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Hewamana S, Skandarajah T, Jayasinghe C, Deshapriya S, Gayashan D, Peiris N, Harischandra M, Gunasena P, Somasundaram G, Srinivasan V, Somiah S, Wickramarathna C, Hewawasam S, Balawardena J, Arseculeratne G, Wadanamby R, Galagoda G, Wijesiriwardana B. Successful Management of Neutropenic Sepsis Is Key to Better Survival of Patients With Blood Cancer in Sri Lanka: Real-World Data From the Resource-Limited Setting. JCO Glob Oncol 2024; 10:e2300412. [PMID: 38484192 PMCID: PMC10954079 DOI: 10.1200/go.23.00412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 12/25/2023] [Accepted: 02/02/2024] [Indexed: 03/19/2024] Open
Abstract
PURPOSE Sepsis is the main cause of nonrelapse mortality, and there are no published data on applicability of supportive care protocols from high-income countries such as Sri Lanka. The aim of the study was to investigate management and mortality of neutropenic episodes among Hemato-Oncology patients. MATERIALS AND METHODS Retrospective analysis of clinical characteristics, management, morbidity, and mortality of neutropenic Hemato-Oncology patients presented to the Lanka Hospital Blood Cancer Centre from January 1, 2019 to December 31, 2019 was performed. RESULTS A total of 169 neutropenic episodes were identified; 115 (68%) of such episodes were related to chemotherapy. Acute leukemia, lymphoproliferative disorders, and plasma cell disorders accounted for 23%, 69%, and 8% of patients, respectively. The median age of patients who had sepsis was 56 years, whereas that of those who had no sepsis was 53 years (P = .49). The median time to neutropenia was 9 days for those in the sepsis group compared with 8 days in the group that had no sepsis (0.64). The median neutrophil count in the group that had sepsis was 0.06, whereas it was 0.69 in the group that had no sepsis (P ≤ .05). The median time to commencement of antibiotics was 20 minutes. CONCLUSION To our knowledge, this is the only documented study related to outcome and successful applicability of western supportive care protocols to Sri Lankan patients with neutropenia. In this study, we have shown that neutropenic sepsis can be successfully managed in the setting of limited resources with service development, following guidelines and staff training.
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Affiliation(s)
| | | | - Chathuri Jayasinghe
- Department of Statistics, University of Sri Jayewardenepura, Colombo, Sri Lanka
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de Souza ILA, Cappellano P, Ferreira DB, Bergamasco MD, das Chagas Neto TC, Kerbauy FR, Baiocchi OCG, Pignatari ACC. Carbapenem-resistant Klebsiella pneumoniae bloodstream infections in haematological malignances and hematopoietic stem cell transplantation: Clinical impact of combination therapy in a 10-year Brazilian cohort. PLoS One 2024; 19:e0297161. [PMID: 38277372 PMCID: PMC10817138 DOI: 10.1371/journal.pone.0297161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 12/29/2023] [Indexed: 01/28/2024] Open
Abstract
Bacterial bloodstream infections (BSI) are a common threat among patients with haematological malignancies (HM) and hematopoietic stem cell transplant recipients (HSCT). The purpose of this research was to describe clinical and microbiological aspects of BSI caused by carbapenem-resistant Klebsiella pneumoniae (CRKp) and assess risk factors associated with 30-day mortality in a 10-year cohort of haematological patients. A total of 65 CRKp-BSI episodes occurring in HM patients and HSCT recipients and CRKp-BSI between January 2010 and December 2019 were retrospectively studied. Acute leukemias were the most frequently observed underlying disease (87.7%) and 18 patients (27.7%) received HSCT. Mucosal barrier injury in the gastrointestinal tract was the primary cause of bacteremia (86.1%). Also, 14 individuals (21.6%) had an Invasive Fungal Disease (IFD) throughout the episode. Regarding treatment, in 31 patients (47.7%) empirical therapy was deemed appropriate, whereas 33 (50.8%) patients received a combination therapy. Microbiological data revealed that the majority of isolates (53-58%) had the Polymyxin B co-resistance phenotype, while amikacin resistance was less common (16 samples, or 24.7%). The mortality rates at 14 and 30 days were 32.3% and 36.9%, respectively. In a multivariate Cox regression analysis, prompt appropriate antibiotic administration within three days was associated with a better outcome (Adjusted Hazard Ratio [aHR]: 0.33; 95% Confidence Interval [CI]: 0.14-0.76; p = 0.01), whereas hypotension at presentation (aHR: 3.88; 95% CI: 1.40-10.74; p = 0.01) and concurrent IFD (aHR: 2.97; 95% CI: 1.20-7.37; p = 0.02) were independently associated with death within 30 days. Additionally, a favorable correlation between combination therapy and overall survival was found (aHR: 0.18; 95%CI: 0.06-0.56; p = 0.002). In conclusion, 30-day mortality CRKp-BSI was elevated and most of the isolates were polymyxin B resistant. Early appropriate antimicrobial treatment and the use of combination therapy were linked to a better outcome.
