Infections in cancer patients

Cannabidiol on the Path from the Lab to the Cancer Patient: Opportunities and Challenges

Cannabidiol (CBD), a major non-psychotropic component of cannabis, is receiving growing attention as a potential anticancer agent. CBD suppresses the development of cancer in both in vitro (cancer cell culture) and in vivo (xenografts in immunodeficient mice) models. For critical evaluation of the advances of CBD on its path from laboratory research to practical application, in this review, we wish to call the attention of scientists and clinicians to the following issues: (a) the biological effects of CBD in cancer and healthy cells; (b) the anticancer effects of CBD in animal models and clinical case reports; (c) CBD’s interaction with conventional anticancer drugs; (d) CBD’s potential in palliative care for cancer patients; (e) CBD’s tolerability and reported side effects; (f) CBD delivery for anticancer treatment.

Oral Complications in Patients with Advanced Cancer

Disturbances caused by lesions of the oral cavity play an important part in the alteration of the qualtity of life of cancer patients. The main complications affecting the oral cavity are infections (fungal, viral, bacterial), neutropenic ulcers, drug-induced stomatitis, dry mouth, and taste alteration. Most of the information available about these entities has been acquired in the cancer patient without advanced disease. The little known about the epidemiology and physiopathology of such lesions in the advanced phase of cancer is presented and approaches to management are suggested.

Tobramycin versus Gentamicin, in Combination with Cephalotin and Carbenecillin, in Patients Undergoing Bone Marrow Transplantation

Thirty-six patients with severe aplastic anemia or acute leukemia undergoing bone marrow transplantation or intensive hematologic treatments were randomized to receive gentamicin (1 mg/kg/iv q8h) or tobramycin (1 mg/kg/iv q8h) in combination with carbenecillin (500 mg/kg/day i.v. in 4 doses) and cephalotin (200 mg/kg/day i.v. in 6 doses), at the onset of fever during granulocytopenia. Patients in the gentamicin group were treated for a total of 541 patient days (minimum 5, maximum 106), and patients in the tobramycin group for 426 patient days (minimum 9, maximum 48). All patients received oral decontamination, which included the amino glycoside (either gentamicin or tobramycin) given intravenously. This study showed that 1) no patient had an increase in creatinine level above 1.3 mg % and no patient developed renal failure, 2) there was no difference between gentamicin and tobramycin in the efficacy of treating febrile episodes and/or major infections, 3) prolonged intravenous administration (up to 48 consecutive days in the tobramycin group and 106 consecutive days in the gentamicin group) was well tolerated and effective in treating fever of unknown origin in granulocytopenic patients: 45 of 72 febrile episodes resolved while the patients had a granulocyte count below 500/mm3.

Invasive Aspergillosis in Neutropenic Patients with Hematological Disorders

Between 1983-1988, 72 patients with acute leukemia and 4 with aplastic anemia were treated in the Hematology Unit of The Chaim Sheba Medical Center. Ten patients with acute leukemia developed invasive pulmonary aspergillosis and 2 with aplastic anemia developed invasive aspergillosis of the nose and paranasal sinuses. These infections were diagnosed during a period of profound neutropenia while these patients were receiving broad spectrum antibiotics. The diagnosis of pulmonary aspergillosis was based on positive sputum cultures in 4 cases and on the appearance of typical clinical and radiologic features in six. In 2 culture-positive and in one culture-negative patient, the diagnosis was confirmed at autopsy. Thus, the diagnosis was definitive in 5 patients and probable in the remaining five patients. The 5 patients who achieved remission responded to antifungal treatment and recovered, while of the 5 who eventually died from the fungal infection, 4 did not achieve remission, and one died while in complete remission. In the 2 patients with aplastic anemia, aspergillosis was detected in cultures from necrotic nasal tissue. Both patients remained neutropenic, failed to respond to antifungal treatment and died within a short time after diagnosis. From this experience it appears that invasive aspergillosis in neutropenic patients is potentially curable if treated early by amphotericin B, provided that the neutrophil count recovers.

The diagnostic value of interleukin-6 and interleukin-8 for early prediction of bacteremia and sepsis in children with febrile neutropenia and cancer

BACKGROUND AND AIM

Early diagnosis of sepsis in children with febrile neutropenia and cancer still remains a challenge for modern medicine because of lack of specific laboratory markers and clinical signs especially at the beginning of the infection. The objective of this study was to evaluate the ability of interleukin-6 and interleukin-8 to predict bacteremia and sepsis during the first 2 days in oncohematologic patients with febrile neutropenia.

PATIENTS AND METHODS

A total of 61 febrile neutropenic episodes in 37 children were studied. Serum samples were collected on day 1 and day 2 from the onset of fever and analyzed using an automated random access analyzer.

RESULTS

Neutropenic children with febrile episodes were classified into the following 2 groups: (1) fever of unknown origin group--patients with a negative blood culture--and (2) bacteremia/sepsis group--patients with a positive blood culture or clinical sepsis. High negative predictive values were found on day 1 for interleukin-6 and interleukin-8 (89% and 82%, respectively) for exclusion of bacteremia/sepsis.

CONCLUSIONS

These interleukins could be used as a screening tool for the rejection of sepsis or bacteremia on the first day of fever in neutropenic children with cancer.

Hepatotoxicity of Combined Treatment with Cisplatin and Gentamicin in the Guinea Pig

The damaging effects on the liver tissue of treatment with cisplatin followed by the aminoglycoside antibiotic gentamicin were studied in guinea pigs. The ultrastructural findings revealed foci of damage in the liver parenchyma, including its vascular component. Injurious effects to cytoplasmatic organelles such as mitochondria and endoplasmic reticulum as well as to nuclei were observed. In addition, abundance of lysosomes, autophagic vacuoles, and amorphous-granular bile in the lumina of bile canaliculi was found. Focal sinusoidal lining damage and capillarization of sinusoids were also present. In vascular lumina, some erythrocytes showed a deformed shape ("ropalocytosis"). Taken together, these findings indicate that the combined treatment with cisplatin followed by gentamicin is toxic to components of liver tissue. Since toxic changes have been shown in vessels of the inner ear and in renal-glomerular capillaries, the present observations of hepatotoxicity indicate the potential vascular damage to various tissues. The injurious effects of the cisplatin-aminoglycoside combination should be considered during its use in clinical conditions.

