Amikacin and ceftazidime as empirical antibiotic therapy in severely neutropenic patients: analysis of prognostic factors

This study aimed to evaluate the efficacy of amikacine and ceftazidime as an empirical antibiotic therapy for neutropenic patients affected by haematological neoplasms and to investigate the presence of prognostic features suggesting a poor outcome with this antibiotic combination at the onset of infection. This could allow the identification of subgroups of patients with a low rate of response to amikacin/ceftazidime therapy; in these patients different initial empirical therapy may be indicated. The study population comprised 166 severely neutropenic (absolute neutrophil count below 500/microliters) oncohaematological patients with fever or clinical signs of infection. Multivariate analysis confirmed four negative prognostic factors: 3 or more days of hospitalization at the onset of an infectious episode, a diagnosis of acute myelmany factors are present, cases can be stratified into three groups, of significantly different prognosis: favourable (0 or 1 factor) 76% success; intermediate (2 factors) 52% success; unfavourable (3 or 4 factors) 19% success. At the onset of an infectious episode a subgroup of patients with a very low response rate to empirical amikacin/ceftazidime antibiotic therapy is identifiable, for whom a different therapy is indicated. Because of the high rate of proven or probable fungal infections in this group, the immediate administration of a systemic antifungal therapy, in addition to antibacterial agents, could be considered in these high-risk patients. Studies should be specifically addressed to evaluating a stratification of empirical antibiotic therapy according to risk factors present at the onset of infection.

[Multiple myeloma. Role of prognostic factors and staging in a therapeutic program]

Patients affected with multiple myeloma constitute an heterogeneous population with very different clinical patterns, varying from asymptomatic to very compromised patients with severe and uncontrolled disease. Most common clinical and biological staging systems have been in use for many years. Recently new prognostic factors have been identified; among them, serum levels of beta-2 microglobulin, C-reactive protein and interleukin-6 employed with already known parameters have been useful in the new staging system, permitting a more focalized therapy. As today is not yet possible to define the best treatment schedule, as the most common treatments are incapable to eradicate myeloma neoplastic clone even in responsive patients. Nevertheless extensive use of biologic response modifiers in the last years, as alpha interferon, have added new powerful and hopeful therapeutic tools even if the results need to be confirmed in future trials. It is important to remind the primary role of bone marrow transplantation associated with high dose polychemotherapy even if just a minority of patients is eligible for this therapeutic chance.

Non-Hodgkin's lymphoma of the elderly. Prognostic factors and outcome

The initial features and prognosis of non-Hodgkin's lymphoma (NHL) of the elderly have been variously evaluated in literature. We have examined 190 patients with NHL: most of them received induction therapies containing vincristine, cyclophosphamide and/or anthracyclines (CVP, CHOP, CEOP); age at diagnosis was over 65 for 62 of them (32.63%). Elderly patients had a lower rate of complete remissions, a shorter duration of complete remissions and, consequently, a poorer overall survival. In our patients, prognosis was related also with stage, histology (according to Working Formulation, WF) and performance status at the diagnosis. Elderly patient had not a significantly increased incidence of these unfavourable prognostic factors at the onset. However, patients aged 65 or more received lower doses of drugs during induction therapy (cyclophosphamide: 81%; vincristine: 73%; anthracyclines: 22% of patients under 55). Patients aged 55-65 had induction therapies of intermediate intensity; also proportion of complete remissions and survival were intermediate between the two other groups. Haematological toxicity appeared the most important cause of these reductions: in fact nadirs of neutrophils and platelets during induction therapy were similar in the 3 groups in spite of the different intensity of treatment. Even if statistical correlations are not possible, the incidence of infections has been higher in the elderly.