Bloodstream infections in patients with solid tumors

Prevalence and impact of multidrug-resistant bacteria in solid cancer patients with bloodstream infection: a 25-year trend analysis

The study aimed to describe the epidemiology of multidrug-resistant (MDR) bacteria among solid cancer (SC) patients with bloodstream infections (BSIs), evaluating inappropriate empiric antibiotic treatment (IEAT) use and mortality trends over a 25-year period. All BSI occurrences in adult SC patients at a university hospital were analyzed across five distinct five-year intervals. MDR bacteria were classified as extended-spectrum beta-lactamases (ESBL)-producing and/or Carbapenem-resistant Enterobacterales, non-fermenting Gram-negative bacilli (GNB) resistant to at least three antibiotic classes, methicillin-resistant Staphylococcus aureus (MRSA), and Vancomycin-resistant Enterococci. A multivariate regression model identified the risk factors for MDR BSI. Of 6,117 BSI episodes, Gram-negative bacilli (GNB) constituted 60.4% (3,695/6,117), being the most common are Escherichia coli with 26.8% (1,637/6,117), Klebsiella spp. with 12.4% (760/6,117), and Pseudomonas aeruginosa with 8.6% (525/6,117). MDR-GNB accounted for 644 episodes (84.8% of MDR or 644/759), predominantly ESBL-producing strains (71.1% or 540/759), which escalated significantly over time. IEAT was administered in 24.8% of episodes, mainly in MDR BSI, and was associated with higher mortality (22.9% vs. 14%, P < 0.001). Independent factors for MDR BSI were prior antibiotic use [odds ratio (OR) 2.93, confidence interval (CI) 2.34-3.67], BSI during antibiotic treatment (OR 1.46, CI 1.18-1.81), biliary (OR 1.84, CI 1.34-2.52) or urinary source (OR 1.86, CI 1.43-2.43), admission period (OR) 1.28, CI 1.18-1.38, and community-acquired infection (OR 0.57, CI 0.39-0.82). The study showed an increase in MDR-GNB among SC patients with BSI. A quarter received IEAT, which was linked to increased mortality. Improving risk assessment for MDR infections and the judicious prescription of empiric antibiotics are crucial for better outcomes.

IMPORTANCE

Multidrug-resistant (MDR) bacteria pose a global public health threat as they are more challenging to treat, and they are on the rise. Solid cancer patients are often immunocompromised due to their disease and cancer treatments, making them more susceptible to infections. Understanding the changes and trends in bloodstream infections in solid cancer patients is crucial, to help physicians make informed decisions about appropriate antibiotic therapies, manage infections in this vulnerable population, and prevent infection. Solid cancer patients often require intensive and prolonged treatments, including surgery, chemotherapy, and radiation therapy. Infections can complicate these treatments, leading to treatment delays, increased healthcare costs, and poorer patient outcomes. Investigating new strategies to combat MDR infections and researching novel antibiotics in these patients is of paramount importance to avoid these negative impacts.

Predictors and outcomes of multi-drug-resistant gram-negative bacteremia in patients with cancer: A retrospective cohort study at a tertiary cancer center in Oman

Objectives

This study aimed to delineate the characteristics and outcomes of gram-negative bacteremia (GNB) in oncology patients; analyze the risk factors for multi-drug-resistant (MDR) GNB; and assess its impact on the recurrence of bloodstream infection (BSI), hospital stay, and 30-day mortality.

Methods

Data, including demographics, clinical features, common cancers, and microbiologic findings, were collected retrospectively from electronic medical records of patients admitted with solid tumors and BSI episodes between January and December 2022. Fisher's exact tests were used to determine the effect of MDR-GNB on 30-day mortality and BSI recurrence. The Wilcoxon rank-sum test assessed the differences in the length of hospital stay. Logistic regression models identified the risk factors for MDR-GNB.

Results

Among 1074 patients, 77 episodes of GNB bacteremia occurred in 59 individuals (47% male, median age 57.4 years). Of these, 37 (48%) were MDR-GNB. Carbapenem resistance was noted in 9.1% of GNB episodes. Previous antibiotic use was significantly associated with MDR-GNB (odds ratio 7.82; 95% confidence interval 2.52-24). MDR-GNB was linked to longer hospital stays (median 23 vs 10.5 days, P = 0.003) and higher recurrence rates than non-MDR-GNB (35.13% vs 5.0%, P <0.001). However, 30-day mortality did not significantly differ between the groups (35.14% vs 32.5%, P = 0.81).

Conclusion

Previous antibiotic use predicted MDR-GNB in patients with solid tumor. MDR-GNB bacteremia increased the length of hospital stay and risk of recurrence compared with non-MDR-GNB bacteremia.

Docetaxel, cyclophosphamide, and epirubicin: application of PBPK modeling to gain new insights for drug-drug interactions

The new adjuvant chemotherapy of docetaxel, epirubicin, and cyclophosphamide has been recommended for treating breast cancer. It is necessary to investigate the potential drug-drug Interactions (DDIs) since they have a narrow therapeutic window in which slight differences in exposure might result in significant differences in treatment efficacy and tolerability. To guide clinical rational drug use, this study aimed to evaluate the DDI potentials of docetaxel, cyclophosphamide, and epirubicin in cancer patients using physiologically based pharmacokinetic (PBPK) models. The GastroPlus™ was used to develop the PBPK models, which were refined and validated with observed data. The established PBPK models accurately described the pharmacokinetics (PKs) of three drugs in cancer patients, and the predicted-to-observed ratios of all the PK parameters met the acceptance criterion. The PBPK model predicted no significant changes in plasma concentrations of these drugs during co-administration, which was consistent with the observed clinical phenomenon. Besides, the verified PBPK models were then used to predict the effect of other Cytochrome P450 3A4 (CYP3A4) inhibitors/inducers on these drug exposures. In the DDI simulation, strong CYP3A4 modulators changed the exposure of three drugs by 0.71-1.61 fold. Therefore, patients receiving these drugs in combination with strong CYP3A4 inhibitors should be monitored regularly to prevent adverse reactions. Furthermore, co-administration of docetaxel, cyclophosphamide, or epirubicin with strong CYP3A4 inducers should be avoided. In conclusion, the PBPK models can be used to further investigate the DDI potential of each drug and to develop dosage recommendations for concurrent usage by additional perpetrators or victims.

Multidrug Resistant Enteric Bacteria from Cancer Patients Admitted in Douala Laquintinie Hospital, Littoral Region of Cameroon

Patients with cancer have weakened immune systems, making them more vulnerable to infections. This study was carried out to determine the bacterial origins of enteric disorders in cancer patients and noncancer patients at the Oncology Department of Laquintinie Hospital in Douala. A cross-sectional study was conducted from October 2021 to March 2023. Stool samples from 307 cancer patients with enteric disorders and 200 noncancer patients with enteric disorders were examined to diagnose the presence of bacteria using various techniques. Among all participants in this study, 62.13% were female and 37.87% were male. The average age of the participants was 46.38 ± 15.81 years, with a minimum age of 10 years and a maximum age of 84 years. The average age of participants was significantly higher (p < 0.000) in cancer patients (49.54 ± 14.65 years) compared to noncancer patients (41.53 ± 16.33 years). Proteus mirabilis, Proteus vulgaris, Salmonella typhi, Enterobacter cloacae, Klebsiella pneumoniae, Yersinia intemedia, and Klebsiella oxytoca were more frequently isolated in cancer patients than in noncancer patients, with the respective percentages of 56.25% versus 43.75%, 50.00% versus 50.00%, 61.66% versus 38.34%, 66.66% versus 33.34%, 72.22% versus 27.78%, 80.00 versus 20.00%, and 100% versus 0.00%. Most isolates were sensitive to imipenem (IMP), gentamicin (GEN), and amikacin (AMK). Proteus vulgaris, the most prevalent isolate, showed significantly high resistance (with p < 0.05) in cancer patients compared to noncancer patients at amoxicillin/clavuranic acid (AMC) (89.13% versus 41.30%), ceftriaxone (CTR) (63.04% versus 39.13%), ciprofloxacin (CIP) (65.22% versus 34.18%), and tetracycline (TET) (93.48% versus 63.04%). Multidrug resistance was observed in cancer patients compared to noncancer patients for Klebsiella pneumoniae (85.00% versus 60.00%), Salmonella typhi (84.62% versus 60.00%), and Klebsiella oxytoca (86.49% versus 43.48%). The increase in the number of Gram-negative infections among cancer patients, as shown in the present study, highlights the need for broad-spectrum therapy and effective planning of control programs to reduce bacterial diseases among cancer patients.

The Etiology, Antibiotic Therapy and Outcomes of Bacteremic Skin and Soft-Tissue Infections in Onco-Hematological Patients

OBJECTIVES

to assess the current epidemiology, antibiotic therapy and outcomes of onco- hematological patients with bacteremic skin and soft-tissue infections (SSTIs), and to identify the risk factors for Gram-negative bacilli (GNB) infection and for early and overall mortality.

METHODS

episodes of bacteremic SSTIs occurring in cancer patients at two hospitals were prospectively recorded and retrospectively analyzed.

RESULTS

Of 164 episodes of bacteremic SSTIs, 53% occurred in patients with solid tumors and 47% with hematological malignancies. GNB represented 45.5% of all episodes, led by Pseudomonas aeruginosa (37.8%). Multidrug resistance rate was 16%. Inadequate empirical antibiotic therapy (IEAT) occurred in 17.7% of episodes, rising to 34.6% in those due to resistant bacteria. Independent risk factors for GNB infection were corticosteroid therapy and skin necrosis. Early and overall case-fatality rates were 12% and 21%, respectively. Risk factors for early mortality were older age, septic shock, and IEAT, and for overall mortality were older age, septic shock and resistant bacteria.

CONCLUSIONS

GNB bacteremic SSTI was common, particularly if corticosteroid therapy or skin necrosis. IEAT was frequent in resistant bacteria infections. Mortality occurred mainly in older patients with septic shock, resistant bacteria and IEAT. These results might guide empirical antibiotic therapy in this high-risk population.

Bloodstream Infection and Colorectal Cancer Risk in Queensland Australia, 2000-2019

BACKGROUND

Bloodstream infections may occur as a complication of colorectal cancer or be a marker for its occult presence. The objectives of this study were to quantify the overall and etiology-specific risks for incident colorectal cancer-associated bloodstream infection.