Evaluation of evidence for infection as a mode of action for induction of rat lymphoma

The European Food Safety Authority (EFSA) released a 2006 report questioning the relationship of aspartame exposure with increased incidence of lymphomas/leukemias in a European Ramazzini Foundation (ERF) rat study. The EFSA report suggested that the lymphoma/leukemia findings were most likely explained by infection in the rat colony. The ERF has also conducted the only available long-term oral study of methyl tertiary-butyl ether (MTBE). Thus, using the EFSA report as support, some have now raised questions about the human relevance of MTBE-associated hemolymphoreticular tumors reported by the ERF in female rats as well as whether their incidence was elevated above background levels. In this report, we discuss the hypothesized mode of action (MOA) of infection-induced lymphoma and its relevance to MTBE-associated lymphomas. We address the relationship of rat strain and study duration to lymphoma susceptibility and review evidence of low background rates of this tumor in control animals at the ERF, similar survival rates for female rats at the ERF and National Toxicology Program (NTP), and chemical- and gender-specificity of tumor induction for this type of tumor in studies at the ERF. We find that the background incidence of hemolymphoreticular tumors in female rats in the MTBE study is consistent with contemporaneous studies at the ERF and that there is an exposure-related effect, which is unlikely to be due to infections. We examine more recent tumor classification schemes for lymphomas, which support the combination of lymphoblastic leukemias and lymphomas reported by Belpoggi et al. ([1995] Toxicol Ind Health 11:119-149; [1998] Eur J Oncol 3:201-206).

[Etiology of bacterial infections in febrile neutropenic patients: the role of the laboratory in the diagnosis]

EPIDEMIOLOGICAL EVOLUTION: Until the mid-eighties, infectious complications (pneumonia, septicemia) observed in neutropenic patients were, in 70% of cases, of bacterial origin with Gram negative bacillae (Escherichia coli, Klebsiella sp, Pseudomonas aeruginosa) isolated 8 times out of 10. Among the Gram positive bacteria, Staphylococcus aureus predominated. The etiological profile of bacterial infections has since evolved with a predominance (60 to 70%) of Gram positive bacteria (coagulase-negative staphylococci, viridans streptococci) and a change in the epidemiology of the Gram positive bacteria notably with a lesser frequency of P. aeruginosa infections. THE GRAM POSITIVE BACTERIA: Coagulase-negative staphylococci are among the first germs responsible for nosocomial bacteremia (central venous catheters) and they are usually multiresistant. Viridans streptococci are a frequent cause of bacteremia; they are generally sensitive to antibiotics active on Gram positive bacteria, but the incidence of resistant strains is increasing. Enterococci are in majority responsible for colonisation in neutropenic patients and less frequently for infections; they raise the problem of resistance to antibiotics, notably to glycopeptides. Other Gram positive bacteria can be responsible for infections in neutropenic patients; it is crucial that they be identified because they require treatment with an appropriate antibiotic. GRAM NEGATIVE BACTERIA: Among the enterobacteria, Escherichia coli is predominantly isolated and raises the problem of the increasing incidence of resistance to fluoroquinolone. Pseudomonas aeruginosa, less frequently responsible today, remains associated with a far greater rate of mortality than that observed with the other microorganisms. Other Gram negative bacteria can be identified; they require an adapted antibiotherapy because they are often naturally multiresistant to antibiotics. THE ROLE OF THE LABORATORY: For the diagnosis of infections in neutropenic patients, the microbiology laboratory has a determinating role. The laboratory ensures the analysis of various biological examinations: blood cultures, methods permitting the diagnosis of an infection on a permanent catheter, copro-cultures (research for common enteropathogens, quantification in the case of digestive decontamination, screening for multiresistant bacteria), cytobacteriological examination of urine, samples of respiratory origin, cytobacteriological examination of cerebro-spinal fluid...).

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.

Infectious morbidity in critically ill patients with cancer

Infection frequently complicates the course of cancer treatment and often adversely affects the outcome. Patients have a greater tendency for acquiring infections caused by opportunistic microorganisms. Agents with low virulence potential may lead to invasive and often life-threatening infections because of altered host immune function. The immune dysfunction may be caused by the underlying malignancy, by antineoplastic chemotherapy, or by invasive procedures during supportive care.

Infections following hematopoietic stem cell transplantation

Numerous advances have been made in the management of infection in HSCT recipients. With increasing knowledge the authors are able to prevent several serious infections from occurring, and reduce the severity of infections once they occur. Despite these advances, several previously unrecognized pathogens have emerged and pose risks to this population. Ongoing surveillance and reporting of atypical infections are warranted. Transplant and infectious disease clinicians alike must be vigilant to the shifts in infectious syndromes as a consequence of various prophylaxis and preemptive strategies, and be ready to modify empiric strategies to meet the changing microbiologic milieu. As we increase our understanding of the HSCT process, and use the immune system rather than relying on high-dose chemotherapy, the authors are likely to reduce toxicities and improve patient outcomes.

STUDY OF YEAST SPECIES ISOLATED FROM CLINICAL SPECIMENS

Opportunistic yeast infections are very common in patients with malignancy or some form of immuno-suppression. Conventional methods of yeast identification are time consuming and labour intensive whereas commercial methods are expensive and beyond reach of most laboratories. Disk diffusion method offers a relatively simple, inexpensive and rapid method of identifying yeasts. 63 specimens of yeasts were isolated and identified from 68 patients by conventional methods. With disk diffusion method 54 of 63 species (85.7%) gave the same identification.

