Initial Empiric Regimen Research Articles

Association of empiric antibiotic selection and clinical outcomes in hospitalised children with severe orbital infections: a retrospective cohort study

ObjectiveTo determine the association of initial empiric antibiotic regimens with clinical outcomes in hospitalised children with severe orbital infections.DesignMulti-centre observational cohort study using data from 2009 to 2018 clinical records.SettingCanadian...

46 Association of Empiric Antibiotic Selection on Clinical Outcomes in Hospitalized Children with Severe Orbital Infections: A Multicenter Cohort Study

Abstract Background Antibiotic selection in children with periorbital and orbital infections is often empiric and regimens vary widely among institutions in their spectrum and inclusion of anti-anaerobic and anti-staphylococcal agents. Objectives Currently, there are no national clinical guidelines for antibiotic selection and no studies comparing commonly used antibiotic regimens in orbital infections. We aimed to determine the association of initial empiric antibiotic regimens with clinical outcomes in children hospitalized with severe orbital infections. Design/Methods We conducted a multicentre cohort study of children with severe orbital infections admitted to ten hospitals between January 1, 2009, and December 31, 2018. The association between empiric antibiotic regimen in the first 24 hours of hospitalization with length of stay and surgical intervention were assessed with multivariable median regression and multivariate logistic regression, respectively. Results Of 1421 patients, 60.0% were male, and mean age was 6.4 years (SD 4.5). Median length of stay was 86.4 hours (IQR 56.9-137.5) and 180 (12.7%) received surgical intervention. The most frequently (23.6%) administered empiric regimen consisted of a third-generation cephalosporin, anaerobic agent, and staphylococcal agent. After adjustment, broad-spectrum empiric antibiotic regimens with dedicated anti-anaerobic and/or staphylococcal coverage were associated with increased length of stay, ranging from an additional 18.4 hours (95% CI, 6.82, 30.0) to 21.5 hours (95% CI, 11.0, 32.0). Only patients with staphylococcal coverage alone had a statistically significant increased odds of surgical intervention (4.45, 95% CI 1.03, 19.2). Conclusion In children hospitalized with severe orbital infections, broad-spectrum therapy with or without coverage for staphylococci and anaerobes were associated with similar clinical outcomes in a clinical setting with low methicillin-resistant Staphylococcus aureus prevalence. Clinical practice guidelines are needed to standardize antibiotic recommendations.

Epidemiology and mortality predictors for severe childhood community-acquired pneumonia in ICUs: A retrospective observational study.

To identify the epidemiology and mortality predictors of severe childhood community-acquired pneumonia (CAP) and evaluate the influence of medications on clinical outcomes in the real world. We conducted a multicenter retrospective observational study among children aged ≤5 years with severe CAP, separately comparing the detailed information between those who experienced in-hospital death and those who survived in three different age groups. A multivariate logistic regression model was used to determine mortality predictors. A total of 945 children were recruited: 341 young children aged 2-59 months, 47 infants aged 29 days to 2 months, and 557 neonates aged less than 28 days. A total of 88 deaths occurred (9.3%). There was low adherence to antimicrobial guidelines in the group aged 2-59 months, and carbapenems widely served as initial empirical regimens. However, analysis of all three age groups showed that the efficacy of antibacterial drugs with initial empirical selection grades higher than those recommended by the guidelines was not better than that of antibacterial drugs with grades recommended by the guidelines. In multivariate analyses, very severe pneumonia (odds ratio (OR): 3.48; 95% confidence interval (CI): 1.36-8.93), lower birth weight (OR: 4.64; 95% CI: 1.78-12.20), severe underweight (OR: 6.06; 95% CI: 2.34-15.63), mechanical ventilation (OR: 2.58; 95% CI: 1.00-6.62; OR: 15.63; 95% CI 3.25-76.92), a higher number of comorbidities (OR: 8.40; 95% CI: 1.89-37.04), comorbidities including anemia (OR: 5.24; 95% CI: 2.33-11.76) and gastrointestinal hemorrhage (OR: 3.79; 95% CI: 1.36-10.53), and the use of sedative-hypnotics (OR: 2.60; 95% CI: 1.14-5.95) were independent risk factors for death; infants treated with probiotics had a lower mortality rate (OR: 0.14; 95% CI: 0.06-0.33). Severe CAP remains a primary cause of death in children under 5 years of age. Clinical characteristics, comorbidities and medications are evidently associated with death. Importantly, we should pay particular attention to the identification of mortality predictors and establish prophylactic measures to reduce mortality.

