Piperacillin-tazobactam plus amikacin as an initial empirical therapy of febrile neutropenia in paediatric cancer patients.

INTRODUCTION: We evaluated piperacillin-tazobactam in association with amikacin in the initial empirical therapy of febrile neutropenic children. METHODS: An open-labelled, non-randomised, prospective trial to assess the efficacy and safety of this association was conducted from June 1, 2001 to December 31, 2002. Children and adolescents were treated for a haematological malignancy or a primary, refractory or relapsed solid tumour, and presented with febrile neutropenia. Patients received intravenous piperacillin-tazobactam (90 mg/kg/dose every eight hours) plus a single daily dose of amikacin at 15 mg/kg/day, maximum 250 mg. If fever persisted, second-line therapy with carbapenem was administered. Teicoplanin was added for gram-positive isolates or for unremitting fever after 48 hours, if clinically indicated. Amphotericin B was added at 96 hours, if fever and neutropenia persisted. RESULTS: 155 episodes of fever and neutropenia in 76 patients were evaluable. 40 (25.8 percent) episodes were a microbiologically-documented infection, 30 (19.4 percent) were clinically-documented, and 85 (54.8 percent) were unexplained fever. 77 (49.7 percent) episodes responded to piperacillin-tazobactam plus amikacin without a need for treatment modification. A higher success rate (63.5 percent) was observed in episodes with unexplained fever. The predominant pathogens isolated in our study were gram-negative organisms (70.7 percent). A mild gastrointestinal intolerance occurred in 35 out of 155 (22.6 percent) episodes. CONCLUSION: This study suggests that piperacillin-tazobactam plus amikacin presents a satisfactory efficacy and a good tolerance as initial empirical therapy for febrile neutropenic children.

Cefepime plus amikacin as an initial empirical therapy of febrile neutropenia in paediatric cancer patients.

INTRODUCTION: We evaluated the efficacy of cefepime in association with amikacin in the initial empirical therapy of febrile neutropenic children. METHODS: The study was an open-labelled, non-randomised prospective trial to assess the efficacy and safety of this association, from January 2003 to December 2003. Children and adolescents were treated for a haematological malignancy or a primary, refractory or relapsed solid tumour, and presented with febrile neutropenia. Patients received cefepime (50 mg per kg per dose every 8 hours for children weighing less than or equal to 40 kg; and 2 g every 8 hours for those weighing more than 40 kg) plus a single daily dose of amikacin at 15 mg per kg per day, up to a maximum 250 mg. If fever persisted, a second-line therapy with carbapenem was administered. Amphotericin B was added at 96 hours if fever and neutropenia persisted. RESULTS: 103 episodes of fever and neutropenia were evaluated in 54 patients. 18.4 percent of the episodes were microbiologically-documented infections, 24.3 percent were clinically documented, and 57.3 percent were episodes with unexplained fever. 54.4 percent of the episodes responded to cefepime plus amikacin without a need for treatment modification. A higher success rate (74.6 percent) was observed in episodes with unexplained fever. In all cases of persistent fever, the antibiotics were changed to carbapenem within 72 hours and all patients survived. One patient died because of culture-negative septic shock within 24 hours of admission. A mild gastrointestinal intolerance occurred in three patients. CONCLUSION: This study suggests that cefepime plus amikacin presents a satisfactory efficacy and a good tolerance as an initial empirical therapy for febrile neutropenic children.

Outcome of bacteraemia in patients admitted to the adult medical wards of the UKM hospital.

The clinical outcome of bacteraemic patients is influenced by many factors. It is vital to know one's own local hospital epidemiological data so as to provide optimal care to the affected patients. This was a prospective, observational study carried out in the said patient population over a period of four months in the year 2005. One hundred and ninety one patients presented with bacteraemia over the study period. Fifty-two (27%) of the patients died. Mechanical ventilation, inappropriate empirical antibiotic usage, Chinese ethnicity and low serum albumin levels independently affected prognosis. These factors should alert physicians to those patients who require more intensive monitoring and care.

Using pulsed-field gel electrophoresis in the molecular investigation of an outbreak of Serratia marcescens infection in an intensive care unit.