METHODS

Population-based surveillance for community-onset bloodstream infection was conducted among adults aged 20 years and older in Queensland, Australia between 2000 and 2019. Statewide databases were used to identify patients with incident colorectal cancer and collect clinical and outcome information.

RESULTS

After exclusion of 1794 patients with prior colorectal cancer, a cohort of 84,754 patients was assembled, of which 1030 had colorectal cancer-associated bloodstream infection and 83,724 had no colorectal cancer. Bloodstream infection was associated with a 16-fold annualized increased risk for diagnosis of colorectal cancer (incidence rate ratio 16.1; 95% confidence interval [CI], 15.1-17.1) in the adult population. Patients who had colorectal cancer-associated bloodstream infection were more likely to be older and male, have hospital-onset and polymicrobial infections, and have fewer non-cancer-related comorbidities. The organisms associated with highest risk for colorectal cancer included Clostridium species (relative risk [RR] 6.1; 95% CI, 4.7-7.9); especially C. septicum (RR 25.0; 95% CI, 16.9-35.7), Bacteroides species (RR 4.7; 95% CI, 3.8-5.8); especially B. ovatus (RR 11.8; 95% CI, 2.4-34.5), Gemella species (RR 6.5; 95% CI, 3.0-12.5), Streptococcus bovis group (RR 4.4; 95% CI, 2.7-6.8); especially S. infantarius subsp. coli (RR 10.6; 95% CI, 2.9-27.3), Streptococcus anginosus group (RR 1.9; 95% CI, 1.3-2.7), and Enterococcus species (RR 1.4; 95% CI, 1.1-1.8).

CONCLUSION

Although much attention has been afforded to S. bovis group over the past decades, there are many other isolates associated with higher risk for colorectal cancer-associated bloodstream infections.

Epidemiology and risk factors for recurrence in biliary source bloodstream infection episodes in oncological patients

We aimed to describe the characteristics and outcomes of biliary source bloodstream infections (BSIs) in oncological patients. Secondarily, we analyzed risk factors for recurrent BSI episodes. All episodes of biliary source BSIs in oncological patients were prospectively collected (2008-2019) and retrospectively analyzed. Logistic regression analyses were performed. A rule to stratify patients into risk groups for recurrent biliary source BSI was conducted. Four hundred biliary source BSIs were documented in 291 oncological patients. The most frequent causative agents were Escherichia coli (42%) and Klebsiella spp. (27%), and 86 (21.5%) episodes were caused by multidrug-resistant Gram-negative bacilli (MDR-GNB). The rates of MDR-GNB increased over time. Overall, 73 patients developed 118 recurrent BSI episodes. Independent risk factors for recurrent BSI episodes were prior antibiotic therapy (OR 3.781, 95% CI 1.906-7.503), biliary prosthesis (OR 2.232, 95% CI 1.157-4.305), prior admission due to suspected biliary source infection (OR 4.409, 95% CI 2.338-8.311), and BSI episode caused by an MDR-GNB (OR 2.857, 95% CI 1.389-5.874). With these variables, a score was generated that predicted recurrent biliary source BSI with an area under the receiver operating characteristic (ROC) curve of 0.819. Inappropriate empirical antibiotic treatment (IEAT) was administered in 23.8% of patients, and 30-d mortality was 19.5%. As a conclusion, biliary source BSI in oncological patients is mainly caused by GNB, with high and increasing MDR rates, frequent IEAT, and high mortality. Recurrent BSI episodes are frequent. A simple score to identify recurrent episodes was developed to potentially establish prophylactic strategies. IMPORTANCE This study shows that biliary source bloodstream infections (BSIs) in oncological patients are mainly caused by Gram-negative bacilli (GNB), with high and increasing rates of multidrug resistance. Importantly, recurrent biliary source BSI episodes were very frequent and associated with delays in chemotherapy, high rates of inappropriate empirical antibiotic therapy, and high 30-d mortality (19.5%). Using the variable independently associated with recurrent BSI episodes, a score was generated that predicted recurrent biliary source BSI with high accuracy. This score could be used to establish prophylactic strategies and lower the risk of relapsing episodes and the associated morbidity and mortality.

Clinical characteristics of bloodstream infections in adult patients with solid tumours and a nomogram for mortality prediction: a 5-year case-controlled retrospective study in a tertiary-level hospital

Background

Bloodstream infections (BSIs) are one of the leading causes of death in cancer patients. Nevertheless, the risk factors of BSIs in solid tumors have rarely been ascertained adequately.

Methods

We conducted a single-center case-controlled retrospective study from 2017 to 2021 among adults with solid tumors in a tertiary-level hospital. The BSIs and control group were matched by the propensity score matching method. We found independent risk factors of occurrence and death of BSIs using univariate and multivariate regression analysis. Additionally, a nomogram was constructed to predict the risk of mortality in BSIs.

Results

Of 602 patients with solid tumors in the study period, 186 had BSIs and 416 had non-BSIs. The incidence of BSIs was 2.0/1,000 admissions (206/102,704), and the 30-day mortality rate was 18.8% (35/186). Compared to the control group, the BSIs had longer hospital stays (24.5 days vs. 20.0 days), and higher frequency complicating with organ failure (10.5% vs. 2.4%), nephropathy (19.6% vs. 3.8%), comorbidities≥3 (35.5% vs. 20.0%), and liver-biliary-pancreatic infections (15.6% vs. 5.3%) (all P<0.001). Among the 186 patients with BSIs, 35 died within 30 days after BSIs. Gram-negative bacteria were the most frequent microorganisms (124/192, 64.6%). Liver cancer, organ failure, a high level of lactate dehydrogenase and septic shock were the independent hazardous factors for death of BSIs. What's more, a nomogram was constructed to predict the 30-day survival rate of BSIs, which was proved to have good accuracy (AUC: 0.854; 95% confidence interval: 0.785~0923) and consistency.

Conclusion

Being aware of the risk factors of BSIs redounds to take preventive measures to reduce the incidence and death of BSIs.

A clinically applicable prediction model for the risk of in-hospital mortality in solid cancer patients admitted to intensive care units with sepsis

PURPOSE

To develop and validate a user-friendly model to predict the risk of in-hospital mortality in solid cancer patients admitted to the ICU with sepsis.

METHODS

Clinical data of critically ill patients with solid cancer and sepsis were obtained from Medical Information Mart for Intensive Care-IV database and randomly assigned to the training cohort and validation cohort. The primary outcome was in-hospital mortality. The least absolute shrinkage and selection operator (LASSO) regression and logistic regression analysis were used to feature selection and model development. The performance of the model was validated and a dynamic nomogram was developed to visualize the model.

RESULTS

A total of 1584 patients were included in this study, of whom 1108 were assigned to the training cohort and 476 to the validation cohort. The LASSO regression and logistic multivariable analysis showed that nine clinical features were associated with in-hospital mortality and enrolled in the model. The area under the curve of the model was 0.809 (95% CI 0.782-0.837) in the training cohort and 0.770 (95% CI 0.722-0.819) in the validation cohort. The model exhibited satisfactory calibration curves and Brier scores in the training set and validation set were 0.149 and 0.152, respectively. The decision curve analysis and clinical impact curve of the model presented good clinical practicability in both the two cohorts.

CONCLUSION

This predictive model could be used to assess the in-hospital mortality of solid cancer patients with sepsis in the ICU, and a dynamic online nomogram could facilitate the sharing of the model.

Establishment of a risk classifier to predict the in-hospital death risk of nosocomial fungal infections in cancer patients

BACKGROUND

Patients with malignancy are at a higher risk of developing nosocomial infections. However, limited studies investigated the clinical features and prognostic factors of nosocomial infections due to fungi in cancer patients. Herein, this study aims to investigate the clinical characteristics of in-hospital fungal infections and develop a nomogram to predict the risk of in-hospital death during fungal infection of hospitalized cancer patients.

METHODS

This retrospective observational study enrolled cancer patients who experienced in-hospital fungal infections between September 2013 and September 2021. Univariate and multivariate logistic regression analyses were performed to identify independent predictors of in-hospital mortality. Variables demonstrating significant statistical differences in the multivariate analysis were utilized to construct a nomogram for personalized prediction of in-hospital death risk associated with nosocomial fungal infections. The predictive performance of the nomogram was evaluated using receiver operating characteristic (ROC) curves, calibration curves, and decision curve analysis.

RESULTS

A total of 216 participants were included in the study, of which 57 experienced in-hospital death. C.albicans was identified as the most prevalent fungal species (68.0%). Respiratory infection accounted for the highest proportion of fungal infections (59.0%), followed by intra-abdominal infection (8.8%). The multivariate regression analysis revealed that Eastern Cooperative Oncology Group Performance Status (ECOG-PS) 3-4 (odds ratio [OR] = 6.08, 95% confidence interval [CI]: 2.04-18.12), pulmonary metastases (OR = 2.76, 95%CI: 1.11-6.85), thrombocytopenia (OR = 2.58, 95%CI: 1.21-5.47), hypoalbuminemia (OR = 2.44, 95%CI: 1.22-4.90), and mechanical ventilation (OR = 2.64, 95%CI: 1.03-6.73) were independent risk factors of in-hospital death. A nomogram based on the identified risk factors was developed to predict the individual probability of in-hospital mortality. The nomogram demonstrated satisfactory performance in terms of classification ability (area under the curve [AUC]: 0.759), calibration ability, and net clinical benefit.

CONCLUSIONS

Fungi-related nosocomial infections are prevalent among cancer patients and are associated with poor prognosis. The constructed nomogram provides an invaluable tool for oncologists, enabling them to make timely and informed clinical decisions that offer substantial net clinical benefit to patients.

Effectiveness of Disinfecting Caps for Intravenous Access Points in Reducing Central Line-Associated Bloodstream Infections, Clinical Utilization, and Cost of Care During COVID-19

Purpose

Intravenous (IV) access point protectors, serving as passive disinfection devices and a cover between line accesses, are available to help reduce the risk of central line-associated bloodstream infections (CLABSIs). This low-maintenance disinfection solution is particularly valuable in situations with excessive workloads. This study examined the effect of a disinfecting cap for an IV access point on CLABSI rates, hospital length of stay, and cost of care in an inpatient setting during the coronavirus disease 2019 (COVID-19) pandemic.

