Blood and guts: how the intestinal microbiome shapes hematopoiesis and treatment of hematologic disease

ABSTRACT

Over the past 10 years, there has been a marked increase in recognition of the interplay between the intestinal microbiome and the hematopoietic system. Despite their apparent distance in the body, a large literature now supports the relevance of the normal intestinal microbiota to steady-state blood production, affecting both hematopoietic stem and progenitor cells as well as differentiated immune cells. Microbial metabolites enter the circulation where they can trigger cytokine signaling that influences hematopoiesis. Furthermore, the state of the microbiome is now recognized to affect outcomes from hematopoietic stem cell transplant, immunotherapy, and cellular therapies for hematologic malignancies. Here we review the mechanisms by which microbiotas influence hematopoiesis in development and adulthood as well as the avenues by which microbiotas are thought to impact stem cell transplant engraftment, graft-versus-host disease, and efficacy of cell and immunotherapies. We highlight areas of future research that may lead to reduced adverse effects of antibiotic use and improved outcomes for patients with hematologic conditions.

An Analysis of the Clinical Benefit of 37 Bronchoalveolar Lavage Procedures in Patients with Hematologic Disease and Pulmonary Complications

Objective Since pulmonary complications are a major cause of mortality in patients with hematologic diseases, their rapid detection and treatment are essential. Bronchoalveolar lavage (BAL) is widely performed to diagnose pulmonary infiltrates not evident with non-invasive investigations; however, reports on its clinical benefits for patients with hematologic diseases are limited. The aim of our study was to investigate the utility of diagnostic bronchoscopy with BAL for those patients. Methods We retrospectively reviewed the clinical records of 37 consecutive BAL procedures in 33 adult patients with hematological diseases and pulmonary infiltrates with at least 6 months of follow-up between August 2013 and September 2017 (total 747 BAL procedures). The BAL results, ensuing treatment modifications, treatment outcomes, survival times, and adverse events were evaluated. Results Microbiological findings were detected in 11 (29.7%), even though wide-spectrum antibiotics and antifungal drugs had been empirically administered to most patients (>70%) prior to the bronchoscopy procedure. Overall, 25 of the 37 BAL procedures (67.6%) had some impact on the diagnosis of pulmonary diseases. Patients without specific diagnostic findings from BAL had a significantly poorer survival than those with diagnostic findings via BAL (30-day survival: 33.3% vs. 92.0%; 180-day survival: 8.3% vs. 64.0%). Four patients (12.1%) experienced complications associated with bronchoscopy; there were no procedure-related deaths. Conclusion BAL seems still important for diagnosing pulmonary infiltrates and/or excluding some of the important respiratory tract pathogens in patients with hematological diseases; furthermore, negative specific diagnostic findings from BAL may be associated with poor prognoses.

Characteristics of culture-positive invasive pulmonary aspergillosis in patients with hematologic diseases: Comparison between Aspergillus fumigatus and non-fumigatus Aspergillus species

While the epidemiology and clinical differences of various Candida spp. has been relatively well-identified, data regarding invasive aspergillosis (IA) caused by different Aspergillus spp. are insufficient.We aimed to determine the epidemiology of culture-positive invasive pulmonary aspergillosis (IPA) and to compare the characteristics and outcomes of Aspergillus fumigatus IPA with those of non-fumigatus IPA in patients with hematologic diseases. All consecutive cases of IPA from 2011 to 2015 were reviewed retrospectively.There were 430 proven/probable IPA and 76 culture-positive proven/probable IPA. Excluding cases of multiple species of fungi or cases having difficulties in species-level identification, 41 A fumigatus and 22 non-fumigatus IPA (Aspergillus flavus [n = 11], Aspergillus niger [n = 6], and Aspergillus terreus [n = 5]) were compared. There were no significant differences in baseline characteristics between the 2 groups. However, disseminated IA was more common in non-fumigatus IPA (2.4% vs 18.2%; P = .046). Paranasal sinus (PNS) involvement was more common in non-fumigatus IPA. There was a trend towards higher peak serum galactomannan values in non-fumigatus IPA than in A fumigatus IPA group (median 1.33 [interquartile 0.98-3.29] vs 0.97 [0.66-1.97]; P = .084). Clinical response and mortality did not differ between groups.The culture-positive rate of proven/probable IPA was 17.7%, of which non-fumigatus Aspergillus accounted for about one-third. Disseminated IA, especially involving the PNS, was more frequent in non-fumigatus IPA than in A fumigatus IPA.

[Pathogens and clinical characteristics of bacterial infection in hematology department between 2010 and 2014]

OBJECTIVE

To analyze the characteristics of distribution and drug resistance of bacterial infection in several different parts of hematology department inpatients of Anhui Provincial Hospital from January 2010 to December 2014, including patients who had received hematopoietic stem cell transplantation (HSCT).

METHODS

Anti-microbial susceptibility test was done by Kirby-Bauer method and automated systems and the data were analysed by WHONET 5.6 software.

RESULTS

A total of 3 312 copies of inspection samples were analyzed, including 2 716 (82%) blood samples and other 596 specimens (18%). 634 bacterial strains were isolated from 3 312 samples (19.14%) including 488 samples (76.97%) from blood culture. 427 (67.35%) bacterial strains were gram-negative, and the other 207 (32.65%) were gram-positive. Escherichia coli, Klebsiella pneumoniae and Pseudomonas aeruginosa were most common gram-negative bacterial and the resistant rates to imipenem were 0.8%, 11.8% and 3.3%, respectively. Detection rates of Extended-spectrum beta-lactamases in Escherichia coli and Klebsiella pneumoniae were 83.9% and 75.0%, respectively. At the same time, Coagulase negative Staphylococcus, Streptococcus and Enterococcus were most common kinds of gram-positive bacteria. Methicillin-resistant coagulase negative staphylococcus accounted for 65.9% antibiotic resistance. No vancomycin and/or linezolid and/or tigecycline resistant strains of Staphylococcus spp. and Enterococcus spp. were found in those patients.

CONCLUSION

Patients with hematology diseases had a higher risk of bacterial infections, mainly caused by Gram-negative bacteria. There are different distributions of bacterial in different wards.

Nonredundant Roles of Interleukin-17A (IL-17A) and IL-22 in Murine Host Defense against Cutaneous and Hematogenous Infection Due to Methicillin-Resistant Staphylococcus aureus

Staphylococcus aureus is the leading cause of skin and skin structure infections (SSSI) in humans. Moreover, the high frequency of recurring SSSI due to S. aureus, particularly methicillin-resistant S. aureus (MRSA) strains, suggests that infection induces suboptimal anamnestic defenses. The present study addresses the hypothesis that interleukin-17A (IL-17A) and IL-22 play distinct roles in immunity to cutaneous and invasive MRSA infection in a mouse model of SSSI. Mice were treated with specific neutralizing antibodies against IL-17A and/or IL-22 and infected with MRSA, after which the severity of infection and host immune response were determined. Neutralization of either IL-17A or IL-22 reduced T cell and neutrophil infiltration and host defense peptide elaboration in lesions. These events corresponded with increased abscess severity, MRSA viability, and CFU density in skin. Interestingly, combined inhibition of IL-17A and IL-22 did not worsen abscesses but did increase gamma interferon (IFN-γ) expression at these sites. The inhibition of IL-22 led to a reduction in IL-17A expression, but not vice versa. These results suggest that the expression of IL-17A is at least partially dependent on IL-22 in this model. Inhibition of IL-17A but not IL-22 led to hematogenous dissemination to kidneys, which correlated with decreased T cell infiltration in renal tissue. Collectively, these findings indicate that IL-17A and IL-22 have complementary but nonredundant roles in host defense against cutaneous versus hematogenous infection. These insights may support targeted immune enhancement or other novel approaches to address the challenge of MRSA infection.

