Subject(s)
Antibiotic Prophylaxis , Bacterial Infections/prevention & control , Fiducial Markers , Prostatic Neoplasms/radiotherapy , Bacterial Infections/epidemiology , Humans , Incidence , Male , Prosthesis Implantation , Radiotherapy Planning, Computer-Assisted , Radiotherapy, Image-Guided , Rectum/drug effects , Rectum/microbiologySubject(s)
Neoplasms, Germ Cell and Embryonal/microbiology , Neutropenia/prevention & control , Sepsis/prevention & control , Testicular Neoplasms/microbiology , Humans , Male , Neoplasms, Germ Cell and Embryonal/blood , Neoplasms, Germ Cell and Embryonal/drug therapy , Neutropenia/therapy , Sepsis/blood , Testicular Neoplasms/blood , Testicular Neoplasms/drug therapyABSTRACT
Empirical antifungal therapy is frequently used in allogeneic transplant patients who have persistent febrile neutropenia and can be associated with high cost, toxicity and breakthrough infections. There are limited reports of strategies for early diagnosis of invasive fungal infection (IFI) and, to our knowledge, no reports of treatment strategies based only on high-resolution computerized tomography (HRCT) scans. We used an early treatment strategy for IFI in 99 consecutive patients undergoing allogeneic transplantation. Patients received caspofungin if they had antibiotic-resistant neutropenic fever for more than 72 h and a positive HRCT scan. Fifty-three of 99 patients (54%) had antibiotic-resistant neutropenic fever at 72 h and would have received parenteral antifungal treatment if an empirical approach had been used. The HRCT-based strategy reduced the use of parenteral antifungal agents to 17/99 patients (17%), a 68% reduction. No subsequent diagnoses of IFI occurred within 100 days in patients with a negative HRCT. Only one patient died from IFI within 100 days. These data suggest that this non-empirical strategy may be feasible and that caspofungin may be effective in this setting. A randomized controlled trial is warranted to further assess these results.
Subject(s)
Antifungal Agents/administration & dosage , Echinocandins/administration & dosage , Hematopoietic Stem Cell Transplantation , Mycoses/diagnostic imaging , Mycoses/drug therapy , Mycoses/mortality , Tomography, X-Ray Computed/methods , Adolescent , Adult , Aged , Caspofungin , Female , Hematologic Neoplasms/diagnostic imaging , Hematologic Neoplasms/mortality , Hematologic Neoplasms/therapy , Humans , Lipopeptides , Male , Middle Aged , Mycoses/etiology , Time Factors , Transplantation, HomologousSubject(s)
Leukemia, Lymphocytic, Chronic, B-Cell/complications , Mycobacterium Infections, Nontuberculous/complications , Mycobacterium chelonae/isolation & purification , Opportunistic Infections/complications , Skin Diseases, Bacterial/complications , Agammaglobulinemia/complications , Aged , Alemtuzumab , Antibodies, Monoclonal/adverse effects , Antibodies, Monoclonal/therapeutic use , Antibodies, Monoclonal, Humanized , Antibodies, Neoplasm/adverse effects , Antibodies, Neoplasm/therapeutic use , Antineoplastic Agents/adverse effects , Antineoplastic Agents/therapeutic use , Antineoplastic Combined Chemotherapy Protocols/adverse effects , Antineoplastic Combined Chemotherapy Protocols/therapeutic use , Combined Modality Therapy , Cyclophosphamide/administration & dosage , Cyclophosphamide/adverse effects , Humans , Immunocompromised Host , Immunotherapy/adverse effects , Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy , Male , Mycobacterium Infections, Nontuberculous/diagnosis , Mycobacterium Infections, Nontuberculous/microbiology , Opportunistic Infections/diagnosis , Opportunistic Infections/microbiology , Skin Diseases, Bacterial/diagnosis , Skin Diseases, Bacterial/microbiology , Vidarabine/administration & dosage , Vidarabine/adverse effects , Vidarabine/analogs & derivativesABSTRACT
