William H. Greene

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.

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 ...

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.

Infections in 92 splenectomized patients with Hodgkin's disease: A clinical review☆

Infections that occurrred in 92 previously untreated patients with Hodgkins disease were reviewed from the time of laprotomy and splenectomy. Pneumonias occurred in nine patients with urinary tract infections in twelve during the immediate postoperative period. Severe bacterial infections did not occur in any patients during initial radiation therapy, adjuvant chemotherapy (stages I through IIIA), initial intensive chemotherapy (stages IIIB and IV) or during remission. Severe infections occurred in eight profoundly granulocytopenic patients with recurrent Hodgkins disease. Streptococcus (Diplococcus) pneumoniae and Hemophilus spp infections were distinctly uncommon during the remission period. Herpes zoster, however, was very common developing in 22 of 92 (24 per cent) patients. Predisposing factors to herpes zoster included sex (female more than male), therapy (radiation plus chemotherapy more than chemotherapy alone), and age (less than 30 years of age more often than 30 to 50 years of age). Severe infection was uncommon in these patients except in ascociation with specific predisposing factors such as the immediate postoperative state of prolonged granulocytopenia associated with recurrent Hodgkins disease or its therapy. Splenectomy per se did not affect either the incidence or the severity of infection during this period of 12+ months of observations per patient.

A combined modality approach to the treatment of Hodgkin's disease. Preliminary results of a prospectively randomized clinical trial

Eighty‐seven previously untreated patients with pathologic Stage IA, II (A or B), or IIIA Hodgkins disease were randomized over a 48‐month period to receive either megavoltage extended field radiotherapy alone or megavoltage radiotherapy limited to involved lymph node sites (including at least an upper mantle field) followed by combination chemotherapy with nitrogen mustard, vincristine, prednisone, and procarbazine (MOPP). Four patients (4.6%) failed to achieve remission with initial radiotherapy. Seventy‐two evaluable patients have currently completed therapy. Ten of 41 patients achieving remission with radiation alone have relapsed, compared to only 1 of 31 receiving radiation plus chemotherapy. Seven patients have died, 3 of whom failed to achieve remission with initial radiotherapy. The other 4 had Stage IIIA disease treated with radiation alone. Severe myelosuppression occurred infrequently during chemotherapy, and neither serious infections nor second neoplasms have been observed. Although these preliminary results are encouraging, longer followup is required to determine the ultimate effects of combined modality therapy on survival and long‐term complications.

Hepatic pathology associated with Hodgkin's disease

Liver biopsies obtained during staging laparotomy for Hodgkins disease from 103 untreated and 25 previously treated patients were reviewed. No significant differences were noted between the two groups as to the incidence of Hodgkins disease, epithelioid cell granulomata, and non‐specific inflammation. There appeared to be some increase (not statistically significant) in fatty infiltration and hemosiderosis in the treated patients. Patients with elevated alkaline phosphatase demonstrated Hodgkins disease, non‐specific hepatic lesions, or no pathologic findings. Biopsies from 5 Hodgkins disease patients with hepatitis‐associated antigen revealed varied hepatic pathologic findings. In 70 patients with both wedge and deep needle biopsies, the needle biopsy did not demonstrate additional lesions than those observed in the wedge specimen. The importance of careful examination of the liver surface during laparotomy was emphasized. Cancer 33:1564–1571, 1974.

Pseudomonas septicemia: Incidence, epidemiology, prevention and therapy in patients with advanced cancer

Abstract In the past decade, Pseudomonas aeruginosa has become a common cause of infection in cancer patients and Pseudomomas sepsis has become the most frequent infection in patients with acute non-lymphocytic leukemia. Although only some patients are colonized with this organism at the time of hospital admission, approximately 50% of ANLL patients will eventually become colonized. Once colonized, subsequent septicemia is the rule in the granulocytopenic patient. Surveillance cultures, in association with serotyping, can assist in detecting the colonized, at-risk patient and aid in establishing and maintaining preventive measures such as environmental decontamination, personnel hygiene, reverse isolation (including sterile water and cooked food), prophylactic non-absorbable antibiotics, and vaccination. Prevention of infection must take high priority because of the high morbidity and mortality of this disease. Until the advent of carbenicillin, death was the rule despite antibiotics such as polymixin B, colistin, and gentamicin which are bactericidal in vitro but not effective in the granulocytopenic patient. Carbenicillin with or without added gentamicin has been shown to consistently achieve an improvement rate of well over 50%. The combination is usually markedly synergistic and resistance, although occurring, has been relatively infrequent. At the present time, we favor this combination for the treatment of Pseudomonas aeruginosa infections in granulocytopenic cancer patients and favor the addition of cephalothin for initial empiric therapy before culture results are available.

Staging laparotomy in Hodgkin's disease: Further evidence in support of its clinical utility

Abstract Records of 99 consecutive previously untreated patients with Hodgkins disease subjected to laparotomy at our institution were reviewed in order to assess the frequency with which inadequate or inappropriate therapy might have been administered on the basis of clinical staging alone. Of the 86 patients judged to be candidates for aggressive radiation therapy prior to laparotomy (clinical stage less than IIIB) unsuspected disease was found in the porta hepatis lateral to the margin of the usual para-aortic radiation field in 4, and occult liver involvement in an additional 2. On the other hand, 2 patients with clinically suspected hepatic involvement were found to be free of parenchymal disease and therefore candidates for aggressive radiotherapy. Of particular interest was the discovery of occult abdominal disease outside conventional extended field radiation ports in 3 patients with clinical stage IIA disease. It was not possible to reliably exclude the presence of occult disease outside standard abdominal radiation ports by previously published guidelines outlining indications for staging laparotomy.

Empiric Carbenicillin, Gentamicin and Cephalothin Therapy for Presumed Infection in Patients with Granulocytopenia and Cancer.

Excerpt The use of empiric, broad-spectrum antibiotic therapy in the treatment of presumed Gram-negative sepsis is nowhere more necessary than in the granulocytopenic patient, for without such ther...

Vascular invasion and hematogenous dissemination of Hodgkin's disease

The clinical records and pathologic material of 125 Hodgkins disease patients consecutively admitted to the Baltimore Cancer Research Center for staging laparotomy were reviewed. Diagnostic lymph node biopsies from 91 of these patients studied for evidence of vascular invasion revealed 4 biopsies that were positive (4.4%). The course of the disease in these patients has not been distinguished by extranodal dissemination or shortened survival. In contrast, vascular invasion in the spleen, present in 7 of 44 spleens involved by Hodgkins disease (16%), was associated with hepatic and bone marrow metastases, early relapse, and shortened survival. The results indicate that while vascular invasion in diagnostic lymph node biopsies may not have prognostic implications, the presence of vascular invasion in the spleen is an ominous sign.