Septicemia in childhood malignancy. Analysis of 101 consecutive episodes

Raised salivary endotoxin concentration as a predictor of infection in pediatric leukemia patients

OBJECTIVE

The aim of this study was to evaluate whether salivary endotoxin could be used as a predictor of infection in pediatric patients (n = 12).

STUDY DESIGN

Oropharyngeal carriage of aerobic gram-negative bacilli was monitored and salivary endotoxin concentration determined. Age-matched and gender-matched healthy children were used as controls.

RESULTS

The range of salivary endotoxin concentrations in the healthy pediatric population was similar to the range previously reported for healthy adults (0-20 ng/mL; 0-240 EU/mL).

CONCLUSION

It was found that salivary endotoxin was not an accurate predictor of sepsis and did not correlate with oropharyngeal carriage of aerobic gram-negative bacilli.

Early hospital discharge of children with fever and neutropenia: a prospective study

PURPOSE

We report a prospective study on brief IV antibiotic therapy in selected children with cancer experiencing fever and neutropenia (FN) after chemotherapy.

PATIENTS AND METHODS

All children with FN (T degree > or = 38 degrees C; ANC < 0.5 x 10(9)/L) were hospitalized for treatment with broad spectrum IV antibiotics. They were divided into three groups: group A (no infection), group B (clinically documented infection), and group C (bacteremia). Children in group A (and some children in group B) were discharged before recovery of neutropenia, if afebrile and in good condition.

RESULTS

Eighty-eight consecutive episodes of FN occurred in 30 children. Children in group A (44 episodes; 50%) received IV antibiotics for a median of 3 days; on 25 occasions (57%), IV antibiotics were stopped before recovery of neutropenia. In children in group B (30 episodes; 34%), early discharge was allowed in eight cases of minor infections (27%); six received oral antibiotics. Two children (group A) were rehospitalized for recurrent FN but recovered without complications.

CONCLUSION

In chemotherapy-induced neutropenia, children hospitalized for fever but without documented infections and some children with minor infections can cautiously be discharged before evidence of bone marrow recovery if afebrile and in good general condition.

Infection risk factors in febrile, neutropenic children and adolescents

We studied 276 fever episodes with an absolute neutrophil count (ANC) < 500/mm3 to determine patient characteristics predicting serious infection. Infections occurred in 38% of patients. Blood cultures were positive in 58% of documented infections. There was no difference in the rates of infection or positive blood culture when ANC was < 200/mm3 compared with a higher ANC. However, certain high risk infections were more common with an ANC < 200/ mm3. Leukemia patients had more infections compared with other groups. Serious infections were more common during induction therapy or relapse. Infection incidence varied significantly with patient age and onset of fever in the inpatients. Less than one fifth of febrile neutropenic episodes had no risk features for serious infection. We conclude that several clinical characteristics correlate with serious infection in febrile, neutropenic children and adolescents receiving modern supportive care. Despite improvements in supportive care measures, most febrile, neutropenic patients need close observation and empiric intravenous antibiotic therapy.

Prospective controlled survey of viral infections in children with acute lymphoblastic leukemia during chemotherapy

BACKGROUND

Infections cause significant morbidity in children with acute lymphoblastic leukemia (ALL). The incidence of viral infections commonly occurring in children with ALL receiving chemotherapy was compared with viral infections in control children and the spread of infections in families was traced.

METHODS

Fifteen families of children with ALL receiving chemotherapy (62 members) and 26 matched control families (106 members) were monitored for a total of 36,197 and 36,583 days, respectively, from November/ 1987 to December/1989 for the occurrence of infections.

RESULTS

The children with ALL had more infections than their control counterparts (P < 0.01) with respiratory infections the most common in both groups. Viral etiology was verified for 47 episodes [5.2/1000 days at risk, 95% confidence interval (CI) 3.9-7.0] in the children with ALL and 22 (2.4/1000 days at risk, 95% CI 1.5-3.7) in the control subjects (P < 0.01 for the difference). Parainfluenza viruses, enteroviruses, and adenoviruses were the most common agents in both groups. The infections of the other members of the patients' families were similar to those of their controls. The children most commonly fell ill first, and although children with ALL had more infections, they did not appear to spread the infections to their family members.

CONCLUSIONS

The children with ALL had more infections than their controls, but they managed to recover well from viral infections caused by common respiratory viruses. The children with ALL did not change the spread of infections among family members.

Serum immunoglobulins to endotoxin core glycolipid: acute leukaemia and other cancers

Circulating antibody to endotoxin core glycolipid and total serum immunoglobulin concentrations were measured in 86 children with cancer (54 with acute lymphoblastic leukaemia, four with acute myeloid leukaemia, and 28 with various solid tumours). Measurements were made before treatment in the group with acute lymphoblastic leukaemia as well as when patients were both on and off chemotherapy. In the other two groups measurements were made when patients were both on and off treatment. Significant reductions in endotoxin antibody and serum immunoglobulin concentrations were found only in patients with acute lymphoblastic leukaemia. In addition, there was a significant correlation between febrile episodes and the concentration of antibody to core glycolipid in the children with acute lymphoblastic leukaemia. These findings suggest that the use of prophylactic high titre endotoxin antibody may be of benefit to children with life threatening Gram negative infections who are receiving cytotoxic chemotherapy.

Infectious complications in childhood acute leukemias

Infectious complications in children with acute leukemias are reviewed as to incidence, predisposing factors, microbiologic etiologies and treatment. Principles of antimicrobiologic therapy are presented for bacterial, fungal, viral, and protozoal infections seen in children with cancer. Prevention of infection is also discussed.