Bloodstream infections in ICU with increased resistance: epidemiology and outcomes

BACKGROUND

Aim of this study was to evaluate the epidemiology and outcomes of hospital-acquired bloodstream infections (HA-BSI) in Greek intensive care units (ICU).

METHODS

Secondary analysis of data from 29 ICU collected during the EUROBACT study, a large prospective, observational, multination survey of HA-BSI. First episodes of HA-BSI acquired in the ICU or within 48 hours prior to admission were recorded.

RESULTS

Gram-negative bacteria predominated namely Acinetobacter sp, Klebsiella sp, Pseudomonas sp (73.3% of monomicrobial infections) followed by Gram-positive cocci (18.3%); fungi (7.6%) and anaerobes (0.8%). Overall 73.3% of isolates were multidrug resistant (MDR), 47.1% extensively resistant (XDR) and 1.2% pan-drug resistant (PDR). Carbapenems were the most frequent empirically prescribed antibiotics, while colistin was the most frequently adequate; for both, calculated mean total daily doses were suboptimal. Overall 28-day all-cause mortality was 33.3%. In the multivariate analysis, factors adversely affecting outcome were higher SOFA score at HA-BSI onset (OR 1.19; 95% CI 1.08-1.31, P=0.0006), need for renal supportive therapy (OR 2.75; 95% CI 1.35-5.59, P=0.0053), and for vasopressors/inotropes (OR 2.68; CI 1.18-6.12, P=0.02); adequate empirical treatment had a protective effect (OR 0.48; CI 0.24-0.95, P=0.03).

CONCLUSION

TIMELY administration of adequately dosed treatment regimens and early ICU admission of critically ill patients could help in improving outcomes.

[Extrapulmonary manifestations of community acquired pneumonia]

The key diagnostic features of community acquired pneumonia are sometimes mixed with extrapulmonary clinical manifestations which are important to recognize. Indeed, when present, these clinical clues can help tailor the diagnostic and therapeutic approach in a more specific way. For example, the presence of diarrhea, acute confusion and hyponatremia are suggestive of Legionella pneumophila, and therefore this pathogen needs to be included in the initial antibiotic regimen. Extrapulmonary manifestations are sometimes difficult to distinguish from septic complications of the pneumonia, but can sometimes warrant a specific treatment. The goal of this review is to remind the reader of the broad spectrum of these manifestations and their association with specific pathogens, most often the "atypical" ones.

Hematologic manifestations of Helicobacter pylori infection

Helicobacter pylori (H. pylori) is the most common infection in humans, with a marked disparity between developed and developing countries. Although H. pylori infections are asymptomatic in most infected individuals, they are intimately related to malignant gastric conditions such as gastric cancer and gastric mucosa-associated lymphoid tissue (MALT) lymphoma and to benign diseases such as gastritis and duodenal and gastric peptic ulcers. Since it was learned that bacteria could colonize the gastric mucosa, there have been reports in the medical literature of over 50 extragastric manifestations involving a variety medical areas of specialization. These areas include cardiology, dermatology, endocrinology, gynecology and obstetrics, hematology, pneumology, odontology, ophthalmology, otorhinolaryngology and pediatrics, and they encompass conditions with a range of clear evidence between the H. pylori infection and development of the disease. This literature review covers extragastric manifestations of H. pylori infection in the hematology field. It focuses on conditions that are included in international consensus and management guides for H. pylori infection, specifically iron deficiency, vitamin B₁₂ (cobalamin) deficiency, immune thrombocytopenia, and MALT lymphoma. In addition, there is discussion of other conditions that are not included in international consensus and management guides on H. pylori, including auto-immune neutropenia, antiphospholipid syndrome, plasma cell dyscrasias, and other hematologic diseases.

Hematologic diseases: High risk of Clostridium difficile associated diarrhea

AIM: To investigate the incidence and clinical outcome of Clostridium difficile (C. difficile) associated diarrhea (CDAD) in patients with hematologic disease.

METHODS: We retrospectively reviewed the medical records of patients who underwent C. difficile testing in a tertiary hospital in 2011. The incidence and risk factors for CDAD and its clinical course including recurrence and mortality were assessed in patients with hematologic disease and compared with those in patients with nonhematologic disease.

RESULTS: About 320 patients were diagnosed with CDAD (144 patients with hematologic disease; 176 with nonhematologic disease). The incidence of CDAD in patients with hematologic disease was estimated to be 36.7 cases/10000 patient hospital days, which was higher than the 5.4 cases/10000 patient hospital days in patients with nonhematologic disease. Recurrence of CDAD was more frequent in patients with hematologic disease compared to those with nonhematologic disease (18.8% vs 8.5%, P < 0.01), which was associated with higher re-use of causative antibiotics for CDAD. Mortality due to CDAD did not differ between the two groups. Multivariate analysis showed that intravenous immunoglobulin was the only significant factor associated with a lower rate of recurrence of CDAD in patients with hematologic disease.

CONCLUSION: The incidence and recurrence of CDAD was higher in patients with hematologic disease than in those with nonhematologic disease.

The role of Helicobacter pylori infection in hematological disorders

Helicobacter pylori (H. pylori) is a Gram-negative spiral bacterium, classified as a carcinogen of class I, according to the World Health Organization (WHO). The infection is a major cause of gastritis, gastric and duodenal ulcer disease and increases the risk of gastric cancer. It has been implicated in the pathogenesis of several gastrointestinal, systemic or hematological diseases. The present review aims in deciphering the role of the bacterium in hematological disorders, increasing the awareness of gastroenterologists, hematologists and internal medicine practitioners, regarding the bacterium-associated hematological diseases. The efficacy of H. pylori eradication in increasing the platelet count in adult patients with primary immune thrombocytopenia (ITP) has been confirmed, linking the infection with the disease. Moreover, as the bacterium causes iron deficiency anemia (IDA) by several mechanisms, recent guidelines indicate H. pylori infection (Hp-I) to be sought in IDA patients if histology is negative and to be eradicated if present. Furthermore, it has been widely recognized that anti-H. pylori treatment causes regression of the low-grade B-cell gastric MALT lymphomas. Despite the well established associations of Hp-I with the aforementioned hematological disorders, we highlight the possible role of the infection to other hematological diseases or conditions such as non-Hodgkin lymphomas of the stomach, monoclonal gammopathy of undetermined significance, megaloblastic anemia and myelodysplastic syndromes. We finally underline the elevated risk of childhood leukemia and of hemorrhage in patients with coagulation disorders, due to the infection.

[Epidemiology of invasive fungal disease in patients with hematological diseases]

OBJECTIVE

To explore the epidemiological profiles of invasive fungal disease (IFD) in hospitalized patients with hematological diseases during 2007-2012.

METHODS

A total of 419 IFD patients with hematological diseases from January 2007 to December 2012 were reviewed. All of them were analyzed with regards to diagnostic levels, infection sites and various related factors.

RESULTS

(1) A total of 233 cases (55.61%) were preliminarily identified as IFD, 140 cases (33.41%) had a clinical diagnosis and 46 cases (10.98%) were confirmed cases of IFD. (2) Among 46 confirmed cases of IFD, there were agranulocytosis (n = 43) and aspergillosis infection (n = 36). (3) Respiratory tract was the most frequent infection site in all IFD patients (85.20%) . (4) And chemotherapy-induced agranulocytosis was a major reason for IFD patients with hematological diseases. The number of IFD patients without chemotherapy had a rising trend. (5) The age group of IFD was during 41-60 years old. (6) All of them stayed on antibiotic therapy at the diagnosis of IFD. The numbers of antibiotics were two(205 cases, 48.93%) and three(179 cases, 42.72%). (7) The peak incidence of IFD was recorded in January, July and December. And June was another lower peak.

