Empirical antimicrobial therapy in pediatric patients with neutropenia and fever. Risk factor for treatment failure

Background. The use of combinations of antibiotics has been the cornerstone of therapy for febrile patients with cancer and severe neutropenia. Each empirical regimen should be selected according to the epidemiology and susceptibility patterns in each center. We describe here the experience wtih empirical antimicrobiial treatments in pediatric patients with cancer, fever and severe neutropenia, and identify the risk factors associated with treatment failure. Methods. This is a prospective study including 145 patients with cancer, and 171 episodes of neutropenia and fever. Blood cultures were taken before initiating empirical treatment: a)carbenicillin (400 mg/kg/day) plus amikacin (21 mg/kg/day) (Cb/ak), and b) ceftazidime (100 mg/kg/day), plus amikacin at the same dosage (Cz/ak). Results. The overall response rate was 54.9 percent and 56.3 percent for Cb/ak and Cz/ak, respectively. Fifty-seven episodes (33.3 percent) were microbiologically documented, gram-positive isolated in 38 percent and gram-negative in 49 percent. Risk factors associated significantly with treatment failure were acute mywlocytic leukemia (AML) (RR 2.59, CI 95 percent 1.42-4.7, p=0.003); bacteriological identification (RR= 4.41, CI 95 percent 2.21 - 8.8, p<0.001), and the presence of two or more sites of infection (RR= 2.89, CI 95 percent 1.03 - 8.11, p=0.03). Conclusions. The rates of response are similar to the combinations used in the hospital (Cb/ak, Cz/ak). The risk factors associated with treatment failure were AML diagnosis, bacteriological identification, and the presence of two or more sites of infection

Randomized trial comparing oral ciprofloxacin plus penicillin V with amikacin plus carbenicillin or ceftazidime for empirical treatment of febrile neutropenic cancer patients.

Aminoglycoside-containing combination therapy has been the standard empirical approach for febrile neutropenic cancer patients. With the advent of the broad-spectrum oral fluoroquinolones, it is now possible to evaluate an initial empirical alternative therapy. A prospective randomized study was conducted comparing oral ciprofloxacin plus penicillin V (group A) with amikacin plus carbenicillin or ceftazidime (group B). Main criteria for eligibility were febrile patients with solid tumor or nonlymphoblastic lymphoma, a Zubrod PS equal to 1 or 2, no diarrhea, mucositis, or long-term central venous catheter. A total of 108 consecutive neutropenic febrile episodes were randomized (5 exclusions); 55 episodes were assigned to group A and 48 to group B. Most febrile episodes were of unknown origin. There were 10 microbiologically documented episodes with two cases of bacteremia. Both regimens were well tolerated. Oral regimen was substantially cheaper than parenteral regimen. Treatment success without regimen modification was 94.5% for group A and 93.8% for group B (p = .86; CI -0.08-0.10). Oral therapy with ciprofloxacin and penicillin V is a safe alternative to standard parenteral therapy in this low-risk group of neutropenic patients, with unquestionable cost containment.

Peritonitis por Serratia marcescens en un paciente sometido a diálisis peritoneal contínua ambulatoria / Serratia marcescens peritonitis in a patient under continous ambulatory peritoneal dialysis

El objetivo del presente trabajo es la exposición de lo que se considera el primer caso de peritonitis en un paciente con diálisis peritoneal continua ambulatoria (DPCA) -por insuficiencia renal crónica terminal-causada por Serratia marcescens y tratado exitosamente con carbenicilina. Se trata de un bacilo gramnegativo, móvil, aerobio, miembro de la división Klebsiella-Enterobacter-Serratia, entre la familia enterobacteriaceae. La Serratia contrasta con otros bacilos enterobacteriaceos en que no es huésped habitual del tracto digestivo y se adquiere por contaminación iatrógena como manipulación genitourinaria, diálisis peritoneal, hemodialisis y punción lumbar. Su tratamiento antibiótico es difícil pues presenta gran resistencia medicamentosa por plásmidos

The treatment of acute myeloid leukemia in Brazil: progress and obstacles.