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Affiliation(s)
- Ingvar Ludwig Augusto de Souza
- Disciplina de Infectologia, Departamento de Medicina, Escola Paulista de Medicina, Universidade Federal de São Paulo, Sao Paulo, Brazil
- Hcor–Hospital do Coracao, Sao Paulo, Brazil
| | - Paola Cappellano
- Disciplina de Infectologia, Departamento de Medicina, Escola Paulista de Medicina, Universidade Federal de São Paulo, Sao Paulo, Brazil
- Fleury–Medicina e Saúde, Sao Paulo, Brazil
| | - Diogo Boldim Ferreira
- Disciplina de Infectologia, Departamento de Medicina, Escola Paulista de Medicina, Universidade Federal de São Paulo, Sao Paulo, Brazil
- Hcor–Hospital do Coracao, Sao Paulo, Brazil
| | - Maria Daniela Bergamasco
- Disciplina de Infectologia, Departamento de Medicina, Escola Paulista de Medicina, Universidade Federal de São Paulo, Sao Paulo, Brazil
- Hcor–Hospital do Coracao, Sao Paulo, Brazil
| | - Thomas Cardoso das Chagas Neto
- Laboratório Central, Hospital São Paulo, Disciplina de Medicina Laboratorial, Departamento de Medicina, Escola Paulista de Medicina, Universidade Federal de São Paulo, Sao Paulo, Brazil
| | - Fabio Rodrigues Kerbauy
- Disciplina de Hematologia e Hemoterapia, Departamento de Oncologia Clínica e Experimental, Escola Paulista de Medicina, Universidade Federal de São Paulo, Sao Paulo, Brazil
| | - Otavio Carvalho Guimarães Baiocchi
- Disciplina de Hematologia e Hemoterapia, Departamento de Oncologia Clínica e Experimental, Escola Paulista de Medicina, Universidade Federal de São Paulo, Sao Paulo, Brazil
| | - Antonio Carlos Campos Pignatari
- Disciplina de Infectologia, Departamento de Medicina, Escola Paulista de Medicina, Universidade Federal de São Paulo, Sao Paulo, Brazil
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Liu Y, Song R, Lu Z, Zhao L, Zhan X, Li Y, Cao X. The RNA m 6A demethylase ALKBH5 drives emergency granulopoiesis and neutrophil mobilization by upregulating G-CSFR expression. Cell Mol Immunol 2024; 21:6-18. [PMID: 38114747 PMCID: PMC10757716 DOI: 10.1038/s41423-023-01115-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 11/29/2023] [Indexed: 12/21/2023] Open
Abstract
Emergency granulopoiesis and neutrophil mobilization that can be triggered by granulocyte colony-stimulating factor (G-CSF) through its receptor G-CSFR are essential for antibacterial innate defense. However, the epigenetic modifiers crucial for intrinsically regulating G-CSFR expression and the antibacterial response of neutrophils remain largely unclear. N6-methyladenosine (m6A) RNA modification and the related demethylase alkB homolog 5 (ALKBH5) are key epigenetic regulators of immunity and inflammation, but their roles in neutrophil production and mobilization are still unknown. We used cecal ligation and puncture (CLP)-induced polymicrobial sepsis to model systemic bacterial infection, and we report that ALKBH5 is required for emergency granulopoiesis and neutrophil mobilization. ALKBH5 depletion significantly impaired the production of immature neutrophils in the bone marrow of septic mice. In addition, Alkbh5-deficient septic mice exhibited higher retention of mature neutrophils in the bone marrow and defective neutrophil release into the circulation, which led to fewer neutrophils at the infection site than in their wild-type littermates. During bacterial infection, ALKBH5 imprinted production- and mobilization-promoting transcriptome signatures in both mouse and human neutrophils. Mechanistically, ALKBH5 erased m6A methylation on the CSF3R mRNA to increase the mRNA stability and protein expression of G-CSFR, consequently upregulating cell surface G-CSFR expression and downstream STAT3 signaling in neutrophils. The RIP-qPCR results confirmed the direct binding of ALKBH5 to the CSF3R mRNA, and the binding strength declined upon bacterial infection, accounting for the decrease in G-CSFR expression on bacteria-infected neutrophils. Considering these results collectively, we define a new role of ALKBH5 in intrinsically driving neutrophil production and mobilization through m6A demethylation-dependent posttranscriptional regulation, indicating that m6A RNA modification in neutrophils is a potential target for treating bacterial infections and neutropenia.
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Affiliation(s)
- Yang Liu
- Department of Immunology, Center for Immunotherapy, Institute of Basic Medical Sciences, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.
- Suzhou Institute of Systems Medicine, Chinese Academy of Medical Sciences, Suzhou, China.
- Frontier Research Center for Cell Response, Institute of Immunology, College of Life Sciences, Nankai University, Tianjin, China.