Molecular detection of Mycoplasma pneumoniae in Community acquired pneumonia

Community acquired pneumonia (CAP) remains a common and serious illness despite availability of potent anti-microbials and effective vaccine. Two types of CAP are commonly recognised - typical and atypical. Typical pneumonia is usually caused by bacteria such as Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catharralis, whereas, atypical pneumonia can be caused by Mycoplasma pneumoniae, Chlamydia pneumoniae, Legionella pneuomophila. Mycoplasma pneumoniae is found to be the most common cause of CAP among atypical pathogens and is called “Walking pneumonia”. It is a common atypical respiratory pathogen that produces diseases of varied severity ranging from mild upper respiratory tract infection to severe atypical pneumonia and is also responsible for producing a wide spectrum of non-pulmonary manifestations like neurological, hepatic, cardiac diseases, hemolytic anemia, polyarthritis and erythema multiforme which occur in as many as 25% of infected persons. As it lacks cell wall they are resistant to β lactam antibiotics, hence accurate and rapid diagnosis of M. pneumoniae infections is critical to initiate appropriate antibiotic treatment. Identification of M pneumoniae allows narrowing of initial empirical regimen which decreases antibiotic selection pressure and may lessen the risk of resistance. In view of this present study will be conducted in a tertiary care hospital for identification of M pneumoniae in cases of CAP by Polymerase chain reaction (PCR). 1. To detect proportion of Mycoplasma Pneumoniae among cases of CAP. 2. Detection of 16SrRNA Mycoplasma pneumoniae by PCR.Clinico-radiologically diagnosed 92 CAP patients were included in the study. Out of which 15 cases were caused by typical CAP pathogens like Streptococcus species, K.pneumoniae & M.tuberculosis. Samples (Sputum Bronchoalveolar lavages) from 77 suspected cases of atypical pneumonia are inoculated on PPLO broth (Difco) followed by identification of genus specific 16S rRNA Mycoplasma pneumoniae using PCR. PCR was found to be positive in 9 (11.68%) out of 77 CAP patients. PCR was found to be positive in 9 (11.68%) out of 77 CAP patients. Detection of M.pneumoniae is essential for prompt diagnosis and start of empirical therapy, thereby reducing antibiotic selection pressure.

Impact of the Inclusion of an Aminoglycoside to the Initial Empirical Antibiotic Therapy for Gram-Negative Bloodstream Infections in Hematological Neutropenic Patients: a Propensity-Matched Cohort Study (AMINOLACTAM Study).

To test the hypothesis that the addition of an aminoglycoside to a β-lactam antibiotic could provide better outcomes than β-lactam monotherapy for the initial empirical treatment of hematological neutropenic patients with subsequently documented Gram-negative bacillus (GNB) bloodstream infection (BSI), a multinational, retrospective, cohort study of GNB BSI episodes in hematological neutropenic patients in six centers (2010 to 2017) was conducted. Combination therapy (β-lactam plus aminoglycoside) was compared to β-lactam monotherapy. The primary endpoint was the case fatality rate, assessed at 7 and 30 days from BSI onset. Secondary endpoints were nephrotoxicity and persistent BSI. Propensity score (PS) matching was performed. Among 542 GNB BSI episodes, 304 (56%) were initially treated with combination therapy, with cefepime plus amikacin being most common (158/304 [52%]). Overall, Escherichia coli (273/304 [50.4%]) was the main etiological agent, followed by Pseudomonas aeruginosa, which predominated in the combination group (76/304 [25%] versus 28/238 [11.8%]; P < 0.001). Multidrug resistance rates were similar between groups (83/294 [28.2%] versus 63/233 [27%]; P = 0.95). In the multivariate analysis, combination therapy was associated with a lower 7-day case fatality rate (odds ratio [OR], 0.37; 95% CI, 0.14 to 0.91; P = 0.035) with a tendency toward lower mortality at 30 days (OR, 0.56; 95% CI, 0.29 to 1.08; P = 0.084). After PS matching, these differences remained for the 7-day case fatality rate (OR, 0.33; 95% CI, 0.13 to 0.82; P = 0.017). In addition, aminoglycoside use was not significantly associated with renal function impairment (OR, 1.12; 95% CI, 0.26 to 4.87; P = 0.9). The addition of an aminoglycoside to the initial empirical therapy regimen for febrile neutropenic hematological patients should be considered.

