Prophylactic trimethoprim-sulfamethoxazole during consolidation chemotherapy for acute leukemia: a controlled trial

Antibiotic prophylaxis for bacterial infections in afebrile neutropenic patients following chemotherapy

BACKGROUND

Bacterial infections are a major cause of morbidity and mortality in patients who are neutropenic following chemotherapy for malignancy. Trials have shown the efficacy of antibiotic prophylaxis in reducing the incidence of bacterial infections but not in reducing mortality rates. Our systematic review from 2006 also showed a reduction in mortality.

OBJECTIVES

This updated review aimed to evaluate whether there is still a benefit of reduction in mortality when compared to placebo or no intervention.

SEARCH METHODS

We searched the Cochrane Cancer Network Register of Trials (2011), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2011), MEDLINE (1966 to March 2011), EMBASE (1980 to March 2011), abstracts of conference proceedings and the references of identified studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs comparing different types of antibiotic prophylaxis with placebo or no intervention, or another antibiotic, to prevent bacterial infections in afebrile neutropenic patients.

DATA COLLECTION AND ANALYSIS

Two authors independently appraised the quality of each trial and extracted data from the included trials. Analyses were performed using RevMan 5.1 software.

MAIN RESULTS

One-hundred and nine trials (involving 13,579 patients) that were conducted between the years 1973 to 2010 met the inclusion criteria. When compared with placebo or no intervention, antibiotic prophylaxis significantly reduced the risk of death from all causes (46 trials, 5635 participants; risk ratio (RR) 0.66, 95% CI 0.55 to 0.79) and the risk of infection-related death (43 trials, 5777 participants; RR 0.61, 95% CI 0.48 to 0.77). The estimated number needed to treat (NNT) to prevent one death was 34 (all-cause mortality) and 48 (infection-related mortality).Prophylaxis also significantly reduced the occurrence of fever (54 trials, 6658 participants; RR 0.80, 95% CI 0.74 to 0.87), clinically documented infection (48 trials, 5758 participants; RR 0.65, 95% CI 0.56 to 0.76), microbiologically documented infection (53 trials, 6383 participants; RR 0.51, 95% CI 0.42 to 0.62) and other indicators of infection.There were no significant differences between quinolone prophylaxis and TMP-SMZ prophylaxis with regard to death from all causes or infection, however, quinolone prophylaxis was associated with fewer side effects leading to discontinuation (seven trials, 850 participants; RR 0.37, 95% CI 0.16 to 0.87) and less resistance to the drugs thereafter (six trials, 366 participants; RR 0.45, 95% CI 0.27 to 0.74).

AUTHORS' CONCLUSIONS

Antibiotic prophylaxis in afebrile neutropenic patients significantly reduced all-cause mortality. In our review, the most significant reduction in mortality was observed in trials assessing prophylaxis with quinolones. The benefits of antibiotic prophylaxis outweighed the harm such as adverse effects and the development of resistance since all-cause mortality was reduced. As most trials in our review were of patients with haematologic cancer, we strongly recommend antibiotic prophylaxis for these patients, preferably with a quinolone. Prophylaxis may also be considered for patients with solid tumours or lymphoma.

Interventions for preventing oral candidiasis for patients with cancer receiving treatment

BACKGROUND

Treatment of cancer is increasingly more effective but is associated with short and long term side effects. Oral side effects remain a major source of illness despite the use of a variety of agents to prevent and treat them. One of these side effects is oral candidiasis.

OBJECTIVES

To assess the effectiveness of interventions (which may include placebo or no treatment) for the prevention of oral candidiasis for patients with cancer receiving chemotherapy or radiotherapy or both.

SEARCH STRATEGY

Computerised searches of Cochrane Oral Health Group and PAPAS Trials Registers, CENTRAL, MEDLINE, EMBASE, CINAHL, CANCERLIT, SIGLE and LILACS were undertaken. Reference lists from relevant articles were searched and the authors of eligible trials were contacted to identify trials and obtain additional information. Date of the most recent searches: June 2006: CENTRAL (The Cochrane Library 2006, Issue 2).

SELECTION CRITERIA

Trials were selected if they met the following criteria: design - random allocation of participants; participants - anyone receiving chemotherapy or radiotherapy treatment for cancer; interventions - agents prescribed to prevent oral candidiasis; primary outcome - prevention of oral candidiasis.

DATA COLLECTION AND ANALYSIS

Data were recorded on the following secondary outcomes if present: relief of pain, amount of analgesia, relief of dysphagia, incidence of systemic infection, duration of stay in hospital (days), cost of oral care, patient quality of life, death, use of empirical antifungal treatment, toxicity and compliance. Information regarding methods, participants, interventions, outcome measures and results were independently extracted, in duplicate, by two review authors. The Cochrane Oral Health Group statistical guidelines were followed and risk ratios (RR) calculated using random-effects models. Potential sources of heterogeneity were examined in random-effects metaregression analyses.

MAIN RESULTS

Twenty-eight trials involving 4226 patients satisfied the inclusion criteria. Drugs absorbed and partially absorbed from the gastrointestinal (GI) tract were found to prevent oral candidiasis when compared to a placebo, or a no treatment control group, with RR for absorbed drugs = 0.47 (95% confidence interval (CI) 0.29 to 0.78). For absorbed drugs in populations with an incidence of 20% (mid range of results in control groups), this implies a NNT of 9 (95% CI 7 to 13) patients need to be treated to avoid one patient getting oral candidiasis. There was no significant benefit shown for drugs not absorbed from the GI tract.

AUTHORS' CONCLUSIONS

There is strong evidence, from randomised controlled trials, that drugs absorbed or partially absorbed from the GI tract prevent oral candidiasis in patients receiving treatment for cancer. There is also evidence that these drugs are significantly better at preventing oral candidiasis than drugs not absorbed from the GI.

