Viola Mae Young

Infection Prevention in Acute Nonlymphocytic Leukemia: Laminar Air Flow Room Reverse Isolation with Oral, Nonabsorbable Antibiotic Prophylaxis

Reverse isolation and prophylactic oral nonabsorbable antibiotics were evaluated among 64 consecutive noninfected adults with acute nonlymphocytic leukemia admitted for remission induction. Patients were randomly allocated to laminar air flow room reverse isolation with oral nonabsorbable antibiotics (LAF plus A), routine hospital ward care with antibiotics (W plus A), or ward care alone (W). The LAF plus A patients had a significantly decreased incidence of total infection, bacteremias, pneumonias, rectal abscesses, urinary tract infection, and pharyngitis. Infectious deaths were reduced in the LAF plus A group and the time to the first infection or to fatal infection was delayed. The W plus A patients who regularly ingested the antibiotics had a reduction in infections similar to that of the LAF plus A patients but those who could not tolerate the antibiotics had an incidence of infection comparable to the ward patients. The LAF plus A and the W plus A patients also had higher complete remission rates and longer median survival than the unprotected ward patients.

A comparison of trimethoprim-sulfamethoxazole plus nystatin with gentamicin plus nystatin in the prevention of infections in acute leukemia.

Fifty-three profoundly granulocytopenic patients with relapsed acute leukemia who were undergoing reinduction chemotherapy were prospectively randomized to receive either trimethoprim-sulfamethoxazole plus nystatin or gentamicin plus nystatin for prevention of infections. The acquisition of new organisms per patient during the total study period was similar in both groups. Thirty-five symptomatic infections (five of which were bacteremias) occurred in patients receiving trimethoprim-sulfamethoxazole plus nystatin, whereas 31 infections (eight bacteremias) occurred in patients receiving gentamicin plus nystatin. Four deaths related to infection occurred in patients taking trimethoprim-sulfamethoxazole, and eight occurred in patients taking gentamicin. We conclude that trimethoprim-sulfamethoxazole plus nystatin was approximately as effective as gentamicin plus nystatin for prophylaxis against infection in relapsed acute leukemia. Furthermore, side effects were fewer and compliance was better with trimethoprim-sulfamethoxazole plus nystatin.

Pneumonia in acute leukemia.

Abstract Pneumonia is a quite frequent and often fatal complication in patients with acute leukemia. During a 19-month period 52 episodes of pneumonia were found among 68 leukemia patients. Except ...

The emergence of coryneform bacteria as a cause of nosocomial infections in compromised hosts.

Corynebacterium species that are normally abundant on the skin and mucous membranes rarely cause infections and are susceptible to most antibiotics. The report in 1976 of four cases of sepsis at the National Institutes of Health caused by a hitherto undescribed corynebacterium that is highly antibiotic resistant, but uniformly susceptible to vancomycin, alerted the medically oriented scientific community to the emergence of these organisms as a possible new cause of nosocomial infections. Although we have always performed antibiotic susceptibility tests on all microorganisms recovered from normally sterile body fluids, our first recovery of these organisms was in August 1977. Since then we have recovered 52 such strains from 39 patients, most frequently from the rectum, followed by the groin, blood, lesions and urine in order of predominance. Characterization by API 50 L strips revealed that most, but not all strains resemble the JK group of Riley et al. [1]. Cell wall studies and DNA base ratios further confirmed their status as corynebacteria. Hospital acquisition has been proved; cross infection between patients is the most likely mode of spread. Their recognition is necessary for optimal preventive and therapeutic care of patients with compromised host defenses.

Torulopsis glabrata infections in patients with cancer: Increasing incidence and relationship to colonization

Torulopsis glabrata, an opportunistic pathogen, was found to be the etiologic agent of infections in patients with cancer. This observation prompted a retrospective review to determine the incidence and underlying factors of infection with this organism. This study showed that T. glabrata had been cultured frequently and that the incidence of infection has been progressively increasing. During a 48-month period (9/70-8/74), T. glabrata was cultured from routine surveillance and diagnostic cultures in 167 patients, 27 of whom had either presumed or documented infection. Review of clinical and necropsy records implicated T. glabrata infections as a contributory factor in the death of 14 of the 27 patients. Etiologic diagnosis of infection was established antemortem in only three patients. Pulmonary isolation in pure growth occurred in 24 of the 27 patients. Seventeen of 19 infected patients who had prior routine surveillance cultures were colonized prior to infection. Infection occurred in the setting of far advanced malignancy or leukopenia and followed the use of systemic, broad spectrum antibiotics. T. glabrata is a frequently overlooked opportunistic pathogen which, in the proper setting, appears to be producing increasing numbers of infections.

Randomized trial of empiric antibiotic therapy with ticarcillin in combination with gentamicin, amikacin or netilmicin in febrile patients with granulocytopenia and cancer

A randomized trial of ticarcillin plus gentamicin (group 1), ticarcillin plus amikacin (group 2) and ticarcillin plus netilmicin (group 3) as empiric antibiotic therapy in patients with granulocytopenia and cancer was carried out at the Baltimore Cancer Research Center. The response rate for all infections was 97 per cent in group 1, 91 per cent in group 2 and 95 per cent in group 3. Patients with bacteremias showed improvement in 93 per cent (group 1), 78 per cent (group 2) and 82 per cent (group 3) of cases. All failures were among patients with gram-negative bacteremias. Both antibiotic susceptibility of the bacteremic organism and granulocyte recovery correlated with patient improvement. Nephrotoxicity and ototoxicity were rare and were not significantly different in three groups of patients. Therefore, ticarcillin plus gentamicin, ticarcillin plus amikacin and ticarcillin plus netilmicin appear to be equally efficacious and minimally toxic in this patient population. Excellent over-all results can be expected with these combinations provided the etiologic agent is susceptible.

