E. Grey

Viridans Streptococcal Bacteraemia Due to Penicillin-Resistant and Penicillin-Sensitive Streptococci: Analysis of Risk Factors and Outcome in 60 Patients from a Single Cancer Centre Before and After Penicillin is Used for Prophylaxis

60 patients with 60 viridans streptococcal bacteraemic episodes (42 due to penicillin-sensitive and 18 due to penicillin-resistant viridans streptococci) were analysed in a population of 12,185 admissions and 1,380 bacteraemic episodes during a 7-year period in a National Cancer Institute. The incidence of viridans streptococci among bacteraemias decreased from 11.5% in 1989 to 2.5% in 1995 after penicillin was introduced for prophylaxis of febrile neutropenia in acute leukaemia in 1993. However, the proportion of penicillin-resistant viridans streptococcal bacteraemias increased from 0 in 1989 and 1990 before any prophylaxis was given, to 12.9-16.7% after quinolones were used for prophylaxis in 1991 and 1992, and to 44.4-81.8% in 1993-1995 after penicillin was added to the quinolones. Mortality rate was higher in the subgroup of penicillin-resistant viridans streptococcal bacteraemias (p < 0.05). Statistically significant risk factors in patients with penicillin-resistant (compared with penicillin-sensitive) viridans streptococcal bacteraemia were: acute leukaemia (p < 0.03), high doses of cytarabine (p < 0.05), mucocutaneous lesions (p < 0.004), breakthrough bacteraemia during prophylaxis with ofloxacine plus penicillin (p < 0.001). Multiple logistic regression analysis showed that only acute leukaemia (OR 2.05, CI 0.85-1.85, p < 0.00452) and penicillin-resistance (OR 0.71, CI 0.103-4.887, p < 0.0209) were significant independent predictors of inferior outcome. Breakthrough bacteraemia during empiric therapy with vancomycine occurred in 5 of 116 patients treated with vancomycine, and during therapy with ampicillin plus gentamicin in 6 patients of 18 treated.

Funguria in Cancer Patients: Analysis of Risk Factors, Clinical Presentation and Outcome in 50 Patients

SummaryFifty cancer patients with funguria of >105 CFU/ml, dysuria and leukocyturia were retrospectively analyzed for etiology, risk factors and outcome. In 72% of casesCandida albicans and in 28% non-albicansCandida spp. (Candida krusei, Candida tropicalis) and non-Candida spp. yeasts (Blastoschizomyces capitatus) were isolated.Torulopsis glabrata was not found among these patients. The most frequent risk factors were: antibiotic therapy with more than one antibiotic agent (96%), concomitant fungal infection in other localizations than the urinary tract (36%), colonization with the same species (48%), catheterization with urinary catheter or nephrostomy (46%), prophylaxis with quinolones (50%) and previous therapy with corticosteroids (72%). Structural or anatomic malformations of the urinary tract (26%), neutropenia (28%), antifungal prophylaxis with azoles (22%), and diabetes mellitus (12%) were less frequently seen. Thirty of 36 patients treated with systemic antifungals were cured and six were not.ZusammenfassungBei 50 Krebspatienten, die eine Fungiurie von >105 KBE/ml mit Dysurie und Leukozyturie aufwiesen, wurde eine retrospektive Analyse durchgeführt, in der die Ätiologie, die Risikofaktoren und die Verläufe berücksichtigt wurden. 72% der Fälle wurden durchCandida albicans und 28% durch nicht-albicansCandida spp. (Candida krusei, Candida tropicalis) und andere Hefen (Blastoschizomyces capitatus) verursacht.Torulopsis glabrata fand sich in dieser Patientengruppe nicht. Die häufigsten Risikofaktoren waren Antibiotikatherapie mit mehr als einem Antibiotikum (96%), gleichzeitige Pilzinfektion in einer anderen Lokalisation als dem Harntrakt (36%), Kolonisation mit derselben Spezies (48%), Harnableitung mit Harnblasenkatheter oder Nephrostomie (46%) Prophylaxe mit Chinolonen (50%) und Vortherapie mit Kortikosteroiden (72%). Seltenere Risiken waren strukturelle oder anatomische Anomalien des Harntraktes (26%), Neutropenie (28%), Pilzprophylaxe mit einem Azolderivat (22%), Diabetes mellitus (12%). 30 der 36 mit systemischen Antimykotika behandelten Patienten wurden geheilt, sechs sprachen auf die Therapie nicht an.