Methods

The study utilized data from the Premier Healthcare Database, focusing on 200,411 hospitalizations involving central venous catheters between January 2020 and September 2020. Among these cases, 7423 patients received a disinfecting cap, while 192,988 patients did not use any disinfecting caps and followed the standard practice of hub scrubbing. The two cohorts, Disinfecting Cap and No-Disinfecting Cap groups, were compared in terms of CLABSI rates, hospital length of stay (LOS), and hospitalization costs. The analysis accounted for baseline group differences and random clustering effects by employing a 34-variable propensity score and mixed-effect multiple regression, respectively.

Results

The findings demonstrated a significant 73% decrease in CLABSI rates (p= 0.0013) in the Disinfecting Cap group, with an adjusted CLABSI rate of 0.3% compared to 1.1% in the No-Disinfecting Cap group. Additionally, the Disinfecting Cap group exhibited a 0.5-day reduction in hospital stay (9.2 days versus 9.7 days; p = 0.0169) and cost savings of $6703 ($35,604 versus $42,307; p = 0.0063) per hospital stay compared to the No-Disinfecting Cap group.

Conclusion

This study provides real-world evidence that implementing a disinfecting cap to protect IV access points effectively reduces the risk of CLABSIs in hospitalized patients compared to standard care, ultimately optimizing the utilization of healthcare resources, particularly in situations where the healthcare system is under significant strain or overloaded.

A novel risk classifier to predict the in-hospital death risk of nosocomial infections in elderly cancer patients

Background

Elderly cancer patients are more predisposed to developing nosocomial infections during anti-neoplastic treatment, and are associated with a bleaker prognosis. This study aimed to develop a novel risk classifier to predict the in-hospital death risk of nosocomial infections in this population.

Methods

Retrospective clinical data were collected from a National Cancer Regional Center in Northwest China. The Least Absolute Shrinkage and Selection Operator (LASSO) algorithm was utilized to filter the optimal variables for model development and avoid model overfitting. Logistic regression analysis was performed to identify the independent predictors of the in-hospital death risk. A nomogram was then developed to predict the in-hospital death risk of each participant. The performance of the nomogram was evaluated using receiver operating characteristics (ROC) curve, calibration curve, and decision curve analysis (DCA).

Results

A total of 569 elderly cancer patients were included in this study, and the estimated in-hospital mortality rate was 13.9%. The results of multivariate logistic regression analysis showed that ECOG-PS (odds ratio [OR]: 4.41, 95% confidence interval [CI]: 1.95-9.99), surgery type (OR: 0.18, 95%CI: 0.04-0.85), septic shock (OR: 5.92, 95%CI: 2.43-14.44), length of antibiotics treatment (OR: 0.21, 95%CI: 0.09-0.50), and prognostic nutritional index (PNI) (OR: 0.14, 95%CI: 0.06-0.33) were independent predictors of the in-hospital death risk of nosocomial infections in elderly cancer patients. A nomogram was then constructed to achieve personalized in-hospital death risk prediction. ROC curves yield excellent discrimination ability in the training (area under the curve [AUC]=0.882) and validation (AUC=0.825) cohorts. Additionally, the nomogram showed good calibration ability and net clinical benefit in both cohorts.

Conclusion

Nosocomial infections are a common and potentially fatal complication in elderly cancer patients. Clinical characteristics and infection types can vary among different age groups. The risk classifier developed in this study could accurately predict the in-hospital death risk for these patients, providing an important tool for personalized risk assessment and clinical decision-making.

Identification of Microbial Species and Analysis of Antimicrobial Resistance Patterns in Acute Cholangitis Patients with Malignant and Benign Biliary Obstructions: A Comparative Study

Background and Objectives: Acute cholangitis (AC) is still lethal if not treated promptly and effectively. Biliary drainage, also known as source control, has been acknowledged as the backbone treatment for patients with AC; nonetheless, antimicrobial therapy allows these patients to undergo non-emergent drainage procedures. This retrospective study aims to observe the bacterial species involved in AC and analyze the antimicrobial resistance patterns. Materials and Methods: Data were collected for four years, comparing patients with benign and malignant bile duct obstruction as an etiology for AC. A total of 262 patients were included in the study, with 124 cases of malignant obstruction and 138 cases of benign obstruction. Results: Positive bile culture was obtained in 192 (73.3%) patients with AC, with a higher rate among the benign group compared with malignant etiologies (55.7%.vs 44.3%). There was no significant difference between the Tokyo severity scores in the two study groups, identifying 34.7% cases of malignant obstruction with Tokyo Grade 1 (TG1) and 43.5% cases of TG1 among patients with benign obstruction. Similarly, there were no significant differences between the number of bacteria types identified in bile, most of them being monobacterial infections (19% in the TG1 group, 17% in the TG2 group, and 10% in the TG3 group). The most commonly identified microorganism in blood and bile cultures among both study groups was E. coli (46.7%), followed by Klebsiella spp. (36.0%) and Pseudomonas spp. (8.0%). Regarding antimicrobial resistance, it was observed that significantly more patients with malignant bile duct obstruction had a higher percentage of bacterial resistance for cefepime (33.3% vs. 11.7%, p-value = 0.0003), ceftazidime (36.5% vs. 14.5%, p-value = 0.0006), meropenem (15.4% vs. 3.6%, p-value = 0.0047), and imipenem (20.2% vs. 2.6%, p-value < 0.0001). Conclusions: The positive rate of biliary cultures is higher among patients with benign biliary obstruction, while the malignant etiology correlates with increased resistance to cefepime, ceftazidime, meropenem, and imipenem.

Increased incidence rates of positive blood cultures shortly after chemotherapy compared to radiotherapy among individuals treated for solid malignant tumours

BACKGROUND

Cancer treatments suppress immune function and are associated with increased risk of infections, but the overall burden of serious infectious diseases in treated patients has not been clearly elucidated.

METHODS

All patients treated for solid malignant tumours with radiotherapy (RT) and/or standard first-line chemotherapy (C) at the Department of Oncology at Rigshospitalet between 01/1/2010 and 31/12/2016 were included. Patients were followed from treatment initiation until the first of new cancer treatment, 1 year after treatment initiation, end of follow-up or death. Incidence rates (IR) of positive blood culture (PBC) per 1000 person-years follow-up (PYFU) were calculated.

FINDINGS

12,433 individuals were included, 3582 (29%), 6349 (51%), and 2502 (20%) treated with RT, C, or both RT & C, respectively, contributing 8182 PYFU. 429 (3%) individuals experienced 502 unique episodes of PBC, incidence rate (95% CI) 52.43 (47.7, 57.6) per 1000 PYFU. The 30-day mortality rate after PBC was 24% independent of treatment modality. Adjusted incidence rate ratios in the first 3 months (95% CI) after PBC significantly varied by treatment: 2.89 (1.83, 4.55) and 2.52 (1.53, 4.14) for C and RT & C compared to RT. Escherichia coli (n = 127, 25%) was the top microorganism identified.

INTERPRETATION

PBCs are not common, but when they occur, mortality is high.

Comparative Effectiveness of 2 Chlorhexidine Gluconate-Containing Dressings in Reducing Central Line-Associated Bloodstream Infections, Hospital Stay, and Costs

Chlorhexidine gluconate (CHG)-containing dressings are recommended to prevent central line associated bloodstream infections (CLABSIs) and other catheter-related infections. This study compared the effect of 2 CHG dressings on CLABSI, cost of care, and contact dermatitis. A retrospective analysis was conducted using the Premier Healthcare Database of hospitalized patients (n = 53 149) with central venous catheters (CVCs) and receiving either a transparent CHG gel dressing (n = 14 488) or an opaque CHG sponge dressing (n = 38 661) between January 2019 and September 2020. Two cohorts (n = 14 488 each), CHG-Gel and CHG-Sponge, were matched 1:1 using a propensity score method on 33 patient and facility characteristics. CLABSI and contact dermatitis rates, hospital length of stay (LOS), and hospitalization costs were compared using mixed-effect multiple regression. This approach effectively controlled for random clustering effects across hospitals and patients' Diagnosis-Related Group (DRG) classifications. CHG gel dressings were associated with a 41% decrease in CLABSI rates (P = .0008) compared to CHG sponge dressings (0.35%vs 0.60%). A 0.4-day shorter LOS (9.53vs 9.90 days, P = .0001) and a cost saving of $3576 per hospital stay ($40 197 vs $43 774, P = .0179) was observed with CHG gel dressing use. There was no statistically significant difference in contact dermatitis rates (P = .7854) between the CHG-Gel and CHG-Sponge cohorts. The findings of this study suggest that the use of CHG gel dressings may be more effective in reducing the risk of CLABSIs and associated clinical costs compared to CHG sponge dressings in hospitalized patients. Moreover, there appears to be no significant discrepancy in contact dermatitis rates between CHG gel and CHG sponge dressings. Healthcare providers may consider using CHG gel dressings as a standard practice for patients with CVCs to reduce the risk of infections and improve patient outcomes.

Risk of Bacterial, Viral, and Fungal Infections in Patients With Solid Malignant Tumors Treated With Curative Intent Radiation Therapy

Purpose

The incidence, etiology, and association of infections with radiation therapy (RT)-induced lymphopenia in patients with solid tumors is not well elucidated.

Methods and Materials

We identified possible, probable, and definite infections caused by bacteria, fungi, and viruses, combining data on medication, microbiology, and diagnoses. Definite infections had either a diagnosis or a positive microbiological isolation. We analyzed the incidence and adjusted incidence-rate ratio of infections in the year after the start of RT among patients who received RT plus chemotherapy and RT monotherapy, by type of infection and according to the degree of RT-induced lymphopenia.