Lessons learned from surveillance cultures in patients with acute nonlymphocytic leukemia: Usefulness for epidemiologic, preventive and therapeutic research

Abstract In 135 consecutive patients with acute nonlymphocytic leukemia (ANLL), who were admitted to the Baltimore Cancer Research Program (BCRP) for their first induction chemotherapy shortly after initial diagnosis and who had received no recent antibiotic therapy, surveillance cultures were obtained of specimens from the nose, gingiva, axillas and rectum twice during the first week of hospitalization and then twice weekly thereafter. All organisms which were morphologically distinct on routine culture media were fully identified, and Pseudomonas aeruginosa was serotyped. Baseline surveillance cultures indicated that there was a higher than expected incidence of colonization with gram-negative bacilli in the nose, gingiva and axillas along with the expected colonization by gram-negative bacilli in the rectum. Among these colonizing gram-negative bacilli, Ps. aeruginosa and, to a lesser extent, Klebsiella pneumoniae, Escherichia coli and Proteus mirabilis were most likely to be associated with a subsequent bacteremia during periods of mucosal damage and granulocytopenia. Follow-up surveillance cultures indicated that new organisms were acquired at a rate of 0.5 organism per patient per week with many of these acquired organisms being gram-negative bacilli of the type likely to cause infection in these patients. Compared to similar surveillance cultures obtained in a previous group of patients not subjected to vigorous infection prevention techniques, the rate of new organism acquisition was less and the development of infection subsequent to colonization was reduced. Surveillance cultures also indicated those patients at highest risk of having yeast infections such as those caused by Torulopsis glabrata or Candida species. Results of nasal surveillance cultures detected a subpopulation of patients at greatest risk for colonization and subsequent infection with Aspergillus flavus. Surveillance cultures have been utilized for the design of systemic therapeutic antibiotic protocols and for the monitoring of oral nonabsorbable antimicrobial regimens for alimentary canal microbial suppression. Despite the usefulness of surveillance cultures for research in the epidemiology, prevention and treatment of infection in patients with acute leukemia, their routine use in a nonresearch setting would not be advised.

Comparative Activity of Tobramycin, Amikacin, and Gentamicin Alone and with Carbenicillin Against Pseudomonas aeruginosa

The effect of gentamicin against 130 clinical isolates of Pseudomonas aeruginosa was compared with that of two investigational aminoglycoside antibiotics, tobramycin and amikacin. Minimal inhibitory concentration data indicated that, on a weight basis, tobramycin was two to four times as active as gentamicin against most isolates. However, 14 of 18 organisms highly resistant to gentamicin (≥80 μg/ml) were also highly resistant to tobramycin. Amikacin was the least active aminoglycoside on a weight basis, but none of the isolates were highly resistant to this antibiotic. When therapeutically achievable concentrations were used, adding carbenicillin to gentamicin or to tobramycin enhanced inhibitory activity against those isolates susceptible (≤5 μg/ml) or moderately resistant (10 to 40 μg/ml) to the aminoglycoside. Such synergy was seldom demonstrated for isolates highly resistant to gentamicin or tobramycin. The combination of carbenicillin and amikacin enhanced inhibition against all but two of the isolates. Both tobramycin and amikacin offer in vitro advantages over gentamicin against P. aeruginosa.

Ticarcillin in Combination with Cephalothin or Gentamicin as Empiric Antibiotic Therapy in Granulocytopenic Cancer Patients

Ticarcillin was used in combination with either cephalothin or gentamicin as initial empiric antibiotic therapy for 127 patient trials of suspected infection in granulocytopenic cancer patients. Bacteremia was present in 20%, nonbacteremic microbiologically documented infections in 21%, clinically documented infections in 23%, and possible infections in 5%; infection was doubtful in 31%. Although Staphylococcus aureus was the most common single organism isolated (23%), gram-negative bacilli accounted for 54% of all pathogens. Both antibiotic regimens were highly efficacious, with complete resolution in 46% of bacteremias, 88% of nonbacteremic microbiologically documented infections, and 95% of clinically documented infections. Among bacteremias, 8 of 9 caused by S. aureus but only 4 of 15 (27%) caused by gram-negative bacilli were completely resolved with these antibiotic combinations. Reasons for nonresponse in bacteremias were persistent granulocytopenia, mixed infection and, in two patients, antibiotic-resistant organisms. Toxicities other than hypokalemia were minimal. Although the rate of further infections was high overall (18/127), only one occurred among the 39 patients with <4 days of antibiotic therapy. Ticarcillin in combination with either cephalothin or gentamicin was effective as initial empiric therapy of suspected infection in granulocytopenic cancer patients.

In Vitro Susceptibility of Pseudomonas cepacia and Pseudomonas maltophilia to Trimethoprim and Trimethoprim-Sulfamethoxazole

Our earlier studies had shown that the two pseudomonads, Pseudomonas cepacia and Pseudomonas maltophilia, were organisms that were highly resistant to most antibiotics. The present study was undertaken to determine the susceptibility of these bacteria to trimethoprim and the trimethoprim-sulfamethoxazole combination which has been used with apparent success in treating infections caused by these pseudomonads. All 51 strains of P. cepacia were inhibited by 2 μg or less of trimethoprim per ml, whereas all 45 of the P. maltophilia were resistant to greater than 32 μg/ml. When the P. maltophilia was tested against trimethoprim-sulfamethoxazole, two strains were resistant and one only moderately resistant, but all other strains were susceptible. All P. cepacia strains were also susceptible with an average zone of inhibition significantly larger than for P. maltophilia (P < 0.005). These in vitro studies support recent case study reports of successful therapy using the trimethoprim-sulfamethoxazole combination.