Multifocal Calcific Periarthritis with Distinctive Clinical and Radiological Features in Patients with CD73 Deficiency

OBJECTIVE

Arterial calcification due to deficiency of CD73 (ACDC) is a hereditary autosomal recessive ectopic mineralization syndrome caused by loss-of-function mutations in the 5'-nucleotidase Ecto (NT5E) gene. Periarticular calcification has been reported but the clinical characterization of arthritis as well as the microstructure and chemical composition of periarticular calcifications and synovial fluid crystals has not been systematically investigated.

METHODS

Eight ACDC patients underwent extensive rheumatological and radiological evaluation over a period of 11 years. Periarticular and synovial biopsies were obtained from four patients. Characterization of crystal composition was evaluated by compensated polarized light microscopy, Alizarin red staining for synovial fluid along with x-ray diffraction and x-ray micro tomosynthesis for periarticular calcification.

RESULTS

Arthritis in ACDC patients has a clinical presentation of mixed erosive-degenerative joint changes with a median onset of articular symptoms at 17 years of age and progresses over time to the development of fixed deformities and functional limitations of small peripheral joints with eventually, larger joint and distinct axial involvement later in life. We have identified calcium pyrophosphate (CPP) and calcium hydroxyapatite (CHA) crystals in synovial fluid specimens and determined that CHA crystals are the principal component of periarticular calcifications.

CONCLUSION

This is the largest study in ACDC patients to describe erosive peripheral arthropathy and axial enthesopathic calcifications over a period of 11 years and the first to identify the composition of periarticular calcifications and synovial fluid crystals. ACDC should be considered among the genetic causes of early-onset osteoarthritis, as musculoskeletal disease signs may often precede vascular symptoms.

Lupus hepatitis, more than just elevated liver enzymes

Systemic lupus erythematosus (SLE), a multisystem autoimmune inflammatory disease, may involve any organs, including the liver. Liver involvement in SLE is not part of the American College of Rheumatology criteria and is relatively rare. Liver disease is usually mild, manifesting as subtle elevation of liver enzymes. Jaundice and hepatomegaly can be seen in some patients; advanced liver disease with cirrhosis is extremely rare. Precise pathology remains obscure. SLE may cause non-specific changes, including hepatocellular, cholestatic, or vascular changes. Alcohol, drugs, viral infections, metabolic disorders, autoimmune hepatitis, and other common causes of liver dysfunction should be excluded. Corticosteroids may expedite the recovery process, but may lead to non-alcoholic fatty liver disease and liver damage. Several large-scale multicentre studies have shown that liver involvement is not the major cause of morbidity and mortality in SLE patients. In this review, we discuss the pathogenesis, diagnosis, differential diagnosis, clinical manifestations, management, complications, and prognosis of lupus hepatitis.

Persistent Isolation of an Unusual Pseudomonas Species From a Phenolic Disinfectant System

A well-characterized unusual Pseudomonas species contaminated the piped disinfectant system of a newly-opened laminar air flow intensive care facility. This organism was frequently isolated (104-106 cfu/ml) from phenolic diluted 1:256 in the system, and could also be recovered (0.01-0.2 cfu/ml) from undiluted phenolic. During the 20-month period when this unusual Pseudomonas was present, none of the severely compromised, granulocytopenic oncology patients treated in the intensive care facility were either colonized or infected with this Pseudomonas sp. Eradication of the organism from the system proved difficult and was accomplished by removing a contaminated reservoir of diluted phenolic disinfectant followed by transient cleansing of the system with very high concentrations (84,000 ppm) of chlorine. This experience demonstrates that phenolics should be added to the list of disinfectants which can harbor Pseudomonas spp. in the clinical setting.

Management of autoimmune neutropenia in Felty's syndrome and systemic lupus erythematosus

Autoimmune neutropenia, caused by neutrophil-specific autoantibodies is a common phenomenon in autoimmune disorders such as Felty's syndrome and systemic lupus erythematosus. Felty's syndrome is associated with neutropenia and splenomegaly in seropositive rheumatoid arthritis which can be severe and with recurrent bacterial infections. Neutropenia is also common in systemic lupus erythematosus and it is included in the current systemic lupus classification criteria. The pathobiology of the autoimmune neutropenia in Felty's syndrome and systemic lupus erythematosus is complex, and it could be a major cause of morbidity and mortality due to increased risk of sepsis. Treatment should be individualized on the basis of patient's clinical situation, and prevention or treatment of the infection. Recombinant human granulocyte colony-stimulating factor is a safe and effective therapeutic modality in management of autoimmune neutropenia associated with Felty's syndrome and systemic lupus erythematosus, which stimulates neutrophil production. There is a slight increased risk of exacerbation of the underlying autoimmune disorder, and recombinant human granulocyte colony-stimulating factor dose and frequency should be adjusted at the lowest effective dose.

