A study of bacteremia in febrile neutropenic patients at a tertiary-care hospital with special reference to anaerobes

Bacteremia due to obligate anaerobes following large bowel surgery in a tertiary care hospital in South India

In view of the rising incidence of Anaerobic bacteremia(AB), the use of anaerobic blood culture bottles have been recommended in addition to the aerobic blood culture bottles. The need to perform antimicrobial susceptibility testing(AST) for anaerobes has become mandatory owing to increasing metronidazole resistance. The frequency of AB following large bowel surgery and the metronidazole susceptibility for members of the Bacteroides fragilis group were determined. The incidence of AB was found to be 16%. Seventeen obligate anaerobes were isolated in total, of which B. fragilis was the most common. Two of twelve isolates of B. fragilis were resistant to metronidazole.

Clinical Profile and Microbiologic Spectrum of Febrile Neutropenic Episodes in Children With Severe Aplastic Anemia

BACKGROUND

Febrile neutropenia (FN) is a common life-threatening complication in patients with severe aplastic anemia (SAA). However, few studies have examined the spectrum of infections in FN in patients with SAA, especially in children. Therefore, the current study was planned to study the clinicomicrobiologic profile of FN episodes in these children.

MATERIALS AND METHODS

Data of 38 episodes of FN that occurred in 31 children with SAA from November 2015 to April 2017 were collected prospectively and analyzed.

RESULTS

FN episodes occurred more frequently (54.8%) in patients on immunosuppressive therapy. Clinically documented infections accounted for 21 (55.26%) episodes, microbiologically documented infections for 15 (39.47%), bacteremia for 13 (34.21%), and invasive fungal diseases for 6 (15.78%) episodes. Among clinically documented infections, the lower respiratory tract was the commonest site in 23.68% episodes, followed by skin and soft tissue infections. No focus of infection could be identified in 12 (31.57%) episodes. Gram-negative bacteria (71.42%) were the predominant isolates (commonest Klebsiella pneumoniae) over Gram-positive bacteria (commonest coagulase-negative Staphylococcus). High prevalence of aminoglycoside, piperacillin-tazobactam, and carbapenem resistance was noted among Gram-negative organisms. Gram-positive organisms showed excellent sensitivity to vancomycin, linezolid, and clindamycin. The overall mortality rate was 42%.

CONCLUSIONS

Empirical antimicrobial therapy should include adequate coverage for Gram-negative pathogens. The antimicrobial regimen should be modified according to the results of the culture and sensitivity testing.

Bloodstream infections in febrile neutropenic patients at a tertiary cancer institute in South India: A timeline of clinical and microbial trends through the years

Introduction:

Febrile neutropenia (FN) is an oncological emergency. The choice of empiric therapy depends on the locally prevalent pathogens and their sensitivities, the sites of infection, and cost. The Infectious Diseases Society of America guidelines are being followed for the management of FN in India.

Methods:

This is a prospective observational study conducted at a tertiary care cancer centre from September 2012 to September 2014.

Objectives:

The objectives of this study were as follows: (1) To review the pattern of microbial flora, susceptibility pattern, and important clinical variables among bloodstream infections in febrile neutropenic patients with solid tumors and hematological malignancies. (2) As per the institutional protocol to periodically review the antibiotic policy and susceptibility pattern, and compare the findings with an earlier study done in our institute in 2010. This was a prospective study conducted from September 2012 to September 2014.

Results:

About 379 episodes of FN were documented among 300 patients. About 887 blood cultures were drawn. Of these, 137 (15%) isolates were cultured. Isolates having identical antibiograms obtained from a single patient during the same hospitalization were considered as one. Hence, 128 isolates were analyzed. About 74 (58%) cultures yielded Gram-negative bacilli, 51 (40%) were positive for Gram-positive cocci, and 3 (2%) grew fungi. Among Gram-negative organisms, Escherichia coli followed by Acinetobacter baumannii and Klebsiella pneumoniae accounted for 78% of the isolates. Among Gram-positive cocci, Staphylococcus species accounted for 84% of the isolates. We have noted a changing trend in the antibiotic sensitivity pattern over the years. Following the switch in empirical antibiotics, based on the results of the study done in 2010 (when the empirical antibiotics were ceftazidime + amikacin), the sensitivity to cefoperazone-sulbactam has plunged from about 80% to 60%%. Similar reduction in susceptibility was noted for piperacillin-tazobactam, imipenem, and meropenem. On the contrary, there was a marked increase in sensitivity to ceftazidime (50–76%). Based on these results, we have reverted to ceftazidime + amikacin as the empirical antibiotics.

