Eduardo Velasco

Risk Factors for Death Among Cancer Patients with Fungemia

In order to identify prognostic factors for death among cancer patients with fungemia, an 18-month survey of fungemia in patients with cancer was undertaken in three hospitals in Rio de Janeiro. For the assessment of risk factors for death, the following variables were analyzed: age; gender; underlying cancer; last treatment for the underlying disease; previous surgery; use of antibiotics, antifungal agents, steroids, or total parenteral nutrition; use of a central venous catheter; chemotherapy; radiotherapy; presence and duration of neutropenia; etiologic agent of the fungemia; treatment of the fungemia; clinical manifestations; and performance status (Karnofsky score) on the day of the positive blood culture. In multivariate analysis, the variables associated with an increased risk for death were older age, persistent neutropenia, and low performance status. Identifying risk factors for death may help to define a group-risk patients for whom new therapeutic options should be tried.

Nosocomial infections in an oncology intensive care unit

INTRODUCTION Treatment of cancer has contributed to a growing number of immunocompromised patients with life-threatening nosocomial infections (NI). High mortality with considerable cost is observed when they are admitted to the intensive care unit (ICU). Few studies on infection control and surveillance have been undertaken in this population group. METHODS All patients treated at a six-bed medical-surgical oncology ICU for > 48 hours were prospectively observed for the development of an NI and the influence of device utilization on infection rates. The analysis used the standard definitions of the National Nosocomial Infection Surveillance System Intensive Care Unit surveillance component. RESULTS From September 1993 through November 1995, 370 infections occurred in 623 patients during 4034 patient-days, for an overall rate of 50.0 per 100 patients or 91.7 per 1000 patient-days. Pneumonia (28.9%), urinary tract infections (25.6%), and bloodstream infections (24.1%) were the main types of infection. The most common microorganisms isolated were Enterobacteriaceae (29.7%), fungi (22.2%), and Pseudomonas aeruginosa (13.2%). The median device utilization ratios were 0.63, 0.83, and 0.86 for ventilator, indwelling urinary catheter, and central venous catheter, respectively. The highest median device-specific associated infection rate was 41.7 for ventilator. The median for the average length of stay was 8.8 days, and the average severity of illness score was 4.0. There was a strong positive correlation between the overall NI patient rate and device utilization (r = 0.56, p < 0.01), average severity of illness score (r = 0.54, p < 0.01), and average length of stay (r = 0.67, p < 0.01). No correlations were statistically significant when patient-days were used in the denominator. Among the devices only the number of central venous catheter days was significantly correlated with infections (r = 0.51, p = 0.01). The NI patient-day rates were progressively higher the longer the patients stayed in the ICU. CONCLUSIONS The high rates reported in this study may reflect a combination of several factors related to the underlying illness, neutrophil count, and exposure to invasive procedures. The adjusted infection rates described here provide specific surveillance data for further interhospital comparisons and also to assess the influence of invasive medical interventions, allowing the implementation of preventable measures to control infections.

Risk factors for infectious complications after abdominal surgery for malignant disease

BACKGROUND The emergence of nosocomial infection as a serious complication after intraabdominal operations for cancer prompted us to identify major independent risk factors associated with postoperative infection. METHODS Risk factors were studied in single and multivariate analyses. Variables considered were remote infection, antimicrobial prophylaxis, preoperative stay, chemotherapy, radiotherapy, weight loss, elective versus emergency operation, wound class, duration of operation, drains, sex, age, and physical status. RESULTS During 24 months, 236 patients were entered in the study. The overall postoperative infection rate was 45.7%; the surgical site infection rate was 22.4%. Multivariate analysis identified three independent variables: duration of operation longer than 5 hours (odds ratio 6.41, 95% confidence interval 3.28 to 12.54), presence of remote infection at operation (odds ratio 3.76, 95% confidence interval 1.76 to 8.03), and preoperative stay longer than 22 days (odds ratio 2.03, 95% confidence interval 1.04 to 3.95). The relative risk of infection increased from 3.0 when one risk factor was present to 7.3 when all three risk factors were present. CONCLUSIONS The predictive power of our final multivariate risk index clearly groups these patients according to differing risk for postoperative infection. This classification contributes substantially to the effectiveness of infection control strategies to prevent the occurrence of postoperative infection in the high-risk population of patients with cancer.