BACKGROUND: The Paediatric Oncology Centres (POCs) treating childhood cancer in South East England produce unified supportive care guidelines for use in the secondary pediatric (shared care) units. This study evaluated the adherence to current guidelines for febrile neutropenia (FN) and documented outcome in terms of bacterial isolates, antibiotic resistance patterns, length of hospital stay, and mortality. PROCEDURE: Prospective study of pediatric FN admissions between July 2001 and December 2002. RESULTS: Data were received on 433 eligible FN episodes in 212 patients. The recommended empirical antibiotics (piptazobactam + gentamicin) were used in 354 (82%) admissions. Blood cultures were positive in 129 episodes (30%). Gram-positive organisms predominated (120/149 organisms isolated) and the majority were coagulase-negative Staphylococci (95/120). There were 27 Gram-negative isolates and 1 fungal isolate. No Gram-negative isolate was resistant to both first-line antibiotics. Only one death was recorded in the study group. The median length of hospital stay was 5 days. CONCLUSIONS: We obtained data on a large number of shared care episodes of FN. The antibiotic guidelines were followed in most episodes. Bacteremia was common, but little resistance to first-line antibiotics was documented among Gram-negative isolates, confirming the safety of the strategy in our population.
Subject(s)
Neutropenia/epidemiology , Adolescent , Anti-Bacterial Agents/therapeutic use , Child , Child, Preschool , Drug Resistance , England/epidemiology , Female , Fever , Fungi/isolation & purification , Gram-Negative Bacteria/isolation & purification , Gram-Positive Bacteria/isolation & purification , Hospitalization , Hospitals, Pediatric , Humans , Infant , Male , Neutropenia/microbiology , Practice Guidelines as Topic , Prospective StudiesABSTRACT
Parainfluenza type 3 (PIV 3) is a well-recognized cause of respiratory illness after stem cell transplantation (SCT), with an estimated incidence of 2-7% and a high mortality rate associated with lower respiratory tract infection (LRTI). A 12-month retrospective study was undertaken in which 23 positive cases of PIV 3 occurred in SCT recipients. The frequency of infection was 36.1% in matched unrelated donor SCT recipients, 23.8% in sibling allogeneic SCT recipients and 2.3% in autologous transplant recipients. Seventeen cases were outpatient or community acquired despite standard infection control measures. Eleven patients only developed upper respiratory tract symptoms. LRTI symptoms developed in 12 patients, of whom eight had a new infiltrate on chest X-ray. Overall mortality at 30 days from PIV 3 diagnosis was 4% (one patient). Four patients died within 100 days of PIV 3 diagnosis, but PIV 3 was not believed to be the primary cause of death in any of these patients. Early ribavirin was used in eight patients and only one patient who received ribavirin died. These results suggest a higher prevalence of PIV 3 but a lower mortality than documented previously, particularly in allogeneic transplant recipients. The authors propose that the high prevalence reflects the unit's policy of active surveillance for respiratory viruses and the difficulty in preventing transmission of PIV 3, especially in the outpatient setting during an outbreak period. Ribavirin treatment may improve outcome in patients with LRTI but is not required in all patients with PIV 3.
Subject(s)
Cross Infection , Parainfluenza Virus 3, Human , Respirovirus Infections , Stem Cell Transplantation/adverse effects , Adolescent , Adult , Antiviral Agents/therapeutic use , Cross Infection/epidemiology , Cross Infection/mortality , Cross Infection/virology , England/epidemiology , Female , Humans , Infection Control , Male , Middle Aged , Prevalence , Respirovirus Infections/complications , Respirovirus Infections/epidemiology , Respirovirus Infections/mortality , Retrospective Studies , Ribavirin/therapeutic use , Transplantation, Autologous , Transplantation, HomologousABSTRACT
The antifungal agents most frequently used in prophylaxis and treatment are amphotericin B (and its new lipid forms) and azoles such as fluconazole, itraconazole, and more recently voriconazole. This review assesses the role of itraconazole in paediatric haematology/oncology practice. Its broader spectrum of activity and availability in oral and intravenous forms allow a flexible approach in the management of fungal infections.