CONCLUSIONS

Agranulocytosis is the main reason for IFD patients with hematological disease. The data is important and valuable for the early diagnosis and therapy of IFD patients with hematological disease.

[The clinical study of invasive fungal infection in 76 cases of hematologic diseases]

OBJECTIVE

To investigate the risk factors, clinical features, efficacy and adverse reactions in patients of hematologic diseases with invasive fungal infections (IFI).

METHODS

The risk factors and clinical features were retrospectively analyzed to compare the efficacy and safety of itraconazole with amphotericin B in treatment of IFI in 76 patients with hematologic diseases.

RESULTS

Of the 76 patients, 68 (89.5%) used broad-spectrum antibiotics, 64 (84.2%) were treated with more than 2 courses chemotherapy, 43 (56.6%) were under agranulocytosis, 34 (44.7%) were using glucocorticoid for long terms, 27 (35.5%) were with peripheral or central venous catheter. The overall effective rates of itraconazole and amphotericin B were 60.5% and 61.5% respectively (P = 0.929). There was a significant difference between itraconazole and amphotericin B in hypokalemia (14.0% vs 42.4%, P = 0.005) while no other differences in adverse reactions were found.

CONCLUSIONS

The risk factors of patients in hematologic diseases with IFI include chemotherapy, using broad septum antibiotics and agranulocysis. The therapeutic effect of itraconazole and amphotericin B in treatment of IFI is similar. The adverse reactions of itraconazole is less and slighter than amphotericin B.

[Epidemiology and antimicrobial resistance of clinical isolates about hospital infection from patients with hematological diseases]

OBJECTIVE

To investigate the epidemiology and antibiotic resistance of isolates from hospitalized patients with hematological disease from 2005 to 2011.

METHODS

A total of 1453 bacterial strains were isolated from patients with hematological disease from January 2005 to December 2011. Antimicrobial susceptibility testing was performed by micro-dilution method.

RESULTS

(1) The majority of the bacterial strains were respiratory passage examples (57.5%). The portage of blood examples in our division (13.60%) was higher than of whole hospital (6.26%), with lower positive rate of bacterial culture (52.37%) than of whole hospital (60.24%). Chemotherapy-induced agranulocytosis was the main reason for hospital infection. 578 (39.8%) bacterial strains were gram positive, and 875 (60.2%) gram negative bacillus. Staphylococcus epidermidis strains and glucose nonfermenters had a tendency of ascensus. (2) Methicillin resistant staphylococcus aureus (MRSA) accounted for 72.8% antibiotic resistance. Detection rates of ESBLs in Escherichia coli and Klebsiella pneumoniae were 18.9% and 10.4%, respectively. (3) No obvious changes of antimicrobial resistances of Staphylococcus and Enterococcus were observed during these years. The Enterobacteriaceae strains showed lowest resistance rates to Carbapenems, next to Cefoperazone/sulbactam and Piperacillin/tazobactam. But the resistance rates of Escherichia coli to Cefepime and Ceftazidime were gradually increasing during the past years. Pseudomonas aeruginosa and Acinetobacter baumannii of glucose nonfermenters showed lowest resistance rates to Cefoperazone/sulbactam, but the resistance rate of Pseudomonas aeruginosa to Carbapenems increased.

CONCLUSIONS

Escherichia coli was the highest in quantity of gram negative bacillus and glucose nonfermenters had a tendency of ascensus. The resistance rates of Escherichia coli to Cefepime and Ceftazidime, Pseudomonas aeruginosa to Carbapenems were gradually increasing in the past years.

[Study on the diagnostic value of lung biopsy in hematologic patients with lung infection]

OBJECTIVE

To evaluate the diagnostic value and safety of percutaneous lung biopsy in hematologic patients with lung infection.

METHODS

28 cases hematologic patients received CT-guided percutaneous lung biopsy when they developed a fever associated with pulmonary nodules or lumps in CT scan whose clinical diagnosis were unclear during or after chemotherapy. Sample of each lesion were drawn twice. The lung tissue was re-scanned after lung biopsy to check up in order to discover bleeding and pneumothorax. Biopsy tissue was examined by bacteria culture, acid-fast staining and pathology. Pathological examination contained HE staining, acid-fast stain, PAS stain, TB-DNA, methenamine silver and others.

RESULTS

28 cases contain 24 males and 4 females. Median age was 40 15 - 77 years old. Blood tests were as follows: 3 cases with HGB > 110 g/L, 9 with HGB 90 - 110 g/L, 12 with HGB 60 - 89 g/L, 4 with HGB < 60 g/L. 8 with WBC > 10×10(9)/L, 6 with WBC (4 - 10)×10(9)/L, 13 with WBC < 4×10(9)/L, 1 with WBC < 2×10(9)/L; 14 with PLT > 100×10(9)/L, 5 with PLT (50 - 100)×10(9)/L, 5 with PLT < 50×10(9)/L, 4 with PLT < 30×10(9)/L. 4 cases had mild extended PT, 3 mild extended APTT, 3 FIB lower than normal. Lung CT scans were as follows: 4 cases with simply lesion in right lung, 4 with simply lesion in left lung, 20 with lesions in bilateral lung. 8 cases were diagnosed as fungal infection, 3 as tuberculosis infection, 1 as lung cancer, 1 as pulmonary infiltration of lymphoma, 1 as pulmonary infiltration of leukemia, and 14 as inflammatory changes with no specific diagnosis. 4 cases came with pneumothorax during lung biopsy, mild to moderate in 3 cases and severe in 1 case. Severe patient turned better after CT-guided suction. 3 cases with mild hemoptysis turned better after treatment.

CONCLUSION

When hematopathy patients are with pulmonary nodules or lumps in CT scan whose clinical diagnosis is unclear, CT-guided percutaneous lung biopsy is safe and conducive to early diagnosis and conducive to early rehabilitation of patients if the coagulation function is basically normal and platelet count is not too low.

[Clinical features and antimicrobial resistance of Gram positive bacterial blood stream infection in patients with hematologic diseases]

OBJECTIVE

To study the clinical characteristics and antimicrobial resistance of bloodstream infections caused by Gram positive bacteria, so as to provide reference for the rational use of antimicrobial agent.

METHODS

One hundred and eight patients with bloodstream infections of Gram positive bacteria in our hospital from January 2009 to December 2009 were retrospectively reviewed. The clinical manifestations, pathogen types and antimicrobial susceptibility results of pathogens isolated from bloodstream were analyzed.

RESULTS

All patients had fever and 31.89% with rigor, 22.41% of the patients had no local infection lesions, 77.59% had clear infection lesions, including oral infections, respiratory tract infections and soft tissue infections. The pathogen testing showed that 12.82% were staphylococci aureus, 50.42% coagulase-negative staphylococci, 24.8% streptococci, 9.4% enterococci and 2.56% Listeria monocytogenes. Antibiotics resistance of staphylococcus and enterococci in our hospital was severe. The percentage of methicillin-resistant staphylococcus aureus in this investigation was 68.92%. The resistant rates of methicillin-resistant coagulase-negative staphylococci (MRCNS) to the most antimicrobial agents were higher than that methicillin-sensitive coagulase-negative staphylococci. One strain of MRCNS was found resistant to teicoplanin and linezolid, and 1 strain of enterococci resistant to teicoplanin and linezolid.

CONCLUSION

Gram positive bacteria shows serious drug resistance, but still keeps highly sensitive to vancomycin, linezolid, teicoplanin and quinupristin/dalfopristin.

Clinical, diagnostic and therapeutic approaches to complications of brucellosis: an experience of 12 years

OBJECTIVE

To describe the clinical presentations, laboratory findings, prevalence and pattern of complications and the response to treatment of brucellosis in a 12-year period in a Turkish research hospital.