Antibiotic modification versus withhold in febrile patients without evidence of bacterial infection, unresponsive to initial empiric regimen: a multicentre retrospective study conducted in Israel.

Prescribing antibiotics for febrile patients without proof of bacterial infection contributes to antimicrobial resistance. Lack of clinical response in these patients often leads to antibiotic escalation, although data supporting this strategy are scarce. This study compared outcomes of modifying, withholding, or continuing the same antibiotic regimen for such patients. Febrile or hypothermic stable patients with suspected infection, unresponsive to empiric antibiotic treatment, admitted to one of 15 internal medicine departments in three hospitals during a 5-year study period, were included. Patients with a definitive clinical or microbiological bacterial infection, malignancy, immunodeficiency, altered mental status, or need for mechanical ventilation were excluded. Participants were divided into groups based on treatment strategy determined 72h after antibiotic initiation: antibiotic modified, withheld or continued. Outcomes measured included in-hospital and 30-day post-discharge-mortality rates, length of hospital stay (LOS) and days of antimicrobial therapy (DOT). A total of 486 patients met the inclusion criteria: 124 in the Antibiotic modified group, 67 in the Antibiotic withheld group and 295 in the Initial antibiotic continued group. Patient characteristics were similar among groups with no differences in mortality rates in-hospital (23% vs. 25% vs. 20%, p= 0.58) and within 30days after discharge (5% vs. 3% vs. 4%, p= 0.83). Changing antibiotics led to longer LOS (9.0 ± 6.8 vs. 6.2 ± 5.6days, p = 0.003) and more DOT (8.6 ± 6.0 vs. 3.2 ± 1.0days, p < 0.001) compared to withholding treatment. Withholding as compared to modifying antibiotics, in febrile patients with no clear evidence of bacterial infection, is a safe strategy associated with decreased LOS and DOT.

Treatment of Helicobacter pylori.

Helicobacter pylori eradication has become more challenging over the past decade due to increasing antimicrobial resistance, especially to clarithromycin and levofloxacin. We identified 508 recent publications on H. pylori treatment (published between January 2018 and June 2019), focusing on the most highly clinically relevant for this review. Declining H. pylori eradication rates with clarithromycin triple therapy have led to most guidelines recommending 14 days bismuth-based quadruple therapy or concomitant therapy as the best initial empiric regimen. Substituting amoxicillin for tetracycline or metronidazole in quadruple therapy, and a three-in-one pill version of the regimen, also appear effective. Vonoprazan, a potent acid inhibitor, can overcome much clarithromycin resistance in triple therapy. High-dose dual therapy (proton pump inhibitor with amoxicillin) is a promising alternative approach. Reviewing resistance patterns to select suitable first-line empiric therapies is important in high resistance regions. Molecular methods to evaluate H. pylori antimicrobial susceptibility promise to be simpler than standard microbiological culture. The cost-effectiveness of antimicrobial susceptibility testing in refractory cases remains unproven. Updating clinicians treating H. pylori is important to combat the emerging problems of multidrug antimicrobial resistance in H. pylori strains. Truly novel approaches to H. pylori eradication are needed.

