Treatment of nosocomial postoperative pneumonia in cancer patients: a prospective randomized study.

BACKGROUND: Nosocomial pneumonia continues to be associated with high morbidity and mortality in cancer patients. METHODS: In an attempt to find an optimal treatment for this infection, nonneutropenic cancer patients with postoperative nosocomial pneumonia were randomized to receive either piperacillin/tazobactam (P/T) 4.5 g i.v. every 6 hours (30 patients) or clindamycin (Cl) 900 mg plus aztreonam (Az) 2 g i.v. every 8 hours (22 patients). Amikacin 500 mg i.v. every 12 hours was given to all patients for the first 48 hours. RESULTS: The two groups were comparable for the characteristics of pneumonia that included gram-negative etiology and duration of intubation. Response rates were 83% for patients who received P/T and 86% for those who received Cl/Az (P > .99). There were no serious adverse events; however, at our center the cost of the P/T regimen was $73.86 compared with $99.15 for the Cl/Az regimen. CONCLUSIONS: The two regimens had comparable high efficacy, and P/T had a slight cost advantage. Either of these antibiotic regimens combined with an aminoglycoside could lead to favorable outcome in cancer patients at high risk for nosocomial pneumonia.

High-dose-rate endobronchial brachytherapy effectively palliates symptoms due to airway tumors: the 10-year M. D. Anderson cancer center experience.

PURPOSE: To evaluate the toxicity and efficacy of Iridium-192 high-dose-rate (HDR) endobronchial brachytherapy (EBBT) for the palliation of symptoms caused by relapsed or persistent endobronchial tumors. METHODS AND MATERIALS: We reviewed the treatment outcomes between 1988 and 1997 in 175 lung cancer patients who underwent HDR EBBT for recurrent or metastatic tumors at The University of Texas M. D. Anderson Cancer Center. One hundred sixty of these patients had previously received thoracic external-beam irradiation. This updated report includes 74 patients from a previous series. Most patients received 3,000-cGy EBBT delivered at a distance of 6 mm and divided into 2 fractions over 2 weeks. Subjective response was assessed by questionnaire at follow-up. Objective response was assessed by physical examination, bronchoscopy, and chest radiograph. RESULTS: The median actuarial survival for the entire group was 6 months from the time of the first EBBT treatment session. Of the 115 patients (66%) who showed symptomatic improvement, 32% were much improved and 34% were slightly improved. Patients showing improvement survived for significantly longer than those who showed no change or worsening symptoms (7 vs. 4 months, p = 0.0032). Repeat bronchoscopy demonstrated a 78% overall objective response rate that correlated significantly with subjective response and symptom relief. Complications occurred in 19 patients (11% crude rate) with an actuarial complication rate of 13% at 1 year from the time of the first EBBT treatment session. The actuarial hazard for fatal hemoptysis due to EBBT was 5%. CONCLUSION: HDR EBBT effectively palliates most patients' symptoms caused by endobronchial lesions. This relief correlates significantly with an overall survival benefit. Treatment complications appear to be few, even for patients who have received prior external-beam irradiation.

Outcome of bone marrow transplantation patients requiring mechanical ventilation.

OBJECTIVE: To identify outcome predictors in bone marrow transplantation (BMT) patients admitted to the intensive care unit (ICU) of The University of Texas M. D. Anderson Cancer Center who required endotracheal intubation and mechanical ventilation. DESIGN: Retrospective, comparative study. SETTING: A 16-bed medical intensive care unit in a university teaching cancer center. PATIENTS: The records of 60 consecutive BMT patients who developed respiratory failure requiring mechanical ventilation were reviewed. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The most frequent complication leading to respiratory failure was pneumonia (41%) followed by diffuse alveolar hemorrhage (37%). Eighteen percent of the patients were extubated and discharged from the ICU, but only 5% were alive at 6 months. Graft vs. host disease was a predictor of a poor outcome (p < .05). Breast cancer as an underlying disease and pulmonary edema as a complication were favorable predictive factors (p < .05). Five of 26 patients with diffuse alveolar hemorrhage and four of 33 patients with pneumonia survived. We found no relationship between survival and age, gender, BMT type, or Acute Physiology and Chronic Health Evaluation II score. Prolonged mechanical ventilation (> or =15 days) and late development of respiratory failure (>30 days after BMT) were associated with poor prognosis. CONCLUSIONS: The ICU survival rate of BMT patients who developed pulmonary complications and required mechanical ventilation was 18%. Prognostic factors were described identifying patients with a substantial survival rate as well as those in whom mechanical ventilation was futile.

Bronchoalveolar lavage in the diagnosis of pulmonary complications of bone marrow transplant patients.

Bronchoalveolar lavage (BAL) has proved valuable in the diagnosis of pulmonary complications in immunosuppressed patients. We evaluated the diagnostic yield of BAL in pulmonary complications in bone marrow transplantation (BMT) recipients. We reviewed sequentially the records of 89 patients during an 18-month period. BAL was diagnostic in 42 patients (47%). The most common pulmonary complication diagnosed by BAL was diffuse alveolar hemorrhage (n = 15); followed by bacterial pneumonia (n = 10), respiratory syncytial virus (n = 8), aspergillosis (n = 6), Pneumocystis carinii pneumonia (n = 5), cytomegalovirus (CMV) (n = 4), and others (n = 4). The final diagnoses in the BAL non-diagnostic group were: bacterial pneumonia (n = 6), CMV (n = 6), idiopathic pneumonia syndrome (n = 5), cancer recurrence (n = 4), cardiogenic pulmonary edema (n = 4), and others (n = 9). We conclude that BAL is a useful diagnostic tool in BMT-related pulmonary complications.

The effect of fluid loading, blood transfusion, and catecholamine infusion on oxygen delivery and consumption in patients with sepsis.

Fifty-four patients with systemic sepsis and signs of circulatory shock were prospectively investigated immediately before and after 1 of 3 therapeutic interventions chosen to increase systemic oxygen delivery (DO2): colloidal fluid loading (Group I, n = 20), blood transfusion (Group II, n = 17), or catecholamine infusion (dopamine or dobutamine, Group III, n = 17). Patients in Groups I and II with normal blood lactate concentrations (less than 2.2 mmol/L) exhibited no significant increases in systemic oxygen consumption (VO2) in response to the increases in DO2. However, significant increases in VO2 were noted in patients in Groups I and II with elevated lactate concentrations (greater than 2.2 mmol/L). In contrast to patients in Groups I and II, patients in Group III with and without lactic acidosis exhibited significant increases in VO2 after catecholamine administration. Lactic acidosis, a clinical marker of anaerobic metabolism or oxygen debt, appears to predict increases in VO2 in response to increases in DO2 in septic patients receiving fluid and catecholamines increase VO2 without regard for the presence or absence of anaerobic metabolism. The results of this clinical trial therefore suggest that catecholamines may exert a direct effect on oxidative metabolism.