Pneumococcal immunity and PCV13 vaccine response in SOT-candidates and recipients.

BACKGROUND: Solid organ transplantation (SOT) candidates and recipients are highly vulnerable to invasive pneumococcal diseases (IPD). Data on which to base optimal immunization recommendations for this population is scant. The national distribution of IPD serotypes led the Swiss Health Authorities to recommend in 2014 one dose of pneumococcal-13-valent-conjugate-vaccine (PCV13), without any subsequent dose of the 23-valent-polysaccharide-pneumococcal-vaccine (PPV23). METHODS: This is a retrospective analysis of pneumococcal immunity using a multiplex binding assay, to assess seroprotection rates against a selection of seven PCV13- and seven PPV23-serotypes in SOT-candidates and recipients evaluated and/or transplanted in 2014/2015 in the University Hospitals of Geneva. Seroprotection was defined as serotype-specific antibody concentration greater than 0.5 mg/l and overall seroprotection when this was achieved for ≥ 6/7 serotypes. RESULTS: Pre-vaccination and at time of transplant sera were available for 35/43 (81%), and 43/43 (100%) SOT-candidates respectively. At listing, 17/35 (49%) SOT-candidates were seroprotected against PCV13 and 21/35 (60%) against PPV23 serotypes. Following one systematic dose of PCV13 at listing, 35/43 (81%) SOT-recipients were seroprotected at day of transplant against PCV13-serotypes and 34/43 (79%) against PPV23 serotypes, compared to 21/41 (51%) and 28/41 (68%) respectively in the controls transplanted in 2013, before the systematic PCV13-vaccination. CONCLUSIONS: The systematic vaccination with PCV13 of all SOT candidates without additional PPV23 is a good strategy as it confers seroprotection against a wide range of pneumococcal serotypes. Indeed, one of five PCV13-vaccinated SOT-candidates was nevertheless not seroprotected at time of transplant, reflecting their partial immune competence, and indicating the need for additional dose of pneumococcal vaccines before transplant.

Prospective evaluation of a model of prediction of invasive bacterial infection risk among children with cancer, fever, and neutropenia.

A risk prediction model for invasive bacterial infection (IBI) was prospectively evaluated among children presenting with cancer, fever, and neutropenia. The model incorporated assessment of 5 previously identified risk factors: serum level of C-reactive protein (CRP) >/=90 mg/L, hypotension, identification of relapse of leukemia as the cancer type, platelet count of

Prospective, multicenter evaluation of risk factors associated with invasive bacterial infection in children with cancer, neutropenia, and fever.

PURPOSE: To identify clinical and laboratory parameters present at the time of a first evaluation that could help predict which children with cancer, fever, and neutropenia were at high risk or low risk for an invasive bacterial infection. PATIENTS AND METHODS: Over a 17-month period, all children with cancer, fever, and neutropenia admitted to five hospitals in Santiago, Chile, were enrolled onto a prospective protocol. Associations between admission parameters and risk for invasive bacterial infection were assessed by univariate and logistic regression analyses. RESULTS: A total of 447 febrile neutropenic episodes occurred in 257 children. Five parameters were statistically independent risk factors for an invasive bacterial infection. Ranked by order of significance, they were as follows: C-reactive protein levels of 90 mg/L or higher (relative risk [RR], 4.2; 95% confidence interval [CI], 3.6 to 4.8); presence of hypotension (RR, 2.7; 95% CI, 2.3 to 3.2); relapse of leukemia as cancer type (RR, 1.8, 95% CI, 1.7 to 2.3); platelet count less than or equal to 50,000/mm(3) (RR, 1.7; 95% CI, 1.4 to 2.2); and recent (< or = 7 days) chemotherapy (RR, 1.3; 95% CI, 1.1 to 1.6). Other previously postulated risk factors (magnitude of fever, monocyte count) were not independent risk factors in this study population. CONCLUSION: In a large population of children, common clinical and laboratory admission parameters were identified that can help predict the risk for an invasive bacterial infection. These results encourage the possibility of a more selective management strategy for these children.

[Causative agents of bloodstream infections in children with neoplasm, in 5 hospitals of Santiago (1994-1998)]. / Agentes causantes de infecciones del torrente circulatorio en niños con cáncer, en cinco hospitales de Santiago (1994-1998).