| | - Renjie Song
- Department of Immunology, Center for Immunotherapy, Institute of Basic Medical Sciences, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Zhike Lu
- School of Life Sciences, Westlake University, Hangzhou, China
| | - Lu Zhao
- Department of Immunology, Center for Immunotherapy, Institute of Basic Medical Sciences, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xinyi Zhan
- Department of Immunology, Center for Immunotherapy, Institute of Basic Medical Sciences, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yini Li
- School of Life Sciences, Westlake University, Hangzhou, China
| | - Xuetao Cao
- Department of Immunology, Center for Immunotherapy, Institute of Basic Medical Sciences, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
- Suzhou Institute of Systems Medicine, Chinese Academy of Medical Sciences, Suzhou, China
- Frontier Research Center for Cell Response, Institute of Immunology, College of Life Sciences, Nankai University, Tianjin, China
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4
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Meschiari M, Kaleci S, Monte MD, Dessilani A, Santoro A, Scialpi F, Franceschini E, Orlando G, Cervo A, Monica M, Forghieri F, Venturelli C, Ricchizzi E, Chester J, Sarti M, Guaraldi G, Luppi M, Mussini C. Vancomycin resistant enterococcus risk factors for hospital colonization in hematological patients: a matched case-control study. Antimicrob Resist Infect Control 2023; 12:126. [PMID: 37957773 PMCID: PMC10644555 DOI: 10.1186/s13756-023-01332-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 11/05/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Vancomycin-resistant enterococcus (VRE) was the fastest growing pathogen in Europe in 2022 (+ 21%) but its clinical relevance is still unclear. We aim to identify risk factors for acquired VRE rectal colonization in hematological patients and evaluate the clinical impact of VRE colonization on subsequent infection, and 30- and 90-day overall mortality rates, compared to a matched control group. METHODS A retrospective, single center, case-control matched study (ratio 1:1) was conducted in a hematological department from January 2017 to December 2020. Case patients with nosocomial isolation of VRE from rectal swab screening (≥ 48 h) were matched to controls by age, sex, ethnicity, and hematologic disease. Univariate and multivariate logistic regression compared risk factors for colonization. RESULTS A total of 83 cases were matched with 83 controls. Risk factors for VRE colonization were febrile neutropenia, bone marrow transplant, central venous catheter, bedsores, reduced mobility, altered bowel habits, cachexia, previous hospitalization and antibiotic treatments before and during hospitalization. VRE bacteraemia and Clostridioides difficile infection (CDI) occurred more frequently among cases without any impact on 30 and 90-days overall mortality. Vancomycin administration and altered bowel habits were the only independent risk factors for VRE colonization at multivariate analysis (OR: 3.53 and 3.1; respectively). CONCLUSIONS Antimicrobial stewardship strategies to reduce inappropriate Gram-positive coverage in hematological patients is urgently required, as independent risk factors for VRE nosocomial colonization identified in this study include any use of vancomycin and altered bowel habits. VRE colonization and infection did not influence 30- and 90-day mortality. There was a strong correlation between CDI and VRE, which deserves further investigation to target new therapeutic approaches.
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Affiliation(s)
- Marianna Meschiari
- Department of Infectious Diseases, Azienda Ospedaliero-Universitaria, University of Modena and Reggio Emilia, Via del Pozzo 71, Modena, 41122, Italy.
| | - Shaniko Kaleci
- Clinical and Experimental Medicine, University of Modena and Reggio Emilia, Via del Pozzo 71, Modena, 41122, Italy
| | - Martina Del Monte
- Department of Infectious Diseases, Azienda Ospedaliero-Universitaria, University of Modena and Reggio Emilia, Via del Pozzo 71, Modena, 41122, Italy
| | - Andrea Dessilani
- Department of Infectious Diseases, Azienda Ospedaliero-Universitaria, University of Modena and Reggio Emilia, Via del Pozzo 71, Modena, 41122, Italy
| | - Antonella Santoro
- Department of Infectious Diseases, Azienda Ospedaliero-Universitaria, University of Modena and Reggio Emilia, Via del Pozzo 71, Modena, 41122, Italy
| | - Francesco Scialpi
- Department of Infectious Diseases, Azienda Ospedaliero-Universitaria, University of Modena and Reggio Emilia, Via del Pozzo 71, Modena, 41122, Italy
| | - Erica Franceschini
- Department of Infectious Diseases, Azienda Ospedaliero-Universitaria, University of Modena and Reggio Emilia, Via del Pozzo 71, Modena, 41122, Italy
| | - Gabriella Orlando
- Department of Infectious Diseases, Azienda Ospedaliero-Universitaria, University of Modena and Reggio Emilia, Via del Pozzo 71, Modena, 41122, Italy
| | - Adriana Cervo
- Department of Infectious Diseases, Azienda Ospedaliero-Universitaria, University of Modena and Reggio Emilia, Via del Pozzo 71, Modena, 41122, Italy
| | - Morselli Monica
- Section of Hematology, Department of Surgical and Medical Sciences, AOU Policlinico, University of Modena and Reggio Emilia, Modena, Italy
| | - Fabio Forghieri
- Section of Hematology, Department of Surgical and Medical Sciences, AOU Policlinico, University of Modena and Reggio Emilia, Modena, Italy
| | - Claudia Venturelli
- Clinical Microbiology Laboratory, University of Modena and Reggio Emilia, Via del Pozzo 71, Modena, 41122, Italy
| | - Enrico Ricchizzi