Double beta-lactam regimen compared to an aminoglycoside/beta-lactam regimen as empiric antibiotic therapy for febrile granulocytopenic cancer patients

In a prospective, randomized trial, 205 febrile episodes in granulocytopenic cancer patients were treated with ceftazidime with or without tobramycin (C +/- T), both agents being administered only if the initial granulocyte count was below 200/microliters, or ceftazidime plus piperacillin (C + P). The overall response rate was 71% (39 of 60 for C +/- T and 45 of 58 for C + P). Logistic regression analyses documented no evidence of a significant difference between the two regimens in overall treatment effect after accounting for the linear effects of potentially important variables, such as infection type and granulocyte count. Although the response rates for the subgroup of patients with bacteremias was better with the C + P regimen (P = 0.06), there was no difference in response for patients with bacteremia and profound (< 100/microliters) sustained granulocytopenia. The double beta-lactam combination demonstrated in vitro synergism in 73%; antagonism was not seen. Both regimens produced excellent serum bactericidal levels (C +/- T geometric mean peak 1:170; C + P peak 1:137) against gram-negative but not gram-positive pathogens (1:4; 1:7 respectively) that had caused bacteremia. Emergence of resistance and significant coagulopathy and/or bleeding did not occur during therapy. Antibiotic-related nephrotoxicity was noted in 7 of 95 trials in the C + P and in 6 of 89 trials in the C +/- T group (P = 0.19). The incidence of secondary infections in patients with profound (< 100/microliters) sustained granulocytopenia was lower in the C +/- T group (P = 0.04). Alimentary canal anaerobic flora preservation with C +/- T, and suppression with C + P, was demonstrated.(ABSTRACT TRUNCATED AT 250 WORDS)

Hickman catheters in association with intensive cancer chemotherapy

Hickman catheters were the major venous access devices utilized at the University of Maryland Cancer Center from November 1978 to 1987. This study provided an opportunity to standardize insertion technique, to manage catheter-related activities and daily maintenance procedures in order to examine the progression of Hickman-catheter-related problems, to identify those factors that may minimize them, and to develop guidelines for the management and prevention of complications and malfunctions. In all, 690 Hickman catheters (368 double lumens) were placed in patients with acute leukemia and other cancers: 401 catheters were placed in patients with leukemia; 269 were placed during neutropenia; and 230 at platelet counts of < 50,000/microliters. Two surgeons inserted 490 catheters, and the remaining 200 were placed by a group of rotating surgeons. All catheters were placed with the intention that they would remain in place as long as clinically necessary. Total Hickman catheter days were 134273. Infectious complications included exit site infections (160), tunnel infections (46) and bacteremias (397). There were 438 instances of noninfectious complications including thrombosis, lack of function, catheter migration, fracture and hemorrhage. Recommendations for prevention and treatment of Hickman-catheter-related complications include the development of a select group committed to placement, daily maintenance and management of problems; prompt removal of catheters with Candida sp. fungemia and bacteremia due to Bacillus sp. or a bacteremia that persists for > 48 h after initiation of appropriate antibiotics, tunnel infections or Hickman-catheter-associated thrombosis. The majority of bacteremias and exit site infections can be effectively treated with antibiotics and local care.

Venous access devices utilized in association with intensive cancer chemotherapy

Consistent and reliable venous access is a major component of the management of patients with cancer undergoing chemotherapy. Venous access devices such as the long-term right atrial catheter and the subcutaneous port have become a major aspect of the supportive care of such individuals, with resultant advantages which have improved their quality of life. Yet, the occurrence of infectious and non-infectious complications restricts the usefulness of these devices and warrants a standardized approach to device placement, patient education and the management of such complications. Infectious complications, including exit site and tunnel infections, as well as bacteremias requiring catheter removal occur at a rate of approximately two episodes for every 1000 catheter days, while non-infectious complications occur more frequently. Uniform patient education and catheter care, as well as placement by a single consistent surgeon will decrease the frequency of complications, improve the longevity and function of these venous access devices, while minimizing the associated morbidity.

Choosing an appropriate implantable device for long-term venous access

A variety of devices is now available for venous access in patients requiring long-term infusions of chemotherapeutic agents, hyperalimentation solutions, blood products or antibiotics. All have advantages and disadvantages which may make the selection of one type of device appropriate under a given set of circumstances but inappropriate in another. Experience has shown that patients needing intensive therapy for hematologic malignancies are best served by lines that require minimal dissection for insertion, such as the Hickman catheter. Patients who are unlikely to hemorrhage at the time of insertion and who need only intermittent therapy can take advantage of the greater convenience and cosmetic appearance of a totally implantable port. Peripheral vein cannulation by means of fine silicone rubber catheters can be performed by trained intravenous nurses to provide access of intermediate duration without the expense and inconvenience of surgical insertion in an operating room.