BACKGROUND: Substantial progress has been made in the treatment of acute myeloid leukemia in the last two decades. We wanted to evaluate the outcome of intensive chemotherapy and the influence of recent therapy changes in underprivileged patients treated in a large urban public university hospital. METHODS: The records of all patients treated for acute myeloid leukemia from 1980 to 1993 were analyzed. RESULTS: 109 patients were identified; 41 did not receive any treatment for the leukemia because of infectious and/or hemorrhagic complications of advanced disease. Median survival in this group was 4 days. The other 68 patients received one of two induction protocols: TAD from 1980 to 1985 (n = 23) and ara-C plus daunorubicin from 1985 to 1992 (n = 45). The complete remission rate was 56%, disease-free survival 24% and overall survival 15% at 13 years. Overall survival was better for patients treated with ara-C plus daunorubicin than with TAD (19% versus 8%, p = 0.01). This is attributed to a reduction in infection mortality after ceftazidime and amikacin replaced cephalotin, carbenicillin and amikacin as the antibiotic regimen. CONCLUSIONS: The most effective intervention in our population would probably be an improvement in the primary health care system, so that earlier diagnosis could allow the treatment of a larger fraction of patients.

Otite externa maligna: diagnóstico e tratamento precoces: relato de um caso clínico / Malignant otitis externa: diagnosis and treatment

A otite externa maligna é uma entidade de prognóstico reservado, quando seu diagnóstico é tardio e a conduta terapêutica apropriada näo é entäo instituida. O autor relata um caso documentado de paciente diabético, obtendo-se em sua propêudica o diagnóstico final. O tratamento foi realizado com o paciente internado durante 32 dias no HSE. O prognóstico da enfermidade em questäo indica êxito letal de 53 por cento em várias casuísticas. Felizmente neste caso o resultado foi favorável com a terapêutica instituída, que incluiu equipe multidisciplinar, levando à cura

Apendicitis aguda en el niño. tratamiento posoperatorio con antimicrobianos y complicaciones (1983 a 1984) / Acute appendicitis in the child: antimicrobial post-operative treatment and complications

Se revisan las historias clinicas de 204 niños operados a causa de apendicitis aguda en el Servicio de Cirugía Pediátrica, durante el período comprendido desde el 1ro de enero de 1983 hasta el 31 de diciembre de 1984. Se prestó especial atención a la evolución de los pacientes y al tratamiento posoperatorio con antimicrobianos. Se analiza lo concerniente a complicaciones posoperatorias y su relación con la estadía, tipo de incisión realizada, antimicrobianos seleccionados para el tratamiento inicial y sensibilidad de los gérmenes aislados durante el acto quirúrgico. Los resultados se expresan en tablas estadísticas y se formulan conclusiones sobre el estudio

Apendicitis aguda en el niño: tratamiento posoperatorio con antimicrobianos y complicaciones (1983 a 1984) / Acute appendicitis in the child: antimicrobial post-operative treatment and complications

Se revisan las historias clinicas de 204 niños operados a causa de apendicitis aguda en el Servicio de Cirugía Pediátrica, durante el período comprendido desde el 1ro de enero de 1983 hasta el 31 de diciembre de 1984. Se prestó especial atención a la evolución de los pacientes y al tratamiento posoperatorio con antimicrobianos. Se analiza lo concerniente a complicaciones posoperatorias y su relación con la estadía, tipo de incisión realizada, antimicrobianos seleccionados para el tratamiento inicial y sensibilidad de los gérmenes aislados durante el acto quirúrgico. Los resultados se expresan en tablas estadísticas y se formulan conclusiones sobre el estudio

Otite externa maligna / Malignant external otitis

Dois casos de otite externa maligna, rebeldes ao tratamento clínico clássico, säo apresentados. Em ambos os casos, a infecçäo causada pela Pseudomonas aeruginosa assume importante agressividade, com penetraçäo para tecidos profundos das proximidades. Esta disseminaçäo é seguida por outras complicaçöes, inclusive recidiva do processo. Discute-se a utilidade da cintilografia óssea do crânio como método diagnóstico e preconiza-se a terapêutica prolongada de seis semanas da associaçäo carbenicilina mais tobramicina como forma de controle das recidivas

Ceftriaxona no tratamento de infecçöes em pacientes neutropênicos / Ceftriaxone in the treatment of infections in neutropenic patients

Setenta e quatro pacientes neutropênicos acometidos de diversos tipos de infecçöes foram alocados randomicamente em um estudo aberto, paralelo e comparativo, em que foram avaliados três esquemas diferentes de antibioticoterapia. O primeiro grupo foi tratado com 2g/dia de cefriaxona, em dose única diária, isoladamente; o segundo grupo recebeu a cefriaxona associada àà amicacina na dose de 15mg/kg/dia fracionada em duas administraçöes diárias, e finalmente o terceiro grupo foi medicado com 500mg/dose de cefaxitina a cada seis horas, carbenicilina 3g/dose a cada quatro horas e amicacina (15mg/kg/dia). O agente bacteriano foi isolado em 16 pacientes (21,64%).A resposta foi considerada boa em 21 (72%) dos 29 pacientes incluídos no primeiro grupo, em 16 (76%) dos 21 do segundo grupo e em 19 (79%) dos 24 do último grupo, resultados que se aproximam aos 70 e 80% de boA resposta encontrada na literatura mundial com os mais diversos esquemas de antibióticos. Näo houve diferença estatisticamente significativa entre o número de respostas nos três grupos