Subject(s)
Antifungal Agents/therapeutic use , Itraconazole/therapeutic use , Mycoses/drug therapy , Absorption , Amphotericin B/adverse effects , Antifungal Agents/adverse effects , Antifungal Agents/pharmacokinetics , Aspergillosis/drug therapy , Candidiasis/drug therapy , Child, Preschool , Cost-Benefit Analysis , Humans , Itraconazole/adverse effects , Itraconazole/pharmacokinetics , Mycoses/prevention & controlABSTRACT
Incidences of and risk factors for Streptococcus pneumoniae sepsis (SPS) after hematopoietic stem cell transplantation were analyzed in 1329 patients treated at a single center between 1973 and 1997. SPS developed in 31 patients a median of 10 months after transplantation (range, 3 to 187 months). The infection was fatal in 7 patients. The probability of SPS developing at 5 and 10 years was 4% and 6%, respectively. Age, sex, diagnosis, and graft versus host disease (GVHD) prophylaxis did not influence the development of SPS. Allogeneic transplantation (10-year probability, 7% vs 3% for nonallogeneic transplants; P =.03) and chronic GVHD (10-year probability, 14% vs 4%; P =.002) were associated with significantly higher risk for SPS. All the episodes of SPS were seen in patients who had undergone allograft or total body irradiation (TBI) (31 of 1202 vs 0 of 127; P =.07). Eight patients were taking regular penicillin prophylaxis at the time of SPS, whereas 23 were not taking any prophylaxis. None of the 7 patients with fatal infections was taking prophylaxis for Pneumococcus. Pneumococcal bacteremia was associated with higher incidences of mortality (6 of 15 vs 1 of 16; P =.04). We conclude that there is a significant long-term risk for pneumococcal infection in patients who have undergone allograft transplantation, especially those with chronic GVHD. Patients who have undergone autograft transplantation after TBI-containing regimens also appear to be at increased risk. These patients should receive lifelong pneumococcus prophylaxis. Consistent with increasing resistance to penicillin, penicillin prophylaxis does not universally prevent SPS, though it may protect against fatal infections. Further studies are required to determine the optimum prophylactic strategy in patients at risk. (Blood. 2000;95:3683-3686)
Subject(s)
Bone Marrow Transplantation , Graft vs Host Disease/epidemiology , Pneumococcal Infections/epidemiology , Adolescent , Adult , Child , Child, Preschool , Databases as Topic , Female , Follow-Up Studies , Humans , Infant , Male , Middle Aged , Postoperative Complications , Probability , Retrospective Studies , Risk Factors , Time Factors , Transplantation, Autologous , Transplantation, HomologousABSTRACT
Candida kruzei-related systemic infections are increasing in frequency, particularly in patients receiving prophylaxis with antifungal triazoles. A Caucasian male with newly diagnosed acute myeloid leukaemia (AML M1) developed severe and persistent fever associated with a micropustular eruption scattered over the trunk and limbs during induction chemotherapy. Blood cultures grew Candida kruzei, and biopsies of the skin lesions revealed a candida vasculitis. He responded to high doses of liposomal amphotericin B and was discharged well from hospital.
Subject(s)
Amphotericin B/therapeutic use , Antifungal Agents/therapeutic use , Candidiasis/etiology , Leukemia, Myeloid/complications , Acute Disease , Candidiasis/drug therapy , Drug Carriers , Humans , Liposomes , Male , Middle Aged , Triazoles/therapeutic use , Vasculitis/etiology , Vasculitis/metabolismABSTRACT
Aspergillus species can cause life-threatening infection in immunocompromised children. Pulmonary infections are the most common, and are usually acquired through inhalations of aspergillus spores in unfiltered air. Some patients acquire invasive aspergillus infection from endogenous spread of colonized para-nasal sinuses.