2417. Risk Factors, Response to Empiric Therapy, and Healthcare Utilization Among Children With UTI Due to Extended Spectrum β-Lactamase-Producing Enterobacteriaceae

BackgroundThere are few data on risk factors, chosen therapy and healthcare utilization among US children with extended spectrum β lactamase-positive urinary tract infection (ESBL UTI). We performed a multicenter case–control study on childhood ESBL UTI from November 2014 to February 2017; herein we present preliminary data from a single Los Angeles County hospital.MethodsWe defined UTI per 2011 AAP guidelines and ESBL per CLSI specifications. ESBL(−) UTI controls were matched by sex and age. Descriptive and matched univariate analyses on medical record data (up to 6 months after index culture) were performed.ResultsAmong 893 urinary Enterobacteriaceae isolates, 28 were ESBL(+), of which 23 were included: 13 girls, 0–5 year olds; 4 girls, ≥6 year olds; and 6 boys, 0–5 year olds. Prior hospitalization (55 vs. 78% for cases vs. controls, respectively), prior receipt of systemic antibiotics (55 vs. 38%), index hospitalization (39 vs. 20%), mean length of stay (3.9 vs. 3.6 days), and medical comorbidity (44 vs. 56%) did not differ significantly between groups. As well, several biosocial risk factors were similar in both groups, including: race, ethnicity, non-English-speaker, access to public benefits, international travel, non-US-birth, domestic violence/child abuse/neglect, and housing insecurity. Of cases and controls receiving any therapy, 16% and 96%, respectively, got empiric antibiotics to which the isolate was susceptible (P = 0.001). After culture results were available, only 39% of cases and 96% of controls received effective agents (P = 0.00002). Forty-two percent of cases had clinical improvement (within a mean of 2–3 days), vs. 43% of controls. Total treatment duration did not differ, and no deaths were recorded. In the 6 months after index UTI, groups did not differ in number of clinical encounters, proportion with documented follow-up, repeat urine tests, receipt of additional therapy, or prophylactic antibiotics. The proportions undergoing any GU-specific imaging were similar (62 vs. 47%), but this imaging included modalities with ionizing radiation in 4 cases vs. none of the controls (P < 0.05).ConclusionOur data suggest that clinical improvement occurs with initial (and potentially ineffective) empiric regimens, regardless of ESBL phenotype. The finding of more ionizing radiation exposure warrants additional study.Disclosures All authors: No reported disclosures.

Evaluating vancomycin and piperacillin-tazobactam in ED patients with severe sepsis and septic shock

Study objectiveTo determine the frequency and cause of inadequate initial antibiotic therapy with vancomycin and piperacillin-tazobactam in patients with severe sepsis and septic shock in the emergency department (ED), characterize its impact on patient outcomes, and identify patients who would benefit from an alternative initial empiric regimen. MethodsRetrospective cohort study conducted between 2012 and 2015 in which 342 patients with culture-positive severe sepsis or septic shock who received initial vancomycin and piperacillin-tazobactam were reviewed to determine appropriateness of antimicrobial therapy, risk factors for inappropriate use, and outcome data. Univariate and multivariate regression analyses were determined to identify associations between inappropriate antibiotic use and outcomes and to identify risk factors that may predict which patients would benefit from an alternative initial regimen. ResultsVancomycin and piperacillin-tazobactam were inappropriate for 24% of patients with severe sepsis or septic shock, largely due to non-susceptible infections, particularly ESBL organisms and Clostridium difficile. Risk factors included multiple sources of infection (OR 4.383), admission from a skilled nursing facility (OR 3.763), a history of chronic obstructive pulmonary disease (COPD) (OR 3.175), intra-abdominal infection (OR 2.890), and immunosuppression (OR 1.930). We did not find a mortality impact. ConclusionVancomycin and piperacillin-tazobactam were an inappropriate antibiotic combination for approximately 24% of patients with either severe sepsis or septic shock in the ED. Patients with known COPD, residence at a skilled nursing facility, a history concerning for Clostridium difficile, and immunosuppression would benefit from an alternative regimen. Future prospective studies are needed to validate these findings.