H1N1pdm Influenza Infection in Hospitalized Cancer Patients: Clinical Evolution and Viral Analysis

Background The novel influenza A pandemic virus (H1N1pdm) caused considerable morbidity and mortality worldwide in 2009. The aim of the present study was to evaluate the clinical course, duration of viral shedding, H1N1pdm evolution and emergence of antiviral resistance in hospitalized cancer patients with severe H1N1pdm infections during the winter of 2009 in Brazil. Methods We performed a prospective single-center cohort study in a cancer center in Rio de Janeiro, Brazil. Hospitalized patients with cancer and a confirmed diagnosis of influenza A H1N1pdm were evaluated. The main outcome measures in this study were in-hospital mortality, duration of viral shedding, viral persistence and both functional and molecular analyses of H1N1pdm susceptibility to oseltamivir. Results A total of 44 hospitalized patients with suspected influenza-like illness were screened. A total of 24 had diagnosed H1N1pdm infections. The overall hospital mortality in our cohort was 21%. Thirteen (54%) patients required intensive care. The median age of the studied cohort was 14.5 years (3–69 years). Eighteen (75%) patients had received chemotherapy in the previous month, and 14 were neutropenic at the onset of influenza. A total of 10 patients were evaluated for their duration of viral shedding, and 5 (50%) displayed prolonged viral shedding (median 23, range = 11–63 days); however, this was not associated with the emergence of a resistant H1N1pdm virus. Viral evolution was observed in sequentially collected samples. Conclusions Prolonged influenza A H1N1pdm shedding was observed in cancer patients. However, oseltamivir resistance was not detected. Taken together, our data suggest that severely ill cancer patients may constitute a pandemic virus reservoir with major implications for viral propagation.

Fungemia in cancer patients in Brazil: Predominance of non-albicans species

The objective of this study was to characterize the epidemiology of candidemia in cancer patients in the city of Rio de Janeiro, Brazil. An 18-month survey of fungemia in patients with cancer was undertaken in three Hospitals in Rio de Janeiro. Forty-three episodes of candidemia were identified in 43 patients, 43 of which were episodes of candidemia; in ten cases the strains were not available for further identification of species and were excluded from this analysis. The overall distribution of fungi causing fungemia was: Candida albicans (5), Candida tropicalis (16), Candida parapsilosis (6), Candida guilliermondii (4), Candida lusitaniae (1) and Candida stellatoidea (1). Antifungal prophylaxis had been administered before the episode of fungemia in only six patients (18.2%): oral itraconazole in three patients and oral nistatin, low dose intravenous amphotericin B and oral fluconazole in one patient each. There was no difference in the presence of risk factors, clinical characteristics or in the outcome between albicans and non-albicans species, nor between Candida tropicalis and other non-albicans species. There was a clear predominance of non-albicans species, regardless of the underlying disease, antifungal prophylaxis or the presence of neutropenia.

Randomized Trial Comparing Oral Ciprofloxacin Plus Penicillin V with Amikacin Plus Carbenicillin or Ceftazidime for Empirical Treatment of Febrile Neutropenic Cancer Patients