Outpatient dobutamine and dopamine infusions in the management of chronic heart failure: clinical experience in 21 patients

Dobutamine (and dopamine) are potent positive inotropic drugs which are frequently given to treat decompensated congestive heart failure. This study reports on the use of ambulatory dobutamine (and dopamine) infusions in 21 outpatients with advanced congestive heart failure. Each patient was initially hospitalized, and hemodynamic and clinical efficacy to dobutamine (and dopamine) was assessed. These 21 patients were carefully selected from a larger population of approximately 40 patients referred for this therapy. Chronic venous access was established and a drug infusion pump was supplied. Patients and family members were trained in the use of these devices. Eleven patients were treated with intermittent dobutamine infusions for 48 consecutive hours weekly, six patients with continuous (i.e., 24 hours daily) dobutamine infusions, and four patients with continuous, daily dobutamine and dopamine infusions. Significant (p less than 0.001) increases in cardiac index (1.8 +/- 0.6 to 2.7 +/- 0.7 L/min/m2) occurred during the initial dobutamine titrations. Functional classification (3.8 +/- 0.4 to 2.8 +/- 0.7) also improved significantly (p less than 0.01) during the 1.8 to 24 (mean 7.8) months of outpatient infusion therapy with dobutamine (and dopamine). Complications during outpatient therapy included drug tolerance (two instances), infection (two with bacteremias, eight with exit site infections), drug extravasation (three instances), and pump malfunction (two instances). Twenty patients have died: eleven from heart failure, four suddenly (one of them 9 months after dobutamine was stopped), and five from noncardiac causes. Our data suggest that outpatient dobutamine (and dopamine) infusions may be an effective form of therapy for selected patients with severe congestive failure who are refractory to more conventional treatment or who are awaiting cardiac transplantation.

Hospital hotel services as risk factors for infection among immunocompromised patients

Much is known about the association of urinary catheters, respiratory-assist devices, intravenous catheters and infusions, and other clinically related equipment with a risk of infection. The compromised host tends to develop infection with organisms that are frequently encountered in the normal flora. However, the results of surveillance cultures suggest that these organisms have indeed been acquired during hospitalization. This report suggests that many of these pathogens are acquired not as a result of clinically related activities but, rather, in conjunction with the "hotel services" of the hospital, such as the supply of food, water, and air. Tentative recommendations to hospitals for reducing the risk of infection from these services include proper design and maintenance of air-ventilating systems, regular monitoring of the water system, and preparation of foods low in microbial content for granulocytopenic patients.

Adherent microorganisms on lumenal surfaces of long-term intravenous catheters. Importance of Staphylococcus epidermidis in patients with cancer

Using electron microscopy, we prospectively evaluated how frequently adherent microorganisms colonized silicone rubber intravenous (Hickman) catheters removed from patients with cancer. Thirteen (87%) of 15 catheters had gram-positive cocci in glycocalyx adherent to the surface of the catheter lumen. Fungal elements or gram-negative bacilli were mixed with the gram-positive cocci in the glycocalyx on the lumens of three catheters. A consistent morphologic form was adherent to, and the same species was recovered from, the corresponding catheter for six of 27 organisms causing septicemia during catheterization: four of five Staphylococcus epidermidis bacteremias and the only Staphylococcus aureus bacteremia, and one of five candidemias. Three of these six septicemias were successfully treated without removal of the catheter. Although adherent organisms, particularly S epidermidis, were likely to be present on the surface of the lumen of long-term, indwelling, silicone intravenous catheters, septicemias potentially related to these organisms occurred infrequently (fewer than two per 1000 days of catheter use), and the suspect septicemias could sometimes be treated without removal of the catheter.

Aspergillus sinusitis in cancer patients

Paranasal sinusitis occurred in 52 immunosuppressed cancer patients treated over 5 years at the University of Maryland Cancer Center. Twenty-one patients had aspergillus sinusitis; Aspergillus sp, including flavus and niger were directly recovered from sinus in 19 of the 21 infections. Two other patients with sinus involvement and positive nose cultures for Aspergillus flavus or fumigatus and microbiologically documented pulmonary aspergillosis were considered clinically, although not microbiologically, documented. Predisposing factors for aspergillus sinusitis during the 60 days prior to infection diagnosis were granulocyte count less than 500 microliter (mean duration, 42 days versus 14 days for sinusitis of other etiology; P less than 0.001), prolonged hospitalization (mean duration, 22 days versus 14 days for patients with nonfungal sinusitis; P less than 0.001), and prolonged antibiotic therapy (mean duration, 22 days versus 9 days; P less than 0.001). Treatment with amphotericin B was initially successful for 18 of 21 patients; however, 11 of 18 patients had infection recurrence that always developed at time of tumor exacerbation and reinstitution or intensification of chemotherapy. These findings suggest that aspergillus sinusitis in cancer patients is seen in association with prolonged neutropenia and antibiotic therapy, is amenable to therapy, but tends to recur with relapse of malignancy.