Antibiotic prophylaxis for bacterial infections in afebrile neutropenic patients following chemotherapy

BACKGROUND

Bacterial infections are a major cause of morbidity and mortality in neutropenic patients following chemotherapy for malignancy. Trials have shown the efficacy of antibiotic prophylaxis in decreasing the incidence of bacterial infections, but not in reducing mortality rates.

OBJECTIVES

This review aimed to evaluate whether antibiotic prophylaxis in afebrile neutropenic patients reduced mortality when compared to placebo or no intervention.

SEARCH STRATEGY

Electronic searches on The Cochrane Cancer Network Register of Trials (2004), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2004), MEDLINE (1966 to 2004) and EMBASE (1980 to 2004) and abstracts of conference proceedings; references of identified studies; the first author of each included trial was contacted.

SELECTION CRITERIA

RCTs or quasi-RCTs comparing different types of antibiotic prophylaxis with placebo or no intervention, or another antibiotic to prevent bacterial infections in afebrile neutropenic patients.

DATA COLLECTION AND ANALYSIS

Two authors independently appraised the quality of each trial and extracted data from the included trials. Relative risks (RR) or average differences, with their 95% confidence intervals (CI) were estimated.

MAIN RESULTS

One hundred trials (10,274 patients) performed between the years 1973 to 2004 met inclusion criteria. Antibiotic prophylaxis significantly decreased the risk for death when compared with placebo or no intervention (RR, 0.66 [95% CI 0.54 to 0.81]). The authors estimated the number needed to treat (NNT) in order to prevent 1 death from all causes as 60 (95% CI 34 to 268). Prophylaxis resulted in a significant decrease in the risk of infection-related death, RR 0.58 (95% CI 0.45 to 0.74) and in the occurrence of fever, RR 0.78 (95% CI 0.75 to 0.82). A reduction in mortality was also evident when the more recently conducted quinolone trials were analysed separately. Quinolone prophylaxis reduced the risk for all-cause mortality, RR 0.52 (95% CI, 0.37 to 0.84).

AUTHORS' CONCLUSIONS

Our review demonstrated that prophylaxis significantly reduced all-cause mortality. The most significant reduction in mortality was observed in trials assessing prophylaxis with quinolones. The benefit demonstrated in our review outweighs harm, such as adverse effects, and development of resistance, since all-cause mortality is reduced. Since most trials in our review were of patients with haematologic cancer, prophylaxis, preferably with a quinolone, should be considered for these patients.

Efficacy of oral prophylactic antibiotics in neutropenic afebrile oncology patients: A systematic review of randomised controlled trials

The use of oral prophylactic antibiotics in oncology patients is still a matter of debate. A systematic review was performed to assess the evidence for the effectiveness of oral prophylactic antibiotics to decrease bacteraemia and infection-related mortality in oncology patients during neutropenic episodes. Medline, Embase and the Cochrane register of controlled trials were searched from 1966 until 2002. The main outcome was the number of patients with documented bacteraemia (Gram-negative or Gram-positive bacteraemia) and infection related mortality. Data-extraction and quality assessment were performed independently by two reviewers. A total of 22 trials met the inclusion criteria. Seventeen trials compared prophylaxis (quinolones or Trimethoprim/sulfamethoxazole (TMP/SMZ)) to no prophylaxis. The incidence of Gram-negative bacteraemia decreased significantly (pooled OR 0.39, 95% CI 0.24-0.62) without an increase in Gram-positive bacteraemia. Quinolone-based regimens showed a stronger reduction in Gram-negative bacteraemia while TMP/SMZ based regimens were more effective in Gram-positive bacteraemia. Infection related mortality due to bacterial causes decreased with the use of prophylactic antibiotics (pooled OR 0.49, 95% CI 0.27-0.88). No increase in fungaemia or fungal related mortality was seen with the use of oral prophylaxis. In conclusion, this study has shown that oral prophylactic antibiotics decreased Gram-negative bacteraemia and infection related mortality due to bacterial causes during neutropenic episodes in oncology patients.

Interventions for preventing oral candidiasis for patients with cancer receiving treatment

BACKGROUND

Treatment of cancer is increasingly more effective but is associated with short and long term side effects. Oral side effects remain a major source of illness despite the use of a variety of agents to prevent and treat them. One of these side effects is oral candidiasis.

OBJECTIVES

To assess the effectiveness of interventions (which may include placebo or no treatment) for the prevention of oral candidiasis for patients with cancer receiving chemotherapy and/or radiotherapy.

SEARCH STRATEGY

Electronic databases: Cochrane Oral Health Group's Trials Register, CENTRAL, MEDLINE, MEDLINE Pre-indexed, EMBASE, CINAHL, CANCERLIT, SIGLE and LILACS were searched. Date of the most recent searches April 2004 (CENTRAL Issue 2, 2004).

SELECTION CRITERIA

Trials were selected if they met the following criteria: design - random allocation of participants; participants - anyone receiving chemotherapy or radiotherapy treatment for cancer; interventions - agents prescribed to prevent oral candidiasis; primary outcome - prevention of oral candidiasis.

DATA COLLECTION AND ANALYSIS

Data were recorded on the following secondary outcomes if present: relief of pain, amount of analgesia, relief of dysphagia, incidence of systemic infection, duration of stay in hospital (days), cost of oral care, patient quality of life, death, use of empirical antifungal treatment, toxicity and compliance. Information regarding methods, participants, interventions, outcome measures and results were independently extracted, in duplicate, by two reviewers (HW & JC). The Cochrane Oral Health Group statistical guidelines were followed and relative risk values calculated using random effects models. Potential sources of heterogeneity were examined in random effects metaregression analyses.

MAIN RESULTS

Twenty-eight trials involving 4226 patients satisfied the inclusion criteria. Drugs absorbed and partially absorbed from the gastrointestinal (GI) tract were found to prevent oral candidiasis when compared to a placebo, or a no treatment control group, with RR for absorbed drugs = 0.47 (95% CI 0.29 to 0.78). For absorbed drugs in populations with an incidence of 20% (mid range of results in control groups), this implies a NNT of 9 (95% CI 7 to 13) patients need to be treated to avoid one patient getting oral candidiasis. There was no significant benefit shown for drugs not absorbed from the GI tract.