Subject(s)
Aspergillosis/etiology , Fungemia/etiology , Precursor Cell Lymphoblastic Leukemia-Lymphoma/complications , Antifungal Agents/therapeutic use , Aspergillosis/drug therapy , Aspergillus fumigatus , Child , Female , Fungemia/drug therapy , Humans , Itraconazole/therapeutic use , MaleABSTRACT
Sixty-four adult patients (median age 43) with hematologic malignancies who were immunocompromised after allogeneic (n = 23) or autologous (n = 9) blood/marrow transplantation, or chemotherapy (n = 32) received 68 courses of amphotericin B lipid complex (ABLC, Abelcet) at the daily dose of 5 mg/kg for presumed (n = 52) or proven (n = 16) fungal infection. The major indications for ABLC were failure of previous antifungal therapy and/or renal dysfunction. Fifty-three treatment courses in 49 patients comprising 4-58 doses (median 10) were considered evaluable. Fourteen courses administered for confirmed infections resulted in nine complete and one partial responses, and four failures (71% response). Thirty-nine empiric courses resulted in 18 complete and six partial responses, and 14 failures (64% response). The overall response rate was 66%. Five of seven evaluable patients with aspergillus pneumonia responded. Response rates were comparable for chemotherapy, autograft and allograft recipients. The change in serum creatinine from the beginning to the end of therapy was -284 to +277 mumol/l (median +24). The creatinine doubled during seven evaluable courses of therapy, five of which were associated with concomitant nephrotoxic therapy. Nephrotoxicity was comparable for transplant and chemotherapy patients. Renal dysfunction necessitated discontinuation of ABLC in only four patients. These data suggest that ABLC is effective in presumed or confirmed fungal infections in immunocompromised patients after transplantation or chemotherapy.
Subject(s)
Amphotericin B/administration & dosage , Antifungal Agents/administration & dosage , Bone Marrow Transplantation/adverse effects , Hematologic Neoplasms/complications , Immunocompromised Host , Mycoses/drug therapy , Phosphatidylcholines/administration & dosage , Phosphatidylglycerols/administration & dosage , Adolescent , Adult , Aged , Drug Combinations , Female , Hematologic Neoplasms/therapy , Humans , Male , Middle Aged , Mycoses/etiology , Transplantation, Autologous , Transplantation, HomologousABSTRACT
Opportunistic infections have been a problem after BMT in CLL. We have allografted seven patients with B-CLL (n = 6) or B-prolymphocytic leukemia (n = 1) from matched siblings (n = 6) or a mismatched unrelated donor (n = 1). Amongst the first six, we saw two cases of recurrent or prolonged cytomegaloviremia and CMV disease, one listeria meningitis, and one fatal toxoplasma encephalitis. The latter two developed in the setting of steroid therapy of GVHD with extensive prior fludarabine therapy. Prophylaxis for opportunistic infections was developed on an ongoing basis as new infectious complications were seen. The current drug prophylaxis, which has been successful for eight months in the last patient despite pretreatment with fludarabine and steroid therapy for GVHD, is directed against pneumocystis, toxoplasma, fungi, and pneumococci. It includes immunoglobulin (for 3 1/2 months), pyrimethamine-sulfadiazine (for 4 months and during steroids), fluconazole (for 2 1/2 months), cotrimoxazole or pentamidine (for 2 years) and penicillin (lifelong). Dietary precautions are followed for 4 months and during steroids to prevent listeriosis. Four patients are alive in remission with no active infectious problems 8-44 months (median 29) after BMT. We recommend adoption of these or similar prophylactic measures for BMT in CLL as a baseline which can be modified if new infections are identified and according to individual needs.