Prospective national survey of viridans streptococcal bacteraemia risk factors, antibacterial susceptibility and outcome of 120 episodes

The aim of this study was to prospectively investigate 120 cases of viridans streptococcal bacteraemia (VSB) in 117 patients in major university hospitals in Slovakia in 2000–2002 (3 y) for antibacterial susceptibility, risk factors and outcome. From 127 episodes, 16 (13%) of VSB were caused by PEN-R strains and 13 (10%) by ERY-R strains. 32 cases had cancer as underlying disease (20 haematological), 41 had endocarditis and 35 were elderly (>65 y of age) patients. Concerning mortality, 29 of 127 patients died (24%). There were several risk factors associated with mortality. Solid tumour as underlying disease (p<0.02), stroke (p<0.002), concomitant lung infection (p<0.01), endoscopic procedure (p<0.036), intubation (p<0.0008), ventilatory support (p<0.002), and coma (p<0.009) were associated with more deaths. A comparison of 115 bacteraemias to 13 bacteraemias caused by erythromycin-resistant strains of Streptococcus viridans was performed. There were no significant differences in underlying disease, risk factors and mortality. Erythromycin resistance in bacteraemias caused by S. viridans did not have significant impact on outcome of the patients, nor did it show specific relation to analysed risk factors in our study. 14.5% of VSB were cause by PEN-resistant viridans streptococci. Risk factors for penicillin resistance were ventilatory support (p<0.01), intubation (p<0.001) and resistance to other antibiotics: 8 of 16 (50%) of PEN-R VSB were resistant also to erythromycin or cotrimoxazole or tetracycline compared with 9% of PEN-R VSB (p<0.005). Endoscopic procedures in the upper respiratory system were at risk for development of PEN-R VSB. There was also difference in outcome; 71% vs 22.5% (p<0.0002) of cases infected with PEN-R VSB died compared to PEN-S VSB. PEN-R is therefore clinically significant in VSB.

Bacteremias caused by Escherichia coli in cancer patients — analysis of 65 episodes

OBJECTIVES The aims of this study were to evaluate risk factors, clinical presentation, outcome and antimicrobial susceptibility in patients with Escherichia coli bacteremia occurring over seven years in a single cancer hospital. METHODS Sixty five episodes of bacteremia from E. coli appearing over seven years from 12,301 admissions in a single cancer institution were retrospectively analyzed. RESULTS The proportion of bacteremia caused by E. coli among Gram-negative bacteremia was 20.8% (the second most common organism after Pseudomonas aeruginosa), and infection-associated mortality was 17%. The incidence in 1989-1995 varied from 14.3 to 24.7%. The most common risk factors were: solid tumors as the underlying disease (70.7%); central venous catheter insertion (32.3%); prior surgery (46.2%), and prior chemotherapy within 48 h (44.4%). Neutropenia and urinary catheters did not place patients at high risk in any of the subgroups. When we compared the two subgroups of 61 cases of bacteremia - monomicrobial and polymicrobial (when E. coli was isolated from blood culture with another microorganism) - we found that acute leukemia and breakthrough (recurrence while receiving antibiotics) bacteremia were more frequently associated with polymicrobial E. coli bacteremia. There was also a difference in infection-associated mortality: monomicrobial bacteremia due to E. coli only had a significantly lower mortality in comparison with polymicrobial E. coli bacteremia (8.9 vs 35.0%, respectively; P<0.03). CONCLUSION The susceptibility of 115 E. coli strains isolated from 65 episodes of bacteremia was stable. Only two episodes caused by quinolone-resistant strains occurred, both in 1995, after six years of using ofloxacin for prophylaxis in neutropenic patients in our hospital. We found that 85.2-91.3% of all strains were susceptible to aminoglycosides, 97.8% to quinolones, and 90-100% to third generation cephalosporins and imipenems. The patients most commonly infected had solid tumors and the mortality was only 17%.