Clinical and microbiological features of refractory periodontitis subjects

The purpose of this investigation was to compare the clinical parameters and the site prevalence and levels of 40 subgingival species in successfully treated and refractory periodontitis subjects. 94 subjects received scaling and root planing and if needed, periodontal surgery and systemically administered tetracycline. 28 refractory subjects showed mean full mouth attachment loss and/or > 3 sites showing attachment loss > 2.5 mm within 1 year post-therapy. 66 successfully treated subjects showed mean attachment level gain and no sites with attachment loss > 2.5 mm. Baseline subgingival plaque samples were taken from the mesial aspect of each tooth and the presence and levels of 40 subgingival taxa were determined using whole genomic DNA probes and checkerboard DNA-DNA hybridization. The mean levels and % of sites colonized by each species (prevalence) was computed for each subject and differences between groups sought using the Mann-Whitney test. Most of the 40 species tested, including Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis, Treponema denticola and Bacteroides forsythus, were equally or less prevalent in the refractory group. Prevotella nigrescens was significantly more prevalent in successfully treated subjects, while refractory subjects harbored a larger proportion of Streptococcus species, particularly Streptococcus constellatus. The odds of a subject being refractory was 8.6 (p < 0.001) if S. constellatus constituted > or = 3.5% of the total DNA probe count. Since few microbiological differences existed between treatment outcome groups using DNA probes to known species, the predominant cultivable microbiota of 33 subgingival samples from 14 refractory subjects was examined. 85% of the 1649 isolates were identified using probes to 69 recognized subgingival species. The remaining unidentified strains were classified by analyzing 16S rRNA gene sequences. Many sequenced isolates were of taxa not considered a common part of the oral microbiota such as Acinetobacter baumanni, Gemella haemolysans, Enterococcus faecalis, Staphylococcus warneri, Pseudomonas aeruginosa and novel species in the genera Bartonella, Ralstonia, Neisseria, Eubacterium, Rothia, Gordona, Gemella, Corynebacterium, Leptotrichia, and Actinomyces. Refractory subjects constituted a heterogeneous group based on their subgingival microbiota. As a group, they did not harbor more of the "classic" periodontopathogens, although elevated proportions of S. constellatus were found.

Advances in supportive care

A range of distressing symptoms, such as nausea and vomiting, dyspnoea and pain, which invariably impair quality of life, may develop in cancer patients as a result of their disease and treatment. The side-effects of cancer treatments place additional burdens on the patient. Patients indicate that they find nausea and vomiting and fatigue to be the most distressing symptoms. The burden of distressing symptoms and the side-effects of cancer treatments may be so great for some patients that they make a decision not to continue with treatment. Developing better methods of managing these complaints is critical for improving both quality of life and treatment outcome. Over the past two decades there have been dramatic advances in supportive care. The most significant advances have occurred in the general approach to symptom management and in the development of new pharmacological agents. Advances have also occurred in non-pharmacological approaches to supportive care and it is now acknowledged that interventions such as patient education and complementary therapies have an important role to play in ameliorating distressing symptoms.

Oropharyngeal candidiasis in immunocompromised children: a randomized, multicenter study of orally administered fluconazole suspension versus nystatin. The Multicenter Fluconazole Study Group

OBJECTIVE

To compare the efficacy, safety, and tolerance of fluconazole suspension versus nystatin in the treatment of oropharyngeal thrush in immunocompromised children.

DESIGN

Multicenter, randomized, observer-masked trial.

SETTING

Thirty-two centers participated, including hospitals and ambulatory care clinics.

PATIENTS

We enrolled 182 immunocompromised infants and children, ages 5 months to 14 years, with signs of oral thrush and presence of yeasts on potassium hydroxide- or gram-stained preparations. Subjects were randomly assigned to receive a single daily dose of fluconazole suspension, 2 to 3 mg/kg per day, or nystatin, 400,000 units four times daily for 14 days; 159 patients, who had culture confirmation of thrush and received at least 7 days of study drug, were evaluated for efficacy; all patients were evaluated for safety.

RESULTS

Clinical cure was demonstrated in 91% of the subjects in the fluconazole group and 51% of the subjects in the nystatin group (p < 0.001), and eradication of the organism cultured at entry occurred in 76% and 11% (p < 0.001), respectively. Gastrointestinal conditions developed in six patients who received fluconazole and in three who received nystatin; two fluconazole recipients were subsequently withdrawn from the study. Laboratory abnormalities occurred with equal frequency in both groups. Clinical relapse rates were similar in both groups at 2 weeks (18% and 24% for fluconazole and nystatin, respectively) and 1 month (28% and 27%, respectively) after the completion of study drug.

CONCLUSIONS

Fluconazole suspension is more effective than nystatin in the treatment of thrush in immunocompromised children. Both regimens were well tolerated.

Orointestinal yeast colonization of paediatric oncologic patients during antifungal prophylaxis: results of quantitative culture and Candida serology and comparison of three polyenes

The orointestinal yeast colonization of 46 children with newly diagnosed malignancies was studied prospectively and longitudinally with quantitative cultures during remission induction chemotherapy. The initial colonization rate was 24%; only 28% of the patients remained free of yeasts during their entire treatment although all of them continuously received oral polyenes as antifungal prophylaxis. A randomized comparison of natamycin (suspension, lozenges), nystatin (suspension) and amphotericin B (suspension, lozenges) failed due to serious problems with patient compliance. Natamycin was best accepted by the patients and natamycin lozenges were the most efficacious drug in the oral cavity. The effectivity of the suspensions of nystatin and amphotericin B was similar; both were equally efficacious in the oral cavity and the gut. Assessment of faecal polyene concentrations by HPLC showed the highest results for amphotericin B (mean 6808 microgram(-1)). Regularly performed Candida serology (indirect haemagglutination, indirect immunofluorescence and immunodiffusion precipitation) revealed significant titre increases in 63% of the patients. In six cases, the synopsis of clinical picture, culture and serology strongly suggested systemic yeast invasion.