INTRODUCTION: Serratia marcescens is a well-known cause of nosocomial infections and outbreaks, particularly in immunocompromised patients with severe underlying disease. An outbreak due to S. marcescens infection was detected from 13 to 22 February 2001 at the intensive care unit (ICU) of our institution. We used pulsed-field gel electrophoresis (PFGE) typing to analyse the outbreak strains involved. METHODS: A total of 25 isolates were included in this study: 12 isolates from infected patients, nine isolates from insulin solution, one isolate from sedative solution (midazolam and morphine infusion) and one isolate from frusemide solution. Two isolates from other wards which were epidemiologically-unrelated were also included. RESULTS: The S. marcescens from patients, insulin solution and sedative solution showed an identical PFGE fingerprint pattern. The isolate from the frusemide solution had a closely-related PFGE pattern to the outbreak strain with one band difference. Attempts were made in the present study to identify the environmental reservoir of S. marcescens during the outbreak. We found that the insulin and sedative solutions used by the patients were contaminated with S. marcescens which was proven to be the source of the outbreak. CONCLUSION: Using PFGE, we showed that the outbreak in the ICU of our hospital was due to the clonal spread of a single strain of S. marcescens.

DNA fingerprinting of methicillin-resistant Staphylococcus aureus (MRSA) by pulsed-field gel electrophoresis (PFGE) in a teaching hospital in Malaysia.

Methicillin-resistant Staphylococcus aureus (MRSA) has been prevalent in our hospital over the last three years. Differentiation among MRSA strains by DNA typing in addition to antibiotic resistance pattern surveillance is crucial in order to implement infection control measures. The aim of this study was to characterize MRSA isolates from patients admitted to Hospital Universiti Kebangsaan Malaysia (HUKM) by phenotypic (analyses of antibiotic susceptibility pattern) and genotypic (PFGE) techniques to determine the genetic relatedness of the MRSA involved and to identify endemic clonal profiles of MRSA circulating in HUKM. Seventy one MRSA strains collected between January to March 2000 from patients from various wards in HUKM were tested for antimicrobial resistance and typed by pulsed-field gel electrophoresis (PFGE). Four major types of PFGE patterns were identified (A, B, C and D) among MRSA strains. Two predominant PFGE types were recognised, Type A (59.2%) and Type B (33.8%). Most of these strains were isolated from ICU, Surgical wards and Medical wards. MRSA strains with different PFGE patterns appeared to be widespread among wards. Strains with the same antibiotype could be of different PFGE types. Most of isolates were resistant to ciprofloxacin, erythromycin, gentamicin and penicillin. One isolate with a unique PFGE pattern Type D and susceptible to gentamicin was identified as a different clone. Some isolates obtained from the same patient showed different PFGE subtypes suggesting that these patients were infected/colonized with multiple MRSA strains. PFGE analysis suggests that MRSA strains with different PFGE types was propagated within our hospital. The relationship between antibiotic susceptibility and PFGE patterns was independent. The ability of PFGE technique in differentiating our MRSA strains make it a method of choice for investigating the source, transmission and spread of nosocomial MRSA infection, and thus an appropriate control programme can be implemented to prevent the spread of MRSA infection.

Contamination of breast milk obtained by manual expression and breast pumps in mothers of very low birthweight infants.

The objective of this study was to compare the rates of bacterial contamination of expressed breast milk (EBM) obtained by manual expression and breast pumps in mothers of very low birthweight (VLBW) infants (<1501 g). This was a randomized, controlled study carried out on 28 mothers of such babies and 92 specimens of EBM were collected: 41 specimens from 13 mothers assigned to the manual group and 51 specimens from 15 mothers in the breast-pump group. EBM was cultured quantitatively by the Miles and Misra method. Breast milk expressed by breast pumps (86.3% or 44/51 specimens) had a significantly higher rate of bacterial contamination than milk expressed by the manual method (61.0% or 25/41 specimens) (P= 0.005). When breast milk was expressed in the hospital, there was no significant difference in contamination rates between the two methods. When breast milk was expressed at home, the rates of bacterial contamination by staphylococci (P= 0.003) and Gram-negative bacilli (P= 0.002) were significantly higher in the breast-pump group than the manual group. In conclusion, the rate of bacterial contamination of EBM of mothers of VLBW infants was high, especially when EBM was obtained by the breast pump or when expression was carried out at home.