Oral trimethoprim/sulfamethoxazole for prevention of bacterial infection during the induction phase of cancer chemotherapy in children.

We conducted a randomized, double-blind, placebo-controlled study to evaluate the efficacy of oral trimethoprim/sulfamethoxazole (TMP/SMX) in the prevention of bacterial infections in children with cancer. Sixty-three patients with acute leukemia were studied during the induction phase of chemotherapy; 28 patients with solid tumors who were starting intensive chemotherapy were also enrolled and treated for 2 months. There was no significant difference in the frequency of febrile episodes between the 43 children receiving trimethoprim/sulfamethoxazole and the 48 receiving placebo. However, when the group of 74 children who experienced granulocytopenia (absolute granulocyte count less than 500/microL) was analyzed separately, significant reductions in the frequencies of confirmed bacteremia (2.6% v 20.0%, P = .02) and febrile episodes (35.9% v 65.7%, P = .01) were observed in the trimethoprim/sulfamethoxazole group. Furthermore, life table analysis showed that children with leukemia receiving trimethoprim/sulfamethoxazole had significantly more days without fever and without bacteremia. No benefits from prophylaxis were recognized in the subgroup with solid tumors. Although the frequency of oral thrush was greater (P = .02) in the trimethoprim/sulfamethoxazole group (25.6%) than in the placebo group (6.3%), invasive fungal infection did not occur. Although the mean duration of granulocytopenia was greater among those receiving trimethoprim/sulfamethoxazole (13.7 v 9.0 days, P = .05), this did not appear to increase the overall risk for bacterial infection. These data suggest that trimethoprim/sulfamethoxazole reduces the frequency of bacteremia and febrile episodes in granulocytopenic children undergoing induction chemotherapy for acute leukemia.

Legionellosis in children with leukemia in relapse.

Two children with legionellosis complicating a relapse of acute lymphoblastic leukemia are reported. A 5-year-old boy with pneumonia had Legionella pneumophila cultured from a tracheal aspirate following a rapid deterioration in his respiratory status and intubation. This child had severe and irreversible granulocytopenia and died in spite of therapy with erythromycin and rifampin added five days later. Combination antimicrobial therapy is suggested for immunosuppressed children with legionellosis if resolution of neutropenia is not readily anticipated. Culture of Legionella sp from respiratory tract secretions or sputum, as reported for the first time in the pediatric literature, should be attempted in all children in whom this infection is suspected. A 13-year-old boy with pneumonia recovered in spite of therapy with antimicrobial agents not proven to be effective against the legionellae. Clinical improvement coincided with increase in absolute granulocyte count. A retrospective diagnosis was made when seroconversion to Legionella micdadei (less than 1:16 to 1:1,024) was determined during a survey of unselected sera from 255 hospitalized children. This is the first documented case of Pittsburgh pneumonia described in a child.

Maxillary sinus radiographs in children with nonrespiratory complaints.

An attempt was made to determine the frequency of abnormal maxillary sinus radiographs in a group of unselected children having diagnostic skull radiographs performed for indications unrelated to respiratory infection. An occipitomental, or Water's, view was obtained in every case in order to evaluate the maxillary sinuses. Prior to performance of the radiographs, a history of recent respiratory symptoms was obtained and a physical examination of the ears, nose, and throat was performed. An abnormal maxillary sinus radiograph was defined as one that revealed an air-fluid level, partial or complete opacification, or mucous membrane thickening of 4 mm or greater. Fifty-nine (53%) of 112 presumably "normal" children had evidence of recent respiratory inflammation by history or at physical examination. In 50 subjects less than 1 year of age, abnormal maxillary sinus radiographs were common, irrespective of respiratory symptoms and signs. In contrast, eight of 14 children (57%) aged 1 to 16 years with both symptoms and signs of respiratory inflammation had abnormal maxillary radiographs, compared with only two of 31 children (7%) with neither symptoms nor signs (P less than .005). Crying alone was not associated with abnormal radiographs in the older age group. In children more than 1 year of age, abnormal maxillary sinus radiographs are infrequent and are generally related to inflammation of the upper respiratory tract.