Effect of cytotoxic drugs on mature neutrophil function in the presence and absence of granulocyte-macrophage colony-stimulating factor

The effects of the cytotoxic drugs, adriamycin, cyclophosphamide, daunomycin (daunorubicin), prednisolone, actinomycin D, azacytidine and vincristine at concentrations of 1 microM on mature neutrophil function were examined. Up to 5 h incubation with adriamycin, azacytidine, cyclophosphamide, daunomycin and prednisolone had no effect on either luminol chemiluminescence or superoxide secretion. However, after 15 min or 1 h (but not 5 h) incubation vincristine enhanced fMet-Leu-Phe stimulated chemiluminescence, whilst after 5 h incubation with actinomycin D the ability of neutrophils to generate reactive oxidants in response to all stimuli tested was impaired: after 5 h incubation with adriamycin reactive oxidant production was also impaired, but only when fMet-Leu-Phe was used as stimulant. All of the drugs tested except azacytidine inhibited neutrophil oxidant production after 5 h incubation in the presence of granulocyte-macrophage colony-stimulating factor (GM-CSF). Actinomycin D and cyclophosphamide also inhibited GM-CSF stimulated protein biosynthesis. These data indicate that cytotoxic drugs may compromise the potentially beneficial effects of CSFs on mature neutrophil function during therapy.

A prospective evaluation of the activity of human granulocyte-colony stimulating factor on the prevention of chemotherapy-related neutropenia in patients with advanced carcinoma

After informed consent, 86 patients with advanced cancer undergoing potentially myelosuppressive cytotoxic chemotherapy were randomized to receive placebo or subcutaneous granulocyte-colony stimulating factor (G-CSF) 5 micrograms/Kg/day in order to prevent severe neutropenia and its related morbidity. The incidence of neutropenia (absolute neutrophil count < 1,000/mm3) was significantly reduced in patients receiving G-CSF than in controls (18% versus 42%; P < 0.05). The duration of neutropenia was also shortened by the administration of G-CSF (4.8 versus 8.2 days; P < 0.05). Therapy with G-CSF has also a positive impact on the dose-intensity of employed regimens. Patients treated with G-CSF showed oral fungal disease in 9% of cases, while control patients had a 21% incidence (NS). Patients treated with G-CSF received 91% of the programmed dose-intensity as compared to 71% of control patients (P < 0.05). These data strengthen the clinical usefulness of G-CSF in the prevention of chemotherapy-related neutropenia, infections, and reduction in dose-intensity. Further studies are required to establish if the increase in dose-intensity allowed by G-CSF treatment may positively influence the outcome of cancer patients.

Paracoccidioidomycosis: an update

This review summarizes knowledge on various aspects of paracoccidioidomycosis. Mycelial propagules, chlamydospores, and arthroconidia exhibit thermal dimorphism; arthroconidia are infectious in animals and, by electron microscopy, appear well provided for survival. The mycelial-to-yeast-phase transformation requires a strict control of glucan synthesis probably mediated by membrane enzymes. Hormonal influences on the transformation of the fungus (mycelium or conidium to yeast phase) have been demonstrated. Estrogen-binding proteins have been detected in the fungal cytosol, and during the transformation novel proteins are produced as a result of estradiol incorporation. Clinical forms have been better defined on the basis of better experimental models. Emphasis has been placed on the lungs as the portal of entry and on the existence of silent pulmonary infections. A specific Paracoccidioides brasiliensis antigen, the 43-kDa glycoprotein (Gp43), has been identified, characterized, and cloned. This has led to improved reproducibility and specificity of serologic tests. The depression of cell-mediated immune responses has been associated with severe disease in humans and in the experimental host. T-cell subsets in patients' tissues were characterized by means of monoclonal antibodies, and a reduced CD4/CD8 ratio was demonstrated. This has been related to alterations in lymphokine and tumor necrosis factor production, production of antigen-antibody complexes, etc. Amphotericin B has provided effective therapy. Azole derivatives have also improved prognosis and facilitated therapy. Itraconazole is presently the drug of choice, yet incapacitating sequelae (mainly pulmonary fibrosis) still constitute major problems.

The Salmonella typhimurium virulence plasmid increases the growth rate of salmonellae in mice

The virulence plasmids of Salmonella typhimurium and other invasive Salmonella serovars have long been associated with the ability of these bacteria to cause systemic infection beyond the intestines in orally inoculated animals. Genetic analysis of virulence genes on the high-molecular-weight plasmids has revealed that no more than five genes spanning a 6.2-kb region are sufficient to replace the entire plasmid for conferring virulence. However, the exact virulence function(s) encoded by these genes has not been elucidated. In this report, we measured the possible effect of the virulence plasmid on the growth rate of S. typhimurium in mice by two complementary procedures. The first procedure used segregation of a temperature-sensitive plasmid in vivo to provide a measure of bacterial divisions and the number of recovered marker plasmid-containing salmonellae as a measure of killing. In the second procedure, aroA deletions were transduced into virulence plasmid-containing and plasmid-cured S. typhimurium. Since AroA- salmonellae are inhibited for growth in vivo, if the virulence plasmid affected only growth rate, no difference in the recoveries of the paired AroA- strains would be seen. Virulence plasmid-containing S. typhimurium segregated the marker plasmid more rapidly than did the virulence plasmid-cured strain, and AroA- derivatives of both strains were recovered equally from mice. Therefore, the S. typhimurium virulence plasmid increased growth rate but had no detectable effect on killing or bacterial movement into deep tissues. To examine whether the plasmid accomplished this function by affecting the intracellular/extracellular location of bacteria, orally infected mice were injected with gentamicin to kill the extracellular bacteria. Wild-type and plasmid-cured S. typhimurium strains were equally resistant to gentamicin in vivo and hence most likely located intracellularly to equal degrees. When wild-type and plasmid-cured S. typhimurium strains were sequestered within peritoneal chambers in mice, the resulting extracellular growth was equal. Therefore, the virulence plasmid increases the growth rate of S. typhimurium in mice, probably within mouse cells.

A pilot study of prophylactic aerosolized amphotericin B in patients at risk for prolonged neutropenia

Invasive aspergillosis continues to be a significant cause of morbidity and mortality in patients with prolonged neutropenia. We performed a phase I trial of escalating doses of aerosolized amphotericin B given by a face mask nebulizer system with a disposable bacterial exhale filter. Five, 10, 15, and 20 mg of drug were dissolved in sterile water and inhaled over 10 to 15 minutes twice daily. Tolerance was studied in 26 patients (18 transplant recipients, and 8 leukemia patients). No side effects were observed at any dose level. Prophylactic treatment ended for 14 patients (54%) when intravenous (IV) amphotericin B was begun empirically for antifungal coverage following fevers. Eleven patients (43%) continued inhaled amphotericin B until blood counts recovered. One patient was taken off study when she developed cardiogenic pulmonary edema. No patient developed clinically suspicious or pathologically documented infection with invasive aspergillosis. Prophylactic aerosolized amphotericin B is well tolerated at 5, 10, 15, and 20 mg twice daily dosing. In addition, prophylactic aerosolized amphotericin B does not appear to sensitize patients to the subsequent use of IV amphotericin B. Although this study suggests that prophylactic inhaled amphotericin B is well tolerated and effective, a large scale controlled trial is needed.