REVIEWERS' CONCLUSIONS

There is strong evidence, from randomised controlled trials, that drugs absorbed or partially absorbed from the GI tract prevent oral candidiasis in patients receiving treatment for cancer. There is also evidence that these drugs are significantly better at preventing oral candidiasis than drugs not absorbed from the GI.

Outpatient supportive care following chemotherapy for acute myeloblastic leukemia

Treatment of acute myeloid leukemia (AML) involves aggressive myelosuppressive chemotherapy that is generally administered on an inpatient basis. In our centre, AML therapy has been initiated in hospital and followed by early outpatient supportive care according to guidelines established in 1996. We conducted a review of all patients presenting with AML in our centre between January 1996 and July 1998 to evaluate the safety and feasibility of early outpatient supportive care. Nineteen consecutive patients treated with induction chemotherapy were analyzed. Patients were treated with cytosine arabinoside and an anthracycline as aggressive AML induction therapy with the intent for early discharge. Ten patients (53%) were discharged within 10 days of starting induction chemotherapy (median 4.5 days). Reasons for remaining in hospital included sepsis, serious medical complications, and social and geographic factors. Patients discharged early had a median of 1.5 readmissions (range 0-3), but had 30% fewer in-hospital days than inpatients (p = 0.03), and 57% fewer days of in-hospital antibiotic therapy (p = 0.01). There were no significant differences in transfusion requirements or episodes of febrile neutropenia between the two groups. Thirty-one cycles of consolidation therapy were administered to the 18 patients who survived induction. Early discharge from hospital was achieved for 30 cycles (97%). Nine cycles of consolidation chemotherapy were delivered using outpatient intravenous infusion pumps (29%). This study supports the feasibility and safety of early discharge and outpatient supportive care following chemotherapy for AML.

Prevention of infection in immunocompromised hosts

The prevention of infection in patients with cancer has changed tremendously over the last decade, but remains in evolution. Despite many clinical trials examining the role of antibacterial, antifungal, and antiviral prophylaxis, there is still discussion among physicians about not only which patients require prophylaxis, but also the optimal regimen. Nevertheless, many of these regimens offer the hope to prevent infection in patients with underlying neoplastic diseases. There is no therapy that is uniformly effective in all settings. This is generally due to the severity of the defects in host defenses and the virulence of the microorganism. Hopefully, the future will hold many new therapeutic options to help prevent infection in patients with cancer.

Selective discharge of patients with acute myeloid leukemia during chemotherapy-induced neutropenia

PURPOSE

It is common practice for patients with acute myeloid leukemia (AML) to be observed in hospital during the entire nadir after intensive chemotherapy. In an attempt to lessen the likelihood of developing infections with hospital acquired pathogens, we usually discharge patients upon completion of chemotherapy and follow them as outpatients. They are readmitted if fever develops. We evaluated the feasibility and safety of this practice.

PATIENTS AND METHODS

We studied 29 patients with AML (median age 40 years, range 16-63) who were treated with intensive remission-induction and consolidation chemotherapy. Afebrile patients not receiving antibiotics were discharged immediately following chemotherapy and were followed every 3-4 days at the day care unit. Patients were instructed to return immediately if fever rose to 38.2 degrees C or a fever of 38 degrees C persisted for 2 hr. The 29 patients received a total of 86 courses. Following 50 courses, patients were discharged. These 50 ambulatory nadir periods (ANPs) were monitored.

RESULTS

Median WBC and platelet counts on discharge were 2,900 per cubic millimeter (range 300-8,300) and 137,000 per cubic millimeter (range 17,000-618,000), respectively. Mean traveling time from the hospital by car was 1.6 hr (range 15 min-3 hr). In three of the 50 ANPs (6%), patients were not readmitted during their entire nadir. During 47 of the ANPs, patients returned to the hospital (because of fever in 44 cases), a mean of 7.2 days (range 1.0-12.7 days) after discharge. In 45 ANPs, patients were readmitted in good general condition. Four patients had life-threatening complications. Two patients were admitted in septic shock due to delay in seeking admission, but rapidly recovered. Two other patients died, one of cardiogenic shock within 24 hr of readmission and one 24 days later. Only one of the 11 gram negative bacteria cultured was resistant to mezlocillin and gentamicin. After 45 ANPs, patients were discharged a mean of 12.2 days (range 5-42 days) following readmission. We estimate that approximately 383 hospital days were saved by this policy, a mean of 7.6 days per patient, representing 16% of total inpatient hospital days.

CONCLUSIONS

For AML patients who are reliable and without complicating medical conditions, selected discharge following chemotherapy is a low-risk practice and may reduce the incidence of infection with resistant hospital-acquired pathogens.

Infection prevention strategies for children with cancer and AIDS: contrasting dilemmas

Infectious complications represent significant challenges for children with cancer and those infected with HIV. Although both have similarities in the disease- and treatment-related alterations in host defences, there are significant differences that can have an impact on the approach to treatment and prevention of the dominant infectious complications. An important difference is that children with cancer readily recover from neutropenia. Thus, the immune deficits are interspersed with intervals of immunological recovery. On the other hand, children with HIV infection do not appreciably recover from the progressive, immunological changes associated with the underlying HIV infection. The loss of cellular and humoral immunity is generally not reversible, and thus the risk of infection only increases over time. Bacteria constitute the predominant pathogen for paediatric cancer patients but invasive mycoses, viruses and parasitic infections are emerging as important pathogens. In paediatric cancer patients, strategies have been directed at altering or suppressing the endogenous colonization patterns of pathogenic bacteria. The success of this approach has been limited and at the expense of selecting for antibiotic-resistant bacterial infections. Children with HIV infection are at risk of developing a wide spectrum of pathogens. Strategies for infection prevention in the HIV setting have been directed at specific organisms, generally using more specific antimicrobial agents and with greater success.