Initial empiric antibiotic therapy for community-acquired pneumonia in Chinese hospitals

ObjectivesStudies on treatment of community-acquired pneumonia (CAP) in China are scarce. We performed a study to investigate empiric antibiotic practices for patients hospitalized with CAP in China and the risk factors for treatment failure. MethodsData were collected from a national Chinese hospitalization database. Adult patients who were diagnosed with CAP between 1 October 2014 and 30 September 2015 were identified. We studied initial empiric antibiotic regimens, microbiologic sampling, treatment failure, in-hospital mortality and length of hospital stay. ResultsWe included 18 043 adult patients from 185 hospitals who met all the study inclusion criteria. The most common initial antibiotic regimen for CAP was monotherapy with a fluoroquinolone (14.8%, 2671/18 043). The most common initial antibiotic (used alone or in combination with other antibiotics) was levofloxacin (15.7%, 4597/29 278 (this denominator represents the total number of initial antibiotics)). The microbiologic sampling rate was 26.9% (4851/18 043). A total of 4050 (22.4%) of 18 043 patients experienced treatment failure. Multivariate logistic regression demonstrated that older age, male sex, coexisting lung cancer and use of regimens not covering atypical pathogens were risk factors for treatment failure. In-hospital mortality was 2.1% (380/18 043). The median hospital length of stay was 11 days (interquartile range, 8–15 days). ConclusionsPatients receiving Chinese guideline-adherent regimens had better outcomes, and atypical pathogen active regimens were associated with a lower treatment failure rate and shorter length of hospital stay.

Prospective Evaluation of a Novel Treatment Algorithm for Health Care-Associated Pneumonia

Background The current health care–associated pneumonia (HCAP) model may be too broad, leading to inappropriate use of broad-spectrum antibiotics. As a result, therapeutic algorithms, such as what Maruyama et al validated, have been developed for a more specific therapy. Our study aims to validate this algorithm in our patient population. Methods This is a single-center, prospective, cohort study, with a historical control cohort. The prospective cohort followed an outlined algorithm to determine empiric therapy as compared with a historical cohort, which followed the standard of care. Prospective cohort patients were categorized as low versus high risk based on the algorithm and started on empiric community-acquired pneumonia (CAP) or HCAP regimens, respectively. Primary objectives included length of stay and initial empiric failure. Secondary objectives included patients treated with CAP versus HCAP regimens, intravenous to oral conversion time, antibiotic duration, and incidence of acute kidney injury. Results There was no difference in the primary outcomes of length of stay and initial empiric regimen. Secondary outcomes were significant for elevated frequency of empiric CAP regimens compared with HCAP regimens and shorter antibiotic duration. Conclusions The current definition of HCAP may be too expansive leading to the overuse of broad-spectrum antibiotics. Risk stratification based on the presence of multidrug-resistant risk factors and severity of illness may prove to be a useful assessment tool in determining targeted empiric therapy and limit the propagation of bacterial resistance.

Theoretical Investigation on Antimicrobial Susceptibility Testing Methods

The resistance to antimicrobial agents has an effect in morbidity and transience from treatment failures and improved health awareness expenses. Although crucial the specific public health risk and estimating the increase in expenses is not an easy responsibility, there is modest uncertainty that growing antibiotic resistance is a severe global problem. Suitable antimicrobial drug use has unquestionable advantage, but physicians and the public frequently use these agents inappropriately. Inappropriate use results from physicians providing antimicrobial drugs to indulge viral infections, using. The simple accessibility of antimicrobial drugs leads to their incorporation into herbal or folk remedies that also increase unsuitable use of these agents. In this present investigation the results of in-vitro antibiotic susceptibility testing, guide clinicians in the suitable selection of initial empiric regimens and, drugs used for individual patients in specific situations are explained in detail.

Emergencies in Hematology and Oncology

Clinicians must be able to recognize and treat emergencies associated with malignancies and cancer treatment. Such emergencies include metabolic, neurologic, cardiovascular, hematologic, and infectious emergencies. This review details the pathophysiology, stabilization and assessment, diagnosis and treatment and disposition and outcomes for these emergencies in hematology and oncology. Figures show mechanisms of spinal cord compression, a magnetic resonance image showing a metastasis to the thoracic spine compressing the spinal cord, a contrast-enhanced magnetic resonance image of a 54-year-old female with metastatic ovarian cancer, an electrocardiogram and a cardiac echocardiogram of a 50-year-old female with malignant pericardial effusion with cardiac tamponade, a computed tomography scan of a mass compressing the superior vena cava, a blood smear from a patient with acute myeloid leukemia, and an algorithm showing the initial management of fever and neutropenia. Tables list the management of hypercalcemia of malignancy; Cairo-Bishop definition of laboratory and clinical tumor lysis; grading, risk stratification, and management of tumor lysis syndrome; management of intracranial hypertension and seizures in adults; factors favoring low risk of severe infection in patients with neutropenic fever; Multinational Association for Supportive Care in Cancer (MASCC) risk index score; and indications for the addition of a gram-positive antibiotic to the initial empirical regimen. This review contains 8 highly rendered figures, 9 tables, and 136 references.