Fatal disseminated Scedosporium inflatum infection in a neutropenic immunocompromised patient

Disseminated infection with the fungus Scedosporium inflatum in a neutropenic patient with non-Hodgkins lymphoma presented with the triad of muscle tenderness, papular skin lesions and fever, and progressed rapidly to a fatal outcome. This represents the first reported instance of fatal widely disseminated infection with this organism, and demonstrates that the triad of presenting clinical features, formerly reported to be pathognomic of systemic candidiasis, can no longer be regarded as specific for infection with a particular species of yeast or fungus.

Skin problems in advanced and terminal cancer patients

Disturbances caused by skin problems may compromise the quality of life of cancer patients. The main complications affecting the skin comprise the dermatologic toxicity of anticancer therapy, bedsores, malignant ulcers, sores due to nonmetastatic cancer, pruritus, and infections. Most of the information available about these entities has been acquired in the cancer patient without advanced disease. The little currently known about the epidemiology and physiopathology of such lesions in the advanced phase of cancer is presented, and approaches to management are suggested.

Long-term use of central venous catheters in paediatric oncology treatment

During a 26-month period, 158 central venous catheters were inserted in 114 children (median age: 4.5 years) with malignant diseases. Polyurethane catheters were used, inserted either using a cut-down procedure or percutaneously in the external or internal jugular vein. All catheters were tunnelled from the point of insertion to the midpoint of the manubrium or upper sternum. The catheter tip reached the superior caval vein or the right atrium in 94% of the cases. The catheters were used for all infusions, including total parenteral nutrition, and for blood sampling. The median catheter duration was 104 days (range 5-835 days). Sixty-eight (43%) of the catheters were removed as they were no longer needed, and 31 (20%) were removed due to local infection or septicaemia. During a total of 23,486 catheter days (64.4 years), 110 episodes of septicaemia occurred. This represents one episode per 214 catheter days. In 43 of the 110 episodes of septicaemia, blood cultures showed growth of bacteria of the kind usually found in the gastrointestinal and respiratory tracts. All septicaemias were treated with intravenous broad-spectrum antibiotics and in 21 cases the catheters were removed due to septicaemia. Thirty-four (22%) catheters were removed accidentally. There were two cases of subclavian vein thrombosis.

The role of infection in the morbidity and mortality of patients with head and neck cancer undergoing multimodality therapy

Cancer of the head and neck is a common cancer worldwide. The majority of patients present with locally advanced disease. Recently a great deal of improvement has been made in multimodality therapy of this disease, warranting more careful consideration of factors affecting quality of life, disease course, and treatment. Infection is clearly a factor. Analysis of 662 hospital admissions of 169 head and neck cancer patients was performed. A definite infection was documented in 86 febrile episodes, pneumonia contributed to 40%, bacteremia to 13%, skin and soft tissue infection to 12%, and tracheobronchitis to 10%. Among the evaluated risk factors, foreign bodies, specifically intravenous (IV) cannulae and gastrostomy tubes, race, performance status, alcohol intake, and nutritional status were statistically significant variables that predicted for or were associated with infection. Infection contributed to 44% of the deaths.

Age and sex relationships of superinfecting microorganisms in periodontitis patients

The occurrence by age and sex of subgingival enteric rods and pseudomonads, yeasts, and staphylococci was studied in 3075 "refractory" periodontitis patients referred for microbiological analysis. Each subject contributed a pooled subgingival sample obtained from 3 deep periodontal pockets with paper points. Selective and nonselective media and commercial identification kit systems were used for microbial isolation and speciation. Females constituted about 60% of the study subjects, and almost one-third of all patients were in their forties. Females (47.3%) showed a higher prevalence of the study organisms than males (43.9%). Older females (15.9%) and males (15.3%) revealed significantly higher prevalences of enteric rods and pseudomonads than younger individuals (10.9%), and older infected females yielded significantly higher viable counts than younger infected females. The sexes demonstrated a similar prevalence of staphylococci (about 28%), but younger infected females and males showed significantly higher viable counts than older infected individuals. No sex or age relationships were found for yeasts (about 14% of individuals infected). The high level of subgingival enteric rods and pseudomonads in some individuals may be important in the pathogenesis of geriatric and other forms of periodontitis and may have therapeutic implications.

Increased aminoglycoside dosage requirements in hematologic malignancy

Aminoglycoside pharmacokinetic parameters were studied prospectively in 27 patients with an underlying hematologic malignancy and fever associated with neutropenia and in 18 control patients. Pharmacokinetic parameters and dosages were determined by linear regression analysis of a one-compartment model by the method of Sawchuk et al. (R. J. Sawchuk, D. E. Zaske, R. J. Cippolle, W. A. Wargin, and R. G. Strate, Clin. Pharmacol. Ther. 21:362-369, 1976). Significant differences between the study and control groups were found for aminoglycoside volume of distribution (0.40 +/- 0.1 versus 0.27 +/- 0.05 liter/kg [mean +/- standard deviation], respectively; P less than 0.0001), clearance (116.6 +/- 48.9 versus 68.6 +/- 26.7 ml/min, respectively; P less than 0.0001), half-life (2.27 +/- 0.66 versus 3.5 +/- 1.8 h, respectively; P less than 0.0001), and elimination rate constant (0.33 +/- 0.11 versus 0.24 +/- 0.09 h-1, respectively; P less than 0.001). The percentage of bone marrow blast cells (at the time of diagnosis) in patients with acute leukemia significantly correlated with increased aminoglycoside clearance (R2 = 36.98%; P = 0.0001). Patients with stage IV lymphomas (Hodgkins disease and non-Hodgkins lymphoma) had a significantly increased clearance compared with patients with lower stages of lymphomas (105.1 +/- 18.5 versus 84.1 +/- 14.9 ml/min; P = 0.014). Fever, leukocyte count, or chemotherapy, among other clinical and laboratory parameters that were studied, had no significant correlation or effect on aminoglycoside disposition. The average dose of amikacin required to maintain peak concentrations in serum above 20 micrograms/ml in patients with a hematologic malignancy was 27.5 +/- 8.43 mg/kg per day. Pharmacokinetic parameters and dosages for the control patients were comparable to general literature standards. we conclude that the dosages recommended by the manufacturers or those derived from nomograms underestimate the aminoglycoside volume of distribution and clearance in patients with a hematologic malignancy and result in suboptimal peak aminoglycoside concentrations in serum. We recommend that in febrile neutropenic patients with an underlying hematologic malignancy, amikacin be initiated at 7.5 to 10 mg/kg per dose every 8 h (2 to 2.5 mg/kg per dose every 8 h for gentamicin) and adjusted within 24 h based on individual pharmacokinetic analysis.