- Agenzia Sanitaria e Sociale Regionale Emilia-Romagna, Viale Aldo Moro 21, Bologna, 40127, Italy
| | - Johanna Chester
- Department of Dermatology, University of Modena and Reggio Emilia, Modena, 41121, Italy
| | - Mario Sarti
- Clinical Microbiology Laboratory, University of Modena and Reggio Emilia, Via del Pozzo 71, Modena, 41122, Italy
| | - Giovanni Guaraldi
- Department of Infectious Diseases, Azienda Ospedaliero-Universitaria, University of Modena and Reggio Emilia, Via del Pozzo 71, Modena, 41122, Italy
| | - Mario Luppi
- Section of Hematology, Department of Surgical and Medical Sciences, AOU Policlinico, University of Modena and Reggio Emilia, Modena, Italy
| | - Cristina Mussini
- Department of Infectious Diseases, Azienda Ospedaliero-Universitaria, University of Modena and Reggio Emilia, Via del Pozzo 71, Modena, 41122, Italy
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5
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Ramos JF, Pereira AD, Seiwald MCN, Gandolpho LS, Molla VC, Guaraná M, Nouér SA, Nucci M, Rodrigues CA. Low utilization of vancomycin in febrile neutropenia: real-world evidence from 4 Brazilian centers. Support Care Cancer 2023; 31:687. [PMID: 37947888 DOI: 10.1007/s00520-023-08152-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 10/30/2023] [Indexed: 11/12/2023]
Abstract
PURPOSE The prompt initiation of a betalactam antibiotic in febrile neutropenic patients is considered standard of care, while the empiric use of vancomycin is recommended by guidelines in specific situations, with a low level of evidence. The objective of this study was to assess the utilization of vancomycin in the management of febrile neutropenia within four Brazilian medical centers that implemented more stringent criteria for its administration. METHODS A comprehensive retrospective analysis was performed encompassing all instances of febrile neutropenia observed during the period from 2013 to 2019. The primary focus was to identify the reasons for initiating vancomycin therapy. RESULTS A total of 536 consecutive episodes of febrile neutropenia were documented, involving 384 patients with a median age of 52 years (range 18-86). Chemotherapy preceded febrile neutropenia in 59.7% of cases, while 40.3% occurred after hematopoietic stem cell transplantation. The most prevalent underlying diseases were acute myeloid leukemia (26.5%) and non-Hodgkin's lymphoma (22%). According to international guidelines, vancomycin should have been initiated at the onset of fever in 145 episodes (27%); however, it was administered in only 27 cases (5.0%). Three episodes were associated with Staphylococcus aureus bacteremia, two of which were methicillin resistant. The 15-day and 30-day mortality rates were 5.0% and 9.9%, respectively. CONCLUSIONS The results of this study underscore the notably low utilization rate of vancomycin in cases of febrile neutropenia, despite clear indications outlined in established guidelines. These findings emphasize the importance of carefully implementing guideline recommendations, considering local epidemiological factors, especially when the strength of recommendation is weak.
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Affiliation(s)
| | - André Domingues Pereira
- Universidade Federal de São Paulo, Sao Paulo, Brazil
- Instituto de Cardiologia Do Distrito Federal, Brasília, Brazil
| | | | - Larissa Simão Gandolpho
- Universidade Federal de São Paulo, Sao Paulo, Brazil
- Hospital Nove de Julho - Rede DASA, Sao Paulo, Brazil
| | - Vinicius Campos Molla
- Universidade Federal de São Paulo, Sao Paulo, Brazil
- Hospital Nove de Julho - Rede DASA, Sao Paulo, Brazil
| | - Mariana Guaraná
- Universidade Federal Do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Simone A Nouér
- Universidade Federal Do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marcio Nucci
- Universidade Federal Do Rio de Janeiro, Rio de Janeiro, Brazil.
- , Grupo Oncoclínicas, Brazil.
| | - Celso Arrais Rodrigues
- Universidade Federal de São Paulo, Sao Paulo, Brazil
- Hospital Nove de Julho - Rede DASA, Sao Paulo, Brazil
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Alves J, Abreu B, Palma P, Alp E, Vieceli T, Rello J. Antimicrobial Stewardship on Patients with Neutropenia: A Narrative Review Commissioned by Microorganisms. Microorganisms 2023; 11:1127. [PMID: 37317101 DOI: 10.3390/microorganisms11051127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 04/21/2023] [Accepted: 04/24/2023] [Indexed: 06/16/2023] Open
Abstract
The emergence of antibiotic resistance poses a global health threat. High-risk patients such as those with neutropenia are particularly vulnerable to opportunistic infections, sepsis, and multidrug-resistant infections, and clinical outcomes remain the primary concern. Antimicrobial stewardship (AMS) programs should mainly focus on optimizing antibiotic use, decreasing adverse effects, and improving patient outcomes. There is a limited number of published studies assessing the impact of AMS programs on patients with neutropenia, where early appropriate antibiotic choice can be the difference between life and death. This narrative review updates the current advances in strategies of AMS for bacterial infections among high-risk patients with neutropenia. Diagnosis, drug, dose, duration, and de-escalation (5D) are the core variables among AMS strategies. Altered volumes of distribution can make standard dose regimens inadequate, and developing skills towards a personalized approach represents a major advance in therapy. Intensivists should partner antibiotic stewardship programs to improve patient care. Assembling multidisciplinary teams with trained and dedicated professionals for AMS is a priority.