Antibiotic synergism and response in gram-negative bacteremia in granulocytopenic cancer patients

To determine whether antimicrobial synergism affects the outcome of gram-negative bacteremia among profoundly (less than 100/microliter) neutropenic cancer patients, the clinical courses of 75 such patients who received empiric therapy with combination, broad-spectrum antibiotics were analyzed. Twenty-nine of 34 (85 percent) patients whose granulocyte count increased to more than 100/microliter during therapy improved, whereas only 12 of 41 (29 percent) patients with no increase in granulocyte count showed improvement (p = 0.0002). The critical group for further analysis was, therefore, those patients with persistent, profound granulocytopenia. Among these 41 patients, synergism was associated with a substantially better response rate: eight of 18 (44 percent) improved compared with none of 13 in whom synergism was not detected (p = 0.005); presence or absence of synergism could not be assessed for the pathogens isolated from the remaining 10 patients because the organisms were exquisitely susceptible to one of the two antibiotics used. Further evaluation of these persistently neutropenic patients indicated that synergism appeared critical even when the pathogen was susceptible to both antibiotics. Thus, seven of 11 (64 percent) showed response when the two drugs were synergistic in activity, compared with none of six when synergism was not present (p = 0.01). These data again demonstrate the importance of granulocyte recovery to patient response and further indicate that synergistic combinations of antibiotics are indicated for cancer patients with gram-negative bacteremia and persistent, profound granulocytopenia.

A double beta-lactam combination versus an aminoglycoside-containing regimen as empiric antibiotic therapy for febrile granulocytopenic cancer patients

The double beta-lactam combination of moxalactam plus piperacillin was compared with the aminoglycoside-containing regimen of moxalactam plus amikacin in a prospective, randomized trial of empiric therapy for 302 febrile episodes in granulocytopenic cancer patients. The moxalactam/piperacillin regimen was found to be as effective as the moxalactam/amikacin regimen (70 percent overall responses); responses with moxalactam/piperacillin and moxalactam/amikacin were similar for microbiologically documented infections (24 of 37, 65 percent, versus 20 of 35, 57 percent), for the subgroup with bacteremias (19 of 32 versus 14 of 28), and for clinically documented infections (41 of 58, 71 percent, versus 40 of 48, 83 percent). Responses were similar also for bacteremia in patients with persistent, profound (less than 100/microliter) granulocytopenia. Among profoundly (less than 100/microliter) granulocytopenic patients with gram-negative bacteremia, an increase in the granulocyte count to more than 100/microliter during therapy and a peak bactericidal activity of 1:16 or more (the latter noted in seven of nine moxalactam/piperacillin trials and six of nine moxalactam/amikacin trials) correlated with a favorable clinical response in 85 percent (p less than or equal to 0.00003) and 92 percent (p less than or equal to 0.044), respectively. Although serious side effects were minimal with either regimen, the double beta-lactam combination was associated with significantly less frequent nephrotoxicity (two of 145 versus 12 of 130; p less than or equal to 0.003) and ototoxicity (none of 34 versus seven of 34; p less than or equal to 0.006). The double beta-lactam combination of moxalactam plus piperacillin was found to be as effective as moxalactam plus amikacin but to have significantly less nephro- and ototoxicity.

Bacterial colonization of Hemasite access devices

Vascular access ports (Hemasites) were recovered from patients in whom they had become foci of infection and were examined according to microbiologic and morphologic techniques. All were covered on their extraluminal surfaces by well-developed biofilms consisting of host material and bacteria and their extracellular products. One Hemasite from which Staphylococcus aureus and Streptococcus faecalis were cultured was covered by a biofilm that consisted of coccoid bacterial cells and occasional fungal cells. Another Hemasite from which Proteus mirabilis was cultured was covered by a polymicrobial biofilm consisting of at least six morphologically distinct bacterial types and their extracellular products. This direct observation of the biofilm mode of bacterial growth on these devices suggests that the colonizing organisms will not be completely recovered by routine microbiologic techniques and that bacteria in the biofilm will tend to resist both host clearance mechanisms and antibiotic therapy. Removal of the device, with its accretion of bacterial biofilm, should allow the resolution of the associated infection.

An improved technique for the removal of long term implantable central venous lines

A method for removing Hickman catheters is described herein. This technique permits removal of the inner catheter tip without contaminating it on the open colonized portion of the subcutaneous exit site. Added advantages are patient comfort and lower risk of catheter breakage.

Autopsy findings after prolonged catheterization of the right atrium for chemotherapy in acute leukemia

Autopsies performed upon 59 patients treated for acute leukemia through venous access provided by long term right atrial catheters demonstrated a significant incidence of thrombus formation in the vena cava or right atrium. Similar thrombi were not present in 49 patients who were treated for the same disease without long term catheters. The clinical significance of these lesions, which were not usually seen with less than 150 days of catheter use, is unclear. No increase in the likelihood of other pathologic lesions, specifically of pulmonary emboli, was seen to accompany thrombus formation nor did they seem in any way contributory to the demise of the patient. No good screening test is yet available to detect these lesions ante mortem.