Subject(s)
Anti-Bacterial Agents , Bone Marrow Transplantation/adverse effects , Drug Therapy, Combination/therapeutic use , Hematopoietic Stem Cell Transplantation/adverse effects , Leukemia, Lymphocytic, Chronic, B-Cell/therapy , Opportunistic Infections/prevention & control , Humans , Leukemia, Lymphocytic, Chronic, B-Cell/complications , Transplantation, HomologousABSTRACT
Oligella urethralis is an organism which is normally isolated as a commensal from the genitourinary tract. We describe the first two reported cases of CAPD-associated peritonitis caused by this organism. Both isolates were found to be resistant to ciprofloxacin, while relatively sensitive to a wide range of antimicrobial drugs. These findings indicate that this organism may be an opportunistic pathogen for CAPD patients, and that extensive ciprofloxacin usage provides a selection pressure for emergence of resistance.
Subject(s)
Anti-Infective Agents/therapeutic use , Moraxella/drug effects , Neisseriaceae Infections/drug therapy , Peritoneal Dialysis, Continuous Ambulatory/adverse effects , Peritonitis/etiology , Adult , Aged , Chronic Disease , Ciprofloxacin/therapeutic use , Drug Resistance, Microbial , Humans , Male , Ofloxacin/therapeutic useABSTRACT
AIMS: To investigate the value of bone marrow biopsy in the diagnosis of mycobacterial infection. METHODS: The culture results of 433 bone marrow samples taken between 1983 and 1992 were reviewed. The histopathology reports on bone marrow trephine specimens of culture positive samples and all those on HIV positive patients sent in 1992 were also reviewed. RESULTS: Fifty one specimens yielded Mycobacterium spp, 47 were obtained from HIV positive patients. Of the isolates, 42 were Mycobacterium avium-intracellulare (MAI), five were M tuberculosis (MTB), and the remaining four comprised a variety of atypical mycobacteria. All MAI positive samples were obtained from HIV positive patients, with the bone marrow being the only culture positive specimen in one third. Bone marrow yielded MTB only in patients from whom it was also isolated in other specimens. Eleven of 47 trephine specimens from positive bone marrow showed granulomata and nine showed acid-fast bacilli. No acid-fast bacilli were seen in the absence of granulomata. CONCLUSION: Bone marrow biopsy for mycobacterial culture should be reserved for severely immunosuppressed patients and should not be advocated for immunocompetent patients with suspected tuberculosis. Bone marrow biopsy still has a role in the investigation of pyrexia of unknown origin in HIV positive patients, despite the advent of mycobacterial blood culture techniques, particularly if these can be processed safely in automated systems.
Subject(s)
Bone Marrow/microbiology , Fever of Unknown Origin/microbiology , Mycobacterium/isolation & purification , HIV Infections/complications , HIV Seropositivity/blood , HIV Seropositivity/microbiology , Humans , Mycobacterium Infections/complications , Mycobacterium avium Complex/isolation & purification , Mycobacterium tuberculosis/isolation & purificationABSTRACT
Pasteurella multocida is a common cause of wound infection following animal-inflicted wounds, but is a rare cause of female genito-urinary sepsis. We present a case of vulval sepsis and a case of intrapartum septicaemia with this bacterium. These two cases indicate that Pasteurella multocida can occasionally colonise the female lower genital tract and this bacterium should be considered in the differential diagnosis of serious infection related to this site.
Subject(s)
Female Urogenital Diseases/microbiology , Pasteurella Infections/microbiology , Pasteurella multocida/isolation & purification , Pregnancy Complications, Infectious/microbiology , Adult , Anti-Bacterial Agents/pharmacology , Female , Humans , Microbial Sensitivity Tests , Pregnancy , Sepsis/microbiology , Vulvar Diseases/microbiologyABSTRACT
Performance of the E test for methicillin sensitivity testing was investigated using 21 methicillin-resistant and 28 methicillin-sensitive staphylococci. Thirty of the strains had previously given equivocal results with a strip diffusion method. The E test performed well with Mueller-Hinton agar plates incubated at 30 degrees C for 24 h but only after supplementation with 5% NaCl. Testing on agar without salt was necessary for the recognition of methicillin resistance in one strain. We recommend a breakpoint of 4 mg/L and heavy inocula. The E test can be controlled by testing a control strain on the same plate.