Roberto Bandettini

A Prospective Study on the Epidemiology of Febrile Episodes during Chemotherapy-Induced Neutropenia in Children with Cancer or after Hemopoietic Stem Cell Transplantation

BACKGROUND The purpose of our study was to evaluate the incidence and clinical characteristics of febrile episodes during neutropenia following chemotherapy in children with cancer. PATIENTS AND METHODS A prospective, 3-year single-center observational study of periods of neutropenia was performed. Epidemiology and clinical diagnoses of febrile episodes occurring during the neutropenic periods were evaluated, taking into consideration different categories of anticancer treatment based on the type of tumor and phase of therapy. RESULTS A total of 703 febrile episodes were observed during 614 (34%) of 1792 neutropenic periods (34%), for a total of 28,001 days at risk, accounting for a rate of 0.76 episodes per 30 days at risk. The highest proportions of neutropenic periods with primary febrile episodes were observed after autologous hemopoietic stem cell transplantation (58%), aggressive treatment for acute leukemia or non-Hodgkin lymphoma (48%), and allogeneic hemopoietic stem cell transplantation (44%); the lowest proportion (9%) was observed during maintenance chemotherapy for acute leukemia (P<.001). The most frequent clinical diagnosis was fever of unknown origin (in 79% of cases), followed by bacteremia (10%); invasive mycosis was diagnosed in only 2% of cases. CONCLUSIONS The overall incidence of febrile neutropenia and severe infectious complications in children with cancer is low, with differences according to the aggressiveness of chemotherapy. This fact must be considered when designing clinical trials on the management of infectious complications in children with cancer.

Thiocyanate Transport in Resting and IL-4-Stimulated Human Bronchial Epithelial Cells: Role of Pendrin and Anion Channels

SCN− (thiocyanate) is an important physiological anion involved in innate defense of mucosal surfaces. SCN− is oxidized by H2O2, a reaction catalyzed by lactoperoxidase, to produce OSCN− (hypothiocyanite), a molecule with antimicrobial activity. Given the importance of the availability of SCN− in the airway surface fluid, we studied transepithelial SCN− transport in the human bronchial epithelium. We found evidence for at least three mechanisms for basolateral to apical SCN− flux. cAMP and Ca2+ regulatory pathways controlled SCN− transport through cystic fibrosis transmembrane conductance regulator and Ca2+-activated Cl− channels, respectively, the latter mechanism being significantly increased by treatment with IL-4. Stimulation with IL-4 also induced the strong up-regulation of an electroneutral SCN−/Cl− exchange. Global gene expression analysis with microarrays and functional studies indicated pendrin (SLC26A4) as the protein responsible for this SCN− transport. Measurements of H2O2 production at the apical surface of bronchial cells indicated that the extent of SCN− transport is important to modulate the conversion of this oxidant molecule by the lactoperoxidase system. Our studies indicate that the human bronchial epithelium expresses various SCN− transport mechanisms under resting and stimulated conditions. Defects in SCN− transport in the airways may be responsible for susceptibility to infections and/or decreased ability to scavenge oxidants.

Zygomycosis in Italy: a Survey of FIMUA-ECMM (Federazione Italiana di Micopatologia Umana ed Animale and European Confederation of Medical Mycology)

Abstract The aims of the study were to analyze the clinical and epidemiological characteristics and treatments for patients who developed zygomycosis enrolled in italy during the european Confederation of medical mycology survey. This prospective multicenter study was performed between 2004 and 2007 at 49 italian Departments. 60 cases of zygomycosis were enrolled: the median age was 59.5 years (range 1-87), with a prevalence of males (70%). The majority of cases were immunocompromised patients (42 cases, 70%), mainly hematological malignancies (37). Among non-immunocompromised (18 cases, 30%), the main category was represented by patients with penetrating trauma (7/18, 39%). The most common sites of infection were sinus (35%) with/without CNS involvement, lung alone (25%), skin (20%), but in 11 cases (18%) dissemination was observed. According to EORTC criteria, the diagnosis of zygomycosis was proven in 46 patients (77%) and in most of them it was made in vivo (40/46 patients, 87%); in the remaining 14 cases (23%) the diagnosis was probable. 51 patients received antifungal therapy and in 30 of them surgical debridement was also performed. The most commonly used antifungal drug was liposomal amphotericin b (L- AmB), administered in 44 patients: 36 of these patients (82%) responded to therapy. Altogether an attributable mortality rate of 32% (19/60) was registered, which was reduced to 18% in patients treated with L-AmB (8/44). Zygomycosis is a rare and aggressive filamentous fungal infection, still associated with a high mortality rate. This study indicates an inversion of this trend, with a better prognosis and significantly lower mortality than that reported in the literature. It is possible that new extensive, aggressive diagnostic and therapeutic procedures, such as the use of L-AmB and surgery, have improved the prognosis of these patients.