MATERIALS AND METHODS

Between 1996 and 2008, 231 patients were diagnosed with brucellosis and treated in our clinic. Medical records of 189 of the 231 patients with at least one demonstrable complication of the disease were reviewed for anamnesis, diagnosis, complications, treatment and clinical outcomes.

RESULTS

The decreasing order of the complications was: hematological, 104 (55%); osteoarticular, 70 (37%); hepatobiliary, 59 (31%), and gastrointestinal, 23 (12%). The most common laboratory findings were anemia, lymphomonocytosis, elevated sedimentation rate and C-reactive protein, and elevated aminotransaminases.

CONCLUSION

The hematological, osteoarticular and hepatobiliary manifestations were predominant. Bursitis, synovitis, glomerulonephritis, cutaneous lesion and deep vein thrombosis were the rare complications observed in our study. In clinical practice, brucellosis should be considered in the differential diagnosis in the presence of infrequent complications.

[Risk factors and prognosis of invasive fungal infections in patients with hematological diseases]

OBJECTIVE

To investigate the incidence, risk factors, prognosis and high risk patients of invasive fungal infections (IFI) in patients with hematological diseases.

METHODS

: Over 2-week hospitalized patients from January 2007 to December 2008 were retrospectively reviewed. Logistic regression was used to analyze the risk factors of IFI, and recursive partitioning to reveal high risk patients. Incidence of IFI was estimated by cumulative incidence function, and the prognosis by Kaplan-Meier method.

RESULTS

A total of 1048 assessable treatment cycles were recorded and 93 cases of IFI were diagnosed, with an incidence of 8.87 per 100 treatment cycles. Multivariate logistic regression revealed the following risk factors: age (OR 1.025, 95% CI 1.010-1.041, P = 0.002), duration of neutropenia (OR 1.028, 95% CI 1.014-1.042, P < 0.0001) and uncontrolled underlying diseases (OR 2.620, 95% CI 1.608-4.268, P = 0.0001). Recursive partitioning found two groups of high risk patients: (1) patients with uncontrolled underlying diseases and neutropenia duration > or = 58 days (7/12, 58.3%), (2) patients with uncontrolled underlying diseases and age > or = 33 years (40/208, 19.2%). At the end of follow-up, 111 cases of IFI were recorded in 451 patients, with a 1-year cumulative incidence of 27.1%. In patients with established IFI, overall survival rate and IFI related mortality rate at 12 weeks after diagnosis were 83.4% and 13.5% respectively.

CONCLUSION

Age, duration of neutropenia and uncontrolled underlying diseases are risk factors of IFI; patients with uncontrolled underlying diseases and age > or = 33 years were at high risk of IFI and need major concern. IFI has a better prognosis and a lower related mortality in this study.

[Changes of pathogens for nosocomial infection of patients with hematological diseases]

In order to investigate the distribution of nosocomial infection in patients with hematological diseases in our hospital, and to explore the changes of the pathogens isolated. The method of retrospective investigation and analysis was employed. 1164 strain pathogens were isolated from the patients with hematological diseases during the period of 1997-2009. The results showed that the Gram-positive cocci infection increased gradually during the 13 years, but has been stable in the last 4 years. The Gram-negative bacteria showed a trend decrease. The fungi increased during these years. The rates of infection with gram-positive cocci, gram-negative bacteria and fungus were 28.2%, 59.8% and 12.0% respectively. For the details, Escherichia coli infection rate was the highest: 12.1%, followed by Pseudomonas aeruginosa (9.1%), Enterobacter (8.4%), Klebsiella pneumoniae (7.4%), Staphylococcus epidermidis (6.3%) and Enterococci (6.6%). The distribution of G(+)- and G⁻ pathogens showed obvious change on end of 1990's and beginning of this century, but it was tending towards stability on recent years; the incidence of fungus was tending towards increase, which was related to wide application of strong broad-spectrum antibiotics. In conclusion, the patients with hematological diseases, as the high-risk group of nosocomial infection, should be monitored strictly. Infection is related to many factors, and the main factor is dysfunction of autoimmunity. The strategies should be explored to strengthen the immune protection and set up a reasonable scheme of antibiotics.

[An analysis of efficacy and related factors of itraconazole in the treatment of invasive fungal infection in hematological diseases]

OBJECTIVE

To investigate the effects and related factors of itraconazole in the treatment of invasive fungal infection (IFI) in the patients with blood diseases (BD).

METHODS

A total of 156 BD patients with IFI treated with itraconazole in General Hospital, Tianjin Medical University from 2005 to 2008, were retrospectively analyzed.

RESULTS

Of these patients, 92 were with underlying malignant BD, and 64 with non-malignant BD; 77 possible IFI, and others proven IFI. A total of 94 (63.5%) patients were responded to itraconazole successfully, while 54 (36.5%) failed. The underlying malignant BD, post-chemotherapy, neutrophil count less than 0.5×10(9)/L, positive fungus culture, and bacteria infection were related with the response to itraconazole significantly, while patient's age, application of other antibiotics, positive G test, IFI localization, haemoglobin level and platelet counts were not. Five patients was changed other anti-IFI therapy because of side effects, including gastrointestinal ill (3 cases with nausea or vomiting) and tachycardia (2 cases).

CONCLUSIONS

Itraconazole was effective and safe in the treatment of IFI in the patients with BD. Underlying malignant BD, agranulocytosis, bacteria infection, and delayed anti-IFI therapy might reduce itraconazole therapeutic effects.

[Diagnostic value of plasma (1, 3)-beta-D glucan assay for invasive fungal infections in patients with hematological disorders]

The invasive fungal infections (IFI) in immunocompromised patients are associated with a high mortality rate and diagnostic difficulty. Serological methods such as aspergillus galactomannan assay (GM test) and (1, 3)-beta-D glucan (BG) assay (G test) can be used as an adjunctive method for IFI diagnosis based on their characteristics of easy-operating, rapidness and high sensitivity. Compared with GM test, G test can be more widely used except for the diagnosis of aspergillosis. The purpose of this study was to investigate the value of G test in the diagnosis of IFI in patients with hematological disorders. The plasma was collected from 162 suspected IFI patients with hematological disorders in Beijing Daopei Hospital, including 85 patients after chemotherapy and 77 patients after stem cell transplantation from May 2007 to May 2008, BG level was measured with MB-80 Microbiology Kinetic Rapid Reader and the measured results together with the clinical characteristics were retrospectively analyzed. According to the European Organization for Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG) criteria, there were 2 patients diagnosed as proven IFI, 18 as probable IFI, 75 as possible IFI and 67 as no IFI. The results showed that at a cutoff of 20 pg/ml, the sensitivity and specificity of G test were 75% and 91% respectively, with a positive predictive value (PPV) of 71.4% and a negative predictive value (NPV) of 92.4%. 51 out of the 75 possible IFI patients with elevated BG level were responsive to antifungal treatment but non responsive to broad-spectrum antibiotics, retrospectively were diagnosed as IFI, suggesting that G test improved the IFI diagnostic rate by 31.4%. In conclusion, G test is a rapid and simple method for early diagnosis of IFI in patients with hematological disorders.