Selective decontamination in neutropenic patients

It is well known that severe neutropenia, as usually seen in patients with acute leukaemia, aplastic anaemia or secondary to aggressive chemotherapy, predisposes to infections with Gram-negative enteric bacilli,Pseudomonas aeruginosa, Staphylococcus aureus, and to fungal infections. Infection with anaerobes, in contrast, is rare in patients with haematologic malignancy [1]. The spectrum of bacterial pathogens in this patient population has recently broadened, and now includes coagulase-negative staphylococci, viridans group streptococci, and, occasionally, coryneforms and other rather unusual opportunistic organisms. All these microorganisms originate either from the patient's own microflora, especially from the digestive tract, or from the hospital environment after having colonized the patient during the hospital stay [2]. Studies have shown that the incidence of fever during periods of severe neutropenia approaches 100%, and most of these fever episodes actually represent bacterial infection. For more than 20 years, methods for the prevention of bacterial and fungal infections have been under investigation in patients with profound neutropenia. These included decontamination trails, oral or systemic antimicrobial prophylaxis, strict reverse isolation and maintenance of germ-free conditions [3–8], prophylactic granulocyte transfusions [9], and, more recently, the application of haemopoietic growth factors [10, 11]. The method which remains the most widely used is oral antimicrobial prophylaxis, especially with agents for so-called selective decontamination of the intestinal tract.

Protecting neutropenic patients from bowel-derived organisms

Prevention of infection from bowel-derived organisms in neutropenic patients requires both the appropriate use of chemoprophylaxis and close attention to the prevention of cross-colonization or cross-infection with resistant Enterobacteriaceae and pseudomonads. Control of common-source infection and control of Gram-positive infection are also important. The objectives of chemoprophylaxis should be considered and their efficacy regularly assessed. Non-absorbable antibiotics may have an important place in minimizing selection of resistant strains, but absorbed agents such as cotrimoxazole (trimethoprim/sulphamethoxazole) and 4-quinolones offer advantages over these and nalidixic acid as prophylactic agents. Ciprofloxacin prophylaxis is probably more effective at reducing Gram-negative bacteraemia than co-trimoxazole but overall mortality may be higher. Further confirmation and investigation of the reasons for this are needed. Protocols of rational antibiotic prophylaxis and treatment involving these agents can be modified to cover only the Gram-negative superinfections that are likely.

Streptococcal bacteremia in adult patients with leukemia undergoing aggressive chemotherapy. A review of 55 cases

We reviewed 55 cases of streptococcal bacteremia in adult patients who received cytotoxic chemotherapy for treatment of acute leukemia. Viridans group streptococci were the most frequent species isolated (45 isolates). Hemolytic streptococci (four isolates), pneumococci (three isolates), and enterococci (three isolates) were infrequent. Clinical features of streptococcal bacteremia included fever, upper and lower respiratory infection, respiratory distress syndrome, soft tissue infection, and septic shock. Forty patients who had only streptococci, but no other organisms isolated from their blood, were compared with 36 cases of gram-negative bacillary bacteremia that occurred during the same study period within the same population at risk. The comparison showed that patients with streptococcal bacteremia had more often received high dose cytosine arabinoside as part of their chemotherapy (17 vs. five), had a longer mean duration of fever (11 vs. seven days, p less than 0.01) needed slightly more days of antibacterial therapy (15 vs. 12 days, p = 0.07, not significant), and were more likely to have been treated with newer quinolones for infection prevention (30 vs. eight). No differences between both groups were found for age, underlying disease, remission status, duration of severe granulocytopenia, and number of superinfections. The overall mortality was 18% in streptococcal bacteremia and 17% in gram-negative bacillary bacteremia. Streptococci, especially viridans group streptococci, should now be regarded as frequent causes of serious life-threatening infections following aggressive chemotherapy in patients with hematologic malignancies.

The toxicity of cytarabine

The principal toxicity of standard induction regimens for acute non-lymphocytic leukemia (ANLL) [including cytarabine (ARA-C) 100 mg/m2 for 7 days plus an anthracycline] is myelotoxicity, leading to death in at least 25% of cases during induction in non-selected patients. The complete remission rate is less than 35% in patients over 65 years of age, due in part to an age-related increase of myelotoxicity. The other important adverse effect of standard-dose cytarabine is gastrointestinal toxicity, especially oral mucositis, diarrhoea, intestinal ulceration, ileus and subsequent Gram-negative septicaemia. Idiosyncratic reactions like exanthema, fever and elevation of hepatic enzymes are relatively frequent, but do not represent therapeutic problems. Intermittent high-dose cytarabine (3 g/m2 in 8 to 12 doses) is extremely myelosuppressive. Similarly, the gastrointestinal toxicity is formidable and dose-limiting. Severe, and sometimes irreversible, cerebellar/cerebral toxicity in 5 to 15% of courses of treatment limits the peak dose of cytarabine. The pathogenesis, prophylactic and therapeutic measures are unknown. These major toxicities are age-related and prohibitive to the use of high-dose cytarabine therapy in patients older than 55 to 60 years. Subacute noncardiogenic pulmonary oedema occurs in some patients, with an incidence of about 20%, and seems to have an intriguing coincidence with precedent streptococcal septicaemia; high-dose systemic steroids may be beneficial. Corneal toxicity is very frequent in high-dose cytarabine therapy but is always reversible. It is largely preventable with prophylactic steroid or 2-deoxycytidine eyedrops. Fever, exanthema and hepatic toxicity have an incidence similar to that in standard dosage. The maximum tolerable cumulated dose of cytarabine is significantly lower when the agent is administered as a continuous infusion, due to myelosuppression and gastrointestinal toxicity. Conversely, continuous infusion may be less neurotoxic. The antileukaemic effect of continuous infusion high-dose cytarabine is less well established. The only significant toxicity of low-dose cytarabine is myelosuppression. Given the generally poor condition of leukaemia patients, low-dose cytarabine therapy is well tolerated, although occasional cases of diarrhoea, reversible cerebellar symptoms, peritoneal and pericardial reactions, and ocular toxicity have been reported. Continuous infusion may be more toxic than the usual intermittent dosage. It is concluded that the toxicity of the standard induction regimen for ANLL is acceptable in patients younger than 60 to 65 years with no concurrent disease. Low dose cytarabine is tolerable for virtually all ANLL patients, but the overall therapeutic efficacy still needs to be defined and compared to standard therapy in the relevant age groups.(ABSTRACT TRUNCATED AT 400 WORDS)

