Saul Rodriguez

Clostridial bacteremia in cancer patients. A 12-year experience

Over 12 years, 136 episodes of bacteremia caused by clostridial species were documented. Eighty‐three were monomicrobial, and 53 were polymicrobial. Gastrointestinal, genitourinary carcinomas, and acute leukemia were the most common underlying malignancies. Septic shock occurred in 29% of monomicrobial bacteremias and 45% of polymicrobial bacteremias and was associated with a high mortality rate. Acute hemolysis, gas gangrene, and diffuse spreading cellulitis occurred infrequently but were associated with a 100% fatality rate. Many infections caused by Clostridium perfringens and C. septicum were associated with abdominal disease. The most commonly isolated organism was C. perfringens, followed by C. septicum and C. sporogenes. Overall survival was 58%, but it was 66% for monomicrobial episodes and 45% for polymicrobial infections. All of the patients with bacteremia due to an aerobic gram‐negative bacillus in addition to the clostridial species died of their infection. The most effective antibiotics were clindamycin, penicillin, metronidazole, and moxalactam. Surgical drainage of abscesses was an important component of therapy.

Incidence, Cost, and Outcomes of Bleeding and Chemotherapy Dose Modification Among Solid Tumor Patients With Chemotherapy-Induced Thrombocytopenia

PURPOSE To describe the incidence and outcomes of bleeding and chemotherapy dose modifications associated with chemotherapy-induced thrombocytopenia (platelets < 50,000/microL). PATIENTS AND METHODS Six hundred nine patients with solid tumors or lymphoma were followed-up during 1,262 chemotherapy cycles complicated by thrombocytopenia for development of bleeding, delay or dose reduction of the subsequent cycle, survival, and resource utilization. The association between survival and bleeding or dose modification was examined using the Cox proportional hazards model. Predisposing factors were identified by logistic regression. RESULTS Bleeding occurred during 9% of cycles among patients with previous bleeding episodes (P <.0001), baseline platelets less than 75,000/microL (P <.0001), bone marrow metastases (P =.001), poor performance status (P =.03), and cisplatin, carboplatin, carmustine or lomustine administration (P =.0002). Major bleeding episodes resulted in shorter survival and higher resource utilization (P <.0001). Chemotherapy delays occurred during 6% of cycles among patients with more than five previous cycles (P =.003), radiotherapy (P =.03), and disseminated disease (P =.04). They experienced similar clinical outcomes but used significantly more resources. Dose reductions occurred during 15% of cycles but were not associated with poor clinical outcomes or excess resource utilization. Significantly shorter survival and higher resource utilization were observed among the 20% of patients who failed to achieve an adequate response to platelet transfusion. CONCLUSION The incidence of bleeding is low among solid tumor patients overall but exceeds 20% in some subgroups. These subgroups are easily identifiable using routinely available clinical information. A clinical prediction rule is being developed. Poor response to platelet transfusion is a clinically and financially significant downstream effect of thrombocytopenia and warrants further investigation.

Pulmonary infections mimicking cancer: A retrospective, three-year review

Pulmonary infections can mimic or occasionally co-exist with pulmonary neoplasms. In order to determine the frequency and nature of these infections, we conducted a retrospective analysis, covering a 3-year period, of patients who were referred to our center with presumed lung cancer but turned out to have pulmonary infection instead. The overwhelming majority of patients (93.3%) referred to “rule out” lung cancer were documented as having a neoplastic process, and only 1.3% had an infection. Fungal infections (histoplasmosis, cryptococcosis, coccidiomycosis) accounted for 46%, mycobacteria for 27%, bacteria for 22%, and parasitic lesions (dirofilariasis) for 5% of these infections. The most common clinical manifestations were cough and chest pain, and the most common radiographic finding was a solitary pulmonary nodule. There were no specific clinical or radiographic features predictive of either infection or neoplastic disease. All patients responded to specific anti-infectioe therapy with or without surgical excision. Our data indicate that pulmonary infections mimic neoplasms very infrequently. However, establishing a specific diagnosis is critical, since the management and outcome of these two processes are entirely different.

Strongyloidiasis in Patients at a Comprehensive Cancer Center in the United States: A Retrospective Study Covering the Years 1971-2003

The frequency of Strongyloides stercoralis infestation and complication in patients with cancer in the United States is unknown.

Time to Clinical Response: An Outcome of Antibiotic Therapy of Febrile Neutropenia With Implications for Quality and Cost of Care

PURPOSE To determine whether antibiotic regimens with similar rates of response differ significantly in the speed of response and to estimate the impact of this difference on the cost of febrile neutropenia. METHODS The time point of clinical response was defined by comparing the sensitivity, specificity, and predictive values of alternative objective and subjective definitions. Data from 488 episodes of febrile neutropenia, treated with either of two commonly used antibiotics (coded A or B) during six clinical trials, were pooled to compare the median time to clinical response, days of antibiotic therapy and hospitalization, and estimated costs. RESULTS Response rates were similar; however, the median time to clinical response was significantly shorter with A-based regimens (5 days) compared with B-based regimens (7 days; P =.003). After 72 hours of therapy, 33% of patients who received A but only 18% of those who received B had responded (P =.01). These differences resulted in fewer days of antibiotic therapy and hospitalization with A-based regimens (7 and 9 days) compared with B-based regimens (9 and 12 days, respectively; P <.04) and in significantly lower estimated median costs (

Klebsiella bacteremia: a 10-year review in a cancer institution

8,491 v

The Bleeding Risk Index: a clinical prediction rule to guide the prophylactic use of platelet transfusions in patients with lymphoma or solid tumors.

11,133 per episode; P =.03). Early discharge at the time of clinical response should reduce the median cost from

Nature and outcome of febrile episodes in patients with pancreatic and hepatobiliary cancer.

10,752 to

Antimicrobial Therapy for Salmonella Infections in the Acquired Immunodeficiency Syndrome (AIDS)

8,162 (P <.001). CONCLUSION Despite virtually identical rates of response, time to clinical response and estimated cost of care varied significantly among regimens. An early discharge strategy based on our definition of the time point of clinical response may further reduce the cost of treating non-low-risk patients with febrile neutropenia.

Eruptive Dysplastic Nevi Associated With Human Immunodeficiency Virus Infection

A total of 368 episodes of Klebsiella bacteremia occurred in 330 cancer patients, representing a rate of four episodes per 1000 hospital admissions. Eighty‐eight percent of these infections were acquired nosocomically and 58% of the patients received antibiotics during the preceding 10‐day period. There was pulmonary infection in 24% of the patients, shock in 25%, and disseminated intravascular coagulation in 7%. The overall response rate was 69%. Response rates were significantly lower among patients with shock (25% versus 83%), hemorrhage (29% versus 76%), and pneumonia (37% versus 79%). The combination of a cephalosporin plus an aminoglycoside produced the highest response rate (79%). Klebsiella sp continue to be an important cause of infection in patients with cancer.