Results

A total of 4450 of 6334 (70.3%) patients experienced 11264 infections overall; 1424 (22.5%) patients developed 2104 definite infections in the first year after RT. Infections were more frequent among patients who received RT plus chemotherapy (2590 of 3469; incidence: 16.5 [95% confidence interval {CI}, 16.1-17.0], per 100 patient-years) compared with patients who received RT monotherapy (1860 of 2865; incidence: 12.7 [95% CI, 12.3-13.2]). The incidence of infection was highest in the first 3 months overall (28.2 vs 18.0 in patients who received RT plus chemotherapy compared with those who received RT monotherapy) and for definite infections (4.7 vs 3.8). The proportion of specific bacterial infections were similar among patients who received RT plus chemotherapy versus those who received RT monotherapy. Urinary tract infections were the most frequent (51.2% vs 56.2%), followed by pneumonias (24.1% vs 22.4%). Viral and fungal infections were more frequent among patients who received RT plus chemotherapy, but they were uncommon. In multivariable analyses, patients who received RT plus chemotherapy with a lymphopenia grade of 1-2 or ≥3 versus no lymphopenia at end of RT had an increased risk of bacterial infections 0 to 3 months after RT (incidence rate ratio, 1.45 [95% CI, 1.06-1.97] and 1.71 [95% CI, 1.26-2.34], respectively). Limiting to definite bacterial infections, the incidence rate ratio for lymphopenia grade ≥3 versus no lymphopenia was 2.66 (95% CI, 1.40-5.03).

Conclusions

The incidence of bacterial infections 0 to 3 months after RT plus chemotherapy for solid tumors was high, especially among patients with RT-induced lymphopenia grade 1-2 and ≥3.

Clinical and microbiological features of intratumor abscess with bloodstream infection caused by Plesiomonas shigelloides, Citrobacter freundii, Streptococcus mitis/oralis, Clostridium perfringens, and Candida albicans in a patient with cholangiocarcinoma: A case report

Plesiomonas shigelloides is a gram-negative facultative anaerobic bacillus, usually found in soil and freshwater, which causes self-limited diarrhea, although reports of bacteremia are rare. Here, we report the first case of an intratumoral abscess with mixed bacteremia caused by P. shigelloides, Citrobacter freundii, Streptococcus mitis/oralis, Clostridium perfringens, and Candida albicans in a patient with recurrent postoperative cholangiocarcinoma. A 77-year-old man with hilar cholangiocarcinoma and hypertension was admitted to our hospital with fever and abdominal pain. He had visited Vietnam for 3 years, 20 years ago. Abdominal computed tomography showed air within the recurrent tumor at the left liver lobectomy resection margin site, which was diagnosed as an intratumor abscess perforating the intestinal tract. P. shigelloides, C. freundii, S. mitis/oralis, C. perfringens, and C. albicans were isolated in blood culture. P. shigelloides was identified using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF-MS) and 16S ribosomal RNA (16S rRNA) sequencing. Piperacillin-tazobactam was administered for almost a week, ampicillin-sulbactam and levofloxacin for almost 3 weeks, and antifungal agents for almost 2 weeks, and the patient was discharged thereafter. Although bloodstream infections caused by P. shigelloides in patients with cancer are extremely rare, long-term colonization and the potential for future intra-abdominal infections were implicated.

Clinical and Epidemiological Characteristics of Bloodstream Infections in Head and Neck Cancer Patients: A Decadal Observational Study

This retrospective study aims to describe the clinico-epidemiological characteristics of bloodstream infections (BSIs) and the risk factors in patients with head and neck cancer (n = 227) treated at the Department of Otolaryngology, Head and Neck Surgery, Tohoku University Hospital between April 2011 and March 2021. Overall, 23.3% of blood cultures were positive. In the culture-positive group, catheter-related bloodstream infections (CRBSIs) were the most common (38.8%), followed by respiratory tract infections (19.4%), and catheter-associated urinary tract infections (6.0%). Methicillin-resistant Staphylococcus aureus (26.9%), Staphylococcus epidermidis (17.9%), and Pseudomonas aeruginosa (10.4%) infections were common. The most frequent treatment for head and neck cancer was surgery (23.9%), followed by treatment interval or palliative care (19.4%), and single radiotherapy (13.4%). The 30-day mortality rate was significantly higher in the BSI than in the non-BSI group (10.4% vs. 1.8%, respectively). CRBSIs are the most frequent source of BSIs in patients with head and neck cancer. In conclusion, central venous catheters or port insertion should be used for a short period to prevent CRBSIs. The risk of developing BSI should be considered in patients with pneumonia. Understanding the epidemiology of BSIs is crucial for diagnosing, preventing, and controlling infections in patients with head and neck cancer.

Relation of Malnutrition and Nosocomical Infections in Cancer Patients in Hospital: An Observational Study

Aim

To investigate the relation between malnutrition and nosocomial infections (NI) in hospitalized cancer patients.

Methods

This observational, cross-sectional, noninterventional, descriptive study was conducted in a 500-bed university hospital in Valencia (Spain). Adult cancer patients admitted to the oncology ward were consecutively enrolled regardless of their nutritional status between November 2019 and March 2020. Patients were nutritionally assessed 24 to 48 hours after admission. Body weight, height and BMI, body composition through measurement of bioelectrical impedance analysis (BIA), and muscle strength and functionality using hand grip strength (HGS) were prospectively collected. The diagnosis of malnutrition and sarcopenia was assessed using the Global Leadership Initiative on Malnutrition (GLIM) criteria and the European Working Group on Sarcopenia in Older People (EWGSOP) criteria, respectively. Patients were followed up during their hospital stay or outpatient oncology visits to identify possible NI.

Results

A total of 107 patients were included in this study (mean age 66 years; 66.4% were men). The most frequent reason for admission was cancer treatment (19.6%), followed by infections (18.7%) and digestive tract symptoms (18.7%). Overall, 77.5% (83/107) of the patients were malnourished at admission according to the GLIM criteria, while 52.3% (56/107) were sarcopenic. Nosocomial infections (NI) were significantly more frequent in malnourished (52.1%; 25/48) and severely malnourished (42.1%; 8/19) patients, compared with well-nourished patients without malnutrition (25%; 10/40; p=0.035). The mean length of hospital stay was 13.9 days, significantly longer in patients with an NI compared to those without infections (18.6 vs. 10.8 days, p < 0.024).

Conclusion

This study evidenced the need to implement a routine protocol for the nutritional assessment and support of cancer patients at risk of malnutrition and sarcopenia to reduce the risk of NI during their hospital stay.

Adaptation of Bacteria to Antineoplastic Agents Involves Persister Cells and Increases Resistance to Antibiotics

The increasing number of life-threatening infections observed in cancer patients has been ascribed to chemotherapy-induced neutropenia and to invasive medical procedures such as surgery and the application of catheters. In this study, it was questioned if the infections could also be favored by an increased resistance of bacteria due to the adaptation to antineoplastic agents used in chemotherapy. After exposure to several antineoplastic agents, it was observed that cells of Staphylococcus aureus, Mycobacterium vaccae, Pseudomonas aeruginosa, and Escherichia coli changed the fatty acid profile of their cellular membranes, produced exopolymeric substances, and formed aggregates that adhered to surfaces. Additionally, when exposed to high concentrations of these compounds, a persister sub-population could be identified. After adaptation to antineoplastic agents, the minimum inhibitory concentration (MIC) of several antibiotics increased considerably in the tested strains.

A novel prognostic model for malignant patients with Gram-negative bacteremia based on real-world research

Gram-negative bacteremia (GNB) is a common complication in malignant patients. Identifying risk factors and developing a prognostic model for GNB might improve the survival rate. In this observational and real-world study, we retrospectively analyzed the risk factors and outcomes of GNB in malignant patients. Multivariable regression was used to identify risk factors for the incidence of GNB, while Cox regression analysis was performed to identify significant prognostic factors. A prognostic model was constructed based on Cox regression analysis and presented on a nomogram. ROC curves, calibration plots, and Kaplan–Meier analysis were used to estimate the model. It comprised 1004 malignant patients with Bloodstream infection (BSI) in the study cohort, 65.7% (N = 660) acquired GNB. Multivariate analysis showed gynecologic cancer, hepatobiliary cancer, and genitourinary cancer were independent risk factors related to the incidence of GNB. Cox regression analysis raised that shock, admission to ICU before infection, pulmonary infection, higher lymphocyte counts, and lower platelet counts were independent risk factors for overall survival (OS). The OS was significantly different between the two groups classified by optimal cut-off value (log-rank, p < 0.001). Above all, a nomogram was created based on the prognostic model, which was presented on a website freely. This real-world study was concentrated on the malignant patients with GNB and proved that shock, admission to ICU before infection, pulmonary infection, higher lymphocyte counts, and lower platelet counts were related to the death of these patients. And a prognostic model was constructed to estimate the risk score of mortality, further to reduce the risk of death.

30-day postoperative sepsis risk factors following laminectomy for intradural extramedullary tumors

BACKGROUND

Posterior laminectomy (LA) for resection of intradural extramedullary tumors (IDEMTs) is associated with postoperative complications, including sepsis. Sepsis is an uncommon but serious complication that can lead to increased morbidity and mortality, prolonged hospital stays, and greater costs. Given the susceptibility of a solid tumor patients to sepsis-related complications, it is important to recognize IDEMT patients as a unique population when assessing the risk factors for sepsis after laminectomy.

METHODS

The study design was a retrospective cohort study. Adult patients undergoing LA for IDEMTs from 2012 to 2018 were identified in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. Baseline patient characteristics/comorbidities, operative and hospital variables, and 30-day postoperative complications were collected.

RESULTS

Of 2,027 total patients undergoing LA for IDEMTs, 38 (2%) had postoperative sepsis. On bivariate analysis sepsis was associated with superficial surgical site infection [odds ratio (OR) 11.62, P<0.001], deep surgical site infection (OR 10.67, P<0.001), deep vein thrombosis (OR 10.75, P<0.001), pulmonary embolism (OR 15.27, P<0.001), transfusion (OR 6.18, P<0.001), length of stay greater than five days (OR 5.41, P<0.001), and return to the operating room within thirty days (OR 8.72, P<0.001). Subsequent multivariate analysis identified the following independent risk factors for sepsis and septic shock: operative time ≥50th percentile (OR 2.11, P=0.032), higher anesthesia class (OR 1.76, P=0.046), dependent functional status (OR 2.23, P=0.001), diabetes (OR 2.31, P=0.037), and chronic obstructive pulmonary disease (OR 3.56, P=0.037).

CONCLUSIONS

These findings can help spine surgeons identify high-risk patients and proactively deploy measures to avoid this potentially devastating complication in individuals who may be more vulnerable than the general elective spine population.