[A preliminary investigation on early diagnosis of invasive aspergillosis in patients with blood diseases by using circulating galactomannan test]

The objective of this study was to explore the useful value of circulating galactomannan (GM) for early diagnosis of invasive aspergillosis. All 141 patients were classified as 103 patients of clinical and possible diagnosis, and 38 non-Aspergillus patients. 209 serum samples for the detection of GM by Platelia Aspergillus were collected before anti-fungal vaccine therapy. ELISA method was used in detection of GM. The results showed that (1) the sensitivity of 87.5%, specificity of 81.6%, positive prediction of 66.7% and negative prediction of 93.9% were determined by using cut-off value. According to the result of ELISA, the clinical diagnosed patients was up to 48, while the possible diagnosed patients were 55. (2) Among 62 patients with consecutive examinations of serum samples, 50 patients were successfully diagnosed and treated, while 12 patients died. A progressive reduction of GM level was found in survivors, however, the patients of poor prognosis showed higher antigen titres. It is concluded that GM test has more significance for earlier diagnosis of aspergillosis, the concentration of GM is related to prognosis of disease.

[Sequential intravenous and oral itraconazole in treatment of invasive fungal infection in hematological diseases]

OBJECTIVE

We performed this study to investigate the efficacy and safety of sequential intravenous and oral itraconazole in the treatment of invasive fungal infection (IFI) in the patients with hematological diseases.

METHODS

All the patients fit for the diagnostic criteria of IFI (proven diagnosis, probable diagnosis and possible diagnosis) with hematological diseases were entered into this study. The trial was designed as an open labeled, multi-centered study, with the total treatment duration of 4 - 6 weeks including intravenous and oral period. Intravenous itraconazole was given at the dose of 200 mg, twice a day in the first two days, and adjusted to 200 mg/d for subsequent 12 days. Sequential oral itraconazole was given at the dose of 200 mg, twice a day, for 2 - 4 weeks for maintenance therapy. Efficacy and safety evaluation was performed every 1 - 2 weeks according to the physician's decision.

RESULTS

Two hundred and twenty seven patients were enrolled into this study. The overall response rate was 75.33% and the cure rate was 47.14%. Two hundred and five patients (205/227, 90.3%) defervesced after a median of 5 days (2 - 20 days). One hundred and eighty six patients were applicable for microbiological evaluation, among them, 69.89% responded to the treatment. Eleven treatment-related adverse events occurred during the study and none of them were severe adverse events.

CONCLUSION

Sequential intravenous and oral itraconazole therapy was effective for IFI and tolerated well in patients with hematological diseases.

[Changes of pathogens and susceptibility to antibiotics in hematology ward from years 2001 to 2005]

The purpose of this study was to determine the changes of pathogens in hematological ward and susceptibility of patients received chemotherapy to antibiotics. The pathogens were taken from blood, urine and sputum of patients who accepted chemotherapy from years 2001 to 2005, then were isolated and identified. The susceptibility test was performed by disk diffusion method. The results showed that the total of 418 strains were detected. Gram-negative bacteria were the most common of nosocomial infection. Pseudomonas aeruginosa, Enterobacter cloacae, E. coli account for the most of Gram negative- bacteria infection and most resistant to broad-spectrum penicillin, Acinetobacter baumannii showed a trend of increase. The ratios of gram positive bacteria and fungi were increased slowly, mainly as Enterococcus and Candida. Enterococcus is the most common cause of Gram-positive bacterial infection. Vancomycin resistance did not occur. It is concluded that Gram-negative bacteria are main cause of nosocomial infection in patients with hematological malignancies. Gram positive bacteria and fungi had been more frequent. Strains resistant to antimicrobial agents increase.

[A retrospective study of efficacy and safety of itraconazole for treatment of invasive fungal infection in hematologic diseases]

OBJECTIVE

To investigate the efficacy and safety of intravenous itraconazole for the treatment of invasive fungal infection (IFI) in patients with hematological disease or undergoing allogeneic hematopoietic stem cell transplantation (HSCT).

METHODS

Six hundred and sixty-six patients with above mentioned conditions and diagnosed as IFI from January, 2007 to July, 2007 were enrolled. Intravenous itraconazole was administered at a dose of 200 mg every 12 hours for 2 days and followed by 200 mg every 24 hours. Patients were then switched to oral itraconazole according to the clinical situation. Responses were determined on the basis of clinical and microbiological criteria.

RESULTS

The probability of defervescence was 69.8% and the total response rates among related to itraconazole were the proven, probable and possible IFI patients were 73.7%, 68.1% and 68.2% (P = 0.380). Adverse effects were found in 58 patients (8.7%), which were mainly mild to medium reversible dysfunction of liver and gastrointestinal tract.

CONCLUSION

Itraconazole is an effective and safe antifungal agent for patients with hematological disease or undergoing HSCT and is suitable for empirical antifungal therapy.

Liposomal amphotericin B prophylaxis of invasive mold infections in children post allogeneic stem cell transplantation

BACKGROUND

Invasive mold infections (IMI) are a leading cause of infectious mortality in allogeneic stem cell transplant (AlloSCT) recipients. Fluconazole, the current standard for fungal prophylaxis, is ineffective against molds. We initiated a pilot study to determine the safety and activity of prophylactic liposomal amphotericin B (AMB) in preventing IMI in pediatric and adolescent AlloSCT recipients during the first 100 days.

PROCEDURE

Fifty-one patients (57 AlloSCT) were given AMB (3 mg/kg/day) intravenously, day 0-100. Median age 6 years, 32 males, 19 females. Donors: 33 unrelated and 2 related cord blood, 13 related and 1 unrelated peripheral blood stem cell and 8 related bone marrow (BM); 30 received myeloablative and 27 reduced intensity conditioning. Graft-versus-host disease (GVHD) prophylaxis comprised tacrolimus and mycophenolate mofetil.

RESULTS

Median follow-up is 557 days. AMB was generally well tolerated. The probability of developing >/=grade II acute GVHD and extensive chronic GVHD was 45% and 7%, respectively. Estimated 1-year OS is 62.4% for all patients with 78.8% and 26.7% for average-risk and poor-risk, respectively. The incidence of IMI was 0%.

CONCLUSIONS

These results suggest prophylactic AMB is tolerable and may prevent IMI, especially Aspergillus, during the first 100 days post AlloSCT in pediatric and adolescent patients. A randomized study is needed to determine the efficacy of this approach.

Follow-up of the health conditions of an urban colony of free-roaming cats (Felis catus Linnaeus, 1758) in the city of Rio de Janeiro, Brazil

Similar to other urban areas where food and shelter are abundant, the zoological garden of Rio de Janeiro has dealt for years with a colony of feral or semi-feral domestic cats. A survey was conducted during 2002–2004 as a follow-up to a previous study in 2001 of the cat colony to identify pathogens circulating among the population and to annually follow the status of the cats to analyze morbidity coefficients and associations among infections and infestations identified in the colony. During the 3 years of the present study, 75 cats were sampled at least once, including 44 that were caught and examined only once, 14 that were examined twice, and 17 that were examined three times. For each cat that was caught, records were kept regarding sex, age, general health, and the presence of ectoparasites. Each year, a blood sample was taken for hematologic testing, platelet count, hemoparasite detection, antibodies to Toxoplasma gondii, and retrovirus detection. Blood counts were within normal range for the majority of cats tested. Feline immunodeficiency virus, fleas, and lice were detected in all years; however, incidence rates for each of these varied significantly throughout the years. Prevalence of Cytauxzoon spp., Mycoplasma spp., T. gondii infections were variable among the 3 years, although differences were not significant. Prevalence of feline leukemia virus increased significantly over the 3 years. Mycoplasma spp. and flea infestations were significantly associated, but no other associations among the pathogens were detected. Over the 3 years, the rate of new cat introductions decreased, and the pathogens showed a tendency to disseminate throughout the colony; however, there was virtually no evidence of clinically detectable disease. Therefore, it seems that stabilizing the population by a judicious control program facilitated the distribution of the pathogens throughout the colony, while the general well-being of the cats was not seriously affected.