In vitro effect of actinomycin D on human neutrophil function

The effect of actinomycin D (ACT-D) on human neutrophil chemotaxis, chemiluminescence (CL), superoxide (O2-) production, phagocytic uptake, and intracellular bacterial killing has been examined. The viability of the ACT-D-treated neutrophils was 98% even at a concentration of 10 micrograms/ml for 4 hr. Using fMLP as the chemotactic factor, depressed chemotaxis was demonstrated following ACT-D (1-10 micrograms/ml) pretreatment of neutrophils as compared with the non-treated controls. Similar ACT-D pretreatment produced the depressed responses in phorbol myristate acetate-induced CL and superoxide production by neutrophils. Moreover, using heat-inactivated human serum as an opsonin for Salmonella enteritidis (NCTC 6676), there was a significant difference in intracellular killing (P less than 0.01) but no difference in phagocytic uptake between ACT-D-treated and non-treated neutrophils. These studies indicate that ACT-D profoundly impairs both intracellular bacterial killing by human neutrophil through an effect on respiratory burst activity and directed cell migration of human neutrophils.

Stimulation of hematopoiesis and antibacterial resistance by interleukin-1

The beneficial effects of IL-1 and other cytokines on hematopoiesis and on resistance to infection are profound. IL-1 stimulates proliferation of bone marrow cells in normal mice and potentiates the recovery of peripheral blood neutrophils in mice with drug-induced neutropenia. Prophylactic cytokine administration provides an elevated level of natural resistance to infections which is correlated with increased numbers of phagocytic leukocytes. These studies suggest that IL-1 has potential clinical application as a therapy to limit bone marrow dysfunction and immunosuppression and to augment hematopoiesis and natural immunity. Further research will continue to elucidate the mechanisms whereby interleukins and colony-stimulating factors act, and interact, to promote restoration of leukocyte production and to enhance host resistance.

Prospective evaluation of a Candida antigen detection test for invasive candidiasis in immunocompromised adult patients with cancer

PURPOSE

Serologic tests to detect invasive candidiasis generally have been unreliable. We prospectively evaluated the clinical utility of a new, promising commercial latex particle agglutination test (i.e., Cand-Tec, Ramco Laboratories, Inc., Houston, Texas). This assay detects Candida antigens in serum.

PATIENTS AND METHODS

We examined the reliability of Cand-Tec to diagnose invasive candidiasis in 142 consecutive in-patients intensively treated with chemo-radiation therapy. Serum samples were collected at admission and then weekly, until the patients' death or hospital discharge. Evaluation for clinical utility was done using various reference titers. Twenty-nine patients had invasive candidiasis whereas 113 patients did not have documented invasive candidal infections.

RESULTS

At a titer of 1:8, the Cand-Tec test had sensitivity of 38%, specificity of 90%, positive predictive value of 50%, and negative predictive value of 85%. Weekly use of the Cand-Tec test did not improve early detection of invasive candidiasis, providing only a mean interval of 0.4 day from the first positive Cand-Tec result to a definitive diagnosis of invasive candidiasis by blood culture, tissue biopsy, or autopsy. In addition, surveillance cultures from the oropharynx or stool were not helpful in identifying those patients who would develop an invasive fungal infection.

CONCLUSION

In the context of current clinical management strategies for suspected fungal infection, the Candida antigen detection assay (Cand-Tec) is not a reliable method for diagnosis of deep candidiasis in neutropenic patients. Until better methods of early detection are available, patients at high risk for the development of invasive candidiasis should continue to receive empiric antifungal agent therapy.

Combination Antibiotic Treatment of Chemotherapy-Induced Neutropenia in Non-Leukemic Patients

The use of more aggressive chemotherapies in the treatment of patients with some tumors has caused a higher frequency of neutropenia and subsequent serious infections. To verify the role in these patients of a combination therapy of amikacin (300 mg/m2 i.v. every 12 hours) plus ceftazidime (2 g/m2 i.v. every 8 hours) adminsitered as initial empiric treatment, followed in non-responsive cases by a second-line therapy with clindamycin (300 mg/m2 i.v. every 8 hours), we conducted a prospective study in 45 febrile episodes (temperature ≥38.5 °C) in neutropenic patients (neutrophils ≤500/ml). The patients' median age was 58 (range, 19-80); 29 were women and 16 were men. The median performance status was 50 (range, 30-90), and 71 % of the patients had progressive tumoral disease. Before antibiotic therapy the median duration of fever was 12 hours (range, 4-48 hours). The median granulocyte count was 350/ml (range, 100-500 cells/ml), and the median peak temperature was 38.8 °C (range, 38.5-41 °C). The median time for neutrophils to rise towards 1000/ml was 4 days (range, 2-12), and the median duration of therapy was 8 days (range, 3-12). Documented bacterial infections were present in 28 patients whereas 17 had clinically possible infections or fever of unknown origin. The infection sites in microbiologically documented infections were: septicemia (12), multiple sites (4), tonsillitis (4), urinary tract (4), pneumonia (2) and fistula (2). Complete response to first-line therapy was obtained in 36 out of 45 episodes (80 %; 95 % confidence limits from 65 % to 90 %). Five out of 8 cases responded to second-line therapy with clindamycin for an overall recovery rate of 91 %. The amikacin-ceftazidime combination followed by clindamycin in non-responsive cases is effective, with moderate toxicity in non-leukemic febrile neutropenic patients.