Establishment of a Risk Prediction Model for Pulmonary Infection in Patients with Advanced Cancer

Objective

Based on clinical data, the risk prediction model of pulmonary infection in patients with advanced cancer was established to predict the risk of pulmonary infection in patients with advanced cancer, and intervention measures were given in advance.

Methods

The clinical data of 2755 patients were divided into infection group and control group according to whether they were complicated with lung infection. 1609 patients' data from January 2016 to December 2018 served as the training set, and 1166 patients' data from January 2019 to December 2020 served as the testing set. Demographics, whether the primary cancer was lung cancer, lung metastasis, the pathological classification of lung cancer patients, the number of metastases, history of surgery, history of chemotherapy, history of radiotherapy, history of central venous catheterization, history of hypertension, diabetes, and whether with myelosuppression were recorded. The presence of concurrent pulmonary infection was recorded and defined as the primary outcome variable. Stepwise forward algorithms were applied to informative predictors based on Akaike's information criterion. Multivariable logistic regression analysis was used to develop the nomogram. An independent testing dataset was used to validate the nomogram. Receiver-operating characteristic curves and the Hosmer-Lemeshow test were used to assess model performance.

Results

The sample included 2755 patients with advanced cancer. An independently validated dataset included 1166 patients with advanced cancer. In the training dataset, gender, age, lung cancer as primary cancer, the pathological classification of lung cancer patients, history of chemotherapy, history of radiation therapy, history of surgery, the number of metastases, presence of central venous catheterization, and myelosuppression were identified as predictors and assembled into the nomogram. The area under curve demonstrated adequate discrimination in the validation dataset (0.77; 95% confidence interval, 0.74 to 0.79). The nomogram was well calibrated, with a Hosmer-Lemeshow χ 2 statistic of 12.4 (P = 0.26) in the testing dataset.

Conclusions

The present study has proposed an effective nomogram with potential application in facilitating the individualized prediction of risk of pulmonary infection in patients with advanced cancer.

Systemic immune dysfunction in cancer patients driven by IL6 induction of LAG3 in peripheral CD8+ T cells

Many cancer patients do not develop a durable response to the current standard of care immunotherapies, despite substantial advances in targeting immune inhibitory receptors. A potential compounding issue, which may serve as an unappreciated, dominant resistance mechanism, is an inherent systemic immune dysfunction that is often associated with advanced cancer. Minimal response to inhibitory receptor (IR) blockade therapy and increased disease burden have been associated with peripheral CD8+ T-cell dysfunction, characterized by suboptimal T-cell proliferation and chronic expression of IRs (eg. Programmed Death 1 [PD1] and Lymphocyte Activation Gene 3 [LAG3]). Here, we demonstrated that approximately a third of cancer patients analyzed in this study have peripheral CD8+ T cells that expressed robust intracellular LAG3 (LAG3IC), but not surface LAG3 (LAG3SUR) due to A Disintegrin and Metalloproteinase domain-containing protein 10 (ADAM10) cleavage. This associated with poor disease prognosis and decreased CD8+ T-cell function, which could be partially reversed by anti-LAG3. Systemic immune dysfunction was restricted to CD8+ T cells, including, in some cases, a high percentage of peripheral naïve CD8+ T cells, and was driven by the cytokine IL6 via STAT3. These data suggest that additional studies are warrented to determine if the combination of increased LAG3IC in peripheral CD8+ T cells and elevated systemic IL6 can serve as predictive biomarkers and identify which cancer patients may benefit from LAG3 blockade.

Microbial spectrum and drug resistance profile in solid malignancies in a large tertiary hospital from Palestine

BACKGROUND

Since the available data for bloodstream infections in solid malignancy tumors are somewhat limited in Palestine, prevention of infection before the occurrence, controlling it when it occurs, and implementing stewardship programs are important ways in the whole therapy of solid tumor patients, which is becoming challenging recently with the evolution of more antimicrobial drug-resistant pathogens. Therefore, our study aims to assess the microbial spectrum and antimicrobial sensitivity and the overall outcome related to many clinical risk factors in patients with solid tumor patients seeking care in a referral hospital as an experience from a developing country.

METHODS

From the onset of 2018 to the end of 2020, a total of 116 episodes with positive blood cultures were retrospectively studied and analyzed in 96 patients who had solid tumors in a referral hospital in Palestine.

RESULTS

We identified 116 positive blood cultures in 96 patients with a male to female ratio of 1:1. The mean age was 58 years. Breast cancer was the tumor most frequently recorded (13.5%), followed by urinary tract tumors (10.4%). The most common source of episodes with positive blood culture was catheter-related. Gram-positive bacteria accounted for 52.6% of blood cultures with the predomination of Staphylococcus species. On the contrary, Gram-negative bacteria were documented in 39.7% of the cultures, with E. coli being the most frequent bacteria. Regarding fungi that were only Candida species, it was isolated in 15.5% of the cultures.28.4% of patients started on a single antimicrobial as an initial regimen, the remaining started combination antimicrobial therapy. The initial antimicrobials used most frequently were aminoglycosides in 29.3% of the episodes. All species of Staphylococcus were sensitive to vancomycin. Enterococcus species were fully resistant to ciprofloxacin. In the case of E. coli, the isolates were 100% sensitive to imipenem, meropenem, and amikacin and were mostly resistant to ampicillin, where the sensitivity was only about 19.5%. P.aeruginosa was sensitive in 83.3% of cultures to both piperacillin-tazobactam and gentamicin, but highly resistant to imipenem, in which sensitivity decreased to 50%. The isolates of Klebsiella species were 72.2% sensitive to gentamicin, meropenem, and imipenem and 100% resistant to ampicillin. A. baumannii was 50% sensitive to trimethoprim-sulfamethoxazole. Candida species showed high sensitivity to both caspofungin and flucytosine (83.3%), followed by 77.8% sensitivity to voriconazole. Death was reported in 27.6% of the episodes and there was a significant relationship between shock at presentation and death (p = 0.010).

CONCLUSIONS

The findings of this investigation confirm the prevalent BSI seen in patients with solid malignancies and demonstrate a significant percentage of antibiotic resistance. Therefore, stewardship programs that dig deep before using any type of antimicrobials will help reduce the risk of resistance to antibiotics. In addition, the implementation of infection control surveillance plays an important role in decreasing the risk of contamination.

Clinical Analysis of Bloodstream Infection of Escherichia coli in Patients with Pancreatic Cancer from 2011 to 2019

Background

Pancreatic cancer patients were particularly predisposed to develop Escherichia coli (E. coli) bloodstream infection (BSI); however, little information is currently available. We set out to find E. coli BSI's risk factors in pancreatic cancer to provide valuable experience.

Methods

We retrospectively analyzed the clinical data of pancreatic cancer patients (31 cases with E. coli BSI and 93 cases without BSI) by a case-control study. SPSS 17.0 was adopted to perform univariate and multivariate analyses. Bacterial resistance analysis was performed by Whonet 5.6.

Results

Hospitalization days ≥7 days, number of admissions ≥2 times, surgery, chemotherapy, the type of antibiotics used ≥2 species, albumin<40.0 g/L, and prealbumin < 0.2 g/L were the potential risk factors for pancreatic cancer patients with E. coli BSI (P < 0.1). Multivariate logistic regression showed hospitalization days ≥7 days (OR = 11.196, 95% CI = 0.024–0.333, P < 0.001), surgery (OR = 32.053, 95% CI = 0.007–0.137, P < 0.001), and chemotherapy (OR = 6.174, 95% CI = 0.038–0.688, P=0.014) were the independent risk factors for E. coli BSI of pancreatic cancer patients. E. coli resistant to carbapenems was rare; they were susceptible to cephamycin and piperacillin/tazobactam. The 90-day mortality rate of the infected group was significantly higher than the control group (41.9% versus 8.6%, P < 0.001).

Conclusions

Hospitalization days ≥7 days, surgery, and chemotherapy are the independent risk factors for E. coli BSI of pancreatic cancer patients, which allows us to identify patients at potential risk and perform preventive treatment in time.

Establishment and validation of a nomogram to predict the in-hospital death risk of nosocomial infections in cancer patients

Background

Attributed to the immunosuppression caused by malignancy itself and its treatments, cancer patients are vulnerable to developing nosocomial infections. This study aimed to develop a nomogram to predict the in-hospital death risk of these patients.

Methods

This retrospective study was conducted at a medical center in Northwestern China. The univariate and multivariate logistic regression analyses were adopted to identify predictive factors for in-hospital mortality of nosocomial infections in cancer patients. A nomogram was developed to predict the in-hospital mortality of each patient, with receiver operating characteristic curves and calibration curves being generated to assess its predictive ability. Furthermore, decision curve analysis (DCA) was also performed to estimate the clinical utility of the nomogram.

Results

A total of 1,008 nosocomial infection episodes were recognized from 14,695 cancer patients. Extended-spectrum β-lactamase (ESBL)-producing Escherichia coli (15.5%) was the most predominant causative pathogen. Besides, multidrug-resistant strains were discovered in 25.5% of cases. The multivariate analysis indicated that Eastern Cooperative Oncology Group Performance Status 3–4, mechanical ventilation, septic shock, hypoproteinemia, and length of antimicrobial treatment < 7 days were correlated with higher in-hospital mortality. Patients who received curative surgery were correlated with favorable survival outcomes. Ultimately, a nomogram was constructed to predict the in-hospital mortality of nosocomial infections in cancer patients. The area under the curve values of the nomogram were 0.811 and 0.795 in the training and validation cohorts. The calibration curve showed high consistency between the actual and predicted in-hospital mortality. DCA indicated that the nomogram was of good clinical utility and more credible net clinical benefits in predicting in-hospital mortality.

Conclusions

Nosocomial infections stay conjoint in cancer patients, with gram-negative bacteria being the most frequent causative pathogens. We developed and verified a nomogram that could effectively predict the in-hospital death risk of nosocomial infections among these patients. Precise management of high-risk patients, early recognition of septic shock, rapid and adequate antimicrobial treatment, and dynamic monitoring of serum albumin levels may improve the prognosis of these individuals.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13756-022-01073-3.