High Levels of β-d-Glucan in Immunocompromised Children with Proven Invasive Fungal Disease

ABSTRACT The plasmatic levels of 1,3-β-d-glucan (BDG) were >523 pg/ml in 4 children, 2 low-birth-weight neonates and 2 stem cell transplant recipients, with the following invasive fungal diseases (IFD) proven apart from this BDG test: 3 cases of Candida parapsilosis candidemias and 1 case of disseminated aspergillosis. The BDG test may be useful for identification of IFD in pediatrics.

Clostridium difficile-associated disease in children with solid tumors

Goals of workThe goal of this study was to describe the incidence of Clostridium difficile-associated disease (CDAD) in children with solid tumours.Patients and methodsAfter documentation of a case of C. difficile-associated pseudomembranous colitis in a patient with neuroblastoma, the presence of C. difficile toxins A and B was prospectively tested in all children undergoing antineoplastic chemotherapy for solid tumours or lymphomas at the “G. Gaslini” Children Hospital in Genoa who presented abdominal pain.Main resultsFrom January 2005 to December 2006, nine (6%) out of 141 patients treated for solid tumours had C. difficile toxin A detected in their stools in the presence of abdominal symptoms including vomit, abdominal pain and diarrhoea. The majority of patients had a normal neutrophil count at onset of gastrointestinal disease No patient developed pseudomembranous colitis, and none died. All patients received antibiotics and/or antineoplastic drugs previously associated with CDAD.ConclusionsCDAD may be a complication of children with solid tumours. Since this disease may be life threatening and cause epidemic clusters, this possibility must be kept in mind for the differential diagnosis of abdominal diseases in children with cancer, especially in absence of neutropenia.

Increasing Incidence of Streptococcus pneumoniae Serotype 19A and Emergence of Two Vaccine Escape Recombinant ST695 Strains in Liguria, Italy, 7 Years after Implementation of the 7-Valent Conjugated Vaccine

ABSTRACT Two serotype 19A (ST695) Streptococcus pneumoniae vaccine escape recombinant strains attributable to capsular switching events were detected by a laboratory surveillance system that is an integral part of a vaccination program begun in Liguria, Italy, in May 2003, an Italian administrative region with long-lasting high coverage, an unusual occurrence in Europe. To our knowledge, this is the first detection of an occurrence of capsular switching outside the United States.

Catheter-related bacteremia caused by methicillin-resistant coagulase negative staphylococci with elevated minimal inhibitory concentration for vancomycin.

Treatment of bacteremia caused by methicillin-resistant coagulase-negative staphylococci with vancomycin minimum inhibitory concentration ≥2 mg/L frequently requires central venous catheter removal in children with cancer. There are few data supporting efficacy and safety of antibiotic catheter lock or use of daptomycin or linezolid for this indication in children.

Voriconazole for cryptococcal meningitis in children with leukemia or receiving allogeneic hemopoietic stem cell transplant.