Assessment of empirical antibiotic therapy optimisation in six hospitals: an observational cohort study

Modification of empirical antimicrobials when warranted by culture results or clinical signs is recommended to control antimicrobial overuse and resistance. We aimed to assess the frequency with which patients were started on empirical antimicrobials, characteristics of the empirical regimen and the clinical characteristics of patients at the time of starting antimicrobials, patterns of changes to empirical therapy at different timepoints, and modifiable factors associated with changes to the initial empirical regimen in the first 5 days of therapy. We did a chart review of adult inpatients receiving one or more antimicrobials in six US hospitals on 4 days during 2009 and 2010. Our primary outcome was the modification of antimicrobial regimen on or before the 5th day of empirical therapy, analysed as a three-category variable. Bivariate analyses were used to establish demographic and clinical variables associated with the outcome. Variables with p values below 0·1 were included in a multivariable generalised linear latent and mixed model with multinomial logit link to adjust for clustering within hospitals and accommodate a non-binary outcome variable. Across the six study sites, 4119 (60%) of 6812 inpatients received antimicrobials. Of 1200 randomly selected patients with active antimicrobials, 730 (61%) met inclusion criteria. At the start of therapy, 220 (30%) patients were afebrile and had normal white blood cell counts. Appropriate cultures were collected from 432 (59%) patients, and 250 (58%) were negative. By the 5th day of therapy, 12·5% of empirical antimicrobials were escalated, 21·5% were narrowed or discontinued, and 66·4% were unchanged. Narrowing or discontinuation was more likely when cultures were collected at the start of therapy (adjusted OR 1·68, 95% CI 1·05-2·70) and no infection was noted on an initial radiological study (1·76, 1·11-2·79). Escalation was associated with multiple infection sites (2·54, 1·34-4·83) and a positive culture (1·99, 1·20-3·29). Broad-spectrum empirical therapy is common, even when clinical signs of infection are absent. Fewer than one in three inpatients have their regimens narrowed within 5 days of starting empirical antimicrobials. Improved diagnostic methods and continued education are needed to guide discontinuation of antimicrobials. US Centers for Disease Control and Prevention, Division of Healthcare Quality Promotion; Robert Wood Johnson Foundation; US Department of Veterans Administration; US Department of Homeland Security.

Improvement in process of care and outcome in patients requiring intensive care unit admission for community acquired pneumonia

BackgroundThe present study was performed to assess the prognosis of patients admitted to the intensive care unit (ICU) for community acquired pneumonia (CAP) after implementation of new processes of care.MethodsTwo groups of patients with CAP were admitted to a 16-bed multidisciplinary ICU in an urban teaching hospital during two different periods: the years 1995–2000, corresponding to the historical group; and 2005–2010, corresponding to the intervention group. New therapeutic procedures were implemented during the period 2005–2010. These procedures included a sepsis management bundle derived from the Surviving Sepsis Campaign, use of a third-generation cephalosporin and levofloxacin as the initial empirical antimicrobial regimen, and noninvasive mechanical ventilation following extubation.ResultsA total of 317 patients were studied: 142 (44.8%) during the historical period and 175 (55.2%) during the intervention period. Sequential Organ Failure Assessment scores were higher in patients in the intervention group (7.2 ± 3.7 vs 6.2 ± 2.8; p=0.008). Mortality changed significantly between the two studied periods, decreasing from 43.6% in the historical group to 30.9% in the intervention group (p < 0.02). A restrictive transfusion strategy, use of systematic postextubation noninvasive mechanical ventilation in patients with severe chronic respiratory or cardiac failure patients, less frequent use of dobutamine and/or epinephrine in patients with sepsis or septic shock, and delivery of a third-generation cephalosporin associated with levofloxacin as empirical antimicrobial therapy were independently associated with better outcomes.ConclusionPositive outcomes in ICU patients with CAP have significantly increased in our ICU in recent years. Many new interventions have contributed to this improvement.