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Affiliation(s)
- Joana Alves
- Infectious Diseases Department, Hospital de Braga, 4710-243 Braga, Portugal
| | - Betânia Abreu
- Pharmaceuticals Department, Hospital de Braga, 4710-243 Braga, Portugal
| | - Pedro Palma
- Infectious Diseases Department, Centro Hospitalar do Tâmega e Sousa, 4564-007 Penafiel, Portugal
| | - Emine Alp
- Infectious Diseases and Clinical Microbiology Department, Ankara Yıldırım Beyazıt University, 06760 Ankara, Turkey
| | - Tarsila Vieceli
- Infectious Diseases Department, Hospital de Clínicas de Porto Alegre, Porto Alegre 90035-903, Brazil
| | - Jordi Rello
- Clinical Research in Pneumonia & Sepsis (CRIPS), Vall d'Hebron Institute of Research (VHIR), 08035 Barcelona, Spain
- FOREVA Research Pôle, Centre Hôpitalaire Universitaire de Nîmes, 30900 Nîmes, France
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7
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Carcò D, Castorina P, Guardo P, Iachelli V, Pace T, Scirè P, Stanco R, Markovic U, Milone GA, Galbo F, Moschetti G, Martorana E. Combination of Interleukin-6, C-Reactive Protein and Procalcitonin Values as Predictive Index of Sepsis in Course of Fever Episode in Adult Haematological Patients: Observational and Statistical Study. J Clin Med 2022; 11:jcm11226800. [PMID: 36431277 PMCID: PMC9694618 DOI: 10.3390/jcm11226800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 10/21/2022] [Accepted: 11/14/2022] [Indexed: 11/19/2022] Open
Abstract
Haematological patients represent a vulnerable population to opportunistic infections, mainly due to the disease itself and chemotherapy-induced neutropenia. The level of immune suppression strongly increases the importance of timely antibiotic treatment in order to prevent sepsis-related mortality. During the initial fever episode, serum biomarkers are usually used to estimate the probability of blood stream infection prior to the results of microbial diagnosis. A new serum biomarker combination study on a febrile haematological population, including C-reactive protein (CRP), interleukin-6 (IL-6) and procalcitonin (PCT), is proposed in order to improve their predictive accuracy. In our prospective study, CRP, IL-6 and PCT were evaluated in 34 immunosuppressed haematological patients immediately after the onset of 51 fever episodes, either during the course of standard chemotherapy or high-dose chemotherapy and autologous stem cell transplant. The fever episodes were divided into documented infections and fever alone. Receiver operating characteristic analysis (ROC) was performed for each biomarker and a combination of all three biomarkers (multiROC) to define a new predictive index. Significant differences were evidenced between the two groups (documented infection and no infection) for both PCT and IL-6 (p = 0.03 and p = 0.035, respectively), but none for CRP (p = 0.1). The composite parameter is more reliable than any single biomarker alone, with an area under the curve (AUC) of 79% and with high sensitivity and specificity. IL-6 gave the closest response compared to the composite index. Composite parameters of serum biomarkers could be used for an early diagnosis of infection at fever onset in haematological patients.
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Affiliation(s)
- Daniela Carcò
- Istituto Oncologico del Mediterraneo, 95029 Viagrande, Italy
- Correspondence: (D.C.); (E.M.)
| | - Paolo Castorina
- Istituto Oncologico del Mediterraneo, 95029 Viagrande, Italy
- Istituto Nazionale Fisica Nucleare, 95125 Catania, Italy
- Faculty of Mathematics and Physics, Charles University, 121 16 Prague, Czech Republic
| | - Paola Guardo
- Istituto Oncologico del Mediterraneo, 95029 Viagrande, Italy
| | | | - Tecla Pace
- Istituto Oncologico del Mediterraneo, 95029 Viagrande, Italy
| | - Paola Scirè
- Istituto Oncologico del Mediterraneo, 95029 Viagrande, Italy
| | - Rosaria Stanco
- Istituto Oncologico del Mediterraneo, 95029 Viagrande, Italy
| | - Uros Markovic
- Division of Hematology, Azienda Ospedaliero Universitaria Policlinico “G.Rodolico-San Marco”, 95123 Catania, Italy
| | | | - Federica Galbo
- Istituto Oncologico del Mediterraneo, 95029 Viagrande, Italy
| | | | - Emanuele Martorana
- Istituto Oncologico del Mediterraneo, 95029 Viagrande, Italy
- Correspondence: (D.C.); (E.M.)
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Siebert M, Lucas N, Gelli M, Sourrouille I, Benhaïm L, Faron M, Micol JB, Ducreux M, Stoclin A, Honoré C. Acute Abdominal Complications in Deeply Neutropenic Onco-Hematology Patients: A Retrospective Series of 105 Cases. World J Surg 2022; 46:2389-2398. [PMID: 35816234 DOI: 10.1007/s00268-022-06653-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2022] [Indexed: 12/07/2022]
Abstract
BACKGROUND Acute abdominal complications (AAC) in patients with deep neutropenia (DN) is challenging to manage because of the expected influence of AAC on oncological prognosis and higher surgical complication rate in a period of DN. In practice, these parameters are difficult to appreciate. This study reported our experience in managing these patients. METHODS All consecutive patients treated in our tertiary care cancer center between 2010 and 2020 who developed AAC in the context of a DN were retrospectively analyzed. AAC was defined as an infection (intra-abdominal, perineal, or cutaneous), bowel obstruction, or intra-abdominal hemorrhage. FINDINGS Among 105 patients, 18 (17%) required emergent surgery (group 1), 34 patients had a complication requiring surgical oversight (group 2), and 53 patients had a non-surgical etiology (group 3). Fifteen patients underwent surgery in the group 1, three in group 2, and one in group 3. Overall, 28 patients died during hospitalization. Mortality was statistically different between the groups (p = 0·01), with a higher rate in group 1 (n = 9/18, 50%) than in group 2 (n = 11/34, 32%) and group 3 (n = 8/53, 15%). All groups together had a median overall survival (OS) of 14 months and disease-free survival (DFS) of 10 months. OS was not comparable between the groups, and the median length of survival in group 1 was 6 months versus 8 months in group 2 and 23 months in group 3. In group 1, five patients (5/18, 28%) did not relapse at the end of the follow-up compared to 13 in group 2 (13/34, 38%) and 25 in group 3 (25/53, 47%). After discharge, OS and DFS were similar between the groups. INTERPRETATION The advent of an AAC necessitating surgery in the context of DN is a deadly event associated with a 50% mortality; nonetheless, in case of unpostponable emergencies, surgery can provide long-term survival in selected patients.