Volatile Halogenated Organic Compounds Released to Seawater from Temperate Marine Macroalgae

Volatile halogenated organic compounds synthesized by various industrial processes are troublesome pollutants because they are persistent in terrestrial ecosystems and because they may be present in sufficient quantities to alter the natural atmospheric cycles of the halogens. Certain of these compounds, including polybromomethanes and several previously unobserved alkyl monohalides and dihalides, appear to be natural products of the marine environment. A variety of temperate marine macroalgae (the brown algae Ascophyllum nodosum and Fucus vesiculosis, the green algae Enteromorpha linza and Ulva lacta, and the red alga Gigartina stellata) not only contain volatile halogenated organic compounds but also release them to seawater at rates of nanograms to micrograms of each compound per gram of dry algae per day. The macroalgae may be an important source of bromine-containing material released to the atmosphere.

Symposium on infections in the compromised host. The leukemias

The treatment of acute leukemia in the adult causes prolonged and profound granulocytopenia. When the patient has less than 100 granulocytes per microliter, the risk of life-threatening infection is extremely high. Major infections include bacteremia, pneumonia, pharyngitis, esophagitis, colitis, perianal or perirectal lesions, and cellulitis. The major organisms are gram-negative bacilli (especially Pseudomonas aeruginosa, Escherichia coli, and Klebsiella pneumoniae), gram-positive organisms (Staphylococcus epidermidis and Staphylococcus aureus), the yeasts (Candida albicans and Torulopsis glabrata), and the filamentous fungi (Aspergillus flavus and fumigatus). Infection prevention includes the return to normal of the patient's host defense mechanisms, reduction of invasive procedures which breach body barriers, and methods to decrease the acquisition of potential pathogens, and to reduce the number of organisms colonizing the patient.

Intermittent dobutamine hydrochloride infusions in outpatients with chronic congestive heart failure

Patients with severe chronic congestive heart failure were treated with intermittent dobutamine hydrochloride infusions administered on an outpatient basis with a portable infusion device. Eleven patients (eight women and three men), ages 28-71 years, were given initial dobutamine hydrochloride infusions at a rate of 1-2 micrograms/kg/min, and the dose was gradually increased to a maximum dose of 15 micrograms/kg/min. Patients were considered dobutamine responders if their cardiac output increased by at least 30% and pulmonary-capillary wedge pressure did not rise. After a sustained hemodynamic response was demonstrated, the infusion was discontinued to assess the patients' symptoms during drug-free intervals. The patients were instructed and trained in proper catheter care after a venous-access catheter was surgically implanted. Patients were also shown how to use the ambulatory infusion pump. The patients were treated with long-term intermittent dobutamine hydrochloride infusions for 3-24 months. All patients adjusted easily to the routine of catheter and pump care and drug administration. The mean dose of dobutamine hydrochloride resulting in the maximum improvement in cardiac index was 9.4 micrograms/kg/min. All patients observed an improvement in their symptoms of congestive heart failure during the drug infusions and the intervals between the infusions. There was a mean reduction of 1.2 in New York Heart Association functional class. There were 18 congestive heart failure-related hospital readmissions among the 11 patients during 108 cumulative months of long-term dobutamine therapy. The intermittent administration of dobutamine hydrochloride via a portable infusion system appears to have improved the functional capacity of the 11 patients studied. This may be a viable treatment alternative for selected ambulatory patients with severe heart failure who demonstrate hemodynamic improvement with dobutamine.

Effect of Hickman catheters on the self-esteem of patients with leukemia

Hickman right atrial catheters are useful in providing prolonged access for chemotherapy. Their presence does alter body image, however, and the maintenance of catheter patency during periods of outpatient care demands patient cooperation and participation. To determine whether the alterations in body image and life-style brought about by catheter insertion would have a negative effect upon the self-esteem of patients with acute leukemia, "purpose-in-life" testing was done prospectively in two groups of patients treated over a 30-day period with and without right atrial catheters. No significant alterations in self-esteem were noted during the study period in response to the use of Hickman catheters. The results suggest that Hickman catheters can be used as needed to improve venous access in patients with acute leukemia, without fear that this will adversely affect self-esteem.

Can antibacterial therapy be discontinued in persistently febrile granulocytopenic cancer patients?

It has been suggested that empiric broad-spectrum antibiotics, instituted for fever in the presence of granulocytopenia, should continue to be administered, even when infection is not demonstrable, to those patients who remain persistently febrile and granulocytopenic. Therefore, the consequences of discontinuing antibiotics when the presence of infection is doubted in this setting were evaluated. In 16 (3.7 percent) of 429 episodes of fever and granulocytopenia for which empiric antibiotic therapy was instituted, after approximately four days, persistence of both fever and granulocytopenia was found, and yet infection was prospectively classified at that time as "doubtful." The initial empiric antibiotic regimen was therefore discontinued after a mean of 4.8 (median 5.0) days. Discontinuation of antibiotics proved appropriate for half of the patients; eight patients received no systemic therapeutic antibiotics with no evidence of infection during a period of at least two weeks. The other eight patients had antibacterial antibiotics reinstituted within a mean of 2.4 days; six infections were subsequently demonstrable. Six of these eight patients also required or were believed to require antifungal therapy with intravenous amphotericin B for presumed fungal infections. Patients with relapsed leukemia or lymphoma and those with a likelihood of continued profound granulocytopenia (counts below 100/microliters) or both were the ones who tended to require reinstitution of antibiotics. Discontinuation of antibiotics when infection was considered doubtful despite persistence of both fever and granulocytopenia was, therefore, successful in eight of 16 patients. Reinstitution of antibiotics was required in the eight remaining patients. No definite rule appears to be applicable to all patients.

