Citrobacter freundii and fatal neutropenic enterocolitis following adjuvant chemotherapy for breast cancer

Detection and spread of carbapenem-resistant Citrobacter freundii in a teaching hospital in China

BACKGROUND

We examined the detection and spread of carbapenem-resistant Citrobacter freundii in Huashan Hospital, Shanghai, China between 2005 and 2008.

METHODS

Twenty-three isolates of carbapenem-resistant C freundii collected in our hospital underwent resistant gene amplification by polymerase chain reaction, followed by minimal inhibitory concentration (MIC) analysis. Molecular epidemiologic analyses included pulsed-field gel electrophoresis and case study.

RESULTS

Analysis of MICs with amikacin, gentamicin, cefotaxime, ceftazidime, cefepime, imipenem, meropenem, ertapenem, cefoxitin, piperacillin-tazobactam, and ciprofloxacin characterized the isolates as highly resistant to antimicrobials. Colistin, tigecycline, minocycline, and doxycycline to all C freundii isolates had lower MICs than the other antimicrobials tested, with MIC(50)/MIC(90) values of 0.5/1, 1/1, 4/8, and 4/4 mg/L, respectively. Molecular typing using pulsed-field gel electrophoresis classified the isolates into 4 groups, of which 15 isolates belonged to a single clone. In total, all of the isolates produced KPC-2-type carbapenemase, of which most were likely to couple with CTX-M-type extended-spectrum β-lactamases and plasmid-mediated CMY-2-type AmpC enzyme. Subsequent clinical investigations involving the general status of patients, the ward, and antimicrobial and therapeutic outcomes showed that a carbapenem-resistant clone had spread critically in the Department of Neurosurgery. Potential risk factors were identified, including invasive procedures, surgical operations, use of indwelling urine catheters, and number of sickbed changes.

CONCLUSION

The spread of carbapenem-hydrolyzing C freundii isolates has emerged in regional hospitals in China. Multidrug-resistant mechanisms of strains severely hamper control efforts. Our findings should alert clinicians to issues involved with preventing the spread of carbapenem-resistant C freundii.

Necrotizing enterocolitis in neutropenia and chemotherapy: a clinical update and old lessons relearned

Neutropenic enterocolitis (NE) must be recognized in patients with fever, neutropenia, and abdominal pain. Classically, NE has been described in patients with hematologic malignancies treated with intensive chemotherapy. Current interest in NE has increased due to recent cases associated with newer, more intensive chemotherapy in solid tumors. This review discusses pathology, clinical presentation, and treatment of NE. Ultrasonography or CT scans are the best radiographic studies to confirm the diagnosis. Management options, including antimicrobial therapy, surgery, and supportive care, are discussed. Chemotherapy incorporating the taxane family of drugs (paclitaxel and docetaxel) associated with NE is also reviewed with observations regarding the earlier onset of the disease in the first weeks following chemotherapy. Even with currently recommended therapy, a high mortality rate, approximating 45%, can occur. Best outcomes for NE rely upon understanding of risks for the condition, prompt empiric therapy with broad-spectrum antimicrobial agents, systemic antifungal therapy, and meticulous attention to supportive care.

Neutropenic enterocolitis in adults: systematic analysis of evidence quality

OBJECTIVE

Neutropenic enterocolitis is a life-threatening complication occurring most frequently after intensive chemotherapy in acute leukaemias. The literature is heterogeneous and a systematic review is lacking.

METHODS

Following a systematic search we categorised all relevant reports according to their quality and extracted evidence to answer the questions: Which diagnostic criteria are appropriate? What is the incidence of neutropenic enterocolitis? Are there good quality studies supporting specific interventions: Which empiric antimicrobial therapy is recommendable? Is neutropenic enterocolitis without surgical emergency complications an indication for bowel resection?

RESULTS

We found and analysed 145 articles of these reports: 64 were reports of single cases, 30 papers reported of two or three cases, 13 were narrative reviews, 34 were retrospective case series of more than three cases and four were prospective diagnostic studies. There were no prospective trials or case control studies on the therapy of neutropenic enterocolitis. There was no consensus on diagnostic criteria. We discuss the difficulty to define diagnostic criteria without having a disease definition. Histology is mostly not available in the living patients. We suggest applying a combination of clinical and radiological criteria: fever, abdominal pain and any bowel wall thickening >4 mm detected by ultrasonography (US) or computed tomography. We calculated a pooled incidence rate from 21 studies of 5.3% (266/5058; 95% CI: 4.7%-5.9%) in patients hospitalised for haematological malignancies, for high-dose chemotherapy in solid tumours or for aplastic anaemia.

CONCLUSIONS

This systematic review provides diagnostic criteria for neutropenic enterocolitis, presents a quantitative synthesis on its incidence and discusses its treatment recommendations. Prospective studies are clearly warranted.

Neutropenic enterocolitis in adults: case series and review of the literature

Necrotizing enterocolitis in adults is a rare disease and, in the past, has been associated with nearly uniform mortality. In recent years, necrotizing enterocolitis, now termed neutropenic enterocolitis, in adults has become more prevalent as a complication of aggressive systemic chemotherapy. In this report, we discuss two cases of neutropenic enterocolitis secondary to the administration of systemic chemotherapy in adult cancer patients: one with lung carcinoma, the other with leukemia. Both patients were successfully treated with early surgical intervention for resection of all necrotizing enteric lesions, and subsequent aggressive critical care support. Our experience suggests that early surgical intervention in adult patients with intestinal necrosis due to chemotherapy is essential to avoid mortality from this condition. Given the widespread, aggressive use of systemic chemotherapy in the neoadjuvant setting, patients at risk for this potentially lethal complication of neutropenic enterocolitis are increasingly common.

[Is there a place for interferon-alpha in the treatment strategy of multicentric Castleman's disease?]

INTRODUCTION

Castleman's disease is an unusual condition of unknown cause, consisting of massive proliferation of lymphoid tissue. Two forms (localized and multicentric) have been described. Interleukin-6 (IL-6) is at the core of the disease, being responsible for most of the clinical and biological signs that may be observed. Despite the benignancy of this pre-lymphoma condition, its course is usually aggressive and of poor prognosis in regard to the multicentric form. No consensus regarding treatment has been defined. Available data on the multicentric form of the disease are to scarce to allow any conclusion about the treatment timing and type of chemotherapy best suited to this condition. We report the case of a patient in whom interferon alpha (IFN-alpha) was used as first line treatment.

EXEGESIS

The case of a 52-year-old man with multicentric Castleman's disease combined with high IL-6, in whom, however, testing for human herpes virus-8 proved to be negative, is described. Interferon alpha (4.5 MU/m2 three times per week during 18 months) administered as first line treatment induced dramatic improvement in the patient's general condition and normalization of the tumoral syndrome. Moreover, biological parameters and IL-6 returned to normal. Two years after interferon disruption, complete remission is still present.

CONCLUSION

On the basis of the present data and those of two previous observations, anti-IL-6 and anti-infective properties of IFN-alpha are discussed. Treatment of multicentric Castleman's disease is based on corticosteroids and drugs derived from those pertaining to treatment of malignant lymphomas. Our results indicate that IFN-alpha is truly directed against Castleman's disease and has less toxicity than drugs usually prescribed. This argues for early use of IFN-alpha in Castleman's disease, in association or not with corticosteroids.