Prophylactic co-trimoxazole versus norfloxacin in neutropenic children--perspective randomized study

Co-trimoxazole or norfloxacin were randomly administered to 44 granulocytopenic children with malignancies in order to prevent bacterial infections. Although more patients in the co-trimoxazole group had febrile episodes (p less than 0.01), the mean of febrile days and the mean of days with systemic antibiotics did not differ significantly in the two groups. Five patients in the co-trimoxazole group had a microbiologically documented infection (four with septicemia) due to Escherichia coli (n = 2), Klebsiella pneumoniae, Pseudomonas aeruginosa, Streptococcus sp. There were four septicemic episodes in the norfloxacin group due to P. aeruginosa, Streptococcus pneumoniae, Streptococcus mitis and Streptococcus faecalis. Compliance was good during administration of both drugs. No signs or symptoms of arthropathy were seen in the norfloxacin group. The number of gram-negative bacilli resistant to co-trimoxazole isolated from stools significantly increased during prophylaxis with co-trimoxazole (p less than 0.001). Norfloxacin did not select resistant strains and was very active in eradicating gram-negative bacilli from stools (27.5% of positive cultures).

Analysis of early infectious complications after autologous bone marrow transplantation

We reviewed the hospital course of 35 patients who underwent autologous bone marrow transplantation. Fever and profound neutropenia developed in all. Microbiologically confirmed infection developed in 22 patients, and unconfirmed but clinically evident infection developed in six. A bacterial infection developed in 21 patients (most commonly bacteremia without a detectable focus). Mucocutaneous fungal (12 patients) and viral (13 patients) infections were common, whereas invasive fungal (two patients) and viral (one patient) infections were uncommon. New pulmonary infiltrates developed in seven patients. Six deaths occurred during the initial hospitalization for transplantation, only one of which was directly attributable to infection. Stepwise logistic regression analysis retained male gender, total body irradiation, administration of trimethoprim/sulfamethoxazole, and development of mucositis or diarrhea as predictors of decreased survival, whereas higher pretreatment albumin levels and the administration of oral nonabsorbable antifungals were associated with an increased likelihood of survival. A comparison of these infectious complications with those found in allogeneic bone marrow transplant recipients shows similarities and differences with potentially important implications for patient management.

Infectious complications in childhood acute leukemias

Infectious complications in children with acute leukemias are reviewed as to incidence, predisposing factors, microbiologic etiologies and treatment. Principles of antimicrobiologic therapy are presented for bacterial, fungal, viral, and protozoal infections seen in children with cancer. Prevention of infection is also discussed.

Biologic characteristics and treatment of acute nonlymphocytic leukemia in children. Report of the ANLL Strategy Group of the Childrens Cancer Study Group

Today approximately 75 per cent of children with ANLL can be induced into a complete remission and approximately 40 per cent will have an event-free survival for more than 3 years, irrespective of whether they received a bone marrow transplantation or chemotherapy after induction. In order to achieve these results very intensive therapy is required. The morbidity and mortality of treatment are high. The length of therapy needed after induction of remission is not known. Whether or not maintenance therapy is required is perhaps related most directly to the intensity of the therapy employed. Similarly, the role of bone marrow transplantation in patients in first remission, treatment of CNS leukemia, and treatment of chloromas are controversial. There is general agreement that WBCs over 100,000, acute monoblastic leukemia in infants less than 2 years of age, and certain chromosomal abnormalities are associated with a poor prognosis. Although there has been a dramatic improvement in the treatment of ANLL over the past 15 years, stratification of therapy based on biologic parameters, and alteration of treatment based on the early responses to treatment may be required before further advances will be made.

Co-trimoxazole in patients with haematological malignancies: a review of 10-years' clinical experience

Co-trimoxazole has been used in a hospital for over 10 years as a major antibacterial agent in the treatment of malignant haematological diseases. Routine selective gut decontamination with co-trimoxazole combined with colistine and an antifungal agent has led to a reduction in infections in neutropenic patients from 40% to 25% since the strategy was adopted, and this had been accompanied by a change in the most frequent pathogens, from Gram-negative to Gram-positive organisms. Co-trimoxazole has proved to be the drug of choice for Pneumocystis carinii infections. Finally, it is used as first-line therapy in febrile immunosuppressed patients who are not on selective decontamination, with an efficacy of over 90%. Apart from mild abdominal discomfort, an elevated allergy rate of 14% in patients with overt leukaemia is a major disadvantage. On the other hand, substantial prolongation of episodes of bone marrow aplasia has not been observed.

Prospective randomized comparison of two prophylactic regimens with trimethoprim-sulfamethoxazole in leukemic children: a two year study

Between 1 July 1984 and 30 June 1986 all children treated for acute hematologic malignancy at our center were randomized to receive continuous (group A) or intermittent (3 days/week, group B) prophylaxis with trimethoprim-sulfamethoxazole (5-25 mg/kg/day/p.o.) against interstitial pneumonia with the aim of investigating if an intermittent regimen is as effective as and less toxic than a continuous regimen. The number of severe infections (group A, 17; group B, 21) and side-effects (group A, 30; group B, 34) was similar in the two groups, and compliance was also similar. We conclude therefore that neither regimen offers advantages over the other and the decision which to use should be based on cost (where regimen B has the advantage) and the children's and parents' preferences and compliance.