Dual lumen catheters for angioaccess in patients with leukemia

Dual lumen long-term indwelling right atrial catheters have been used to improve venous access in adult patients with leukemia. Twenty-eight such catheters have functioned for 1,895 days in 28 patients over the past eight months at the University of Maryland Hospital. Although insertion of the dual lumen catheter was more technically demanding than insertion of a single lumen catheter, the greater versatility in drug management (e.g., administration of two continuous infusions simultaneously or one continuous infusion leaving one line for platelets, blood, antibiotics or venous sampling) provided by the extra venous portal of entry more than compensated for any increased operative time (average, 58 vs 39 min/insertion). Eight episodes of bacteremia (0.37/100 patient days) occurred in these patients, but only one of these was associated with an exit site infection: the remainder were secondary to infections remote from the catheter. No catheter was removed as a result of these episodes, nor was any removed for ante mortem mechanical failure. The dual lumen catheter is a safe reliable device for providing angioaccess in patients with leukemia and offers substantially greater flexibility than the single lumen catheter.

Prolonged venous access for chemotherapy by means of the Hickman catheter

One hundred and six long-term right atrial (Hickman) catheters have been used to establish permanent venous access in 99 patients undergoing prolonged chemotherapy for leukemia and other malignancies at the University of Maryland/Baltimore Cancer Research Center over the 30-month period from November 1978 to May 1981. A uniform technique for insertion, using cannulation of the external or internal jugular vein and atraumatic dissection of the subcutaneous tunnel, has resulted in no episodes of hemorrhage or tunnel infection in the last 55 placements in these high-risk granulocytopenic, thrombocytopenic patients. Twelve catheters have now been in place for over one year, and two catheters have been in place for over two years without apparent ill effects. A low catheter related infection rate is attributed to meticulous adherence to catheter care guidelines, supervised by a single trained and interested nurse.

Selective antimicrobial modulation as prophylaxis against infection during granulocytopenia: trimethoprim-sulfamethoxazole vs. nalidixic acid

Sixty-two profoundly granulocytopenic patients with acute leukemia undergoing induction chemotherapy were prospectively randomized to receive either trimethoprim-sulfamethoxazole plus nystatin or nalidixic acid plus nystatin for prevention of infection. Patients given trimethoprim-sulfamethoxazole plus nystatin during initial remission induction experienced an increased duration (22.6 vs. 13.6 days) of profound granulocytopenia (less than 100 granulocytes/mm3; P = 0.007). Acquisition of gram-negative bacilli was more frequent among patients treated with nalidixic acid plus nystatin while filamentous fungi were acquired more frequently by patients receiving trimethoprim-sulfamethoxazole plus nystatin (P = 0.05). The median duration of on-study time prior to documentation of first infection was longer for patients receiving trimethoprim-sulfamethoxazole plus nystatin (17 days) than for those receiving nalidixic acid plus nystatin (eight days) (P = 0.0002). Three infection-related deaths occurred among patients receiving nalidixic acid; seven occurred among patients receiving trimethoprim-sulfamethoxazole, five of which were secondary to pneumonia due to Aspergillus flavus. Both of these methods of selective antimicrobial modulation have apparent advantages, but each has disadvantages serious enough to limit their routine use.

An improved technique for the insertion of Hickman catheters in patients with thrombocytopenia and granulocytopenia

A more delicate means of catheter insertion has been developed to minimize the hemorrhagic and infectious complications which occur with the use of right atrial catheters in patients with thrombocytopenia and granulocytopenia. The essential features of this improved technique are the substitution of intravenous sedation for chest wall infiltration by a local anesthetic and reliance upon a less traumatic tunneling instrument to form the subcutaneous pathway.

Intermittent, continuous outpatient dobutamine infusion in the management of congestive heart failure

The use of outpatient dobutamine infusions by a small, portable infusion pump in 3 patients with intractable congestive heart failure (CHF) is described. With this therapy left ventricular function improved and CHF resolved in each. Tolerance to dobutamine was obviated by giving infusions twice weekly. Except for 3 mild infections around the catheter exit site, there have been no complications of this therapy is 58 cumulative patient weeks.