Resistance Pattern of 2 816 Isolates Isolated from 17 631 Blood Cultures and Etiology of Bacteremia and Fungemia in a Single Cancer Institution

The resistance pattern of 2816 isolates from 17631 blood cultures and the etiology of isolates causing bacteremia and fungemia among 14591 admissions were investigated in an 80-bed single cancer institute during seven years (1990-1996) under the same empiric therapeutic antibiotic policy but with different prophylactic strategies. No change was found in the proportion of Gram-positive versus Gram-negative bacteria isolated from bacteremias (70% vs. 30%) during the past seven years. Furthermore, the proportion of coagulase-negative staphylococci and enterococci was about the same before and after the introduction of ofloxacin in prophylaxis. However, the proportion of Pseudomonas aeruginosa and Stenotrophomonas maltophilia causing bacteremia increased. There was no increase in Candida krusei and Candida glabrata after the introduction of fluconazole into our prophylactic regimen in 1992. Penicillin-resistance in viridans streptococci increased after penicillin was introduced into prophylaxis in acute leukemia in 1993. Until 1995 no quinolone-resistant Enterobacteriaceae were observed. Susceptibility to quinolones did not significantly change within the past seven years in Enterobacteriaceae after their introduction to prophylaxis in 1991, but Pseudomonas aeruginosa decreased from 90 to 58.2%. Glycopeptide resistance in enterococci and staphylococci was minimal in the observed period (0.9-4.3%).

Bacteremia Due to Pseudomonas aeruginosa: Results from a 3-Year National Study in the Slovak Republic

Abstract Risk factors, mortality and antimicrobial susceptibility of Pseudomonas aeruginosa bacteremias isolated from 148 patients from all University Hospitals in Slovakia were analyzed. Only 1.2% of 169 strains of P. aeruginosa were resistant to meropenem, 4.1% to piperacillin/tazobactam, 7.7% to ceftazidime as well as cefepime and 12% to amikacin. More than 30% of P. aeruginosa were resistant to ciprofloxacin. Our analysis of risk factors for antimicrobial resistance to the particular antimicrobials, indicated no difference in risk factors and outcome in cases infected with P. aeruginosa bacteremias resistant to amikacin, piperacillin/tazobactam or ceftazidime in comparison to episodes caused by P. aeruginosa due to susceptible isolates. When comparing risk factors for P. aeruginosa bacteremia in children vs. adults, cancer vs. non-cancer patients, several differences in risk factors were observed. Neither antimicrobial resistance to amikacin, ceftazidime or piperacillin/tazobactam, nor appropriateness of therapy according to two separate analyses were associated with better outcome.

Penicillin Resistance in Viridans Streptococcal Bacteremia is Related with High Mortality

Sir, Viridans streptococci (VS) are a significant cause of bacteremia in neutropenic patients with cancer, in those with endocarditis or in patients after dental surgery or endoscopy. These infections have traditionally been associated with limited morbidity, but serious complications such as septicaemic shock and adult respiratory distress syndrome (ARDS) have been described sporadically in recent years (1, 2). Clinical significance has been demonstrated in penicillin resistant (PEN-R) S. pneumoniae in several studies (3, 4); however, in viridans streptococci only one study in cancer patients (5) revealed in a multivariate fashion that those infected with PEN-R strains had higher mortality in comparison to individuals infected with PEN / susceptible VS. This was not demonstrated with erythromycin resistance (ERY-R) (6). The aim of this short letter is to assess the clinical significance and outcome of PEN and ERY resistance of VSB within a national bacteremia survey in Slovakia. Within 2 y, 127 cases of viridans streptococcal bacteremia (VSB) were observed in national surveillance of streptococcal bacteremia in Slovakia: assessing risk factors and impact of PEN-R on mortality, we compared PEN-R VSB to PEN-S VSB. 111 cases were due to penicillin susceptible (PEN-S) and 16 due to penicillin resistant (PEN-R) VSB (Table I). 13% of VSB cases were caused by PEN-R strains. Risk factors for penicillin resistance (MIC /2 mg/ml) were ventilatory support (p B/0.01), intubation (p B/0.001) and resistance to other antibiotics; 44% of PEN-R VSB were resistant also to erythromycin or cotrimoxazol or tetracycline in comparison to 7% of PEN-R VSB (p B/0.005). Endoscopic procedures in the upper respiratory system were at risk for development of PEN-R VSB. Also, there was difference in outcome, 69% vs 21% (p B/0.0002) of cases infected with PEN-RVSB dying in comparison to PEN-S VSB. Penicillin resistance is therefore clinically significant in viridans streptococcal bacteremia.