Conclusion:

Every institute must have a regular revision of antibiotic policy based on periodic assessment of the clinical and microbiological profile in FN. This will combat antibiotic resistance.

Evaluation of predictors of adverse outcome in febrile neutropenic episodes in pediatric oncology patients

OBJECTIVES

To identify predictors associated with adverse outcome in febrile neutropenic episodes among pediatric oncology patients between 1 and 18 y age, to ascertain the prevalence of invasive bacterial or fungal infection/mortality, to determine the common organisms causing invasive bacterial infection in children with febrile neutropenia and to evaluate their current antimicrobial sensitivity pattern.

METHODS

It was an observational descriptive study conducted between February 2009 through July 2010. Febrile neutropenic episodes satisfying the inclusion criteria were enrolled. Relevant history was taken followed by a detailed clinical examination and laboratory examination. Logistic Regression analysis was used to identify significant predictors of adverse outcome in febrile neutropenic episodes.

RESULTS

Out of the 155 febrile neutropenic episodes studied, adverse outcome occurred in 53(34 %) of the episodes. History of three or more previous episodes of febrile neutropenia, child being already on oral antibiotics and Chest Radiograph abnormality at presentation were found to be significantly associated with adverse outcome on multivariate logistic regression analysis. Documented invasive bacterial and fungal infection was seen in 27.8 % and 14.2 % episodes. Mortality occurred in 8 (5 %) of episodes. Gram negative bacterial infections were more common. Most common bacteria isolated was Escherichia coli and the commonest gram positive organism isolated was Staphylococcus aureus (MSSA).

CONCLUSIONS

On multivariate analysis, the variables found to be significantly associated with adverse outcome in febrile neutropenic episodes were three or more previous episodes of febrile neutropenia, child being already on oral antibiotics and Chest Radioraph abnormality at presentation.

Febrile neutropenia: outline of management

Febrile neutropenia is a common emergency encountered in children receiving chemotherapy for a malignancy. Left untreated, it can lead to serious morbidity and mortality. Febrile neutropenia is suspected in any patient on chemotherapy who presents with fever. Prompt evaluation and management by the primary contact pediatrician is essential for a successful outcome. A detailed history and physical examination is warranted to identify source of infection, although two thirds of them may not have localizing symptoms or signs. Risk stratification is valuable in categorizing the severity and guiding therapy. Initial stabilization, prompt initiation of appropriate antibiotics and adequate supportive care are the cornerstone of treatment. Knowledge of the locally prevailing bacteriological profile and antimicrobial susceptibility data is crucial for each hospital/unit to frame and periodically modify guidelines for the choice of antimicrobials. Delay in initiating antimicrobials significantly worsens the outcome. Education of the family as well as the members of the treating unit is important in this regard. Pro-active steps must be taken to reduce incidence of hospital acquired sepsis. Diagnosis and management in relevance to the emergency room is reviewed and institutional practice is shared.

Profile of infections and outcome in high-risk febrile neutropenia: experience from a tertiary care cancer center in India