A comparative evaluation of two fiberoptic bronchoscopy catheters: the plugged telescoping catheter versus the single sheathed nonplugged catheter

We prospectively evaluated the ability of the plugged telescoping catheter (PTC) brush and the single sheathed nonplugged catheter brush to provide sterile lower respiratory tract samples during fiberoptic bronchoscopy in 19 noninfected patients with cancer. Both brushes were evaluated, in random order, in each of the 19 patients. The PTC brush and the single sheath brush were sterile in 12 and 5 patients, respectively, and in 7 patients, the PTC brush alone was sterile (p = 0.016, two-sided). Patients were anesthetized by lidocaine administered through the bronchoscope (6 patients), via an aerosol (3 patients), or by transtracheal injection (10 patients). The advantage of the PTC brush was evident only when aerosol or transtracheal anesthesia were used; the PTC brush was sterile in 9 of 13 patients, whereas the single sheathed brush was sterile in only 2 of these 13 (p = 0.016, two-sided). The plugged telescoping catheter brush is therefore more suitable than the single sheathed brush catheter for delivering sterile brushes to the lower respiratory tract during fiberoptic bronchoscopy.

Staphylococcus epidermidis: an increasing cause of infection in patients with granulocytopenia

Staphylococcus epidermidis, a major component of the skin flora, is usually considered a contaminant when recovered from diagnostic cultures. Since 1974 infections caused by gram-negative bacilli and S. aureus occurring among patients with granulocytopenic cancer have remained constant; infections due to S. epidermidis occurring before 1977 at a rate of 2.0 per 1000 days of hospitalization of patients with acute leukemia, increased to 14.6 per 1000 days in 1979. All S. epidermidis infections before 1977 originated from skin sites; since 1977 the respiratory tract and alimentary canal have become the predominant sites of origin. Predisposing factors for infection were profound granulocytopenia (less than 100/microL), a diagnosis of acute leukemia, and an oral nonabsorbable antibiotic regimen lacking vancomycin. The increased incidence of infection was not related to a nosocomial source or the more frequent use of long-term indwelling catheters. Methicillin resistance among isolates was common (40%). Intravenous vancomycin therapy provided the best therapeutic results. Diagnostic cultures positive for S. epidermidis in the setting of infection and profound granulocytopenia warrant appropriate antibiotic therapy.

Comparison of standard versus pharmacokinetically adjusted amikacin dosing in granulocytopenic cancer patients

The capabilities of two pharmacokinetic amikacin dosing methods were evaluated and compared with the standard amikacin dosage recommended by the manufacturer. Study patients participated in two consecutive prospective randomized double-blind trials of empiric antibiotic therapy for febrile episodes during granulocytopenia. Patients in study 1 received amikacin at a dosage of 15 mg/kg per day in four divided doses in combination with either ticarcillin or piperacillin. Patients in study 2 received either ticarcillin or moxalactam in combination with amikacin. Amikacin dosages in study 2 were adjusted to achieve a 1-h-postinfusion concentration of approximately 25 micrograms/ml and a trough concentration of approximately 8 micrograms/ml. Initial amikacin dosage requirements were established based on the lean body weight and estimated renal function of the patient. If amikacin serum concentrations were not within acceptable ranges, further dosage adjustments were made by using patient-specific pharmacokinetic parameters. The median 1-h-postinfusion concentration of amikacin in study 1 was 13.0 micrograms/ml, with a median trough concentration of 6.1 micrograms/ml. In study 2 the median 1-h-postinfusion concentration was 20.8 micrograms/ml, with a median trough of 6.4 micrograms/ml. Patients in study 2 required a mean dosage of 29.4 mg/kg per day. The incidence of amikacin-induced nephrotoxicity was not increased despite the substantial increase in dosage. Ototoxicity was not evaluated in study 1, but the incidence of ototoxicity in study 2 (17%) exceeded the incidence observed in a previous amikacin-plus-ticarcillin trial in which patients received 15 mg of amikacin per kg per day.

Empiric antibiotic therapy for suspected infection in granulocytopenic cancer patients: a comparison between the combination of moxalactam plus amikacin and ticarcillin plus amikacin

Moxalactam is a new cephalosporin with a broad spectrum of activity which includes Pseudomonas aeruginosa in addition to Klebsiella species Escherichia coli, and Staphylococcus aureus. Moxalactam was combined with amikacin (M + A) compared to ticarcillin plus amikacin (T + A) in a prospective, randomized double-blind trial of empiric therapy for febrile episodes among granulocytopenic cancer patients. One hundred and ninety-one epidoses were evaluated; T + A, 93 episodes and M + A, 98 episodes. Median granulocyte count of initiation of therapy was less than 100/microliters. Overall response rates were good. In the T + A group, 21 of 29 (72 percent) microbiologically documented infections, including seven of 14 (50 percent) bacteremias, and 24 of 27 (89 percent) clinically documented infections improved. In the M + A group, 20 of 28 (71 percent) microbiologically documented infections, including 11 of 18 (61 percent) bacteremias, and 25 of 25 (96 percent) clinically documented infections resolved. Adverse effects were minimal and equivalent in both groups. Hypokalemia (decrease in serum potassium of greater than 11 mEq/liter from baseline) occurred in 14 of the 93 episodes in the T + A group and in 10 of the 98 episodes in the M + A group with decline in mean serum potassium level of 0.5 and 0.4 mEq/liter respectively. Nephrotoxicity (increase in serum creatinine greater than 0.04 mg/dl) occurred in only one patient in the T + A group and in two patients in the M + A group. Moxalactam plus amikacin has a broader in vitro spectrum, is as effective, and is no more toxic than ticarcillin plus amikacin as empiric therapy for febrile granulocytopenic cancer patients.