Risk Factors for Infections, Antibiotic Therapy, and Its Impact on Cancer Therapy Outcomes for Patients with Solid Tumors

Infections represent a significant cause of morbidity and mortality in cancer patients. Multiple factors related to the patient, tumor, and cancer therapy can affect the risk of infection in patients with solid tumors. A thorough understanding of such factors can aid in the identification of patients with substantial risk of infection, allowing medical practitioners to tailor therapy and apply prophylactic measures to avoid serious complications. The use of novel treatment modalities, including targeted therapy and immunotherapy, brings diagnostic and therapeutic challenges into the management of infections in cancer patients. A growing body of evidence suggests that antibiotic therapy can modulate both toxicity and antitumor response induced by chemotherapy, radiotherapy, and especially immunotherapy. This article provides a comprehensive review of potential risk factors for infections and therapeutic approaches for the most prevalent infections in patients with solid tumors, and discusses the potential effect of antibiotic therapy on toxicity and efficacy of cancer therapy.

Risk of infections and mortality in Danish patients with cancer diagnosed with bone metastases: a population-based cohort study

OBJECTIVES

Risk of infections in patients with solid cancers and bone metastases (BM) and the subsequent impact on prognosis is unclear. We examined the risk of infections among patients with cancer diagnosed with BM and the subsequent impact of infections on mortality.

DESIGN

Population-based cohort study.

SETTING

Danish medical databases holding information on all hospital contacts in Denmark.

PARTICIPANTS

Adult patients with solid cancers and BM between 1 January 1994 and 30 November 2013.

OUTCOME MEASURES

In the risk analyses, the outcome was time to hospitalisation for common severe infections, pneumonia, sepsis and urinary tract infections. In the mortality analysis, we used Cox regression to compute HRs of death, modelling infection as time-varying exposure, stratifying for primary cancer type and adjusting for age, sex and comorbidities.

RESULTS

Among 23 336 patients with cancer and BM, cumulative incidences of common severe infections were 4.6%, 14.0% and 20.0% during 1 month, 1 year and 10 years follow-up. The highest incidence was observed for pneumonia, followed by urinary tract infections and sepsis. Infection was a strong predictor of 1 month mortality (adjusted HR: 2.1 (95% CI 1.8 to 2.3)) and HRs increased after 1 and 10 years: 2.4 (95% CI 2.3 to 2.6) and 2.4 (95% CI 2.4 to 2.6). Sepsis and pneumonia were the strongest predictors of death. Results were consistent across cancer types.

CONCLUSION

Patients with cancer and BM were at high risk of infections, which was associated with a more than twofold increased risk of death for up to 10 years of follow-up. The findings underscore the importance of preventing infections in patients with cancer and BM.

Antibiotic resistance in the patient with cancer: Escalating challenges and paths forward

Infection is the second leading cause of death in patients with cancer. Loss of efficacy in antibiotics due to antibiotic resistance in bacteria is an urgent threat against the continuing success of cancer therapy. In this review, the authors focus on recent updates on the impact of antibiotic resistance in the cancer setting, particularly on the ESKAPE pathogens (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter spp.). This review highlights the health and financial impact of antibiotic resistance in patients with cancer. Furthermore, the authors recommend measures to control the emergence of antibiotic resistance, highlighting the risk factors associated with cancer care. A lack of data in the etiology of infections, specifically in oncology patients in United States, is identified as a concern, and the authors advocate for a centralized and specialized surveillance system for patients with cancer to predict and prevent the emergence of antibiotic resistance. Finding better ways to predict, prevent, and treat antibiotic-resistant infections will have a major positive impact on the care of those with cancer.

Patterns of Bacterial Isolates and their Resistance to Antibiotics in Patients with Chemotherapy-induced Febrile Neutropenia at a University Hospital

Objectives

Febrile neutropenia is a major complication of cytotoxic chemotherapy and is associated with a high rate of mortality and morbidity if not treated appropriately. Consequently, it is important to know the bacterial spectrum and pattern of its resistance in each hospital to formulate an appropriate empiric antibiotic regimen. We sought to study the bacterial spectrum in patients with chemotherapy-induced neutropenia and report their resistance patterns.

Methods

We conducted a retrospective study on patients admitted with febrile neutropenia between January 2010 and December 2016 in the oncology unit at Sultan Qaboos University Hospital in Oman. Consecutive patients diagnosed with non-hematological malignancies who had febrile neutropenia and positive blood culture were included in this study.

Results

A total of 76 bacterial isolates were documented in 67 episodes in 62 patients. There were 26 male and 36 female patients. The median age was 51 (14–81) years. The most common cancers were breast cancer (17.7%), non-Hodgkin lymphoma (16.1%), and colon cancer (14.5%). Gram-negative and gram-positive organisms accounted for 73.7% and 26.3% of all isolates, respectively. The most common gram-negative organisms were Pseudomonas aeruginosa (26.8%), Escherichia coli (23.2%), Klebsiella species (17.9%), and Acinetobacter baumannii (12.5%). The most common gram-positive organisms were Staphylococcus aureus (30.0%), followed by coagulase-negative Staphylococcus (25.0%). There were 14 multidrug-resistant organisms and eight extended-spectrum beta-lactamases (ESBL). The resistance among gram-negative organisms to the commonly used broad-spectrum antibiotics was 23.5–55.6%. No resistance was recorded against vancomycin amongst the gram-positive organisms. Eight (12.1%) patients died while neutropenic.

Conclusions

Gram-negative organisms were the predominant organisms. There is a high rate of resistance to the commonly used antibiotics. Using a combination of antibiotics is warranted in patients presenting with chemotherapy-induced febrile neutropenia.

Comparison of therapy with β-lactam/β-lactamase inhibitor combinations or carbapenems for bacteraemia of nonurinary source caused by ESBL-producing Escherichia coli or Klebsiella pneumoniae

Background

Extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae has become a public health concern. This study aimed to compare the clinical outcomes of patients with nonurinary source bacteraemia caused by ESBL-producing Escherichia coli (E. coli) or Klebsiella pneumoniae (ESBL-producing EK) receiving β-lactam/β-lactamase inhibitor combinations (BLICs) versus carbapenem treatment and assess the risk factors of mortality with these two drugs.

Methods

We conducted a retrospective single-centre study of adult hospitalised patients with ESBL-producing EK bloodstream infection (BSI) from nonurinary source at our centre over a 4-year period. One hundred and eighty patients who received BLICs or carbapenems were included in the analysis. The outcome variables were 14-day treatment failure and 30-day mortality. For more reliable results, propensity score analysis was performed to compare the efficacy of the two drugs and analyse their risk factors for 30-day mortality.

Results

Out of 180 patients, 114 received BLICs, and 66 received carbapenem therapy. Compared to carbapenem-treated patients, those treated with BLICs were older and had higher age-adjusted Charlson comorbidity index, but they had shorter stay in the hospital. Additionally, their Pitt bacteraemia score, SOFA score, rate of leukaemia, and immune compromise were lower. After propensity score matching (PSM), the baseline characteristics of patients in the two treatment groups were balanced. BLICs were associated with a higher 14-day treatment failure rate (20.6%, 13/63) than carbapenems (16.3%, 7/43), although the difference was not significant in either univariate analysis (P = 0.429) or multivariate analysis (P = 0.122). And the 30-day mortality rate in BTG (11.1%, 7/63) and CTG (11.6%, 5/43) did not significantly differ (univariate analysis, P = 0.926; multivariate analysis, P = 0.420). In the multivariate analysis, after PSM, leukaemia was the only independent predictor of mortality in both BTG and CTG.

Conclusions

Our study showed that BLICs had higher 14-day treatment failure rate compared with carbapenems, although there were no statistically significant differences because of the small number of patients, therefore, further evaluation of the efficacy of BLICs is needed.

Immediate risk of non-cancer deaths after a cancer diagnosis

BACKGROUND

Receiving a cancer diagnosis may trigger immediate fatal non-cancer health outcomes in addition to dying of cancer itself. We aim to investigate the full pattern of non-cancer deaths in patients within a year of a cancer diagnosis.

METHODS

Patients diagnosed with cancer between 1990 and 2016 were identified from the SEER program. Standardized mortality ratios (SMRs) were calculated to characterize the relative risks of non-cancer deaths compared with the general population.

RESULTS

Among 7,366,229 patients, 241,575 non-cancer deaths (15.9%) were recorded in the first year following a cancer diagnosis. The relative risk of non-cancer deaths was 2.34-fold (95% confidence interval (CI): 2.33-2.35) that of the general population. The majority of non-cancer deaths were caused by cardiovascular diseases (21.8%), followed by infectious diseases (7.2%). Significant elevations in mortality risks were observed for nearly all non-cancer causes, particularly in infectious diseases (SMR: 5.08; 95% CI: 5.03-5.13). Patients with liver cancer (SMR: 12.29; 95% CI: 12.06-12.53) were at the highest risk of early non-cancer deaths. The risks of non-cancer deaths were highest within the first month after diagnosis, and decreased rapidly thereafter.

CONCLUSIONS

Risks of non-cancer deaths vary by the types of causes and anatomic sites of cancer. Our data underscore the importance of close observation and early multidisciplinary care for noncancer conditions in patients who have recently received a cancer diagnosis.

A TTP-incorporated scoring model for predicting mortality of solid tumor patients with bloodstream infection caused by Escherichia coli

Background

Few mortality-scoring models are available for solid tumor patients who are predisposed to develop Escherichia coli–caused bloodstream infection (ECBSI). We aimed to develop a mortality-scoring model by using information from blood culture time to positivity (TTP) and other clinical variables.

Methods

A cohort of solid tumor patients who were admitted to hospital with ECBSI and received empirical antimicrobial therapy was enrolled. Survivors and non-survivors were compared to identify the risk factors of in-hospital mortality. Univariable and multivariable regression analyses were adopted to identify the mortality-associated predictors. Risk scores were assigned by weighting the regression coefficients with corresponding natural logarithm of the odds ratio for each predictor.