Norfloxacin: its potential in clinical practice

The in vitro spectrum and potency of norfloxacin against both aerobic gram-negative and gram-positive bacteria, its limited activity against anaerobes, and the apparent difficulty organisms have in acquiring resistance to it, have provided a rationale for the clinical development of this oral fluoroquinolone antimicrobial agent. The clinical experience with norfloxacin as treatment for a variety of urinary tract infection syndromes, uncomplicated gonococcal infection, and diarrheal disease, and as prophylaxis of infection in neutropenic patients with cancer, is reviewed. Norfloxacin appears at least equivalent to standard regimens for the treatment of acute urinary tract infections; however, long-term studies are needed to define its role in the treatment of recurrent urinary infections. Initial studies of norfloxacin treatment of uncomplicated gonococcal infection and bacterial gastroenteritis are also promising, and in neutropenic patients, continuous norfloxacin prophylaxis has been shown to reduce the incidence of gram-negative infections. Further prospective evaluation is required to confirm these findings.

Selective gut decontamination with nalidixic acid or trimethoprim-sulfamethoxazole for infection prophylaxis in neutropenic cancer patients: relationship of efficacy to antimicrobial spectrum and timing of administration

Eighty-four cancer patients at risk of infection because of neutropenia were randomized to receive nalidixic acid as an alternative to trimethoprim-sulfamethoxazole (TMP-SMX) for infection prophylaxis. Infections were documented significantly earlier and more often among patients who entered the trial with neutrophil counts of less than 0.1 X 10(9)/liter. TMP-SMX recipients experienced fewer microbiologically documented infections and bacteremias and were free of infection for a higher proportion of days with severe neutropenia (less than 0.1 X 10(9)/liter) than nalidixic acid recipients. Gram-negative bacillary and Staphylococcus aureus infections accounted for the major differences. Although the majority of aerobic gram-negative bacilli were eliminated from the feces after 1 week of prophylaxis with either agent, TMP-SMX was proved superior to nalidixic acid in this regard and was associated with acquired drug resistance by gram-negative bacilli less frequently. Both agents selected for colonization and subsequent infection by gram-positive cocci. Our data suggest that prophylaxis is most likely to be effective if administered to patients for at least 1 week before they become severely neutropenic. Nalidixic acid used as a single agent in doses of 4 g daily, however, cannot be recommended as an alternative to TMP-SMX for infection prophylaxis in neutropenic cancer patients.

Granulocytopenia and cancer therapy. Past problems, current solutions, future challenges

Granulocytopenia has been closely associated with cancer and its treatment. The risk for a life-threatening infection when the granulocyte count falls below 500/mm3 not only is an important complication of therapy and a major cause of death in cancer patients but also plays an important role in the design, schedule, and doses of cancer treatment regimens. While granulocytopenia remains an unavoidable complication of current therapy, improved recognition of patients at risk and prompt initiation of aggressive supportive care have had a significant impact on reducing its infection-related morbidity and mortality. In particular, early empiric antibiotic therapy when the granulocytopenic patient becomes febrile has resulted in a significant reduction in the early mortality from undiagnosed bacterial infections. New antibiotics (extended-spectrum penicillins, third generation cephalosporins) provide new options because of their broad efficacy and potential for reducing the toxicity of antimicrobial therapy. However, as bacterial infections have become better controlled, fungi have emerged as important pathogens. Early aggressive empiric antifungal therapy appears to have reduced infectious mortality, although the repertoire of effective antifungal agents is quite limited. Considerable efforts have been expended in trying to replenish granulocytes by transfusion in infected patients, but technical deficiencies have limited this approach. Current and future efforts are directed toward refining management as well as to developing methods to improve host defenses and provide prophylaxis against infections. If the full potential of current cancer therapy is to be realized, control of granulocytopenia and the prevention of infections are essential goals.

Oral trimethoprim/sulfamethoxazole in attempt to prevent infection after induction chemotherapy for acute leukemia

The efficacy of orally administered trimethoprim/sulfamethoxazole for infection prevention following induction chemotherapy was evaluated in 43 patients with acute leukemia. Twenty patients were randomly assigned to treatment with trimethoprim/sulfamethoxazole during 20 episodes of profound granulocytopenia; 23 patients in the control group were followed through 25 granulocytopenic episodes. The incidences of superficial skin and overall infections were significantly lower in those patients with multiple relapses who received trimethoprim/sulfamethoxazole (p = 0.008); however, there was no difference between the groups in regard to days of fever, days of antibiotic administration, days of hospitalization, or gram-negative rod bacteremia. As a result of this study, this regimen cannot be unequivocally recommended for infection prevention in neutropenic patients with acute leukemia undergoing induction or reinduction chemotherapy.

Myelosuppression associated with co-trimoxazole as a prophylactic antibiotic in the maintenance phase of childhood acute lymphocytic leukemia

Thirty-seven children with acute lymphocytic leukemia in clinical remission for at least 6 months completed a 1-year trial in which they were randomly assigned in a double-blind fashion to receive co-trimoxazole twice daily for 6 months followed by placebo for 6 months (18 patients) or placebo followed by co-trimoxazole (19 patients). Total amounts of maintenance chemotherapy administered during both periods were similar. During administration of co-trimoxazole significant reductions were documented in the patients' average total white blood count (P less than 0.001), absolute neutrophil count (P less than 0.001), absolute lymphocyte count (P = 0.009), and platelet count (P = 0.002) compared with values obtained during the placebo period. Patients had on the average 1.6 infections during the co-trimoxazole period compared with 2.5 infections during placebo administration (P = 0.008). It is concluded that, although co-trimoxazole is an effective prophylactic antibiotic in children with acute lymphocytic leukemia, the resultant myelosuppression could potentially hamper the administration of maintenance cancer chemotherapy.