Helicobacter pylori and extragastric diseases

Since the discovery of Helicobacter pylori, several studies have investigated the hypothetical role of this bacterium in various extragastric diseases, e.g. ischemic heart disease, idiopathic thrombocytopenic purpura, iron-deficiency anaemia, and other disorders. The majority of these studies are epidemiological or eradication trials, but there are also case reports and in-vitro studies. Idiopathic thromobocytopenic purpura is the disease that shows the strongest link with H. pylori infection. There is also evidence of a role of CagA-positive H. pylori infection in iron-deficiency anaemia and ischemic heart disease. The association between H. pylori infection and other extragastric diseases remains controversial, being mostly supported by 'case reports', small pilot studies, or just in-vitro data. Further studies are needed to identify whether there is any pathological implication for H. pylori infection in these diseases.

Overview: Helicobacter pylori and extragastric disease

Isolation of the gastric spiral bacterium Helicobacter pylori totally reversed the false dogma that the stomach was sterile. In addition to its causal role in peptic ulceration, the newly identified bacterium has now been implicated in other gastric and even extragastric diseases, including chronic atrophic gastritis, gastric MALT lymphoma, gastric cancer, functional dyspepsia, idiopathic thrombocytopenic purpura (ITP), iron deficiency anemia, chronic urticaria, ischemic heart disease, and others. The majority of the reports are anecdotal, epidemiologic, or eradication studies, but there are also relevant in vitro studies. ITP represents one disease showing a strong link with H pylori infection. There are also accumulating data on the role of H pylori infection in iron deficiency anemia and ischemic heart disease. In summary, the association between H pylori infection and other extragut diseases is still controversial but worthy of further investigation.

Haemoparasites of common shrews (Sorex araneus) in Northwest England

The presence of haemoparasites belonging to the taxa Anaplasma, Bartonella and Trypanosoma was determined among 76 common shrews (Sorex araneus) from Northwest England. Anaplasma phagocytophilum DNA was recovered from the blood of 1 shrew (1.3%), with the amplified 16S rRNA sequence identical to one previously reported from a bank vole (Clethrionomys glareolus). Trypanosoma spp. DNA was detected in 9 shrews (11.8%), the amplified 18S rDNA fragments being indistinguishable from one another, and distinct from previously published data. This represents the first report of trypanosome infection in S. araneus and suggests they are susceptible to an uncharacterized Trypanosoma species. Blood from 11 shrews (14.5%) yielded Bartonella spp., with characterization of isolates using comparative sequence analysis of partial gltA and 16S-23S rRNA intergenic spacer regions revealing 2 different genotypes. Phylogenetic inference from alignment of partial gltA sequences found that both UK S. araneus types formed a well-supported cluster with Bartonella sp. isolated from S. araneus in Sweden. No significant effect of host age, sex, or year of collection was found on prevalence of Bartonella or trypanosome infections. The results of this survey demonstrate that common shrews in the UK are susceptible to haemoparasitic infections, at prevalences similar to those reported from sympatric rodents.

[Genotyping of gram-negative bacteria isolated from blood in sepsis in patients with hematological diseases]

AIM

Genotyping of hospital strains of gram-negative bacteria isolated from blood of patients with hematological diseases in the presence of sepsis.

MATERIAL AND METHODS

Bacterial DNA were studied with pulse-electrophoresis with commercial kits Genepath Reagent Kits (BioRad, USA). Comparison and interpretation of the results were made with application of the computer analysis program Bionumerics, Applied Maths.

RESULTS

DNA of bacteria of 152 hospital strains was studied. In genotyping of 26 strains of P. aeruginosa 21 clones was isolated, 15 strains of Enterobacter spp.--12 clones, 31 strains of K. pneumoniae--27 clones, 80 strains of E.coli--79 clones. The greatest number of clones of identical bacteria (19%) was detected in the strains of P. aeruginosa, 17%--Enterobacter spp., 11%--K. pneumoniae, minimal (1%) in the strains of E. coli (p < 0.001). Incidence of isolation of clonal-relative strains among P. aeruginosa isolates was 35% (n = 9), Enterobacter spp.--33% (n = 5), K. pneumoniae--23% (n = 7), E. coli--2% (n = 2).

CONCLUSION

Polyclonality of the microorganisms was detected. Frequency of isolation of clones containing identical bacteria in the test bacteria was variable. In clinic there are endogenic and exogenic mechanisms of infection with prevalence of endogenic.

[The value of serum galactomannan antigen for detection of invasive aspergillosis in hematological patients]

OBJECTIVE

The incidence of invasive aspergillosis (IA) is increasing in patients with hematological disorders and it may lead to a high mortality rate. This study was to evaluate serum aspergillus galactomannan (GM) antigen assay as a potential early diagnosis and follow-up of IA.

METHODS

From October 2004 to October 2005, 302 blood samples were obtained from 81 neutropenic hematological patients with fever over 38.5 degrees C and shown to have no response to broad-spectrum antibiotics treatment. Blood samples were collected twice a week. The detection of aspergillus GM antigen was carried out with a sandwich enzyme-linked immunosorbent assay and a GM positivity was defined as A index > 1.5 in two consecutive mensuration. Furthermore, the patients with positive GM test received preemptive antifungal therapy with amphotericin B or itraconazole.

RESULTS

Twenty seven patients (33.0%) were considered GM test positive from a total of 81 cases and 11 patients were diagnosed as proven or probable IA. The GM test correctly identified 7 of the 11 patients who had aspergillus antigen (63.6% sensitivity). When 14 patients without signs or symptoms of invasive fungal infection (IFI) were tested, the test correctly identified 12 of the 14 (85.7% specificity) as not having the antigen. GM positivity allowed also the anticipation of IA diagnosis (from 3 to 30 days before mycological culture). 19 of 27 GM test positive patients were given preemptive anti aspergillus therapy and there was a good response in 12 patients but no response in 7 cases with 36.8% mortality. After treatment, GM antigen decreased to normal with a good response. Otherwise, an elevated value hinted a unsatisfactory result as judged with Wilcoxon signed rank test (P < 0.0005).

CONCLUSIONS

It is suggested that serum GM antigen detection may be a useful test for early diagnosis of IA and GM test-based preemptive antifungal therapy in hematological patients at high risk can decrease mortality of IA substantively. Moreover, the dynamic change of GM test value can be useful for assessing therapeutic response.

Sibling cases of Mycobacterium avium complex disease associated with hematological disease

A 22-year-old man who was admitted to our respiratory division complaining of fever and cough of 1 month's duration had been diagnosed with myelodysplastic syndrome 5 years earlier. On admission, radiological findings showed bilateral diffuse small nodular shadows. Although the results of an acid-fast bacilli examination of blood, sputum, and urine samples were all negative, we initiated antituberculous therapy for suspected miliary tuberculosis because the histological diagnosis from a bone marrow biopsy was epitheloid granuloma. The abnormalities on his chest radiographs improved, but his left cervical lymph nodes became swollen. The histological result of a lymph node biopsy revealed epitheloid granuloma with caseating necrosis. The DNA-DNA hybridization result of a resected lymph node culture indicated Mycobacterium avium. The final diagnosis was disseminated Mycobacterium avium complex (MAC) disease. Both leukocytopenia and thrombocytopenia had been noted in the patient's 19-year-old younger brother, who had been living in the same home 5 years earlier, and for whom a diagnosis of myelodysplastic syndrome was made from bone marrow aspiration on admission. An infiltration shadow with nodular shadows was noted in the right upper lung field on a chest radiograph. A bronchoscopic examination revealed pulmonary MAC disease. As for the route of infection, although we investigated restriction fragment length polymorphism (RFLP), a different pattern was found in the two brothers. We suspect that they were infected by different species of Mycobacterium avium in the same environment rather than by droplet infection from the younger brother to the older brother.