Combination antibiotic therapy in pediatrics

Combinations of beta-lactam and aminoglycoside antibiotics are frequently used in the treatment of pediatric infections. At our institution, amikacin has been the sole aminoglycoside utilized for the past five years. Such regimens are used empirically in specific patient populations to treat the pathogens most likely to be responsible for a symptom complex, e.g., sepsis in the immunocompromised host, pneumonitis in patients with cystic fibrosis, neonatal infections such as sepsis or meningitis, and infections in patients with intestinal perforations. Beta-lactam and aminoglycoside combinations are employed as definitive therapy when synergistic interactions can be predicted, such as in systemic Pseudomonas infections, viridans streptococcal endocarditis, or enterococcal infections. In all of these circumstances, we have utilized amikacin extensively as the sole aminoglycoside, with highly satisfactory results. In vitro antibiotic synergy studies, including those employing aminoglycosides such as amikacin, may be used to predict in vivo antibiotic interactions. However, definitions of in vitro synergy vary with the laboratory method used to evaluate synergy. Furthermore, recent data from our laboratory suggest that the absence of demonstrated in vitro synergy between amikacin and imipenem may not correlate with improved survival of neutropenic rats with gram-negative sepsis that are treated with both agents. Thus, in vitro studies of synergy may underestimate the frequency of improved outcomes with combination antibiotics, especially with amikacin and imipenem. There are potential risks associated with the use of multiple, broad-spectrum antibiotics, including fungal or bacterial superinfection and increased drug toxicity. Although the former is common in pediatric patients, aminoglycoside (amikacin) toxicity has rarely been a problem. Combination antibiotic regimens that include an aminoglycoside such as amikacin continue to have an important role in pediatrics and should be used empirically or definitively for the specific indications discussed.

[Septicemia in leukemia and malignant lymphoma. Incidence pathogens--causes]

Septicemia occurred in 81 (= 23.9%) of 339 patients with leukemias an malignant lymphomas during 1979-1984/VI. In leukemias the acute forms and in malignant lymphomas the high malignant forms were mostly affected. The frequency of gramnegative bacterias (46 = 56.8%) was higher than that of gram-positive bacterias (32 = 39.5%) and of fungus (3 = 3.7%). The frequency of septicemia in leukemias (alone) between 1966-1977 was 13.9%, between 1979-1984/VI 30%. In this comparison septicemias caused by gram-negative bacterias and fungus decreased, whereas gram-positive septicemias increased. The focus of septicemia remained unknown in 30 cases, Pneumonias and the urinary tract were the most common source, followed by the skin. All patients were under cytostatics and therefore leukopenic, most of them received corticosteroids simultaneously and were thus immunosuppressed. A combination of granulocytopenia less than 1,000 mm3 with hypogammaglobulinemia less than 10 rel.% were mostly found in acute leukemias and in chronic lymphatic leukemia. 41.5% of febrile episodes from all groups of these diseases were of non-microbic origin (local or septic) an thus possibly symptom of activity of the underlying disease.

Severe infections in childhood leukemia. A follow-up study of 100 consecutive ALL patients

Severe infections during the course of childhood ALL were surveyed as a whole in 100 consecutive patients, followed up for 2-8.5 years from the ALL diagnosis. The most important findings were a total absence of disseminated candidiasis, a relative infrequency of gram-negative septicemia (8 episodes), and a predominance of gram-positive cocci (29 episodes) in the 48 verified septicemias. S. aureus was responsible for 50% of culture-positive septicemias. The gram-positive predominance depended probably on local factors, and reservation in using broad-spectrum antibiotics might have played a part. There were 9 cases of disseminated Varicella-zoster, cured successfully with antiviral agents. Pneumocystis carinii pneumonitis numbered 8 episodes, concentrated to the early remission period. One case of miliary tuberculosis was found. Risk factors regarding age of patient and phase or intensity of cytotoxic therapy are evaluated.

Symposium on infectious complications of neoplastic disease (Part I). Introduction and epidemiology

An approach to infections in cancer patients is outlined that divides such infections into those due to underlying disease, those related to underlying disease plus therapy, and those related to therapy alone. The incidence of such infections in each of the categories is discussed, together with a general outline of patterns and trends in regard to involved microorganisms. Several specific areas discussed include: problems of superinfection with newer antimicrobial agents; the current inadequacy of diagnostic techniques; the potential for early treatment with monoclonal antibodies; the potential for augmenting one or more host defenses prior to sundering other defenses during antitumor chemotherapy; the potential value of a variety of nutrients that either may be depleted or might be of benefit in enhancing host defense mechanisms.

Comparative in vitro study of temocillin (BRL 17421), a new penicillin

The activity of temocillin (BRL 17421), a new penicillin, was tested in vitro against 653 isolates of gram-negative bacilli and gram-positive cocci. The drug was compared with other beta-lactam antibiotics and tobramycin. It inhibited the majority of gram-negative bacilli tested except for Pseudomonas aeruginosa and Acinetobacter calcoaceticus, which were highly resistant. It was active against more than 50% of the multiresistant strains tested. Temocillin was more active than mezlocillin against most gram-negative bacilli and more active than moxalactam, ceftriaxone, and ceftazidime against Enterobacter spp. In general, it was slightly less active than the other drugs tested and had no activity against the gram-positive cocci. There was no significant change in drug activity when pH and medium were varied, and the effect of serum binding was minimal. There was no significant inoculum effect when the size of the inoculum was increased from 10(4) to 10(6) organisms per ml.