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Affiliation(s)
- Matthieu Siebert
- Department of Surgical Oncology, Gustave Roussy Cancer Campus, 114, Rue Edouard Vaillant, 94805, Villejuif, France.
| | - Nolwenn Lucas
- Department of Intensive Care, Gustave Roussy Cancer Campus, Villejuif, France
| | - Maximiliano Gelli
- Department of Surgical Oncology, Gustave Roussy Cancer Campus, 114, Rue Edouard Vaillant, 94805, Villejuif, France
| | - Isabelle Sourrouille
- Department of Surgical Oncology, Gustave Roussy Cancer Campus, 114, Rue Edouard Vaillant, 94805, Villejuif, France
| | - Léonor Benhaïm
- Department of Surgical Oncology, Gustave Roussy Cancer Campus, 114, Rue Edouard Vaillant, 94805, Villejuif, France
| | - Matthieu Faron
- Department of Surgical Oncology, Gustave Roussy Cancer Campus, 114, Rue Edouard Vaillant, 94805, Villejuif, France
| | | | - Michel Ducreux
- Department of Medical Oncology, Gustave Roussy Cancer Campus, Villejuif, France
| | - Annabelle Stoclin
- Department of Intensive Care, Gustave Roussy Cancer Campus, Villejuif, France
| | - Charles Honoré
- Department of Surgical Oncology, Gustave Roussy Cancer Campus, 114, Rue Edouard Vaillant, 94805, Villejuif, France
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Effect of Combination Antibiotic Empirical Therapy on Mortality in Neutropenic Cancer Patients with Pseudomonas aeruginosa Pneumonia. Microorganisms 2022; 10:microorganisms10040733. [PMID: 35456784 PMCID: PMC9027680 DOI: 10.3390/microorganisms10040733] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 03/18/2022] [Accepted: 03/21/2022] [Indexed: 12/30/2022] Open
Abstract
To assess the effect of combination antibiotic empirical therapy on 30-day case-fatality rate in neutropenic cancer patients with Pseudomonas aeruginosa (PA) bacteremic pneumonia. This was a multinational, retrospective cohort study of neutropenic onco-hematological patients with PA bloodstream infection (BSI) (2006−2018). The effect of appropriate empirical combination therapy, appropriate monotherapy and inappropriate empirical antibiotic therapy [IEAT] on 30-day case-fatality was assessed only in patients with PA bacteremic pneumonia. Among 1017 PA BSI episodes, pneumonia was the source of BSI in 294 (28.9%). Among those, 52 (17.7%) were caused by a multidrug-resistant (MDR) strain and 68 (23.1%) received IEAT, mainly when the infection was caused by an MDR strain [38/52 (73.1%) vs. 30/242 (12.4%); p < 0.001]. The 30-day case-fatality rate was higher in patients with PA bacteremic pneumonia than in those with PA BSI from other sources (55.1% vs. 31.4%; p < 0.001). IEAT was associated with increased 30-day case-fatality (aHR 1.44 [95%CI 1.01−2.03]; p = 0.042), whereas the use of appropriate combination empirical treatment was independently associated with improved survival (aHR 0.46 [95%CI 0.27−0.78]; p = 0.004). Appropriate empirical monotherapy was not associated with improved overall survival (aHR 1.25 [95%CI 0.76−2.05]; p = 0.39). Combination antibiotic empirical therapy should be administered promptly in febrile neutropenic patients with suspected pneumonia as the source of infection.
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10
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Impact of empirical antibiotic regimens on mortality in neutropenic patients with bloodstream infection presenting with septic shock. Antimicrob Agents Chemother 2021; 66:e0174421. [PMID: 34843387 DOI: 10.1128/aac.01744-21] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Objectives: We analyzed risk factors for mortality in febrile neutropenic patients with bloodstream infections (BSI) presenting with septic shock and assessed the impact of empirical antibiotic regimens. Methods: Multicenter retrospective study (2010-2019) of two prospective cohorts comparing BSI episodes in patients with or without septic shock. Multivariate analysis was performed to identify independent risk factors for mortality in episodes with septic shock. Results: Of 1563 patients with BSI, 257 (16%) presented with septic shock. Those patients with septic shock had higher mortality than those without septic shock (55% vs 15%, p<0.001). Gram-negative bacilli caused 81% of episodes with septic shock; gram-positive cocci, 22%; and Candida species 5%. Inappropriate empirical antibiotic treatment (IEAT) was administered in 17.5% of septic shock episodes. Empirical β-lactam combined with other active antibiotics was associated with the lowest mortality observed. When amikacin was the only active antibiotic, mortality was 90%. Addition of empirical specific gram-positive coverage had no impact on mortality. Mortality was higher when IEAT was administered (76% vs 51%, p=0.002). Age >70 years (OR 2.3, 95% CI 1.2-4.7), IEAT for Candida spp. or gram-negative bacilli (OR 3.8, 1.3-11.1), acute kidney injury (OR 2.6, 1.4-4.9) and amikacin as the only active antibiotic (OR 15.2, 1.7-134.5) were independent risk factors for mortality, while combination of β-lactam and amikacin was protective (OR 0.32, 0.18-0.57). Conclusions: Septic shock in febrile neutropenic patients with BSI is associated with extremely high mortality, especially when IEAT is administered. Combination therapy including an active β-lactam and amikacin results in the best outcomes.