Results

Solid tumor patients with ECBSI were distributed in the development and validation groups, respectively. Six mortality-associated predictors were identified and included in the scoring model: acute respiratory distress (ARDS), TTP ≤ 8 h, inappropriate antibiotic therapy, blood transfusion, fever ≥ 39 °C, and metastasis. Prognostic scores were categorized into three groups that predicted mortality: low risk (< 10% mortality, 0–1 points), medium risk (10–20% mortality, 2 points), and high risk (> 20% mortality, ≥ 3 points). The TTP-incorporated scoring model showed excellent discrimination and calibration for both groups, with AUC being 0.833 vs 0.844, respectively, and no significant difference in the Hosmer–Lemeshow test (6.709, P = 0.48) and the chi-square test (6.993, P = 0.46). Youden index showed the best cutoff value of ≥ 3 with 76.11% sensitivity and 79.29% specificity. TTP-incorporated scoring model had higher AUC than no TTP-incorporated model (0.837 vs 0.817, P < 0.01).

Conclusions

Our TTP-incorporated scoring model was associated with improving capability in predicting ECBSI-related mortality. It can be a practical tool for clinicians to identify and manage bacteremic solid tumor patients with high risk of mortality.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00520-021-06442-z.

Temporal Trends in Sepsis Incidence and Mortality in Patients With Cancer in the US Population

BACKGROUND

Few population-based studies assess the impact of cancer on sepsis incidence and mortality.

OBJECTIVES

To evaluate epidemiological trends of sepsis in patients with cancer.

METHODS

This retrospective cohort study included adults (≥20 years old) identified using sepsis-indicator International Classification of Diseases codes from the Nationwide Inpatient Sample database (2006-2014). A generalized linear model was used to trend incidence and mortality. Outcomes in patients with cancer and patients without cancer were compared using propensity score matching. Cox regression modeling was used to calculate hazard ratios for mortality rates.

RESULTS

The study included 13 996 374 patients, 13.6% of whom had cancer. Gram-positive infections were most common, but the incidence of gram-negative infections increased at a greater rate. Compared with patients without cancer, those with cancer had significantly higher rates of lower respiratory tract (35.0% vs 31.6%), intra-abdominal (5.5% vs 4.6%), fungal (4.8% vs 2.9%), and anaerobic (1.2% vs 0.9%) infections. Sepsis incidence increased at a higher rate in patients with cancer than in those without cancer, but hospital mortality rates improved equally in both groups. After propensity score matching, hospital mortality was higher in patients with cancer than in those without cancer (hazard ratio, 1.25; 95% CI, 1.24-1.26). Of patients with sepsis and cancer, those with lung cancer had the lowest survival (hazard ratio, 1.65) compared with those with breast cancer, who had the highest survival.

CONCLUSIONS

Cancer patients are at high risk for sepsis and associated mortality. Research is needed to guide sepsis monitoring and prevention in patients with cancer.

Bacteremia in critically ill immunocompromised patients with acute hypoxic respiratory failure: A post-hoc analysis of a prospective multicenter multinational cohort

PURPOSE

The characteristics and impact of bacteremia have not been widely investigated in immunocompromised patients with acute respiratory failure (ARF).

METHODS

We performed a secondary analysis of a prospective cohort of immunocompromised patients with ARF (EFRAIM study). After exclusion of blood cultures positive for coagulase negative Staphylococci, we compared patients with (n = 236) and without (n = 1127) bacteremia.

RESULTS

The incidence of bacteremia was 17%. Bacterial pneumonia and extra-pulmonary ARDS were the main causes of ARF in bacteremic patients. Bacteremia involved gram negative rods (48%), gram positive cocci (40%) or were polymicrobial (10%). Bacteremic patients had more hematological malignancy, higher SOFA scores and increased organ support within 7 days. Bacteremia was associated with higher crude ICU mortality (40% versus 32%, p = 0.02), but neither hospital (49% versus 44%, p = 0.17) nor 90-day mortality (60% versus 56%, p = 0.25) were different from non-bacteremic patients. After propensity score matching based on baseline characteristics, the difference in ICU mortality lost statistical significance (p = 0.06), including in a sensitivity analysis restricted to patients with pneumonia.

CONCLUSIONS

We analyzed a large population of immunocompromised patients with ARF and an incidence of bacteremia of 17%. We could not demonstrate an impact of bacteremia on mortality after adjusting for baseline characteristics.

Understanding and Managing Sepsis in Patients With Cancer in the Era of Antimicrobial Resistance

Sepsis is a frequent complication in immunosuppressed cancer patients and hematopoietic stem cell transplant recipients that is associated with high morbidity and mortality rates. The worldwide emergence of antimicrobial resistance is of special concern in this population because any delay in starting adequate empirical antibiotic therapy can lead to poor outcomes. In this review, we aim to address: (1) the mechanisms involved in the development of sepsis and septic shock in these patients; (2) the risk factors associated with a worse prognosis; (3) the impact of adequate initial empirical antibiotic therapy given the current era of widespread antimicrobial resistance; and (4) the optimal management of sepsis, including adequate and early source control of infection, optimized antibiotic use based on the pharmacokinetic and pharmacodynamics changes in these patients, and the role of the new available antibiotics.

[Clinical and microbiological characteristics of bloodstream infections in adult neutropenic patients]

Bloodstream infections (BI) are relevant in neutropenic patients because they are associated with an increased number of complications and death. The objective was determinate the epidemiologic and microbiologic features of the BI in neutropenic patients with solid neoplasm (SN) and hematologic neoplasm (HN). Retrospective study in two third level hospitals between 2009 and 2016. They were included all the patients older than 18 years-old with active oncologic disease and neutropenia, who had BI. Patients with dermatologic cancer other than melanoma where excluded. A total of 143 BI in neutropenic were observed, of which 80.4% occurred in HN. Around 97.9% of the patients had a high-risk neutropenia without differences between both groups. The most frequent site of BI was primary bacteremia (46.9%) and catheter-associated infection (21%), without significant differences between the two groups. The gram negatives bacilli (GNB) predominated over the gram positive cocci (GPC) and they represented 74.1% of the isolated bacteria, being Escherichia coli the most frequent (32.8%). Among the gram positive cocci, Staphylococcus aureus (28.1%) was the most frequent isolated, followed by coagulase-negative Staphylococci (CNS). There were no differences in microbiological isolates between both groups. With regard to the antimicrobial susceptibility 67.5% of the CNS, 17.6% of the E. coli and 27.6% of the Klebsiella pneumoniae were multiresistant with no differences between both groups. Only 11.1% of S. aureus isolates were methicillin resistant. In conclusion BI of the neutropenic patients where most frequents within patients with HN, GNB were the main microbiological isolates. High mortality was observed in neutropenic patients with BI.

Clinical outcomes and prognostic factors in bloodstream infections due to extended-spectrum β-lactamase-producing Enterobacteriaceae among patients with malignancy: a meta-analysis

Background

The colonization of Extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-PE) in bloodstream infections (BSIs) has been increased dramatically worldwide, and it was associated with worse clinical outcomes in patients with malignancy. We performed the meta-analysis to investigate the prognosis and risk factors in BSIs caused by ESBL-PE in oncological patients.

Methods

PubMed, EMBASE, and Cochrane Library were searched for related studies. All-cause mortality was considered as the primary outcome. Subgroup analyses, meta-regression analyses, and sensitivity analysis were used to investigate heterogeneity and reliability in results.

Results

6,729 patients from 25 studies were eligible. Six studies enrolled oncological patients with BSIs caused by ESBL-PE only, while 19 studies both enrolled ESBL-PE and non-ESBL-PE infections. The results showed that BSIs caused by ESBL-PE in patients with malignancy was associated with higher mortality than non-ESBL-PE infections (RR = 2.21, 95% CI: 1.60–3.06, P < 0.001), with a significant between-study heterogeneity (I² =78.3%, P < 0.001). Subgroup analyses showed that children (RR = 2.80, 95% CI: 2.29–3.43, P < 0.001) and hematological malignancy (RR = 3.20, 95% CI: 2.54–4.03, P < 0.001) were associated with a higher mortality. Severe sepsis/ septic shock, pneumonia, and ICU admission were the most common predictors of mortality.

Conclusions

Our study identified that BSIs caused by ESBL-PE in patients with malignancy were associated with worse clinical outcomes compared with non-ESBL-PE infections. Furthermore, children and hematological malignancy were associated with higher mortality. Severe sepsis/ septic shock, pneumonia, and ICU admission were the most common predictors of mortality.

Infectious disease considerations in immunocompromised patients

Immunocompromised patients account for about 3% of the US population. Complications arising from infection are common in these patients and can present diagnostic and therapeutic challenges. This article describes the pathophysiology of immunosuppression in five common immunocompromised states-asplenia, HIV infection, solid organ transplant, biologic use, and cancer-as well as specific infectious risks and considerations for affected patients and how to manage them.

Modeling of the immune response in the pathogenesis of solid tumors and its prognostic significance

BACKGROUND

Tumor initiation and subsequent progression are usually long-term processes, spread over time and conditioned by diverse aspects. Many cancers develop on the basis of chronic inflammation; however, despite dozens of years of research, little is known about the factors triggering neoplastic transformation under these conditions. Molecular characterization of both pathogenetic states, i.e., similarities and differences between chronic inflammation and cancer, is also poorly defined. The secretory activity of tumor cells may change the immunophenotype of immune cells and modify the extracellular microenvironment, which allows the bypass of host defense mechanisms and seems to have diagnostic and prognostic value. The phenomenon of immunosuppression is also present during chronic inflammation, and the development of cancer, due to its duration, predisposes patients to the promotion of chronic inflammation. The aim of our work was to discuss the above issues based on the latest scientific insights. A theoretical mechanism of cancer immunosuppression is also proposed.

CONCLUSIONS

Development of solid tumors may occur both during acute and chronic phases of inflammation. Differences in the regulation of immune responses between precancerous states and the cancers resulting from them emphasize the importance of immunosuppressive factors in oncogenesis. Cancer cells may, through their secretory activity and extracellular transport mechanisms, enhance deterioration of the immune system which, in turn, may have prognostic implications.

Nosocomial infections due to multidrug-resistant bacteria in cancer patients: a six-year retrospective study of an oncology Center in Western China

BACKGROUND

Bacterial infections are the most frequent complications in patients with malignancy, and the epidemiology of nosocomial infections among cancer patients has changed over time. This study aimed to evaluate the characteristics, antibiotic resistance patterns, and prognosis of nosocomial infections due to multidrug-resistant (MDR) bacteria in cancer patients.