Cryptococcus neoformans is an encapsulated heterobasidiomycetous that represents a major human pathogen in immunocompromised hosts 1, but invasive cryptococcosis is a rare complication during chemotherapy in patients with acute leukemia or following allogeneic hemopoietic stem cell transplant (HsCT) 2-6. The clinical picture of C. neoformans infections varies from asymptomatic colonization of the respiratory tract to disseminated disease, with meningitis being the most frequent clinical picture 1. Amphotericin B is the golden standard therapy for cryptococcosis, and its association with flucytosine leads to more rapid clearance of the fungus from the cerebrospinal fluid (CsF) 7,8. After treating the invasive infection, long term prophylaxis is required in patients persistently immunocompromised, and fluconazole represents the drug of choice 8. Other triazoles, such as itraconazole and voriconazole, have been proven to be active in vitro against C. neoformans 9. We report two cases of invasive C. neoformans meningitis infections in immunocompromised children who were successfully managed with voriconazole. Case 1: The first patient was a 6-year-old girl affected with acute lymphoblastic leukemia who developed pneumonia with severe acute respiratory insufficiency that required mechanical ventilation during administration of high dose dexamethasone for the treatment of her leukemia. Blood cultures showed the presence of yeasts that were subsequently identified as C. neoformans, and the search for the cryptococcal antigen in the serum was positive. she received antifungal therapy with liposomal amphotericin B (3 mg/kg/q24 h) that led to an improvement in her condition. After 3 weeks of this treatment, serum antigen became negative and fluconazole prophylaxis (10 mg/kg/q24 h) was started. One week later, fever reappeared and serum cryptococcal antigen became positive again. she received liposomal amphotericin B at the same dosage for another week and achieved negative antigen, but abdominal ultrasound demonstrated the presence of spleen nodules. Moreover, cryptococcal antigen was also positive in the CsF despite the absence of clinical signs of central nervous system involvement. since the patient desired to be discharged from the hospital, voriconazole was administered (7 mg/kg q12 h for 3 days, then 200 mg q12 h orally, on empty stomach) because of the availability of an oral formulation that allowed good compliance and considering its in vitro activity, ability to cross the blood-brain barrier, the failure of fluconazole prophylaxis and the persistence of antigen in the CsF. Cryptococcal antigen in the CsF resulted negative after 10 days of voriconazole. This drug was administered until 7 months after elective discontinuation of chemotherapy without any reactivation of the infection or any adverse effects. The patient relapsed with her acute lymphoblastic leukemia 2 months after discontinuation of voriconazole. At this time, cryptococcal antigen resulted negative both in the blood and CsF. she received an allogeneic HsCT from her brother after a myeloablative-conditioning regimen including body irradiation. During the first 100 days after HsCT she received fluconazole as prophylaxis (6 mg/kg/q24 h) for invasive mycosis on the basis of our standard procedures, and C. neoformans was never again detected in the blood or in the CsF. Case 2: The second patient was an 18-year-old boy with incomplete immunological reconstitution (CD4+ lymphocytes, 9%, 54/cmm and absence of CD19+/CD20+ lymphocytes) after alternative donor HsCT. He developed sudden fever associated with impaired consciousness, headache, blurred vision and rash 36 months after HsCT. Magnetic Resonance imaging showed the presence of mild intracranial hypertension and C. neoformans was isolated from cerebrospinal fluid. in view of the fact that the patient RepRint

Whole-genome sequencing as standard practice for the analysis of clonality in outbreaks of meticillin-resistant Staphylococcus aureus in a paediatric setting.

Meticillin-resistant Staphylococcus aureus (MRSA) is one of the leading causes of hospital-associated infections. This study investigated the potential use of whole-genome sequencing (WGS) for surveillance purposes by re-examining MRSA strains related to past outbreaks among hospitalized paediatric patients. WGS data ameliorated the genotypic profile previously obtained with Sanger sequencing and pulsed-field gel electrophoresis typing, and discriminated between strains that were related and unrelated to the outbreaks. This allowed strain clonality to be defined with a higher level of resolution than achieved previously. This study demonstrates the potential of WGS to trace hospital outbreaks, which may lead to WGS becoming standard practice in outbreak investigations.

Quantification of piperacillin, tazobactam, meropenem, ceftazidime, and linezolid in human plasma by liquid chromatography/tandem mass spectrometry

Therapeutic drug monitoring is a cornerstone of antibacterial therapy, especially in an era of increasing antibacterial resistance in individualizing antimicrobial therapy. Liquid chromatography/tandem mass spectrometry (LC–MS/MS) assay was used for the simultaneous measurement of piperacillin, tazobactam, meropenem, ceftazidime, and linezolid in 50 μl plasma samples over a wide range. The overall turnaround time for the assay was 20 minutes. Intra-assay precision and accuracy for quality control samples ranged within 1·8–8·5 and 91·4–106·7%, respectively. Inter-assay precision and accuracy ranged within 1·3–14·4 and 95·8–104·6%, respectively. The lower limit of quantification was below 1·5 μg/ml for all the five antibiotics. No ion suppression due to matrix effects was found. A simple and rapid LC–MS/MS method which provides high specificity, precision and accuracy for the simultaneous quantification of piperacillin, tazobactam, meropenem, ceftazidime, and linezolid in human plasma has been developed and validated. The present method is suitable for therapeutic drug monitoring in paediatrics.