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11
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Buchan CA, Li HOY, Herry C, Scales N, MacPherson P, Faller E, Bredeson C, Huebsch L, Hodgins M, Seely AJE. Early Warning of Infection in Patients Undergoing Hematopoietic Stem Cell Transplantation Using Heart Rate Variability and Serum Biomarkers. Transplant Cell Ther 2021; 28:166.e1-166.e8. [PMID: 33964517 DOI: 10.1016/j.jtct.2021.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 04/22/2021] [Accepted: 04/25/2021] [Indexed: 10/21/2022]
Abstract
Early warning of infection is critical to reduce the risk of deterioration and mortality, especially in neutropenic patients following hematopoietic stem cell transplantation (HCT). Given that heart rate variability (HRV) is a sensitive and early marker for infection, and that serum inflammatory biomarkers can have high specificity for infection, we hypothesized their combination may be useful for accurate early warning of infection. In this study, we developed and evaluated a composite predictive model using continuous HRV with daily serum biomarker measurements to provide risk stratification of future deterioration in HCT recipients. A total of 116 ambulatory outpatients about to undergo HCT consented to collection of prospective demographic, clinical (daily vital signs), HRV (continuous electrocardiography [ECG] monitoring, laboratory [daily serum samples frozen at -80 °C]), and infection outcome variables (defined as the time of escalation of antibiotics), all from 24 hours pre-HCT to the onset of infection or 14 days post-HCT. Indications for antibiotic escalation were adjudicated as "true infection" or not by 2 blinded HCT clinicians. A composite time series of 8 HRV metrics was created for each patient, and the probability of deterioration within the next 72 hours was estimated using logistic regression modeling of composite HRV and serum biomarkers using a rule-based naïve Bayes model if the HRV-based probability exceeded a median threshold. Thirty-five patients (30%) withdrew within <24 hours owing to intolerability of ECG monitoring, leaving 81 patients, of whom 48 (59%) had antibiotic escalation adjudicated as true infection. The combined HRV and biomarker (TNF-α, IL-6, and IL-7) predictive model began increasing at ∼48 hours on average before the diagnosis of infection, could distinguish between high risk of impending infection (>90% incidence of subsequent infection within 72 hours), average risk (∼50%), and low risk (<10%), with an area under the receiver operating characteristic curve of 0.87. However, given that prophylactic predictive ECG monitoring and daily serum collection proved challenging for many patients, further refinement in measurement is necessary for further study.
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Affiliation(s)
- C Arianne Buchan
- Division of Infectious Diseases, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada; Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
| | - Heidi Oi-Yee Li
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Nathan Scales
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Paul MacPherson
- Division of Infectious Diseases, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada; Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Elliott Faller
- Division of Infectious Diseases, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Christopher Bredeson
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Division of Hematology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Lothar Huebsch
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Division of Hematology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Michael Hodgins
- Division of Hematology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Andrew J E Seely
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Departments of Critical Care Medicine and Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
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12
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Gudiol C, Albasanz-Puig A, Cuervo G, Carratalà J. Understanding and Managing Sepsis in Patients With Cancer in the Era of Antimicrobial Resistance. Front Med (Lausanne) 2021; 8:636547. [PMID: 33869250 PMCID: PMC8044357 DOI: 10.3389/fmed.2021.636547] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 03/08/2021] [Indexed: 12/23/2022] Open
Abstract
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.
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Affiliation(s)
- Carlota Gudiol
- Infectious Diseases Department, Bellvitge University Hospital, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona, Barcelona, Spain.,Institut Català d'Oncologia (ICO), Hospital Duran i Reynals, Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain.,Spanish Network for Research in Infectious Diseases (REIPI RD16/0016/0001), Instituto de Salud Carlos III, Madrid, Spain
| | - Adaia Albasanz-Puig
- Infectious Diseases Department, Bellvitge University Hospital, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona, Barcelona, Spain.,Spanish Network for Research in Infectious Diseases (REIPI RD16/0016/0001), Instituto de Salud Carlos III, Madrid, Spain
| | - Guillermo Cuervo
- Infectious Diseases Department, Bellvitge University Hospital, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona, Barcelona, Spain.,Spanish Network for Research in Infectious Diseases (REIPI RD16/0016/0001), Instituto de Salud Carlos III, Madrid, Spain
| | - Jordi Carratalà
- Infectious Diseases Department, Bellvitge University Hospital, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona, Barcelona, Spain.,Spanish Network for Research in Infectious Diseases (REIPI RD16/0016/0001), Instituto de Salud Carlos III, Madrid, Spain
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13
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Abstract
The management of febrile neutropenia is a backbone of treating patients with hematologic malignancies and has evolved over the past decades. This article reviews my approach to the evaluation and treatment of febrile neutropenic patients. Key topics discussed include antibacterial and antifungal prophylaxis, the initial workup for fever, the choice of the empiric antibiotic regimen and its modifications, and criteria for discontinuation. For each of these questions, I review the literature and present my perspective.
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14
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Abstract
Critically ill patients with cancer are vulnerable to infections because of the underlying malignancy, tumor-directed therapy, immunosuppression, breaches in mucosa or skin, malnutrition, and other factors. Neutropenia remains the most important risk factor for infection. Infectious complications occurring in critically ill patients with cancer can affect the bloodstream, lungs, gastrointestinal tract, central nervous system, urinary tract, and the skin. Pneumonias are the leading cause of infection in patients with cancer admitted to the intensive care unit. Consideration of opportunistic pathogens in the differential diagnosis is important in patients with impaired cellular and/or humoral immunity or compromised splenic function.