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

Epidemiology of Bloodstream Infections at a Cancer Center

CONTEXT Cancer patients are at unusually high risk for developing bloodstream infections (BSI), which are a major cause of in-hospital morbidity and mortality. OBJECTIVE To describe the epidemiological characteristics and the etiology of BSI in cancer patients. DESIGN Descriptive study. SETTING Terciary Oncology Care Center. PARTICIPANTS During a 24-month period all hospitalized patients with clinically significant BSI were evaluated in relation to several clinical and demographic factors. RESULTS The study enrolled 435 episodes of BSI (349 patients). The majority of the episodes occurred among non-neutropenic patients (58.6%) and in those younger than 40 years (58.2%). There was a higher occurrence of unimicrobial infections (74.9%), nosocomial episodes (68.3%) and of those of undetermined origin (52.8%). Central venous catheters (CVC) were present in 63.2% of the episodes. Overall, the commonest isolates from blood in patients with hematology diseases and solid tumors were staphylococci (32% and 34.7%, respectively). There were 70 episodes of fungemia with a predominance of Candida albicans organisms (50.6%). Fungi were identified in 52.5% of persistent BSI and in 91.4% of patients with CVC. Gram-negative bacilli prompted the CVC removal in 45.5% of the episodes. Oxacillin resistance was detected in 26.3% of Staphylococcus aureus isolates and in 61.8% of coagulase-negative Staphylococcus. Vancomycin-resistant enterococci were not observed. Initial empirical antimicrobial therapy was considered appropriate in 60.5% of the cases. CONCLUSION The identification of the microbiology profile of BSI and the recognition of possible risk factors in high-risk cancer patients may help in planning and conducting more effective infection control and preventive measures, and may also allow further analytical studies for reducing severe infectious complications in such groups of patients.

Risk index for prediction of surgical site infection after oncology operations

INTRODUCTION Several studies have shown that surgical site infections represent most hospital-acquired infections, with the major impact being on average hospital stay and cost of hospitalization. METHODS To develop a risk model for prediction of surgical site infections in cancer patients undergoing operative procedures and identify those with high probability of infection we performed a prospective cohort study in a tertiary cancer care hospital in Rio de Janeiro, Brazil. Risk factors were studied in single and multivariate analyses. RESULTS Over a 24-month period, 1205 patients underwent operations for malignant disease. The overall surgical site infection rate was 17.3%. A multivariate stepwise logistic regression model identified six independent predictive risk factors: contaminated and infected operations, surgical duration greater than 280 minutes, male sex, prior radiotherapy, American Society of Anesthesiology class III to V, and antimicrobial prophylaxis not according to protocol. On the basis of individual risk scores, two groups of patients were identified: a low-risk (score < or = 8; surgical site infection rate 10%) and a high-risk group (score > or = 9; surgical site infection rate 33.6%; relative risk 3.4; 95% confidence interval 2.6 to 4.4). CONCLUSION The oncology risk model allowed for the identification of a high-risk score group of patients and implementation of a more efficient and selective intervention program.

An outbreak of Bacillus species in a cancer hospital.

Bacillus species were recovered from the blood cultures of 39 oncology patients over 14 weeks. A matched case-control study showed a strong association of Bacillus species bacteremia with use of calcium gluconate solution (odds ratio=25.0) and of central venous lines (odds ratio=8.8). Stopping use of the implicated calcium gluconate vials controlled the outbreak.

A simple score to predict early death in adult cancer patients with bloodstream infections.

OBJECTIVE To develop a simple score to predict early death in adult cancer patients with bloodstream infection. METHODS A prediction score was developed by analyzing data collected from 361 episodes of BSI at an oncology cancer care center in Brazil. Early death was defined as all deaths occurring within 7 days of the first positive blood culture. RESULTS Multivariate regression analysis identified poor Karnofsky performance status, uncontrolled cancer, hypotension, pulmonary infiltrates, associated infectious sites, and neutropenia as independently associated with death. Predictive scores were developed assigning points to each significant independent variable. The overall mortality was 20.5% and, the total weighted score ranged from 0 to 11 points, with a very good calibration (Hosmer-Lemeshow statistic, P=0.92) and discrimination (area under receiver operating characteristic curve=0.893). The cutoff value for the predictive score was 3 points, with a negative predictive value of 99% and sensitivity of 98.6%. CONCLUSION The score model was able to identify adult cancer patients with bloodstream infection at lower risk for early death with an elevated degree of certainty as depicted by a very high negative predictive value. It is essential to prospectively validate the rule in a different group of patients.