Issues in symptom control. Part 4. Oral complications in patients with advanced cancer

Disturbances caused by lesions of the oral cavity play an important part in the alteration of the quality of life of cancer patients. The main complications affecting the oral cavity are infections (fungal, viral, bacterial), neutropenic ulcers, drug-induced stomatitis, dry mouth, and taste alteration. Most of the information available about these entities has been acquired in the cancer patient without advanced disease. The little knowledge about the epidemiology and physiopathology of such lesions in the advanced phase of cancer is presented, and approaches to management are suggested.

Enhancement of antibacterial resistance of neutropenic, bone marrow-suppressed mice by interleukin-1 alpha

The effect of recombinant human interleukin-1 alpha (IL-1) on the resistance of normal and bone marrow-suppressed mice against bacterial infection was evaluated. IL-1 induced neutrophilia and enhanced the resistance of normal mice against acute, systemic intraperitoneal infection with Klebsiella pneumoniae and methicillin-resistant Staphylococcus aureus. Mice with cyclophosphamide-induced bone marrow suppression were neutropenic and exhibited increased susceptibility to infection. Treatment of neutropenic C57BL/6 and C3H/HeJ mice with IL-1 before infection accelerated recovery of peripheral neutrophil counts and stimulated resistance against infection. Increases in neutrophils and enhancement of resistance induced by IL-1 were both dose and time dependent. Both neutrophilia and augmented resistance to infection were eliminated by a second dose of cyclophosphamide administered during the IL-1 treatments. Bone marrow-suppressed mice treated with IL-1 showed, at 4 h postinfection, greater increases in peripheral blood neutrophils and in numbers of peritoneal exudate neutrophils than suppressed mice treated with vehicle. The data suggest that the IL-1-stimulated recovery of myelopoiesis is an important factor in the enhancement of antibacterial resistance in bone marrow-suppressed, neutropenic mice. These findings indicate that IL-1 may be efficacious in limiting the duration of the neutropenia and of the increased risk for the development of bacterial infection associated with bone marrow suppression.

Invasive aspergillosis: clinical and pathological features of a new animal model

A new animal model of invasive aspergillosis is described in which female New Zealand White rabbits were immunosuppressed with corticosteroids and cyclophosphamide and were given an intratracheal inoculation of 4 x 10(4) conidia of Aspergillus fumigatus. Thirteen of 15 animals survived during a 10-day-period of observation. Most had clinical signs of a respiratory infection (dyspnoea) and at autopsy there was macroscopic and microscopic evidence of invasive pulmonary aspergillosis. Six control animals (infected but not immunosuppressed) showed no such signs. The extent of hyphal invasion was assessed histologically and quantified by calculating the number of colony forming units (c.f.u.) g-1 of tissue: in the experimental group the mean c.f.u. value for the lungs was 1.25 x 10(3) compared to 73.3 c.f.u. g-1 of lung for the control group (P = 0.003). The infection was also quantified by a whole lung chitin assay: in the experimental group the mean chitin content (expressed as a glucosamine equivalent) was 3.05 micrograms g-1 lung tissue compared to a 0.53 micrograms g-1 lung tissue for the control group (P = 0.01). We conclude that this model of invasive aspergillosis in rabbits reflects closely the pathological features of the disease in man and that it may prove useful for studies of the pathogenesis and the treatment of invasive aspergillosis.

Side effects of antibiotics on immune response parameters and their possible implications in antimicrobial chemotherapy

Antibiotics may influence immune response by quite different ways. By screening the multitude of publications on this subject, the aim of this overview was to arrive at a basic generalizing statement on the relationship between chemical structure or mode of action of antibiotics and the effect on immune response and to get an indication on whether certain in vitro and/or ex vivo parameters could represent comparable effects under clinical conditions. - The influence of antibiotics on immune response may arise by direct effects on immunocompetent cells, i.e. in the absence of microorganisms, or indirectly by changes in structure or metabolic products of germs induced by subminimal inhibitory concentrations (subMIC's). In the former case, stimulatory and inhibitory effects have been observed on phagocytosis and intracellular killing activity, on antibody production including IgE, on different parameters of cellular immunity (e.g. foodpad swelling reaction, MIF-production, mitogen/antigen induced lymphocyte proliferation and delayed type hypersensitivity skin reaction), on mediator production as interleukins or prostaglandins and the expression of corresponding receptors on immunocompetent cells as well as on the course of experimental infections with primary resistant microorganisms. - Indirect effects are related to the influence of subMIC's of antibiotics on the morphology and structure of microorganisms, on their antigenicity/immunogenicity or on their serosensitivity and enzyme and toxin production. - This overview shows that - according to the actual knowledge - antibiotics may exhibit immunological side effects which, however, can not strictly be attributed to certain chemical structures or to a certain mode of action. - It has to be considered that a literary study comparing the results of different authors is rendered difficult by the often nonhomogeneity of experimental procedures and the fact that little is known yet about immunological side effects of antibiotics in man, i.e. under clinical conditions.

Development of DNA probes for Candida albicans

An attempt was made to produce DNA probes that could be used as a rapid and efficient means of detecting candidiasis (invasive Candida infection) in immunocompromised patients. Whole DNA from Candida albicans was digested with restriction endonuclease, and the resulting fragments were randomly cloned into a plasmid vector. Several recombinant plasmids were evaluated for cross-hybridization to various other Candida species, other fungal DNAs, and to nonfungal DNAs. Cross reactions were observed between the probes and different yeasts, but none with unrelated DNAs. Some recombinants were genus-specific, and two of these were applied to the analysis of C. albicans growth curves. It became evident that, although both 32P- and biotin-labelled probes could be made quite sensitive, a possible limitation in their diagnostic potential was the poor liberation of Candida DNA from cells. Thus, better methods of treatment of clinical specimens will be required before such probes will be useful in routine diagnosis.