Symposium on infectious complications of neoplastic disease (Part II). Chemoprophylaxis of bacterial infections in granulocytopenic patients

Several prospectively randomized trials have shown that the administration of prophylactic oral nonabsorbable antibiotics may be beneficial in decreasing the incidence of infection in granulocytopenic patients, whereas others have not. Intolerable nausea and vomiting have prevented the prolonged use of these agents in some studies. Discontinuation of therapy while patients are still granulocytopenic has carried the risk of life-threatening infections, often with aminoglycoside-resistant gram-negative organisms. The benefit of selective decontamination with trimethoprim/sulfamethoxazole used prophylactically remains controversial. The use of trimethoprim/sulfamethoxazole may also be associated with the development of resistant, potentially pathogenic, organisms or prolonged neutropenia. These regimens do not appear to be indicated when patients are anticipated to be neutropenic for less than three weeks. Even in patients with prolonged neutropenia, the risks of such treatment must be weighed against potential benefits.

Limitations of current antimicrobial therapy in the immunosuppressed host: looking at both sides of the coin

During the last twenty years there have been considerable advances in the antimicrobial management of the immunosuppressed host. These include the development of antibiotics with broad-spectrum and high bactericidal activity along with the appreciation of the importance of promptly initiating empiric antibiotic therapy when the granulocytopenic patient becomes febrile and continuing them (in some cases with empiric antifungal therapy) until the resolution of granulocytopenia. Nonetheless, infection still remains a major cause of death in compromised hosts and a number of limitations of therapy persist. Included are a limited repertoire of drugs active against fungi (particularly Aspergillus) as well as certain viruses (for example, cytomegalovirus) and the inability to eradicate certain sites of infection (for example, Pseudomonas pneumonia) even with effective agents. Current investigations are focused on developing new antimicrobial agents as well as methods to improve the altered host defenses of immunosuppressed patients, both as adjuvants to therapy and, eventually, as a means to prevent infectious complications.

Randomized controlled trial comparing trimethoprim/sulfamethoxazole and trimethoprim for infection prophylaxis in hospitalized granulocytopenic patients

The clinical and microbiologic efficacy of trimethoprim alone and trimethoprim/sulfamethoxazole for infection prevention was evaluated in 75 patients during 92 episodes of granulocytopenia. Ultimately, 60 patients were evaluable during 77 episodes of granulocytopenia, 36 episodes in the trimethoprim group and 41 episodes in the trimethoprim/sulfamethoxazole group. The incidence of infection was higher in the trimethoprim group (50 percent) than in the trimethoprim/sulfamethoxazole group (39 percent), but this did not reach statistical significance. Trimethoprim did not appear to be as protective as trimethoprim/sulfamethoxazole when the granulocyte count was less than 100/mm3. In patients receiving trimethoprim/sulfamethoxazole, aerobic gram-negative bacilli cleared from fecal surveillance cultures more often and new aerobic gram-negative bacilli were acquired less often than in those receiving trimethoprim alone (p less than 0.05). More myelosuppression was observed among patients receiving trimethoprim/sulfamethoxazole (p less than 0.001). These observations suggest that trimethoprim alone may not be optimal for preventing colonization and infection in granulocytopenic patients and that combination with other agents may be necessary to increase the spectrum of activity. Trimethoprim/sulfamethoxazole itself may predispose toward an increased risk of infection by prolonging myelosuppression.

Prophylaxis of fever and infection in adult cancer patients. A placebo-controlled trial of oral trimethoprim-sulfamethoxazole plus erythromycin

Oral trimethoprim-sulfamethoxazole (Bactrim) plus erythromycin (TMZ-E) was tested versus placebo (P) as prophylaxis for bacterial infection in a randomized, double-blind trial in adult cancer patients receiving cytotoxic chemotherapy expected to result in significant neutropenia. The incidence of adverse reactions attributable to TMZ and/or E was higher in drug-treated episodes (18 of 28 vs 3 of 29 for P, P less than 0.0005) resulting in poorer compliance. The incidence of fever was not significantly different between episodes treated with TMZ-E (18/27) and those treated with P (17/29), nor was there a significant difference in the median interval between the onset of neutropenia and the onset of fever. However, 14 of 18 fevers in TMZ-E recipients were without a documented infectious source compared with only 6 of 17 in P recipients (P less than 0.05). The same patterns were apparent even when episodes in which compliance with the regimen was either excellent or good were considered separately. There was no significant difference in the number of deaths from infection between TMZ-E and P recipients (3/27 vs 1/29). It is concluded that TMZ-E prophylaxis is of no practical benefit, may mask the cause of infection in febrile neutropenic cancer patients, and is associated with substantial toxicity.

Occlusion and infection in Broviac catheters during intensive cancer therapy

Before administration of intensive cytotoxic therapy, 90 central venous catheters were inserted into 80 patients with malignancies. Twenty-seven episodes of bacteremia and fungemia occurred during 96 treatment courses. The majority of these infections were due to gram-positive bacteria (45%) or fungi (22%), although gram-negative organisms accounted for 33%. Catheter occlusion occurred in patients receiving intravenous phenytoin, but blood products could be infused without difficulty. An increase in gram-positive bacteremias in patients with these catheters and drug-induced catheter occlusion must now be appreciated.

Prevention of infection among patients with cancer

Recognition of the alterations of host defense allows a rational approach to preventing associated infections. One of the most effective strategies for preventing infection in the granulocytopenic patient is the combined use of oral non-absorbable antibiotics, laminar air-flow room reverse isolation with strict housekeeping techniques, low microbial diet, sterile water, and topical antiseptics and antibiotics. The prohibitive cost, however, warrants that this system be restricted to research settings. The suppression of aerobic Gram-negative bacilli and fungi and the preservation of colonization resistance with such combinations as trimethoprim-sulfamethoxazole and nystatin show promise in preventing infection in the granulocytopenic patient. Prevention of infection in neutropenic patients also requires attention to simpler but very effective measures such as immunizations, antimicrobial prophylaxis against intracellular and nonbacterial pathogens in high-risk patients, limiting invasive diagnostic and monitoring procedures, hand-washing by all personnel between visiting patients, oral hygiene, low microbial diets, axillary and perianal swabbing, and care with venipunctures and marrow aspirates. Finally, while the recommendations for prevention of infection are likely to continue to change with resulting improvement in patient care [92, 93], a tabulation summarizing current practices can be established based on our current knowledge (Table 1).