Catheter-associated Bloodstream Infections in Pediatric Hematology-Oncology Patients

Catheter-associated bloodstream infections (CABSIs) are common complications encountered with cancer treatment. The aims of this study were to analyze the factors associated with recurrent infection and catheter removal in pediatric hematology-oncology patients. All cases of CABSIs in patients attending the Department of Pediatric Hematology-Oncology between January 2008 and December 2010 were reviewed. A total of 44 episodes of CABSIs, including multiple episodes involving the same catheter, were identified in 31 children with cancer. The overall CABSIs rate was 7.4 infections per 1000 central venous catheter (CVC) days. The most frequent organism isolated was coagulase-negative Staphylococcus (CONS). The CVC was removed in nine (20.4%) episodes. We found that hypotension, persistent bacteremia, Candida infection, exit-side infection, neutropenia, and prolonged duration of neutropenia were the factors for catheter removal. There were 23 (52.2%) episodes of recurrence or reinfection. Mortality rate was found to be 9.6% in children with CABSIs. In this study, we found that CABSIs rate was 7.4 infections per 1000 catheter-days. CABSIs rates in our hematology-oncology patients are comparable to prior reports. Because CONS is the most common isolated microorganism in CABSIs, vancomycin can be considered part of the initial empirical regimen.

The Effects of Biocompatible Compared with Standard Peritoneal Dialysis Solutions on Peritonitis Microbiology, Treatment, and Outcomes: The Balanz Trial

A multicenter, multi-country randomized controlled trial (the balANZ study) recently reported that peritonitis rates significantly improved with the use of neutral-pH peritoneal dialysis (PD) solutions low in glucose degradation products ("biocompatible") compared with standard solutions. The present paper reports a secondary outcome analysis of the balANZ trial with respect to peritonitis microbiology, treatment, and outcomes. Adult incident PD patients with residual renal function were randomized to receive either biocompatible or conventional (control) PD solutions for 2 years. The safety population analysis for peritonitis included 91 patients in each group. The unadjusted geometric mean peritonitis rates in those groups were 0.30 [95% confidence interval (CI): 0.22 to 0.41] episodes per patient-year for the biocompatible group and 0.49 (95% CI: 0.39 to 0.62) episodes per patient-year for the control group [incidence rate ratio (IRR): 0.61; 95% CI: 0.41 to 0.90; p = 0.01]. When specific causative organisms were examined, the rates of culture-negative, gram-positive, gram-negative, and polymicrobial peritonitis episodes were not significantly different between the biocompatible and control groups, although the biocompatible group did experience a significantly lower rate of non-pseudomonal gram-negative peritonitis (IRR: 0.41; 95% CI: 0.18 to 0.92; p = 0.03). Initial empiric antibiotic regimens were comparable between the groups. Biocompatible fluid use did not significantly reduce the risk of peritonitis-associated hospitalization (adjusted odds ratio: 0.80; 95% CI: 0.48 to 1.34), but did result in a shorter median duration of peritonitis-associated hospitalization (6 days vs 11 days, p = 0.05). Peritonitis severity was more likely to be rated as mild in the biocompatible group (37% vs 10%, p = 0.001). Overall peritonitis-associated technique failures and peritonitis-related deaths were comparable in the two groups. Biocompatible PD fluid use was associated with a broad reduction in gram-positive, gram-negative, and culture-negative peritonitis that reached statistical significance for non-pseudomonal gram-negative organisms. Peritonitis hospitalization duration was shorter, and peritonitis severity was more commonly rated as mild in patients receiving biocompatible PD fluids, although other peritonitis outcomes were comparable between the groups.

