Empiric therapy for infections in the febrile, neutropenic, compromised host

Predictors of Outcome and Severity in Adult Filipino Patients with Febrile Neutropenia

Aim. The study aimed to describe the profile of Filipino febrile neutropenia patients and to determine parameters associated with severe outcomes.Methods. This is a retrospective study of Filipino febrile neutropenia patients admitted to the Philippine General Hospital. Patients were described in terms of clinical presentation and stratified according to the presence or absence of severe outcomes. Prognostic factors were then identified using regression analysis.Results. 115 febrile episodes in 102 patients were identified. Regression analysis yielded prolonged fever >7 days prior to admission (OR 2.43; 95% CI, 0.77–7.74), isolation of a pathogen on cultures (OR 2.69; 95% CI, 1.04–6.98), and nadir absolute neutrophil count (ANC) < 100 during admission (OR 1.96; 95% CI, 0.75–5.12) as significant predictors of poor outcome. Factors that significantly correlated with better outcome were granulocyte colony-stimulating factor (G-CSF) use (OR 0.31; 95% CI, 0.11–0.85) and completeness of antibiotic therapy (OR 0.26; 95% CI, 0.10–0.67).Conclusion. Prolonged fever >7 days prior to admission, positive pathogen on cultures, and nadir ANC < 100 during admission predicted severe outcomes, whereas G-CSF use and complete antibiotic therapy were associated with better outcomes. These prognostic variables might be useful in identifying patients that need more intensive treatment and monitoring.

The use of systemic antibiotics in the treatment of chronic wounds

The role of microorganisms in the etiology and persistence of chronic wounds remains poorly understood. The chronic wound bed houses a complex microenvironment that typically includes more than one bacterial species. Difficulty lies in determining when the presence of bacteria impedes wound healing, thereby warranting intervention. Indications for antibiotic therapy and optimal treatment regimens are ill defined. The goal of this article is to describe the appropriate role of systemic antibiotics in the management of chronic wounds. A common sense approach will be offered based on six clinically pertinent questions: Is infection present? Are systemic antibiotics necessary? Should treatment be enteral or parenteral? What antibiotic or combination of antibiotics should be used? What should be the duration of therapy? What special circumstances are present (i.e., concomitant illnesses, potential drug-drug interactions) that can impact therapy?

Review of statistical data about severe burn patients treated during 2001 and evidence of septic cases in Albania

The objective of this study is to review the incidence of severe burns and the complications of burns sepsis in Albanians. The data are from clinical records of the patients hospitalised in the intensive care unit (ICU) of the Service of Burns, "Mother Teresa" University Hospital Center (UHC), Tirana, Albania during 2001. For the identification of sepsis in burned patients the classification of the American College of Chest Physicians/Society Critical Care Medicine (ACCP/SCCM) was used. All the cases were evaluated according to the clinical, diagnostic and laboratory data. The study presents some epidemiological data about the causative agent, the extent of burn, the depth of burn and the subjects injured. The study also identifies the pathogens responsible for the development of sepsis among patients. Such data was used to establish compound therapies focused on two or three antibiotics for each subject in order to treat sepsis and its possible complications. As a most important part of the treatment regime it is essential to identify patients at risk of sepsis, and to apply compound therapy with antibiotics in order to resist and treat this sepsis, which is the main cause of high mortality among our severely burned patients.

Infectious complications of febrile leukopenia

It can be foreseen that in the years to come major improvements in neutropenic host infections will be achieved regarding the exact identification of risk factors, allowing better patient stratification; the application of molecular techniques to recognize pathogens; the development of effective new oral antimicrobials allowing home therapy or abbreviated hospitalization; the development of new antifungals; and the development of new effective immunomodulators and cytokines to ameliorate chemotherapy-induced neutropenia. In the years to come the threat of nosocomial infections unfortunately will not be eliminated, while the development of major new parenteral antibiotics cannot be foreseen. It is therefore the caregiver/physician himself who, by applying rational antibiotic policies and strict handwashing rules, will probably escape, for his neutropenic patient's sake, the imminent threat of multiresistant pathogens.