Sangrado postquirúrgico por carbenicilina / Postsurgical bleeding due to cabernicillin

Se presenta el caso de un adolescente de 14 años de edad que ingresó al hospital por fístula estercorácea como complicación de una apendicectomía. Diecinueve días después de su ingreso, se llevó a cabo la resección de la fístula sin complicaciones transquirúrgicas. Se administró carbenicilina a 400 mg/kg/día; dos horas después de la primera dosis, presentó sangrado masivo que ameritó reintervención encontrándose 500 ml de sangre libre en cavidad. Se demostró disfución plaquetaria. Se suspendió la carbenicilina y se manejó con plasma rico en plaquetas, con lo que se controló el episodio hemorrágico. Se discute la fisipatología y se revisa la literatura al respecto

Allergy to semisynthetic penicillins in cystic fibrosis.

Allergic reactions to anti-Pseudomonal penicillin derivatives are an increasing problem in therapy of cystic fibrosis lung disease. We evaluated 15 patients, ages 12 to 37 years, with documented allergic reactions to carbenicillin, ticarcillin, or piperacillin. Intradermal skin test reactions were positive for benzylpenicillin in seven patients, penicilloyl-polylysine in one, and ticarcillin or piperacillin in eight, for a total of 11 of 11 tested. Results of radioallergosorbent testing to penicilloyl conjugates were positive in eight of 14 patients and equivocal in four others. Overall, skin tests or RAST results were positive in 13 of 15 patients. All patients were desensitized with a semisynthetic penicillin by continuous serial intravenous infusion of 10-fold dose increments, beginning with 10(-6) of the therapeutic dose. Desensitization was successful in 25 of 26 instances. After intravenously administered therapy, maintenance of desensitization with dicloxacillin orally was unsuccessful in four of six patients. We conclude that (1) allergy to semisynthetic penicillins in cystic fibrosis usually is IgE mediated; (2) such allergy can be evaluated by skin testing; (3) it can be safely and in most cases successfully treated by intravenous desensitization; and (4) allergic patients should be desensitized on each subsequent admission for intravenously administered therapy.

A double-blind controlled trial of anti-Pseudomonas chemotherapy of acute respiratory exacerbations in patients with cystic fibrosis.

A double-blind controlled trail of anti-Pseudomonas chemotherapy was carried out in 24 exacerbations of pulmonary disease in patients with cystic fibrosis. Fifteen exacerbations were treated with oxacillin plus sisomicin and carbenicillin (treatment group); nine were treated with oxacillin alone (control group). The planned length of treatment was 14 days. The difference between the failure rate in the treatment group (3/15) and the control group (7/9) was statistically significant (P less than 0.015). The difference in improvement of forced expiratory volume in 1 second was also significant (P less than 0.025). At the end of the study, Pseudomonas aeruginosa was still present in the sputum of all nine patients in the control group, but was not isolated from six of the 15 patients in the treatment group. The data suggest a beneficial role for anti-Pseudomonas chemotherapy in the treatment of acute pulmonary exacerbations in patients with cystic fibrosis.

Is anti-Pseudomonas therapy warranted in acute respiratory exacerbations in children with cystic fibrosis?

A controlled study was designed to clarify the indications for antibiotic therapy in children with advanced cystic fibrosis hospitalized with respiratory exacerbations. Twenty-two children with severe CF and signs of acute lower respiratory infection were randomly assigned to receive either cloxacillin or carbenicillin plus gentamicin administered intravenously for ten days. Other aspects of therapy were constant. The groups were comparable in all respects and Pseudomonas aeruginosa was the predominant sputum pathogen in most patients. Clinical improvement, chest radiograph changes, evidence of airway obstruction, and bacteriologic flora of sputum were no different regardless of the regimen used. These results suggest that the use of anti-Pseudomonas medication in these children may not always be necessary. These observations need to be confirmed by blind-controlled studies in larger numbers of patients with mild as well as severe respiratory involvement.