Nosocomial postsurgical meningitis in children: a 12-year survey comparing data from 1993-1998 with data from 1999-2004.

1. Centers for Disease Control and Prevention. Acinetobacter baumannii infections among patients at military medical facilities treating injured US service members, 2002-2004. MMWR Morb Mortal Wkly Rep 2004; 53: 1063-1066. 2. Chu YW, Leung CM, Houang ETS, et al. Skin carriage of Acinetobacters in Hong Kong. / Clin Microbiol 1999; 37:2962-2967. 3. Seifert H, Dijkshoorn L, Gerner-Smidt P, et al. Distribution of Acinetobacter species on human skin: comparison of phenotypic and genotypic identification methods. / Clin Microbiol 1997; 35:2819-2825. 4. Kloos WE, Musselwhite MS. Distribution and persistence of Staphylococcus and Micrococcus species and other aerobic bacteria on human skin. Appl Microbiol 1975; 30:381-395.

Vancomycin plus imipenem ceftazidime or ciprofloxacin in second line therapy in patients with febrile neutropenia not responding to first line therapy.

137 patients with febrile neutropenia after cytotoxic therapy not responding to ceftazidime plus or ceftriaxone plus netilmicin in received additionally to the previous combination either vancomycin alone or combined with another anti-gram-negative compound: imipenem in those treated prophylactically with ofloxacin and ciprofloxacin in those without prophylaxis. The addition of vancomycin to the previously ineffective combination of a third generation cephalosporin plus aminoglycoside, and replacement of ceftriaxone plus netilmicin with ceftazidime plus amikacin plus vancomycin or with ceftazidime plus vancomycin seems to be less effective (71.8-75 vs. 87.5-90.9%, p < 0.02) and more toxic (20.5-7.2 vs. 0-5%, p < 0.0005) than vancomycin in combination with a different anti-gram-negative compound as previously used: imipenem or ciprofloxacin.

Erythromycin resistance in viridans streptococci bacteremia is clinically significant.

We compared 115 cases of bacteremia caused by erythromycin-sensitive VS with 13 cases of bacteremia caused by erythromycin-resistant VS. There were no signifi cant differences in the underlying disease and source/site of infection in both groups. The only risk factor for erythromycin resistance was concomitant PEN resistance (p ! 0.008). Complications were equally distributed. However, there was a signifi cant difference in outcome between the groups: 82% of the cases infected with the erythromycin-sensitive strain were cured in comparison with 54% (p ! 0.03) of the cases infected with erythromycin-resistant VS ( table 1 ). In conclusion, erythromycin resistance in bacteremias caused by VS had a signifi cant impact on the outcome. Viridans streptococci (VS) are a signifi cant cause of bacteremia in neutropenic patients with cancer, in patients with endocarditis, or in patients after dental surgery or endoscopy. Traditionally, these infections have been associated with limited morbidity, but serious complications such as septicemic shock and adult respiratory distress syndrome have been described sporadically in recent years [1, 2] . Clinical signifi cance has been demonstrated in penicillin-resistant (PEN-R) Streptococcus pneumoniae in several studies [3, 4] ; however, in VS, only one study [5] , using multivariate analysis, showed that cancer patients infected with PEN-R strains had higher mortality in comparison with individuals infected with PEN-susceptible VS. This was not demonstrated with erythromycin resistance [6] . The aim of this short letter was to assess the clinical signifi cance and outcome of erythromycin resistance of VS bacteremia within a national bacteremia survey in Slovakia. Published online: January 3, 2007