Emergencies in Hematology and Oncology

With the rising incidence of malignancies and expanding treatment options, clinicians must learn to recognize and treat emergencies associated with them. Oncologic emergencies can be broadly classified according to organ systems, which can facilitate recognition and management. Pathophysiology, presentation, diagnosis, and treatment are discussed for complications categorized by metabolic emergencies (hypercalcemia of malignancy, tumor lysis syndrome, lactic acidosis), neurologic emergencies (malignant spinal cord compression, brain metastases, and increased intracranial pressure), cardiovascular emergencies (malignant pericardial effusion and tamponade, superior vena cava syndrome), hematologic emergencies (hyperviscosity due to monoclonal proteins, hyperleukocytosis and leukostasis), infectious emergencies (neutropenic fever, neutropenic enterocolitis, fever associated with splenectomy or functional asplenia), and pulmonary emergencies (acute airway obstruction, acute airway hemorrhage). Figures illustrate spinal cord compression, brain metastases, electrical alternans, malignant pericardial effusion, superior vena cava syndrome, hyperleukocytosis, and an algorithm for initial management of fever and neutropenia. Tables cover management of hypercalcemia of malignancy; the Cairo-Bishop definition of laboratory and clinical tumor lysis; grading, risk stratification, and management of tumor lysis syndrome; management of intracranial hypertension and seizures; infection in patients with neutropenic fever; the Multinational Association for Supportive Care in Cancer Risk Index; and indications for the addition of a gram-positive antibiotic to the initial empirical regimen. This chapter contains 181 references.

Intravenous colistin sulfate: A rarely used form of polymyxin E for the treatment of severe multidrug-resistant Gram-negative bacterial infections

In recent reports polymyxins have been considered an effective and safe treatment option for the management of multidrug-resistant (MDR) Gram-negative bacterial infections. Here we report our clinical experience with the use of intravenous colistin sulfate in critically ill patients hospitalized from January 2006 to October 2008, as a last treatment resort in China, and assess its effectiveness and adverse effects. Fifteen patients who suffered from severe infections caused by MDR or pandrug-resistant (PDR) Gram-negative bacteria (13 isolates of Acinetobacter baumannii, 4 isolates of Pseudomonas aeruginosa and 2 isolates of Klebsiella pneumoniae), unresponsive to the initial empirical regimens, were treated with colistin sulfate (daily dose of 1.28 +/- 0.25 million IU and duration of 22.3 +/- 6.2 days), based on sensitivity results. The treatment resulted in a good clinical response in 73.3%, microbiological clearance in 60% and mortality in 20%. Possible nephrotoxicity occurred in 1 patient and no patients developed neurotoxicity. In conclusion, intravenous colistin sulfate is a safe and viable alternative for the treatment of severe infections due to sensitive MDR Gram-negative bacteria.

Piperacillin/tazobactam versus cefepime for the empirical treatment of pediatric cancer patients with neutropenia and fever: A randomized and open‐label study

This is a prospective, randomized, and open-label clinical trial that examines the efficiency and safety of PIP/TAZO monotherapy in comparison to cefepime (CEF), for the empirical treatment of pediatric cancer patients with neutropenia and fever. One hundred thirty-one consecutive febrile episodes in 70 neutropenic pediatric cancer patients received randomized treatment either with piperacillin/tazobactam (PIP/TAZO) 80 mg/kg piperacillin/10 mg/kg tazobactam every 6 hr or CEF 50 mg/kg every 8 hr. Clinical response was determined at completion of therapy. Duration of fever, neutropenia, hospitalization, the need for modification of the therapy, and mortality rates were compared between the two groups. One hundred twenty-seven episodes in 69 patients (35 females, 34 males) with a median age of 4.2 years were assessed for efficiency (65 PIP/TAZO, 62 CEF). The frequency of success without modification of treatment was nearly identical for both PIP/TAZO (60.0%) and CEF (61.3%) (P > 0.05). The overall response rate, with or without modification of assigned treatment, was 96.9% for PIP/TAZO and 98.4% for CEP (P > 0.05). Infection-related mortality at the end of the febrile episode was 2.4%. Duration of fever and hospitalization were not different between the treatment groups. No major side effects were observed in neither of the groups. PIP/TAZO treatment was as effective and safe as CEF monotherapy as an initial empirical regimen in pediatric cancer patients with fever and neutropenia.