Double-blind randomized study of prophylactic trimethoprim/sulfamethoxazole in granulocytopenic patients with hematologic malignancies

In a double blind study, oral prophylactic trimethoprim/sulfamethoxazole was evaluated for its utility in preventing serious infections in patients with hematologic malignancy. Of 58 evaluated granulocytopenic episodes in 47 patients, acute leukemia was the underlying malignancy in 46 episodes. Trimethoprim/sulfamethoxazole prophylaxis resulted in fewer microbiologically documented infections (seven versus 15; p = 0.029). This was primarily the result of a reduction in episodes of bacteremia in the trimethoprim/sulfamethoxazole-treated group as compared with the placebo-treated group (three versus nine episodes; p = 0.05). The combined frequency of disseminated candidiasis, candidemia, and esophagitis of presumed fungal etiology was greater in the trimethoprim/sulfamethoxazole-treated group (six) than in the placebo-treated group (two) but not significantly so (p = 0.13). Similarly, there were no significant differences between groups in the overall incidence of infectious complications, number of febrile days, use of parenteral antibiotics, or number of days following randomization to first infectious episode. Throat and rectal surveillance cultures more frequently revealed trimethoprim/sulfamethoxazole-resistant gram-negative bacilli and yeasts in the trimethoprim/sulfamethoxazole-treated group. More frequent emergence of yeast isolates from previously culture-negative patients was documented (p = 0.033). Thus, in this study, trimethoprim/sulfamethoxazole prophylaxis during granulocytopenia reduced the incidence of microbiologically documented infections. However, the emergence of resistant bacteria and of fungi may limit the potential usefulness of this approach.

A prospective study of infectious diseases following bone marrow transplantation: emergence of Aspergillus and Cytomegalovirus as the major causes of mortality

We performed a prospective study of infections following bone marrow transplantation in 50 patients treated for aplastic anemia or hematologic malignancy. Early, continuous prophylaxis with trimethoprim/sulfamethoxazole and oral nystatin, and empiric intravenous antimicrobial therapy during febrile granulocytopenic episodes were standard treatment for all patients. The use of trimethoprim/sulfamethoxazole did not appear to adversely affect donor marrow engraftment. Serious gram-negative bacillary and systemic Candida infections were uncommon. Although gram-positive bacterial infections were frequent, they were rarely associated with mortality. Aspergillosis emerged as the single most important infection, contributing to the death of nine patients. Cytomegalovirus diseases developed in 13 patients, seven of whom died. Patient age and chronic myelogenous leukemia were risk factors for the development of fatal infections. This study demonstrates that although certain serious infections can be controlled, there is a critical need for effective measures to prevent and treat aspergillosis and cytomegalovirus disease in these seriously compromised hosts.

Oral antibiotic prophylaxis in patients with cancer: a double-blind randomized placebo-controlled trial

In an attempt to reduce the incidence of fever and infection, we randomized patients with cancer to receive trimethoprim/sulfamethoxazole plus erythromycin (TMP/SMX + E) versus placebos after each cycle of chemotherapy (no crossover) and to continue until granulocytopenia (polymorphonuclear leukocytes less than 500/mm3) resolved or the patient became febrile. We evaluated 541 episodes (150 patients); 249 episodes (77 patients) with TMP/SMX + E and 292 episodes (73 patients) with placebos. The patients' median age was 17 years. Thirty percent of the patients had leukemia, 23% had lymphoma, and 47% had solid tumors. Compliance with prescribed medication was prospectively rated as excellent in 60.6%, good in 11.7%, poor in 11.1%, and unknown in 16.6%; compliance was better for the placebo group (P = 0.001). The overall incidence of fever or infection was 22.1% for the TMP/SMX + E group versus 26.9% for the placebo group. When only episodes with excellent compliance in which granulocytopenia was documented were compared, the incidence of fever or infection was 18.1% for the TMP/SMX + E group vs 32.2% for the placebo group (P = 0.009), with bacterial infection occurring in 3.8% of the TMP/SMX + E group vs 11.9% of the placebo group (P = 0.019), and unexplained fever in 10.5% of the TMP/SMX + E group vs 19.6% of the placebo group (P = 0.037). Patients with good or poor compliance showed no significant benefit from the TMP/SMX + E, and patients with excellent compliance did best, regardless of whether they were receiving antibiotics or placebos, suggesting that patient compliance is an important independent variable. The incidence of fever or infection was significantly lower for patients with leukemia with excellent compliance who received antibiotics (P = 0.037) than for patients with lymphomas or solid tumors. Oral antibiotic prophylaxis reduced the incidence of fever and infection in some granulocytopenic patients, but the benefit was limited and restricted to patients whose compliance was complete.

Controversies in the therapy of acute myelogenous leukemia

In the past 10 years, there has been substantial progress in the treatment of patients with acute myelogenous leukemia. Intensive induction chemotherapy and consolidation chemotherapy have increased complete remission rates from 25 percent to more than 70 percent and have extended median survival from six months to more than two years. Attempts to prolong remission with maintenance chemotherapy, immunotherapy, and central nervous system prophylaxis have been less successful. Recent data suggest that the use of intensification chemotherapy or bone marrow transplantation in patients in remission may further reduce or eliminate residual leukemia. As a result of one or more of these advances an increasing proportion of patients, up to 25 percent in some series, are alive and free of disease three to five years following diagnosis. Most data indicate that some of these patients may be cured. In this article, we review the therapeutic interventions responsible for this substantial increase in survival in what was previously a uniformly fatal disease. Recent advances are discussed as are controversies in management and future directions.