METHODS

This retrospective observational study analyzed cancer patients with nosocomial infections caused by MDR from August 2013 to May 2019. The extracted clinical data were recorded in a standardized form and compared based on the survival status of the patients after infection and during hospitalization. The data were analyzed using independent samples t-test, Chi-square test, and binary logistic regression. P-values < 0.05 were considered significant.

RESULTS

One thousand eight patients developed nosocomial infections during hospitalization, with MDR strains detected in 257 patients. Urinary tract infection (38.1%), respiratory tract infection (26.8%), and bloodstream infection (BSI) (12.5%) were the most common infection types. Extended-spectrum β-lactamase producing Enterobacteriaceae (ESBL-PE) (72.8%) members were the most frequently isolated MDR strains, followed by Acinetobacter baumannii (11.7%), and Stenotrophomonas maltophilia (6.2%). The results of multivariate regression analysis revealed that smoking history, intrapleural/abdominal infusion history within 30 days, the presence of an indwelling urinary catheter, length of hospitalization, and hemoglobin were independent factors for in-hospital mortality in the study population. The isolated MDR bacteria exhibited high rates of sensitivity to amikacin, meropenem, and imipenem.

CONCLUSIONS

The burden of nosocomial infections due to MDR bacteria is considerably high in oncological patients, with ESBL-PE being the most predominant causative pathogen. Our findings suggest that amikacin and carbapenems actively against more than 89.7% of MDR isolates. The precise management of MDR bacterial infections in cancer patients may improve the prognosis of these individuals.

Nosocomial Infections in Gastrointestinal Cancer Patients: Bacterial Profile, Antibiotic Resistance Pattern, and Prognostic Factors

Background

Cancers of the gastrointestinal (GI) tract and its associated excretory glands are one of the most common causes of cancer-related death worldwide, and these patients are more likely to developing nosocomial infections due to immunodeficiency.

Objective

To explore the bacterial profile, antibiotic resistance pattern, and prognostic factors of nosocomial infections in hospitalized GI cancer patients.

Methods

All electronic medical records of nosocomial infection episodes in hospitalized GI cancer patients were retrospectively reviewed. In-hospital mortality was used to evaluate the prognosis of patients. Mann–Whitney test, Chi-square test, and binary logistic regression analysis were used to identify potential risk factors for in-hospital mortality. P-values <0.05 were considered statistically significant.

Results

A total of 428 GI cancer patients developed nosocomial infections during hospitalization. Respiratory tract infections (44.2%), bloodstream infections (BSIs) (11.7%), and abdominal cavity infections (11.4%) were the most common infection sites. The predominant causative pathogens were extended-spectrum β-lactamase (ESBL)-producing Escherichia coli (13.6%), ESBL-negative E. coli (11.9%), and Klebsiella pneumoniae (10.0%). Multidrug-resistant (MDR) strains were detected in 27.6% of isolates. Antimicrobial susceptibility analysis showed that the isolated Gram-negative bacteria (GNB) exhibited high sensitivity to amikacin, meropenem, imipenem, and piperacillin/tazobactam, while the isolated Gram-positive bacteria exhibited high sensitivity to tigecycline, linezolid, and vancomycin. The overall in-hospital mortality of all patients was 11.2% in the study. Multivariate analysis showed that ECOG performance status ≥two scores, length of antibiotic treatment <9.0 days, existence of septic shock, and hypoproteinemia were independent risk factors for in-hospital mortality.

Conclusion

The burden of nosocomial infections in GI cancer patients is considerably high, with GNB being predominantly isolated causative pathogens. Surveillance on serum albumin level, adequate antibiotic treatment, early identification, and prompt treatment of septic shock could benefit the prognosis.

Clinical characteristics and implications of mixed candida/bacterial bloodstream infections in patients with hematological diseases

The incidence of mixed candida/bacterial blood infections (BSIs) has been reported to account for 20% of all cases of candidaemia. However, its clinical characteristics and implications in patients with hematological diseases are not clear. We conducted a retrospective case-control study of hematological patients complicated with candidaemia over the past 5-year period to identify the risk factors and clinical implications of mixed candidia/bacterial BSIs (case group) vs. monobacterial candidiasis (control group). Of all 65 enrolled patients with candidaemia, 20 cases (30.8%) met the diagnostic criteria for mixed candida/bacterial BSIs. Candida tropicalis was the most common candida species in all patients. Klebsiella pneumoniae was the most detected bacteria (35%) in case group. Previous hospital stay ≥ 28 days, organic damage during candidaemia, and positive procalcitonin (PCT) test were the risk factors of mixed candida/bacterial BSIs. Cumulative mortality of all patients enrolled was 26.2% at day 30, with significant differences between case and control group. In multivariate analysis, organic damage and granulocyte recovery were the two predictive factors for 30-day mortality. Mixed candida/bacterial BSIs are fatal complications of infection which account for a considerable part of candidaemia; multicenter and large-scale clinical studies are required in the future.

Microbial Growth on the Nails of Direct Patient Care Nurses Wearing Nail Polish

OBJECTIVES

To determine whether nurses wearing nail polish pose a greater infection risk to patients than nurses who are not wearing nail polish.

SAMPLE & SETTING

89 direct patient care oncology nurses at a large midwestern National Cancer Institute-designated comprehensive cancer center.

METHODS & VARIABLES

The investigators assigned participants' three middle fingers of their dominant hand to three groups.

RESULTS

Comparison of colony-forming units revealed that one-day-old polish exhibited fewer gram-positive microorganisms than the unpolished nail (p = 0.04). The four-day-old polish showed significantly more microorganisms than the one-day-old polish (p = 0.03). The same trend was demonstrated for gram-negative microorganisms, but the difference was not statistically significant (p = 0.3 and p = 0.17, respectively).

IMPLICATIONS FOR NURSING

The results should be interpreted and applied to expert nursing practice in the care of vulnerable patient populations. Each institution and practitioner should make their own decisions and interpretation of evidence into practice.

Impact of antibiotic resistance on outcomes of neutropenic cancer patients with Pseudomonas aeruginosa bacteraemia (IRONIC study): study protocol of a retrospective multicentre international study

INTRODUCTION

Pseudomonas aeruginosa (PA) has historically been one of the major causes of severe sepsis and death among neutropenic cancer patients. There has been a recent increase of multidrug-resistant PA (MDRPA) isolates that may determine a worse prognosis, particularly in immunosuppressed patients. The aim of this study is to establish the impact of antibiotic resistance on the outcome of neutropenic onco-haematological patients with PA bacteraemia, and to identify the risk factors for MDRPA bacteraemia and mortality.

METHODS AND ANALYSIS

This is a retrospective, observational, multicentre, international study. All episodes of PA bacteraemia occurring in neutropenic onco-haematological patients followed up at the participating centres from 1 January 2006 to 31 May 2018 will be retrospectively reviewed. The primary end point will be overall case-fatality rate within 30 days of onset of PA bacteraemia. The secondary end points will be to describe the following: the incidence and risk factors for multidrug-resistant and extremely drug-resistant PA bacteraemia (by comparing the episodes due to susceptible PA with those produced by MDRPA), the efficacy of ceftolozane/tazobactam, the rates of persistent bacteraemia and bacteraemia relapse and the risk factors for very early (48 hours), early (7 days) and overall (30 days) case-fatality rates.

ETHICS AND DISSEMINATION

The Clinical Research Ethics Committee of Bellvitge University Hospital approved the protocol of the study at the primary site. To protect personal privacy, identifying information of each patient in the electronic database will be encrypted. The processing of the patients' personal data collected in the study will comply with the Spanish Data Protection Act of 1998 and with the European Directive on the privacy of data. All data collected, stored and processed will be anonymised. Results will be reported at conferences and in peer-reviewed publications.

Noncancer mortality among adolescents and young adults with cancer

BACKGROUND

Relative to the general population, cancer patients and survivors may have an elevated risk of mortality from noncancer causes, such as cardiovascular disease and infections, but few studies have examined rates of noncancer mortality among patients diagnosed as adolescents and young adults (AYAs) (ages 15-39 years).

METHODS

The Surveillance, Epidemiology, and End Results database was used to identify AYA patients who were diagnosed with a first malignant cancer between 1973 and 2015. Rates of mortality from noncancer causes among AYAs with cancer were compared with those in the general US population using standardized mortality ratios (SMRs), adjusted for age, sex, race, and calendar year.

RESULTS

Among 235,541 AYAs with cancer, a total of 12,948 deaths from noncancer causes occurred over 3.1 million total person-years of follow-up. Overall, noncancer mortality was significantly increased among AYAs with cancer relative to the general population (SMR, 1.84; 95% CI, 1.80-1.87). SMRs were particularly elevated for infectious diseases (SMR, 5.13; 95% CI, 4.95-5.32), cardiovascular disease (SMR, 1.55; 95% CI, 1.50-1.60), and renal diseases (SMR, 2.40; 95% CI, 2.12-2.71). These associations persisted for more than 20 years after cancer diagnosis. Cancer types associated with the highest SMRs for all noncancer mortality included leukemias (SMR, 5.26), Hodgkin lymphoma (SMR, 3.12), non-Hodgkin lymphoma (SMR, 6.33), central nervous system tumors (SMR, 3.38), head and neck cancers (SMR, 2.09), and cervical/uterine cancers (SMR, 2.03).

CONCLUSIONS

AYAs with cancer have an elevated burden of mortality from noncancer causes that persists many years after cancer diagnosis, highlighting the importance of comprehensive, long-term follow-up care for noncancer conditions throughout survivorship.

Prevention of Infection: A Systematic Review of Evidence-Based Practice Interventions for Management in Patients With Cancer

BACKGROUND

Cancer-related infections lead to increases in mortality, antibiotic use, and hospital stays. Other adverse outcomes include dose delays and reductions, which can result in suboptimal treatment outcomes.

OBJECTIVES

Effective implementation of risk assessment and evidence-based interventions for the prevention and treatment of infection are essential to improve care and reduce costs related to infections in patients with cancer receiving immunosuppressive therapy.

METHODS

The Oncology Nursing Society (ONS) Putting Evidence Into Practice (PEP) prevention of infection resource have been developed and updated to identify and disseminate the best available scientific evidence.

FINDINGS

Pharmacologic and nonpharmacologic interventions were evaluated, resulting in recommended for practice rating for catheter care bundles, antimicrobial prophylaxis, vaccination for specific populations, and implementation of contact precautions for resistant organisms.