Objective of the present study was to describe the profile of infections in febrile neutropenia (FN) in acute leukemia and hematopoietic stem cell transplant (HSCT) with emphasis on response to therapy and outcome. In a prospective, observational single-institutional study, consecutive episodes of high-risk FN were enrolled over a 1½-year period. Uniform antibiotic policy and response criteria were used. Of the 200 episodes enrolled, acute leukemia induction comprised 40.5%, consolidation with high-dose cytarabine 22.5%, HSCT 29% (auto-HSCT 84%), and others 8% of the episodes, respectively. Microbiologically documented infections comprised 30% episodes, while bacteremia was documented in 26% episodes. Gram-negative isolates were more common (55.7%). Cefoperazone-sulbactam had the highest in vitro efficacy against Gram-negative rods. Carbapenem resistance was most prevalent among Acinetobacter spp. (80%) and Pseudomonas aeruginosa (50%). All Gram-positive cocci other than enterococci were susceptible to vancomycin, while 2/8 enterococci were resistant to it. Cefoperazone-sulbactam and amikacin were used as first-line antibiotics. Overall mortality was 8%. On multivariate analysis, mortality was associated with a nadir leukocyte count < 200/μl and an abnormal chest radiograph. Among high-risk FN patients, inspite of a high-level of resistance to antibiotics, a frontline regime containing cefoperazone-sulbactam could restrict the use of imipenem and resulted in an acceptable mortality of 8%.

Prophylactic and therapeutic strategies in chemotherapy-induced neutropenia

INTRODUCTION

Neutropenia poses a serious threat to patients on chemotherapy. It exposes them to the risk of infection--including potentially fatal infections--and also leads to delays in treatment and reductions in dose intensity, which can compromise the possibility of a favorable outcome.

AREAS COVERED

The use of granulocyte colony-stimulating factors (G-CSF) and antibiotics to prevent febrile neutropenia (FN) and to ameliorate cancer chemotherapy-induced myelosuppression is discussed, based on a systematic search of Pubmed for clinical trials, reviews and meta-analysis published in the last 20 years. We consider that the treatment of FN, with the emphasis on careful attention to the patient, prompts antibiotic therapy and good hospital care.

EXPERT OPINION

We would argue that antibiotic prophylaxis should be offered routinely to patients receiving cytotoxic chemotherapy for acute leukemia and for patients with solid tumors and lymphoma receiving high-dose chemotherapy. In patients undergoing cyclical standard-dose myelosuppressive chemotherapy, we believe that prophylaxis is indicated during the first cycle of chemotherapy in which there is an expectation of grade 4 neutropenia (< 500 neutrophils). However, although the use of antibiotics and haematopoietic growth factors may improve quality of life by reducing the risk and consequences of FN, further study of the magnitude of their effects is needed.

Diagnostic approach of pulmonary disease in the HIV negative immunocompromised host

The advances in medicine have resulted in increasing number of immunocompromised patients with complications related to their underlying disease or the treatment of these conditions. Pulmonary infectious and non-infectious conditions are a major cause of morbidity and mortality in these patients, and represent a diagnostic challenge. This article reviews the major conditions causing pulmonary symptoms in the HIV negative immunocompromised host. It also discusses the role of the different diagnostic methods, including the recent advances in non-invasive studies, in reaching a diagnosis of pulmonary disease in this patient population.

Emergence of MRSA in positive blood cultures from patients with febrile neutropenia--a cause for concern

GOALS OF WORK

Febrile neutropenia (FN) causes considerable morbidity in patients on cytotoxic chemotherapy. Recently, there has been a trend towards fewer Gram-negative and more Gram-positive infections with increasing antibiotic resistance. To assess these patterns, data from a supra-regional cancer centre in Ireland were reviewed.

PATIENTS AND METHODS

A 5-year review of all positive blood cultures in patients undergoing anti-cancer chemotherapy was carried out.

MAIN RESULTS

Eight hundred and ninety-four patients were reviewed. The mean incidence of FN was 64.2 cases per year. Eight hundred and forty-six blood culture specimens were taken and 173 (20.4%) were culture positive. The isolated organisms were Gram positive (71.1%), Gram negative (27.8%) and fungal (1.1%). Of the Gram-positive organisms, 75.6% were staphylococci. Of these, 67.8% were coagulase-negative staphylococci and 30.1% were Staphylococci aureus. Amongst the S. aureus, 89.3% were methicillin-resistant (MRSA). Vancomycin-resistant enterococci were not identified as a cause of positive blood cultures.

CONCLUSIONS

Amongst patients with cancer who develop FN in our hospital, Gram-positive bacteria account for the largest proportion. The high proportion of MRSA as a cause of positive blood cultures is of concern.