The relationship of oral Candida tropicalis infection to systemic candidiasis in a patient with leukemia

Oropharyngeal candidiasis is an extremely common complication in patients receiving chemotherapy for leukemia. Candida tropicalis appears to be the major infectious agent when these patients develop candidemia. In this article, a case of C tropicalis fungemia with oropharyngeal manifestations is presented. The relationship of oropharyngeal candidiasis to oral candidal infection is discussed.

A comparison of the effects of cisplatin and N-methyliminodiacetato-(1,2-diaminocyclohexane)-platinum(II) on renal function and gentamicin excretion in rats

N-methyliminodiacetato(1,2-diaminocyclohexane)-platinum(II) (MIDP) is a new third-generation water-soluble antitumor platinum complex. This study compares the effects of MIDP (3 injections of 25 mg/kg each on days 1, 5 and 9) on renal structure and function and the urinary excretion of gentamicin (GENT) with those of a single 6 mg/kg dose of cisplatin (DDP) in F-344 (Fischer) rats. GENT was given as a single dose of 30 mg/kg 7 days after DDP injection or the last MIDP injection. Rats given DDP and GENT had significantly different plasma urea nitrogen (BUN) levels (315 +/- 79 mg/dl) and creatinine clearance (0.40 +/- 0.24 ml/[min.kg]) than did the control group that was given only GENT (15 +/- 1 mg/dl and 5.5 +/- 0.6 ml/[min.kg]). MIDP did not affect renal function (BUN, 16 +/- 3 mg/dl; creatinine clearance, 6.1 +/- 1.0 ml/[min.kg]). Light microscopic examination of renal tissue from MIDP-treated rats did not reveal any evidence of cell degeneration or necrosis. Rats given GENT alone excreted 72 +/- 4% of the dose in 24 h and had plasma gentamicin levels of 19 +/- 2 ng/ml 24 h after injection. The group pretreated with DDP had lower urinary GENT excretion (31 +/- 10%) and higher plasma GENT levels (7491 +/- 3750 ng/ml). MIDP pretreatment had no effect on GENT excretion (72 +/- 8%) or plasma GENT levels (16 +/- 2 ng/ml). Thus, MIDP did not cause any measureable decrease in renal function or GENT excretion in our study. Since nephrotoxicity is a significant problem with DDP administration, further studies with MIDP are warranted.

Prevention of fungal sepsis in patients with prolonged neutropenia: a randomized, double-blind, placebo-controlled trial of intravenous miconazole

Patients treated with cytotoxic therapy expected to produce neutropenia lasting two or more weeks were randomly assigned in a double-blind study to receive intravenous miconazole or placebo concomitant with empiric antibiotics to test whether miconazole can prevent fungal sepsis. The study drug was initiated at the time of first fever along with antibiotics and was continued until neutropenia resolved, fungal sepsis occurred, or persistent or recurrent unexplained fever after six or more days prompted substitution of the study drug by amphotericin B. Two hundred eight treatment courses in 180 patients were evaluated. Fungal sepsis occurred in only one patient receiving miconazole compared with eight patients receiving placebo (p = 0.03). Fatal fungal sepsis occurred in four patients receiving placebo and in none of the patients receiving miconazole (p = 0.08). There was no evidence for the development of resistance to polyenes or imidazoles in fungal isolates recovered from patients in this randomized trial or an increase in Aspergillus infections in patients who received miconazole in this randomized trial or in 121 subsequently treated patients who received unblinded use of miconazole. Thus, intravenous miconazole was more effective than placebo in preventing fungal sepsis in patients with chemotherapy-induced prolonged neutropenia.

Antibacterial therapy in patients with malignancies

Patients with malignant disease may be predisposed to bacterial infections because of neoplastic disruption of normal tissue barriers, exogenous immunosuppressive therapy (drugs with or without radiation), and intrinsic host immune deficits secondary to these diseases. Diminished polymorphonuclear leukocyte numbers or function and impaired humoral immunity are highly correlated with the development of serious bacterial infections. The usual signs and symptoms of infection may be absent or altered in a compromised host. Therapy must be instituted promptly upon clinical suspicion of bacterial infection, and empirical choices should usually include combinations that are synergistic for likely pathogens based on knowledge of the local predominant flora and susceptibility data. Synergism has most often been demonstrated in combinations that utilize a beta-lactam (semisynthetic penicillin or cephalosporin) and an aminoglycoside. Triple drug therapy has not been shown to be advantageous. Monotherapy with third generation cephalosporins, carbapenems, monobactams, or ureidopenicillins has not been proven to offer advantages over 2-drug regimens for these patients. Patients with blood deficient in granulocytes (granulocytopenic) who respond to 2-drug therapy but remain deficient in neutrophils (neutropenic) may need continued treatment until the neutropenia subsides. Those who do not respond and remain febrile with an unclear focus of infection may need to be started on antifungal therapy in addition to the antibacterial agent. The use of oral agents for the prophylaxis of neutropenic patients against bacteremia remains controversial. If drugs are used, co-trimoxazole and nystatin suspension may be preferable.

Activity of phenothiazines against medically important yeasts

Two phenothiazine compounds, trifluoperazine and chlorpromazine, inhibited growth in vitro of the five most common pathogenic yeasts, with MICs ranging from 10 to 40 micrograms/ml. Daily intraperitoneal injections of trifluoperazine (4 to 7 mg/kg of body weight) increased the survival of mice experimentally infected with Candida albicans or Cryptococcus neoformans. The potential use of these drugs against fungal meningitis is discussed.

Massive hemolysis in Clostridium perfringens infections

Over a 14-month period at the Cleveland Clinic Foundation, 424 strains of Clostridium were isolated; of these, 52 strains were Clostridium perfringens isolated from 41 patients. Eight strains of C. perfringens were isolated from the blood of six patients; five of these patients had neoplastic disease and three developed massive intravascular hemolysis with rapidly developing shock and death. Clinical details are given on three patients with fatal Clostridium perfringens sepsis, and the nature of presentation and pathophysiologic mechanisms are discussed.

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.