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Affiliation(s)
- Susan K Seo
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA; Department of Medicine, Weill Cornell Medical College, New York, NY, USA.
| | - Catherine Liu
- Vaccine and Infectious Disease Division, Fred Hutchison Cancer Research Center, 1100 Fairview Avenue North, Seattle, WA 98109, USA; Department of Medicine, University of Washington, Seattle, WA, USA
| | - Sanjeet S Dadwal
- Division of Infectious Diseases, Department of Medicine, City of Hope National Medical Center, 1500 East Duarte Road, Duarte, CA 91010, USA
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15
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Ghosh S, Chakraborty M, Samanta S, Sinha N, Saha S, Chattopadhyay A, Roy SS, Bhattacharyya M. Analysis of blood stream infections, antibiograms and clinical outcomes in haematological patients with febrile neutropenia: data from a tertiary care haematology institute in India. Ann Hematol 2020; 100:395-403. [PMID: 33140134 DOI: 10.1007/s00277-020-04324-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 10/26/2020] [Indexed: 12/25/2022]
Abstract
Timely administration of appropriate empirical antibiotics in febrile neutropenia is crucial for favourable patient outcomes. There are guidelines in place recommending such antibiotics. However, regional variations and local epidemiological data must be evaluated to tailor the antibiotics for best possible and rational use. In this study, we audited the clinical and microbiological data of febrile neutropenic episodes occurring at a tertiary care haematology institution. Three hundred and ninety-three febrile neutropenic episodes occurring in 123 patients over a 1-year period were analysed for microbial profile, sensitivity and resistance patterns, and finally clinical outcomes. Gram-negative bacilli (GNB) blood stream infections (46.9%) were more prevalent as compared to gram-positive infections (41.9%). Overall mortality due to complicated neutropenic sepsis was 19.5% (24/123 patients). Increased resistance to carbapenems, beta-lactam beta-lactamase inhibitor combinations, aminoglycosides, fluoroquinolones, and cephalosporins were observed. Cefepime and tigecycline resistance were seen in 20% and 15% GNB isolates, respectively. Chest was the most frequent focus of infection, and acute myeloid leukaemia (AML) was the most common underlying disorder which correlated with the likelihood of death (p < 0.01). Multidrug-resistant GNB (esp. Klebsiella sp.) are still most worrisome isolates in neutropenic patients. Single-agent cefepime or piperacillin-tazobactam/tigecycline combination may be considered empirical agents. Chest infections and AML were independent predictors of poor clinical outcome in neutropenic patients. Regular audit of infections and antibiotic susceptibility data is needed to improve clinical outcomes in patients with febrile neutropenia.
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Affiliation(s)
- Shouriyo Ghosh
- Institute of Haematology and Transfusion Medicine, Medical College Hospital, 88, College Street, Kolkata, West Bengal, 700073, India
| | | | - Sambit Samanta
- Institute of Haematology and Transfusion Medicine, Medical College Hospital, 88, College Street, Kolkata, West Bengal, 700073, India
| | - Nilanjan Sinha
- Institute of Haematology and Transfusion Medicine, Medical College Hospital, 88, College Street, Kolkata, West Bengal, 700073, India
| | - Sandeep Saha
- Institute of Haematology and Transfusion Medicine, Medical College Hospital, 88, College Street, Kolkata, West Bengal, 700073, India
| | - Arnab Chattopadhyay
- Institute of Haematology and Transfusion Medicine, Medical College Hospital, 88, College Street, Kolkata, West Bengal, 700073, India
| | - Siddhartha Sankar Roy
- Institute of Haematology and Transfusion Medicine, Medical College Hospital, 88, College Street, Kolkata, West Bengal, 700073, India
| | - Maitreyee Bhattacharyya
- Institute of Haematology and Transfusion Medicine, Medical College Hospital, 88, College Street, Kolkata, West Bengal, 700073, India.
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16
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Moore Pardo SM, Patel RH, Ramsakal A, Greene J. Disseminated Corynebacterium jeikeium Infection in Cancer Patients. Cureus 2020; 12:e8764. [PMID: 32714702 PMCID: PMC7377673 DOI: 10.7759/cureus.8764] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Corynebacterium jeikeium is a multidrug-resistant gram-positive bacterium of the human skin flora and one of the most clinically important nondiphtherial corynebacteria in the acute care setting. C. jeikeium can cause different forms of infections, especially in immunocompromised patients with underlying risk factors and comorbidities. C. jeikeium was initially described in 1976 as a highly resistant coryneform bacteria causing severe sepsis in patients with hematologic malignancies and profound neutropenia. C. jeikeium infection has also been reported in the setting of endocarditis, septicemia, meningitis, pneumonia, and soft tissue infections. Management of disseminated C. jeikeium infection in immunocompromised cancer patients can be challenging due to its high virulence and rapid skin colonization. We present two cases of disseminated C. jeikeium infection in patients with acute myelogenous leukemia (AML) and underlying comorbidities. Both patients presented with neutropenic fever resistant to initial standard empiric antibiotic therapy.
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Affiliation(s)
| | - Raj H Patel
- Internal Medicine, University of South Florida, Tampa, USA
| | - Asha Ramsakal
- Internal Medicine, Moffitt Cancer Center, Tampa, USA
| | - John Greene
- Internal Medicine, Moffitt Cancer Center, Tampa, USA
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