerous factors promoting the development of PEM in the child with cancer. Some of these factors are related to the tumor, many to the treatment itself, and some to failure of recognition of PEM. Not all children with cancer are at great risk for the development of PEM. These patients must be monitored and supported with comprehensive enteral programs. Children who have developed or are at risk for PEM must be identified and supported with CPN or PPN plus CEN during early intensive periods of treatment and during the later phases of abdominal radiotherapy, operative resection of tumor, or relapse. The decision to institute CPN must be based not only on the child's current nutritional status but also on the nature of the therapy he or she is soon to receive and the likelihood that he or she will be able to maintain an adequate intake during that therapy. Realistic goals must be set for nutritional support. The value of nutritional intervention lies in its ability to correct or prevent the development of adverse effects related to PEM. This support is hoped to contribute to improved tolerance of therapy, increased energy to complete normal day-to-day activities, and an improved sense of well-being for the child. If these goals have been accomplished, then the nutritional therapy has been successful.

Interaction between Clostridium difficile and polymorphonuclear leucocytes from the elderly and post-operative cancer patients: phagocytosis and bactericidal function

The ability of polymorphonuclear leucocytes (PMNs) from elderly healthy subjects and post-operative cancer patients to ingest and kill Clostridium difficile was studied. The percentage of phagocytosis in clinically healthy subjects aged 69-82 years ranged from 20.2 +/- 3.2 (mean +/- SD) to 34.1 +/- 4.2, depending on the strain of C. difficile, from 6.7 +/- 2.2 to 11.2 +/- 2.2 in post-operative cancer patients aged 65-69, and from 68.4 +/- 3.1 to 81.1 +/- 6.3 in young healthy control subjects. In both study groups, the defect was in part serum-associated. Although the total number of bacteria killed by the PMNs was reduced in the two study groups, the percentage of ingested bacteria killed by the PMNs was similar to that in the young healthy subjects. These differences were not noted when Escherichia coli and Staphylococcus aureus were used as the test organisms. The defective PMN function against C. difficile in the elderly and post-operative cancer patients described in this study may offer an explanation as to why these individuals are at high risk of developing antibiotic-associated colitis.

Malnutrition and hyperglycemia associated with TPN do not alter polymorphonuclear leukocyte adherence to nylon

Polymorphonuclear leukocyte (PMN) adherence to nylon was assayed in blood obtained from 10 malnourished patients before and during therapy with total parenteral nutrition (TPN). All patients demonstrated minimal to moderate loss of visceral and somatic protein. Adherence of PMN was unaltered by malnutrition or during the 4 wk of TPN in spite of hyperglycemia, which required insulin therapy in 4 patients. There was no correlation of blood sugar levels and PMN adherence.