Antipseudomonal antibiotics

Pseudomonas aeruginosa is responsible for a variety of nosocomial infections associated with high morbidity and mortality, involving the immunocompromised and immunocompetent host. There are several groups of antipseudomonal antibiotics available today: antipseudomonal penicillins (carboxy and ureido penicillins), antipseudomonal cephalosporins, monobactams, quinolones, aminoglycosides, and carbapenems. This article reviews the newer antipseudomonal compounds and focuses on recent and important pieces of information for older compounds. Antibacterial spectrum, with particular emphasis on contemporary resistance mechanisms, and recent global resistance surveillance reports, pharmacokinetics, in vitro combination studies and in vivo interactions, and adverse effects and dosage schedules are described in an effort to approach the clinicians' needs.

Pseudomonas aeruginosa bacteremia in children: analysis of trends in prevalence, antibiotic resistance and prognostic factors

OBJECTIVE

To determine the factors predisposing to Pseudomonas aeruginosa bacteremia as well as the prevalence, source of infection, outcome and prognostic factors in pediatric patients.

METHODS

Retrospective review of pediatric patients with P. aeruginosa bacteremia, at a large tertiary care hospital during a 6.5-year period.

RESULTS

Seventy patients with P. aeruginosa bacteremia were identified. The annual rate of P. aeruginosa bacteremia remained unchanged during the study period. Antibiotic susceptibility remained unchanged except for two patients with extensive burns who developed resistant strains. Underlying diseases were malignancy (50%), prematurity (6%), burns (7%) and others (37%). The overall mortality associated with P. aeruginosa bacteremia was 20%. The fatality rate was higher among the young infants (compared with older children) and those who received previous antibiotic therapy (P = 0.02). Mortality rate was higher in nosocomial than in community-acquired infections (25% compared with 11.5%). The mortality rate of low birth weight and burns patients was significantly higher when compared with oncology patients or other patients, 75 and 40% compared with 11 and 19%, P = 0.01. Multiple regression analysis revealed a correlation only between the underlying disease and mortality (P = 0.02). In the oncology patients the only significant risk factor for mortality was absolute neutrophil count < or =0.1 x 10(9)/l (P = 0.06).

CONCLUSION

P. aeruginosa bacteremia, although apparently not increasing in incidence and antibiotic resistance, is still a common serious complication in immunocompromised children with a high mortality rate. We conclude that the underlying disease is the main determinant of the clinical outcome.

Cost effectiveness of cephalosporin monotherapy and aminoglycoside/ureidopenicillin combination therapy. For the treatment of febrile episodes in neutropenic patients

OBJECTIVE

To assess the relative cost effectiveness of cephalosporin monotherapy options and aminoglycoside/ureidopenicillin combination therapy for the treatment of febrile episodes in adult patients with neutropenia.

DESIGN AND SETTING

This was a retrospective cost-effectiveness analysis conducted from the institutional perspective.

METHODS

The analysis was based on 741 febrile episodes in adult patients with neutropenia enrolled in 5 randomised trials: 3 comparing monotherapy with ceftazidime or cefepime, and 2 comparing cefepime monotherapy versus aminoglycoside/ureidopenicillin combination therapy. Resource utilisation included costs for study antibacterials, treatment of adverse effects and failures, and hospitalisation. The primary end-point was the overall cost of treatment per patient. Cost-effectiveness ratios were also analysed.

RESULTS

No significant differences in clinical success rates were detected. Median per-patient costs in the monotherapy comparisons were $US7849 for cefepime and $US7788 for ceftazidime [1997 values; not significantly different (NS)]. Corresponding costs for the monotherapy versus combination therapy comparisons were $US9780 for cefepime and $US10 159 for gentamicin/ureidopenicillin (NS). Despite a higher acquisition cost for cefepime, there were no statistically significant differences in cost effectiveness compared with either ceftazidime monotherapy or gentamicin/ureidopenicillin combination therapy. Sensitivity analyses revealed that monotherapy can be cost effective compared with combination therapy in many situations.

CONCLUSION

There were no economic differences between the 3 regimens tested. Therefore drug cost should not be a deciding factor when choosing antibacterial therapy for the treatment of febrile episodes in adult patients with neutropenia.

Fever in the immunocompromised host

A broad classification of immune defects provides a framework for the approach to fever in the immunocompromised host. Practical, historical, and physical examination findings are reviewed, and common clinical scenarios are highlighted. A general initial work-up and treatment plan are outlined.