BACKGROUND: Pediatric patients in treatment for cancer can have fatal bacterial infections. Thus, in the presence of fever or other signs infection, antimicrobials have to be prescribed empirically. AIM: To know the causative agents of bacteremia in children with cancer, their changes with time and between different hospitals and their patterns of susceptibility. MATERIAL AND METHODS: We reviewed the blood cultores of children with cancer in five hospitals of Santiago, from 1994 at 1998. RESULTS: During the study period, 707 agents were isolated. The most frequently isolated species or genus were coagulase negative Staphylococcus (43%), Staphylococcus aureus (16%), Escherichia coli (9%), Klebsiella spp. (8%), Pseudomonas spp. (5%) and Candida spp. (4%). Coagulase negative Staphylococcus was 55% resistant to meticilin and S. aureus was 44% resistant. Enterobacteriaceae had 15% resistance to gentamicin and amikacin, 2% to imipenem, 26% to ceftriaxone, 21% to cefotaxime and 20% to ceftazidime. Among non fermenting agents resistance was 6% for imipenem, 9% for amikacin 10% for ciprofloxacin, 19% for ceftazidime and 22% for cefoperazone. The resistance of Streptococcus spp. (non pneumoniae) to penicillin reached 50% and that of Enterococcus spp. was of 33%. CONCLUSIONS: Treatment for pediatric patients with cancer must be modified and new guidelines including more active medications for patients at risk for bacteremia, should be devised.

Epidemiology of invasive pneumococcal infections in infants and young children in Metropolitan Santiago, Chile, a newly industrializing country.

AIM: To study the epidemiology of invasive pneumococcal infections in infants and young children in Santiago, Chile, as a representative pediatric population in a newly industrializing country where pneumococcal conjugate vaccines may be used in the future. METHODS: A 5-year retrospective laboratory-based review (1989 to 1993) was followed by a 3-year prospective laboratory and hospital surveillance study in two of the six health administrative areas of Santiago to detect all hospitalized cases of invasive pneumococcal disease (defined as Streptococcus pneumoniae isolated from blood, cerebrospinal fluid or another normally sterile site) among infants and children (0 to 23 months of age in the retrospective and 0 to 59 months of age in the prospective study). RESULTS: During the 5-year retrospective survey the incidence of invasive pneumococcal disease was 90.6 cases per 10(5) infants 0 to 11 months old and 18.5 cases per 10(5) toddlers 12 to 23 months old. Similar rates (60.2 per 10(5) infants and 18.1 per 10(5) toddlers) were recorded during the 3 years of prospective surveillance. Among the 110 cases in children 0 to 59 months of age detected during the 3-year prospective surveillance, 2 clinical forms, pneumonia and meningitis, accounted for 87.2% of all cases; 13 of the 49 pneumonia patients (26%) had empyema as a complication. Notably 40 of the 110 cases (36.4%) occurred before 6 months of age (63.4% of the 63 infant cases). Serotypes 1, 14, 5 and 6B were the most prevalent. Overall 76 and 69%, respectively, of S. pneumoniae isolates were antigenic types that would be covered by the 11- or 9-valent conjugate vaccines under development. CONCLUSIONS: Invasive pneumococcal infections in Santiago, Chile, exhibit an epidemiologic pattern intermediate between that of developing and industrialized countries. The high burden of disease in early infancy dictates that an accelerated immunization schedule (beginning in the perinatal period) or maternal immunization with pneumococcal vaccines should be explored.

Can pre-emptive lumbar epidural blockade reduce postoperative pain following lower abdominal surgery?

In a double-blind study, 36 patients who received a standard general anaesthetic for abdominal hysterectomy or myomectomy, received either 15 ml of bupivacaine 0.5% with adrenaline by lumbar epidural injection 15 min before surgery (group A) or the same dose at the end of surgery but before waking (group B). Pain was assessed for 24 h by cumulative morphine dose (self-administered by patient-controlled analgesia), visual analogue scale and verbal rating score. Patients were included for analysis if they were pain free on waking and for at least 2 h after. There was no significant difference (p > 0.05) between the two groups in morphine dose, visual analogue scale or verbal rating score at 6 and 24 h after waking. As expected, there was a significant difference in the mean time of first use of patient-controlled analgesia (4.26 h in group A vs 5.06 h in group B, p < 0.05). Consequently, we compared the morphine dose, visual analogue scale and verbal rating score at 23 h in group A with those at 24 h in group B. Again there were no significant differences between the two groups. We were unable to demonstrate that epidural blockade had a significantly better effect on postoperative pain when administered before, rather than after, surgery.

A guideline for establishing medication teaching groups for schizophrenic patients.

Guidelines for establishing patient-oriented medication teaching groups for the schizophrenic patient are described. The importance of patient education has been well documented, although the effort and subsequent efficacy is still equivocal. Schizophrenic patients have several factors that may lead to drug default. By increasing the patient's database regarding the neuroleptic drug class, an increase in patient compliance may result. An approach to surveying existing programs, soliciting administrative support, addressing the patient, and plans for followup evaluation are outlined in a comprehensive format. It is the author's opinion that this format is highly successful and can be implemented at other institutions.