Serological response to syphilis treatment in HIV-positive and HIV-negative patients attending sexually transmitted diseases clinics

BACKGROUND

HIV-positive patients treated for syphilis may be at increased risk for serological failure.

OBJECTIVE

To compare follow-up serologies and serological responses to treatment between HIV-positive and HIV-negative patients attending two sexually transmitted disease (STD) clinics.

STUDY DESIGN

Existing records were reviewed from HIV-positive patients who were diagnosed and treated for syphilis at the public STD clinics in Baltimore, Maryland, USA, between 1992 and 2000. Results of their serological follow-up were compared with those of HIV-negative clinic patients at the time of syphilis treatment. Failure was defined as lack of a fourfold drop in rapid plasma reagin (RPR) titre by 400 days after treatment or a fourfold increased titre between 30 and 400 days.

RESULTS

Of the 450 HIV-positive patients with syphilis, 288 (64%) did not have documented follow-up serologies and 129 (28.5%) met the inclusion criteria; 168 (17%) of 1000 known HIV-negative patients were similarly eligible. There were 22 failures in the HIV-positive group and 5 in the HIV-negative group (p<0.001). The median times to successful serological responses in both groups were 278 (95% confidence interval (CI) 209 to 350) and 126 (95% CI 108 to 157) days, respectively (p<0.001). A multivariate Cox's proportional hazards model showed an increased risk of serological failure among the HIV-positive patients (hazards ratio 6.0, 95% CI 1.5 to 23.9; p = 0.01).

CONCLUSION

HIV-positive patients treated for syphilis may be at higher risk of serological failure. Despite recommendations for more frequent serological follow-up, most patients did not have documentation of serological response after standard treatment for syphilis.

[Occurrence of the yeast and filamentous fungi in haematological patients during 2002 to August 2005]

BACKGROUND

The number of diseases caused by yeast and fungi has been increasing recently. The primary disease is caused by dermatophytes and Cryptococcus neoformans. Other types of yeast and fungi can cause secondary infections of patients with predisposition factors. Among the mycotic diseases diagnosed in our laboratory can be included candidosis, cryptococcosis, aspergillosis and mucormycosis.

METHODS AND RESULTS

In haematological patients Candida albicans, Candida glabrata, Candida krusei, Candida tropicalis and Saccharomyces cerevisiae are the most frequently diagnosed.

CONCLUSIONS

Together with the increased number of examined samples, the rising number of strains resistant to azole antimycotics can be observed.

Faecal prevalence of extended-spectrum Beta-lactamase (ESBL)-producing coliforms in a geriatric population and among haematology patients

Antimicrobial resistance to the extended-spectrum cephalosporins is increasingly reported worldwide. In the local setting, nosocomial infections with multi-resistant Gram-negative bacilli are not uncommon and are a growing concern. However, there is limited data on the carriage rates of such organisms in the local setting. In May 2001, a prospective study was carried out to determine the enteric carriage rates of ceftazidime-resistant Gram negative bacilli (CAZ-R GNB) among residents of nursing homes and from in-patients of the geriatric and adult haematology wards of University Malaya Medical Centre. Ceftazidime-resistant Gram-negative bacilli (CAZ-R GNB) were detected in 25 samples (30%), out of which 6 were from nursing home residents, 5 from geriatric in-patients and 14 from the haematology unit. A total of 28 CAZ-R GNB were isolated and Escherichia coli (10) and Klebsiella pneumoniae (7) were the predominant organisms. Resistance to ceftazidime in E. coli and Klebsiella was mediated by extended-spectrum beta-lactamases (ESBLs). Although the majority of the CAZ-R GNB were from patients in the haematology ward, the six nursing home residents with CAZ-R GNB were enteric carriers of ESBL-producing coliforms. Prior exposure to antibiotics was associated with carriage of ESBL organisms and to a lesser extent, the presence of urinary catheters.

Fecal fungal flora of pediatric healthy volunteers and immunosuppressed patients

Most hematogenous candidiasis originates from endogeneous host flora. Fungal flora of gastrointestinal system are important source of infection especially in immunosupressed patients. The purpose of this study was to investigate the fecal fungal flora of pediatric patients with hematologic malignancy or disorders and to compare the results with healthy volunteers. For this purpose, fungal etiological agents were investigated retrospectively in stool samples of 80 patients followed in Bone marrow transplantation and Hematology-Oncology units. The diagnosis of patients were as follows: 26 acute myelogeneous leukemia, 19 acute lymphocytic leukemia, 5 lymphoma, 3 chronic myelogeneous leukemia, 2 solid tumor, 4 neuroblastoma and 21 hematologic disorders. In patients, totally 102 fungal growth was detected and 42 (41.2%) C. albicans and 51 (50%) non-albicans Candida species and 9 (8.8%) yeast other than Candida and mould was isolated. The results were compared prospectively with growth in stool samples of 61 healthy children. C. albicans was detected in 16 (43.2%) and non-albicans Candida species in 15 (40.5%) and yeasts other than Candida and mould in 6 (16.2%) of 37 fungal growth in controls. Non-albicans Candida species growth was found significantly higher and C. glabrata was more prevelant in patients than in controls (p < 0.001).

Helicobacter pylori and extragastric diseases--other Helicobacters

The involvement of Helicobacter pylori in the pathogenesis of extragastric diseases continues to be an interesting topic in the field of Helicobacter-related pathology. Although conflicting findings have been reported for most of the disorders, a role of H. pylori seems to be important especially for the development of cardiovascular and hematologic disorders. Previously isolated human and animal Helicobacter sp. flexispira and "Helicobacter heilmannii" strains have been validated using polyphasic taxonomy. A novel enterohepatic Helicobacter has been isolated from mastomys and mice, adding to the list of helicobacters that colonize the liver. Genetic targets that may aid the classification of novel Helicobacter species have emerged. Animal models of Helicobacter-induced gastric and hepatobiliary diseases have offered insights to the mechanisms associated with premalignant transformation.

Application of nucleic acid sequence-based amplification for diagnosis of and monitoring the clinical course of invasive aspergillosis in patients with hematologic diseases

BACKGROUND AND METHODS

We evaluated nucleic acid sequence-based amplification (NASBA) and a galactomannan enzyme immunosorbent assay (GM-EIA) for the diagnosis of invasive aspergillosis (IA) in neutropenic febrile patients and for monitoring of its clinical course and outcome. Blood samples were collected twice per week from 128 patients with hematologic diseases during periods of neutropenic fever after undergoing chemotherapy or hematopoietic stem cell transplantation. A total of 448 blood samples were tested.

RESULTS

There were 14 patients with IA (2 patients with proven IA and 12 with probable IA). The median index of the initial NASBA in the IA group was more than 10-fold higher than that in the non-IA group. Galactomannan antigenemia (index, >0.5) was detected with a sensitivity of 86%. In receiver-operator characteristic analysis, the cutoff index of NASBA for the presumptive diagnosis of IA was determined to be 5.0. Combination of these 2 parameters (either a GM-EIA index of >or=0.5 or a NASBA index of >or=5.0) improved the sensitivity of diagnosis to 100%. There was a close relationship between patient outcome and the kinetics of NASBA values: failure of negative conversion during treatment resulted in death in almost all cases.

CONCLUSION

If either GM-EIA or NASBA results suggest IA, the diagnostic yield for IA could be improved, and NASBA could be a useful marker for predicting the clinical course and outcome of treatment.