Piperacillin or ticarcillin plus amikacin. A double-blind prospective comparison of empiric antibiotic therapy for febrile granulocytopenic cancer patients

Piperacillin plus amikacin was compared in a prospective randomized double-blind trial with our standard regimen of ticarcillin plus amikacin as empiric therapy of fever in patients with granulocytopenia. Profound persistent granulocytopenia (fewer than 100/microliter polymorphonuclear leukocytes without any rise during therapy) was present in 60 percent of the patient trials in both treatment groups. Of 38 microbiologically and clinically documented infections treated with piperacillin plus amikacin, 22 (58 percent) showed improvement. Of 34 microbiologically and clinically documented infections treated with ticarcillin plus amikacin, 19 (56 percent) showed improvement. There was no difference in response between groups according to the site of infection or infecting pathogen. Toxicity was minimal, with an equivalent incidence of immediate reactions, nephrotoxicity and superinfection. Patients receiving ticarcillin plus amikacin became colonized with more resistant gram-negative bacilli (17) than did those receiving piperacillin plus amikacin (3). Despite the monosodium structure of piperacillin, hypokalemia was not reduced for patients who received piperacillin plus amikacin. Although piperacillin has a wider in vitro antibacterial spectrum than ticarcillin, the clinical efficacy and toxicity of the combination of piperacillin plus amikacin were similar to those of ticarcillin plus amikacin as empiric therapy.

Two methods for improved venous access in acute leukemia patients

Arteriovenous fistulae and long-term indwelling right atrial (Hickman) catheters have been used as methods to improve venous access in patients with acute leukemia. The creation of 28 fistulae provided short duration of function (median, 12 days), with eight fistulae functioning less than 24 hours. Complications were negligible, and no increase in the incidence of bacteremia occurred. Fifty-one Hickman catheters have been placed, with a median placement granulocyte count of 335/microliters. The median duration of function has been 91 days or more, with 19 still functioning and 25 other catheters functioning at the time of the patient's death. Complications have been minimal, with substantial postoperative hemorrhage occurring primarily in patients with active disseminated intravascular coagulopathy at the time of catheter placement. Catheter-associated infections were uncommon. The overall incidence of bacteremia was not increased in patients with Hickman catheters, and 28 of the 30 bacteremias that occurred while catheters were in place (three catheter associated) resolved without catheter removal. The Hickman catheter is a safe, reliable device for improvement of venous access in adult patients with acute leukemia.

Potential of mezlocillin as empiric single-agent therapy in febrile granulocytopenic cancer patients

Mezlocillin was used as an initial empiric antibiotic therapy for febrile (> 101 degrees F, ca. 38.33 degrees C) granulocytopenic (< 1,000/microliter) cancer patients. Patients known to be colonized with an organism resistant to 100 micrograms of mezlocillin per mol were excluded. The initial 25 cases (23 patients) received intravenous mezlocillin, 260 mg per kg per day in six divided doses; the mean 1-h-postinfusion serum level was 69 micrograms/ml. Because of the low serum level, the next 25 cases (22 patients) received 450 mg/kg per day, also in six divided doses, resulting in a mean 1-h-postinfusion serum level of 161 micrograms/ml. Both dosage regimens provided similar efficacy. Combined results show that 11 of 21 microbiologically documented infections and 7 of 13 clinically documented infections improved. Instances of bacteremia (number of cases in parentheses) were caused by Pseudomonas aeruginosa (two), Staphylococcus epidermidis (two), Clostridia perfringens (one), and Bacillus species (one); only one case improved. A rise in granulocyte count to > 500/microliters, a serum bactericidal activity of greater than or equal to 1:8 against the infecting pathogen, or both were indicators of a good therapeutic response. Despite exclusion of patients known to be previously colonized with mezlocillin-resistant organisms, 7 of 23 pathogens required a minimal concentration of greater than or equal to 100 micrograms of mezlocillin per ml for inhibition. In addition, surveillance cultures from 18 cases showed resistant organisms colonizing the gingiva, rectum, or both. Side effects of mezlocillin were minimal and included pseudoproteinuria, asymptomatic transient rise in bilirubin, and easily reversible kypokalemia. Mezlocillin, a new semisynthetic penicillin with little toxicity, was found to be inadequate as a single-agent empiric antibiotic therapy for febrile, granulocytopenic cancer patients.