[Analysis of the distribution characteristics and drug sensitivity of infection pathogens in hematology department ward]

The objective of this study was to investigate clinical distribution characteristics and drug sensitivity of infection pathogens in hematology department wards of our hospital during recent two years. The isolation and cultivation of pathogens from samples were performed by routine methods. Drug sensitivity tests of bacteria were performed by Kirby-Bauer method. Drug sensitivity tests of fungi were performed by ATBFUNGUS Drug sensitivity strips. The results showed that 102 strains of pathogens were isolated from all detected samples. The composition ratio of Gram-positive bacteria, Gram-negative bacteria and fungi was 42.2%, 34.3%, 3.5%, respectively. 58.8% of pathogens were isolated from samples of malignant hematopathy patients. 27.5% were isolated from samples of the patients with fever of unknown origin (FUO). 51.0% of pathogens were isolated from samples of the patients who suffered from agranulocytosis or leucocytopenia. Isolated fungi were mostly sensitive to anti-fungal drugs. G+ bacteria were most sensitive to vancomycin. G- bacteria were most sensitive to imipenem. Most bacteria were resistant to multiple antibiotics. It is concluded that the infection in hematology department wards was related with many conditions, such as weakened resistance of patients, leucocytopenia or agranulocytosis, tumor loading, etc. The prompt microbiological examination and drug sensitivity tests are important to rationally select antibiotics, reduce infection incidence and mortality rate, and decrease the occurrence of drug resistant strains.

Helicobacter pylori and extragastric diseases--other Helicobacters

Reports on Helicobacter pylori and extragastric diseases have almost doubled this year compared with last year, bearing witness to the persistent scientific interest in this branch of Helicobacter-related pathology. Data belong increasingly to the area of vascular medicine, as well as hematology, dermatology, pediatrics and other fields. Unfortunately, these studies show overall controversial results, due to the impact of several confounding factors, and to the difficulty of recruiting homogeneous patient populations. Furthermore, many studies continue to be conducted on Helicobacter species other than H. pylori, focusing on animal models of gastroenterological illnesses which may retain strong similarities with human diseases. In this paper, taxonomy, detection and characterisation of Helicobacter spp. will be reviewed, together with the most important data issued this year on other Helicobacters and animal models.

[Invasive aspergillosis in autopsy material of patients treated at the Institute of Tuberculosis and Chest Diseases during the years 1993-2000]

The aim of this paper is an analysis of clinical documentation and results of autopsy of 21 patients (pts) who died of invasive aspergillosis (IA) in the Institute of Tuberculosis and Chest Diseases in years 1993-2000 and the assessment of predisposing factors for IA. In 17 pts IA was the main and in other 4 only an accessory cause of death. All pts were treated with corticosteroids and/or cytostatic drugs--because of lung cancer (11 pts), cancer in other site (2 pts), haematologic disorders (2 pts), Wegener's granulomatosis (1 pt), polymyositis (1 pt), idiopathic pulmonary fibrosis (1 pt) and other diseases (3 pts). In 15 out of 21 pts granulocytopenia was revealed (from 0.008 x 10(9)/L to 0.82 x 10(9)/L) on an average one month before death. In 15 pts IA was limited to the lungs, in 6 others there were also fungal lesions in brain, kidneys, liver, spleen and heart. Pts with disseminated form of IA had significantly lower granulocyte count and were treated with higher doses of corticosteroids than others. Immunosuppressive drugs and granulocytopenia can be regarded as predisposing factors. Fatal course of IA depended also on the late diagnosis.

Streptococcus viridans septicaemia: a comparison study in patients admitted to the departments of infectious diseases and haematology in a university hospital

Infective endocarditis caused by viridans streptococci is a well-described disease. Streptococcus viridans is also an important etiologic agent causing septicaemia in neutropenic patients with haematological diseases. In this study we retrospectively reviewed charts from 111 patients with 121 episodes of viridans streptococci septicaemia during the period 1992-97 for clinical data, presence of endocarditis, subtype and outcome. Forty-seven episodes of S. viridans septicaemia were documented in 45 non-neutropenic patients treated at the Department of Infectious Diseases (Group A). Thirty of these episodes were defined as definite and 9 as possible infective endocarditis, using Duke's critera. Seventy-four episodes of S. viridans septicaemia were identified in 66 patients treated at the Department of Haematology (Group B), only 1 of which fulfilled the criteria for possible infective endocarditis. S. sanguis was the most common subtype (18/47; 38%) in Group A and S. mitis was the major subtype (51/74; 69%) in Group B.

Surveillance study of bacteraemic episodes in febrile neutropenic children

We prospectively studied the type, frequency and outcome of infections in 513 patients with 762 consecutive episodes of febrile neutropenia (FN) over a five-year period between 1995 and 1999 in a single paediatric oncology unit. The findings were then compared with a similar study carried out in our unit between 1990 and 1994. The types of bacterial isolates and sensitivity patterns were also studied to identify trends and to gauge the suitability of antibiotics chosen for empirical therapy. Bacteraemia was documented in 35.4% of FN episodes, although 70% of patients did not have an obvious site of sepsis. The majority of isolates (61.9%) were gram-negative bacteria, a consistent finding throughout the study period. Resistance to ceftazidime, amikacin and imipenem among gram-negative bacteria was 26.3%, 21.2% and 0.7%, respectively. Methicillin resistance among gram-positive bacteria was 26.3%, while no vancomycin-resistant bacteria were encountered. There were 36 sepsis-related deaths. Factors associated with a fatal outome were prolonged capillary refill time, hypotension, fever above 39 degrees C and pneumonia. Rapid neutrophil recovery was associated with a good prognosis. A change to our current choice of empirical antibiotics for FN, comprising ceftazidime/ceftriaxone and amikacin appears necessary because of the relatively high resistance rates found.

The occurrence of vancomycin-resistant enterococci in hematological patients in relation to antibiotic use

Very important bacterial pathogens found in hematological patients at present are vancomycin-resistant enterococci (VRE). The main goal of this retrospective study was to assess their occurrence in relation to antibiotic use. We isolated 1918 Enterococcus strains, in toto, 138 (7.2%) of which proved to be VRE. The VRE most frequently identified were Enterococcus faecium VanA (77%) and Enterococcusfaecalis VanB (12%), mostly isolated from stools (57%). Comparing the development of the selection pressure of antibiotics and percentage of VRE in each period of observation, an effect of the administration of each antibiotic group on the occurrence of VRE can be presumed. A reduction in the administration of third generation cephalosporins, glycopeptides and fluoroquinolones and its replacement by penicillin antibiotics combined with inhibitors of bacterial beta-lactamases, contributed to the cessation of VRE incidence and succeeding reduced occurrence from 15.1% in the second half of 1998 to 6.1% in the first half of 2000.

Multidrug resistance in bacterial isolates from blood cultures of haematology patients

The bacteria most frequently isolated from blood cultures of haematology patients in Warsaw were staphylococci (58.0%), Enterobacteriaceae (18.6%), non-fermenting rods (6.9%), enterococci (4.3%) and anaerobes (4.3%). Coagulase-negative staphylococci were the most common species isolated (92.7%) with 83.2% of these strains resistant to methicillin. Among enteric bacteria, 17.3% strains produced extended-spectrum-beta-lactamases. All eight isolates of enterococci showed high level resistance to aminoglycosides.

Revisiting the source of candidemia: skin or gut?

The source of candidemia has been the subject of considerable debate, with some suggesting a origin in the gastrointestinal tract and others suggesting a skin origin. To evaluate the potential sources of candidemia, we performed a computerized search of the MEDLINE database for studies published from January 1966 through September 2000 and we identified relevant abstracts presented at national meetings. We reviewed the literature with special emphasis on studies that used appropriate definitions, evaluated both gut and skin as sources, and conducted molecular-relatedness studies. Among 203 candidemia studies published, we identified 21 that evaluated a specific source for candidemia and only 5 that performed molecular typing. Those studies and additional experimental, epidemiologic, and molecular-relatedness studies strongly suggested that the gut is an important source of candidemia, and studies that supported the skin as a source for this infection were surprisingly incomplete.